Pelvic congestion syndrome: a potentially treatable cause of intractable dysmenorrhoea

Pelvic congestion syndrome (PCS) comprises a constellation of symptoms such as noncyclical pelvic pain, pelvic varicosities, dysmenorrhea and dyspareunia in multiparous women of reproductive age. It occurs due to pelvic venous insufficiency. The condition is a challenging entity and diagnosed after excluding other pelvic pathologies. Although venography has been considered gold standard for imaging diagnosis, Doppler ultrasonography, cross sectional imaging of pelvic veins at CT and MRI have been shown to provide adequate and accurate diagnosis. Here we report a case of intractable dysmenorrhoea in a 42-year multiparous woman and its successful management with embolization of pelvic varicose veins.

Acromegaly incidentally diagnosed at term in a pregnant woman presenting with ventricular premature complexes

Pituitary adenomas lead to increased growth hormone production and acromegaly. Pregnancy in acromegaly is rare as spontaneous conception is affected. We presented a case of 31 year old lady conceived by ovulation induction and presented at term gestation with ventricular premature complexes and was subsequently diagnosed with pituitary micro adenoma causing acromegaly. There has been no reported case of pregnancy with acromegaly presenting with premature ventricular complexes. Moreover, diagnosis of acromegaly in pregnancy is difficult and limited literature is available on its effects as well as management

The trends of isolation and antimicrobial susceptibility of group B Streptococcus in urine culture: a 7-years cross sectional study

Background: Group B Streptococcus (GBS)/Streptococcus agalactiae (S. agalactiae) is a common rectovaginal colonizer, thereby a potential agent of neonatal and maternal infection. This study estimates the trends of isolation of GBS, its antimicrobial profile in urine culture and the demographic characteristics of these patients over a 7-year period. Methods: A record-based study was conducted, which included all the urine culture reports of GBS/S. agalactiae from January 2014 to December 2020. The trend of occurrence of GBS bacteriuria, demographic characteristics and antimicrobial susceptibility pattern were analyzed. Results: Out of 137 urine samples which grew GBS/S. agalactiae, 55(40.15%) were from antenatal women. Most of the isolates were from females (72.26%), with a male preponderance noted among the elderly population (age>60 years). The predominant age group affected were adults between 20 to 59 years. The majority of the isolates (60.58%) were susceptible to all the four tested antibiotics, namely, ciprofloxacin, nitrofurantoin, ampicillin and vancomycin. Ciprofloxacin resistance was observed in 32.85% (45/137) isolates, 5.84% (8/137) isolates were resistant to ampicillin and 2.92% (4/137) were resistant to nitrofurantoin. Conclusions: All the isolates were susceptible to vancomycin. GBS/S. agalactiae is an important agent of bacteriuria in antenatal women as well as in non-pregnant population, especially the elderly males. Emerging resistance to various group of antibiotics warrants routine susceptibility testing

Uterine artery embolization for uterine arterio-venous malformation

Uterine arteriovenous malformations (AVM) as a cause of abnormal uterine bleeding are listed under “not otherwise classified” in Palm-Coein classification, is an abnormal communication between an artery and vein without an intervening capillary bed resulting in increased pressure and high velocity in the venous system. We report the case of heavy menstrual bleeding in a thirty-five-year-old primiparous lady for five years with fourteen weeks sized uterus and six gm hemoglobin. Ultrasound revealed an enlarged uterus with tubular spaces and color doppler showed tubular anechoic structures, both within the myometrium, with low resistance and high-velocity pattern suggestive of uterine arteriovenous malformations. Because of nonresponse to medical management, uterine artery embolization was carried out following which she had significant reduction in menstrual bleeding emphasizing it as a differential diagnosis in all cases presenting with heavy menses. Uterine artery embolization appears to be an effective modality of treatment especially in women whose wish to preserve fertility

Co-existence of hypertensive urgency and hemolysis elevated liver enzymes and low platelets syndrome in a parturient with myasthenia gravis: a therapeutic challenge

Hemolysis elevated liver enzymes and low platelets (HELLP syndrome) is an obstetric emergency developed in the settings of hypertensive disorder of pregnancy and it is associated with a heightened risk of adverse fetomaternal outcomes. Obstetric and anaesthetic management is indeed challenging in HELLP syndrome. The presence of myasthenia gravis further complicates the managements issues in these women. Here, in this report, we describe a 35 years G2P1L1 known case of myasthenia gravis, who presented in emergency with uncontrolled hypertension, imminent eclampsia and HELLP syndrome at 29+1 weeks of gestation. Antihypertensive medication included hydralazine, alpha methyldopa, infusions of labetolol and nitroglycerine. She underwent successful vaginal delivery using fentanyl as labour analgesia. Prompt decision making using multidisciplinary team appeared vital in controlling the hypertension adequately and quickly without aggravating myasthenic crisis

