Asian Journal of
Online Submission
Volume 2, April-June 2013
CONTENTS
An IJCP Group Publication Corporate Panel Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor
FROM THE ISSUE EDITOR
5
Alka Kriplani
Dr Deepak Chopra Chief Editorial Advisor Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal Group Editor-in-Chief Dr Veena Aggarwal MD, Group Executive Editor
FROM THE DESK OF GROUP EDITOR-IN-CHIEF
Woman Given Wrong Blood in Hospital, Dies
6
KK Aggarwal
AJOG Specialty Panel
Dr Alka Kriplani Editor Consultant Editor Dr Urmil Sharma Assistant Editors Dr Nutan Agarwal (Delhi) Dr Neera Aggarwal (Delhi) Dr A Biswas (Singapore) Dr CS Dawn (Kolkata) Dr Gauri (Delhi) Dr Suneeta Mittal (Delhi) Dr S Mehra (Delhi) Dr Prashant Mangeshikar (Mumbai) Dr Prakash Trivedi (Mumbai) Dr Gita Ganguly Mukherjee (Kolkata)
Dr (Mrs) Prabha Arora (Delhi) Dr Hema Divakar (Bangalore) Dr Kamini A Rao (Bangalore) Dr Deepti Goswami (Delhi) Dr Neerja Bhatla (Delhi) Dr Bhawna Malhotra (Delhi) Dr Biswas Nicholas (Australia) Dr Sudhaa Sharma (Jammu) Dr Jaibhagwan Sharma (Delhi) Dr Veena Mathur (Agra) Dr Pradeep Garg (Delhi)
Editorial Board
CLINICAL STUDY
Analysis of Maternal Mortality in a Rural Referral Medical College Hospital in Hassan, Karnataka Premalatha HL, Abhilasha
Outcome of Laparoscopic Ovarian Drilling with Multiple versus Fewer Punctures
REVIEW ARTICLE
Anemia in Men and Post-menopausal Women
Obstetrics and Gynaecology Dr Alka Kriplani Dr Thankam Verma Dr Kamala Selvaraj
ENT Dr Jasveer Singh Dentistry Dr KMK Masthan Dr Rajesh Chandna
Self-perceived Antenatal Maternal Stress, Related Factors, and Low Birth Weight Newborns
Cardiology Dr Praveen Chandra Dr SK Parashar
Gastroenterology Dr Ajay Kumar
Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses Dr Sidhartha Das Dr A Ramachandran Dr Samith A Shetty
Neurology Dr V Nagarajan Journal of Applied Medicine and Surgery Dr SM Rajendran Dr Jayakar Thomas
Anand Gopal Bhatnagar Editorial Anchor Advisory Body Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions
13
Vidya Bhat, Prashant Joshi, SS Bhat, Archana Manoj
Nithyashree Nandagopal, C Vijaikumar, Arshad Akeel, Udhaya Balasubramaniam
Dermatology Dr Hasmukh J Shroff
7
16
23
Savita Chandra, SM Clare
The Evaluation of Leiomyoma Uteri and their Management Among Indian Women
27
S Biswas, S Mahana
ORIGINAL ARTICLE
Comparison between Serum Anti-Mullerian Hormone and Day 3 FSH for Prediction of Ovarian Reserve in a Population of Infertile Patients 32 ML Swarankar, Manju Maheshwari, Richa Bhargava
Asian Journal of Volume 2, April-June 2013
CONTENTS
Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E - 219, Greater Kailash, Part - 1 New Delhi - 110 048 E-mail: editorial@ijcp.com
CASE REPORT
Rare Presentation of Partial Hydatiform Mole and its Unusual Management 36 Shikha Singh, Rekha Rani, Saroj Singh, Chetali, Krishna Singh, Tulika
Printed at Nikeda Art Printers Pvt. Ltd., Mumbai Š Copyright 2012 IJCP Publications Ltd. All rights reserved. The copyright for all the editorial material contained in journal, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.
Placenta Percreta: A Cause of Second Trimester Spontaneous Rupture of Uterus
40
Poonam Yadav, Richa Singh, Harpreet Kaur
An Unusual Case of Huge Broad Ligament Myoma Presenting as Pseudocyesis 42 Anu Pathak, Saroj Singh
Editorial Policies The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article. Note: Asian Journal of Obs & Gynae Practice does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature in this issue.
Pregnancy in an Untreated Ectopia Vesicae
44
Premalatha HL, Manjunath
PHOTO QUIZ 45
Dr Nutan Agarwal
FLOW CHART
Management of Abruptio Placentae
47
Vidushi Kulshrestha, Alka Kriplani
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FROM THE ISSUE EDITOR
Dr Alka Kriplani Professor and Head of Unit II Dept. of Obstetrics and Gynecology AIIMS, New Delhi E-mail: kriplanialka@gmail.com
Dear Reader And now womb transplant In January 2014, the world may see a child born to a woman who has undergone the first ever successful womb transplant. The breakthrough procedure was carried out last year by Turkish surgeons on 21-year-old Derya Sert, who was born without a uterus. Dr J Richard Smith, a British gynecologist from Queen Charlotte’s and Chelsea Hospital in London, is leading efforts in the UK to start a womb transplant programme. One in every 5,000 women in the UK is born without a womb. Besides, around 1,000 UK women from the 15-24 age groups have hysterectomies every year, a commonly performed procedure for treating cervical cancer. The British charity says the only two options available for these women are adoption and surrogacy, both acceptable options but fraught with moral, ethical and financial difficulties. The majority of the research, published in the 1960s to the 1980s, involved transplantation of the entire female genital tract (ovaries, womb, cervix and upper vagina) in a range of different mammals. In 2000, the world’s first womb transplant was performed on a 26-year-old woman in Saudi Arabia. Although this attempt was unsuccessful, much was learned and it was the stimulation for extensive research to continue around the world. In December 2010, doctors in Sweden were able to report a pregnancy as a result of a womb transplant on a rat.
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
5
FROM THE DESK OF GROUP EDITOR-IN-CHIEF
Woman Given Wrong Blood in Hospital, Dies
Dr KK Aggarwal Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist, Moolchand Medcity, New Delhi President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS National Vice President-Elect, IMA Chairman Ethical Committee, Delhi Medical Council Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http//twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)
A 25-year-old woman died after being given blood of a wrong group in KC General Hospital. Malleswaram resident Rajeshwari breathed her last in Victoria Hospital early on Thursday. Police booked cases against physician, nurse and two other employees of the government-run KC General Hospital. Her blood group was O positive, but she was given B positive blood, causing grave complications. Comments • MCI 7.18 In the case of running of a nursing home by a physician and employing assistants to help him / her, the ultimate responsibility rests on the physician. • Giving a wrong blood is a never event . •
As defined by the National Quality Forum and commonly agreed upon by health care providers, one of the 28 never events are: Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA incompatible blood or blood products.
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Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
CLINICAL STUDY
Analysis of Maternal Mortality in a Rural Referral Medical College Hospital in Hassan, Karnataka Premalatha HL*, Abhilasha
ABSTRACT Maternal mortality ratio (MMR) is an indicator to measure the summary of information about mother and child birth. It is estimated that about 350-450 maternal deaths occur per 100000 live births each year in India. Key words: Retrospective study, maternal mortality, risk factors, cause of death
T
hough India has made an appreciable progress in improving the overall health status of its population, but it is far from satisfaction. Pregnancy is a normal health state that most women aspire to at some point in their lives. This physiological process carries with it serious risks of maternal morbidity and mortality.
Those who suffer generally live in remote places and are poor and helpless. It is not only useful to evaluate the performance but also is a measure of the social status of community and availability of Maternal and Child Health Services. The major causes of maternal mortality are hemorrhage, hypertension disorder, sepsis, obstructed labor, unsafe abortions.7,8
Maternal mortality ratio (MMR) is the measure of number of maternal deaths due to pregnancy or with in 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy from any cause related to or aggravated by the pregnancy and its management but not from accidental or incidental causes.
UNICEF’s 2009 State of the world’s children report, which was released in January said that India’s fight to lower MMR is failing due to growing social inequalities and shortages in primary healthcare facilities. In most developed nations MMR has been reduced to as low as 5-20/1,00,000 live births. Maternal mortality rate in India stands at 450/1,00,000 live births against China’s 50/100000 and Srilanka’s 35/1,00,000, by comparison and China is the most populated country in the world.29
Although various safe motherhood initiatives have been taken, yet the decline in MMR is far from the desired level of 100 by 2012 set by National Rural Health Mission (NRHM) and 109 by 2015 as per millennium development goals.6 Maternal death is a greater social tragedy than a perinatal loss. In spite of advances in obstetrics, anesthesia, and blood product transfusion and in antibiotics, decline in MMR in India has been slow.
*Assistant Professor Dept. of Obstetrics and Gynecology Hassan Institute of Medical Sciences, Hassan, Karnataka Address for correspondence Dr Premalatha HL Assistant Professor Dept. of Obstetrics and Gynecology Hassan Institute of Medical Sciences, Hassan, Karnataka E-mail: premalatha.gowda@yahoo.in
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
Maternal audit is essential to make critical appraisal of standards and to continue to improve the methods of management pattern of maternal complications. In 1960, four major causes of death were hemorrhage, abortion, hypertensive disorders and pulmonary embolism. Even today hemorrhage stands first as the cause for death as reported in some studies.9-12 The health problems of mother and new born arise as a result of synergistic effects of malnutrition, poverty, illiteracy, unhygienic living conditions, infections and unregulated fertility, ignorance, apathy. At the same time poor infrastructure and ineffective public health services, failure of transport facilities, failure to provide adequate man power, failure to empower the woman resources, failure to provide adequate functioning blood banks, is 7
CLINICAL STUDY also responsible for low inadequate obstetric care and rise in maternal mortality, rather than a lack of technical knowledge World Health Organization (WHO). The result of large scale survey have however shown that there was no decline in the MMR in India over time indicating an urgent public health concern.13 WHO estimates show that out of the 5,29,000 maternal deaths globally each year, 1,36,000 (25.7%) are likely to experience some obstetrical and medical complications and die in India.14,15,17 Recent estimates (WHO and UNICEF) place the figure around 300-500/1,00,000 live births16 in Karnataka MMR is 217/1,00,000 live births. But in reality it may be higher because of under registration of deaths in the country and absence of cause of death information. Aims and Objectives To analyze the causes of maternal deaths in a rural referral hospital like Hassan Institute of Medical Sciences Hassan (HIMS), Karnataka. Analysis of maternal death is an essential exercise with a view
to understand the common complication leading to maternal deaths and is helpful to find out the remedies. This knowledge may help to decrease maternal deaths, for the majority of causes are preventable with the current day knowledge and technology. Material and Methods Analysis of maternal deaths over four years were carried out from 2006 to 2009, which occurred at HIMS, karnataka, Hassan. Cases were scrutinized from various aspects likely to be related to maternal deaths like age, parity, locality, socioeconomic status, literacy, antenatal registration and check-ups, period of gestation, mode of delivery, admission to death interval, direct and indirect causes of death. All the data was collected from records and maternal mortality statistics of the year provided by the record section of the hospital. Maternal mortality was calculated by means of maternal deaths and total live births for that particular year. Results and Analysis
Table 1. Year-wise Distribution of Maternal Deaths
Table 2. Age and Parity Distribution
Years
Age Prime Second Multi Grand (years) gravida gravida gravida multi
No. of maternal deaths
No. of live births
MMR/1,00,000 live births
Percentage (%)
2006
5
4,698
106.43
<20
7
---
---
---
23.34
2007
8
4,982
160.58
21-30
9
4
5
---
60
2008
6
5,848
102.6
>30
---
1
4
---
16.66
2009
11
7,529
146.1 60
60 180 160.58
160
50
120 MMR
100
106.43
102.6
80 60 40
Percentage (%)
146.1
140
40 30 23.34 20
16.66
10
20 0
0 2006 2007 2008 2009 Years
Figure 1. Year-wise distribution of maternal deaths.
8
<20 21-30 >30 Age group
Figure 2 A. Age-wise distributions of subjects.
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
CLINICAL STUDY 9
9 8 7
6.67%
6.67%
Home delivery
6.67%
Hospital vaginal delivery
7
Forceps delivery
Number
6
Cesarean delivery
5
5 4
4
33.33%
4
43.33%
Laparotomy for rupture uterus Undelivered
3 2 0
3.33%
1
1 0
0 Second gravida
Prime gravida
0 Parity
Multi gravida
0 0 0 Grand multi
Figure 2 B. Parity-wise distributions of subjects.
Figure 4. Distribution of subject-based on type of delivery.
Table 5. Distribution of Subject Based on Admission to Death Interval. Admission Death interval
No. of cases
Percentage of cases
Table 3. Distribution of Subject Based on Time of Maternal Death.
<24 hours
24
80%
Timing of maternal death
1-3 days
1
3.33%
>3 days
5
16.67%
No. of maternal deaths
Percentage of maternal deaths
Antepartum
5
16.67%
Intrapartum
----
0%
Postpartum
24
80%
Post abortal
1
3.33%
3.33%
16.67%
<24 hours 1-3 days
3.33%
>3 days 16.67%
80%
0%
Antepartum Intrapartum Postpartum Post abortal
80%
Figure 3. Distribution of subject-based on time of maternal death.
