Ajog april june 2016 by IJCP

ISSN 0971-8788

Volume 2, Number 2, 2016

Asian Journal of

Obstetrics &

Gynecology Practice In this Issue Role of Endocrine Disruptors in Premature Menopause A Study of Somatic Status and Complications Among Female Hospitalized and Non-hospitalized Diabetic Patients from Mysore Urban Area Comparison of Laparoscopic-assisted Vaginal Hysterectomy and Non-descent Vaginal Hysterectomy: A Retrospective Study P osterior Reversible Encephalopathy Syndrome in Postpartum Normotensive Woman: A Rare Presentation Enlarged Ovaries Following IVF/ICSI as an Etiology of Obstructive Uropathy Resulting in Acute Renal Failure Omental Herniation: A Complication of Intraperitoneal Drain Bilateral Pregnancy Luteoma 59th All India Congress of Obstetrics & Gynaecology (AICOG 2016) Journal Scan

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Asian Journal of

Online Submission

Volume 2, Number 2, 2016

An IJCP Group Publication Corporate Panel Dr Sanjiv Chopra Prof. of Medicine and Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor Dr KK Aggarwal Group Editor-in-Chief IJCP Group, eMedinewS and eMediNexus Dr Veena Aggarwal MD, Group Executive Editor 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

Cardiology Dr Praveen Chandra Dr SK Parashar Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses Dr Sidhartha Das Dr A Ramachandran Dr Samith A Shetty Dr Vijay Viswanathan Dr V Mohan, Dr V Seshiah Dr Vijayakumar ENT Dr Jasveer Singh Dr Chanchal Pal

from the issue editor

Prolonged Overnight Fasting can Prevent Cancer

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 Garima Kachhawa Dentistry Dr KMK Masthan Dr Rajesh Chandna Gastroenterology Dr Ajay Kumar Dr Rajiv Khosla Dr JS Rajkumar Dermatology Dr Hasmukh J Shroff Dr Pasricha Dr Koushik Lahiri Dr Jayakar Thomas Nephrology Dr Georgi Abraham Neurology Dr V Nagarajan Dr Vineet Suri Dr AV Srinivasan Oncology Dr V Shanta Orthopedics Dr J Maheshwari

Anand Gopal Bhatnagar Editorial Anchor Advisory Body Heart Care Foundation of India Non-Resident Indians Chamber of Commerce and Industry World Fellowship of Religions

Alka Kriplani

FROM THE DESK OF the GROUP EDITOR-IN-CHIEF

Cardiologists and Gynecologists Need to Work Together

KK Aggarwal

Mukherjee (Kolkata)

Editorial Board

Obstetrics and Gynaecology Dr Alka Kriplani Dr Thankam Verma Dr Kamala Selvaraj

Contents

Review article

Role of Endocrine Disruptors in Premature Menopause 7 Shweta Pathak

Original Study

A Study of Somatic Status and Complications Among Female Hospitalized and Non-hospitalized Diabetic Patients from Mysore Urban Area 10 Prabhavathi SN, Charlotte G Karunakaran, Ashoka HG

Clinical study

Comparison of Laparoscopic-assisted Vaginal Hysterectomy and Non-descent Vaginal Hysterectomy: A Retrospective Study

Geeta Jain, sk Jha, U Palaria, G Joshi, pk Verma, N Pangti

Case report

Posterior Reversible Encephalopathy Syndrome in Postpartum Normotensive Woman: A Rare Presentation 21 Siva Sundari, KS Rajeswari, Nandhini Elumalai

Enlarged Ovaries Following IVF/ICSI as an Etiology of Obstructive Uropathy Resulting in Acute Renal Failure

Pratibha Vishwakarma, Priya Mohan, Kundavi Shankar, Thangam R Varma

Omental Herniation: A Complication of Intraperitoneal Drain Shweta Singh, Taru Gupta, Sangeeta Gupta

Asian Journal of Volume 2, Number 2, 2016

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

Bilateral Pregnancy Luteoma

P Thulasi, Shanthi M

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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 and 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.

Conference Update

59th All India Congress of Obstetrics & Gynaecology (AICOG 2016)

Research Review

Journal Scan

Increased Levels of Circulating Advanced Glycation EndProducts in Menopausal Women with Osteoporosis

Clinical Evaluation of Effects of Chronic Resveratrol Supplementation on Cerebrovascular Function, Cognition, Mood, Physical Function and General Well-Being in Postmenopausal Women—Rationale and Study Design

A Pilot Clinical Study of Resveratrol in Postmenopausal Women with High Body Mass Index: Effects on Systemic Sex Steroid Hormones

Benefits of Physical Exercise in Postmenopausal Women

Beyond Joints: a Review of Ocular Abnormalities in Gout and Hyperuricemia

Vitamin D Status and Cardio-Metabolic Risk in Indian Postmenopausal Women

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from the issue editor

Prolonged Overnight Fasting can Prevent Cancer

Dr Alka Kriplani

Professor and Head of Unit II Dept. of Obstetrics and Gynecology AIIMS, New Delhi

Jainism promotes not eating after sunset and Vipassana Meditation course does not allow eating after 5 pm. A western study has now shown that prolonging the overnight fasting interval may be a simple, nonpharmacological strategy for reducing a person's risk of breast cancer recurrence and even other cancers. Not eating in the evening and at night could reduce the risk for recurrence of breast cancer as per a study in the March 31 issue of JAMA Oncology. In a cohort of 2,400 women with early-stage breast cancer, it was found that fasting less than 13 hours per night was associated with a 36% higher risk for disease recurrence as compared with fasting 13 or more hours per night. A nonsignificant 22% higher risk for mortality from any cause was also observed among patients who fasted for shorter periods in comparison with those who fasted for 13 hours or more overnight. The authors also found that fasting fewer hours per night was associated with significantly less sleep and higher levels of glycosylated hemoglobin (HbA1C). Each 2-hour increase in nightly fasting duration was statistically significantly associated with a 0.37 mmol/mol lower HbA1c level (b = –0.37) and more hours of sleep per night (β = 0.20). ■■■■

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

FROM THE DESK OF the GROUP EDITOR-IN-CHIEF

Cardiologists and Gynecologists Need to Work Together

Prof. Dr KK Aggarwal

Group Editor-in-Chief IJCP Group, eMedinewS and eMediNexus

Look for Underlying Heart Disease in Endometriosis Endometriosis raises the summary risk for any coronary heart disease (CHD) by 62% overall and by a staggering 200% in women aged 40 or younger as per the analysis of Nurses' Health Study 2. The association between endometriosis and CHD was found to be consistent no matter how CHD was defined - myocardial infarction (MI), angina, or coronary bypass/angioplasty/stent. Women with endometriosis are known to have systemic, chronic inflammation, an atherogenic lipid profile, heightened oxidative stress and several overlapping risk factors for cardiovascular disease. It affects about 10% of women of reproductive age. Compared with women without endometriosis, women with endometriosis were 1.52 times more

likely to have an MI, 1.91 times more likely to develop angiographically confirmed angina and 1.35 times more likely to need coronary artery disease graft (CABG) surgery, a coronary angioplasty procedure or a stent. The association was independent of several potential confounders, including use of oral contraceptives and hormone replacement therapy. The research is published online March 29, 2016 in Circulation: Cardiovascular Quality Outcomes. The cardiologist does need to be aware of whether the woman has undergone surgical menopause, regardless of her age and that surgical menopause may confer cardiovascular risk. Prevention is the most critical piece of women in heart disease because once women get heart disease, their outcomes are significantly worse.

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Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

Review Article

Role of Endocrine Disruptors in Premature Menopause Shweta Pathak

Abstract Premature menopause or early menopause at a younger age is closely linked to an increased all-cause mortality, metabolic disorders, the onset of an accelerated decline in ovarian function and cardiovascular risk. The term Endocrinedisrupting chemical (EDC) refers to chemicals found in the external environment that have the ability to mimic or inhibit endogenous hormones. EDCs can cause premature menopause thereby affecting quality-of-life, fertility and longevity. Among several types of EDCs, supporting evidences has shown an association of perfluorochemicals, and onset of early menopause. Keywords: Premature menopause, endocrine-disruptors, perfluorochemicals, phthalates

remature menopause is a common entity, affecting approximately 1% of women younger than 40 years. Multisystem implications of premenopause are reported as a sequel to the premature deprivation of ovarian steroids causing unique healthrelated complications in these women.1 Premature menopause or early menopause at a younger age is closely linked to an increased all-cause mortality, metabolic disorders, the onset of an accelerated decline in ovarian function and cardiovascular risk. Moreover, early menopause also causes excessive bone loss, altered cognitive functions and mood, thereby impairing longevity and overall quality-of-life.2,3 The onset of an accelerated decline in ovarian function on early menopause is suggestive of reduced fertility at a very young age.2 Sex hormones including estrogens and testosterone are known to affect adipocyte physiology. The role of estrogens and estrogen receptors (ERs) in glucose and lipid metabolism is well-established. Therefore, alterations in metabolic signal often increases a risk of metabolic syndrome and cardiovascular diseases in women. The absence of estrogens is an alarming

Dept. of Pediatrics and Neonatology Fortis Escorts and Research Centre, Faridabad, Haryana Address for correspondence Dr Shweta Pathak Dept. of Pediatrics and Neonatology Fortis Escorts and Research Centre, Faridabad, Haryana E-mail: dr.shwetapgupta@gmail.com

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

sign of cardiovascular disease during the menopausal period. It is indicated by varying lipid profiles and excess accumulation of abdominal fats.4 Early Menopause and Endocrine-disrupting Chemicals Growing industrialization has led to the production of thousands of chemicals, thereby increasing concerns about its health consequences. Endocrine-disrupting chemicals (EDCs), that interfere with in vivo hormonal action, are of main concern.5 The term EDC refers to chemicals found in the external environment that have the ability to mimic or inhibit endogenous hormones. Most of these chemicals are industrial byproducts or contaminants and the rest are natural phytoestrogens found in plants and herbal supplements.6 Exposure to EDCs has been associated with increased risk of metabolic disorders, various cancers, cardiovascular diseases, reduced sperm quality, early puberty, infertility and pregnancy complications. Although the association between EDC exposure and age at menopause has not been well-established, a possible effect of EDCs can cause premature menopause thereby affecting qualityof-life, fertility and longevity. Among several types of EDCs, supporting evidences has shown an association of perfluorochemicals, and onset of early menopause.5 Estrogen plays a crucial role in puberty and the menopause of reproductive life in women; therefore it is important to investigate the estrogenic chemicals and other endocrine disrupters that might affect womenâ&#x20AC;&#x2122;s health.6 The prominent EDCs that target 7

review article primordial and preantral follicles include genistein, bisphenol-A (BPA) and diethylstilbestrol (DES).7 Moreover, the variety of EDCs including pollutants, plastic components, detergents, pesticides, sunscreens, cosmetics and hair dyes have been identiďŹ ed to exhibit an estrogenic properties.8 Approximately 800 chemicals are suspected to exhibit the characteristics of EDC.8 Some xenobiotics in the environment have the ability to modulate the ER activity and induce an adipogenic effect. Therefore, such endocrine disruptors play an important role in sexual behavior, menopause and some gonadal diseases. Numerous chemicals and compounds, including BPA, phthalates and heavy metals, exhibit estrogenic activity. Endocrine disruptors exhibit their effect by impairing the transcriptional activity of nuclear receptors by altering the action of competitively binding with ligand-binding domain, which may modify coactivator activity and dissociate corepressors that reduce deacetylases action. However, some endocrine disruptors may act by modifying the DNA methylation in the regulatory region of specific genes.4 Moreover, EDCs have been shown to affect trophoblast and placental function, the female hypothalamicpituitary-gonadal axis, onset of puberty and adult ovarian function. Additionally, it has also been proven that EDCs can alter the epigenome in a sexually dimorphic manner, thereby altering the germ line and perhaps may even lead to transgenerational effects.9 Perfluorocarbons

According to the largest study of the endocrinedisrupting effects of perfluorocarbons (PFC), women of perimenopausal and menopausal age are more likely to experience menopause if they have high serum concentrations of perfluorooctane sulfonate (PFOS) and perfluorooctanoic acid (PFOA) when compared to their peers. On examining endogenous estradiol concentrations with respect to PFC in the same age groups, only PFOS was reported to be inversely associated with estradiol levels. PFC have multiple toxic effects such as elevatesd lipids imposing cardiovascular risk and immunotoxicity. Owing to the fact that postmenopausal women do not bleed, the possibility of higher concentration of PFC in postmenopausal women cannot be neglected. Therefore, the 8

significance associated with an increased risk of menopause associated with increased PFC might be due to the disappearance of menses causing increases in PFC concentrations rather than an increase in PFC causing early menopause. This argument was supported by the evidences from Knox et al. In their study, women who had experienced hysterectomy had higher mean levels of PFC than their peers without hysterectomy. These results suggest that the increased PFC exposure could be the natural result of menopause or hysterectomy.2 Animal studies have demonstrated the estrogen-like properties of PFOA, causing degeneration of ovaries in PFOA-exposed females.2 On assessing the levels of estrogen and the onset of menopause, an inverse association between PFC sulfonate and estrogen in both perimenopausal and menopausal groups, suggesting a potential association to early menopause was reported.8 Phthalates

Phthalates is a ubiquitous class of environmental chemicals that is believed to alter the typical reproductive hormone production both in utero and in adulthood. It has been observed that phthalates, particularly di-2-ethylhexyl phthalate (DEHP), may suppress estrogen production and thus, have the ability to alter sexual function.10 Barrett and colleagues collected data from 360 women participating in a pregnancy cohort study and evaluated the association between urinary concentrations of phthalate metabolites and reduced sexual desire and vaginal dryness. Women with highest urinary concentrations of mono-2-ethyl-5hydroxyhexyl phthalate, a DEHP metabolite showed 2.58 (confidence interval [CI] = 95%, 1.33, 5.00) times the adjusted odds of reporting, suggesting that they often or always experienced low sexual desire and results were similar for mono-2-ethyl-5-oxohexyl phthalate (odds ratio [OR]: 2.56, CI = 95%, 4.95). However, vaginal dryness reported by participants was not associated with any phthalate metabolite concentration.10 Evidences - EDC can Alter Onset of Puberty/Timing of Menopause The established link between long-term exposure to estrogen and the risk of developing a gynecological Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

Review article cancer supports the onset of puberty and timing of menopause as important risk factors. The onset of early puberty has been reported to be linked with exposure to EDC, such as dichlorodiphenyltrichloroethane (DDT), dichlorodiphenyldichloroethylene (DDE) and polybrominated biphenyls (PBB).

