Hysterectomy for dysfunctional uterine bleeding in the era of uterine conservation

Background: Hysterectomy is one of the modalities to manage dysfunctional uterine bleeding (DUB) where medical management fails or is contraindicated. Hysterectomy leads to guaranteed cure but does have a significant morbidity rate. In this era of popularization of various uterine conservation techniques there is a definite need to audit justification of causes which led to hysterectomy in DUB.Methods: Women with a diagnosis of DUB, based on clinical and ultrasound findings, which underwent endometrial sampling/curettage were recruited for the study. All these patients were followed up. Those who underwent hysterectomy for the sake of DUB were thoroughly studied. Information regarding the histopathology report of hysterectomy specimen was collected. Finally reason and justification of hysterectomy for these women was evaluated.Results: A total of 252 women were with DUB were included. In this group 76 women (30.2%) underwent hysterectomy. Noncompliance to medical management was the most common indication (in 37.6% women), which led to hysterectomy in our study group. Significant result was seen with final histology of simple endometrial hyperplasia in which 19 out of 41 (46.4 %) cases were missed on curettage. Similarly around 50% cases (21 out of 43) diagnosed as simple hyperplasia on curettage had normal endometrium on final histopathology. Contrary to this a 100% concordance was seen in complex hyperplasia (without atypia), with only two cases in our sample. More than three fourth (78%) cases had a coincidental pathology in the myometrium.Conclusions: Thorough counseling for the benefits and side effects of medical management prior to starting it is imperative, as the most common indication for hysterectomy for DUB was non-compliance to medical management.  If women with normal histopathology reports on curettage are not responding to medical management, further imaging and sampling is required. Women non responsive to medical management may have underlying/ co-existent myometrial pathology.

Primary fallopian tube cancer in the setting of endometriosis

We report the first case of PFTC arising in the setting of pelvic endometriosis. A 45 year old nulliparous lady, menopausal lady presented with pelvic mass. She had history of pelvic endometriosis. MRI findings were suggestive of ovarian malignancy. Histological analysis of specimen obtained following staging laparotomy proved it to be a case of bilateral PFTC. She received 6 cycles of adjuvant chemotherapy. This case opens a new door to think or investigate if fallopian tube endometrioma behaves as a more aggressive premalignant lesion. This case also poses questions whether it is important to differentiate an endometrioma arising from the ovary to one which is arising from a fallopian tube. Once identified can fallopian tube endometrioma also be managed medically or should it be always removed surgically

Modified Goff Symptom Index : Simple triage tool for ovarian malignancy

Objectives: Ovarian cancer often goes undiagnosed or misdiagnosed in the early stages. The present study aimed to validate a modified version of the Goff Symptom Index (GSI) in an Indian population. Methods: This prospective case-control study was conducted between July 2010 and June 2012 in a university hospital in Manipal, Karnataka, India. A total of 305 inpatients admitted for ovarian pathology investigations and outpatients undergoing routine gynaecological check-ups were included in the study. The modified GSI (MGSI) was used to investigate the presence, severity, frequency and duration of 10 ovarian cancer symptoms on a scale of 1–5. Four additional symptoms were included with those of the original GSI (two symptoms from a previous MGSI and two new symptoms). Patients were regarded as positive for ovarian cancer if symptoms occurred >12 times per month and time since onset was <1 year. Histopathology confirmed the diagnosis of ovarian tumours. Results: A total of 13 patients were excluded. The final sample (n = 292) was divided into a test group (n = 74) and a control group (n = 218) based on histopathology. Within the controls, 144 women were found to have benign tumours. The MGSI was positive in 71.6% of the test group as opposed to only 11.5% of the control group. The addition of two symptoms (loss of appetite and weight) to the GSI increased the test’s sensitivity from 71.6% to 77% without compromising specificity (88.5%). Conclusion: Based on these findings, the addition of two new symptoms (loss of appetite and weight) to the GSI is proposed in order to increase the test’s sensitivity. However, the addition of urinary symptoms to the GSI requires further validation

Cardiotocography in a perinatal armamentarium: boon or bane?

