Correlation of ultrasound with histopathology for retained products of conception in medically managed abortions

Background: Medical abortion uses an anti-progestin, mifepristone (RU486), followed by a prostaglandin (misoprostol). Objective of present study was to correlate findings of transvaginal ultrasound with histopathology for retained products of conception in medical abortions.Methods: An observational, prospective study was conducted on hundred women with gestation upto 12 weeks who underwent medical abortion with excessive or prolonged post abortal vaginal bleeding. Transvaginal scan followed by uterine evacuation was done under anesthesia, followed by histopathology.Results: Analysis was done statistically using Pearson Chi- square method. Sixty five percent subjects took MTP pill by unsupervised, self-intake and 35% on prescription. Among women who took misoprostol in dose of 400mcg, 89% had RPOC on histopathology. At the dose of 800 mcg, 73.3% had retained Products of Conception (RPOC) on histopathology. The correlation was found to be statistically non-significant (p value at 5% was 1.13). Ultrasound showed echogenic mass in the uterine cavity in 62 (62%) women, increased endometrial thickness ≥10mm in 13 (13%), gestational sac with no fetal pole in 6 (6%), blood clots in uterine cavity in 6 (6%), and empty uterine cavity in 3 (3%). Seventy five percent of women had histologically proven RPOC at endometrial cut off of equal to or greater than 10mm. The sensitivity, specificity, positive and negative predictive value of transvaginal ultrasonography in detection of retained products of conception were 92%, 60%, 87.3%, 71.4% respectively. The diagnostic accuracy was 84%.Conclusions: Transvaginal ultrasound for detecting retained products of conception in medically managed abortions has a high sensitivity and positive predictive value and is useful for screening women with clinically suspected incomplete abortion who require further intervention -medical or surgical

A study of maternal near miss cases in tertiary health centre in north India

Background: Maternal near miss is defined as woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy.Methods: It was one-and-a-half-year prospective study from April 2016 to September 2017 conducted in the department of Obstetrics and Gynecology, Government Medical College, Patiala. The causes of maternal near miss based on WHO 2010 Near Miss criteria were studied.Results: In the present study out of total deliveries of 6166, there were 5461 live births and 123 maternal near miss cases which were included based on WHO 2010 maternal near miss approach. The maternal near miss incidence ratio (MNMR) in present study is 22.5. Literature reports the similar trends and MNMR varies between 15 to 40 per 1000 live births. Maternal near miss to mortality ratio is 1.89:1 in the present study.Conclusions: The most common direct cause for maternal near miss is hemorrhage. Severe preeclampsia is one of the easiest identifiable and avoidable factors for preventing maternal death. Studying near miss in detail allows us proper assessment of opportunities that were missed, analyzing the gaps and patient care related factors and helps to develop an audit system for maternal care

PILOT STUDY OF LOWER UTERINE SEGMENT CESAREAN SCAR THICKNESS PREOPERATIVELY BY TRANSVAGINAL SONOGRAPHY AND ITS CORRELATION WITH INTRA-OPERATIVE FINDINGS

Objectives: Cesarean section rates are increasing with a decrease in the rate of trial of labor after first cesarean section. Proper assessment of uterus especially scar of the previous lower segment cesarean sections (LSCS) in pregnant females is the key stone for the successful vaginal birth after cesarean section. The objective of this pilot study was to evaluate LSCS scar thickness using transvaginal sonography (TVS) and to determine the correlation between TVS and intraoperatively measured lower uterine segment cesarean scar thickness. Methods: This prospective observational analytic pilot study was carried out jointly by the Departments of Obstetrics and Gynaecology and Radiodiagnosis, Government Medical College and Rajindra Hospital, Patiala after due ethical and research committee approval. 100 women at term with history of previous LSCS and who were scheduled for elective LSCS were recruited for the study after taking the informed consent. Pre-operative scar measurement as on TVS was compared with and analyzed with intraoperative (I/o) scar measurements taken by Calipers. Results: The cutoff value for TVS readings was found to be ≤2.5 mm using receiver operating characteristic analysis. It has significant correlation with I/o scar measurements. It also has a significant relationship with age, pre-pregnancy overweight, number of the previous LSCS, and gestational age. Conclusion: Assessment of the scar integrity and quality by TVS will be helpful in selecting candidates for trial of labor with an optimally informed decision but still a number of studies have to be done to develop a robust scoring system

