A Prospective Observational Study to Determine the Aetiology of Postmenopausal Bleeding and Correlation of Endometrial Thickness in Endometrial Carcinoma in Our Population

OBJECTIVE : 1. To determine the most common cause of postmenopausal bleeding (PMB) in our menopausal women. 2. To determine the correlation of endometrial thickness in endometrial carcinoma and to set a cut-off thickness. METHODS : This prospective observational study was conducted in Christian Medical College Hospital, Vellore between February 2016 to July 2016 in the department of Obstetrics and Gynaecology. We included all postmenopausal women who presented any time after one year of menopause with vaginal bleeding. Detailed history, clinical examination, per speculum and per vaginal examination was done systematically to evaluate the clinical diagnosis of postmenopausal bleeding. Details of the patient including her age, age of menarche, age of menopause, parity, body mass index, amount of bleeding, number of episodes of postmenopausal bleeding, associated co morbidities and any drug intake like hormone therapy, and anticoagulants are noted, following which, the diagnostic evaluation for postmenopausal bleeding is done by using transvaginal ultra sonogram and the endometrial thickness was determined. Endometrial biopsy is done after ultrasound and the histopathological report was correlated. RESULTS : Total 144 patients were included in our study. Mean age of PMB was 56.6 years. Mean age of developing malignancy was 58.8 years when compared to 55.71 years in benign conditionswhich is statistically significant. Risk factors for endometrial malignancy like nulliparity, increasing BMI, medical co-morbidities like diabetes and hypertension had statistically significant correlation in our study. Other risk factors like, early menarche, late menopause, drug intake, family h/o malignancies did not show any association in our study. Based on the histopathological findings, atrophic endometrium constituted for 19.4%, endometrial polyps 16.66%, endometrial cancer 15.27%, cancer cervix 14.48%, endometrial hyperplasia 9.72%, ovarian cancers 4.16%, proliferative endometrium 2.08%, secretory endometrium 2.77% and others with no specific histopathological diagnosis 15.27%. Of the total pipelle sampling done, 7.3% had tissue inadequate for evaluation. In our study, 43.75% of women with postmenopausal bleeding had malignancies and 56.25% had benign conditions. The prevalence of endometrial cancer in our study population was 14.6% with 95% CI (9.3%-21.5%). By transvaginal ultrasound, endometrial thickness of 4mm was set as a cut-off thickness to discriminate women who are at risk for endometrial malignancies with a sensitivity of 96.97%, specificity of 15.5% and a negative predictive value of 92.3%.We also found that, the risk of developing endometrial cancer is increased five times when the endometrial thickness is >=4mm (Odds ratio 5.91). CONCLUSION: All women with postmenopausal bleeding should be evaluated even if it is the first episode. Transvaginal ultrasound and pipelle sampling still holds good for evaluation of PMB. In developing countries like India, cervical cancer evaluation should also be a part in evaluating PMB. Endometrial thickness of >=4mm correlates well with malignancy in Indian women too. Hence, women with endometrial thickness of <4mm need not have any other with invasive tests like endometrial biopsy, unless there is recurrent bleeding or ultrasound features suggestive of any abnormalities like adnexal mass

Focused Cardiac Ultrasound to Guide the Diagnosis of Heart Failure in Pregnant Women in India.

BACKGROUND: Cardiac complications are a leading cause of maternal death. Cardiac imaging with echocardiography is important for prompt diagnosis, but it is not available in many low-resource settings. The aim of this study was to determine whether focused cardiac ultrasound performed by trained obstetricians and interpreted remotely by experts can identify cardiac abnormalities in pregnant women in low-resource settings. METHODS: A cross-sectional study was conducted among 301 pregnant and postpartum women recruited from 10 hospitals across three states in India. Twenty-two obstetricians were trained in image acquisition using a portable cardiac ultrasound device following a simplified protocol adapted from focus-assessed transthoracic echocardiography protocol. It included parasternal long-axis, parasternal short-axis, and apical four-chamber views on two-dimensional and color Doppler. Independent image interpretation was performed remotely by two experts, in the United Kingdom and India, using a standard semiquantitative assessment protocol. Interrater agreement between the experts was examined using Cohen's κ. Diagnostic accuracy of the method was examined in a subsample for whom both focused and conventional scans were available. RESULTS: Cardiac abnormalities identified using the focused method included valvular abnormalities (27%), rheumatic heart disease (6.6%), derangements in left ventricular size (4.7%) and function (22%), atrial dilatation (19.5%), and pericardial effusion (30%). There was substantial agreement on the cardiac parameters between the two experts, ranging from 93.6% (κ = 0.84) for left ventricular ejection fraction to 100% (κ = 1) for valvular disease. Image quality was graded as good in 79% of parasternal long-axis, 77% of parasternal short-axis and 64% of apical four-chamber views. The chance-corrected κ coefficients indicated fair to moderate agreement (κ = 0.28-0.51) for the image quality parameters. There was good agreement on diagnosis between the focused method and standard echocardiography (78% agreement), compared in 36 participants. CONCLUSIONS: The focused method accurately identified cardiac abnormalities in pregnant women and could be used for screening cardiac problems in obstetric settings

Relationship between anaemia, coagulation parameters during pregnancy and postpartum haemorrhage at childbirth: a prospective cohort study

OBJECTIVES: To investigate the association between coagulation parameters and severity of anaemia (moderate anaemia: haemoglobin (Hb) 7-9.9 g/dL and severe anaemia: Hb <7 g/dL) during pregnancy and relate these to postpartum haemorrhage (PPH) at childbirth. DESIGN: A prospective cohort study of pregnant women recruited in the third trimester and followed-up after childbirth. SETTING: Ten hospitals across four states in India. PARTICIPANTS: 1342 pregnant women. INTERVENTION: Not applicable. METHODS: Hb and coagulation parameters: fibrinogen, D-dimer, D-dimer/fibrinogen ratio, platelets and international normalised ratio (INR) were measured at baseline. Participants were followed-up to measure blood loss within 2 hours after childbirth and PPH was defined based on blood loss and clinical assessment. Associations between coagulation parameters, Hb, anaemia and PPH were examined using multivariable logistic regression models. OUTCOMES MEASURES: Adjusted OR with 95% CI. RESULTS: In women with severe anaemia during the third trimester, the D-dimer was 27% higher, mean fibrinogen 117 mg/dL lower, D-dimer/fibrinogen ratio 69% higher and INR 12% higher compared with women with no/mild anaemia. Mean platelets in severe anaemia was 37.8×109/L lower compared with women with moderate anaemia. Similar relationships with smaller effect sizes were identified for women with moderate anaemia compared with women with no/mild anaemia. Low Hb and high INR at third trimester of pregnancy independently increased the odds of PPH at childbirth, but the other coagulation parameters were not found to be significantly associated with PPH. CONCLUSION: Altered blood coagulation profile in pregnant women with severe anaemia could be a risk factor for PPH and requires further evaluation