Impact of COVID-19 pandemic on maternity services and challenges faced by pregnant women delivering at a tertiary care centre in South India

Background: Coronavirus disease 2019 (COVID-19), was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. India entered a nationwide lockdown on March 25, 2020, disrupting regular health services. Hence this study was conducted to estimate the impact of the COVID-19 pandemic on maternity services and to describe the challenges faced by pregnant women. Methods: A descriptive cross-sectional study conducted from July 2020 to October 2020 at tertiary care hospital, Puducherry, India. 422 pregnant women delivered during this period were included and detailed questionnaire was administered regarding antenatal, intrapartum, postnatal services and, challenges faced during the pandemic via telephonic call. Responses were documented in Epicollect version 5, transferred to Microsoft excel and analysed using Stata version 14.2. Continuous variables were expressed as mean (SD), and Categorical variables as proportions. Results: The 100% response rate was achieved with 32.5% high risk pregnancies. The 71.8% women availed direct emergency medical services while 28.2%. were referrals. The 79.9% and 25% of the women in third trimester had less antenatal visits and discontinued haematinics respectively. The 47.4% had first trimester testing, 30% didn’t receive lactation support. 81% and 69% of primiparous and multiparous women respectively had adopted postpartum Intrauterine contraceptive device as contraception. The 35-50% women faced challenges in availing essential obstetric care services.Conclusions: Development of robust linkage system between existing primary healthcare and tertiary care for managing both low and high-risk pregnancies is of paramount importance to alleviate maternal and perinatal mortality and morbidity. 

Impact of COVID-19 pandemic on postpartum contraception services in women delivering at a tertiary care centre in South India

Background: Contraception and sexual health are a fundamental human right and an integral part of women’s health services. Postpartum period is the unique opportunity for counselling and availing contraception. COVID-19 pandemic hindered routine and special services like postpartum clinics has negative impact on family planning services. Objectives were to assess the effect of the COVID-19 pandemic on postpartum contraceptive care services received and to describe the challenges faced in availing these services among pregnant women delivering at a tertiary care centre in South India.Methods: A descriptive study carried out in 422 women who had delivered at our hospital from July 2020 to October 2020. Data was collected in Epicollect version 5 and analysed using Stata version 14.2.Results: A total of 422 women were interviewed. Only one-third of the participants received contraceptive counselling in the antenatal period compared to 90% postpartum. 39% (primiparous-34%/multiparous-5%) had adopted barrier methods followed by post-partum intrauterine uterine contraceptive devices in 33% (primiparous-19.6%/multiparous-13.4%) and 5% had sterilisation concurrent with caesarean section. Around 30-40% of women faced challenges in accessing the family planning methods due to closure of elective services like postpartum clinics, operation theatres, nationwide lockdown, and non-availability of field health workers.Conclusions: Contraceptive choices for postpartum women appear to be largely restricted to temporary methods with additional challenges of availing these services during the pandemic. With the ongoing COVID-19 crisis and continuous need for contraception, there is a need to refocus and motivate eligible couples for long-acting reversible contraceptive methods (LARC) with significantly lower failure rates

Management of life-threatening uterine hemorrhage in a young patient with choriocarcinoma

A 22-year-old primigravida who underwent medical abortion at 45 days of amenorrhea was diagnosed to have choriocarcinoma by histopathological examination after dilatation and curettage (D and C) for persistent bleeding per vaginum. Her serum β human chorionic gonadotropin values were less than 1 lakh and she was treated initially with methotrexate monotherapy elsewhere. She needed 10 units of packed cell transfusion for persistent hemorrhage and she was referred to our Institute because of persistent gestational trophoblastic neoplasia and intractable hemorrhage. She needed multiple transfusions and underwent laparotomy and bilateral internal iliac artery ligation with intrauterine packing as she had a severe bout of bleeding resulting in hemorrhagic shock. Post-operatively she was managed with chemotherapy employing EMACO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine/oncovine) and EMA (etoposide, methotrexate, actinomycin D) and thus her fertility was preserved