References

A recent report from the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey (NHANES, 2003-2008), stated a close association between concentrations of 2,5-DCP, the major metabolite of dichlorobenzene and early onset of puberty.

3. Faubion SS, Kuhle CL, Shuster LT, Rocca WA. Long-term health consequences of premature or early menopause and considerations for management. Climacteric. 2015; 18(4):483-91.

Early menopause is likely to increase the risk of endometrial cancer, especially in obese women, while women exposed to DES are likely to be at increased risk of early menopause. Evidences have shown that exposure to methoxychlor, advanced reproductive senescence in female rats and exposure to the polychlorinated biphenyl (PCB) mixture A1221 in utero caused elongation of an estrous cycles, which is suggestive of reproductive aging.8 Applying hormone therapy has shown benefits in minimizing some of these risks of early menopause. Therefore, cumulative evidences suggest undertaking hormone therapy at least until the women reach her natural age of menopause. It is important to personalize the hormone therapy, and higher dosages may be required to approximate physiological concentrations found in premenopausal women.3

1. Torrealday S, Pal L. Premature Menopause. Endocrinol Metab Clin North Am. 2015;44(3):543-57. 2. Knox SS, Jackson T, Javins B, Frisbee SJ, Shankar A, Ducatman AM. Implications of early menopause in women exposed to perfluorocarbons. J Clin Endocrinol Metab. 2011;96(6):1747-53.

4. Lizcano F, Guzmán G. Estrogen deficiency and the origin of obesity during menopause. Biomed Res Int. 2014;2014:757461. 5. Grindler NM, Allsworth JE, Macones GA, Kannan K, Roehl KA, Cooper AR. Persistent organic pollutants and early menopause in U.S. women. PLoS One. 2015; 10(1):e0116057. 6. McLachlan JA, Simpson E, Martin M. Endocrine disrupters and female reproductive health. Best Pract Res Clin Endocrinol Metab. 2006;20(1):63-75. 7. Mark-Kappeler CJ, Hoyer PB, Devine PJ. Xenobiotic effects on ovarian preantral follicles. Biol Reprod. 2011;85(5):871-83. 8. Gibson DA, Saunders PT. Endocrine disruption of oestrogen action and female reproductive tract cancers. Endocr Relat Cancer. 2014;21(2):T13-31. 9. Fowler PA, Bellingham M, Sinclair KD, Evans NP, Pocar P, Fischer B, et al. Impact of endocrine-disrupting compounds (EDCs) on female reproductive health. Mol Cell Endocrinol. 2012;355(2):231-9. 10. Barrett ES, Parlett LE, Wang C, Drobnis EZ, Redmon JB, et al. Environmental exposure to di-2-ethylhexyl phthalate is associated with low interest in sexual activity in premenopausal women. Horm Behav. 2014;66(5):787-92.

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Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

Original Study

A Study of Somatic Status and Complications Among Female Hospitalized and Non-hospitalized Diabetic Patients from Mysore Urban Area Prabhavathi SN*, Charlotte G Karunakaran†, Ashoka HG‡

Abstract In recent years, India has undergone rapid urbanization and socioeconomic development. Changes in time trends have resulted in erratic lifestyle, characterized by physical inactivity, unhealthy eating habits and resultant increase in obesity and diabetes. Diabetes is a major cause of mortality and morbidity in India and its prevalence is increasing at an alarming rate. Chronic complications of diabetes, especially coronary artery diseases and chronic renal diseases results in frequent hospitalization. The main aim of the investigation was to study the somatic status and diabetic complications among the female hospitalized and non-hospitalized patients. A total of 80 female volunteers (40 hospitalized and 40 non-hospitalized) of a private hospital in Mysore, with known history of type 2 diabetes mellitus for more than 2 years, were recruited for the study. The tools were developed to collect information on personal history, demography, socioeconomic status, dietary habits and anthropometric measurements. Suitable statistical analysis was applied to the data. The results projected that majority of the patients were hospitalized on an average of at least three times a year. More than 90% of the subjects exhibited blood sugar >300 mg on admission. The reason for high morbidity status included poor dietary habits and erratic lifestyle practices among the female hospitalized patients as compared to non-hospitalized patients. Adapting a healthy lifestyle and maintenance of normal blood sugar level can reduce the incidence of complications and hospitalization among the subjects. Keywords: Urbanization, socioeconomic development, obesity, diabetes, somatic status, diabetic complications, hospitalized and non-hospitalized patients

iabetes is a multifactorial disease that combines hereditary and environmental factors. The prevalence of diabetes is increasing globally. Diabetes is pandemic in both developed and developing countries. In the year 2000, it was estimated that there are 175 million diabetics worldwide and expected to increase to 354 million by the year 2030.

Based on a compilation of studies from different parts of the world, World Health Organization (WHO) has projected that the maximum increase in diabetes would occur in India.1 Presently, India is facing a major healthcare burden due to the high prevalence of type 2 diabetes as it is a major cause of mortality and morbidity in India, and is increasing at an alarming rate. Genetic predisposition superimposed by erratic *Dept. of Studies in Food Science and Nutrition Manasagangothri, Mysore, Karnataka † Clinical Nutritionist Aaditya Hospital, Mysore, Karnataka ‡ Assistant Professor Dept. of General Medicine JSS Medical College and Hospital, JSS University, Mysore, Karnataka Address for correspondence E-mail: pprabhavathisn@gmail.com

lifestyle - physical inactivity, unhealthy eating habits is one of the major causes for increase of diabetes in India. The prevalence of type 2 diabetes is found to be 4-6 times higher in the urban areas as compared to rural areas. The onset of diabetes among Indians is about a decade earlier than their western counterparts and this has been noted in Asian Indians in several studies. Studies show that among urban Asian Indians even minor changes in body mass index (BMI) central adiposity tilts the metabolic balance towards hyperglycemia/insulinemia. Asian Indians are said to have higher upper body adiposity measured as waist-hip ratio (WHR). The cutoff values for normal waist circumference were 80 cm and 0.8 for WHR among women.2 The cardiometabolic risk associated with abdominal obesity is attributed to the presence of visceral adipose tissue (VAT), which promotes insulin resistance, dyslipidemia and hypertension.3-5 A national survey of diabetes in the year 2000 conducted in six major cities in India reported 54.1% of diabetes developed in most productive years of life and had higher risk of developing complications of diabetes.6,7 Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

original Study Asian dyslipidemia is characterized by high serum levels of triglycerides (TG) and lipoprotein a {Lp(a)}, borderline high levels of low-density lipoprotein (LDL) and low levels of high-density lipoprotein (HDL) cholesterol. Asian Indians have high ratio of total cholesterol (TC) to HDL, TG/HDL and apoB/apoA.8-10 These ratios are highly correlated with premature incidence and severity of coronary artery disease (CAD) as well as acute myocardial infraction among Asian Indians. On an average, diabetic patients stay in the hospital 1-3 days longer than patients without diabetes. The prevalence of micro- and macrovascular complications were more in Asians when compared to Europeans. Acute and chronic complications of diabetes, especially cardiovascular diseases (CVDs), results in hospitalization of many patients with diabetes.11 The projections of the present study throw light on the Mysore female diabetic subjects and can be used to develop prevention strategies by consulting physicians.

MUAC (cm) was measured on the right arm at the point between the tip of shoulder and tip of olecranon in the elbow bent at 90°.

Skin fold thickness (mm) was measured according to the protocol described by Durmin and Womersley (1) using skin fold calipers (beta-technology incorporated; USA).

Triceps skin fold (mm) was measured at mid-point of right arm elbow, bent at 90° on the lateral side.

Waist circumference (cm) was measured midway between the lateral ribs and iliac crests. The subjects were asked not to tuck their stomach in, and the measurement was taken in gentle expiration. Their clothes were loosened around the waist area.

Hip circumference (cm) was measured at the widest part over the trochanters with the feet kept 25-30 cm apart.

Methodology

Statistical Analysis

A total of 80 volunteers (40 non-hospitalized and 40 hospitalized) with known history of type 2 diabetes mellitus for more than 2 years were recruited for the study. Volunteers willing to participate and belonging to the age group of 30-70 years with no history of hormonal therapy or hyperthyroidism were included as subjects. Anthropometric measurements like height, weight, mid-upper-arm circumference (MUAC), triceps skin fold (TSF), were recorded using standard procedures.12 Indices viz. BMI, WHR were calculated as an index of obesity. Biochemical assessment included fasting blood sugar (FBS), postprandial blood sugar (PPBS) and lipid profile. The values were recorded from the medical record of the patients. A pretested questionnaire was applied to elicit information. Description of the methods applied to collect the data is given below.

The collected data was compiled for obtaining mean ± SD. Student t-test was used for comparison of groups. All the analysis was done using windows based SPSS statistical package (version 11.0). Significant figures used; 0.05 < p < 0.10* Moderately significant, 0.01 < p ≤ 0.05** Strongly significant p ≤ 0.01. Results

Anthropometric Measurements

The baseline characteristics of the subjects are shown in Table 1. From among the 80 subjects, 40 were hospitalized and the other 40 non-hospitalized. The mean age of the subjects was 57 (hospitalized) and 60 (non-hospitalized) years. Majority of the subjects from both the groups (74%) reported to have family history of diabetes. It was observed that majority (32%) of hospitalized subjects developed diabetes at an younger age (35-45 years), while among the non-hospitalized subjects the onset was after 45 years of age (37%).

Height (cm) was measured with the subject standing, back to a stadiometer in the base feet. Feet were kept parallel with the heels together. The moving arm of the stadiometer was lowered to touch the top of the head and height was measured to the nearest 1.0 mm. Weight (kg) was measured to the nearest 0.005 kg with a weighing machine, which was calibrated daily by using known 5 kg weights.

