Re: Non-disabled and disabled women sexual health comparison

The authors stressed the fact that the provision of sexual and reproductive health services to disabled women poses a special challenge as these women do not seek medical help when in need. We opine that the disabled subset of women deserves a compassionate and unprejudiced attitude from health care professionals towards their sexual well-being.According to WHO, sexual health is defined as - ‘a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled’.2 Free of discrimination and violence is the key here, wherein we suggest that disabled women need to be protected with special legal and social protection which is easily accessible to them

Role of surgical management in invasive mole: a report of 2 cases and review of literature

Invasive mole is a rare gestational trophoblastic neoplasia with proliferative trophoblast invading into myometrium or uterine vasculature. Primary management of invasive mole is chemotherapy, but hysterectomy can be performed in selective cases. In this report, we discuss two cases of invasive mole, which required surgical intervention in the form of a hysterectomy. Both patients had a favorable outcome and are in remission

Aggressive angiomyxoma of the vulva - a rare entity: case report and review of literature

Aggressive angiomyxoma (AA) is an extremely rare locally invasive mesenchymal tumor with a high risk of recurrence. Till date, only about 350 cases reported worldwide. Because of the rarity it should be considered as differential diagnosis whenever patient present with vulvovaginal growth. The diagnosis is clinched on histopathology. These are hormone-dependent and have estrogen and progesterone receptors. Hence sometimes GnRH agonists are used for ovarian estrogen secretion suppression but long-term use is not advocated due to side effects. A 45-year-old P4 L4 perimenopausal female presented to the GOPD with a 4×4×3 cms pedunculated painless globular mass on right labia majora. On palpation, the globular mass was firm, non-tender and with a smooth surface. Mass was excised and on gross histopathology, cut sections showed white myxoid areas. On microscopy epidermal lined tissue with stellate and spindle-shaped mesenchymal cells was found, embedded in a loose myxoid stroma with few collagen fibers. The cells were small and bland and lacked nuclear atypia. Small to medium-sized blood vessels were present with the thickened wall. Entrapped nerves and adipocytes were also present. No necrosis or mitosis was identified. All these features were suggestive of an aggressive angiomyxoma. Immunohistochemistry markers ER, PR, CD34, desmin, SMA were all positive. Imaging was done to rule out metastatic lesions and wide local excision was done around the stump with laparoscopic bilateral oophorectomy. Aggressive angiomyxoma is a rare disease. In women with asymptomatic growth in the vulvovaginal region, perineum or pelvis, aggressive angiomyxoma should be considered as a differential diagnosis. Ideal treatment is a wide local excision to prevent local recurrences, which are common and a hypoestrogenic milieu is created by either GnRH Agonists or by bilateral oophorectomy due to their hormone-sensitive nature

Pancytopenia and transient synovitis of hip joint in a SARS CoV-2 positive pregnant female: a case report

Pregnant women are at an increased risk for severe COVID-19 illness. Apart from the typical clinical manifestations, atypical presenting features of COVID-19 are also being found. We report the case of a 20 years old COVID positive antenatal patient with pancytopenia. The patient presented with scar tenderness and was taken up for emergency caesarean section at a platelet count of 5860 per microlitre. She was managed with intraoperative and postoperative transfusion of blood products. She developed chronic persistent hip pain and was diagnosed to have transient synovitis of the hip joint, which was managed conservatively. COVID-19 is a new disease with evolving clinical presentation. Pancytopenia and synovitis of hip are a rare manifestation of COVID-19 and has never been reported in a pregnant woman with COVID-19

Incidentally diagnosed placenta accreta managed conservatively in a primigravida: case report and review of literature

Placenta accrete spectrum (PAS) disorder is rarely reported in primigravida woman without recognisable risk factors. It can be encountered intraoperatively without prior suspicion. Massive obstetric haemorrhage and increased maternal morbidity and mortality is often associated with emergency caesarean hysterectomy. We presented a 26-year-old primigravida who was presented to our institute as post-dated pregnancy in labour with no other comorbidities. She was taken up for cesarean section in view of prolonged labor. After birth of the baby, the placenta failed to separate on its own and could not be delivered with gentle controlled cord traction and uterine massage. Placenta was seen bulging out at left cornuo-fundal site as boggy mass in serosa of uterus as bluish distended placental bulge suggestive of placenta accreta. Placenta was left in situ and postoperatively uterine artery embolisation was done. Post-operatively patient did not develop any complications and follow up period of 6 months was uneventful. Conservative management of PAS can be judiciously contemplated in primiparous women desirous of fertility preservation and uterus conservation. The woman needs to be emphasised upon need for close follow up and risk of haemorrhage and sepsis till complete resorption of placenta occurs

Minimally invasive management of pyoperitoneum attributed by spontaneous perforated pyosalpinx and pyometra

Pyoperitoneum, apart from bowel perforation, can occur due to gynecologic causes like ruptured pyometra or ruptured tubo-ovarian abscess. Earlier, the management of pyoperitoneum included broad-spectrum antibiotics and emergency laparotomy with or without a hysterectomy and bilateral saphingo-oophorectomy. A higher rate of surgical complications like bowel or bladder injury was noted with surgery, and future fertility was also compromised in these patients. Later on, treatment strategies improved to laparoscopic drainage of pus with antibiotics without extensive surgery. However, such cases can be managed with an even more minimally invasive approach by image-guided pigtail drainage. In this report, we describe two cases of pyoperitoneum that were managed successfully with pigtail insertion and continuous drainage of pus along with antibiotics obviating the need for anaesthesia and surgery. It seems to be a promising approach for pyoperitoneum in a hemodynamically stable patient, not showing any features of severe sepsis

