Placenta percreta: a rare presentation of obstetric emergency in second trimester

Incidence of adherent placenta is on the rise nowadays due to various reasons. Placenta percreta is seen in 5-7% of cases with adherent placenta, patients with morbidly adherent placenta are at increased risk for major obstetric hemorrhage, usually in the third trimester. Here we present an unusual case of placenta percreta presenting with obstetric emergency after trauma to abdomen in the second trimester. Emergency exploratory laparotomy was done for abruptio placentae with scar dehiscence at 20 weeks period of gestation. Consent for obstetric hysterectomy, if needed, was also taken. Intraoperatively, the placenta was found to be adherent to posterior wall of bladder. Emergency obstetric hysterectomy with bilateral internal iliac ligation with cystoscopy with detrusorrhaphy was done. Patient had an uneventful recovery. Multidisciplinary management with obstetricians, urologists and intensivist is presented hereed

A comprehensive review of 53 gynae surgeries on the versius robotic system in a tertiary care hospital

Background: Robotic-assisted surgery has attained widespread acceptance within clinical practice, emerging as the definitive standard for various medical indications. Within the realm of Gynae surgery, there has been a notable upsurge in the utilization of robotic and laparoscopic techniques. The Versius robotic system, developed by CMR Surgical, has demonstrated its efficacy on a global scale since its introduction in 2018, marking a significant stride in the landscape of robotic-assisted surgery. This review article was dedicated to providing an impartial assessment of robotic technology, elucidating our insights gleaned from 53 gynaecological surgeries conducted with the Versius robotic system. Methods: A meticulous examination of 53 cases was undertaken, wherein average operative time, estimated blood loss, postoperative hospital stay, Intraoperative and postoperative complications, and conversion rates were subjected to retrospective scrutiny. Results: The study conducted at a Tertiary care hospital involved the analysis of 53 gynecological cases using the Versius system. Results indicate the feasibility, efficiency, and patient-friendly nature of the Versius system, with notable advantages such as reduced hospital stay and smoother manipulation of tissues. Conclusions: We acknowledge the ongoing evolutionary trajectory of robotic surgery and it is evident that its merit has already been substantiated by the endorsement of numerous medical practitioners and patients worldwide. The Versius robotic system stands as a revolutionary force within the healthcare paradigm, distinguished not only by its favorability among medical professionals but also by its patient-friendly attributes. In the realm of minimally invasive gynecologic surgery, robot-assisted surgery emerges as a compelling alternative

Correlation of ultrasound, hysteroscopic and endometrial histopathology findings in patients with post-menopausal bleeding

Background: To study endometrial changes by hysteroscopy and ultrasonography in women presenting with postmenopausal bleeding and correlate it with histopathological endometrial findings.Methods: This was prospective observational study carried out in the Department of Obstetrics and Gynaecology at Lokmanya Tilak Municipal Medical College and General Hospital. The materials for the present study included patients diagnosed with postmenopausal bleeding visited to a Municipal Tertiary care centre and teaching institute in between January 2019 to June 2020. Total 51 eligible patients were evaluated.Results: In this study, on TVS examination, maximum patients 45.10% were having endometrial thickness in between 6-12mm. On hysteroscopy, 35.29% of the patients were having atrophic endometrium which was the most common finding followed by Endometrial Hyperplasia in 29.41% patients. The most common histopathological finding was atrophic endometrium in 41.18% patients followed by endometrial hyperplasia in 23.53% patients. In TVS, lowest sensitivity and lowest specificity was in case of Atrophic Endometrium and highest sensitivity and highest specificity was in case of fibroid. In Hysteroscopy, lowest sensitivity was in case of carcinoma and lowest specificity was in case of Endometrial Hyperplasia and highest sensitivity was in case of fibroid and highest specificity was in case of fibroid and carcinoma.Conclusions: Hence from this study, hysteroscopy is found to be an easy, safe, alternative and effective means to investigate postmenopausal women with a thickened endometrium found on TVS. Hysteroscopy guided biopsy in postmenopausal women with uterine bleeding decreases the risk of false negative histopathological report which is more commonly found in blind dilatation and curettage. This is also a useful method of visualizing the uterine cavity pathologies.

