Critical evaluation of various methods of estimating foetal weight by ultrasound

Summary: This prospective study was conducted in a peripheral hospital of Kasturba Medical College; Manipal to know which sonographic method of estimation of foetal weight reliably predicts the birth weight. 100 patients were scanned thoroughly within 48 hours of delivery. Seven different models of ultrasonic weight estimation were analysed critically. It was found that the method of Hadlock2, predicted the birth weight more accurately than others. The average deviation from the actual birth weight (226gms), the percentile values of absolute error of difference were least with this method and it predicted maximum number of cases within 10% of actual birth weight (85%). Significant differences were observed between the predicted and actual birth weight in all other methods (p<0.01). It was concluded that this method is superior predictor of birth weight compared to other six and is a method of choice to estimate the birth weight in term pregnancies where the measurements of foetal head is inaccurate either because of engagement or moulding, as it incorporates only FL and AC measurements which is not affected by these changes

ROLE OF FETAL THIGH CIRCUMFERENCE IN ESTIMATION OF BIRTH WEIGHT BY ULTRASOUND

OBJECTIVE: To evaluate the accuracy and usefulness of predicting birth weight by measuring fetal thigh circumference by ultrasound. METHODS: In 110 pregnant women, fetuses without structural or chromosomal anomalies were studied prospectively and cross-sectionally. Thigh circumference (TC) was determined at the mid level of the thigh. Biparietal diameter (BPD), Head circumference (HC), Abdominal circumference (AC), and Femur length (FL) were measured using standard techniques. Fetal weights were estimated within a week prior to delivery. Statistical analysis of various ultrasound birth weight formulae in different weight categories was done and compared with each other and also with clinical methods. RESULTS: Estimated fetal birth weight using TC correlated well with actual birth weights in all categories and was superior to clinical and birth weight formulae using BPD, HC, AC and FL measurements. CONCLUSIONS: There was a good correlation between ultrasound measurement and actual postnatal measurements of thigh circumference (r2=0.89, p<0.01). Thigh circumference measurement was simple and there was better accuracy when it was combined along with BPD, HC, AC and FL measurements

An unusual case of Foetal Gastroschisis with Limb aplasia and Extra-corporal liver

Gastroschisis represents a herniation of abdominal contents through a paramedian full-thickness abdominal fusion defect without involving the umbilical cord. Evisceration usually only contains intestinal loops and has no surrounding membrane unlike in ophalocoele. It is unusual for a newborn born with gastroschisis to have other serious birth defects and neonates have better prognosis than those with an omphalocele. Very rarely gastroschisis is associated with herniation of major viscus and their presence makes the prognosis worst. This case is reported because of its rare association with extra-corporal liver and limb aplasia

Role of laparoscopy in evaluation of chronic pelvic pain

Introduction: Chronic pelvic pain (CPP) is a common medical problem affecting women. Too often the physical signs are not specific. This study aims at determining the accuracy of diagnostic laparoscopy over clinical pelvic examination. Settings and Design: A retrospective study of patients who underwent diagnostic laparoscopy for CPP. Materials and Methods: The medical records of 86 women who underwent laparoscopic evaluation for CPP of at least 6-month duration were reviewed for presentation of symptoms, pelvic examination findings at the admission, operative findings and follow up when available. Statistical analysis used: McNemar Chi-square test for frequencies in a 2 x 2 table. Results: The most common presentation was acyclic lower abdominal pain (79.1%), followed by congestive dysmenorrhoea (26.7%). 61.6% of women did not reveal any significant signs on pelvic examination. Pelvic tenderness was elicited in 27.9%. Diagnostic laparoscopy revealed significant pelvic pathology in 58% of those who essentially had normal pervaginal findings. The most common pelvic pathology by laparoscopy was pelvic adhesions (20.9%), followed by pelvic congestion (18.6%). Laparoscopic adhesiolyis achieved pain relief only in one-third of the women. Conclusion: The study revealed very low incidence of endometriosis (4.7%). Overall clinical examination could detect abnormality in only 38% of women, where as laparoscopy could detect significant pathology in 66% of women with CPP. This shows superiority of diagnostic laparoscopy over clinical examination in detection of aetiology in women with CPP (P < 0.001). Adhesiolysis helps only small proportion of women in achieving pain control

Patient satisfaction and experience with various modes of Xylocaine administration for cervical dilatation and endometrial curettage: a randomized interventional study

Background: Patient satisfaction after a surgical procedure is an important outcome of hospital care. Many of the gynaecological menstrual problems such as abnormal uterine bleeding, postmenopausal bleeding requires endometrial evaluation which is done traditionally by dilatation and curettage. But this procedure is painful and requires appropriate pain management protocol. The aim is to evaluate the post-operative patient satisfaction following dilatation and curettage procedure.Methods: This study was conducted in a tertiary care hospital belonging to a medical college. A total of 236 patients were recruited for the study who subsequently underwent dilatation and curettage with different mode of Xylocaine anesthesia for pain relief. Of them 16 patients were excluded due to valid reasons and the remaining 220 were interviewed face to face following the procedure. The level of anxiety was assessed using Beck’s Anxiety inventory and also perception of satisfaction was documented along with complication related to the anesthesia.Results: The overall level of satisfaction was higher in the group receiving both paracervical block and intrauterine instillation of lidocaine during the procedure of dilatation and curettage. A further analysis showed that increase in level of satisfaction was due to improvement in pain scores due to combined mode of paracervical and endometrial anesthesia.Conclusions: A multimodal pain management protocol which involves pre-procedural sedation, combined cervical and endometrial anesthesia improves overall outcome with respect to reduction in anxiety scores and postoperative satisfaction levels

Validation of a new ovarian malignancy suspicion index for preoperative evaluation of adnexal masses

