Ultrasound guided detection of position of post partum intra uterine contraceptive device and its relation to complications

Background: Worldwide, Intrauterine Contraceptive Device (IUCD) is one of the most commonly used reversible methods of contraception among married women of reproductive age. It is the second most commonly used forms of contraception, ranking second only to female sterilization. Proper positioning of Copper containing IUCD is of utmost importance for efficacy and safety. The immediate postpartum period, after a birth but prior to discharge from the hospital is an important but under utilized time frame to initiate contraceptives, specially long acting contraceptives such as intrauterine contraceptive device (IUCD). To study the location of Copper IUCD by ultrasound, relationship between position and complaints, failure rate and expulsion rate in post-partum IUCD cases.Methods: The study was prospective, analytical study conducted on 200 women for one year.  IUCD insertion was done in two groups; group A (normal delivery, postplacental) and group B (caesarean section, intracaesarean). On ultrasonography, position and distance of IUCD from fundus of uterus was measured. Outcome measures were expulsion, complication and failure rate upto six months. Informed consent was taken from each participant and ethical justification for the study was sought.Results: Majority of the patients were in age group of 21-25 years. Multigravidae patients had more acceptability of IUCD than primigravidae. More than half of IUCD insertion was done by senior residents (56%). Malpositions were more common in vaginal delivery (62%) than caesarean section (28%). Most common malposition was mid cavity and least common was oblique. Most common complaint was pain abdomen and least common was expulsion.Conclusions: Sonography can be used as an adjunct to clinical examination to examine the position of the IUCD. Ultrasonography done after PPIUCD insertion helps in determining, whether PPIUCDs are placed in normal position or malposition. Malpositioned PPIUCDs have more complications as compared to normally placed IUCD

Incidence of post-operative (caesarean section) infectious morbidities in cleansing and non-cleansing group after povidone iodine vaginal cleaning

Background: Despite of wide spread use of prophylactic antibiotics and various antiseptic measures, post-operative infection remains one of the significant and serious complication of caesarean delivery contributing to high maternal morbidity and mortality. Objective was to study the incidence of post-operative infectious morbidities in patients with/without povidone iodine vaginal cleansing done prior to caesarean section.Methods: A prospective randomized control study was done in the department of obstetrics and gynecology of Dr. Baba Saheb Ambedkar Medical College and Hospital, New Delhi.Results: Mean age of participants in group A is 26.22±2.47 years and in group B is 26.48±2.3 years. Majority women (84.0%) underwent emergency lower segment caesarean section (LSCS). (6.4%) women developed post-operative endometritis, out of which maximum (4.6%) belong to no vaginal cleansing group (B) compared to 1.8% in povidone iodine vaginal cleansing group(A), which is statistically significant (p=0.01). Over all (13%) women had post-operative fever, with significant difference among the two groups i.e. (8.6%) were in group B versus (4.4%) in group A (p=0.005).Conclusions: Povidone iodine vaginal cleansing prior to caesarean section is significantly effective in reducing post-operative infectious morbidities

Broad ligament ectopic pregnancy: a dilemma to diagnose

Broad ligament ectopic pregnancy is a rare and serious form of extrauterine pregnancy with a high risk of maternal mortality. There are no specific clinical features. Ultrasonography may help in diagnosis but definitive diagnosis is made only during surgery. A 20-year-old woman with previous 2 abortions presented with acute abdomen. She had no history of amenorrhoea but there was history of two episodes of bleeding in the last month at an interval of 14 days, each episode lasting for two-three days. The last episode of bleeding was 10 days back. Her urine pregnancy test was done and it was positive. There was marked abdominal tenderness with guarding and rigidity. Per vaginal examination revealed marked tenderness in the right fornix and cervical motion tenderness, uterus size could not be assessed due to tenderness.  It was diagnosed as a case of ruptured ectopic pregnancy. Since she was haemodynamically unstable, emergency laparotomy was done. She had a right sided broad ligament ectopic pregnancy which had ruptured. The tissue was completely removed and haemostatic sutures were taken. High index of clinical suspicion, early diagnosis and prompt surgery is the key to management