Table 4. Distribution of Subject Based on Type of Delivery Type of delivery
No. of maternal deaths
Percentage of maternal deaths
Home delivery
2
6.67%
Hospital vaginal delivery
13
43.33%
Forceps delivery
1
3.33%
Cesarean delivery
10
33.33%
Laparotomy for rupture uterus
2
Undelivered
2
Figure 5. Distribution of subject-based on admission to Death interval.
Table 6. Analysis of causes of maternal mortality. Cause of death 2006 2007 2008 2009 Percentage (%) CHD with CCF APH ABRUPTION
1
Eclampsia
1
-
1
7.14
1
-
1
10.7
2
-
1
10.7
Postpartum sepsis and CVT
1
1
1
-
10.7
PPH
2
2
1
5
35.7
Anemia
1
1
1
1
14.2
6.67%
Septic abortion
-
-
1
-
3.57
Jaundice
-
-
1
1
7.14
6.67%
Rupture uterus
-
-
2
-
7.14
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
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CLINICAL STUDY
7.14%
7.14% 7.14%
CHD with CCF APH abruption
3.57%
10.70% 14.20%
10.70% 10.70%
35.70%
Eclampsia Postpartum sepsis and CVT PPH Anemia Septic abortion Jaundice
8% 12%
Haemorrage
7%
Indirect Causes Sepsis 25%
Unsafe Abortion Eclampsia
13% 15%
20%
Rupture uterus Figure 6. Analysis of causes of maternal mortality.
Figure 7. Causes of maternal deaths in standard books .
Discussion
Mortality ratio measurements are difficult and complex. As a matter of fact under registration is frequent in both developing and developed countries. MMR measurement should be simple affordable, effective and evidence-based, particularly in poorer countries. The information collected should be used to help improve maternal health outcome and empower health professionals to examine their current practices or those of the facility in which they work. For correct estimation of maternal mortality it requires knowledge of death of pregnant women and cause of death, because the information obtained will be used as the basic for action. Health promoters and community health workers can be trained to report these events as part of their jobs, as can traditional birth attendants who provide antenatal care and attend deliveries. India’s long-standing strategy has been promotion of facility- based intrapartum care.21 One of the vowed goals of the national population policy (2000) is to attain an institutional delivery rate of 80% by 2010. Nation wide, the proportion of deliveries in institutions has increased from 34% in 1998-99 to 41% in 2002-2004. Further acceleration in the direction is inevitable under NRHM. launched in 2005. This scheme provides a conditional cash transfer to mothers for institutional deliveries and a cash incentive for health workers, who facilitate this process, with 24/7 delivery services and nearly 3,000 public facilities will be upgraded to provide comprehensive emergency obstetric care by 2012. In 1997-98, India’s MMR stood at 398, this declined to 301 in 2001-2003. The prediction for 2015 is 160, although this misses India’s 5th Millennium Development Goal (MDG-5), which is pegged at 109.22,23 A faster decline in MMR is a distinct possibility because of the extraordinary attention given to maternal health under the NRHM, increased resources are also flowing to education,
Recent MMR of India is 300-500 as reported by WHO in 2008 (The Hindustan times, April 3, 2008) this study was conducted in the rural medical college to investigate the risk factors for maternal mortality. After going through the statistics, it is found that MMR is increased with increase in number of deliveries. Increased MMR is seen in women aged between 21-30 years - 60%. zz 80% of deaths have occurred with in 24 hours zz 43% are hospital vaginal deliveries zz 33% delivered by cesarean operation zz 35.7% due to postpartum hemorrhage (PPH) zz 14.2% - anemia. zz 10.7%- antepartum hemorrhage (APH), eclampsia, postpartum sepsis zz 7.14%-, coronary heart disease (CHD) and congestive cardiac failure (CCF), rupture uterus, jaundice, deaths due to abortion is less than 3.57% may be due to safe abortion practices. The causes of maternal deaths are multiple, complex but almost preventable. forty-three percent of deaths have occurred following institutional delivery at HIMS. A study published in April 2010 in the Lancet shows that the number of annual maternal deaths worldwide declined from roughly 5,25,000 in 1980 to about 3,43,000 in 2008. The troubling news in these two studies is that progress has been unequal: While many countries are showing a downward trend, in some maternal deaths actually increased. Study has shown MMR has also increased in America from 7.1% in 1999 to 13.3% in 2008.17,18,29 The fact is that pregnancy always carries risk of unexpected complications, and 15% of pregnancies everywhere are life-threatening.
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Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
CLINICAL STUDY women’s empowerment, and rural employment. One priority of the NRHM is to have a female health volunteer called ASHA (accredidated social health activist). Other efforts are being made to provide quality reproductive health services24 including institutional delivery, safe abortions, treatment of RTIs and family planning services to meet unmet needs while ensuring full reproductive choice to women. Under NRHM, the main strategy to reduce MMR focuses on institutional deliveries and provision of EMOC. The government has recently changed policy to allow staff nurse and ANMs to initiate treatment of pregnancy-related complications, including IV fluids, oxytocics, antibiotics and magnesium sulfate all earlier restricted to administration by doctors. The government has also started the retraining of ANMs to improve their skills as skilled birth attendants (SBAs) The central government has encouraged a 16week training of MBBS doctors in Anesthesia and comprehensive EMOC. Conclusion Maternal health services and MCH focused on antenatal care and high-risk approach. It is thought that good antenatal care and identifying high-risk women, institutional deliveries, Janani Suraksha Yojanas, help of ASHA’s will reduce the MMR. But, after implementing several years of these Yojanas, the studies have shown that MMR is still high. After going through the statistics in our institution, it is not possible to predict which mother will develop complications and hence the high-risk approach does not help much. Anemia should be eradicated in the society. The project development process should ensure that all the critical inputs such as staff, drugs, blood banks, equipments are provided, which is extremely small at present. Mass education about the importance of antenatal check-ups and registration, institutional deliveries and providing timely transportation facilities will reduce the MMR. References
3. Maternal mortality rate decrease not significant, experts, PTI (Press Trust of India). August 31st 2003. 4. Institute for research in medical statistics ICMR. Ansari Nagar, New Delhi, July 2009. 5. Rashmi Singh, Nivedita Sinha, et al. Pattern of Maternal Mortality in a tertiary care hospital of Patna, Bihar, Indian. J Community Med 2009;34(1);73-4. 6. Agarval A, Pandey A, Bhattacharya BN. Risk factors for maternal mortality in Delhi Indian. J Med Sci 2007;61: 517-26. 7. Mother-baby packages, implementing safe motherhood in countries WHO Geneva; 1994 world health day safe motherhood 7 April, 1998. 8. Tinker AG improving women’s health in Pakistan, human development network Band, 1998.) 9. RCH II Document 2, the principles and evidence base for state RCH program implementation plan. Chapter 1: improving health outcomes, pp 23-5. 10. Gupta N, Kumar S, Saxena N, Nandan D. Maternal Mortality in Seven Districts of Uttar Pradesh - ICMR Task Force Study. J Indian Public Health 2006;50(3):173-83. 11. Padma singh, Aravind pandey and Abha aggarwal-House to house survey vs. snowball technique for capturing maternal deaths in India: A search for a cost effective method Indian. J Med Res April 2007,pp 550-6. 12. Nasir Farooq, Huma Jadoon, Tayyeb Imran Masood, M Saleem Wazir, Umer Farooq, Mohammad Saqib Lodhi An assessment study of MMR databank in five districts of north western frontier province Pakistan, Department of Community Medicine, Ayub Medical College, Abbottabad, Pakistan) 13. Abha Agarval, Aravind Pandey. estimation of MMR in India and its state –a pilot study –institute for research in medical statistics –ICMR. Ansari Nagar New Delhi, July 2003. 14. India Needs Medical will to Reduce Maternal Mortality – WHO. April 2, 2008 15. Maternal health situation in India. J Health Population Nutr 2009;27(2):184-201. 16. National family health survey 1992-1993, RGI 1999-registration system bulletin 1999; vol. 33 no I. 17. Prof Dileep Mayalankar IIM –Azad India foundation -state of maternal health in India
1. WHO, UNICEF, UNFPA. Maternal mortality in 2000: Estimates by WHO, UNICEF, UNFPA, GENEVA: available from http://www.childinfo.org/areas/maternal mortality. (Last accessed on 2007 Jun 6).
18. Jennifer Block reported for TIME in March, that study, based on data from the Centers for Disease Control and Prevention as well as other sources,Dr .Christopher Murray, university of Washington, institute for health metrics and evaluation.
2. India needs to make major strides on health front UNICEF August 5TH 2008 by IANS.
19. Fouvier-colle MH, evaluation of the quality of care for severe obstetric haemorrage in three -b French regions.
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
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CLINICAL STUDY Br J Obstetric-Gynaec 2001;108:898-903.) 20. Berg C,Danel I,Mora G CDC-guide lines for maternal mortality epidemiologic surveillance WashingtonDC,pan American health organization,1996 (English and Spanish) 21. Vinod K Paul, meeting MDG 5 Good news from India, the lancet, 17 Feb 2007;369(9561)p.558. 22. Registrar general of India: 1997-2003. Trends, causes and risk factors New Delhi; registrar general of India, 2006. p 1-29. 23. Fauveau V. Strategies for reducing maternal mortality. Lancet 2006;368:2121-22. 24. Kranthi S. Vora, Dileep V, Mavalankar, K.V Ramani,et al maternal health situation in India :A case study .J health popul nutr 2009;27(2):184-201 25. Trends in maternal mortality 1990 -2008.estimates developed by WHO, UNICEF, UNFPA, and the World
Bank, September, 2010 http://www.unfpa.org/public/site/ global/lang/en/pid/ 6598last accessed September 17, 2010. 26. The United Nations Govt. New York. 55th Session of United Nations Millennium Declaration. Millennium Summit; 6-8 September 2000. Available from: www.un.org. (Accessed on December 2, 2006). 27. United Nations. A/RES/S-27/2. General Assembly Distr. General 11 October 2002. Available from: http://www. un.org (accessed on December 2006). 28. WHO maternal mortality in 2005: estimates developed by WHO, UNICEF, available at http://www.who.int/whosis/ mmr-2005 pdf last accessed Sep 17.2010. 29. Francis Coeytaux, Debra Bingham, Ana Langer. Reducing maternal mortality; A global imperative, contraceptive editorial February 2011.
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Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
CLINICAL STUDY
Outcome of Laparoscopic Ovarian Drilling with Multiple versus Fewer Punctures Vidya Bhat*, Prashant Joshi**, SS Bhat†, Archana Manoj‡
ABSTRACT Objective: To analyze the outcome of laparoscopic ovarian drilling (LOD) with multiple punctures using short burst of cutting current when compared with LOD with fewer punctures. Material and methods: Eighty-seven patients included in the study after fulfilling inclusion and exclusion criteria. LOD was carried out by doing multiple punctures using cutting current of 30-40 weeks in 64 patients, while in 23 patients only 3-6 punctures were done. Results: Better conception rates were observed over a period of two years in the group with multiple puncture. Conclusion: LOD with short burst cutting current and multiple punctures has good outcome in terms of regularization of menstrual cycles, ovulation and conception. Key words: Laparoscopic ovarian drilling, menstrual cycle, conception
L
aparoscopic ovarian drilling (LOD) is a secondline of treatment for patients with polycystic ovarian syndrome (PCOS). The sole purpose of LOD is to achieve good decompression of the ovary with minimal damage to the ovarian tissue resulting in good ovulation, thus conception. But, there is a fear that more number of punctures done for better decompression can cause premature ovarian failure. This is probably due to coagulation current used with longer burst. When LOD is carried out with lesser punctures it may not cause optimal decompression of the ovary. Hence, multiple punctures on all four surfaces of ovary with short bursts of cutting current should cause optimal decompression with good results without premature ovarian failure.
Material and Methods
Aim
We excluded patients with male factor of infertility, infertility due to other factors and body mass index (BMI) >28 kg/m2.
To analyze the results of LOD with multiple punctures using short bursts of pure cutting current when compared with LOD with fewer punctures.
*Consultant and Director Dept. of Obstetrics and Gynecology Radhakrishna Hospital and IVF Centre, Bangalore **Associate Professor Dept. of Obstetrics and Gynecology Adichunchanagiri Institute of Medical Sciences, BG Nagara, Karnataka † Consultant Dept. of Obstetrics and Gynecology Radhakrishna Hospital and IVF Centre, Bangalore ‡ Fellowship Resident Radhakrishna Hospital and IVF Centre, Bangalore
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
The study period is January 2003 to December 2010, among the 3,254 patients attending our infertility OPD, 829 diagnostic laparoscopies were carried out, of which 87 patients were included in study after fulfilling inclusion and exclusion criteria. Inclusion Criteria
Infertile women with irregular cycles, who had PCOS with clomiphene resistance, had high luteinizing hormone (LH) levels with LH:FSH (follicle-stimulating hormone) ratio >2, ovarian volume measured >10 CC. Exclusion Criteria
Of the 87 patients who were included in the study, 64 patients underwent LOD with multiple punctures and 23 patients underwent LOD with 3-6 punctures. We divided them accordingly into two groups: Group- I and Group-II respectively. Procedure
After introducing three ports, ovary was held at ovarian ligament by using atraumatic forceps. In the Group I, from the contralateral port we used monopolar short bursts of cutting current of 30-40 watts and multiple 13
CLINICAL STUDY punctures 12-16 were made on all surfaces of both ovaries. Each puncture was about 3 mm deep and 3 mm wide. Thorough irrigation was done to cool the ovaries. No charring of ovarian tissue was seen in any of the patients with this method. In the Group-II, only 3-6 punctures were made on all surfaces of both the ovaries. After the procedure ovarian stimulation was started with gap of six months. Stimulation was started with clomiphene citrate or letrozole and stepped up with gonadotropins if required. Observation and Results Results were analyzed in terms of regularization of menstrual cycles ovulation rates and conception rates. Patients were also followed up for further subsequent conception. As seen in Table 1, the difference in the number of punctures is statistically significant between the two groups. Patients in both groups were well-matched in terms of other characteristics like age, BMI, number of years of marriage and ovarian volume.