Evaluation of preventable causes and risk factors of maternal mortality

Background: The primary objective was to evaluate preventable causes of maternal deaths at tertiary, second and primary care in Patiala district, Punjab. Secondary objective was to determine impact of socio-demographic characteristics, anemia and three delays on maternal death.Methods: This is a retrospective observational study carried out between 1. 7. 2013 till 30. 6. 2014, for period of one year in department of a tertiary care hospital and district health authorities catering to secondary and primary care deaths for evaluation of preventable causes and risk factors for maternal deaths at tertiary, secondary and primary level.Results: A total of 54 maternal deaths with MMR of 170.42/100000 live births, occurred in stipulated period, 87.03% at tertiary care, one at second care, 7.41% at home and 3.7% on the way to tertiary care. Majority of maternal deaths (92.6%) were unbooked, between 21-30 years (64.82%) of age, primi or second gravida (35.18%), para 1 or 2 (37.03%), illiterate (40.74%), low income group (57.41%) with rural background (59.26%). Majority of maternal deaths (77.7%) occurred in postpartum period. Most of maternal deaths (75.93%) were due to direct causes, pre-eclampsia 25.93% followed by sepsis (22.2%) and haemorrhage (20.3%). Anemia was contributory factor in 79.63% maternal deaths. 7.4% maternal deaths occurred at home with delay in seeking care while 29.62% died due to delay in reaching care. In 40.42% maternal deaths, it took more than two hours to reach tertiary care hospital.Conclusions: Skilled antenatal, intranatal and postnatal care, women empowerment, counseling, early diagnosis and referral of pre-eclampsia and other high-risk cases with curbing anemia at grass root level is need of millennium. Preventing delay in seeking care or reaching care-a step towards sustainable development goals (SDG) to reduce MMR

Maternal mortality in a tertiary care hospital: a five-year review

Background: This study was aimed at analyzing the maternal mortality ratio over five years, the causes leading to maternal deaths in a tertiary care hospital and factors which are preventable.Methods: The records of maternal death from August 2010 to July 2015 (5 years) were collected and analyzed. Various factors like maternal age, parity, literacy, place of residence, antenatal registration, admission-death interval, mode of delivery and causes of deaths were reviewed.Results: The mean maternal mortality ratio (MMR) was 1039. The direct causes of maternal mortality were hemorrhage (22.4%), eclampsia (21.2%), sepsis (18.78%) and amniotic fluid embolism (8.48%). Indirect obstetric deaths were due to hepatitis (10.9%), anemia (3.6%), respiratory diseases (6.06%), heart diseases (3.03%), CNS disease (5.45%).  Most of the deaths (69.7%) occurred in age group 20 and30 years. 63.6% were multigravida and 85.4% were unbooked cases.Conclusions: Antenatal care, screening and management of high risk pregnancies are most important to prevent complications and maternal deaths by timely detection and intervention

Ultrasonographic evaluation of antenatal umbilical cord coiling index (aUCI) in second trimester of gestation and pregnancy outcome

Background: To evaluate the role of antenatal umbilical cord coiling index (aUCI) obtained during routine second trimester ultrasound as a predictor of perinatal outcome.Methods: Fetal ultrasound of 100 pregnant women was done between 18-24 weeks of gestation. Antenatal UCI was calculated as a reciprocal value of the distance between a pair of coils. Patients were followed up till delivery for perinatal outcome. UCI was correlated with: (1) gestational age (2) mode of delivery, (3) presence of meconium-stained amniotic fluid, (4) APGAR scores and (5) birth weight.Results: aUCI was categorized as hypocoiled, normocoiled or hypercoiled. Hypocoiled cord was associated with LBW (1%), preterm delivery (1%) while hypercoiled cord was associated with LBW (4%). No statistical difference was found for birth weight, gestational age, APGAR scores and MSAF between the groups with normal and abnormal aUCI.Conclusions: In present study, no association was found between abnormal aUCI with higher prevalence of interventional delivery, presence of MSAF, preterm and LBW. Therefore, more specific parameters need to be developed as promising prognostic marker for predicting adverse perinatal outcome and further studies are needed to test this hypothesis

Colposcopic and microbiological correlation in patients with vaginal infections: a prospective study

