Asian Journal of
Online Submission
Volume 1, January-March 2013
CONTENTS
An IJCP Group Publication Corporate Panel Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal Group Editor-in-Chief Dr Veena Aggarwal MD, Group Executive Editor
FROM THE ISSUE EDITOR
Vaginal Delivery Safe for Head First Births before 32 Weeks
5
Alka Kriplani
FROM THE DESK OF GROUP EDITOR-IN-CHIEF
What’s New in Gynecology?
6
KK Agarwal
AJOG Specialty Panel
Dr Alka Kriplani Editor Consultant Editor Dr Urmil Sharma Assistant Editors Dr Nutan Agarwal (Delhi) Dr Neera Aggarwal (Delhi) Dr A Biswas (Singapore) Dr CS Dawn (Kolkata) Dr Gauri (Delhi) Dr Suneeta Mittal (Delhi) Dr S Mehra (Delhi) Dr Prashant Mangeshikar (Mumbai) Dr Prakash Trivedi (Mumbai) Dr Gita Ganguly Mukherjee (Kolkata)
Dr (Mrs) Prabha Arora (Delhi) Dr Hema Divakar (Bangalore) Dr Kamini A Rao (Bangalore) Dr Deepti Goswami (Delhi) Dr Neerja Bhatla (Delhi) Dr Bhawna Malhotra (Delhi) Dr Biswas Nicholas (Australia) Dr Sudhaa Sharma (Jammu) Dr Jaibhagwan Sharma (Delhi) Dr Veena Mathur (Agra) Dr Pradeep Garg (Delhi)
Editorial Board Obstetrics and Gynaecology Dr Alka Kriplani Dr Thankam Verma Dr Kamala Selvaraj
ENT Dr Jasveer Singh
Cardiology Dr Praveen Chandra Dr SK Parashar
Gastroenterology Dr Ajay Kumar
Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses Dr Sidhartha Das Dr A Ramachandran Dr Samith A Shetty
Dentistry Dr KMK Masthan Dr Rajesh Chandna
Dermatology Dr Hasmukh J Shroff Neurology Dr V Nagarajan Journal of Applied Medicine and Surgery Dr SM Rajendran Dr Jayakar Thomas
Anand Gopal Bhatnagar Editorial Anchor Advisory Body Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions
REVIEW ARTICLE
Clostridium sordellii Infection of Female Genital Tract
7
Prabhat Kumar Agrawal, Ruchika Garg
ORIGINAL ARTICLE
Cardiotocographic Changes and Perinatal Outcome with Ropivacaine for Epidural Analgesia in Labor
10
Neha Agarwal, Saroj Singh, Richa Singh, Uma Srivastava, Anu Pathak, Jyoti Sharma
CLINICAL STUDY
Incidence of First Trimester Miscarriage among Women Undergoing ICSI According to Origin of Sperm for Male Factor and Non-male Factor
15
Alka Gahlot, ML Swarankar, Ravikant Soni
The Usefulness of Ultrasound Guidance in Fresh Embryo Transfers: A Retrospective Study
19
Alka Gahlot, ML Swarankar, Ravikant Soni
Aquadissection in Nondescent Vaginal Hysterectomy: A Comparative Study of Intraoperative and Postoperative Parameters
24
Mohita Agarwal, Saroj Singh, Arun Nagrath
CASE REPORT
Heterotopic Pregnancy Anshu Mishra, Seema Dwivedi, Neena Gupta, Shefali Pande
31
Asian Journal of Volume 1, January-March 2013
CONTENTS
Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E - 219, Greater Kailash, Part - 1 New Delhi - 110 048 E-mail: editorial@ijcp.com
CASE REPORT
A Rare Case of Secondary Abdominal Pregnancy with Placental Implantation between Leaves of Broad Ligament
Printed at Nikeda Art Printers Pvt. Ltd., Mumbai
33
Seema Dwivedi, Neena Gupta, GN Dwivedi, Shefali Pande
Š Copyright 2013 IJCP Publications Ltd. All rights reserved. The copyright for all the editorial material contained in journal, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.
