Placenta previa: outcomes in scarred and unscarred uterus

Background: Placenta previa complicates 0.3% - 0.5% of all pregnancies and is a major cause of third-trimester hemorrhage. Almost 30 % maternal deaths in the Asian population are due to major obstetrical haemorrhage in placenta previa, especially due to rise in the incidence of cesearean sections. Significant maternal morbidity in the form of increased incidence of fetalmalpresentation, cesearean delivery, increased blood loss and peripartum hysterectomy have been noted in cases of placenta previa and can lead to prolonged hospitalization in these women. Premature deliveries can occur which lead to higher admission to neonatal intensive care unit and stillbirths.Methods: This retrospective study was conducted in the Department of Obstetrics and Gynecology at Cama and Albless Hospital (Sir J.J Group of Hospitals), Mumbai. Cases of placenta previa from January 2013 to December 2015 were studied.Results: Significantly high number of patients delivered before 37 weeks of gestation in Group A (66.7%) than that in group B (20%). (p=0.003, Hsig). There was only case of placenta accreting in Group A (6.7%) and only this patient required an obstetric hysterectomy. Both Groups showed a favourable fetal outcome (Group A 100%, Group B 96%).Conclusions: In conclusion, primary prevention in the form of reduction in the rate of primi cesearean section must be done in order to prevent likelihood of placenta previa in scarred uteri. Early diagnosis by Ultrasound and planned delivery should be the goal

A rare and successfully managed case of idiopathic thrombocytopenic purpura (ITP) with previous caesarean with splenectomy with hepatitis C positive

ITP occurs in approximately 2 of 1000 pregnant women. ITP may develop at any time during pregnancy, but is often initially recognized in the first trimester and is the most common cause of isolated thrombocytopenia in this time period. A 33 year old, married since 6 years, G2p1l1 with 33 weeks gestation referred to our tertiary centre. She was a known case of ITP with splenectomy done. She had a 5 year old male child, delivered by LSCS. She was diagnosed as having ITP at the age of 12 years. HCV antibody was weakly positive. ANA was positive. Emergency LSCS was done in view of scar tenderness. Post op she developed epistaxis, bleeding gums and per vaginum. Patient received multiple FFP, platelet transfusions and responded to treatment with methylprednisolone. The diagnosis and management of ITP in pregnancy is similar to that in the non-pregnant adult patient, but the risks to the developing fetus must be taken into account when choosing treatment and the maintenance of a safe platelet count, rather than prolonged remission, is the goal. Mode of delivery must be guided by obstetrical indications

Huge mucinous cystadenoma of ovary with massive third degree uterovaginal prolapse in postmenopausal woman: rare case report and review of literature

Mucinous cystadenomas make up 15-20% of all ovarian tumors. They often become very large and can extend up into the abdomen. These tumors are usually evaluated using ultrasound, CT scan, or MRI. Findings on imaging studies are nonspecific. These ovarian tumors are usually multi-septated, cystic masses with thin walls. They also contain varying amounts of solid tissue which consists of proliferating stromal tissue, papillae, or malignant tumor cells. Benign mucinous cystadenomas compose 80% of mucinous ovarian tumors and 20-25% of benign ovarian tumors overall. The peak incidence occurs between 30-50 years of age. Benign tumors are bilateral in 5-10% of cases. Here we would like to present a case of huge benign mucinous cystadenoma with procedentia in a 70 year old female where the patient could not access medical care, and presented with huge tumour which lead to pressure symptoms and responded remarkably to surgical excision. The patient could go back to her normal life following the procedure

Role of diagnostic laparoscopy in the management of female infertility

Background: With recent improvements in the assisted reproductive technology (ART), there has been a growing tendency that bypasses diagnostic laparoscopy and proceeds directly to ART. Therefore, the value of diagnostic laparoscopy in current fertility practice is under debate. The objective of this study was to study role of diagnostic laparoscopy in the management of unexplained infertility.Methods: 50 case of primary or secondary infertility with unknown etiology that underwent diagnostic laparoscopy in a tertiary care institute. Diagnostic laparoscopy was offered as a final option for patients with normal diagnostic workup for infertility like semen analysis, ovulation testing, ultrasound examination, hysterosalpingogram, and testing for ovarian reserve. Outcomes in terms of cause detected and immediate laparoscopic management done which is helpful in improving fertility.Results: Out of 50 cases studied, in 27 cases we found most probable cause of infertility and in remaining 23 cases we did not found any cause of infertility. Of the 27 cases, 11 cases had endometriosis, 5 cases had multiple pelvic adhesions, 5 cases of bulky cystic ovaries, 3 cases had combined endometriosis with pelvic adhesions and 2 cases had bilateral tubal blockade contrary to hysterosalpingographic findings, 1 case showed combination of cystic ovaries with pelvic adhesions. Intraoperative adhesiolysis, endometriosis ablation, and ovarian drilling were done in respective cases.Conclusions: We concluded that Laparoscopy has important role in the diagnosis and treatment of unexplained infertility. It also helps in Prediction and improvement of success rate of assisted reproductive technologies like IUI and IVF

