Successful conservative surgical management of ovarian mucinous cystadenoma with silent torsion in pregnancy: a case report

To report the successful conservative surgical management of Ovarian mucinous cystadenoma with silent torsion in a 24 years old pregnant woman in a tertiary care center in Delhi. An antenatal woman came for a routine visit to the OPD of the hospital at 13 weeks gestation. She had a vague, mild pain in lower abdomen since the last four weeks. A cystic mass was discovered during an abdominal examination. Further on sonography, a multisepatated cystic mass was seen, likely to be mucinous cystadenoma. Routine tumor markers came out to be negative. A laparotomy was planned at 15 weeks. On laparotomy a 20 × 15 cm multiloculated cyst with one and half turns of torsion was found. Detorsion, cystectomy of the intact cyst followed by ovarian reconstruction was done after due consent. On histopathological examination the cyst was found to be Benign mucinous cystadenoma. The pregnancy continued without any adverse effects. The woman delivered vaginally at 38 weeks without any feto-maternal complications. She was able to conceive again spontaneously at 18 months post-delivery. After 16 weeks of gestation in the second pregnancy she went to her home town and no further follow-up was possible. This case emphasizes the importance of a thorough examination in all pregnant woman to rule out any adnexal mass separate from the gravid uterus. Big ovarian masses in pregnancy, if not diagnosed can cause growth retardation, preterm deliveries, acute abdomen due to infection, rupture or torsion. Sonography, MRI and tumor markers can facilitate diagnosis before surgery. Torsion and rupture of mucinous cystadenoma need prompt surgery. Wherever possible conservative surgery (detorsion and cystectomy) should be done especially in young women

Successful vaginal delivery of spontaneously conceived twins in each horn of a bicornuate uterus with previous caesarean: a case report

Mullerian duct fusion anomalies resulting in uterine malformations have prevalence of 3-4%. Among this, bicornuate uterus has a rare incidence of 0.4%. Uterine malformations pose significant threat in terms of obstetric outcomes. We report an extremely rare case of spontaneous conception of twin pregnancy with the fetus occupying each horn of a bicornuate uterus (bicornis unicollis), in a woman with a history of previous caesarean section. She was booked at our hospital and the pregnancy remained uneventful. At 35 weeks she went into spontaneous labour and delivered vaginally without any maternal-fetal complications. The case is unique and the management is worth discussing as till date no protocols or guidelines have been proposed for the mode of delivery of bicornuate uterus with twins with previous cesarean.  Only 12 cases of twins with bicornuate uterus have been reported till date. This is the first case in literature in which a successful VBAC has been conducted in a woman with bicornuate uterus with twins with previous caesarean

Varied clinical presentations of scar endometriosis: case reports

Endometriosis is the second most prevalent benign gynaecological condition, in reproductive age women, defined as the presence of functioning endometrial tissue outside uterine cavity. Scar endometriosis is a rare entity with an incidence of 0.3-1% among reproductive age women following obstetric and gynaecologic surgeries. Complaints of pain, tender mass, cyclical association with menstrual cycle is almost pathognomonic. Here we present two case reports of scar endometriosis recently encountered at our institute – caesarean scar endometriosis and episiotomy scar endometriosis. The quoted episiotomy scar endometriosis incidence is about 0.06 - 0.07% while that of caesarean scar endometriosis is 0.03-0.4%

Maternal and fetal outcomes in pregnant women with Takayasu aortoarteritis: Does optimally timed intervention in women with renal artery involvement improve pregnancy outcome?