A considerably higher percentage of the subjects were found to have basic primary school education (40%) and 30% were illiterate. High majority (47%) of the subjects were found to be daily wagers and were economically backward and belonged to the among the hospitalized group. Diet history showed that a high percentage (68%) of the subjects were nonvegetarians. It is noteworthy to mention that a significantly higher

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

original Study Table 1. Baseline Characteristics of the Subjects

Age (years) ≥35-<45 ≥45-<55 ≥55-<65 >65

Hospitalized (n = 40)

Nonhospitalized (n = 40)

Total (n = 80) Percentage

4 (10) 10 (26) 13 (32) 13 (32.5)

3 (7) 9 (23) 12 (30) 16 (40)

7 (8.7) 19 (23.7) 25 (31.3) 29 (36.3)

13 (32) 08 (20) 12 (30) 07 (18)

07 (18) 15 (37) 8 (20) 10 (25)

25 (20) 29 (23) 25 (20) 21 (17)

40 (100) -

80 (100) -

10 (25) 14 (35) 8 (20) 8 (20)

13 (32.5) 10 (25) 10 (25) 7 (17.5)

24 (30) 18 (22.5) 15 (18.7) 23 (28.8)

Age of onset of diabetes ≥35-<45 ≥45-<55 ≥55-<65 >65

Table 2. Mean + SD Anthropometric Measures and Indices Parameters

Hospitalized patients n = 40

Nonhospitalized patients n = 40

p-value

Height (cm)

157.4 ± 5.4

157.4 ± 5.8

1.000

Weight (kg)

63.2 ± 10.1

58.8 ± 7.5

0.031*

BMI (kg/m )

25.9 ± 4.2

23.6 ± 2.9

0.005**

Waist (cm)

88.6 ± 10.5

85.8 ± 6.1

0.219

WHR (cm)

0.83 ± 0.04

0.81 ± 0.03

0.204

MUAC (cm)

28.0 ± 3.7

26.8 ± 2.6

0.093

TSF (cm)

19.6 ± 2.7

20.9 ± 2.8

0.038

Marital status Married Unmarried Education Illiterates 1-7th 8-10th PUC and above

Family history of diabetes mellitus Yes No

30 (75) 10 (25)

29 (73) 11 (27)

59 (74) 21 (26)

4 (10) 19 (47.5) 8 (20) 4 (10) 5 (12.5)

9 (22.5) 11 (27.5) 12 (30) 8 (20)

4 (5) 28 (35) 19 (23.8) 16 (20) 13 (16.2)

14 (35) 26 (65)

12 (30) 28 (70)

26 (32) 54 (68)

Income: ≥5,000 10-20,000 20-40,000 40-60,000 >60,000 Type of diet Vegetarians Nonvegetarians

mean body weight (p = 0.031) and BMI (p = 0.005) was seen among the hospitalized subjects while, TSF (0.038) was significantly higher among the non-hospitalized subjects. Waist circumferences was above the normal cut-off level (>80 cm) recommended for Asian Indians in both the groups. Protein status as indicated through MUAC was within the normal range (Table 2). Different comorbid conditions of the subjects are presented in Table 3. Sixty-two percent of the hospitalized subjects had myocardial infarction as a 12

Table 3. Complications and Duration of Diabetes Hospitalized patients

Non-hospitalized patients

Complications

Duration of diabetes

Myocardial infarction

COPD

CKD

>15

major complication. The mean duration of diabetes among these subjects was found to be 8 years. Among the non-hospitalized subjects, though the duration of diabetes was longer, complication of myocardial infarction was found only in 22% of the subjects. Among the subjects, chronic obstructive pulmonary disease (COPD) appeared to be a common complication in both the groups. It was observed that subjects having diabetes for more than 15 years developed chronic kidney diseases (CKDs), which accounted for 13% among hospitalized and 7% in non-hospitalized subjects. The correlation of somatic measures with biochemical parameters are presented in Table 4. Significant associations were observed in hospitalized subjects against various body and biochemical parameters. Higher BMI showed significant association with TC and LDL. Hip circumference showed inversely significant relationship with LDL. BMI showed moderately significant association with FBS only in non-hospitalized subjects (Table 5). Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

original Study Table 4. Mean Biochemical Parameters of the Subjects HP

NHP

t-value

p-value

Biochemical parameters (mg)

199.5 ± 36.7

198.0 ± 35.8

0.179

0.858

HDL

46.4 ± 13.2

40.4 ± 7.4

2.57

0.012

LDL

119.6 ± 31.2

112.7 ± 30.4

1.00

0.315

TGs

157.1 ± 59.9

146.4 ± 35.8

0.98

0.331

FBS

176.7 ± 68.3

158.0 ± 23.5

1.63

0.107

PPBS

326.2 ± 99.8

267.2 ± 62.7

3.16

0.002

HP = Hospitalized; NHP = Non-hospitalized; TGs = Triglycerides

Table 5. Correlation for Somatic Measures

Table 6. Correlation of Biochemical Parameters

Parameters

BMI

Hospitalized patients

Non-hospitalized patients

T. Cho

0.016*

LDL

0.015*

FBS

0.041*

PPBS

Hip circumference

LDL

0.018*

WHR

LDL

0.038*

TSF

LDL

0.042*

FBS

Hospitalized patients TGL

0.016*

PPBS

0.0002**

Non-hospitalized patients

PPBS

HDL

0.004**

Triglyceride

T.Cho

0.0001**

LDL

0.001**

**Highly significant

Discussion

Insulin resistance has been demonstrated to be a characteristic feature of Asian Indians. In the present study, the onset of diabetes was found to be between the age groups of 35-45 years and all the subjects reported family history of diabetes. The mean age of onset of diabetes was found to be 35 years. Several studies on the Asian population reveal that the onset of diabetes is seen before the age of 50 years and at the time of diagnosis of diabetes most of them had developed micro- and macrovascular complications.18 Familial aggregation, a typical feature of the Indian population, could be one of the cause for early onset of diabetes among the subjects.

Epidemiological studies conducted in southern India show a steady increase in the prevalence of diabetes in the urban population. The earlier reports from Chennai showed a male preponderance in the prevalence of diabetes, which in subsequent years had shifted slightly towards a female excess.6,7,13-16 In India, nearly 75% of the type 2 diabetics have first-degree family history of diabetes indicating a strong familial aggregation. Risk factors for developing type 2 diabetes, peculiar to the Indian population, are high familial aggregation, central obesity, insulin resistance and lifestyle changes due to urbanization.17

The three urban diabetic surveys conducted in 1989, 1995 and 2000 in randomly collected areas in the city of Madras (now known as Chennai) reported no significant time-related change in the prevalence of obesity as measured by BMI.7,13 Analysis of these surveys showed, that among the diabetic women, a higher percentage had BMI of 23-24.9 kg/m2,19 The normal cut-off values for Asian Indians are below 23 kg/m2. A BMI of ≥25 kg/m2 has been considered to indicate different grades of obesity. In the present study, the hospitalized patients had a mean BMI of 25.9 and 23.6 among the non-hospitalized subjects.7 A peculiar

*Moderately significant, NS = Not significant

Correlation between various biochemical parameters are shown in Table 6. Significant association was found between FBS and TG only among hospitalized subjects. Those with high FBS also had high PPBS among the hospitalized subjects. While among nonhospitalized subjects PPBS was highly significant with HDL. TG showed significant correlation with TC and LDL among only the non-hospitalized subjects.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

original Study pattern was observed among the study population that, there was no significant association between BMI and PPBS in the hospitalized subjects while, non-hospitalized subjects had significant association with only FBS. Studies show that the factors, which influence the BMI and the WHR have also frequently lacked specificity with respect to women.7,13 Central obesity is common among Indians despite low rates of general obesity and this android pattern of body fat typified by more upper body adiposity measured as WHR was found to be a greater risk factor as compared to general obesity. The cut-off values for normal waist circumference are 80 cm and 0.8 for WHR in women.20-22 Asian Indians have higher upper body adiposity measured as WHR. This has been suggested to be a superior predictor of CVD risk because it includes a measurement of hip circumference, which is inversely associated with dysglycemia, dyslipidemia, diabetes, hypertension, CVD and death.23-27 The present study population also exhibited higher WHR as compared to the Asian standards. This could be one of the major causes for dyslipidemia exhibited by the subjects. Increasing evidence suggests that waist and hip circumferences have independent and opposite associations with glucose and lipid levels and risk of diabetes and CVD.28,29 Study by Ramachandran et al17 has reported that Asian Indians require higher levels of plasma insulin to maintain normoglycemia; they also have other features of insulin resistance such as central obesity and high percentage of body fat in comparison to many other populations. Significant association was found between various lipid profile parameters and blood sugar levels in hospitalized subjects, while for non-hospitalized subjects PPBS was strongly associated with HDL and TG with TC and LDL. Based on the available published data there is a paucity of reliable data on diabetes related complications among people worldwide. A common complication of diabetes and the most common cause of mortality in people with diabetes is CVD.18 This was prominently seen among hospitalized subjects who had blood sugar levels of >300 mg% on admission. The most common complications seen was myocardial infarction followed by COPD and CKD. Among the subjects majority were hospitalized on an average of at least 3 times a year. The reason for hospitalization included; myocardial 14

infraction, COPD and/or nephropathy. More than 90% of the subjects exhibited blood sugar >300 mg on admission despite being on oral hypoglycemic agents. Evaluation of elevated blood sugar revealed-poor dietary habits, irregular meal timings, festive occasions, physical inactivity and poor morbidity status. Conclusion The main findings of the study were that, majority of the subjects had onset of diabetes mellitus at the mean age of 35 years. This early onset of diabetes will result in higher diabetes related complications at an earlier age, which can lead to increased mortality in the productive years of life. There is an urgent need to prevent diabetes and its complications rather than simply treat it once established. Patients should be ducated for lifestyle changes such as weight control, increased physical exercise and smoking cessation, which are potentially beneficial in preventing diabetes mellitus and CAD. The limited data available on gender-wise, regionwise diabetes complication rates highlight the need for nation-specific and population-specific studies. Furthermore, the morbidity and mortality caused by diabetes mellitus can be reduced by secondary prevention through regular screening, early detection and appropriate treatment of chronic complications. References 1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27(5):1047-53. 2. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med. 1992;327(19):1350-5. 3. Tchernof A, Lamarche B, Prud’Homme D, Nadeau A, Moorjani S, Labrie F, et al. The dense LDL phenotype. Association with plasma lipoprotein levels, visceral obesity, and hyperinsulinemia in men. Diabetes Care. 1996;19(6):629-37. 4. Pouliot MC, Després JP, Nadeau A, Moorjani S, Prud’Homme D, Lupien PJ, et al. Visceral obesity in men. Associations with glucose tolerance, plasma insulin, and lipoprotein levels. Diabetes. 1992;41(7):826-34. 5. Després JP, Moorjani S, Lupien PJ, Tremblay A, Nadeau A, Bouchard C. Regional distribution of body fat, plasma lipoproteins, and cardiovascular disease. Arteriosclerosis. 1990;10(4):497-511.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

original Study 6. Ramaiya KL, Kodali VR, Alberti KG. Epidemiology of diabetes in Asians of the Indian subcontinent. Diabetes Metab Rev. 1990;6(3):125-46. 7. Ramachandran A, Snehalatha C, Dharmaraj D, Viswanathan M. Prevalence of glucose intolerance in Asian Indians. Urban-rural difference and significance of upper body adiposity. Diabetes Care. 1992;15(10):1348-55. 8. Enas EA. How to beat the heart disease epidemic among south Asians; a prevention and management guide for asian Indians and their doctors. Downers Grove IL; Advanced Heart Lipid Clinic USA; 2007. 9. Smith J, Cianflone K, Al-Amri M, Sniderman A. Body composition and the apoB/apoA-I ratio in migrant Asian Indians and white Caucasians in Canada. Clin Sci (Lond). 2006;111(3):201-7. 10. Sierra-Johnson J, Somers VK, Kuniyoshi FH, Garza CA, Isley WL, Gami AS, et al. Comparison of apolipoprotein-B/ apolipoprotein-AI in subjects with versus without the metabolic syndrome. Am J Cardiol. 2006;98(10):1369-73. 11. Chowdhury TA, Lasker SS. Complications and cardiovascular risk factors in South Asians and Europeans with early-onset type 2 diabetes. QJM. 2002;95(4):241-6. 12. Jelliffee DB. The Assessment of the Nutritional Status of the Community. WHO Monograph Series no. 53. Geneva: World Health Organization, 1966. 13. Ramachandran A, Snehalatha C, Latha E, Manoharan M, Vijay V. Impacts of urbanisation on the lifestyle and on the prevalence of diabetes in native Asian Indian population. Diabetes Res Clin Pract. 1999;44(3):207-13. 14. Iyer R, Upasani S, Baitule MN. Diabetes mellitus in Dombivli – an urban population study. 17th International Diabetes Federation Congress. Mexico city. Diabetes Res Clin Pract. 2000;50(Suppl 1):519. 15. Mohan V, Shanthirani S, Deepa R, Premalatha G, Sastry NG, Saroja R; Chennai Urban Population Study (CUPS No. 4). Intra-urban differences in the prevalence of the metabolic syndrome in southern India - the Chennai Urban Population Study (CUPS No. 4). Diabet Med. 2001;18(4):280-7. 16. Verma NPS, Madhu SV. Prevalence of known diabetes in urban east Delhi. Diabetes Res Clin Pract. 2000;50 (Suppl 1):121. 17. Davey G, Ramachandran A, Snehalatha C, Hitman GA, McKeigue PM. Familial aggregation of central obesity in Southern Indians. Int J Obes Relat Metab Disord. 2000;24(11):1523-7.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

18. Ramachandran A, Snehalatha C, Satyavani K, Sivasankari SS, Vijay V. Metabolic syndrome in urban Asian Indian adults - a population study using modified ATP III criteria. Diabetes Res Clin Pract. 2003;60(3):199-204. 19. Ramachandran A, Snehalatha C, Vijay V. Temporal changes in prevalence of type 2 diabetes and impaired glucose tolerance in urban southern India. Diabetes Res Clin Pract. 2002;58(1):55-60. 20. Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK, et al; Diabetes Epidemiology Study Group in India (DESI). High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diabetologia. 2001;44(9):1094-101. 21. Pope SK, Sowers MF, Welch GW, Albrecht G. Functional limitations in women at midlife: the role of health conditions, behavioral and environmental factors. Womens Health Issues. 2001;11(6):494-502. 22. Luke A, Durazo-Arvizu R, Rotimi C, Prewitt TE, Forrester T, Wilks R, et al. Relation between body mass index and body fat in black population samples from Nigeria, Jamaica, and the United States. Am J Epidemiol. 1997;145(7):620-8. 23. Willett WC. Anthropometric measures and body composition. In: Nutritional Epidemiology. Oxford University Press: New York 199:p.244-72. 24. Seidell JC, Pérusse L, Després JP, Bouchard C. Waist and hip circumferences have independent and opposite effects on cardiovascular disease risk factors: the Quebec Family Study. Am J Clin Nutr. 2001;74(3):315-21. 25. Okura T, Nakata Y, Yamabuki K, Tanaka K. Regional body composition changes exhibit opposing effects on coronary heart disease risk factors. Arterioscler Thromb Vasc Biol. 2004;24(5):923-9. 26. Lissner L, Björkelund C, Heitmann BL, Seidell JC, Bengtsson C. Larger hip circumference independently predicts health and longevity in a Swedish female cohort. Obes Res. 2001;9(10):644-6. 27. Heitmann BL, Frederiksen P, Lissner L. Hip circumference and cardiovascular morbidity and mortality in men and women. Obes Res. 2004;12(3):482-7. 28. Snijder MB, Dekker JM, Visser M, Yudkin JS, Stehouwer CD, Bouter LM, et al. Larger thigh and hip circumferences are associated with better glucose tolerance: the Hoorn study. Obes Res. 2003;11(1):104-11. 29. Snijder MB, Dekker JM, Visser M, Bouter LM, Stehouwer CD, Kostense PJ, et al. Associations of hip and thigh circumferences independent of waist circumference with the incidence of type 2 diabetes: the Hoorn Study. Am J Clin Nutr. 2003;77(5):1192-7.