Feto-maternal outcome in COVID-19 positive patients with hypertensive disorders in pregnancy

Background: Since the first confirmed case in December 2019, the data pertaining to the COVID-19 pandemic has been rapidly evolving. In current study, the relation of COVID-19 and its effect on pregnant women with hypertensive disorders in pregnancy, including symptoms and foetomaternal outcome were studied.Methods: Women with hypertensive disorders in pregnancy consecutively admitted for delivery and tested via nasopharyngeal swab for SARS-CoV-2 using reverse transcriptase polymerase chain reaction (RT-PCR) from 1 April 2020 to 30 September 2020 were included in the study.Results: In our study, 56 women having hypertensive disorders in pregnancy with COVID-19 infections delivering 60 babies (4 twins), 46.43% were in the age group of <25 years, 51.78 % were <37 weeks gestation. Delivery was by caesarean section in 76.78%. Out of these, 33.92% patients required ICU admission. 40% babies delivered had birth weight of <2.5 kg out of which 13.33% had IUGR and 26.66% were preterm. There was 13.33% stillbirth and 6.66% neonatal deaths. 4 maternal death has been reported.Conclusions: With the current data available it does not appear that pregnant women are at increased risk of severe infection than the general population, but clinicians should be aware of high-risk groups. Women will need to be monitored in their booking maternity units and should be transferred to centres with appropriate neonatal intensive care facilities for delivery. In pregnant women with COVID-19 infection, if maternal illness is not severe, the considerations should be based more on obstetric indications for delivery

Survey on common practice in management of preeclampsia by obstetricians

Background: Approximately 72,000 pregnant women all over the world die every year due to direct or indirect complications related to eclampsia and severe preeclampsia. Incidence of hypertensive disorders in pregnancy in India is found to be 10.08% as per the data collected by the National Eclampsia Registry (NER). Here we present the results of a survey conducted among obstetricians in India to know the common practices in the management of pre-eclampsia followed in our country.Methods: Observational study of survey which was conducted for the period of 1 month from 22nd May 2020 to 22nd June 2020. Questionnaire was prepared on surveyheart.com and sent to obstetricians via Social media platforms to the members of FOGSI. all answers 'collected' and results were prepared from given answers. The survey was answered online by 289 obstetricians.Results: For mild to moderate pre-eclampsia Labetalol is still first line antihypertensive agent being used by many of the obstetricians. In our study also we found out Tab Labetalol 100mg BD is the most preferred type (278, 96.19%) of first line anti-hypertensive in cases of pre-eclampsia followed by Cap Nifedipine 5mg QID and Tab Amlodipine 5mg OD respectively.Conclusions: Comprehensive educational efforts and skill building modules are need of hour to keep every practicing obstetrician regarding recent advances in standard practice protocols.With close monitoring of all cases and well selected anti-hypertensive treatment, it is possible to achieve favourable outcomes for the mother and the baby

Role of age and comorbidities in mortality of patients with infective endocarditis

[Purpose]: The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality. [Methods]: Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk. [Results]: A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32–3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39–1.88),and non-performed surgery (HR:1.64;95% CI:11.16–1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality. [Conclusion]: There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group

Prosthetic Valve Candida spp. Endocarditis: New Insights into Long-term Prognosis-The ESCAPE Study

