Diagnosis of caesarean section scar niche causing chronic pelvic pain

The common causes of chronic pelvic pain include chronic pelvic inflammatory disease, endometriosis, inflammatory bowel disease etc. Caesarean scar defect is recently recognized as a cause for chronic pelvic pain. A 33 years old para 2 with previous 2 caesarean sections, whose last child birth was 18 months back consulted for rectal pain of 4 months duration. She was treated with progesterones with a provisional diagnosis of endometriosis without much relief. She developed congestive dysmenorrhea and dyspareunia after last child birth. Her clinical examination revealed retroverted uterus with left forniceal tenderness. USG evaluation confirmed the clinical findings and evaluation of uterine scar was not undertaken as the possibility of caesarean scar defect (CSD) was not thought of as a cause for chronic pelvic pain. MRI pelvis reported semicircular myometrial defect at LSCS scar site and this was confirmed by hystero-laparoscopy and she was counselled to undergo repair of CSD. The case illustrated the clinical picture and diagnosis of CSD as a cause for chronic pelvic pain

Needs of laboring women: tools for training desired birth companion

Presence of a birth companion through labour, childbirth and postpartum is one of the universal rights of child bearing women. Not only that, the choice of birth companion is also one of the components of respectful maternity care. The characteristics of the birth companion of women’s choice [desired birth (DBC)] is well spelt by WHO as well as govt, of India. In practice it is observed that most of the DBC companions (DBC) who were relative, friends of the birthing women are unaware of their roles and responsibilities and are not well prepared to render the necessary maternal support. Trained birth companions or on call birth companions (OBC/Doulas) are not available in developing countries like India and all women cannot afford the costs of OBCs and the Govt hospitals do not encourage the participation of Doulas. Hence there is a need to train the DBC with resources in the health care system. This review is intended to search literature regarding the tools for training the DBCs. The literature search showed very few studies regarding the same and the workshops in training DBC are not implemented across the health care facilities.

Symphysio-fundal height measurement as a tool in antenatal care: current understanding: narrative review

Symphysio-fundal height (SFH) measurement during pregnancy was recognized as a simple clinical indicator for monitoring fetal growth since decades. However, its significance and validity are questioned in recent era of Sonography. This is a narrative review of the topic published. Conclusions of systematic reviews, meta-analysis as well as studies which compared SFH and ultrasound for fetal growth monitoring were included. The review revealed SFH has poor sensitivity as a tool for screening and diagnosing fetal growth restriction and inter-observer variations are high and hence fallacious. However multiple measurement model incorporating standard international guidelines may be useful in resource poor settings. Limitations of SFH include that it is not useful in hydramnios, multiple pregnancies and pregnancies with uterine or ovarian masses and fetuses in transverse lie. For screening and early diagnosis of growth restriction, estimation of gestational age and fetal weight estimation USG is the standard tool

Maternal and fetal outcomes in diabetes mellitus in hospitalized women at a tertiary care institute in South India

Background: Objectives of current study were to find out the proportion of types of diabetes and to know the factors for adverse maternal and fetal outcome in pre-gestational diabetes and gestational diabetes at a tertiary care Institute and to compare the outcomes between pre-gestational diabetes and GDM.Methods: Prospective descriptive study conducted in the department of obstetrics and gynaecology, at a tertiary care center over a period of 1 year. The inclusion criteria were: pre-gestational diabetes (pregnant women with type 1 & type 2 diabetes mellitus) and gestational diabetes mellitus. Exclusion criteria were steroid induced diabetes, tuberculosis, heart disease, autoimmune disorder, chronic renal failure. Statistical analysis: Maternal & fetal outcomes, presence of complications were expressed as proportions and comparison between the 2 groups is done using Chi-square test.Results: Majority of the women (81.5%) were GDM and 18.5% were pre-gestational diabetics (type I DM-5% and Type II-13.5% of total). Past history of GDM was present in 29% of GDM and 31% of type II DM. Sixty percent of GDM and 40% of PGDM were primigravidae. Significantly a greater number of women were obese in PGDM than GDM. Blood sugars were uncontrolled in 20% more so in women with PGDM. Pregnancy loss was more in PGDM when compared to GDM (17.5% vs. 9.1%). Statistically significantly more number with PGDM suffered from hypertension and preterm labour.Conclusions: Obesity, uncontrolled blood sugars, development of hypertension and pre-term labour are the significant factors resulting in adverse maternal and fetal outcomes and these are more common in women with PGDM

Prediction of success of induction of labour: Bishop’s score versus transvaginal sonographic parameters

Bishop’s score is a standard method of pre-induction assessment of parameters to predict induction of labour. It is subjective and has interobserver variability and it does not take in to account the supra-vaginal cervix which forms more than 50% of cervical length. During the past 3 decades studies undertaken to find out a better predictor of labour induction found ultrasonographic assessment of cervix to be a better method. Cervical length, posterior cervical angle and head position are some of the parameters that were studied and compared with Bishops score. Among these posterior cervical angles of >1100 and cervical length of <2 cm are the best predictors for success of induction of labour. These parameters would help to explain the chances of vaginal delivery and the risk of undergoing caesarean section in an objective way.