Clinical study

Comparison of Laparoscopic-assisted Vaginal Hysterectomy and Non-descent Vaginal Hysterectomy: A Retrospective Study Geeta Jain*, sk Jha†, U Palaria‡, G Joshi#, pk Verma¥, N Pangti$

Abstract Objective: To compare the two techniques of hysterectomy, laparoscopic-assisted vaginal hysterectomy (LAVH) and nondescent vaginal hysterectomy (NDVH), in a retrospective non-randomized analysis. Material and methods: Eighteen patients in the LAVH group were compared with 22 patients in the NDVH group, the procedure being carried out by the same surgeon, after identifying them from operation theater records and computerized medical records over a period of 15 months. The two groups were compared with respect to intraoperative and postoperative parameters. Results: The mean age, parity, size of uterus and indications of surgery were similar in the both groups. However, LAVH was more expensive and more time consuming compared to NDVH. Otherwise, there was no significant difference between adverse events, recovery time and hospital stay in the two groups. Conclusion: Except for longer operating time and higher cost of surgery in the LAVH group, there was no difference between the two techniques. Keywords: Laparoscopic-assisted vaginal hysterectomy, non-descent vaginal hysterectomy

ysterectomy is by far the most frequently performed major surgery in Obstetrics and Gynecology, second only to cesarean section. Traditionally, it was done by two routes abdominal or vaginal, but now with the advent of endoscopy a third route i.e., laparoscopic route is gaining popularity. Though the vaginal route is the preferred route because of lower morbidity, less operative time and faster recovery, but the Vaginal Abdominal or Laparoscopic Uterine Excision (VALUE) study suggested that 67% of surgeons still use the abdominal approach as the operation of choice, particularly when dealing with pelvic pathology or carrying out oophorectomy.1

Laparoscopic hysterectomy was first done by Reich et al in 1989,2 and since then it has gained widespread acceptance. In laparoscopic-assisted vaginal *Professor, Dept. of Obstetrics and Gynecology † Assistant Professor, Dept. of PSM ‡ Associate Professor, Dept. of Anesthesia # Associate Professor, Dept. of Obstetrics and Gynecology ¥ Assistant Professor, Dept. of Surgery $ Assistant Professor, Dept. of Obstetrics and Gynecology Government Medical College, Haldwani, Uttarakhand Address for correspondence Dr Geeta Jain Professor, Dept. Of Obstetrics and Gynecology Government Medical College, Rampur Road, Haldwani - 263 139, Uttarakhand E-mail: ikneiv@hotmail.com

hysterectomy (LAVH), laparoscopic dissection of parauterine tissues is done to the level of uterine arteries. It also allows removal of adnexae or adhesiolysis under direct vision more easily than vaginal hysterectomy. Although LAVH is becoming increasingly popular, it is more expensive, more time consuming and above all, needs special training. On the other hand, vaginal hysterectomy is cheaper, cosmetic (stitch-less surgery) and associated with decreased morbidity.3 It can be accomplished even in large sized uterus by bisection, myomectomy, bisection debulking and clamp-less approach.4 Sheth5 with his experience of 5,655 vaginal hysterectomies has brought a new dimension to nondescent vaginal hysterectomy (NDVH) in our country. However, there is ample evidence in favor and against LAVH.6 Summit et al,7 in his randomized trial found the outcomes of NDVH and LAVH similar, but with reduced cost. A surgeon's reluctance to perform vaginal hysterectomy in nonprolapsed enlarged uteri either because of lack of training or experience or fear of increased blood loss because access to uterine arteries sometimes becomes difficult or even impossible especially when dealing with large uterus; may contribute to the preference for LAVH. According to American College of Obstetricians and Gynecologists, vaginal hysterectomies are preferred in women with a uterus no larger than 12 weeks of gestation size (approximately 280-300 g).8 Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

clinical study Recently, the eVALuate Study9 concluded, that LAVH was associated with a significantly higher rate of major complications than abdominal hysterectomy. LAVH took longer to perform, but was associated with less pain, quicker recovery and better short-term qualityof-life measures.

teaching hospital) comparing LAVH and NDVH from October 2010 to December 2011.

Material and Methods

A total of 40 patients were identified from operation theater records and hospital-based computerized medical records undergoing hysterectomy for nonmalignant conditions by the same surgeon. Eighteen patients in LAVH group were compared with 22 in the NDVH group. The medical records of the patients were reviewed in terms of demographic characteristics, i.e., age, socioeconomic status and parity, indication for hysterectomy, size of uterus. The intraoperative details like type of anesthesia, necessity of blood transfusion, injury to bladder/bowel or any other complication were studied. Post-operative complications were compared in both the groups.

This was a retrospective observational study carried out in the Dept. of Obstetrics and Gynecology, Government Medical College, Haldwani (a tertiary

NDVH was done under spinal anesthesia. Circular incision was made around the cervix. After cutting the pubovesicocervical ligament urinary bladder was pushed

Aims and Objectives The aim of the present study was to compare LAVH with NDVH in a retrospective nonrandomized analysis, and to evaluate intraoperative and postoperative complications, operating time, hospital stay and cost of surgery.

Table 1. Comparison of Two Groups by Indications Indications

LAVH (N = 18)

NDVH (N = 22)

No. (%)

DUB

07 (38.9)

11(50.0)

χ2=1.5, df = 3

Fibroid

05 (27.8)

06 (27.3)

p = 0.7

04 (22.2)

02 (09.1)

02 (11.1)

03 (13.6)

Others

Statistical tests

Age Wise Distribution of Cases Between the Two Groups (Age (in years) ≤ 40

08 (44.4)

08 (36.4)

χ2 = 0.5, df = 2

41- 45

06 (33.3)

07 (31.8)

p = 0.8

> 45

04 (22.2)

07 (31.8)

Mean ± SD

42.7 ± 5.6

42.6 ± 4.8

t (38) = 0.05, p = 0.9

Parity Wise Distribution of Cases in the Groups (Parity) 2-3

05 (27.8)

07 (31.8)

χ2 = 0.1, df = 2

4-5

10 (55.6)

11(50.0)

p = 0.9

6-7

03 (16.6)

04 (18.2)

Comparison of Size of Uterus between the Groups (Size of uterus) < 8 weeks

13 (72.2%)

14 (63.6%)

χ2 = 0.5, df = 2

≥ 8-12 weeks

04 (22.2%)

07 (31.8%)

p = 0.8

>12 weeks

01 (05.6%)

01 (04.6%)

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

clinical study upwards. Then anterior and posterior pouches were opened. The uterosacral and Mackenrodt ligaments were clamped, cut and ligated bilaterally. Then the uterine vessels were secured. Next step, in bigger sized uteri, was uterine bisection, myomectomy or a combination. In case of fundal fibroids, myomectomy was done only if the fibroid was interfering with the delivery of fundus. In total hysterectomy, last clamp was placed on fundal structures (i.e., round ligament, medial part of fallopian tube, ovarian ligament). In case of salpingo-oophorectomy, after clamping the fundal structures, the ovary was pulled and the clamp was placed on infundibulopelvic ligament. After removing the uterus the vault was closed. LAVH was done under general anesthesia. Bipolar cautery was used. The uterus was manipulated with the help of myoma screw. The round ligaments were cauterized and cut bilaterally. If adnexa had to be preserved, fallopian tubes and ovarian ligaments were cauterized and cut and in patients requiring salpingooophorectomy, infundibulopelvic ligaments were cauterized and cut. The uterovesical fold of peritoneum was cut. The vaginal procedure began with opening the anterior and posterior pouches. The Mackenrodt and uterosacral ligaments were clamped, cut and ligated bilaterally. After ligating the uterine arteries, the uterus was brought out and vault closed. Results The commonest indication for surgery in both the groups was dysfunctional uterine bleeding (DUB), followed by fibroid and cervical dysplasia as shown in Table 1. The age-wise distribution of cases, was almost similar in the two groups. Approximately 55.5% patients in LAVH group and 50% in NDVH group had parity 4 to 5, a favorable factor for vaginal surgery.

Majority of the patients (72.2% in LAVH group and 63.6% in NDVH group) had uterine size less than or equal to 8 weeks. The size was similar in both the groups. LAVH took significantly longer time than NDVH. The operation could be completed in less than 90 minutes in 81.8% patients in the NDVH group, while the rest required 90-120 minutes. On the other hand, majority (94.4%) patients of LAVH group required more than 120 minutes; p was 0.001 (Table 2). One patient of LAVH group had urinary bladder injury and the surgery had to be converted to abdominal hysterectomy, along with urinary bladder repair. In the NDVH group, one case had to be converted to abdominal hysterectomy because of minimal descent of cervix. Minor postoperative complications like fever, urinary tract infection were noted in both the groups. However, one patient in the LAVH group had prolonged hospital stay (15 days) because of typhoid. Two patients in the NDVH group also had prolonged hospital stay, because of secondary hemorrhage, which was managed conservatively. One patient in LAVH group required readmission because of urinary tract infection on account of ureteric stone. One patient in the NDVH group required readmission, because of secondary hemorrhage which responded to conservative treatment (vaginal packing, systemic and local antibiotics) (Table 3). In the NDVH group, majority patients (59.1%) required 3 suture materials, while in the LAVH group 83.3% required only 2 suture materials. One major difference in both the groups was the cost of surgery. Ours being a Government Medical College, the cost of NDVH in our hospital is only

Table 2. Comparison of operating time between the groups Operating time 60-90 minutes

LAVH (n = 18)

NDVH (n = 22)

No. (%)

0 (0.0)

18 (81.8)

Statistical tests χ2= 38.7, df = 2 p = 0.001

90-120 minutes

01 (5.6%)

04 (18.2]

>120 minutes

17 (94.4%)

0 (0.0)

140.6 ± 8

73.2 ± 14.7

Mean ± SD

t(33.7) = 18.5, p = 0.001

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

clinical study Table 3. Comparison of Complications Between the Groups Intra-operative Complications

LAVH (n = 18)

NDVH (n = 22)

Requiring blood transfusion

1 (5.6%)

2 (9.1%)

Urinary bladder injury

1 (5.6%)

Bowel injury

1 (5.6%)

1 (4.6%)

2 (9.1%)

Pyrexia ≥ 380C

2 (11.1%)

3 (13.6%)

UTI

3 (16.7%)

4 (18.2%)

1(5.6%)

1 (4.6%)

Laparotomy/Laparoscopy Post-operative complications Secondary haemorrhage

Vault haematoma Readmission

eight hundred ± three hundred rupees, while that of LAVH is four thousand three hundred ± five hundred rupees (p = 0.001). The cost of medicines used during and after surgery was excluded from this. Discussion In our study, the mean age of the patients was same for both the groups. The major indication of surgery was DUB in both the groups, and majority of patients had uterine size equal to or less than 8 weeks. Since the advent of LAVH by Reich in 1989, the uptake of this procedure has been slow and subject to considerable geographic variation. The reasons could be many folds. One is the cost of equipment, as laparoscope is an expensive instrument and may not be available in many hospitals, second is the training for laparoscopic surgery. Laparoscopic surgery needs more training and the learning curve is slow. A third factor is the time, LAVH takes compared to NDVH. This has been shown in a number of studies,6,10,11 including this one. NDVH took less than 90 minutes in 81.8% patients, while 94.4% patients of LAVH group required more than 120 minutes (p = 0.001). Therefore, given the pressure on operating time, there is often a reluctance to spend longer performing a surgery than is required. A fourth important factor is the cost of surgery. The cost of NDVH was approximately eight hundred ± Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

three hundred rupees, while that of LAVH is four thousand three hundred ± five hundred rupees. The reasons are twofolds, one is the higher cost of laparoscopic surgery and second is the charge of general anesthesia. The charges in our hospital are very low, being a Government Medical College, where the beds are free and majority of medicines are provided free by the government. However, there was no significant difference in the adverse events, postoperative recovery phase, which were almost similar in both the groups. Like Richardson12 and Roy et al,11 we also did not find any difference in terms of blood loss, intra- and postoperative complications, requirement of analgesics, recuperation time and hospital stay. Conclusion The aim of the present study was to compare NDVH with LAVH. The main findings which came out from this study was the increased operating time and higher cost of surgery in the LAVH group. In comparison NDVH was cheaper and less time consuming. Otherwise, other outcome variables like intra- and postoperative complications, blood loss, postoperative pain and hospital stay were similar in both the groups. References 1. McPherson K, Metcalfe MA, Herbert A, Maresh M, Casbard A, Hargreaves J, et al. Severe complications of hysterectomy: the VALUE study. BJOG. 2004;111(7):688-94. 2. Reich H, De Caprio J, McGlynn F. Laparoscopic hysterectomy. J Gynaecol Surg. 1989;5:213-6. 3. Clinch J. Length of hospital stay after vaginal hysterectomy. Br J Obstet Gynaecol. 1994;101(3):253-4. 4. Unger JB. Vaginal hysterectomy for the woman with a moderately enlarged uterus weighing 200 to 700 grams. Am J Obstet Gynecol. 1999;180(6 Pt 1):1337-44. 5. Sheth SS. The scope of vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol. 2004;115(2):224-30. 6. McCracken G, Hunter D, Morgan D, Price JH. Comparison of laparoscopic-assisted vaginal hysterectomy, total abdominal hysterectomy and vaginal hysterectomy. Ulster Med J. 2006;75(1):54-8. 7. Summitt RL Jr, Stovall TG, Steege JF, Lipscomb GH. A multicenter randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet Gynecol. 1998;92(3):321-6.

clinical study 8. Precis I. An update in obstetrics and gynaecology. CD-ROM. Washington, DC: American College of Obstetricians and Gynecologists; 1989.