Post Cesarean Vaginal Omental Prolapse
36
Asavari Ashok Bachhav
Pregnancy with Eisenmenger Syndrome: A Challenge to Obstetrician
39
Kiran Pandey, Shefali Pande Editorial Policies The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article. Note: Asian Journal of Obs & Gynae Practice does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature in this issue.
A Case of Displaced Intrauterine Contraceptive Device
41
Preeti Lewis, Som Subhro Biswas
Hysterosalpingographic Findings in a Case of Genital Tuberculosis
43
Som Subhro Biswas, Tara Sharma
PHOTO QUIZ
45
Nutan Agarwal
FLOW CHART
Carcinoma Endometrium
47
Sumita Agarwal, Garima Kachhawa, Alka Kriplani
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FROM THE ISSUE EDITOR
Vaginal Delivery Safe for Head First Births before 32 Weeks
Dr Alka Kriplani Professor and Head of Unit II Dept. of Obstetrics and Gynecology AIIMS, New Delhi E-mail: kriplanialka@gmail.com
Dear Reader Infants born to mothers attempting to deliver vaginally before the 32nd week of pregnancy are as likely to survive as those delivered by a planned cesarean, provided the fetus is in the head-first position, according to researchers at the National Institutes of Health. Pregnancy typically lasts about 40 weeks. Infants born before the 37th week of pregnancy are classified as preterm, and those born before the 32nd week of pregnancy are classified as early preterm. Preterm infants are at risk for a number of health problems, including increased risk of infant death, cerebral palsy, developmental delays, infection and vision and hearing problems. According to the Centers for Disease Control and Prevention, 54 percent of all infant deaths in the United States occur among the 2 percent of infants born before the 32nd week of pregnancy. Some studies have suggested that infants delivered vaginally before 32 weeks are less likely to survive through infancy than those delivered by a planned cesarean delivery and more likely to suffer injury and health effects after passing through the birth canal. Cesarean delivery, especially in the early preterm period, poses risks for the mother, such as hemorrhage, bladder injury, and other complications. Women who undergo cesarean delivery are at risk for rupture of the uterus during labor and other complications in subsequent pregnancies. Their findings appear online in the American Journal of Obstetrics and Gynecology.
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
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FROM THE DESK OF GROUP EDITOR-IN-CHIEF
What’s New in Gynecology?
Dr KK Aggarwal Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist, Moolchand Medcity, New Delhi President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS National Vice President-Elect, IMA Chairman Ethical Committee, Delhi Medical Council Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http//twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)
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se of selective serotonin reuptake inhibitors (SSRIs) to treat pregnant patients does not appear to be associated with stillbirth or infant mortality.1 The United States Advisory Committee on Immunization Practices (ACIP) recommended that all pregnant women receive the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine during each pregnancy, optimally between 27 and 36 weeks of gestation, regardless of prior vaccination status, to increase the likelihood of optimal protection against pertussis for both the mother and her infant during the first few months of the infant’s life.2 Previously, Tdap was recommended only for pregnant women who had not previously received the acellular pertussis vaccine during adulthood. Vaccination during pregnancy substantially reduced the risk of a maternal influenza diagnosis (adjusted hazard ratio, 0.30) and was associated with a trend in reduction of fetal death. All women who are pregnant or will be pregnant during influenza season should receive the inactivated influenza vaccine, regardless of pregnancy trimester.3
A December 2012 American College of Obstetricians and Gynecologists (ACOG) Committee opinion concluded that the decision to perform early versus delayed cord clamping in term deliveries should be based on patientspecific factors, particularly the infant’s risk of developing iron deficiency anemia.4 For preterm deliveries, they recommended delayed cord clamping given the significant reduction in intraventricular hemorrhage associated with this intervention.3 In a prospective study of mothers who used benzodiazepines (primarily lorazepam, clonazepam and midazolam) while breastfeeding, central nervous system depression (defined as sleepiness, poor latching, limpness or lack of response to stimuli) in infants was an infrequent finding (affecting 2 out of 124 or 1.6%).5 References 1. Stephansson O, Kieler H, Haglund B, et al. Selective serotonin reuptake inhibitors during pregnancy and risk of stillbirth and infant mortality. JAMA 2013;309(1):48-54. 2. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Tdap) in Pregnant Women - Advisory Committee on Immunization Practices (ACIP), 2012. http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm6207a4.htm?s_cid=mm6207a4_e (Accessed on February 21, 2013). 3. Håberg SE, Trogstad L, Gunnes N, et al. Risk of fetal death after pandemic influenza virus infection or vaccination. N Engl J Med 2013;368(4):333-40. 4. Rabe H, Diaz-Rossello JL, Duley L, et al. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst Rev 2012;(8):CD003248. 5. Kelly LE, Poon S, Madadi P, et al. Neonatal benzodiazepines exposure during breastfeeding. J Pediatr 2012;161(3):448-51.