Background: Objective of the study was to evaluate the association of abnormal vaginal flora with pathological colposcopic and microbiological findings.Methods: The present study was conducted in outpatient’s department of Obstetrics and Gynaecology, Government Medical College, Patiala. We studied 300 cases with symptoms and signs of vaginal infections in reproductive age group (15-49 years). After taking detailed history and examination, samples of vaginal discharge were collected for microbiological analysis and patients were subjected to colposcopy. Recorded data was analysed to find out any association of abnormal vaginal flora with pathological colposcopic and microbiological analysis.Results: The prevalence rate of vaginal infections was 31% among patients who reported to us with symptoms and signs of vaginal infections. The most common micro-organism detected was B. vaginosis (BV) in 14%, C. albicans (C) in 12% and T. vaginalis (T) in 3.33%. The normal colposcopic findings were observed in 81.33% and abnormal colposcopic findings were noted in 18.67% of the patients which were vaginal hyperaemia in 9%, chronic cervicitis in 5.33%, small iodine negative area in 2.33%, keratosis in 1.33% and cervical polyp in 0.67% of the patients.Conclusions: We concluded that vaginal discharge is a common gynaecological complaint and vaginal infections are an important cause of the vaginal discharge thus leading to significant proportion of female morbidity in reproductive age group. So, vaginitis and vaginal discharge highlights the importance of microbiological investigations to find out the causative organisms and the specific findings due to particular micro-organism can be correlated colposcopically and specific treatment can be provided

Multiple urinary bladder calculi: a rare cause of irreducible uterovaginal prolapse

A case of irreducible prolapse with multiple bladder calculi in a 65-years-old multiparous, postmenopausal woman is reported. Inability to walk, constipation and urinary incontinence were her primary complaints. Routine ultrasound of the abdomen and pelvis failed to reveal multiple vesical calculi as the prolapse was lying outside the pelvis. However, targeted plain X-ray of the prolapsed mass showed multiple vesical calculi. The patient was managed with single-stage vaginal hysterectomy and laparotomy. First vaginal hysterectomy was done then prolapsed cystocele was reduced and extraperitoneal vesicolithotomy done. Currently, the patient is relieved of all symptoms. Management of an irreducible procidentia and a hard mass in the anterior compartment, as in this case, can be challenging and requires a diligent effort to confirm the diagnosis and to execute the appropriate surgical protocol to achieve optimal outcome with minimal intra- and post-operative complications

Para vaginal dermoid cyst: a rare occurrence

Dermoid cyst (cystic teratoma) showing well differentiated derivatives of all three germs cell layers, is a benign germ cell tumour. Ovaries remain the commonest site. Paravaginal dermoid cyst is a rare occurrence. Pre-operative diagnosis is usually difficult in majority of cases. They constitute less than 4% of all extragonadal teratomas. A 28-year old, P2L2 female presented with paravaginal cyst, 10×10cms, non-tender, soft swelling, cystic in consistency occupying posterior and left part of rectovaginal septum. Trans vaginal excision of cyst under regional anaesthesia done. Cyst was ruptured while excision showing putty material with tuft of hairs. A retrospective diagnosis of mature teratoma/paravaginal dermoid cyst was made on histopathological examination. Paravaginal dermoid cyst, a benign cystic teratoma is a very rare occurrence. Transvaginal excision of dermoid cyst under anaesthesia remains treatment of choice. Retrospective diagnosis on histopathological examination remains confirmatory as it may be missed on sonography if teeth are not present in dermoid cyst

COMPARISON OF INTERMITTENT BOLUS AND CONTINUOUS INFUSION OF 0.1% LEVOBUPIVACAINE WITH FENTANYL FOR EPIDURAL LABOR ANALGESIA

Objectives: This study was carried out to compare intermittent bolus and continuous infusion for epidural labor analgesia in terms of total dose requirement of local anesthetic and quality of analgesia as primary objective. Secondary objective was level of sensory block, motor block, hemodynamic variables, mode of delivery, duration of second stage, neonatal outcome, side effects, and postpartum complications. Methods: Eighty women of ASA physical status I or II, with single pregnancy, cephalic presentation and cervical dilatation 3–5 cm, that is, during active labor were included in the study. Patients were randomly divided into two groups. In Group A, a bolus of 8 ml of 0.1% levobupivacaine (plain) with fentanyl 2 mcg/ml was given every hour and in Group B, an infusion of 0.1% levobupivacaine (plain) with fentanyl 2 mcg/ml at 8 ml/h was given. Pain scores using visual analog scale and verbal rating score, additional bolus requirement and total dose of local anesthetic, motor blockade, fetal and neonatal outcome, mode of delivery, and duration of second stage were recorded and compared. Side effects and postpartum complications if any were documented. Results: Additional bolus requirement and total dose of local anesthetic were significantly high in Group B (45.60±6.67 mg) as compared to Group A (34.20±5.58 mg). There was no difference in the quality of analgesia, neonatal outcome, mode of delivery, duration of second stage, side effects, and complications. Conclusion: Intermittent epidural bolus is better in terms of less drug consumption and less number of additional bolus requirement