AbstractObjectiveTakayasu aortoarteritis (TA) is common in the Southeast Asian and Indian subcontinent regions with a female-to-male ratio of 8:1. Age at diagnosis is < 30 years in 90% of the cases. Because the disease is common in women of child-bearing age, management of pregnancy in these patients becomes an important issue. The purpose of this study is to evaluate the maternal and fetal outcomes in pregnancies with TA and also to evaluate whether early intervention for renal artery involvement is associated with improved outcomes.Materials and methodsWe collected data of 12 patients with 18 pregnancies prospectively from 2006 to 2012. The patients were divided into three groups and their outcomes were noted: (1) without renal artery involvement; (2) with renal artery involvement without intervention; and (3) with renal artery involvement for which intervention has been done.ResultsBody mass index of patients was between 18.5 kg/m2 and 23.2 kg/m2. Renal artery involvement and hypertension were seen in four patients. One patient had percutaneous transluminal balloon angioplasty and another had renal artery stenting. In patients without renal artery involvement, gestational hypertension was seen in 50%, pre-eclampsia in 10%, abortion in 10%, and intrauterine growth restriction (IUGR) in 40% of pregnancies. In patients with renal artery involvement without intervention, gestational hypertension was seen in 90%, pre-eclampsia in 20%, abortion in 60%, preterm in 20%, IUGR in 20%, fetal demise in 20%, and neonatal death in 20% of pregnancies. In patients with renal artery involvement for which intervention has been carried out, gestational hypertension was seen in 66%, and abortion and IUGR were seen in 33% of pregnancies.ConclusionPatients with renovascular involvement without intervention are at high risk of having maternal and fetal complications. Early intervention prior to conception in these women is recommended to prevent pregnancy complications

Correlation of Doppler assessment of fetal aortic isthmus with perinatal outcome in intrauterine growth restriction

Background: The objective of the present study was to find out association between aortic isthmus Doppler changes and perinatal outcome in growth restricted fetuses with placental insufficiency.Methods: It is a prospective case control study, cases were 43 pregnant women with fetal growth restriction (FGR) with abnormal umbilical artery (UA) Doppler while 43 pregnant women with FGR but normal UA doppler, matched with period of gestation were taken as control. The direction of blood flow in aortic isthmus studied which may be antegrade, absent or retrograde and correlation between qualitative parameters of umbilical artery, aortic isthmus and ductus venosus were studied. Quantitative parameters, PI and RI were also calculated. Patients were managed as per hospital protocols. Perinatal outcome and any adverse event e.g. stillbirth, neonatal death, respiratory distress syndrome, intensive care unit stay >14 days etc. was noted.Results: The number of intrauterine death (IUD) and still birth was increased in women with absent and retrograde flow in aortic isthmus, 66.7% and 71.4% respectively (p value <0.001). Retrograde blood flow in the aortic isthmus is consistently associated with absent or reverse end diastolic velocity in umbilical artery and ductus venosus.Conclusions: Doppler of aortic isthmus is an additional parameter to assess severity of FGR. It plays an important role in termination of preterm FGR fetuses

Prediction of severe adverse maternal outcome in women admitted in obstetric ward using physiological and biochemical parameters

Background: To study physiological and biochemical parameters to predict serious adverse maternal outcomes and to develop risk score using above parameters.Methods: This prospective study was conducted in 500 high risk pregnant women attending tertiary care teaching hospital. We noted physiological and biochemical parameters as soon as they were available .The primary outcome measures was “severe adverse maternal outcome(SAMO)” in form of one or more among  mortality, near miss morbidity and ICU admissions.Results: Out-off 500 women, severe adverse maternal outcomes were seen in 158 (31.6%) women. Most common cause of near miss maternal morbidity was hypertensive disease of pregnancy (62.7%) followed by major obstetric hemorrhage (18.9%). There were 33(6.6%) ICU admission, 23 (4.6%) maternal death and 153 (30.6%) near miss maternal morbidity. The most common cause of maternal death in our study was obstetric hemorrhage. The significant variables after multivariate analysis [temp, pulse, urine protein] were used  to devise a Maternal early warning score (MEWS) based on physiological parameters at score value of  ≥1/6 was found to have  sensitivity of 70% and specificity of 82% in predicting SAMO with AUROC of 0.76. The significant laboratory parameters after multivariate analysis were blood urea, serum creatinine, serum bilirubin and liver enzymes. The obstetric risk score (Maternal risk prediction score MRPS) which incorporated of these laboratory parameters in addition to physiological parameters has sensitivity of 82% and specificity of 75% with AUROC 0.79 value ≥ 2/18.Conclusions: The addition of laboratotory parameters to physiological variables improves performance of risk score to predict SAMO

An Improved Method for High Quality Metagenomics DNA Extraction from Human and Environmental Samples