Misdiagnosed advanced interstitial pregnancy - A case report

Interstitial pregnancy is a rare and dangerous form of ectopic pregnancy that can be mistaken for a normal intrauterine pregnancy on ultrasonography leading to catastrophic results. Gynecologist should be aware of the potential for mistaking an interstitial pregnancy for intrauterine pregnancy. We present a case of 14 weeks interstitial pregnancy misdiagnosed on abdominal ultrasonography as intrauterine pregnancy with ascites. She was treated as sub-acute intestinal obstruction with severe anemia in pregnancy for 2 days. The correct diagnosis was first made at emergency laparotomy which showed hemoperitoneum and rent involving the right superolateral end of the uterus, with fetus and placenta lying in pouch of Douglas. Wedge resection of the right superolateral end of uterus along with repair done. Lack of suspicion and lack of expertise are a common cause for missing this rare ectopic pregnancy

Paraurethral leomyoma: a manageable challenge

Leiomyoma is a most common benign tumour of uterus. But it is very rare in vagina urethral and paraurethral. There are approximately 330 case reports are available in literature and the paraurethral site is extremely uncommon. Here, we report a case of 38-year nulliparous woman presented with complain of mass coming out of vagina as well as dyspareunia. Provisional diagnosis of anterior vaginal cyst along with the differential diagnosis of paraurethral and anterior wall vaginal leiomyoma was made. Transvaginal removal of mass was done and diagnosis of paraurethral leiomyoma was confirmed by histopathology

Dinoprostone Gel versus Intra-cervical Foley’s Catheter for Pre-induction Cervical Ripening: An audit

Background  One of the common practices in modern obstetrical care is labour induction when foetal and maternal complications arise. We endeavoured to compare the efficacy and safety of the inexpensive mechanical method of induction Foley’s catheter to the more established pharmacological agent Intracervical Prostaglandin E2 gel Method  The present prospective randomised control study was carried out on 200 women with a term singleton pregnancy in cephalic presentation, with an unfavourable cervix and a valid indication for induction of labour. The patients were randomly allocated using the chit method to either Foley’s catheter [group A, n=100] or PGE2 gel [group B, n=100] . Augmentation with oxytocin was done if required and labor was closely monitored till delivery and the perinatal outcome and maternal side effects was recorded Quantitative variables were compared using unpaired t-test/Mann-Whitney Test and qualitative variables were compared using Chi-Square test /Fisher’s exact test. Analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0   RESULTThe caesarean section rate did not show a significant difference between the Foley’s group(18%) and PGE2 group(11%) The incidence of fetal distress, Meconium stained liquor and APGAR score <7 at 5 minutes  was significantly with PGE2  as compared to group A. (P<.05) Incidence of hyperstimulation of uterus was reported in 6% women who received PGE2  as compared to none in Foley’s group. The induction delivery interval did not show any significant difference between the two groups.   CONCLUSION In women undergoing induction of labour at  term in resource constraint set ups like ours, Foley catheter is a good  alternative to the more established  prostaglandin E2 gel, with good efficacy and better neonatal and maternal safety profile.   Keywords: cervical ripening; dinoprostone; obstetric labor, induce

Role of immunomarkers (P16 and Ki67) in identifying pre-malignant and malignant lesion of cervix: a comparative study

Background: Cancer of the cervix is the second most common cancer among women worldwide. Although pap test has successfully reduced the incidence of cervical cancer, it is associated with high false positive and high false negative test results. In order to improve the efficacy of screening program, United States cervical cancer screening guidelines recommend use of combined testing (cytology + HPV-DNA) in women above 30-65 years of age. However, due to application of current HPV vaccines, cervical screening will face challenges due to declining trends in the prevalence of HPV genotypes covered by vaccines. Aim: The study is aimed at finding out the role of immunomarkers (P16 and Ki67) in identifying pre-malignant and malignant lesion of carcinoma cervix and their comparison with the co-testing (cytology + HPV-DNA) method of screening. Methods: A cross-sectional observational study was conducted on 32 cases after consent. The tests done were cytology + HPV-DNA, cytology+p16, cytology+ Ki-67 and were compared in terms of their sensitivity, specificity, positive predictive value and negative predictive value against the gold standard, histopathology. Result: Majority of cases were in 30-40 years of age group. The sensitivity, specificity, positive predictive value and negative predictive value of cytology + HPV-DNA testing was 94.44%, 50%, 77.27%, 83.33% while that of cytology + P16 was 88.88%, 60%, 80%, 75% and cytology + Ki-67 was 88.88%, 100%, 100%, 91.66% respectively. Conclusion: Ki67 immunomarker is a better screening tool in terms of specificity, positive predictive value and negative predictive value when compared to cytology + HPV/p16. Ki-67 can be considered as a potential screening tool in future for both vaccinated and unvaccinated population