Socio-epidemiological factors of medical termination of pregnancy: an overview in a tertiary care institute

Background: The Medical Termination of Pregnancy (MTP) was legalized in India by an Act in 1971. The present study is a data analysis over 5 years to gauge the changing trends in the urban government establishment with respect to various socio economical parameters. The objective of the study was to find out the incidence rate of the MTP in the urban government run hospital. The auxiliary objective was to find out the reason for which the MTP is carried out; the age group availing the facility of the services and the secondary contraception the couple uses after the MTP.Methods: A Five (5) year data of MTP was analyzed by keeping the MTP register of the hospital as a reference. The data is presented in the formal protocol of data presentation.Results: The incidence rate of MTP is 27.93/1000 live births in the institute. The primary reason of MTP is failure of contraception. This fact highlights unmet need of contraception and counselling. The maternal age group of 21-30 yrs is availing MTP services the most. The surgical method is more prevalent than the medical method in practicing the MTP. The permanent method of contraception in the form of Tubal ligation is increasing as a choice of contraception after MTP.Conclusions: The awareness of MTP Act and impact of legalizing the abortion is increasing the society and the increasing number of service rendered through the government establishment underlines the increasing faith in the system. The incidence rate of MTP is 27.93/1000 live births in the institute. The primary reason of MTP is failure of contraception. This fact highlights the huge unmet need of contraception and counselling. The maternal age group of 21-30 yrs is availing MTP services the most. Though there is changing trends for medical method of termination of pregnancy but the surgical method is still favoured. The permanent method of contraception in the form of Tubal ligation is increasing as a choice of contraception after MTP. Still the religious differences are evident in availing the MTP services and needs to be addressed tactfully

Minimally invasive hysterectomy for benign disease: our experience study

Background: The incidence of hysterectomy in India ranges from 7-8 % and 60% of major gynaecological surgeries are hysterectomies at government teaching institutions. The objective of this study was to assess feasibility and safety of laparoscopic hysterectomy.Methods: It was a retrospective case series. Study duration was two years. Setting was at Cama and Albless hospital which is a government hospital affiliated to grant medical college, Mumbai. Cases with benign indication for hysterectomy were which were unsuitable for vaginal approach were assessed and those deemed suitable for laparoscopic approach were selected. Total laparoscopic approach was used to perform hysterectomy. Patient demographics and outcome measures were analyzed. Outcome measures included duration of surgery, length of postoperative stay, estimated blood loss, complication rate and laparotomy conversion rates.Results: It was a two year study period. Total number of women who underwent hysterectomies during this period for benign indications were 303, out of which 146 were done by vaginal route, 126 by abdominal route and the remaining 35 (22%) were done by laparoscopic route. Main indication was dysfunctional uterine bleeding not responding to medical management. Median age of patients was 43 years, majorities were parous and none of them were obese. Uterine size ranged from normal size to 16 weeks. Duration of surgery was between 1.5-2.5 hours with an estimated blood loss of less than 100 ml in 2/3rd of them. Median duration of postoperative stay was 7 days. The major complication and laparotomy conversion and readmission rates were nil.Conclusions: Laparoscopic hysterectomy was well accepted and was found to feasible and safe in our setting

Use of diagnostic hysteroscopy in abnormal uterine bleeding in perimenopausal age group and its clinicopathological co-relation with ultrasound and histopathology findings: experience in a tertiary care institute