Background. Prosthetic valve endocarditis caused by Candida spp. (PVE-C) is rare and devastating, with international guidelines based on expert recommendations supporting the combination of surgery and subsequent azole treatment. Methods. We retrospectively analyzed PVE-C cases collected in Spain and France between 2001 and 2015, with a focus on management and outcome. Results. Forty-six cases were followed up for a median of 9 months. Twenty-two patients (48%) had a history of endocarditis, 30 cases (65%) were nosocomial or healthcare related, and 9 (20%) patients were intravenous drug users. "Induction" therapy consisted mainly of liposomal amphotericin B (L-amB)-based (n = 21) or echinocandin-based therapy (n = 13). Overall, 19 patients (41%) were operated on. Patients &lt;66 years old and without cardiac failure were more likely to undergo cardiac surgery (adjusted odds ratios [aORs], 6.80 [95% confdence interval [CI], 1.59-29.13] and 10.92 [1.15-104.06], respectively). Surgery was not associated with better survival rates at 6 months. Patients who received L-amB alone had a better 6-month survival rate than those who received an echinocandin alone (aOR, 13.52; 95% CI, 1.03-838.10). "Maintenance" fluconazole therapy, prescribed in 21 patients for a median duration of 13 months (range, 2-84 months), led to minor adverse effects. Conclusion. L-amB induction treatment improves survival in patients with PVE-C. Medical treatment followed by long-term maintenance fluconazole may be the best treatment option for frail patients

Prosthetic Valve Candida spp. Endocarditis: New Insights Into Long-term Prognosis—The ESCAPE Study

International audienceBackground: Prosthetic valve endocarditis caused by Candida spp. (PVE-C) is rare and devastating, with international guidelines based on expert recommendations supporting the combination of surgery and subsequent azole treatment.Methods: We retrospectively analyzed PVE-C cases collected in Spain and France between 2001 and 2015, with a focus on management and outcome.Results: Forty-six cases were followed up for a median of 9 months. Twenty-two patients (48%) had a history of endocarditis, 30 cases (65%) were nosocomial or healthcare related, and 9 (20%) patients were intravenous drug users. "Induction" therapy consisted mainly of liposomal amphotericin B (L-amB)-based (n = 21) or echinocandin-based therapy (n = 13). Overall, 19 patients (41%) were operated on. Patients <66 years old and without cardiac failure were more likely to undergo cardiac surgery (adjusted odds ratios [aORs], 6.80 [95% confidence interval [CI], 1.59-29.13] and 10.92 [1.15-104.06], respectively). Surgery was not associated with better survival rates at 6 months. Patients who received L-amB alone had a better 6-month survival rate than those who received an echinocandin alone (aOR, 13.52; 95% CI, 1.03-838.10). "Maintenance" fluconazole therapy, prescribed in 21 patients for a median duration of 13 months (range, 2-84 months), led to minor adverse effects.Conclusion: L-amB induction treatment improves survival in patients with PVE-C. Medical treatment followed by long-term maintenance fluconazole may be the best treatment option for frail patients

Antimicrobial management of Tropheryma whipplei endocarditis: the Spanish Collaboration on Endocarditis (GAMES) experience

OBJECTIVES: Tropheryma whipplei has been detected in 3.5% of the blood culture-negative cases of endocarditis in Spain. Experience in the management of T. whipplei endocarditis is limited. Here we report the long-term outcome of the treatment of previously reported patients who were diagnosed with infective endocarditis (IE) caused by T. whipplei from the Spanish Collaboration on Endocarditis-Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en Espana (GAMES) and discuss potential options for antimicrobial therapy for IE caused by T. whipplei. PATIENTS AND METHODS: Seventeen patients with T. whipplei endocarditis were recruited between 2008 and 2014 in 25 Spanish hospitals. Patients were classified according to the therapeutic regimen: ceftriaxone and trimethoprim/sulfamethoxazole, doxycycline + hydroxychloroquine and other treatment options. RESULTS: Follow-up data were obtained from 14 patients. The median follow-up was 46.5 months. All patients completed the antibiotic treatment prescribed, with a median duration of 13 months. Six patients were treated with ceftriaxone and trimethoprim/sulfamethoxazole (median duration 13 months), four with doxycycline + hydroxychloroquine (median duration 13.8 months) and four with other treatment options (median duration 22.3 months). The follow-up after the end of the treatments was between 5 and 84 months (median 24 months). CONCLUSIONS: All treatment lines were effective and well tolerated. Therapeutic failures were not detected during the treatment. None of the patients died or experienced a relapse during the follow-up. Only six patients received antibiotic treatment in accordance with guidelines. These data suggest that shorter antimicrobial treatments could be effective