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Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
REVIEW ARTICLE
Clostridium sordellii Infection of Female Genital Tract Prabhat Kumar Agrawal*, Ruchika Garg**
ABSTRACT Clostridium sordellii, an anaerobic pathogen, is ubiquitously distributed in the environment and causes fatal necrotizing infections in approximately 70% of all reported cases. Characteristic clinical features include absence of fever and rash, dramatic leukemoid reaction, capillary leak and fluid sequestration with hemoconcentration, refractory tachycardia and hypotension, and marked edema of infected tissues without gas production or extensive myonecrosis. C. sordellii has rarely been identified in the genital tract, other Clostridium species colonize the vagina in 4-8% of healthy women and commonly are associated with postpartum endometritis and septic abortion. Pregnancy, childbirth or abortion may predispose a some women to acquire C. sordellii in the vaginal tract. Dilatation of the cervix may lead to ascending infection of necrotic decidual tissue. The acidic pH of the vaginal tract may enhance the cytopathic effects of C. sordellii lethal toxin. C. sordellii infections pose difficult clinical challenges and are usually fatal. Key words: Clostridium sordellii, toxic shock syndrome, leukemoid reaction
S
ince its first report in 1922, only a few cases of bacteremia due to Clostridium sordellii have been reported.1 In the world literature only very few cases of a toxic shock syndrome (TSS) due to C. sordellii necrotizing infections have been reported till now. It has rarely been implicated as a human pathogen. It is a normal inhabitant of intestinal flora of both humans and animals.2 C. sordellii have been isolated in vaginal secretions of 5-10% of nonpregnant women. During labor or abortion open cervix permits the passage of vaginal pathogens, which appears to be the critical event that leads to infection of the endometrium. Infection occurs almost exclusively in association with infection of the uterus or the perineum after either infected episiotomy or postpartum endometritis.3 Serious infection can occur after trauma, medicallyinduced abortion, childbirth, spontaneous abortion and surgical abortion and injection drug use.