South Asian Federation Obstet Gynecol. 2009;1(1): 47-52.

9. Garry R, Fountain J, Mason S, Hawe J, Napp V, Abbott J, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ. 2004;328(7432):129.

11. Roy KK, Goyal M, Singla S, Sharma JB, Malhotra N, Kumar S. A prospective randomised study of total laparoscopic hysterectomy, laparoscopically assisted vaginal hysterectomy and non-descent vaginal hysterectomy for the treatment of benign diseases of the uterus. Arch Gynecol Obstet. 2011;284(4):907-12.

10. Khanam NN, Chakma B, Chowdhary SB, Nahar K, Rahman N, Homaira R. Non-descended vaginal hysterectomy - Is a reasonable alternative to LAVH?

12. Richardson RE, Bournas N, Magos AL. Is laparoscopic hysterectomy a waste of time? Lancet. 1995;345(8941): 36-41.

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Risk of Venous Thromboembolism Lower in Women who Use Local Estrogen Swedish researchers suggest that women who take hormone replacement therapy (HRT) to ease menopause symptoms may have a lower risk of blood clots if they use estrogens applied vaginally or via skin patches. And overall, estrogen-only therapy had a lower risk of blood clots than systemic combined estrogen-progestin. The Swedish study led by Dr Annica Bergendal of the Karolinska Institute in Stockholm analyzed data on 838 women who developed blood clots from 2003 to 2009 and a control group of 891 similar women who did not develop clots. The results of this study are published in Menopause, the journal of the North American Menopause Society.

Study Finds Women with Pcos to have Higher Prevalence of Asthma New results from the Australian longitudinal study on women's health presented at the recently concluded 98th annual meeting of the Endocrine Society, Endo 2016 in Boston, USA suggest that polycystic ovary syndrome (PCOS) was associated with a 34% increased risk for asthma, regardless of body weight. Anju Joham, MBBS, of Monash University in Melbourne, and colleagues, reported survey data from more than 8,000 women which showed a higher prevalence of asthma in women who had PCOS vs those who did not have PCOS; 15.2% versus 10.6%. According to the authors, this may be “related to the inflammation associated with both conditions”.

Ondansetron should not be First Choice for Nausea in Pregnancy Use of ondansetron to relieve nausea and vomiting of pregnancy should be reserved for those women whose symptoms have not been adequately controlled by other methods, says a new study published online April 4 in Obstetrics & Gynecology. According to a systematic review by Shaun D Carstairs, MD, from the Division of Medical Toxicology, Department of Emergency Medicine, University of California, San Diego, there is an overall low risk of birth defects associated with ondansetron exposure. There may be a small increase in the incidence of cardiac abnormalities in ondansetron-exposed neonates.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

Case report

Posterior Reversible Encephalopathy Syndrome in Postpartum Normotensive Woman: A Rare Presentation Siva Sundari*, KS Rajeswari†, Nandhini Elumalai‡

Abstract Posterior reversible encephalopathy syndrome (PRES) is a rare acute neurologic condition characterized by headache followed by deterioration, including confusion, seizures or cortical visual disturbances. Our case is a rare presentation of PRES in a postpartum normotensive woman after an uneventful cesarean delivery under spinal anesthesia. Keywords: Posterior reversible encephalopathy syndrome, spinal anesthesia

osterior reversible encephalopathy syndrome (PRES) has occurred in patients with hypertensive encephalopathy, renal failure, immunosuppression and postpartum eclampsia.1,2 We report a case of PRES, which occurred in the postpartum period with normal blood pressure (BP) and managed successfully. Case Report A 26-year-old primigravida, booked, normotensive was induced at 37 weeks of gestation in view of obstetric cholestasis of pregnancy. She underwent emergency lower-segment cesarean section under spinal anesthesia because of fetal distress. Postoperatively, her blood pressure was normal. On second postoperative day, patient developed bifrontal headache, particularly when in an erect position; it was relieved by being recumbent. Headache improved (visual analog scale [VAS] 1/10) after supportive therapy including oral analgesics (paracetamol, 2 g/day), intravenous (IV) hydration and bed rest. Her BP was 120/70 mmHg. On third postoperative day, patient complained of

*Associate Professor † Professor ‡

III Year MS Postgraduate Dept. of Obstetrics and Gynecology Sri Ramachandra University, Porur, Chennai, Tamil Nadu Address for correspondence Dr Siva Sundari L-170, Marvel Apoorva Apartments 4/12, Kalacsathaman Koil Street Ramapuram, Chennai - 600 089, Tami Nadu E-mail: sivasundaridr@yahoo.com

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severe throbbing headache (VAS 10/10) over the occipital area, which was no longer postural. BP was 130/70 mmHg, treated conservatively with analgesics and IV hydration. After 2 hours, she developed blurring of vision followed by one episode of generalized tonic and clonic convulsions. During postictal period, she had total loss of vision. Neurologist opinion was obtained. Patient was treated in intensive care unit with magnesium sulfate (Zuspan’s regime) for 24 hours, injection levetiracetam 1 g IV b.i.d. for 48 hours and injection mannitol 100 mL infusion t.d.s. for 24 hours. Magnetic resonance imaging (MRI) brain FLAIR T2 weighted axial images showed bilateral symmetric hyperintense areas involving the bilateral frontal, parietal subcortical white matter, bilateral basal ganglia, occipital and cerebellar hemispheres suggestive of PRES (Fig. 1 a and b). MR venogram was normal. Fundus-normal. Throughout the BP was 130/70 mmHg. There was no proteinuria, renal function test, liver function test, serum electrolytes and serum calcium were normal. She completely regained her vision after 24 hours. Her neurological symptoms completely resolved by 48 hours. She was discharged on 8th postoperative day with anticonvulsant medications for 1 month. She was followed up for almost 5 months and she is free of neurological symptoms. Discussion PRES is a rare acute neurologic condition characterized by headache followed by deterioration, including confusion, seizures or cortical visual disturbances. PRES has been reported to be reversible.1 21

Case Report symptom resolution without neurological deficit. Acute treatment for cerebral vasospasm is essential.6 Nimodipine, a calcium antagonist, has been shown to be associated with a reduced rate of infarction because of cerebral vasospasm, but the efficacy of magnesium, a drug with calcium antagonist properties in treating cerebral vasospasm is comparable to that of nimodipine.6 Several clinical studies have shown that intravascular magnesium sulfate safely relieved maternal cerebral vasospasm.7-9 Conclusion We report this case due to rare presentation of PRES in a postpartum normotensive woman after spinal anesthesia and successful appropriate management. References 1. Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334(8):494-500. 2. Lamy C, Oppenheim C, MĂŠder JF, Mas JL. Neuroimaging in posterior reversible encephalopathy syndrome. J Neuroimaging. 2004;14(2):89-96. 3. Naqi R, Ahsan H, Azeemuddin M. Posterior reversible encephalopathy syndrome: a case series in patients with eclampsia. J Pak Med Assoc. 2010;60(5):394-7. Figure 1 a and b. MRI brain FLAIR T2 weighted axial images showing bilateral symmetric hyperintense areas involving the bilateral frontal, parietal subcortical white matter, bilateral basal ganglia, occipital and cerebellar hemispheres.

PRES refers to a clinicoradiological entity with characteristic features on neuroimaging and nonspecific symptoms comprising headache, confusion, visual disturbances and seizures.3 The lesions in PRES are thought to be due to vasogenic edema, predominantly in the posterior cerebral hemispheres and reversible with appropriate management.3 The typical MRI findings of PRES are most apparent as hyperintensity of FLAIR images in the parietooccipital and posterior-frontal cortical and subcortical white matters. Less commonly brainstem, basal ganglia and cerebellum are involved.3 However, irreversible brain damage can sometimes occur due to laterecognition or incorrect treatment.4,5 Importantly, treating the underlying problem usually leads to

4. Stott VL, Hurrell MA, Anderson TJ. Reversible posterior leukoencephalopathy syndrome: a misnomer reviewed. Intern Med J. 2005;35(2):83-90. 5. Antunes NL, Small TN, George D, Boulad F, Lis E. Posterior leukoencephalopathy syndrome may not be reversible. Pediatr Neurol. 1999;20(3):241-3. 6. Ho CM, Chan KH. Posterior reversible encephalopathy syndrome with vasospasm in a postpartum woman after postdural puncture headache following spinal anesthesia. Anesth Analg. 2007;105(3):770-2. 7. Belfort MA, Moise KJ Jr. Effect of magnesium sulfate on maternal brain blood flow in preeclampsia: a randomized, placebo-controlled study. Am J Obstet Gynecol. 1992;167(3):661-6. 8. Belfort MA, Saade GR, Moise KJ Jr. The effect of magnesium sulfate on maternal and fetal blood flow in pregnancy-induced hypertension. Acta Obstet Gynecol Scand. 1993;72(7):526-30. 9. Naidu S, Payne AJ, Moodley J, Hoffmann M, Gouws E. Randomised study assessing the effect of phenytoin and magnesium sulphate on maternal cerebral circulation in eclampsia using transcranial Doppler ultrasound. Br J Obstet Gynaecol. 1996;103(2):111-6.

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Case Report

Enlarged Ovaries Following IVF/ICSI as an Etiology of Obstructive Uropathy Resulting in Acute Renal Failure Pratibha Vishwakarma*, Priya Mohan†, Kundavi Shankar‡, Thangam R Varma#

Abstract In vitro fertilization (IVF) is one of the most comprehensively registered interventions in clinical medicine. IVF is regarded as safe with very few complications. We report a woman who developed acute renal failure due to compression of both ureters from enlarged stimulated ovaries. The condition was diagnosed using magnetic resonance imaging. It was treated with insertion of double-J stents in both ureters and dialysis. Compression of the ureters due to enlarged ovaries should be considered if a patient especially with pre-existing endometriosis develops acute renal failure following IVF. Keywords: Acute renal failure, in vitro fertilization, ovarian hyperstimulation syndrome, ultrasound

uring the last 35 years, in vitro fertilization, (IVF) has become an important treatment option in patients with infertility. Following hormone stimulation, the oocytes are collected from the ovaries transvaginally using ultrasound guidance. The procedure is regarded as safe. The most common complications are hemorrhages, pelvic abscesses and pain. There are also some reports of ureteric damage after puncture by the collecting needle.1,2 We report a case, where a woman with pre-existing endometriosis developed acute renal failure due to compression of both ureters from enlarged stimulated ovaries. Case Report A 28-year-old woman married for 8 years, with two previous first trimester miscarriages presented to us for treatment of secondary subfertility. She had history of 2 laparoscopies elsewhere suggestive of bilateral tubal block and extensive adhesions between tubes, ovaries and uterus suggestive of stage IV endometriosis. She had regular cycles with a body mass index (BMI) of 20. She had a past history of surgically corrected atrial

*Post Doctor Fellow † Private Practitioner ‡ Senior Consultant # Medical Director Institute of Reproductive Medicine and Women’s Health Madras Medical Mission Hospital, Chennai, Tamil Nadu Address for correspondence Dr Pratibha Vishwakarma H. No. 1/2641, Street No-3, Loni Road, Ram Nagar, Shahdara, New Delhi -110 032 E-mail: pratibha_vish@yahoo.co.in

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

septal defect at 5 years of age, asymptomatic; since then with good left ventricular ejection fraction. She had ureteric calculi diagnosed on both sides on ultrasound done outside with no renal changes 3 years back, for which she underwent conservative management. Her follicle-stimulating hormone (FSH) was 12.3 mIU/L and luteinizing hormone (LH) was 14.2 mIU/L, antimullerian hormone (AMH)-1.2 pmol/L with reduced antral follicle count with 2 cm endometriotic cysts in both ovaries. Kidneys were normal. Husband’s semen analysis was normal. Hysteroscopy and trial transfer was done as preIVF evaluation. She was counseled for therapeutic trial and a flexible antagonist protocol was followed. Recombinant FSH was used for stimulation. Five oocytes were retrieved under ultrasound guidance after 35 hours of human chorionic gonadotropin (hCG) trigger. Three embryos were fertilized and three 8-cell Grade A embryos were transferred without any difficulty. Six days following embryo transfer, she reported with loin pain and high-grade fever and reduced urinary output. There was no tenderness on abdominal examination. Investigations revealed normal leukocyte count with more than hundred pus cells on routine urine analysis. Renal function test revealed a picture of pre-renal failure with a serum urea of 100 mg/dL and creatinine of 7.9 mg/dL. Serum electrolytes showed hyperkalemia. Investigations to rule out other causes of pyrexia were normal. Ultrasound showed bilateral enlarged ovaries measuring right 5 × 6 cm and left 6 × 7 cm and bilateral hydronephrosis (Fig. 1). 23

Case Report Approximately, 1 liter of blood and clots were removed along with necrotic and hemorrhagic tissue scattered in the abdominal cavity. Right tube was the seat of rupture and salpingectomy was done. Right ovary was stuck to the back of uterus, and left ovary stuck to lateral pelvic wall. Abdomen was washed with saline and a drain was placed. Two units of packed cells were transfused postoperatively. Histopathology confirmed ruptured ectopic gestation in the right tube. She was discharged in a stable condition. DJ stent was removed 6 weeks later. Discussion

Figure 1. Ultrasound showing bilateral stimulated enlarged ovaries compressing both ureters resulting in bilateral hydronephrosis.