Number of patients who conceived spontaneously and after stimulation with clomiphene citrate in Group-I was significantly more than in Group-II. However, conception after stimulation with other methods did not carry any statistical significance. Of the patients who conceived, 90% patients were in the first two years following LOD. For the patient who underwent lower segment cesarean section (LSCS) for obstetric indication we looked for pelvic adhesions, no significant ovarian adhesions were encountered. Discussion Polycystic ovarian syndrome (PCOS) is seen in 5-10% of women in reproductive age group, is the most common cause of anovulatory infertility. LOD is a simple surgical approach currently used to treat Clomiphene citrate resistant PCOS. Surgical treatment of polycystic ovaries to restore regular menstruation was described by Stein and Leventhal in 1935.1 They performed wedge resection of the ovaries
Table 1. Patients Characteristics
Group I n-64
Group II n-23
t value
p value
Mean
SD
Mean
SD
Age (years)
25.64
2.12
25.39
1.03
0.540
0.590
ML
2.99
1.33
3.07
0.68
0.251
0.802
Obstetric history
1.86
0.35
2.00
0.00
1.918
0.059
BMI
24.16
1.61
24.26
1.60
0.268
0.789
USG (ov vol)
12.81
1.17
12.83
1.15
0.048
0.962
No. of punctures
23.80
1.68
8.00
0.00
44.857
0.0001
Table 2. Conception Rates Group I Number
14
Group II
Total
%
Number
%
z value
p value
Not conceived
9
14.1
13
56.5
22
4.018
0.001
Spontaneous conception
12
18.8
-
-
12
2.237
0.012
Conception after stimulation with clomiphene citrate
24
37.5
4
17.4
28
1.771
0.038
Conception after stimulation with GnRH
12
18.8
3
13.0
15
0.621
0.267
Conception after stimulation with letrozole
7
10.9
3
13.0
10
0.272
0.396
Total
64
100.0
23
100.0
87
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
CLINICAL STUDY in women with amenorrhea. Regular menstruation and spontaneous conception was achieved. This did not gain popularity, because after a period of time, women who underwent bilateral wedge resection had peritubal adhesions, which in turn caused infertility.2 In 1984, Gjonnaess reported the LOD with a conception rate of 84%.1 LOD has some advantages over gonadotrophin treatment such as lower cost per pregnancy, improvement in menstrual regularity and better long-term reproductive performance and decreased rate of miscarriage due to PCO. Once LOD is performed the risk of multiple pregnancy and ovarian hyperstimulation may not be seen. The response of the ovary to medical treatment improves.3 The number of punctures done in LOD is not clear in literature. If more number of punctures are done, then the decompression of ovary, in turn the success rate is expected to be higher. There are some controversial reports, which suggest that LOD done with multiple punctures on the ovary causes premature ovarian failure. But, this could be due to technical reasons of using coagulation current with longer bursts. Amer et al 2004, however has shown 57% of ovulation rates with four punctures, however pregnancy rates have not been studied.3 Mode of action of LOD is by release of follicular fluid that triggers ovulation by decreasing androgenesis.1 Hence, more the punctures better the outcome with good decompression. When we look into the amount of thermal energy that should be used Amer et al3 proved that cutting current of dose 600-1,200 J will result in higher ovulation pregnancy rates. Energy can be calculated by â&#x2020;&#x2019; current X duration in sec X no. of punctures. Damages are noted with thermal dose of 16,000 J. Recently, its shown that an adjusted diathermy dosebased on ovarian volume during LOD for PCOS has a better reproductive outcome rather than a fixed thermal dose.4 Also long-term beneficial effects have been seen after LOD in patient with PCO for upto nine years.3,5 We observed 40% patients conceiving subsequently on their own and other enjoyed good outcome like regular menstrual cycles. Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
When we carried out the study in the beginning with 3-6 punctures we had no spontaneous ovulation and only 40% conception was seen with stimulated cycles. With multiple punctures spontaneous conception was seen in 62% of patients. Two patients required repeat drilling who had previously undergone LOD with four punctures. LOD is an effective alternative in women who may not respond or who hyperrespond with combination of clomiphene citrate and metformin.6 Recurrence was noted in 10% of our patients, which is attributed to excessive weight gain after the procedure. Weight loss is associated with improved reproductive outcome in PCOS6 also PCO women with BMI, 35 kg/m2 achieved significantly lower ovulation and pregnancy rates after LOD compared to moderately overweight and normal weight women.7 In our study, we had included patient of BMI between 22-28 and obtained good results. Cochrane database system 2005 provides insufficient evidence in cumulative pregnancy rates after LOD8 (which may be attributed to multicentric and varying observation and efficiency). In properly selected patients, 12-16 punctures using short bursts of 30-40 W cutting current, resulted in good reproductive outcome in our study. But with 3-6 punctures there were no spontaneous conceptions. In women with 12-16 punctures, in addition to more spontaneous conceptions there was also better pregnancy rates with stimulated cycles. In our study, in women with 3-8 punctures, no spontaneous ovulation was observed and about 40% conception was seen with stimulated cycles whereas with multiple punctures, spontaneous conception was seen in 62% of patients. Among the patients who have been previously undergone LOD with four punctures, two patients also required repeat drilling as they did not conceive even on stimulation. Conclusion From the present study, we can conclude that LOD is effective with multiple punctures on all four surfaces with short burst of cutting current and has good reproductive outcome provided proper patient are selected. Contâ&#x20AC;&#x2122;d on 20 page ...
15
REVIEW ARTICLE
Anemia in Men and Post-menopausal Women Nithyashree Nandagopal, C Vijaikumar, Arshad Akeel, Udhaya Balasubramaniam
ABSTRACT The prevalence of anemia is disproportionately high in developing countries. Anemia is a critical health concern because it affects growth and energy levels. The present study aims to analyze the demographic profile and the type of anemia among apparently healthy men and post- menopausal women attending to the master health check at a tertiary care hospital in Southern India. The collection of data was carried out between the period of November 2010 and November 2011. Data included history and examination, haemoglobin, determination technique and further tests such as stool for occult blood by faecal occult blood (FOB). It has found that the highest prevalence of anemia among the adult male population in the study group was between the ages of 51-70 years followed closely by 31-50 years. A negative correlation was observed between vegetarian diet and the prevalence of anemia. Further studies can be done to observe this correlation between anemia and impaired renal function in diabetics. Stool for occult blood is thus more specific and less sensitive for gastrointestinal blood loss. Key Words: Anemia, haemoglobin, history and examination, faecal occult blood, gastrointestinal blood loss
A
nemia afflicts an estimated two billion people worldwide, mostly due to iron deficiency â&#x20AC;&#x2026;secondary to either chronic blood loss or nutritional deficiency. The prevalence of anemia is disproportionately high in developing countries. Young people are particularly susceptible because of their rapid growth and associated high iron requirements. Anemia is a critical health concern because it affects growth and energy levels. In the older population, anemia is more often a subtle marker of either chronic disease states or internal malignancies. It primarily affects women.1 Yet, among adolescents and adults, prevalence rates of anemia are more or less equal in both genders in some parts of the world.2,3 Even among women, the age group that has thus far been screened or studied for anemia is either adolescent women or women in the child-bearing age group. The prevalence of anemia in men is seldom studied and has not been an area of interest for many researchers, unlike its prevalence in women. Therefore, reliable data regarding the prevalence of anemia in the adult male and elderly
Dept. of Internal Medicine Apollo Hospitals, Chennai
16
female population is not available.4,5 The present study aims to analyze the demographic profile and the type of anemia among apparently healthy men and postmenopausal women attending to the master health check at a tertiary care hospital in Southern India. Objectives To assess the age distribution of anemia in men and postmenopausal women. To assess the type and the degree of anemia in men and postmenopausal women. Methods Data Collection
The collection of data was carried out between the period of November 2010 and November 2011. Individuals who were found to be anemic on a routine master health check at our hospital were included in the present study. History and Examination
Each individual was interviewed and examined separately. The details in the history included food habits and food fads (if any), significant past history leading to the cause of anemia like chronic gastrointestinal blood loss. Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
REVIEW ARTICLE Hemoglobin Determination Technique
Study Sample
A sample of venous blood was drawn from individuals and used for determination of plasma hemoglobin concentration using cyanmethemoglobin method. Patients with hemoglobin concentrations below the cut-off levels suggested by the World Health Organization (WHO)2 were considered anemic and their peripheral smears were examined to ascertain the type of anemia .
Apparently healthy individuals attending the master health check at our hospital.
Further Tests
Further tests were ordered to assess for gastrointestinal blood loss. They included stool for occult blood by fecal occult blood (FOB) and all patients were referred to the medical gastroenterologist for upper and lower gastrointestinal scopy.
Inclusion Criteria zz Age: Men of any age group Post-menopausal women zz Anemia: Defined by serum hemoglobin of <12 g/dl in women and <13 g/dl in men as per WHO cut-off criteria. Exclusion Criteria zz Men and women with chronic kidney disease and chronic liver disease zz Past history of any gastrointestinal bleed zz Previously known to have anemia of any cause zz Past history of gastric surgeries and malignancies
29
30 10
Male Female
No of cases
25
26
20 15
Male
10 5 0
56
Figure 1. Sex distribution.
1
30-50 years
50
55
50
51-70 years Age in years
40 30 20
47
30 Yes 20 10
8
No 9 3
3 0
0
>70 years
40
No of cases
No of cases
3
Figure 2. Age distribution.
60
10
Female
7
Microcytic Macrocytic Normocytic Type of anemia
Figure 3. Type of anemia.
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
0
Male
7
Female Diabetes mellitus
Figure 4. Diabetes and anemia
17
REVIEW ARTICLE Results During our study period 66 individuals were identified to have anemia according the WHO criteria.2 Out of which 56 were males (83.33%) and 10 were females (16.66%) (Fig. 1). The average age of the sample was 52.30 years, with the average age of women being 55.60 years and the average of men being 51.78 years. With regard to the dietary habits, none of the patients had any food fads, 6/66 (9.09%) were vegetarians and 60/66 (90.90%) consumed a mixed diet of both vegetarian and nonvegetarian food. Among the type of anemia, as determined by peripheral smear, 3/66 (5.3%) had macrocytic anemia, 8/66 (12.1%) had microcytic anemia and 55/66 (83.3%) had normocytic anemia (Fig. 3). Among the study group, 12 were diabetic and 54 were nondiabetic. All diabetics had normal creatinine clearance (Fig. 4).
50
Stool for occult blood was requested for in all subjects and only 54 individuals had come for follow-up with stool for occult blood. Among them, 49 were negative and five were positive (Fig. 5). Among 34 individuals who underwent colonoscopy, 24 showed normal study, 10 had some abnormality and the remaining 32 were lost to follow-up (Fig. 6). The abnormal findings on colonoscopy are shown in Table 1. The correlation between stool for occult blood and abnormal findings on colonoscopy are shown in Table 2. A significant correlation was noted between negative stool for occult blood and normal colonoscopic finding indicating that stool for occult blood is a less specific but a more sensitive marker for gastrointestinal blood loss. Discussion The Indian National Family Health Survey - III had identified increased risk of anemia among adult males and nonpregnant adult females, which was not studied in the previous surveys.6 Sufficient information 40
49
32 30 No of cases
No of cases
40 30 20
20 10
10
12 10
24
5
0 Abnormal findings
0 No
Yes
Not done
Stool for occult blood
Normal
Not done
Colonoscopy Figure 6. Colonoscopy.
Figure 5. Stool for occult blood.