Background: The currently available ovarian malignancy probability scores incorporate biochemical markers such as CA 125 (Carbohydrate Antigen 125), which is not routinely available in peripheral centers. There is a need for tumour marker independent prediction model to differentiate malignant ovarian masses from their benign counterparts in order to plan appropriate surgery. To formulate and prospectively validate a new Ovarian Malignancy Suspicion Index (OMSI) independent of serum CA 125 level, in preoperative evaluation of adnexal masses admitted for surgery.Methods: This was a combined retrospective and prospective cohort study conducted in a tertiary referral hospital over a period of one and half years. Retrospective sample included 100 subjects who had undergone surgery for adnexal masses and who had definite histopathological report. Detailed data were obtained with respect to age, menopausal status, sonographic findings including solid areas, ascites, mean diameter, bilateralism, and presence of septa. A logistic multivariate regression analysis was carried out to find the best prediction score (OMSI - Ovarian Malignancy Suspicion Index). This model was further evaluated prospectively in 60 subjects for its diagnostic ability to identify benign and malignant ovarian pathology.Results: OMSI at the cut off value of 3.9 differentiated effectively malignant ovarian mass from benign variety with a good diagnostic performance (Sensitivity 100%, Specificity 90.5%, Positive Predictive Value 81.8% and Negative Predictive Value 100%) as good as currently recommended RMI (Risk Malignancy Index) score. It was also found that OMSI > 3.9 was associated with positive ultrasound evidence for ovarian malignancy such as presence of thick septae (90%), solid areas within the tumour (93.8%), papillary projections (100%), bilaterality (90%) and ascites (100%).Conclusions: This study shows that it is possible to derive ovarian malignancy prediction model such as OMSI without including CA 125 with diagnostic ability in par with risk scoring systems such as WHO recommended RMI. Using this model, physicians working in peripheral centers without facilities for estimating serum tumour markers can arrive at the possible diagnosis and plan appropriate management strategies

Imaging in ovarian cancer

Ovarian cancer is the fifth most common cause of death from cancer in women after lung, breast, colon, and pancreatic cancer. The incidence of ovarian cancer rises continuously between the ages 30 and 70 years and peaks at 59 years of age. Ovarian cancer is more lethal than endometrial and cervical cancer combined due to delayed diagnosis.Owing to the lack of symptoms and early peritoneal dissemination, the tumour has spread outside the pelvis in approximately 70% of cases at the time of diagnosis. The stage at diagnosis is the most important prognostic factor. The 5-year survival rates drop from 93% in patients with localized disease to 28% in those with distant metastases. Bimanual pelvic exam and CA 125 levels have failed to allow consistent detection of ovarian malignancy.CA 125 is a high molecular weight glycoprotein recognised by the OC 125 monoclonal antibody (sensitivity & specificity is better with combination of TVS). Since the sensitivities of these techniques are below 50%, particularly ultrasonography, CT and MRI has become indispensable in detection and staging of ovarian malignancy

Kidney length, a visceral parameter predicts foetal age between 24 to 40 weeks of gestation

Background: Accurate estimation of gestational age is important in providing appropriate antenatal care. Recent evidence suggests that weightage should also be given to kidney length in addition to standard biometric parameters in determining the duration of pregnancy by ultrasound.Methods: In a single centre, prospective cross-sectional study was done in 120 pregnant women. In addition to standard biometric parameters, kidney length was also measured between 24 to 40 weeks at two-week intervals. A total of 240 renal vertical measurements were done and average of right and left renal lengths was taken as a final kidney length. Descriptive analysis was carried out to find the mean and standard deviations for each variable. Regression analysis was carried for each variable either singly or in combinations and Pearson regression coefficients was used to find the association between gestational age and various foetal parameters and to determine which of the regression model gives the best fit for prediction of gestational age.Results: Foetal kidney length progressively increased throughout the gestation (from 23.2 mm at 24 weeks to 40.1 mm at 40 weeks). The regression formula using only kidney length as an independent variable (gestational age=2.195±0.942 X kidney length) had high degree of correlation (R2 0.97, p<0.001, SE of prediction 4.7±3.9), which was superior to other prediction models using standard biometric parameters. In multiple regression models using several conventional parameters, when femur length was added in a stepwise manner, there was significant improvement in forecasting gestational age.Conclusions: Present study showed that foetal kidney length is a reliable indicator of gestational age between 24 to 40 weeks of pregnancy and may be of utility in pregnancies with wrong dates, non-availability of dating scan and women who have conceived during lactational period

Understanding King’s Health Questionnaire (KHQ) in assessment of female urinary incontinence

Urinary incontinence has emerged as one of the leading medical problems for the geriatric population worldwide. Women are affected physically, mentally and socially and face embarrassment, depression and isolation. Increased life expectancy further adds to the prevalence of the condition and social, economic and health care burden. Although not sinister by itself, urinary incontinence has a profound impact on a woman’s quality of life and warrants appropriate management. The efficacy of interventional procedures is measured by the caregiver mainly by improvement in urodynamic parameters. However, these gadgets do not assess the individual's satisfaction and feeling of wellbeing following the therapeutic intervention. Several generic QoL tools have been developed in an attempt to quantify these changes. But ironically, generic QoL questionnaires lack precision when applied to subjects with specific disease condition. In the context of female urinary problems, various QoL tools have been designed and investigated. King’s Health Questionnaire (KHQ), which was formulated as early as 1997 by the group of researchers from King’s College Hospital London still enjoys popularity till today, because of its strong psychometric properties, ease of administration and it adds objectivity to patient’s subjective symptoms. However, the available information about KHQ is somewhat inadequate for the novice research scholar. The following brief essay aims at easy understanding of implementation, documentation, analysis and interpretation of King’s Health Questionnaire in research settings.