To explore the natural microbial community of any ecosystems by high-resolution molecular approaches including next generation sequencing, it is extremely important to develop a sensitive and reproducible DNA extraction method that facilitate isolation of microbial DNA of sufficient purity and quantity from culturable and uncultured microbial species living in that environment. Proper lysis of heterogeneous community microbial cells without damaging their genomes is a major challenge. In this study, we have developed an improved method for extraction of community DNA from different environmental and human origin samples. We introduced a combination of physical, chemical and mechanical lysis methods for proper lysis of microbial inhabitants. The community microbial DNA was precipitated by using salt and organic solvent. Both the quality and quantity of isolated DNA was compared with the existing methodologies and the supremacy of our method was confirmed. Maximum recovery of genomic DNA in the absence of substantial amount of impurities made the method convenient for nucleic acid extraction. The nucleic acids obtained using this method are suitable for different downstream applications. This improved method has been named as the THSTI method to depict the Institute where the method was developed

Developing Standard Treatment Workflows—way to universal healthcare in India

Primary healthcare caters to nearly 70% of the population in India and provides treatment for approximately 80–90% of common conditions. To achieve universal health coverage (UHC), the Indian healthcare system is gearing up by initiating several schemes such as National Health Protection Scheme, Ayushman Bharat, Nutrition Supplementation Schemes, and Inderdhanush Schemes. The healthcare delivery system is facing challenges such as irrational use of medicines, over- and under-diagnosis, high out-of-pocket expenditure, lack of targeted attention to preventive and promotive health services, and poor referral mechanisms. Healthcare providers are unable to keep pace with the volume of growing new scientific evidence and rising healthcare costs as the literature is not published at the same pace. In addition, there is a lack of common standard treatment guidelines, workflows, and reference manuals from the Government of India. Indian Council of Medical Research in collaboration with the National Health Authority, Govt. of India, and the WHO India country office has developed Standard Treatment Workflows (STWs) with the objective to be utilized at various levels of healthcare starting from primary to tertiary level care. A systematic approach was adopted to formulate the STWs. An advisory committee was constituted for planning and oversight of the process. Specialty experts' group for each specialty comprised of clinicians working at government and private medical colleges and hospitals. The expert groups prioritized the topics through extensive literature searches and meeting with different stakeholders. Then, the contents of each STW were finalized in the form of single-pager infographics. These STWs were further reviewed by an editorial committee before publication. Presently, 125 STWs pertaining to 23 specialties have been developed. It needs to be ensured that STWs are implemented effectively at all levels and ensure quality healthcare at an affordable cost as part of UHC

Huge abdominopelvic mass arising from cervical fibroid around an infected cervical diverticulum: A very rare case and a review of literature

Primary uterine diverticula are a very rare congenital anomaly of the uterus with only 21 reported cases. Even rarer is the occurrence of primary cervical diverticula with only six cases reported so far. This is a unique case of a huge abdominopelvic mass arising from cervical fibroid around an infected cervical diverticulum. A 44 year-old, P4L4 came to the OPD with a eighteen weeks size abdomino-pelvic mass. She had a failed surgery 6 months back, attempted to remove the mass. Magnetic resonance imaging revealed a cervical diverticulum which possibly had a pus collection. Relaparotomy was done. It revealed a huge cervical fibroid with dense adhesions all around the mass. A pan hysterectomy was done. In the postoperative period, she developed high-grade fever owing to the development of a pelvic collection, which had to be drained by dilating the vault sutures. Histopathology report confirmed a cervical fibroid with an infected diverticulum within. Primary uterine or cervical diverticula are a very rare anamoly which possibly arise because of a weakness in the area where the two mullerian ducts fuse. Women with this rare condition may suffer from infertility, fever and pain abdomen, acute abdomen owing to torsion or hemoperitoneum, pregnancy complications, and menorrhagia. Diverticulectomy and cervical/uterine reconstruction can be done on nulliparous women while hysterectomy can be offered to perimenopausal women. To conclude, unless known by the gynecologists, radiologists, and the pathologists, this diagnosis can be easily missed out, leading to multiple preventable complications