Table 2. Correlation between Stool for Occult Blood and Colonoscopy
Table 1. Abnormal Colonoscopy Findings Colonoscopy findings
18
Colonoscopy
Number of cases Normal
Abnormal
Not done
Positive
3
1
1
1
Negative
18
6
25
1
Not done
3
3
6
Hemorrhoids
3
Ulcers
2
Stool for occult blood
Polyps
2
Diverticular disease Ascending colonic growth
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
REVIEW ARTICLE on the prevalence and causes of anemia among this group is needed to justify the development of an intervention program. The WHO proposed a scheme for classification of public health severity of anemia.7 Anemia was considered as mild if prevalence is 1-9%, moderate if it is 10-39% or severe problem if it is more than 40%. Although, the present study has not assessed the prevalence of anemia among men and postmenopausal women in the general population, it has found that the highest prevalence of anemia among the adult male population in the study group was between the ages of 51-70 years followed closely by 31-50 years. The percentage of individuals in the 51-70 years age group among the general population is slowly on the rise owing to the improved healthcare delivery system and increasing life expectancy in the developing countries. Anemia is most often a subtle marker of malignancy in the adult population. Thus, the presence of anemia warrants screening for internal malignancies, which in turn when detected early will improve the prognostic outcome in these individuals. Secondly, the high prevalence of anemia in the 31-50 years age group not only causes a significant strain on the public healthcare system of developing countries but also poses a risk of increasing the economic burden of the society, as this group constitutes the majority to revenue generation. In this study, a negative correlation was observed between vegetarian diet and the prevalence of anemia. This is probably due to two reasons, the small sample size and also a normal wellbalanced vegetarian diet does dot predispose to risk of anemia. The commonest type of anemia was found to be normocytic normochromic anemia on peripheral smear, which was contrary to the expected microcytic hypochromic anemia commonly seen due to chronic blood loss or nutritional deficiency. However, it is difficult to comment upon the causes of anemia because the prevalence of various parasitic infestations and other chronic illnesses were not studied in this study. The association of anemia with type 2 diabetes mellitus has been well-documented in several trials previously.8-11 Anemia is more prevalent in the diabetic patients with creatinine clearance (CrCl) <60 ml/min.12 In most studies till date, impaired renal function and albuminuria are the predominant risk factors for anemia in diabetic patients.13,14 In this study, only 12 of the subjects were diabetic. Further studies can be done to observe this correlation between Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
anemia and impaired renal function in diabetics. In this study, colonoscopy was performed in 34 out of 67 patients. In spite of the poor follow-up rate and small sample size, a significant number of individuals who underwent colonoscopy were detected to have some cause of gastrointestinal bleed. Also a strong correlation was observed between negative stool for occult blood and normal colonoscopy. Stool for occult blood is thus more specific and less sensitive for gastrointestinal blood loss. Techniques to improve sensitivity include testing of three consecutive early morning samples; following certain dietary restrictions and avoidance of certain prescription prior to testing.15 Hence, stool for occult blood can be used as a fairly reliable screening test for detecting gastrointestinal bleed. Limitations of the Study Although, the present study was not designed specifically to study all the risk factors for anemia in this population, the lack of data on adult population, high prevalence of anemia among adult male population and the significant colonoscopic results prompted us to publish our findings. Studies with bigger sample sizes are required. Another drawback of our study was poor compliance and high attrition rate among the study subjects. There is a need for a systematic study to find out the prevalence as well as the causes of anemia at community level both among males and females. These findings also suggest that intervention for anemia should be directed at all members of the community. References 1. World Health Organization (WHO) 1991. National Strategies for Overcoming Micronutrient Malnutrition. 2. DeMaeyer E, Aaiels-Tegman M. The Prevalence of Anemia in the World.â&#x20AC;? World Health Statistics Quarterly 1985;38:302-16. 3. Kurz, KM, C. Johnson-Welch 1994. The Nutrition and Lives of Adolescents in Developing Countries: Findings from the Nutrition of Adolescent Girls Research Program. International Center for Research on Women. 4. Seshadri S. A database on iron deficiency anemia (IDA) in India: prevalence, causes, consequences and strategies for prevention. Department of Foods and Nutrition. WHO Collaborating Centre for Nutrition Research. The Maharaja Sayajirao University of Baroda, Vadodara India, 1999.
19
REVIEW ARTICLE 5. Kumar A. National nutritional anemia control program in India. Indian J Public Health 1999;43(16):3-5. 6. National family health survey of India - III, 2005-2006, Ministry for Health and Family Welfare, India. 7. Verster A. Anemia in the region - a call for action. Guideline for the control of iron deficiency in countries of eastern mediterranean Middle East and North Africa. In: Vester A. Editor. Based on a joint WHO/UNICEF consultation on strategies for the control of iron deficiency aneamia. Teheran (Islamic Republic of Iran): Institute for Nutrition and Food Technology; 1995 Oct. Report No.: WHO/ EMRO. WHO-EM/Nut/177, EIG/11.96 . 8. Thomas MC, MacIsaac RJ, Tsalamandris C, et al. The burden of anemia in type 2 diabetes and the role of nephropathy: a cross sectional audit. Nephro Dial Transplantation 2004;19:1792-7. 9. Griac K, Williams JD, Riley SG, et al. Anemia and diabetes in the absence of nephropathy 2005;28:1118-23.
10. Thomas MC, Cooper ME, Tsalamandris C, MacIsaac R, Jerums G. Anemia with impaired erythropoietin response in diabetic patients. Arch Intern Med 2005;165:466-9. 11. Cawood TJ, Buckley U, Murray A, et al. Prevalence of anemia in patients with diabetes mellitus. Ir J Med Sci 2006;175:25-7. 12. Li Vecchi M, Fuiano G, Francesco M, et al. Prevalence and severity of anemia in patients with type 2 diabetic nephropathy and different degrees of chronic renal insufficiency. Nephron Clin Prac 2007;105:62-7. 13. Thomas MC, Macisaac RJ, Tsalamandris C, et al. Anemia in patients with type 1 diabetes. J Clin Endocrinol Metab 2004;89:4359-63. 14. Fioretto P, Mauer M, Brocco E, et al. Patterns of renal injury in NIDDM patients with microalbuminuria. Diabetologia 1996;39:1569-76. 15. Tests for Fecal Occult Blood, J. Donald Ostrow, Laboratory, Chapter 98, pages 489-491.
... Cont’d from 15 page
References 1. Gjonnaess H. Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertility and Sterility 1984;41:20-5.
5. SAKS Amer, Z Bame, TC Li and ID Cooke, Long term follow up of patients with polycystic ovary syndrome after laparoscopic ovarian drilling: endocrine and ultrasonographic outcomes, Human reproduction 2002;17(11):2851-57.
2. Francesco Mereorio, Antanio Mercorio, Attilio Di Spiezio Sardo evaluation of ovarian adhesion formation after laparoscopic ovarian drilling by second look minilaparoscopy Fertility - Sterility 2008;89(5):1229-33.
6. The Thessaloniki ESHRE/ASRM sponsored PCOS consensus workshop group, Greece - consensus on infertility treatment related to polycystic ovary syndrome. Ferti- Steril 2008;89(3):505-22.
3. SAK amer, TC Li and WLL Ledger, Ovaulation induction using laparoscopic ovarian drilling in women with polycystic ovarian syndrome: predictors of success. Human reproduction 2004;19(8):1719-24.
7. Pasquali R, Pelnsi C. Genglvini S, Cacciari M, Gambinori A Obesity and reproductive disorders in women. Human reproductive update 2003;9:359-72.
4. Zakherah MS, Laparoscopic ovarian drilling in PCOS: Efficacy of adjusted thermal dose based on ovarian volume, Fertil - steril 2011;95(3):1115-8.
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8. Farquhar C, Lilford RJ, Marjoribanks J, Vandekerckhove P. Laparoscopic ‘drilling’ by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev2005;20(3):CD001122.
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
REVIEW ARTICLE
Self-perceived Antenatal Maternal Stress, Related Factors, and Low Birth Weight Newborns Savita Chandra*, SM Clare**
ABSTRACT Objective: To evaluate whether self-perceived maternal stress is a risk factor for low birth weight (LBW) newborns. Material and methods: One thousand three hundred thirty-nine mothers who delivered LBW newborns were interrogated, to identify self-perceived maternal stress and its causative factors. Results: Self-perceived maternal stress was related to socioeconomic, physical and psychosocial factors mothers of 45.85% of LBW babies belonged to the low socioeconomic group, mothers of 34.96% of the LBW babies to the middle, while 19.19% to the upper socioeconomic group. Odds ratio low/ upper was 18.95, p < 0.001(highly significant). Physical exertion when self-perceived as stress was also a risk factor for LBW babies. About 23.15% of the LBW neonates were born to mothers doing domestic chores and office work, 33.90% babies to those doing external manual work and domestic chores, while the highest 42.95% to those doing only household work. Available help during pregnancy affected the perceived degree of physical stress. Mothers of 56.53% LBW neonates received no help for the domestic work, 27.33% received family help, while mothers of 16.14% of LBW newborns got hired help. Mothers of 29.87% of the LBW neonates had psychosocial stress of which 77% were intrauterine growth restriction (IUGR) neonates. Conclusion: Stress as perceived by the potential mother is a risk factor for LBW babies. Measures to recognize it’s causes, understand and reduce perceived maternal stress both at home, and at work, would contribute to reduce the incidence of LBW babies. Key words: Maternal stress, low birth weight newborns
P
regnancy is a physiological state during which mother nature ensures adequate adaptive changes in all systems of the body, thereby, gearing the potential mother to cope with the physiological stress of pregnancy and deliver a healthy normal weight baby. However, these adaptive changes may not adequately suffice when there exists any other stress additional to the physiological stress of pregnancy which, may then contribute to result in a low birth weight (LBW) baby. While prenatal medical disorders are well-established as an additional form of stress and are contributory to LBW babies, but whether the antenatal self-perceived stress by the pregnant woman is a risk factor for LBW babies is less addressed. This ‘antenatal self-perceived
*Professor and Head **Postgraduate Student, Dept. of Obstetrics and Gynecology Goa Medical College, Bambolim, Goa Address for correspondence Dr Savita Chandra F-2, Type 6, Medical Staff Qtrs. Bambolim Complex, Goa - 403 202 E-mail: savirsp@gmail.com
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
maternal stress’ if persistent, may subtly alter the maternal milieu interior, bring about biochemical changes at the molecular level, affect the uterine circulation, impair metabolism and modify the placental functions to the disadvantage of the fetus and result in a low birth weight baby. Hippocrates thus rightly advised the pregnant women to beware of unnecessary stress. Aim With this in mind, the study was undertaken to analyze the factors, which contributed to the ‘maternal perceived stress’. Material and Methods The study was carried out in the Dept. of Obstetrics and Gynecology, Goa Medical College from December 2005 to 30th November 2008. Women who delivered babies >1.0 kg but <2.5 kg birth weight were enrolled including booked, unbooked and referred cases. Those who delivered twins, congenitally malformed newborn and those mothers who had an underlying pre-pregnancy existing medical disorder were excluded. 23
REVIEW ARTICLE The mothers enrolled were interrogated during their lying- in period through a structured questionnaire, which aimed to identify antenatal stressful factors as perceived by her. The predominant stressful factor was considered for analysis, when there were coexisting multiple stressful factors. Mothers stress attributed to financial reasons was analyzed. The respondents were placed into three groupâ&#x20AC;&#x2122;s i.e., low, middle and high socioeconomic status (based on the Prasad BG classification applying correction factor and consumer price index to the per capita monthly income).1-3 To analyze physical stress the details of physical work were recorded, the type of work, available help and the respondents placed into groups depending on the type of work and available help. Stress attributed by the mother to spouse behavior, family environment, interpersonal relationships within the family, relations with neighbors and sad events as loss or sickness of a near one, was considered as psychosocial stress. Results During the period under study, 1,339 LBW babies were born whose mothers fulfilled the inclusion criteria. These mothers were interrogated to find out their self-perceived stress during the antenatal period and the factors responsible for their stress. The data was then analyzed.
Table 1 shows that mothers of 575 LBW babies (42.95%) were engaged in physical work pertaining to domestic chores, 454 (33.90%) were doing household work plus outside manual work, while 310 (23.15%) were those who were doing their household work and office desk work. Highest number of LBW babies were in the group, where women were doing physical work related to domestic chores. As seen from Table 2, the maximum LBW babies fell in the group, where mothers had no help for the household work i.e., 757 mothers (56.53%); while help from other family members was available to 366 (27.33%) mothers and hired help was available to 216 (16.14%) mothers. Of the two categories of LBW newborns, the impact of physical stress appeared to be more related to intrauterine growth restriction (IUGR) than preterm babies as in each category the number of the former exceed that of the latter as seen from Table 2. Table 3 shows that of the 1,339 LBW babies, mothers of 614 (45.85%) belonged to low socioeconomic status, 468 (34.96%) to the middle, while the least 257 (19.19%) to the high socioeconomic status. (The control group were mothers whose newborns were >2.5 kg in weight.) The odds ratio for lower/upper status was 18.95, p < 0.01, statistically significant. Thus maternal stress because of financial and economic factors is a significant risk factor for LBW babies.
Table 1. Distribution of Respondents by Perceived Physical Stress Type of work
Preterm
IUGR
Total
No.
%
No.
%
No.
%
Only household work
148
11.05
427
31.88
575
42.95
Household plus manual work
99
7.39
355
26.51
454
33.90
Household plus office work
92
6.87
218
16.28
310
23.15
Total
339
25.31
1,000
74.67
1,339.
100.00
Table 2. Distribution of Respondents Based on Available Physical Help Household help
24
Preterm
IUGR
Total
No.
%
No.
%
No.
%
None
181
13.51
576
43.05
757
56.53
Family help
83
6.18
283
21.13
366
27.33
Hired help
75
5.60
141
10.53
216
16.14
Total
339
25.29
1,000
74.71
1,339
100.00
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
REVIEW ARTICLE Table 3. Socioeconomic Status of Mothers with Low Birth Weight Newborns
Table 4. Psychosocial Stress and LBW Babies
Socioeconomic status
Birth weight (< 2.5 kg)
Birth weight (> 2.5 kg)
Low
614 (45.85%)
106 (7.91%)
Total mothers with LBW babies with social/family psychosocial stress: = 400
Middle
468 (34.96%)
392 (29.20%)
High
257 (19.19%)
841 (62.80%)
Total
1,339 (100%)
1,339 (100%)
Odds ratio: Low/Middle = 4.85 Middle/High = 3.9 Low/High = 18.95 X2 = 57.79 , df = 2 (p <0.01) statistically significant.