Background: As electronic foetal monitoring (EFM) is becoming commoner in obstetric armamentarium, so are caesarean deliveries. Present study was conducted with an aim to find out correlation between cardiotocography (CTG) findings, intraoperative findings, and perinatal outcome in subjects who underwent emergency caesarean deliveries. We also intended to estimate the sensitivity, specificity and positive predictive value of CTG in diagnosing foetal distress.Methods: A total of 271 women were included. Based on the CTG findings, the patients were divided into two groups: A) Case group: comprising subjects with Category II (suspicious) and Category III (pathological) CTG tracings; B) Control group: comprising subjects with Category I CTG tracings. Results: We found that 90.5% women with suspicious and pathological CTG (cases) undergoing emergency caesarean had one or the other abnormal per-operative findings that might cause foetal distress or CTG abnormality.  Around a third (33.7%) with abnormal CTG had normal per-operative findings and good neonatal outcome suggesting false positivity. APGAR score of less than 5 at 5 minutes was seen in 17.9% of patients with pathological CTG. The sensitivity, specificity, positive predictive value and negative predictive value of CTG for prediction of an abnormal perinatal outcome were found to be 90.5, 66.3, 44.9, and 95.8 respectively.Conclusions: CTG should only be used as a screening tool for monitoring of foetal status during labour. It is worth remembering that normal CTG is more predictive of normal outcomes than abnormal CTG regarding abnormal outcomes

Drotaverine to improve progression of labour among parturient women- a case control study

Background: Prolonged labour contributes to increased perinatal and maternal morbidity. Pharmacological interventions can hasten cervical dilation and help obstetrician to accomplish the delivery in the shortest possible time without compromising maternal and fetal safety. Aims and objectives were to evaluate the acceleration effect of drotaverine on the dilatation of the cervix in both primigravidae and multigravida and compare it with control group. Methods: A total of 70 patients were studied (35 in drotaverine group and 35 in control group). The inclusion criteria were pregnancy with at least 37 weeks completed, cervical dilatation 3-4 cm, regular uterine contractions and cephalic presentation. The study group received 40 mg drotaverine hydrochloride i.m. in active phase of labour, control group received standard delivery care. Parameters such as duration of first and second stage of labour, mode of delivery, neonatal outcome and side effects to drug was recorded. Results: 6 subjects from the study group and 4 from the control group developed complications in first stage of labour and were taken up for operative delivery and hence they were excluded from calculation of various labour parameters. The mean rate of cervical dilatation with drotaverine was 2.26 cm/hour, while it was 1.67 cm/hour without any intervention (p value <0.05). Mean duration of active phase of first stage of labor was 3.09 hours in drotaverine group against 4.98 hours in study group (p value <0.05). There were no significant untoward effects noted in either of the groups. Conclusions: Drotaverine was found to be an effective and safe drug in shortening the duration of the first stage of labor without any significant detrimental effects on the mother and newborn. Drotaverine did not interfere with uterine contractility and there was no increased incidence of operative deliveries.

Is it worth preserving the uterus? unanticipated pathology in hysterectomy for pelvic organ prolapse (POP)

Background: In recent years concept of uterine conservation has been increasing at the time of surgical management of pelvic organ prolapse (POP). This study was intended to assess the risk of premalignant and malignant uterine/endometrial, and cervical pathology at the time of hysterectomy-based POP procedures, to better understand the risks of uterine conservation in the surgical treatment of POP in Indian setup.Methods: Patients who had undergone vaginal hysterectomy for POP in last five years were identified by medical record tracking using ICD-9 codes. Case records then were reviewed to collect patient characteristics and the final histopathological diagnosis of the hysterectomy specimen. Cases with premalignant or malignant uterine/endometrial or cervical pathology recognized prior to surgery were excluded.Results: A total of 573 women who underwent vaginal hysterectomy and pelvic floor repair for the sole indication of POP were included. On analyzing the histopathological diagnosis of the specimen obtained during surgery in 57.1% of cases the findings were consistent with the changes seen in cases of POP. Only 5.9 % of cases had cervical or endometrial pathologies who would have required treatment/follow up in future if the uterus was left in situ.Conclusions: The risk of missing a malignant and premalignant cervical or uterine pathology in women presenting with uterine prolapse is low if appropriate preoperative workup has been done. Uterine preservation in surgical management of POP could be considered an option