Magnetic resonance imaging (MRI) scan showed bilateral hydronephrosis and enlarged ovaries, which led to compression of ureters. She was catheterized and her urine output was only 300 mL/24 hours. Nephrologist’s and urologist’s opinion were taken. Injection carbapenem, following sensitivity to Klebsiella and extended-spectrum beta-lactamase (ESBL) growth on culture, was started. Patient was transferred to nephrology department and dialysis was done as her creatinine showed increasing trend and persistent oliguria. Serum creatinine started to decline following dialysis. Double-J (DJ) stent was inserted. The postoperative course was uneventful and her creatinine level showed declining trends. Oral progesterone was continued as luteal support and on Day 16 of embryo transfer, b-hCG was positive. Her b-hCG showed an increasing trend. Renal sonogram was repeated and it was normal. The patient was asymptomatic and urine culture was negative. At 6 weeks from last menstrual period (LMP), ultrasound showed evidence of echogenic ring and presence of yolk sac with no cardiac activity and fluid collection was seen in the right adnexa suggestive of right ectopic pregnancy. She was posted for an emergency laparoscopy as she was hemodynamically stable, which needed conversion to laparotomy in view of frozen pelvis. 24

Transvaginally, ultrasound-guided oocyte retrieval has become the gold standard for IVF therapy. It is considered as a well-tolerated, cost-effective and safe procedure.3,4 A few cases of ureteral damage due to puncture of the ureter by the collecting needle have been described. In one case, the ureter was compressed by a stimulated ovary in a patient with a transplanted pelvic kidney.5 The diagnosis of ureteral compression was confirmed by MRI scan, a procedure without ionizing radiation and which should not cause any harm to fertilized embryos.6 Severe pelvic adhesions may have worsened the situation by limiting the normal movement of the ovaries. Ovarian hyperstimulation syndrome (OHSS) is a common complication in assisted reproductive technologies. In spite of frequent occurrence of abdominal compartment syndrome and oliguria in OHSS, acute renal failure secondary to obstructive uropathy is uncommon in OHSS.7 Acute renal failure due to a hypovolemic state following production of protein-rich ascites in patients with OHSS has been reported,8 but in this case, no ascites and only slight hemoconcentration was noted. The most pronounced finding was the huge enlargement of the ovaries and bilateral hydronephrosis. To date, there have been just two case reports of obstructive uropathy associated with OHSS.9 The patient was diagnosed earlier as having stage 4 endometriosis and frozen pelvis. Even though the complication risk related to IVF is low, one should be aware of a possible compression or damage to the ureters with subsequent development of acute renal failure. Injury, either by direct puncture or extrinsic compression, compromised ureteral function, but did not completely halt urination—a testimony to the Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

Case Report resilient nature of this structure and an intimation of more frequent, unrecognized injury. We, therefore, suggest that obstructive uropathy should also be considered as a possible etiology in patients with enlarged ovaries who develop oliguria or acute renal failure. References 1. Coroleu B, Lopez Mourelle F, Hereter L, Veiga A, Calderon G, Martinez F, et al. Ureteral lesion secondary to vaginal ultrasound follicular puncture for oocyte recovery in in-vitro fertilization. Hum Reprod. 1997;12(5):948-50. 2. Miller PB, Price T, Nichols JE Jr, Hill L. Acute ureteral obstruction following transvaginal oocyte retrieval for IVF. Hum Reprod. 2002;17(1):137-8.

5. Khalaf Y, Elkington N, Anderson H, Taylor A, Braude P. Ovarian hyperstimulation syndrome and its effect on renal function in a renal transplant patient undergoing IVF treatment: case report. Hum Reprod. 2000;15(6): 1275-7. 6. Vilos AG, Feyles V, Vilos GA, Oraif A, Abdul-Jabbar H, Power N. Ureteric injury during transvaginal ultrasound guided oocyte retrieval. J Obstet Gynaecol Can. 2015;37(1):52-5. 7. Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, et al. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions. Intensive Care Med. 2006;32(11):1722-32.

3. L enz S, Lauritsen JG, Kjellow M. Collection of human oocytes for in vitro fertilization by ultrasonically guided follicular puncture. Lancet. 1981;1(8230):1163-4.

8. Winkler J, Pinkas H, Tadir Y, Boner G, Ovadia J. Acute decline in renal function as a consequence of ovarian hyperstimulation syndrome. Nephron. 1992;60(1): 104-7.

4. Tanbo T, Henriksen T, Magnus Ø, Abyholm T. Oocyte retrieval in an IVF program. A comparison of laparoscopic and transvaginal ultrasound-guided follicular puncture. Acta Obstet Gynecol Scand. 1988;67(3):243-6.

9. Merrilees DA, Kennedy-Smith A, Robinson RG. Obstructive uropathy as the etiology of renal failure in ovarian hyperstimulation syndrome. Fertil Steril. 2008;89(4):992.e1-2.

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Women Health: Irregular Menses Predict Ovarian Cancer Possibility A recent study published in International Journal of Cancer suggests higher risk for ovarian cancer in women with irregular menstruation cycles. These women are easy to identify and many may have polycystic ovarian syndrome. These studies can help in early detection of ovarian cancer.

Epilepsy Appears not to Affect Conception A new study shows that epilepsy does not affect the success rate of women who are trying to have a baby. The Women with Epilepsy Pregnancy Outcomes and Deliveries (WEPOD) observational study evaluated women keen to get pregnant. Women aged 18 to 40 years were studied with one year follow-up from attempting conception through their pregnancy and delivery. American Academy of Neurology (AAN) 2016 Annual Meeting Presented April 17, 2016

Night Shift Disturbances More Prevalent in Women Studies have show that circadian rhythmicity in mental functions exhibits sex differences so that the nighttime impairment in cognitive performance is greater in women than in men. These findings are significant in view of shift-work-related disturbances of mood, which are more prevalent in women. Source: PNAS April 18, 2016

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

Case report

Omental Herniation: A Complication of Intraperitoneal Drain Shweta Singh*, Taru Gupta†, Sangeeta Gupta‡

Abstract Intraperitoneal drains are usually inserted in abdominal surgery for the purpose of preventing fluid accumulation. However, the efficacy and safety of using abdominal drains following abdominal surgery have been contentious. In obstetrics and gynecology practice, drains are kept during ruptured ectopic with gross hemoperitoneum or with cesarean section and laparotomies with difficult hemostasis to prevent abdominal collection of blood. We present the case of a 33-year-old female who underwent left-sided salpingectomy with right side tubal ligation and developed omental herniation at the drain site on post-op Day 8. Keywords: Intraperitoneal drain, complication cough, omental herniation

he dictum “when in doubt, drain”, from Lawson Tait, is well-known to most surgeons. An intraperitoneal drain, commonly used by surgeons usually inserted in abdominal surgery for the purpose of preventing fluid accumulation had always been controversial. These drains have been noted with complications such as secondary infection, intestinal perforation, adhesions, hemorrhage and migration.1 Omental herniation at the drain site is one of the complications and illustrated case report is about the omental herniation through drain site. Case Report

drain was kept for drainage. Patient was uneventful in post-op period. Drain was removed on Day 5 of surgery when drain output was 25 cc in the preceding 24 hours and dressing was done. On post-op Day 8, when patient was called for stitch removal, a red fragile mass of around 2 × 2 cm was protruding from drain site. Mass was nontender, firm and nonreducible (Fig. 1 a and b). According to patient, she developed cough on post-op Day 5. USG whole abdomen was done to rule out any bowel involvement.

A 33-year-old female, G4, P3, L3 came to Gyne casualty of ESI Hospital, Basaidarapur, New Delhi, with history of 6 weeks of amenorrhea and spotting per vaginum and pain abdomen. Her urine pregnancy test was faintly positive. She was diagnosed as a case of left side ruptured ectopic pregnancy and was operated in emergency and left-sided salpingectomy with right side tubal ligation was done; since, there was 750 cc of hemoperitoneum, after thorough suction, a pelvic *Senior Resident † Professor ‡ Senior Consultant Dept. of Obstetrics and Gynecology ESI-PGIMSR, Basaidarapur, New Delhi Address for correspondence Dr Taru Gupta Professor Dept. of Obstetrics and Gynecology ESI-PGIMSR, Basaidarapur, 110 015, New Delhi E-mail: tarugupta1971@yahoo.com

Figure 1 a and b. Drain site omental herniation.

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Case Report Patient was again taken up in OT with preparation of laparotomy. Surgeons were called for bowel exploration. Initially, drain site incision was increased to 3 cm, mass was reached till the base and it was found to be omental in origin. Mass was excised and drain site was closed with interrupted stitches. Histopathology report confirmed presence of fibro-fatty tissue, which was suggestive of omentum. Post-op period was uneventful and patient was discharged.

Wrong technique of insertion and removal can also be a causative factor but it was not so in this case. Asymmetrical method which causes peritoneal stretching for insertion of drain should be used rather than using direct stab incision. If a stab incision is to be made, it should be made obliquely and not reach the peritoneum, so that the latter is stretched as the drain is inserted. While removing, gradual sustained pressure should be used to withdraw the drain.

Discussion

Conclusion

The efficacy and safety of using abdominal drains following abdominal surgery have been contentious. Surgical drain use may be kept for therapeutic purposes i.e., to evacuate existing collection of fluid or for preventing collection of fluid prophylactically. There are reports of herniation of intestine,2 appendix,3 omentum,4 gallbladder5 (single report) and ovary6 (single report) from surgical drain site. In obstetrics and gynecology practice, drains are kept during ruptured ectopic with gross hemoperitoneum or with cesarean section and laparotomies with difficult hemostasis to prevent abdominal collection of blood. In our patient a passive, closed Penrose drain (no. 32) was placed prophylactically in pouch of Douglas. The drain used had side holes which do not have any influence on drainage but lead to tissue entanglement. Predisposing factor for herniation are recurrent increase in intra-abdominal pressure caused by coughing or straining, prolonged surgery, poor nutrition, wound infection, obesity and steroid use which are known to cause poor healing and herniation.7 It has been reported that herniation of viscera increases with increase in port size ≥10 mm.8 Whereever possible fascial defects of ≥10 mm should be closed. Large meta-analyses9 have revealed that the indications of prophylactic drains should be minimized in case of uncomplicated surgeries. In our case, the patient developed cough on post-op Day 5, which led to herniation of omentum. Whenever a drain is kept, cough, straining and wound infection should be prevented to avoid such complications.