Table 4 shows the impact of psychosocial stress related to social, interpersonal and family relationships. Emotional stress related to social/interpersonal relationships was elicited in 400 cases. i.e., in 29.87% of the 1,339 mothers. (Amongst these 400 mothers, 29 were unwed mothers.) Psychological stress related to social/family/interpersonal relationships was more significantly connected to IUGR babies since of these 400 newborns, 308 were IUGR and only 92 were preterm babies. Discussion LBW babies are a major contributor to the perinatal mortality and morbidity. This study was an attempt to find whether maternally perceived stress due to various issues: Financial, socioeconomic, physical, psychological and psychosocial was a risk factor for LBW babies. The term stress is difficult to define but can be considered as an internal state of an individual, which can be caused by physical demands on the body, or by environmental and social situations, which are evaluated as exceeding the individual’s resource of coping, and therefore stressful and potentially harmful. Thus while optimal stress, shouldered with a sense of well-being and happiness is beneficial, but stress, beyond some point/threshold becomes ‘distress’. This stress threshold is individual based, and so varies from person to person. In this context, stress as perceived by the mother becomes of paramount significance as what may be optimal stress for one potential mother may become distress for another and therefore maternal subjective perception is of great significance. With regard to the physical stress the present study showed that Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
Total mothers with LBW babies: = 1339
Percentage of total mothers with low birth weight babies: 29.87% Number
% (n = 400)
Mothers with preterm babies
92
23.00
Mothers with IUGR babies
308
77.00
Total mothers with psychosocial stress
400
100.00
pregnant women doing household work plus an occupation involving ‘office desk work’ had the lowest LBW babies (i.e., 23.15%) (Table 1). This was an interesting finding of this study. By simple logic, this group of women would be expected to be under greater stress trying to cope up with both the household chores and office work. However, this group had the lowest LBW babies. This can be explained because this group of respondents had a sense of mental satisfaction, appeared happier, carried a sense of well-being, confidence and self-esteem, which subtly decreased the subjective perceived maternal stress accounting for lesser LBW babies in them. Pompeii et al,4 in their study observed that 40% reduction in risk for preterm delivery was observed among women formally employed and working at least 46 hours/weeks. Launer et al5 1990, found a similar pattern in connection with the occupation of pregnant women with the lowest LBW babies 19.08% amongst those employed in office. It is also seen from Table 1 that physical activity involving only household work had the highest number of low birth weight babies i.e. of 575 babies in this group 427 were IUGR babies. Arafa et al6 also made the observation that there was an excess rate of small for gestation age babies among the nonworking group. This could be due to prolonged physical activity and standing, which may have resulted in reducing the venous return and the cardiac output thereof and consequently reduced uterine blood flow. Further, prolonged standing in a subtle way may lead to hormonal changes resulting in irritability of the uterus and preterm labor. 25
REVIEW ARTICLE Hendrickson et al7 in their study found that physical activity involving long hours of standing or walking had a three times higher risk of resulting in a LBW baby.
Wilcox et al9 1995 where such factors were identified in 32%. It is also seen from Table 4 that of these 400 newborns, 77% were IUGR while preterm neonates were 23%.
As seen from Table 2 56.53% of the mothers with LBW babies did not get any help for their domestic chores. Launer et al5 found that 24.19% of the mothers of LBW babies received no assistance for domestic work, which is significantly lower than our study. This difference could be explained because in affluent countries with the availability of sophisticated household machines and gadgets, tedious domestic chores become less laborious and therefore pose less physical and psychological maternal stress. Lack of affordability for usage of such machines/gadgets could account for the difference when compared with the study by Launer et al.5
It can be therefore said that psychosocial stress is more closely connected with causation of IUGR as compared with prematurity. Rothberg et al10 in their study identified moderate-to-severe stress factors in 48% of the mothers and observed an inverse relation between cumulative stress and birth weight of newborns.
This study shows that amongst the mothers of LBW babies, 45.85% belonged to the low socioeconomic status (Table 3), while 257 (19.19%) belonged to the high socioeconomic group. Using logistic regression equation the odds ratio of lower/upper socioeconomic class was very high i.e., 18.75, p < 0.00, statistically highly significant. Poverty and low socioeconomic status is therefore a highly significant factor contributing to maternally perceived stress and to LBW babies. In Salam’s8 study, 196 (85.5%) of the 229 LBW newborns belonged to mothers in the low income group. Thus, in both the studies, the maximum number of LBW newborns were in women belonging to the lowest income groups yet in terms of percentage the two studies are in contrast i.e. 45.04% in this study versus 85.5% in Salam’s study.8 The study settings could explain this difference. The setting of Salam’s study8 was in the Northern part of the state of Karnataka, which is socioeconomically backward as mentioned in his study, whereas this study is in the state of Goa, which relatively is a better state socioeconomically with a higher per capita income as well as overall better health indices. Table 4 shows that in 400 (29.87%) of the 1,339 mothers of LBW babies there were significant emotional factors related to social, interpersonal and family environment and is comparable to the study of 26
Peacock et al11 in their study also observed that pregnant women who reported having trouble with ‘nerves and depression had 2-fold increase of preterm deliveries.’ Conclusion Maternally perceived stress is an important risk factor for LBW babies be it due to social, financial, physical or psychological factors - its degree whether optimal or at distress level is determined as per the perception of the potential mother. The LBW babies currently believed to be due to idiopathic reasons may actually be attributed to this underlying ‘maternally perceived stress.’ Measures taken at home or at the workplace to reduce the level of maternal stress may assist in significantly reducing the incidence of LBW babies. References 1. Prasad BG. Social classification of Indian families. J Indian Medical Assoc 1961;37:250-1. 2. Prasad BG. Social classification of Indian families. J Indian Medical Assoc 1968;51:3653. Prasad BG. Changes proposed in social classification of Indian families. J Indian Medical Assoc 1970;55:198-9. 4. Pompeii LA, Savitz DA, Evenson KR, Rogers B, McMahon M. Physical exertion at work and the risk of preterm delivery and small for gestation age birth: Obstet Gynecol 2005;106(6):1279-88. 5. Launer LJ, Villar J, Kestlar E, et al: The effect of maternal works on foetal growth and duration of pregnancy outcome: A prospective study. Am J Obstet and Gyn 1990;97: 62-70. 6. Arafa MA, Amine T, Abdel Fatteh M, Association of maternal work with adverse perinatal outcome. Can J Public Health 2007;98(3):217-21. 7. Hendrikson TB, Hedegaard M, Secher NJ, and Wilcox AJ: Standing at work and preterm delivery: Br J Obstet and Gynecol 1995;102:198-205. Cont’d on page 31...
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
REVIEW ARTICLE
The Evaluation of Leiomyoma Uteri and their Management Among Indian Women S Biswas*, S Mahana**
ABSTRACT Objective: Fibroids are the most common benign tumors in females but still the data in the Indian subcontinent is limited and not up-to-date. We conducted a prospective study of 110 cases of fibroid in Indian women who came to a hospital in Mumbai. Study design: Various aspects like age at diagnosis, clinical features, associated medical disorder and modalities of management were studied over a period of three years. Result and conclusion: The various results spanned from similar to markedly varied when compared to standard western textbook data. Key words: Leiomyoma uteri, prospective study, epidemiology of fibroid, fibroid india
A
uterine fibroid is a benign (non-cancerous) tumor that originates from the smooth muscle layer (myometrium) and the accompanying connective tissue of the uterus. Fibroids are the most common benign tumors in females and typically found during the middle and later reproductive years. While most fibroids are asymptomatic, they can grow and cause heavy and painful menstruation, painful sexual intercourse, and urinary frequency and urgency. Some fibroids may interfere with pregnancy although this appears to be very rare.1 Rarely (less than one in 1,000) a cancerous fibroid will occur. Aims and Objectives of this Study zz To study the epidemiology, clinical features, gross and microscopic characters of fibroid. zz To study histopathology of endometrium associated with fibroid. zz To study association of other factors like obesity, OCP, DM and HTN. zz To study various modalities of management of fibroid. *Assistant Professor Dept. of Obstetrics & Gynaecology GGMC & Sir JJ Group of Hospitals, Mumbai ** Professor & Head of Department Dept. of Obstetrics & Gynaecology ESIC Hospital & Postgraduate Institute of Medical Research, Mumbai Address for correspondence Dr Som Subhro Biswas C/o Dr TK Biswas F-199, Raghunath Vihar, Khargar, Sector -14 Navi Mumbai, Maharashtra - 410 210 E-mail: tonitedeschi@gmail.com
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
Materials and Method A prospective study of 110 cases of fibroid and various aspects like age at diagnosis, clinical features, associated medical disorder and modalities of management were noted. The study is conducted at a tertiary institution in Mumbai. Complete clinical history was noted with special attention to age, marital status, parity, presenting complaints, duration of complaints, menstrual history, obstetric history, past history, family history. Details of clinical examination was noted like weight, presence of anemia, breast examination and complete gynecological examination. Routine blood investigations were recorded. Ultrasonography was done with special attention to size, number, site of fibroid, endometrial thickness, and any adnexal or ovarian pathology. Some patients underwent D & C, CT and MRI. Gross features of specimens obtained were noted after surgery followed by histopathological report. Results Age Distribution of Fibroids Table 1. Age (in years)
Numbers
Percentage
< 30
11
10%
> 30-40
39
35.45%
>40-50
52
47.27%
>50-60
4
36.36%
>60-70
1
0.9%
>70
3
2.7%
27
REVIEW ARTICLE 70
50.00
60
40.00
50
30.00
40
20.00
30 20
10.00 0.00
10 0
<=30 >30-40 >40-50 >50-60 >60-70 >70
Figure 1. This data shows that the commonest age group for fibroid is 40-50 years (47.27%) (PERIMENOPAUSAL) and it is rare above 60 years of age.
Parity Distribution in Patient
Figure 3. Women with fibroid mostly presented with menstrual complaints (61.8%).
Distribution of Various Menstrual Complaints
Table 2. Parity
Menstrual Pain Infertility Pressure Others complaints Abdomen Symptoms
Table 4. Number
Percentage
Complaints
Number
Percentage
Nullipara
22
20%
Menorrhagia
40
58.8%
Primipara
16
14.5%
Polymenorhea
8
11.76%
Multipara
72
65.45%
Polymenorrhagia
13
1.55%
Total
110
100%
80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00
Dysmenorhea
15
22.05%
Metrorhagia
2
2.94%
Total
68
100%
60 50 40 30 20 10
Nullipara Primipara Multipara
0 Figure 2. This data shows that most women who develop fibroid are mostly multiparas (65.45%) and least in primipara (14.5%).
Menorrhagia
Polymenorhea Polymenorrhagia Dysmenorhea
Metrorhagia
Figure 4. Most common menstrual complaint was menorrhagia (58.8%) and least common was polymenorrhagia (1.55%).
Distribution of the Presenting Complaints Distribution of Patients According to Hemoglobin Table 3. Number
Percentage
Menstrual complaints
Symptoms
69
61.8%
Hemoglobin
Pain in abdomen
14
19.09%
Number
Percentage
<7
11
10%
Infertility
3
8.18%
>7-9
45
40.9%
Pressure symptoms
2
1.8%
>9-11
40
36.36%
Others
6
9.09%
>11
14
12.7%
110
100%
Total
110
100%
Total
28
Table 5.
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
REVIEW ARTICLE
<=7gm% >7-9 gm%
Single
>9-11gm%
2-3 No.
>11gm%
>3
Figure 5. Most women (40.9%) with fibroid uterus presented with Hemoglobin between 7 to 9 gm%.
Distribution by Size of Fibroid Uterus Figure 7. Mostly single fibroids (78.18%) were seen among patients in this study.
Table 6. Size
Number
Percentage
<= 6 wks
21
19.09%
>6-8 wks
28
25.45%
>8-12 wks
20
18.18%
Table 8.
>12-16 wks
26
23.63%
Management
Number
Percentage
>16 wks
15
13.63%
Medical
24
21.81%
Total
110
100%
Surgical
86
78.18%
TAH
46
41.81%
TAH + BSO/LSO/RSO
20
18.18%
MYOMECTOMY
09
8.18%
VAGINAL HYSTERECTOMY
11
10.0%
Total
110
100%
30 25 20 15
Line of Management
10 5
45 <=6 wks >6-8 wks >8-12 wks >12-16 wks >16 wks
40
Figure 6. Most commonly (25.45%) fibroid corresponded to 6-8 weeks uterine size and least common (13.63%) were >16 weeks.
35
Distribution by Number of Fibroids
25
30
20
Table 7. Number
15
Number of patients
Percentage
Single
86
78.18
5
2-3
10
9.09
0
>3
14
12.72
Total
110
100%
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
10
<=6 wks >6-8 wks >8-12 wks>12-16 wks >16 wks
Figure 8. Surgical mode of management was more common (78.18%).
29
REVIEW ARTICLE Types of Fibroid
Distribution According to Type of Endometrium
Table 9. Types
Table 11. Number
Percentage
Types
Number
Percentage
Subserosal
26
31.7%
Proliferative
46
51.68
Intramural Submucosal
20
24.39%
Secretory
38
42.69
36
43.9%
Atrophic
3
3.37
Total
83
100%
Cystic glandular hyperplasia
2
2.24
Proliferative Secretory Atrophic
Subserosal Intramural Submucosal
Cystic glandular hyperplasia Endometrial Ca
Figure 9. Submucosal fibroid were most common (43.9%) and intramural was least common (24.39%).