Diagnostic difficulties of leptospirosis during pregnancy: a maternal near miss

A 24-year-old G2A1 at 34 weeks of gestation was admitted with complaints of nausea, vomiting, pedal edema and high blood pressure recordings. She developed imminent symptoms after admission for which she received prophylactic magnesium sulphate therapy and a provisional diagnosis of severe preeclampsia with imminent symptoms was made. With worsening hematological, liver and renal parameters as she did not fulfill the Swansea’s criteria for acute fatty liver of pregnancy (AFLP), partial hemolysis elevated liver enzymes and low platelet count (HELLP) was suspected. She was delivered by cesarean section. Infectious disease work up was sent in view of rising counts and elevated liver enzymes which was positive for leptospirosis. There was also history of walking in the rice fields bare foot and rat infestations in the fields supporting the diagnosis. Both the mother and baby were discharged in a healthy condition. The diagnosis becomes challenging in pregnancy as it mimics pregnancy induced hypertension, acute fatty liver of pregnancy, partial HELLP, obstetric cholestasis and viral hepatitis

Clinical profile of women seeking medical termination of pregnancy at a tertiary care institute, South India

Background: Medical termination of pregnancy (MTP) has largely become a medical procedure rather than surgical and in the recent times and few women approach public health care facility and hence the profile of women has changed and is different in various hospitals. Hence this study was undertaken with the objectives to know the proportion of indications as per MTP act and gestational age in women who opted MTP. The study also aimed to find out the clinic-demographic profile and the method of MTP and contraception adopted along with MTP.Methods: A retrospective cohort over 3 year period (2016-2019). Data was extracted from the medical records of women who were hospitalised for MTP and analysed for the outcome parameters Viz: Women were categorised as per the indication for MTP. In each category of indication, age, socioeconomic status, trimester of MTP, number of living children, methods of MTP and methods of contraception adopted was noted. The results were expressed as proportions and frequencies and the trend over 3 years was expressed as percentage per total number of deliveries per year.Results: There were 640 MTPs over 3 year period and this constituted 1.22% of total deliveries (52,555). Fifty one percent were first trimester MTPs. Thirty eight percent were done for congenital malformations, 32% for socio-economic reasons of family limitation, 17% for saving physical or mental health , 4% for rape victims and 8% for failure of contraception. The mean age was 28 years and the age in humanitarian group was ≤ 20 years. More than 88% belonged to lower socioeconomic class and 37% were third gravidae with 2 living children. Medical methods were used in 90% of terminations and 46% adopted contraception.Conclusions: The most common reason for opting MTP is congenital malformation of fetus. Women who achieved the desired family size and non-practice of contraception was the next common indication for termination of pregnancy and majority of terminations in this group were first trimester. Practice of contraception to avoid unwanted pregnancy and measures to prevent congenital malformations are essential to reduce medical termination of pregnancies

Pelvic congestion syndrome: a potentially treatable cause of intractable dysmenorrhoea

Pelvic congestion syndrome (PCS) comprises a constellation of symptoms such as noncyclical pelvic pain, pelvic varicosities, dysmenorrhea and dyspareunia in multiparous women of reproductive age. It occurs due to pelvic venous insufficiency. The condition is a challenging entity and diagnosed after excluding other pelvic pathologies. Although venography has been considered gold standard for imaging diagnosis, Doppler ultrasonography, cross sectional imaging of pelvic veins at CT and MRI have been shown to provide adequate and accurate diagnosis. Here we report a case of intractable dysmenorrhoea in a 42-year multiparous woman and its successful management with embolization of pelvic varicose veins.

Radiation for Gynaecological Malignancies

Gynaecological malignancies are the most common cancers of women and they contribute to the significant amount of mortality. Women in developing countries are diagnosed in late stages and hence radiation is the common modality of therapy. Radiation is required in managing 80–90% of women with carcinoma cervix, 60% of women with endometrial cancer and 50% of women with carcinoma vulva. The stage of the disease is the most important factor in survival and counselling is essential to ensure complete therapy. Radiation is used as a primary therapy, adjuvant therapy, neo‐adjuvant therapy and as palliation. The techniques include external beam radiation and brachytherapy or the combination of both. The newer techniques include IMRT‐, IGRT‐ and PET‐CT‐guided therapies. Side effects/complications occur as acute during therapy, subacute within 3 months and chronic after 6 months. Management of these side effects is essential for increasing compliance of the patient so as to achieve high cure rates. Management of recurrent disease is a challenge and requires multidisciplinary approach involving Gynaecological Oncologist, Radiation Oncologist and Surgical Oncologist

Conservative surgical management of immediate post-caesarean uterine dehiscence and pelvis abscess due to proteus mirabilis infection: a rare complication of puerperal endomyometritis

Cesarean delivery is the most commonly performed major abdominal operation in women with prevalence ranging from 12% in public sectors to 28% in private sectors in India (DLHS-3 survey). Parallel to this, the complications of surgery are increased. Among these complications, uterine dehiscence and pelvic hematoma with abscess collection is rare but serious complication which might end in hysterectomy. We hereby describe the conservative surgical management of a case of infected uterine incisional necrosis and dehiscence after primary cesarean delivery. We encountered a 25-years-old woman presenting to our emergency department (ED) with severe suprapubic pain and high-grade fever. She had an emergency cesarean delivery performed 14 days prior to presentation due to non-reassuring fetal heart rate. At the ED, ultrasonography revealed collection with septation around uterus with communication into uterine cavity. CT scan of pelvis was ordered and showed an intraperitoneal collection anterior to the uterus at the level of the uterine cesarean scar. Exploratory laparotomy showed a uterine rupture at the previous incision site. We performed resection of necrotic edges, peritoneal lavage, approximation of uterine edges with separate interrupted sutures, placement of a suction drain in the cul-de-sac. During postoperative follow up, patient was stable with no symptoms or signs of uterine/pelvic infection. Conservative management by drainage and resection of necrotic edges in addition to intravenous antibiotics may be considered as an option before resorting to hysterectomy in selected young patients.