Though the surgical drains are used infrequently in obstetrics and gynecology, more restricted and judicial use should be practiced still to prevent complications. In the postoperative period, predisposing factors should be addressed properly to prevent further complications. References 1. Mosley JG, Jantet G. Herniation at the site of an abdominal drain. Br J Clin Pract. 1978;32(2):56, 58. 2. Kulkarni S, Krijgsman B, Sharma D, Kaisary AV. Incarcerated small bowel hernia through drain site. Ann R Coll Surg Engl. 2004;86(6):W24-5. 3. O’Riordan DC, Horgan LF, Davidson BR. Drain-site herniation of the appendix. Br J Surg. 1995;82(12):1628. 4. Howard FM, Sweeney TR. Omental herniation after operative laparoscopy. A case report. J Reprod Med. 1994;39(5):415-6. 5. Vedat B, Aziz S, Cetin K. Evisceration of gallbladder at the site of a Pezzer drain: a case report. Cases J. 2009;2:8601. 6. Pianon P, Lise M. Exteriorization of an ovary: an unusual complication of abdominal drainage. Br J Surg. 1992;79(9):963. 7. Loh A, Jones PA. Evisceration and other complications of abdominal drains. Postgrad Med J. 1991;67(789):687-8. 8. Dulskas A, Lunevičius R, Stanaitis J. A case report of incisional hernia through a 5 mm lateral port site following laparoscopic cholecystectomy. J Minim Access Surg. 2011;7(3):187-9. 9. Gurusamy KS, Samraj K, Mullerat P, Davidson BR. Routine abdominal drainage for uncomplicated laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2007;(4):CD006004.

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case Report

Bilateral Pregnancy Luteoma P Thulasi*, Shanthi M

Abstract Luteoma of pregnancy is a benign, hyperplastic tumor-like lesion of the ovary. It has been postulated that the pregnancy luteoma arises from pre-existing luteinized stromal cells, which respond in an exaggerated manner to the elevated levels of gonadotropin during pregnancy. In general, luteomas are asymptomatic and found incidentally at the time of cesarean section or postpartum tubal ligation. It may be a diagnostic and management challenge as it can mimic the presentation of malignant ovarian tumors. We report a 29-year-old primigravida, 34 weeks gestation case of polycystic ovary syndrome, who was found to have bilateral lobulated adnexal masses in maternal abdomen showing mild internal vascularity, likely of ovarian origin. The patient was investigated and was diagnosed to have bilateral pregnancy luteoma. Keywords: Luteoma of pregnancy, benign tumors, ovary, hyperandrogenism

regnancy luteoma was first described by Sternberg and Barclay in 1966. Until now, fewer than 200 cases of pregnancy luteomas have been reported. In general, luteomas are asymptomatic and found incidentally at the time of cesarean section or postpartum tubal ligation. Luteoma of pregnancy is a benign, hyperplastic tumor like lesion of the ovary. The etiology is unclear and it has been postulated that the pregnancy luteoma arises from pre-existing luteinized stromal cells, which respond in an exaggerated manner to the elevated levels of gonadotropin during pregnancy. Hypersecretion of androgens occurs in approximately 25% of women with pregnancy luteoma; from 10% to 50% of these women will show clinical signs of hyperandrogenism and 60% to 70% of female infants born to masculinized mothers will themselves exhibit some degree of virilization. Most cases resolve completely in about 3 months postpartum. It may be a diagnostic and management challenge as it can *Associate Professor Dept. of Obstetrics and Gynecology PK DAS Institute of Medical Sciences, Palakkad, Kerala Address for correspondence Dr P Thulasi Associate Professor Dept. of Obstetrics and Gynecology PK DAS Institute of Medical Sciences, Vaniyamkulam Ottapalam, Palakkad - 679 522, Kerala E-mail: drpthulasi@rediffmail.com/drrckkrishna@rediffmail.com

mimic the presentation of malignant ovarian tumors. An accurate diagnosis is important to avoid unnecessary surgery. Case Report A 29-year-old primigravida, 34 weeks gestation case of polycystic ovary syndrome (PCOS), came for regular antenatal care (ANC) to our hospital. She had spontaneous conception. First and second trimesters were uneventful. One week prior to our hospital ANC, she was admitted with history of fever, vomiting and pain abdomen at a local hospital and treated symptomatically. Medical history - hypothyroid on eltroxin 50 Âľg o.d. - 3 years. GPE - patient was found to be hirsute. Body mass index (BMI) - 23.66 m2. Per abdomen - uterus was 34 weeks size with relaxed head lower pole. Fetal heart rate (FHR) good. Blood investigations - normal. Obstetric scan - single live intrauterine gestation corresponding to gestational age of 34 weeks. EFW 2 kg. Amniotic fluid index (AFI) 11.8, two large heterogeneous predominantly hyperechoic bilateral lobulated adnexal masses in maternal abdomen showing mild internal vascularity, likely of ovarian origin. Possibilities included ovarian hyperstimulation with hemorrhagic change/Krukenbergâ&#x20AC;&#x2122;s tumors. Cancer antigen (CA) 125-27.4 U/mL. Patient was counseled and we proceeded with magnetic resonance imaging (MRI) for further evaluation of bilateral ovarian masses. MRI reported as bilateral large lobulated soft tissue signal intensity mass lesions Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

Case Report Discussion

Figure 1 a and b. Bilaterally enlarged ovaries seen on elective LSCS.

in both adnexae, right measuring 11.9 Ă&#x2014; 8.6 cm and left measuring 9 Ă&#x2014; 5.8 cm. Areas of hemorrhages were seen inside the masses. Ovaries were not seen separately from the lesions. There was no calcification/ necrosis within and there was no ascites. We discussed the case with the patient and attendants and they were counseled regarding ovarian masses. It was planned to continue pregnancy up to term and terminate by elective lower segment cesarean section (LSCS). At term, patient underwent elective LSCS with bilateral partial oophorectomy. Findings: Straw-colored minimal peritoneal fluid, which was sent for cytology. A live active baby was delivered with good Apgar score and a birth weight of 2.175 kg. Ambiguous genitalia were noted. No uterine anomaly. Right and left ovaries were enlarged to a size of 12 Ă&#x2014; 10 cm (Fig. 1 a and b). On vaginal toileting after cesarean section, patient was found to have clitoromegaly. Intraoperative and postoperative period was uneventful. Sutures were removed on Day 6 and patient was discharged with HPE of right and left ovariectomy specimens suggestive of pregnancy luteoma. Peritoneal fluid was negative for malignant cells. Hormonal profile with dehydroepiandrosterone (DHEA) sulfate, 17A-hydroxyprogesterone, total testosterone was found to be normal. Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

Luteoma of pregnancy is a rare condition. It most often occurs in the 3rd and 4th decades and is associated with increased prevalence in African American population and in the multiparous state. Pregnancy luteoma is a non-neoplastic lesion of ovary occurring during pregnancy and is known to spontaneously regress, which begins within days after the delivery. It is multinodular in half the cases and bilateral in a third of cases. Serum androgen levels decrease rapidly after delivery usually reaching normal concentration within 2 weeks postpartum. To date, fewer than 200 cases have been reported in literature. Most patients are asymptomatic with enlarged ovary discovered incidentally during cesarean section or at time of postpartum tubal ligation. In 25% of cases, luteomas are hormonally active, leading to secretion of androgens causing masculinization in mothers and female infants (60-70% cases). Pregnancy luteomas are variable in size ranging from microscopic to over 20 cm in diameter. In our case, bilateral ovaries measured 12 cm in dimension. On gross examination, cut surfaces of luteomas are solid, soft, tan or flesh-colored with hemorrhagic foci. Microscopically, luteomas are sharply circumscribed nodules composed of polygonal cells arranged in sheets, cords or small clusters or they surround follicle-like spaces containing colloid-like material. The cytoplasm is abundant eosinophilic and finally granular. The nuclei may be slightly pleomorphic and hyperchromatic; hence, it was diagnosed as pregnancy luteoma. The occurrence of an ovarian tumor presenting during pregnancy seems to be rare with the incidence ranging from 1:815 to 1:2200. Among these, the incidence of malignancy ranges from 2% to 8% with arrhenoblastomas, granulosa - theca tumor, Krukenberg tumor, papillary mucinous cystadenocarcinoma and mucinous cystadenoma were commonly seen during pregnancy. The differential diagnosis for pregnancy luteomas includes granulose cell tumors, thecomas, Sertoli-Leydig cell tumors, pure Leydig (Hilar) cell tumors, unclassified sex cord - stromal tumors, stromal hypertherosis, stromal luteomas and hyperreactio luteinalis. Young et al recommended an ultrasound if an enlarged ovary was palpable during an initial pelvic examination 29

Case Report to identify the size and whether it was cystic or solid. The ultrasonographic features of luteoma of pregnancy have been described as that of a solid mass, which can be unilateral or bilateral with either single or multiple nodules. Bilaterality and multinodularity are more common in luteomas that in other ovarian tumors.

Suggested Reading

The etiology of pregnancy luteoma remains unclear. It is hypothesized that they arise from stromal cells, which were present before pregnancy and respond in an unusual manner to elevated levels of gonadotropins encountered during pregnancy. PCOS is one condition predisposing a woman to form a luteoma during pregnancy. High levels of hormones in PCOS is responsible for this. Women who have already had a luteoma during a previous pregnancy have a high risk of having another luteoma. Other risk factors associated with luteomas are multiple pregnancies, advanced maternal age and Afro-Caribbean ethnicity.

3. Wang YC, Su HY, Liu JY, Chang FW, Chen CH. Maternal and female fetal virilization caused by pregnancy luteomas. Fertil Steril. 2005;84(2):509.

During a normal pregnancy, maternal circulating testosterone level can increase in third trimester. Serum levels of total testosterone may rise up to 7 times the nonpregnant levels and this physiological condition does not cause virilization. Virilization during pregnancy is a rare clinical event. It is most commonly caused by pregnancy luteoma or hyperreactio luteinalis. Pregnancy luteomas typically undergo spontaneous postpartum regression usually within 3 months of delivery. Serum testosterone levels usually return to normal by 2 weeks postpartum. Luteoma of pregnancy must be differentiated in pregnant females with ovarian masses as recognition of this entity will obviate unnecessary oophorectomy. It should be considered in the differential diagnosis of ovarian masses in females who are pregnant or have been recently pregnant. Conclusion Luteoma of pregnancy is a rare condition, which represents an unusual response to the altered hormonal environment in pregnancy and mimics either a solid or complex cystic ovarian neoplasm. It regresses in postpartum period. It should be considered in the D/D to avoid unnecessary radical surgery. In difficult clinical cases with atypical presentation biopsy of this lesion with intraoperative frozen section may allow preservation of the ovary.

1. Kumar RV, Ranjan DS, Rao B, Rao ES. Maternal luteoma of pregnancy: a rare case report. J NTR Univ Health Sci. 2014;3(4):267-9. 2. Sternberg WH, Barclay DL. Luteoma of pregnancy. Am J Obstet Gynecol. 1966;95(2):165-84.

4. Verhoeven AT, Mastboom JL, van Leusden HA, van der Velden WH. Virilization in pregnancy coexisting with an (ovarian) mucinous cystadenoma: A case report and review of virilizing ovarian tumors in pregnancy. Obstet Gynecol Surv. 1973;28(9):597-622. 5. Sternberg WH. Nonfunctioning ovarian neoplasms. In: Grady HG (Ed.). The Ovary. Baltimore: Williams & Wilkins; 1963. p. 209. 6. Garcia-Bunuel R, Berek JS, Woodruff JD. Luteomas of pregnancy. Obstet Gynecol. 1975;45(4):407-14. 7. Wang HK, Sheu MH, Guo WY, Hong CH, Chang CY. Magnetic resonance imaging of pregnancy luteoma. J Comput Assist Tomogr. 2003;27(2):155-7. 8. Nanda A, Gokhale UA, Pillai GR. Bilateral pregnancy luteoma: a case report. Oman Med J. 2014;29(5):371-2. 9. Wang Y, Zhou F, Qin JL, Qian ZD, Huang LL. Pregnancy luteoma followed with massive ascites and elevated CA125 after ovulation induction therapy: a case report and review of literatures. Int J Clin Exp Med. 2015;8(1):1491-3. 10. Krause DE, Stembridge VA. Luteomas of pregnancy. Am J Obstet Gynecol. 1966;95(2):192-206. 11. Tannus JF, Hertzberg BS, Haystead CM, Paulson EK. Unilateral luteoma of pregnancy mimicking a malignant ovarian mass on magnetic resonance and ultrasound. J Magn Reson Imaging. 2009;29(3):713-7. 12. Clement PB. Tumor-like lesions of the ovary associated with pregnancy. Int J Gynecol Pathol. 1993;12(2):108-15. 13. Joshi R, Dunaif A. Ovarian disorders of pregnancy. Endocrinol Metab Clin North Am. 1995;24(1):153-69. 14. Young RH, Dudley AG, Scully RE. Granulosa cell, SertoliLeydig cell, and unclassified sex cord-stromal tumors associated with pregnancy: a clinicopathological analysis of thirty-six cases. Gynecol Oncol. 1984;18(2):181-205. 15. Janovski NA, Paramanandhan TL. Ovarian tumors. Tumors and tumor-like conditions of the ovaries, fallopian tubes and ligaments of the uterus. Major Probl Obstet Gynecol. 1973;4:1-245.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

Conference Update

59th All India Congress of Obstetrics & Gynaecology (AICOG 2016) Hyperhomocystinemia

Vitamins - folate, B6, B12 - play an important role in metabolism of homocysteine.

Deficiency of vitamins (folate, B6, B12) is associated with hyperhomocysteinemia

Homocysteine normal serum levels: 5-15 µmol/L zz

Hyperhomocysteinemia

Mild: 15-30 mmol/L

Moderate: 30-100 mmol/L

Dr Aswath Kumar, Thrissur

Hyperhomocysteinemia may be associated with some of the complications in pregnancy; women who develop severe pre-eclampsia have higher plasma homocysteine levels in early pregnancy than women who remain normotensive throughout pregnancy.