*Lecturer, Dept. of Medicine **Lecturer, Dept. of Obstetrics and Gynecology SN Medical College, Agra, Uttar Pradesh Address for correspondence Dr Ruchika Garg D1, Sulahkul Nagar, Bodla Road, Agra, Uttar Pradesh E-mail: ruchikagargsnmc@gmail.com
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
Clinical presentation includes sudden onset influenza like prodrome, progressive refractory hypotension, hypothermia or absence of fever and absence of purulent discharge. Distinctive pathological finding include significant local edema with pleural and peritoneal effusion, localized tissue necrosis and thrombosis of nearby vessels. C. sordellii produce several exotoxins that lead to progressive edema and shock. C. sordellii is associated with a profound exotoxinmediated systemic response characterized by anasarca, refractory hypotension and marked leukocytosis. Diagnosis C. sordellii is confounded by early, nonspecific signs and symptoms and by the absence of fever. Diagnosis is often delayed because there is no rapid diagnostic test for the pathogen.4 Diagnosis of C. sordellii TSS should be suspected, when previously healthy women with recent ‘clean’ obstetric wound present with rapidly spreading edema with cardiovascular decompensation with progressive refractory shock. Definitive diagnosis requires isolation of C. sordellii from infected tissue as blood culture is usually negative. Aldape et al have described 45 cases, eight (18%) were associated with normal childbirth, five (11%) were associated with medically7
REVIEW ARTICLE induced abortion and two (0.4%) were associated with spontaneous abortion. The case-fatality rate was 100%. Ten (22%) of the C. sordellii infections occurred in injection drug users. Other cases of C. sordellii infection (in 19 patients [43%]) occurred after trauma or surgery. Overall, the mortality rate was 69%. Eighty-five percent of all patients with fatal cases died within 2-6 days of initial infection, and nearly 80% of fatal cases developed leukemoid reaction (LR). C. sordellii neuraminidase stimulates proliferation of promyelocytic HL-60 cells. It also modifies vascular cell adhesion molecule 1, which orchestrates the release of mature and immature granulocytes from bone marrow stromal cells. Thus, neuraminidase likely plays an important role in the characteristic LR in C. sordellii infection.5 McGregor et al,6 Rorbye et al7 and Bitti et al8 have reported a case of postpartum death due to C. sordellii TSS. Fischer et al,9 Cohen et al10 have reported a fatal case after abortion with mifepristone and misoprostol. Sosolik et al have reported a case of primipara developing an episiotomy infection, which progressed to involve the underlying fascia and muscle. Despite early and adequate debridement of the devitalized tissue, she developed anasarca, marked leukocytosis, refractory hypotension hypothermia and a persistent coagulopathy, and expired on postpartum Day 5. The cultures from the excised tissue grew C. sordellii. All blood cultures were negative.11 Discussion Patients with a C. sordellii characteristically develop a profound systemic capillary leak, refractory hypotension and a marked LR, where circulating white blood cell (WBC) counts often exceed 1,00,000/L. The fastidious anaerobic growth, variable staining characteristics and complex biochemical profiles of Clostridium species make them difficult to isolate. Additional cases of C. sordellii infection of the genital tract in which the organism was not cultured, speciated or reported probably exist. Evidence of C. sordellii infection can be established with the use of anti-Clostridium species immunohistochemical assay and both organismspecific and broad-range polymerase chain reaction (PCR) assays performed on fixed uterine 8
tissue. Anaerobic culture techniques or new diagnostic approaches are needed to define the true burden of C. sordellii in gynecologic infections. Limited data is available regarding optimum therapy for C. sordellii. Aggressive surgical wound débridement, removal of infected organs (e.g., by means of hysterectomy), and antibacterial agents are first steps to decrease the bacterial load and further production of toxins. In vitro susceptibility testing on C. sordellii strains showed low minimal inhibitory concentrations for penicillin, ampicillin, erythromycin, rifampin, tetracycline, cefoxitin, clindamycin and metronidazole. However, débridement, surgery and antibacterial therapy will not mitigate the effects of preformed toxin. There are no clinical data on the use of immunoglobulin or antilethal toxin antibodies for treatment of C. sordellii infections. Strong suspicion should be made if peripartum female presents with TSS with refractory shock, edema, ascites, pleural effusion without fever or pain. Conclusion For C. sordellii TSS, early recognition of condition may be life-saving as this infection has higher mortality and fatal outcome with delayed treatment or unrecognization of condition. The true burden of C. sordellii in gynecologic infections is not known. New diagnostic approaches are needed as they pose a difficult clinical challenge. Limited data is available regarding optimum therapy for C. sordellii. Improved treatments are needed to reduce the morbidity and mortality of these infections as these infections are usually fatal. References 1. Matten J, Buechner V, Schwarz R. A rare case of Clostridium sordellii bacteremia in an immunocompromised patient. Infection 2009;37(4):368-9. 2. Spera RV, Kaplan MH, Allen SL. Clostridium sordellii bacteremia: case report and review. Clin Infect Dis 1992;15:950-4. 3. Sinave C, Le Templier G, Blouin D, Léveillé F, Deland E. Toxic shock syndrome due to Clostridium sordellii: a dramatic postpartum and postabortion disease. Clin Infect Dis 2002;35(11):1441-3. 4. Aldape MJ, Bryant AE, Stevens DL. Clostridium sordellii infection: epidemiology, clinical findings, and current perspectives on diagnosis and treatment. Clin Infect Dis 2006;43(11):1436-46.