Therapeutic plasma exchange in acute fatty liver of pregnancy: a case report and literature review

Acute fatty liver of pregnancy(AFLP) is characterised by acute liver failure that occurs most commonly in the third trimester of pregnancy. Emergent delivery of the foetus reverses liver failure in most cases. Rarely, termination of pregnancy may not reverse liver failure, and adjunct interventions may be required. Therapeutic plasma exchange (TPE) has been described in AFLP in very few reports. We describe a patient in whom liver failure and extrahepatic organ failure persisted four days after delivery. She underwent TPE for persistent liver failure which resulted in prompt clinical improvement. We propose that TPE be considered as a measure to salvage AFLP patients with liver failure that does not reverse after termination of pregnancy

Comparison of extra-peritoneal cesarean section with conventional trans-peritoneal cesarean section: An open label randomized controlled trial

Objective: To ascertain whether extra-peritoneal approach is superior to conventional trans-peritoneal approach of cesarean section in terms of fetus delivery time, intra-operative and postoperative outcomes, including return of bowel activity and pain. Study design: An open-label randomized controlled trial conducted over one year and six months at a tertiary care center in India. As per sample size calculation, 68 women enrolled in the study; 34 underwent extra-peritoneal, and another 34 underwent trans-peritoneal cesarean section after randomization. Statistical analysis was done with independent sample 't' test, chi-squared test, and fisher's exact test. Results: Baseline characteristics were comparable in both groups. Fetus delivery time was significantly higher in extra-peritoneal than trans-peritoneal cesarean section (14.26 ± 1.26 vs. 9.38 ± 1.83 min; p = <0.001). Total operation time was also higher in extra-peritoneal than trans-peritoneal approach (63.24 ± 12.74 vs. 57.41 ± 8.62 min; p = 0.027). Whereas average blood loss was comparable in both groups (733.82 ± 219.06 vs. 694.12 ± 351.57 ml; p = 0.063). Postoperatively, return of bowel activity was significantly earlier in extra-peritoneal than trans-peritoneal approach (4.59 ± 0.56 vs. 8.65 ± 1.23 h; p = <0.001). Mean time taken for passage of flatus was also significantly less in extra-peritoneal cesarean section (8.56 ± 0.99 vs. 12.76 ± 2.05 h; p = <0.001). Pain score at 6, 12, and 18 h was significantly lower in extra-peritoneal approach. No patient in extra-peritoneal approach had nausea, vomiting, and abdominal distension. Whereas 11.8 % of patients had nausea, 5.9 % had constipation, and 14.7 % had abdominal distension in trans-peritoneal cesarean section. Requirement of injectable antibiotics and analgesics, and hospital stay was less with extra-peritoneal approach. Conclusion: Extra-peritoneal cesarean section is associated with better postoperative outcomes with respect to return of bowel functions, pain, and requirement of injectable analgesics and antibiotics than the routine trans-peritoneal cesarean section. However, the significantly higher fetus delivery time questions its feasibility in patients with acute fetal distress. Additionally, it is technically difficult and has a longer learning curve

The effect of intrauterine misoprostol on blood loss during caesarean section

Excessive bleeding during and after caesarean section is a major cause of maternal morbidity and mortality, especially in low resource countries. This study evaluates the effect of intrauterine misoprostol with oxytocin in comparison with oxytocin alone on blood loss during caesarean section. A retrospective data analysis of 160 women who underwent lower segment caesarean section was conducted. Eighty-five out of 160 (53%) women received tablet misoprostol 800 µg by intrauterine route after delivery of a baby in addition to routine oxytocin infusion (group A), while 75 women (47%) received only oxytocin (group B). Blood loss, Haemoglobin (Hb) difference (pre-operative Hb – post-operative Hb) and need of any other oxytocic were compared in both the groups. Demographic variables such as mean age, parity, and an indication of caesarean section were comparable in both the groups. Mean blood loss during caesarean section was lower in group A (680 ± 202 mL) than group B (740 ± 228 mL) (p = .08). Higher Hb difference was noted in group B (1.03 ± 0.83 gm%) than group A (0.93 ± 0.68 gm%) (p = .41). No patient required additional oxytocic and no patient had postpartum haemorrhage in both the groups. The use of misoprostol by the intrauterine route in addition to routine oxytocin infusion during caesarean section is associated with a clinically significant reduction in intra-operative and post-operative blood loss.IMPACT STATEMENT What is already known on this subject? The role of misoprostol in the prevention and treatment of haemorrhage during and after caesarean section is well known and well studied. It is a better alternative to oxytocin in low resource settings. Various routes of misoprostol, with or without oxytocin, and its effect on intrapartum and postpartum haemorrhage are described in the literature. Misoprostol is an autocoid substance and acts better if it is close to the target organ (uterus). The use of misoprostol by the intrauterine route during caesarean section has not been well explored. What do the results of this study add? The use of misoprostol by intrauterine route in addition to routine oxytocin infusion during caesarean section is associated with decreased intra-operative and post-operative -blood loss. What are the implications of these findings for clinical practice and/or further research? The findings of this study reveal that misoprostol is also effective by the intrauterine route. It is a convenient way to insert misoprostol during caesarean section and it can be considered to prevent intrapartum and postpartum haemorrhage. More studies including randomised controlled trials with bigger sample size are needed to reach to any firm conclusion