Distribution of Associated Pathologies
Distribution of Site of Fibroids
Table 12.
Table 10. Site
Numbers
Percentage
Corporeal
83
75.45%
Broad Ligament
12
10.9%
Cervical
10
9.09%
Pedunculated
5
4.56%
110
100%
Total
Figure 11. Mostly endometrium was proliferative (51.68%) and rarely cystic glandular hyperplasia was present. (2.24%)
Pathologies
Number
Percentage
Adenomyosis
10
9.09%
Ovarian pathologies
15
13.6%
Endometriosis
5
4.5%
Degeneration of fibroid
3
2.7%
Endometrial hyperplasia
2
1.85
Total
35
100%
14 Corporeal Broad Ligament Cervical Pedunculated
12 10 8 6 4 2 0
Figure 10. Fibroids were mostly corporeal (75.45%) and rarely pedunculated (4.56%) according to this study.
30
Adenomyosis
Ovarian Endometriosis Degeneration Endometrial Pathologies of Fibroid Hyperplasia
Figure 12. Mostly Ovarian pathologies (13.6%) were associated with fibroids like benign cysts, polycystic ovaries etc according to this study.
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
REVIEW ARTICLE Discussion The present study of 110 patients with fibroid was done to find out the clinical & histopathological presentation of fibroids and evaluate their mode of management. In this study most women with fibroid were of the age group 40-50 years (47.27%) (PERIMENOPAUSAL) and it is rare above 60 years of age. Our findings correlate well with studies of Cramer et al (1990)2 and Marshall et al (1997).3 According to this study most women who develop fibroid were mostly multiparas (65.45%) and least in primipara (14.5%), whereas as per Jeffcoate (1975)4 uterine fibroid is mostly seen in nulliparous women. Women with fibroid mostly presented with menstrual complaints (61.8%) in this study which is higher than observed by Rubo et al (1985).5 Most common menstrual complaint was menorrhagia (58.8%) and least common was polymenorrhagia (1.55%) which was found true in study by Madhu U (1988).6 Most women (40.9%) with fibroid uterus presented with Hemoglobin between 7 to 9 gm%. Stovall and associates (1995)7 found that heavy menstruation in Uterine fibroid need not cause anemia if iron supplement was maintained. Most commonly (25.45%) fibroid corresponded to 6-8 weeks uterine size and least common (13.63%) were >16 weeks. Mostly single fibroids (78.18%) were seen among patients in this study. Surgical mode of management
was more common (78.18%). Most patients with fibroid underwent Total Abdominal Hysterectomy (41.81%). Submucosal fibroid were most common (43.9%) and intramural was least common (24.39%). Fibroids were mostly corporeal (75.45%) and rarely pedunculated (4.56%) according to this study. Mostly endometrium was proliferative (51.68%) and rarely cystic glandular hyperplasia was present. (2.24%). Mostly Ovarian pathologies (13.6%) were associated with fibroids like benign cysts, polycystic ovaries etc according to this study. References 1. Neiger R, Sonek J, Croom C, Ventolini G. Pregnancyrelated changes in the size of uterine leiomyomas. J Reproduct Med 2006;51(9):671-4. 2. Cramer SF, Patel A. The frequency of uterine leiomyoma. Am J Clin Pathol 1990;94:435. 3. Marshall LM , Barbieri RL, et al. Variation in the incidence of uterine leiomyoma among premenopausal women by age and race. Obstet Gynecol 1997:90:967 4. Jeffcoate T. Principles of Gynaecology. London: Butterworth 1975. 5. Rubo R, Menstrual Bleeding in leiomyoma. Obstet Gynecol 1985;43:170. 6. Madhu U, et al. A study of menstrual disturbance in cases of fibroid uterus. J Obstet Gynecol, India 1988;6:710. 7. Stovall, et al. Iron versus placebo in the anemic patient before surgery for leiomyomas: a randomized control trial. Obstet Gynecol 1995;86:65.
... Cont’d from 26 page
8. Salam A. Birth weight correlates to mother’s age and parity: J of Obst and Gyn of India 1996;46:4.
stress during pregnancy: Effect on birth weight. Am J Obst and Gyn 1991;165:403-7.
9. Wilcox MA, Smith SJ. Effect of social deprivation on birth weight Br J Obst and Gyn 102;918:1995.
11. Peacock J, Bland JM, Anderson HR. Preterm delivery: Effects of socioeconomic factors, psychological stress, smoking, alcohol and caffeine. Br Med J 311;535:1995.
10. Rothberg AD, Lits B. Psychosocial support for maternal
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
31
ORIGINAL ARTICLE
Comparison between Serum Anti-Mullerian Hormone and Day 3 FSH for Prediction of Ovarian Reserve in a Population of Infertile Patients ML Swarankar*, Manju Maheshwari*, Richa Bhargava**
ABSTRACT Objective: To establish whether the values of Anti-mullerian hormone (AMH), a newly accepted marker of ovarian reserve, correlate with Day 3 follicle-stimulating hormone (FSH) and ovarian response to controlled ovarian hyperstimulation (COH) in a population of infertile patients undergoing in vitro fertilization and embryo transfer/intracytoplasmic sperm injection (IVF-ET/ICSI). Study design: In this analytic, cross-sectional study, sequential sampling was done on 100 infertile women who underwent IVF-ET/ICSI treatment at Jaipur Fertility and Microsurgery Research Centre (JFMRC), Jaipur. Initially, 5cc of venous blood was drawn from each patient to measure serum AMH and FSH levels on the Day 3 cycle. The outcome was measured in terms of oocytes retrieved and clinical pregnancy rate. Results: The basal AMH level correlated with the no. of oocytes retrieved (Linear Pearson correlation coefficient = 0.522), however, the basal FSH level had a weakly reverse correlation (correlation coefficient = -0.11). Conclusion: AMH is a better biomarker of ovarian reserve than day 3 FSH in predicting response to COH. Key words: Anti-mullerian hormone, follicle-stimulating hormone, in vitro fertilization
T
he ovarian reserve, constituted by the size of ovarian follicle pool and the quality of oocytes therein declines with increasing age, resulting in decrease in woman’s reproductive function (te Velde et al 1998a). At birth human ovary contains finite amount of primordial follicles that are responsible for support of oocytes. This pool of available follicles is referred to as ovarian reserve.
neither cycle dependent, can be measured any day, nor affected by gonadotropin-releasing hormone (GnRh) agonist can be measured during down-regulation.
Follicle development is dependent on interplay of many hormones such as follicle-stimulating hormone (FSH) and anti-mullerian hormone (AMH) secreted from anterior pituitary gland and ovary, respectively.1 Abnormal levels of these hormones may indicate woman’s diminished ability or inability of conception.
Reference ranges for AMH, as estimated from reference groups in the United states, are as follows:
AMH - a glycoprotein hormone, transforming growth factor-b (TGF-b) superfamily. (Pepinsky et al, 1988). Secreted by small antral follicles2 and in reproductive aged women is expressed by granulosa cells of ovary.3 AMH inhibits excessive follicular recruitment by FSH, therefore has a critical role in folliculogenesis.3,4 AMH is *Professor **Resident, Dept. of Obstetrics and Gynecology Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan Address for correspondence Dr Richa Bhargava C-37 Piyush Path, Bapu Nagar, Jaipur - 302 015, Rajasthan E-mail: thanviricha@gmail.com
32
High serum AMH levels have been associated with greater number of retrieved oocytes in in vitro fertilization (IVF) cycles5,6 and with improved embryo morphology.7
>24 month
:
<5 ng/ml
24 month-12 years
:
<10 ng/ml
13-45 years
:
1-10 ng/ml
>45 years
:
<1 ng/ml
AMH, serum from Mayo Medical Laboratories. Retrieved April 2012) (Fig. 1). As infertility has a social and emotional impact on the life of couple and its treatment can be financially and emotionally draining. So, it is important to consider the patient’s ability of becoming pregnant based on determination of ovarian reserve. The preferred methods consider the chronological age, level of Day 3 FSH and the follicle count through transvaginal ultrasound. The measurement of serum AMH is a relatively new method that is being Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
ORIGINAL ARTICLE Results
Possible action of AMH in the ovary: – Inhibition of follicular activation and growth – Inhibition of FSH stimulated growth – Inhibition of granulosa cell growth – Inhibition of aromatase
FSH AMH
AMH
primary
preantral
– +
–
primordial
antral
Figure 1. Showing possible actions of AMH.
Total 100 patients were randomized for the study. Table 1 shows result of our study with various international studies. Table 2 shows demographic data showing mean age of men and women in years along with mean levels of AMH and FSH and no. of oocytes retrieved and no. of embryo (n). Table 3 shows Linear Pearson coefficient correlations between AMH and oocyte and embryo. The basal AMH correlated with the no. of oocytes retrieved (Fig. 2). Table 4 Shows Linear Pearson coefficient correlation between FSH and oocyte and embryo. Basal FSH had a weakly reverse correlation (Fig. 3). Positive pregnancy outcome was found in 31% (Fig. 4).
considered for determination of the ovarian reserve, giving a more direct and accurate measurement.
Table 1. Results of Various International Studies
Material and Methods
Our study
One hundred patients aged 25-40 years undergoing IVF/ICSI (intracytoplasmic sperm injection) cycles between January 2012 and April 2012 were included in our study, meeting the inclusion criteria set namely; 2-15 years of infertility, body mass index (BMI) <30 kg/ m2 having normal uterine cavity and nonsmoker. Complete work-up of patient was done, male partners were also evaluated. In this study, 5 cc of venous blood was drawn from each patient to measure serum AMH and FSH levels on Day 3 of cycle. The outcome was measured in terms of oocytes retrieved and clinical pregnancy rate. Serum b-human chorionic gonadotropin (b-hCG) was performed on Day 15 following embryo transfer and if positive then transvaginal sonography was performed 15 days later to detect and confirm intrauterine pregnancy. Positive cases were followed till six weeks to check for fetal cardiac activity. Study Analysis:
Statistical analysis was performed with SPSS 15. Specificity and sensitivity were calculated for both AMH and FSH levels. Pearson correlation coefficient was analyzed with student’s t-test. P <0.05 is considered statistically significant. Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
Riggs et al.
8
Fanchin et al.
9
Correlation coefficient
P value
0.599
<0.001
0.539
<0.001
0.75
<0.001
Table 2. Demographic Data Min.
Max.
Mean
Age of women years
21
48
30.72
Age of men years)
23
54
35.7
AMH (ng/ml)
0.3
11.6
4.30
FSH (mIU/ml)
2.4
15
8.34
Retrieved oocytes
0
30
10.24
Embryo (n)
0
11
3.42
Table 3. Linear Pearson Coefficient Correlations Between AMH and Oocyte and Embryo Correlation coefficient
P value
AMH and oocytes
0.599
0.001
AMH and embryos
0.258
0.035
The basal AMH correlated with the no. of oocytes retrieved.
Table 4. Linear Pearson Coefficient Correlation between FSH and Oocyte and Embryo Correlation coefficient
P value
FSH and oocytes
–0.119
0.336
FSH and embryos
–0.150
0.225
Basal FSH had a weakly reverse correlation.
33
ORIGINAL ARTICLE zz
10 9 8 No. of oocytes
7
Elder-Geva et al the only predictor of pregnancy was follicular or luteal phase AMH.10
6 5 4
No. of oocytes
3 2 1 0
0
1
2
3 4 AMH (ng/ml)
5
6
7
8
Figure 2. Showing correlation between serum AMH and no. of oocytes.
10 No. of oocytes
Serum FSH levels had a sensitivity of 74.04% and a specificity of 38.46% with a cut-off point of 2.3 mIU/ml.
8 6
No. of oocytes
4 2 0
0 5 10 15 20 FSH mIU/ml
Figure 3. Showing correlation between serum FSH and no. of oocytes.
Positive Negative
31%
Visser et al11 have reported that serum levels of AMH correlate strongly with the number of antral follicles, which suggested that AMH levels reflect the size of primordial follicle pool. Silberstein AMH Values are Inversely Correlated with Basal FSH Values Additionally, has reported that serum level of AMH could predict not only ovarian reserve, but also embryo morphology.7 Seifer et al5 Higher Day 3 serum mullerian-inhibiting substance (MIS) concentrations were associated with greater number of retrieved oocytes. Ficicioglu et al,6 the mean serum AMH levels of patients with more than five retrieved oocytes were found to be higher (0.67 Âą 0.41 vs 0.15 Âą 0.11 pg/ml). These data demonstrate an association between early follicular serum AMH and ovarian response, but no association with pregnancy success. Conclusion Serum AMH levels are good predictors of ovarian reserve in comparison with FSH. References
69%
Figure 4. Positive pregnancy outcome was found in 31% patients.