Hyperhomocysteinemia could affect IVF outcome.

Time of screening:

Severe: >100 mmol/L The presence of a dietary deficiency of one or more of the vitamins involved in the metabolism of homocysteine superimposed on a background of MTHFR deficiency seems to be responsible for the very high incidence of hyperhomocysteinemia and the high homocysteine levels noticed in the Indian population. zz

Values in early pregnancy are more reliable.

Second-trimester plasma homocysteine concentrations do not predict the subsequent development of pregnancy-induced hypertension, pre-eclampsia and intrauterine growth restriction.

Supplementation of folic acid, vitamin B6 and B12 is effective and safe in reducing homocysteine levels.

Root Cause for Persistently High Maternal Mortality in Eclampsia and Possible Solutions

Root cause of mortality zz

Delayed initiation of treatment

Inadequate treatment at first referral center

Nonavailability of well-equipped healthcare facility near home

Nonexistent referral

Transferred without life support facility

Absence of antenatal care.

What is needed to save these women zz

Universal, adequate antenatal care: detection of high-risk factor; early detection and management of pre-eclampsia

Increased awareness about need of antenatal care

Availability of adequate, affordable healthcare near their residence

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

Dr Banashree Das, New Delhi

Mother and child tracking system (MCTS), if implemented properly may have an impact

Adequate treatment at first referral unit (FRU): Improvement in infrastructure and availability of trained man power in FRU; periodic, refresher course on emergency obstetric management

Provision of well-equipped transfer vehicle with trained paramedics is a must for transfer of these patients

Complete treatment history and all relevant facts should be documented and sent with patients

Counseling of relatives. Maternal mortality due to eclampsia/severe preeclampsia can be reduced with genuine effort from society/policy makers besides correct execution of medical knowledge and skill by healthcare provider. zz

Special effort is needed because majority of these young mothers are poor and illiterate.

Conference Update Polycystic Ovary Syndrome and Metabolic Syndrome

Metabolic problems in PCOS zz

Younger nonpregnant patient: Diabetes mellitus and impaired glucose tolerance; underlying insulin resistance; dyslipidemia - low HDL-C and hypertriglyceridemia; hypertension; metabolic syndrome; obstructive sleep apnea; increased inflammatory markers; fatty liver

Pregnant patient: Pre-eclampsia; gestational diabetes; fetal macrosomia; preterm labor; adverse neonatal consequences

Post-reproductive patient: Diabetes mellitus; cardiovascular risk; obesity; sleep apnea; endometrial cancer.

Tests for metabolic problems in PCOS: Body mass index and waist circumference; oral glucose tolerance test, repeated as required; fasting lipid profiles; hemoglobin A1c; insulin; liver function tests; liver ultrasound; sleep studies. Higher prevalence of PCOS is noted with increasing weight; however, thin patients still have insulin resistance. Management of metabolic problems: Dietary, exercise and behavioral interventions. Weight loss requires reduction of 2-4 Mj (500-1,000 kcals)/day to achieve 5-10% weight loss over 6 months. Weight gain prevention requires 250 kj (60 kcals)/ day less.

Fertility Preservation in Adolescent Cancers

Dr Nikhil Purandare, Galway

Female infertility has biological and psychological implications.

revolutionized the reproductive outlook of male patients who have reached puberty.

For cancer survivors who may be dealing with additional physical and emotional concerns, infertility may add yet another concern to an already lengthy list of fears and worries.

Decisions regarding fertility preservation should occur before treatment begins, yet parents are typically naïve, unfamiliar with, and inexperienced with treatment options for their child’s disease.

There are deleterious effects of chemotherapy and radiotherapy on gonadal development in both male and female childhood and adolescent cancer survivors.

Radiation doses of >25 Gy directly to the uterus in childhood appear to induce irreversible damage.

In female adolescents, ovarian transposition is radiationdependent; not suitable for chemo+radiotherapy; can cause adhesions, POF, cyst formation; complicates oocyte recovery.

Ovarian tissue freezing:

In male childhood cancer survivors, fertility is compromised with a radiation dose of ≥7.5 Gy to the testes with a hazard ratio (HR) of 0.21. Advancements in semen cryopreservation and intracytoplasmic sperm injection (ICSI) have

Ovarian insult is defined as injury to the ovary due to: zz

Radiation

Chemotherapy

Infection

Surgery. A successful operation means not only removal of ovarian pathology but also maintenance of ovarian function and subsequent pregnancy with live birth.

Only option for prepubertal girls

Risks: Reseeding

Benefits: Orthotopic and heterotopic pregnancy. In vitro maturation is in research phase. zz

Surgical Ovarian Insult

Dr Sonia Malik, New Delhi

Physicians should be aware that laparoscopic conservative surgery for endometriosis is a challenging task. The skill and experience of laparoscopists play an important role in determining the final IVF-ICSI outcome for infertile patients operated on for ovarian endometriomas.

Surgery on the ovary; however, minimal, must be carefully planned and executed so that it does not produce adverse results and poor fertility outcome.

Dr Robert Norman, Adelaide

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

Research Review

Journal Scan

Increased Levels of Circulating Advanced Glycation End-Products in Menopausal Women with Osteoporosis Advanced glycation end-products (AGEs) can accumulate in organs and tissues during ageing and diabetes. Increased levels of AGEs are found in the bone tissue of patients with osteoporosis. Higher levels of serum AGEs were found in the osteoporosis or osteopenia group compared to healthy women (P < 0.0001). A negative correlation was observed between serum AGEs and lumbar spine bone density (BMD of lumbar spine, r = -0.249, P = 0.028; T-score of lumbar spine, r = -0.261, P = 0.021). Women with a increased level of serum AGEs (> 8.12 U/mL) had a 5.34-fold risk of osteopenia regarding lumbar spine T-score and a 3.31-fold risk of osteopenia regarding the hip T-score. Serum AGEs could be used to monitor the severity and progression of osteoporosis. An increased serum level of AGEs was associated with impaired bone formation and was a risk factor for the development of osteoporosis. Targeting AGEs may represent a novel therapeutic approach for primary or secondary osteoporosis. Osteoporosis is also a disease of osteopenia caused by an imbalance between osteoclasts and osteoblasts. Increased production of AGEs formation is found in diabetic rats with a negative correlation of bone density. Circulating AGEs may also lead to decrease in bone strength by damage of structural bone. AGEs appear to trigger inflammation and bone loss in the pathogenesis of RA and osteoporosis. AGE level could be used to predict the progression of osteoporosis despite serum estrogen levels. Targeting AGEs may represent a novel therapeutic approach for primary or secondary osteoporosis.

Source: Int J Med Sci. 2014;11(5):453-60. Clinical Evaluation of Effects of Chronic Resveratrol Supplementation on Cerebrovascular Function, Cognition, Mood, Physical Function and General Well-Being in Postmenopausal Womenâ&#x20AC;&#x201D; Rationale and Study Design Dementia is predicted to be the top health crisis in this century, outpacing heart disease and cancer in terms of years lost due to disability and there is currently no cure nor means of slowing its progression. Early intervention Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

to maintain high-level cognitive function and well-being may help prolong independent living in older adults. Resveratrol, a phytoestrogen, may counteract the risk of developing dementia by enhancing cerebrovascular function and improving regional blood flow in response to cognitive demands. However, the hypothesis that resveratrol enhances cerebrovascular function has yet to be evaluated. Resveratrol is a phytoestrogen found in grapes, berries and nuts with multiple targeted benefits including cardiovascular and neurological, particularly attenuating learning impairment and hippocampal degeneration. It may act similarly to estrogen and genistein to confer neurovascular protection by up-regulating eNOS activity, resulting in enhanced NO bioavailability and vasorelaxation. Resveratrol also rapidly stimulates the mitogen-activated protein kinase signalling pathway via both ER-_ and ER-_ to increase eNOS activity in human endothelial cells at nanomolar concentrations that can be achieved through habitual diet, e.g., a glass of grape juice. A clinical trial was designed to test this hypothesis. Healthy postmenopausal women were recruited to participate in a randomised, double-blind, placebo-controlled (parallel comparison) dietary intervention trial to evaluate the effects of resveratrol supplementation (75 mg twice daily) on cognition, cerebrovascular responsiveness to cognitive tasks and overall well-being. The following tests were performed at baseline and after 14 weeks of supplementation: Rey Auditory Verbal Learning Test, Cambridge Semantic Memory Battery, the Double Span and the Trail Making Task. Cerebrovascular function was assessed simultaneously by monitoring blood flow velocity in the middle cerebral arteries using transcranial Doppler ultrasound. This trial provided a model approach to demonstrate that, by optimizing circulatory function in the brain, resveratrol and other vasoactive nutrients may enhance mood and cognition and ameliorate the risk of developing dementia in postmenopausal women and other at-risk populations.

A Pilot Clinical Study of Resveratrol in Postmenopausal Women with High Body Mass Index: Effects on Systemic Sex Steroid Hormones Among overweight and obese postmenopausal women, daily 1 gm dose of resveratrol has favorable effects on

RESEARCH REVIEW estrogen metabolism and sex hormone-binding globulin (SHBG). Further placebo-controlled studies are needed to confirm our findings on these hormone-related breast cancer risk factors and the attribution of the adverse effects observed in the study population. In postmenopausal women with high BMI, daily 1 gm dose of resveratrol had favorable effects on SHBG and estrogen metabolites. Further placebo controlled studies are needed to confirm our findings on these hormonerelated breast cancer risk

coincidentally diagnosed in asymptomatic patients, while the majority were symptomatic. Other ocular abnormalities include dry eye syndrome, red eye, uveitis, intraocular hypertension, glaucoma and cataracts. Herein, we review the medical literature pertaining to ocular manifestations in gout and hyperuricemia and propose a possible association between ocular abnormalities, hyperuricemia and gout, including their common risk factors and comorbidities.

Source: Curr Rheumatol Rep. 2016;18(6):37.

Benefits of Physical Exercise in Postmenopausal Women

Vitamin D Status and Cardio-Metabolic Risk in Indian Postmenopausal Women

Physical inactivity not only places women's health at risk during menopause, but also increases menopausal problems. Abundant evidence links habitual physical exercise (PE) to a better status on numerous health indicators and better quality of life and to the prevention and treatment of the ailments that typically occur from mid-life onwards. We can infer that PE is something more than a lifestyle: it constitutes a form of therapy in itself. A panel of experts from various Spanish scientific societies related to PE and menopause (Spanish Menopause Society, Spanish Cardiology Society, Spanish Federation of Sports Medicine) met to reach a consensus on these issues and to decide the optimal timing of and methods of exercise, based on the best evidence available.

The prevalence of chronic and non-communicable health disorders like cardiovascular diseases and metabolic syndrome is increasing worldwide including in India. The various risk factors for these health issues need to be addressed. The role of vitamin D deficiency in the causation of all these abnormal health conditions among postmenopausal women is a matter of debate now-a-days. To determine the correlation of serum vitamin D levels with various cardio-metabolic risk factors and metabolic syndrome (MetS) in postmenopausal women (PMW). Total of 64 PMW were included in this cross-sectional study. Clinical (waist circumference, body mass index, blood pressure) and biochemical (fasting plasma glucose, lipid profile and serum 25-hydroxyl vitamin D levels) parameters were measured. MetS was defined using modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP-III) guidelines. Serum 25-hydroxyl vitamin D levels <50 nmol/L, between 52.572.5 nmol/L and >75 nmol/L were classified as deficient, insufficient and sufficient, respectively. MetS was prevalent in 33 (52%) subjects. There were no differences in serum vitamin D levels or proportion of vitamin D deficient individuals in those with and without MetS. 33 women (52%) had vitamin D deficiency. Cardio-metabolic risk profile was similar in both vitamin D deficient and replete women. Despite a high prevalence of vitamin D deficiency and MetS in Indian PMW, serum vitamin D concentrations do not correlate with the cardio-metabolic risk factors or MetS.

Source: Maturitas 2016.pii:S0378-5122(16):30096-2. Beyond Joints: a Review of Ocular Abnormalities in Gout and Hyperuricemia Gout is a common inflammatory arthritis among middleaged men and postmenopausal women and can be a debilitating disease. Gout results from an elevated body uric acid pool, which leads to deposition of monosodium urate (MSU) crystals, mainly in and around the joints. The MSU crystals trigger release of proinflammatory cytokines, such as interleukin (IL)-1b, IL-6 and tumor necrosis factor (TNF)-a. Ocular manifestations have been uncommonly reported in patients with gout. These include descriptions of tophaceous deposits in different locations of the eye including the eyelids, conjunctiva, cornea, iris, sclera and orbit. Some depositions were

Source: J Clin Diagn Res. 2016;10(3):OC17-20.

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Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

Asian

Journal of

OBSTETRICS & GYNECOLOGYPractice

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Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767). Asian Journal of Obstetrics and Gynaecology Practice strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so. The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript. Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper. Covering letter -

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Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016

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Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985.

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Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470.

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Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 2, 2016