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
REVIEW ARTICLE 5. Aldape MJ, Bryant AE, Ma Y, Stevens DL. The leukemoid reaction in Clostridium sordellii infection: neuraminidase induction of promyelocytic cell proliferation. J Infect Dis 2007;195(12):1838-45. 6. McGregor JA, Soper DE, Lovell G, Todd JK. Maternal deaths associated with Clostridium sordellii infection. Am J Obstet Gynecol 1989;161(4):987-95. 7. Rørbye C, Petersen IS, Nilas L. Postpartum Clostridium sordellii infection associated with fatal toxic shock syndrome. Acta Obstet Gynecol Scand 2000;79(12): 1134-5. 8. Bitti A, Mastrantonio P, Spigaglia P, Urru G, Spano AI, Moretti G, et al. A fatal postpartum Clostridium
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
sordellii associated toxic shock syndrome. J Clin Pathol 1997;50(3):259-60. 9. Fischer M, Bhatnagar J, Guarner J, Reagan S, Hacker JK, Van Meter SH, et al. Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion. N Engl J Med 2005;353(22):2352-60. 10. Cohen AL, Bhatnagar J, Reagan S, Zane SB, D’Angeli MA, Fischer M, et al. Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion. Obstet Gynecol 2007;110(5):1027-33. 11. Sosolik RC, Savage BA, Vaccarello L. Clostridium sordellii toxic shock syndrome: a case report and review of the literature. Infect Dis Obstet Gynecol 1996;4(1):31-5.
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ORIGINAL ARTICLE
Cardiotocographic Changes and Perinatal Outcome with Ropivacaine for Epidural Analgesia in Labor Neha Agarwal*, Saroj Singh**, Richa Singh†, Uma Srivastava‡, Anu Pathak*, Jyoti Sharma#
ABSTRACT Objective: To study the cardiotocographic (CTG) changes and perinatal outcome of epidural analgesia with ropivacaine in labor. Material and methods: Sixty women with term pregnancy in active labor were randomly distributed in two equal groups. Epidural group received 10 ml of 0.1% ropivacaine as a bolus with top up doses according to parturient’s demand. Control group did not receive epidural analgesia. Maternal monitoring and continuous fetal monitoring with CTG were done. Neonatal outcome was evaluated. Results: The mean time for onset of analgesia after first dose of epidural ropivacaine was 13.13 minutes. The visual analog scale (VAS) score was reduced from 74.57 mm to 13.5 mm at 30 min and 17.17 mm at one hour providing significant pain relief (p < 0.05). About 83.3% cases had normal CTG tracing and 16.7% had suspicious tracing with ropivacaine, which was comparable to 90% and 10% respectively in control group. Instrumental delivery or cesarean section rate did not increase with ropivacaine. There was no significant difference in birth weight, Apgar score, intensive care admission or neonatal mortality. Patient satisfaction rate with epidural ropivacaine was excellent in 53% cases. Conclusion: Epidural analgesia with ropivacaine provides rapid and significant pain relief during labor and is efficacious and safe for the mother as well as the baby. Key words: Cardiotocography, epidural analgesia, labor analgesia, ropivacaine
“The delivery of the infant into the arms of a conscious and pain free mother is one of the most exciting & rewarding moments in medicine”. –Moir DD
L
abor analgesia has come a long way in providing pain relief to women during labor, so that the experience remains just a wonderful memory of the birth of their child. Epidural analgesia is commonly used for this purpose.