Discussion zz In our study, we found that the measurement of serum AMH levels may be useful for accurate assessment of ovarian reserves, although it was not completely accurate in predicting success or failure of ART cycles. zz The serum level of AMH had a sensitivity of 85% and specificity of 61.2% at a cut-off point equal to 2.3 ng/ml. 34
1. Melechko A, Shpanskaya K, 2007. Folliculogenesis. How to Make Humans [Internet] [cited 2010 Dec 7]. 2. Baarends WM, Uilenbroek JT, Kramer P, Hoogerbrugge JW, van Leeuwen EC, Themmen AP, et al. Anti-mullerian hormone and Anti-mullerian hormone type 2 receptor messenger ribonucleic acid expression in rat ovaries during postnatal development, the estrous cycle, and gonadotropininduced follicle growth. Endocrinology 1995;136:4951-62. 3. Weenen C, Laven JS, Von Bergh AR, Cranfield M, Groome NP, Visser JA, et al. Anti-mullerian hormone expression pattern in the human ovary: potential implications for initial and cyclic follicle recruitment. Mol Hum Reprod 2004;10:77-83. 4. Durlinger AL, Visser JA, Themmen AP. Regulation of ovarian function: the role of Anti-mullerian hormone. Reproduction 2002;124:601-9.
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
ORIGINAL ARTICLE 5. Seifer DB, McLaughlin DT, Christian BP, Feng B, Shelden RM. Early follicular serum mullerian-inhibiting substance levels are associated with ovarian response during assisted reproductive technology cycles. Fertil Steril 2002;77:468-71.
of anti-mullerian hormone, follicle – stimulating hormone, inhibin B, and age. AJOG 2008;1992:202.el-202.e8
6. Ficicioglu C, Kutlu T, Baglam E, Bakacak Z. Early follicular antimullerian hormone as an indicator of ovarian reserve. Fertil Steril 2006;85:592-6.
9. Fanchin R, Schonauer LM, Righini C, Guibourdenche J, Frydman R, Taieb J. Serum antimullerian hormone is more strongly related to ovarian follicular status than serum inhibin B, estradiol, FSH and LH on day 3. Hum Reprod 2003;18:323-327.
7. Silberstein T, McLaughlin DT, Shai I, Trimarchi JR, Lambert -Messerlian G, Seifer DB, et al. Mullerian inhibiting substance levels at the time of HCG administration in IVF cycles predict both ovarian reserve and embryo morphology. Hum Reprod 2006;21:159-63.
10. Elder-Geva T, Ben-Chtrit A, Spitz IM, Rabinowitz R, Markowitz E, Mimoni T, et al. Dynamic assays of inhibin B, antimullerian hormone and estradiol following FSH Stimulation and ovarian ultrasonography as predictors of IVF outcome. Hum Reprod 2005;20(11):3178-83.
8. Riggs RM, Duran EH, Baker MW, Kimble TD, Hobeika E, Yin L, et al. Assessment of ovarian reserve with antimullerian hormone: a comparison of the predictive value
11. Visser JA, de Jong FH, Laven JS, Themmen AP. Antimullerian hormone: a new marker for ovarian function Reproduction 2006;131(1):1-9.
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
35
CASE REPORT
Rare Presentation of Partial Hydatiform Mole and its Unusual Management Shikha Singh*, Rekha Rani**, Saroj Singh**, Chetali†, Krishna Singh‡, Tulika#
ABSTRACT Molar pregnancy with no foetal tissue except foetal membrane is very rare presentation. In this article we report a rare case of partial hydatiform mole pregnancy in which patient presented with three months amenorrhoea with bleeding per vaginum for three days on ultrasonography, there was a picture of partial hydatiform mole with a compact mass suspecting of placenta with no foetus. This patient plant for expulsion of tissue, a different management of partial hydatiform mole pregnancy. After expulsion her histopathological report shows a partial hydatiform mole with placenta with foetal membrane and extensive haemorrhage. Key words: Hydatiform mole, gestational trophoblastic diseases
G
estational trophoblastic diseases encompasses a spectrum of proliferative abnormalities of trophoblastics associated with pregnancy. Molar pregnancy is an abnormal form of pregnancy, wherein a nonviable fertilized egg implants in the uterus, and thereby converts normal pregnancy processes into pathological ones. It is characterized by the presence of hydatiform mole (or hydatid mole, mola hydatidosa). Molar pregnancies are categorized into partial and complete mole.
There is wide range of geographical and ethnic variation of the prevalence of the conditions. The molar pregnancy is common in oriental countries-Philippines, Indonesia, Japan, India, Central and Latin America and Africa. The highest incidence is in Philippines being one in 80 pregnancies and lowest in European countries one in 752 and USA being about one in 2,000. The incidence in India is about one in 400.
A complete mole is caused by a single sperm combining with an egg, which has lost its DNA (the sperm then reduplicates forming a ‘complete’ 46 chromosome set) the genotype is typically 46XX. In contrast a partial mole occurs when an egg is fertilized by two sperm or by one sperm, which reduplicates itself yielding the genotypes of 69XXY (triploid) or 92, XXXY (quadriploid).
Mrs. A, 28-year-old, G5P4L2AO with previous four normal vaginal delivery conducted at home and last childbirth 2½ years back, presented in our OPD on 1/7/11 with chief complaints of amenorrhea for 3½ months and bleeding per vaginum for three days and dizziness for three days. She had a ultrasound done from outside, which showed a compact large heterogeneous mass 22 ×12 cm with numerous cyst like structure completely filling the uterine cavity.
*Assistant Professor **Lecturer ***Professor and Head Dept. of Obstetrics and Gynaecology † Asstt. Professor, Dept. of Pathology ‡ PG Student III year Dept. of Obstetrics and Gynaecology # PG Student III year Dept. of Pathology SN Medical College, Agra Address for correspondence Dr Shikha Singh Assistant Professor Dept. of Obstetrics and Gynaecology SN Medical College, Agra E-mail: drshikhasingh.shikha@gmail.com
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Case Report
On general examination, patient was conscious and thin built, height 150 cm, weight 42 kg, pallor+++, icterus +nt, pedal edema not present, pulse was 110/min and blood pressure was 110/70 mmHg. Examination of respiratory, cardiovascular system revealed no abnormality. Urine pregnancy test was faintly positive. On per abdominal examination uterus was 24-26 weeks size doughy, relaxed and fetal parts not felt nor any fetal movements, external ballotment could not be elicited. On per speculum examination there was slight Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
CASE REPORT
Figure 1. On P/V - os closed, Cx uneffaced.
Figure 2.
bleeding through os present, which was fresh red in colour (Fig. 1). A ultrasound was done in the department which showed a mass of 20 × 12 cm with cyst like structure in a part of the mass, whereas remaining portion was homogeneous and blood collection was seen posterior to mass (Fig. 2).
emergency cerviprime gel induction was given and six hours after cerviprime gel she was given injection prostodin ½ amp. IM 3-hourly for six doses. The os was 2-3 cm dilated after 18 hours and then oxytocin drip was started 5 unit @ 30d/min. She expelled a big placenta like mass on 5/7/11 at 3 am along with cystic structures, foetal membranes and numerous retroplacental clots (Fig. 3). Placenta like mass was 21 × 3 × 10 cm its maternal surface showed grape like vesicles. Cut section showed hemorrhage. No umbilical cord or fetal tissue was seen.
Patient’s condition was stable but she was severely anemic and bleeding was slight, she was put on conservative management and planned for explusion of products of uterine cavity after building her hemoglobin (Hb) status. Her blood sample was sent for cross-matching and arrangement of 4 units of blood. Patient was properly investigated for her coagulation profile, renal functions test and liver function. Her investigation revealed: Hb - 4.5 g/dl, total leukocyte count (TLC)13,400/mm3, b-human chorionic gonadotropin-1,798 mlU/l. Human immunodeficiency virus (HIV), hepatitis B surface antigen (HBsAg) and venereal disease research laboratory (VDRL) - nonreactive, prothrombin time - 15 second. (INR-1.11), patient activated partial thromboplastin time (APTT) - 35 second, bilirubin 2.0 mg/dl. So, a probable diagnosis of G5P4L2AO with 24 weeks size uterus with partial hydatiform mole/? Placental site trophoblastic tumor? With severe anemia was made. After transfusing 3 units of whole blood under cover of lasix and keeping 1 unit of blood in hand for Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
Figure 3.
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CASE REPORT
Figure 4.
Figure 5.
After expulsion of placenta like mass, injection oxytocin 10 units IM was given tab misoprostol 1,000 Âľg was instilled per rectally.
ovum) is fertilized by a single sperm, followed by a duplication of all chromosomes, the moles are diploid. Most partial moles are triploid. The nucleus contain one maternal set of gene and two paternal sets. The mechanism is usually the reduplication of the paternal haploid set from a single sperm but may also be the consequence of dispermic (two sperm) fertilization of egg. This means there is too much genetic material present. There is also too much trophoblast tissue. The growth of the trophoblastic tissue over takes the growth of any fetal tissue and fetus does not develop normally but the complete absence of fetal tissue except amniotic membranes is an extremely rare condition as observed in our case. To the best of one search we could not find such a case reporting of partial hydatiform mole without any fetal tissue except fetal membranes.
A repeat ultrasound was done, which showed empty uterine cavity. Her expelled products were sent for histopathological examination. The histopathological report showed partial hydatiform mole with placenta and fetal membranes and extensive hemorrhage (Figs. 4 and 5). Discussion A hydatiform mole is a pregnancy/conceptus in which the placenta contains grape like vesicles (small sacs) that are usually visible with naked eye. The vesicles arise by distension of chorionic villi by fluid. If left untreated, a hydratiform mole will almost always end as spontaneous abortion. Hydatiform moles are common complication of pregnancy occurring once in every 1,000 pregnancies in the US, with much higher rates in Asia and one in 400 in India. Hydatiform mole is characterized by abnormal growth of womb, about half of cases have nausea and vomiting which may be severe enough to require hospital stay vaginal bleeding, during the first three months of the pregnancy. The etiology of this condition is not completely understood. Potential risk factors may include defects in the egg, abnormalities in the uterus or nutritional deficiencies. In most complete moles, all nuclear genes are inherited from the father only (androgenesis) in approximately 80% of these androgenic moles, the most probable mechanism is that an empty egg (dead 38
Diagnosis can be made by history, urine pregnancy test that may turn out position because of high levels of circulatory human chorionic gonadotropin (HCG), a transvaginal ultrasound is usually ordered to check the presence and characteristic of uterine mass and definitive diagnosis is made by biopsy. Chest X-ray and ultrasound are usually done to check for any metastasis of villous tissues, blood examination are usually done prior to check for liver and kidney function in preparation for possible chemotherapy treatment. Suction and curettage is the treatment of choice of complete mole since blood loss is expected during the surgery. Compatible blood is usually prepared before hand, typed and cross-matched. Medically supported expulsion of mole can also be done according to the Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
CASE REPORT favorable condition applied to the patient (as applied in our case) specimens obtained during the procedure are sent to the histopathological diagnosis. Serum levels are monitored bi-weekly until the level reaches undetectable levels and advised the patient not to be pregnant within one year. Prognosis of H mole is usually very good 80% do not result in malignant conversion of the 20% who do develop malignancy. Chance of recurrence rate is about 1% and H mole does not affect the chances of a future normal pregnancy. Conclusion This case is a good example of concerned effort by a multidisciplinary team in managing complicated obstetric case. The obstetric scenario was very challenging to the entire team. Prompt discussion and appropriate decisions of the team are crucial while managing partially hydatiform mole with severely anemic patient with deranged coagulation profile. The obvious risk to patient needs to be well-explained. Our case was managed conservatively and induction
of was done by cerviprime gel, prostidin and oxytocin drip and simultaneously blood transfusion was done. Gross features of partial hydatiform mole was noted on explusion of placental tissue and whole mass was sent for histopathological examination. This case is presented for rare presentation of partial hydatiform mole with complete absence of fetal tissue except membranes and enormous size of uterus with unusual management of the disease according to conditions. References 1. Cottran RS, Kumar V, Fausto N, et al. Robbins and Cotran Pathologic Basis of Disease. 7th edition St. Louis, No Elxvier Saunder, 2005. 2. Entrics Hydatid n(a) and Mole, n in the Oxford English Dictionary Online (http://dictionary.old.com/subscription required). 3. Di Cintio E, Parazzini F, Rosa C, et al. The epidemiology of gestranol trophoblastic disease. Gen Diagn Pathol 1997;143: (2-3):103-8. 4. Williams Obstetrics 23rd edition. 5. Lawler SD, Fisher RA, Rent J. A prospective genetic study of complete and partial hydatiform moles. Am J Obstet Gynecol 1991;164(5 Pt):1270-7. 6. Sim R, Mehio A. The genetics of hydatiform moles: new lights on an ancient disease. Clin Genet 2007;71(1):25-34. 7. Sebire NJ, Seekl MJ. Gestational trophoblastic disease: current management of hydatiform mole. BMJ 2008;337:a1193.
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CASE REPORT
Placenta Percreta: A Cause of Second Trimester Spontaneous Rupture of Uterus Poonam Yadav*, Richa Singh**, Harpreet Kaurâ&#x20AC;
ABSTRACT Reports on placenta percreta in early pregnancy leading to a spontaneous rupture of uterus are rare. We report a case of this potentially life-threatening complication at the 20 weeks of pregnancy in an otherwise healthy woman who underwent a manual extraction of the placenta during previous delivery but had no history of severe pathology that could have potentially resulted in uterine damage. The main lesson to be learnt from this case is that in patients with a history of placenta accreta and subsequent manual extraction of the placenta a close investigation of the uterine wall and placentation should be performed in the first trimester in order to anticipate a placenta percreta. Key words: Placenta percreta, manual removal of placenta, spontaneous rupture
S
pontaneous uterine rupture in nonscarred uterus is usually caused by: Coincidental uterine trauma: Abortion with instrumentation curette, sound any sharp or blunt trauma - accidents. Abnormality during current pregnancy like, placenta increta or percreta, gestational trophoblastic neoplasia, adenomyosis, sacculation of entrapped retroverted uterus.