Reduced Pelvic Floor Muscle Tone Predisposes to Persistence of Lower Urinary Tract Symptoms after Puerperium

Pregnant primiparous women at term were enrolled in the study. ICIQ-FLUTS questionnaire was used to find out prevalence of LUTS. MOS was used to assess pelvic floor muscle strength. Women were followed up after 8–10 weeks of delivery to find out remission or persistence of these symptoms. We found that increased frequency of micturition was the most common (82%) LUTS seen in primiparous women at term. More than half (51%) of these women who complained of LUTS had a poor pelvic floor muscle tone (MOS grade 3). Out of those who had symptoms during pregnancy 11% remained symptomatic even after puerperium. Interestingly 61% of those with persistence of symptoms demonstrated a very poor pelvic floor muscle tone at term (MOS grade 2), while the remaining 39% also had a tone of only MOS grade 3. Thus women with LUTS during pregnancy should be screened for their pelvic floor muscle tone with simple MOS system which will help to predict the persistence of these symptoms later on. Women with a low score (three or less) should be triaged for regular pelvic floor muscle exercises

Nanocolumnar Crystalline Vanadium Oxide-Molybdenum Oxide Antireflective Smart Thin Films with Superior Nanomechanical Properties

Vanadium oxide-molybdenum oxide (VO-MO) thin (21-475 nm) films were grown on quartz and silicon substrates by pulsed RF magnetron sputtering technique by altering the RF power from 100 to 600 W. Crystalline VO-MO thin films showed the mixed phases of vanadium oxides e.g., V2O5, V2O3 and VO2 along with MoO3. Reversible or smart transition was found to occur just above the room temperature i.e., at similar to 45-50 degrees C. The VO-MO films deposited on quartz showed a gradual decrease in transmittance with increase in film thickness. But, the VO-MO films on silicon exhibited reflectance that was significantly lower than that of the substrate. Further, the effect of low temperature (i.e., 100 degrees C) vacuum (10(-5) mbar) annealing on optical properties e.g., solar absorptance, transmittance and reflectance as well as the optical constants e.g., optical band gap, refractive index and extinction coefficient were studied. Sheet resistance, oxidation state and nanomechanical properties e.g., nanohardness and elastic modulus of the VO-MO thin films were also investigated in as-deposited condition as well as after the vacuum annealing treatment. Finally, the combination of the nanoindentation technique and the finite element modeling (FEM) was employed to investigate yield stress and von Mises stress distribution of the VO-MO thin films

Converting Potential Abdominal Hysterectomy to Vaginal One: Laparoscopic Assisted Vaginal Hysterectomy

Background. The idea of laparoscopic assisted vaginal hysterectomy (LAVH) is to convert a potential abdominal hysterectomy to a vaginal one, thus decreasing associated morbidity and hastening recovery. We compared intraoperative and postoperative outcomes between LAVH and abdominal hysterectomy, to find out if LAVH achieves better clinical results compared with abdominal hysterectomy. Material and methods. A total of 48 women were enrolled in the study. Finally 17 patients underwent LAVH (cases) and 20 underwent abdominal hysterectomy (controls). All surgeries were performed by a set of gynecologists with more or less same level of surgical experience and expertise. Results.None of the patients in LAVH required conversion to laparotomy. Mean operating time was 30 minutes longer in LAVH group as compared to abdominal hysterectomy group (167.06 + 31.97 min versus 135.25 + 31.72 min; P<0.05). However, the mean blood loss in LAVH was 100 mL lesser than that in abdominal hysterectomy and the difference was found to be statistically significant (248.24 + 117.79 mL versus 340.00 + 119.86 mL; P<0.05). Another advantage of LAVH was significantly lower pain scores on second and third postoperative days. Overall complications and postoperative hospital stay were not significantly different between the two groups