Background: Abnormal Uterine Bleeding (AUB) refers to bleeding that is excessive or occurs outside of normal cyclic menstruation. It accounts for two-thirds of all hysterectomies worldwide. Evaluation of the endometrium as a cause of AUB is done mainly in three modes i.e. by Imaging of endometrium by transvaginal/transabdominal ultrasound, visual assessment by hysteroscopy and cellular assessment by microscopic evaluation of endometrial samples.Methods: Ours is a retrospective observational study of all diagnostic hysteroscopies performed for AUB in 40-45 year age group at Cama and Albless hospital, Mumbai between April 2012 and January 2015. We studied 66 cases of conventional diagnostic hysteroscopy at our institute to establish correlation of hysteroscopy findings with other diagnostic tools i.e. ultrasound and histopathological findings.Results: On ultrasound 65.2% of the endometrial pathologies leading to AUB were due to endometrial hyperplasia with polyp accounting for 4.5%. 43.9% of the total patients were having fibroid as associated pathology on ultrasound. On hysteroscopy more number of cases of polyp were diagnosed (21.2%) as compared to ultrasound (4.5%). On histopathological appearance we found simple hyperplasia in 4.5% of cases and simple hyperplasia with atypia in 1.5% all of cases i.e. 6% total cases of hyperplasia. These are potentially carcinogenic patients. 47% of cases had endometrium in proliferative phase which is the commonest pathological finding on histopathological examination.Conclusions: The relatively poor sensitivity of both endometrial biopsy and ultrasound in the detection of intrauterine focal pathology encourage us to propose that Hysteroscopy be utilized as a first line investigation in AUB

Thrombocytopenia during pregnancy: an institutional based study

Background: Thrombocytopenia affects 6% to 10% of all pregnant women and other than anemia is the most common hematologic disorder in pregnancy. All pregnant women with platelet counts less than 100000/mm3 require careful hematological and obstetric consultation to exclude more serious disorders. Objectives of the study were to study the number and percentage of cases, the various etiological factors associated, the effect and outcome of the mother and neonates borne.Methods: The study was conducted in this tertiary institute over a period of two years and three months. 103 pregnant patients with a platelet count of or less than 100000/mL were included. The course of pregnancy was studied and the investigation profile was monitored.Results: Out of 103 cases of thrombocytopenia, 73 (70.9%) patients had moderate, 30 (29.1%) patients had severe thrombocytopenia. In this study 35% cases were primigravidas, 32% cases were gravida 2, 33% cases were gravida 3 to 5. Gestational thrombocytopenia was the most common etiological factor with 30.1% cases, 27.2% cases due to hypertensive disorders, 18.4% cases due to malaria followed by 12.6% cases due to dengue. In the study group the mean gestational age was 33 ± 5.139, maximum cases belonged to gestational age 30 to ≥40. 14 patients (14.1%) had still births. 9 patients (8.7%) had Neonatal deaths (NNDs).  Conclusions: The challenge to the clinician is to weigh the risks of maternal and fetal bleeding complications against the benefits of diagnostic tests and interventions.

Uterus didelphys with pregnancy and its different maternal and perinatal outcomes

Mullerian duct anomalies (MDAs) are congenital defects of the female genital system that arise from abnormal embryological development of the Mullerian ducts. A didelphys uterus, also known as a “double uterus,” is one of the least common amongst MDAs. These abnormalities can include failure of development, fusion, canalization, or reabsorption, which normally occurs between 6 and 22 weeks in utero. Most sources estimate an incidence of these abnormalities to be from 0.5 to 5.0% in the general population. It is an observational study of cases of uterine didelphys with pregnancy over a period of 2 years. Uterus didelphys with pregnancy has variable maternal and perinatal outcome. First case presents an uneventful course in pregnancy which was terminated with caesarian section with a healthy baby. Second case presented to us with retained placenta with perforation of left horn which was managed by obstetric hysterectomy. The third case presents a didelphys uterus with a congenitally abnormal fetus with Hydrops fetalis with IUFD at 7th month of gestation terminated by caesarian section due to associated vertical vaginal septum. Pregnancy in a uterus Didelphys deserves early diagnosis of the anomaly, and meticulous care in pregnancy and delivery to avert the associated adverse outcomes

Rising incidence of unwed mothers in India; associated social parameters & institutional guidelines for managing them

Background: Globally the incidence of unwed mothers is rising. While the incidence is higher in western countries, developing countries like India are soon catching up.Methods: Ours is a retrospective study from January 2009 to December 2013 analyzing 51 cases of unwed mothers for - changing incidence of unwed mothers in India, to look for predisposing social & family pressures which may have led to the pregnancy, to study neonatal outcomes in such mothers & to analyze the role of social worker intervention in the management of such pregnancies.Results: Our study showed a 50% rise in the incidence of unwed mothers in our institute over the years with a majority (49%) of them being teenaged girls. 68% unwed mothers were uneducated or had only primary education & 58.9% unwed mothers had some predisposing factor which might have contributed to the pregnancy. 52% unwed mothers (who delivered) opted for institutional admission till term and 35.4% of these underwent a caesarean section at term (higher than institute LSCS rates). 21.5% unwed mother united with father with social worker intervention.Conclusions: Social and demographic parameters play a significant role in the incidence of unwed mothers. Several of these parameters are subject to external regulation & can reduce incidence of unwed mothers. Also the role of a social worker is priceless in management of these patients