Case Report A 25-year-old lady G3P2L1, was admitted in emergency with the complaints of 20 weeks pregnancy with abdominal pain and bleeding per vaginum. Her vitals was stable on admission pulse rate was 80/min and blood pressure was 120/80 mmHg. On per abdominal examination, uterus was enlarged due to 20-22 weeks size and abdominal tenderness was present. On per speculum examination, slight bleeding per vaginum was noted. She was gravida 3, her both babies were full-term vaginal delivery at home but she had history of retained placenta in second child birth for which manual *Lecturer **Associate Professor â&#x20AC; Junior Resident-II Dept. of Obstetrics and Gynecology S.N. Medical College, Agra, UP Address for correspondence: Dr Poonam Yadav Dept. of Obstetrics and Gynecology SN Medical College, Agra UP E-mail: dr.poonamneeraj@gmail.com
40
removal of placenta was done. This time patient presented with amenorrhea for five months and pain in abdomen and bleeding per vaginum for five hours. On her ultrasonography, report showed: Uterus bulky showing hypoechoic rent in anterior wall on left side suggestive of uterine rupture, placenta seen in right pelvic region with surrounding echogenic collection, a 20 weeks fetus is seen just under abdominal wall in left hypochondrial and lumbar area, cardiac activity was absent, suggestive of intrauterine death. Moderate amount of free fluid was seen in the peritoneal cavity. Then her exploratory laparotomy was done on same day. On laparotomy uterus was found enlarged and rupture was found at the fundus. Placenta was attached to uterus and no plane of separation was found. A 20 weeks fetus was lying in left hypochondrial region. As placenta was adhered to uterus her hysterectomy was done. Third units of blood were transfused in postoperative period. Her postoperative recovery was uneventful and patient was discharged under satisfactory conditions on her 12th postoperative day. Histopathology: Histopathology report shows infiltration of chorionic villi through the whole thickness of myometrium consistent with placenta percreta. Discussion Placenta percreta associated with rupture is a rare complication of pregnancy with an incidence of one Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
CASE REPORT Uterus
Placenta
Fetus
Myometrium
Chorionic villi
Figure 2. Histology of the placenta showing the myometrium with invasion of chorionic villi (20 × hematoxylin and eosin staining). Figure 1. Overview of the abdomen as observed during the laparotomy showing uterine rupture at fundus with attached placenta and fetus.
in 5,000 pregnant women and is potentially lifethreatening for both mother and the fetus.1 Reports of spontaneous uterine rupture as a result of a placenta percreta during early pregnancy have been made in Weeks 10-21 of gestation.1,2 One of the most severe complication is a spontaneous rupture of the uterus with a hemoperitoneum as was observed in our patient during laparotomy. This type of complication has been reported in a number of cases, which all necessitated a hysterectomy. In the present case, the placenta percreta was diagnosed at Week 20 of gestation when a spontaneous rupture of the uterus occurred, the fact that the patient’s obstetric history did not include a cesarean section or other pathology resulting in a scarred uterus. At such an early stage
of pregnancy, a routine ultrasound generally does not include a detailed examination of both localization and implantation of the placenta. Conclusion In patient with a history of placenta accreta and subsequent manual extraction of the placenta, a close investigation of uterine wall and placentation should be performed in the first trimester in order to anticipate a placenta percreta. References 1. Jang DG, Lee GS, Yoon JH, Lee SJ. Placenta percreta induced uterine rupture diagnose by laparoscopy in the first trimester. Int J Med Sci 2011;8(5):424-7. 2. Passini Junior R, Knobel R, Barini R, Marussi E. Placenta percreta with silent rupture of uterus. Sao Paulo Med J 1996;114(5):1270-3.
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CASE REPORT
An Unusual Case of Huge Broad Ligament Myoma Presenting as Pseudocyesis Anu Pathak*, Saroj Singh**
ABSTRACT A 40-year-old woman came to our antenatal OPD with complaints of six months amenorrhea with gradual enlargement of abdomen and pain in lower abdomen for last two months with the hope of pregnancy. On per abdominal examination, a mass was felt in right lower abdomen, mass was freely movable side-to-side. There was no tenderness on palpation. On per vaginum examination, an abdominopelvic mass of 20 weeks size was felt. Her ultrasound scan showed bulky uterus with large right- sided posterior wall subserous myoma. Patient was taken for laparotomy, a large fibroid was seen in right broad ligament. Key words: Pseudocyesis, broad ligament myoma, broad ligament fibroid
E
xtrauterine fibroids are not as common as uterine fibroids.1 Among the extrauterine fibroids, broad ligament fibroids are the most common to occur, although its overall incidence being rare, because of its rarity it poses specific diagnostic difficulties causing an error in making the final diagnosis and therefore the management. This is one such case report, where patient presented in antenatal OPD for antenatal check-up and was diagnosed to be a case of broad ligament myoma. Case Report
A 40-year-old woman came to our antenatal OPD with complaints of six months amenorrhea with gradual enlargement of abdomen and pain in lower abdomen for last two months. She was P4L4A1, all were normal deliveries with last child birth 15-year back. Her previous menstrual cycles were regular. She was the known case of hypothyroidism and hypertension.
side-to-side. There was no tenderness on palpation. On per vaginum examination, an abdominopelvic mass of 20 weeks size was felt. Bilateral fornices were nonpalpable and nontender. Her clinical diagnosis of large uterine fibroid was made and she was further investigated. Her routine investigations including hemogram, liver function test (LFT), kidney function test (KFT), urine examination were normal. Her ultrasound scan showed bulky uterus with large right-sided posterior wall subserous myoma. With a probable diagnosis of huge fibroid uterus, patient was taken for laparotomy. Operative Findings zz Uterus was bulky in size zz Bilateral ovaries were normal
On examination, her vitals were stable and systemic examination was normal, on per abdominal examination a mass of approximately 10 Ă&#x2014; 12 cm size was felt in right lower abdomen, mass was freely movable *Lecturer **Professor and Head Dept. of Obstetrics and Gynecology SN Medical College, Agra, UP Address for correspondence Dr Anu Pathak W/o Dr Vinit Pathak 238-A, New Agra, Bye Pass Road, Agra - 282 005, UP E-mail: dr.anupathak@ymail.com
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Figure 1.
Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
CASE REPORT zz
zz
A large fibroid was seen in right broad ligament. It was measuring 20 × 15 cm in size and firm in consistency. Ureter was traced and myoma was enucleated carefully.
Her total abdominal hysterectomy with bilateral salpingo-oophorectomy was done. Patient had uneventful postoperative recovery. Stitches were removed on 9th postoperative day and she was discharged on 10th postoperative day. Discussion Leiomyomas are not uncommon in the round, ovarian and broad ligaments.2 They are often found in association with similar uterine tumors and their pathology and complications are the same.3 Broad ligament leiomyomas are of two types either a uterine tumor (usually cervical), which grows into the broad ligament (false broad ligament tumor) but preserves uterine attachment or a primary (true) broad ligament leiomyoma arising from the subperitoneal connective tissue of the ligament.
It is the anatomy of these tumors, which makes them important clinically. They are extraperitoneal and therefore remain fixed in the pelvis, displacing uterus to one side. The true broad ligament tumor may lie lateral to the ureter but the false broad ligament tumor is always medial to it. This is important in estimating the course of the ureter during surgery. In pregnancy, broad ligament leiomyomas are likely to obstruct labor and to cause retention of urine. In nonpregnant state, they may cause hydronephrosis. The symptoms they cause are those resulting from pressure on adjacent organs, or the patient may notice a lower abdominal tumor. Their removal can be difficult and hazardous chiefly because of the risk to the ureter. References 1. Gowri V, Sudhesndra R, Oumachigui A, Sankaran V. Giant broad ligament leiomyoma. Int J Gynaecol Obstet 1992;37(3):207-10. 2. Berek JS. Benign diseases of the female reproductive tract. In: Novak’s Gynecology. 13th edition, Lippincott Williams and Wilkins: Philadelphia 2002:p380. 3. Jeffcoate’s Principles of Gynaecology. 5th edition, Arnold Publishers 2001;Ch.27:p.500-3.
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CASE REPORT
Pregnancy in an Untreated Ectopia Vesicae Premalatha HL*, Manjunath
ABSTRACT Reports of pregnancies in women with ectopia vesicae have been reported in literature, but these are cases with corrected ectopia vesicae. We are reporting pregnancy in a woman with uncorrected ectopia vesicae. Key words:
I
ncidence of ectopia vesicae is 1 in 50000 births. It is of two varieties, complete and incomplete. Complete variety is more common. Male to female ratio being 4:1. In females, there will be cleft clitoris and the labia minora are separated anteriorly exposing the vaginal orifice. Separation of pubic bone also seen. Case Report A 35 year old elderly primigravida married for 13 years with uncorrected ectopia vesicae came with history of 7 months of amenorrhoea. She is a unbooked pregnant woman with the first antenatal check up at 7th month and then she did not come for follow up. She came back at 9th month with labour pains. On examination we found deficient lower anterior abdominal wall with bladder exstrophy, with short vagina about 1 inch, cervix not visualized. She was taken for emergency cesarean operation. A midline vertical incision was taken on the upper abdomen and live female term baby was delivered by classical cesarean section as the lower segment of uterus was not approachable. She recovered well and both mother and baby were discharged in good condition on the 7th post operative day with an advice to come for follow up for further management of ectopia vesicae. But she never came for follow up.
Before surgery
Intra ureter catheterization
Upper abdominal approach
References 1. Njoku O, Wedderbum K, Pregnancies following a treated Ectopia Vesicae, Port Harcourt Med J 2006;1(1):62-4. 2. A case of ectopia vesicae in an elderly woman. Br J Urol 1955;27(3):232-4. 3. Zimmer M, Omanwa K, Kolaczyk W, et al. Pregnancy in a women with treated bladder extrophy, split pelvis and hypoplasia of ishcheal bones. Case report, Neuroendocrinol Lett 2008;29(3):292-4. 4. Journal of gynaecology obstet Biol Reprod (Paris) 1984; 13(8):5. 5. Br J Urol. 1955;27(3);232-49-55-4.
*Assistant Professor Dept. of Obstetrics and Gynecology Hassan Institute of Medical Sciences, Hassan, Karnataka Address for correspondence Dr Premalatha HL Assistant Professor Dept. of Obstetrics and Gynecology Hassan Institute of Medical Sciences, Hassan, Karnataka E-mail: premalatha.gowda@yahoo.in
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6. Burbiqe. KA, Hensle TW, Chambers WJ. Pregnancy and sexual function in women with bladder exstrophy. Urol 1986;28(1):12-4. 7. CAB Clemetson MA, Pregnancy in a women with treated Ectopia Vesicae and split pelvis, BJOG, 1958;65(6):973-81. (DOI: 10.11.11/j.1471-0528.tb08591.x) published online: 23/08/2005.
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Asian Journal of Obs and Gynae Practice, Vol. 2, April-June 2013
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Answers 1. This is a picture of hydrosonography showing a polyp in the endometrial cavity along with balloon of Foleyâ&#x20AC;&#x2122;s catheter. 2. Symptoms of this patient will be moderate-to-severe menorrhagia with prolonged duration of bleeding. 3. Endometrial aspiration (EA) can be done for histopathology. If no malignant element, hysteroscopic polypectomy can be done. If EA or polypectomy specimen reveals malignancy, complete surgery may be required.
3. How will you treat the condition? 2. What will be symptoms of this patient? 1. What is this picture showing?
Questions
Photo Quiz
AIIMS, New Delhi Dept. of Obstetrics and Gynecology Additional Professor Dr Nutan Agarwal
PHOTO QUIZ
FLOW CHART
Dr Vidushi Kulshrestha Senior Research Associate
Dr Alka Kriplani
Management of Abruptio Placentae
Professor and Head of Unit II Dept. of Obstetrics and Gynecology AIIMS, New Delhi
Abruptio placentae
zz zz
zz zz
General and abdominal examination Fetal status
Assess clotting status using bedside clotting test Transfuse as necessary
Yes
No
Bleeding heavy
Revealed Resuscitation
Concealed
zz zz
Observe urine output
zz
Patient not in labor
FHS
Injection morphine Fresh blood transfusion Periodic coagulation profile
zz
Patient in labor
If IUD ARM + Oxytocin if needed
Normal or absent FHS
Abnormal
>38 weeks
<38 weeks
Perform rapid vaginal delivery
ARM + Oxytocin if needed
Not possible
ARM + Oxytocin zz
If fetus alive Bleeding stops No uterine tenderness FHS present
Bleeding PV continuing
zz zz
No response Falling fibrinogen level Oliguria
CS
Rupture the membrane with an amniotic hook or Kocher clamp
If contractions poor, augment labor with oxytocin
CS
ARM Expectant treatment close monitoring
Try to continue the pregnancy upto 38 weeks but no tocolysis to be given
ARM: Artificial rupture of membranes CS: Cesarean section FHS: Fetal heart sound PV: Per vagina
Oxytocin
Hysterectomy (rare) (atonic uterus)
Source: Asian Journal of Obs and Gynae Practice
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