Bupivacaine is a commonly used local anesthetic for labor epidural analgesia. Ropivacaine is a new longacting amide closely related structurally to bupivacaine and mepivacaine, with a similar potency and duration.1 Ropivacaine has the advantage of having a lower neurotoxic and cardiotoxic potential and less intense motor block than bupivacaine;2 thus reducing the
*Lecturer **Professor and Head † Associate Professor ‡ Professor Dept. of Anesthesia # Ex-resident Dept. of Obstetrics and Gynecology Sarojini Naidu Medical College, Agra, Uttar Pradesh Address for correspondence Dr Neha Agarwal F-56, Professor Colony, Kamla Nagar, Agra - 282 004, Uttar Pradesh Email: its_my_ishtyle@yahoo.com
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instrument delivery rate and cesarean delivery rate with ropivacaine.1,3 These properties make ropivacaine a desirable local anesthetic agent for obstetrical analgesia. Cardiotocography (CTG) is a dynamic test for the state of oxygenation of fetus during labor. There is controversy whether epidural analgesia affects the maternal and fetal outcomes and progress of labor. Baseline fetal heart rate (FHR) variability has become an important parameter in the diagnosis of fetal distress, when electronically monitoring the fetus. Loss of this baseline variability has been noted to be associated with fetal distress and in association with late deceleration or severe variable deceleration patterns has been shown to be ominous. However, it can also be modified by prematurity and the administration of certain drugs to the mother.4 Objective The objectives of this study were to assess the CTG changes and perinatal outcome with ropivacaine for epidural analgesia in labor. Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
ORIGINAL ARTICLE Material And Methods This is a prospective randomized study, conducted in the Dept. of Obstetrics and Gynecology, Sarojini Naidu Medical College Agra, Uttar Pardesh. Sixty women with term pregnancy (37-41 weeks), in active labor were selected for this study. They were randomly distributed in two groups of 30 each. Group A (Epidural group) received epidural ropivacaine for pain relief and Group B (Control group) did not receive epidural analgesia. The inclusion criteria were - singleton pregnancy with vertex presentation, reactive nonstress test and established active stage of labor (uterine contractions 2 per 10 minutes, lasting 30-40 seconds and cervical dilatation ≥3 cm). Both primipara and multipara were included. The exclusion criteria were women with malpresentations, cephalopelvic disproportion, previous cesarean delivery, antepartum hemorrhage, medical complications like diabetes, hypertension or asthma and neurological conditions, where rise in intracranial tension during delivery is anticipated (meningitis, cancer, brain abscess, brain hemorrhage, head injury). Informed consent was taken. After prehydrating the women in Group A with 500 ml of Ringer lactate solution, the epidural catheter was put in place and 10 ml of 0.1% ropivacaine was injected as a bolus dose. The top up doses were given according to parturient’s demand. After each dose, maternal vitals (blood pressure, pulse rate and respiratory rate) were monitored every five minutes for the next 20 minutes and then every 30 minutes till delivery. Degree of pain relief was evaluated with a visual analogue scale (VAS) score before the first epidural injection and at 30 minutes and one hour. CTG tracing was taken at the time of admission and was repeated half hourly in the first stage and continuously in the second stage for fetal monitoring. Baseline FHR, beat-to-beat variability, accelerations and decelerations were noted and the CTG was classified as normal, suspicious or pathological as per the National Institute for Health an Clinical Excellence (NICE) guidelines.5 A partogram was maintained to assess the progress of labor. The effect of drug on neonatal outcome was studied by observing Apgar score at 1, 5 and 10 minutes after birth, birth weight, neonatal intensive care unit (NICU) admission and neonatal mortality. Maternal side effects were noted. The analgesic effect Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
and patient satisfaction was assessed after 24 hours and rated as excellent, good, average and poor. The student t-test and Chi-square test were applied and p value calculated. A p value <0.05 was considered statistically significant. Observation and Results The clinical characteristics of the epidural group and control group are given in Table 1. In both the groups, most of the women were primiparas (60% in epidural group and 73.3% in control group). Both the groups were also comparable in terms of age, height, weight and period of gestation of the women at the time of admission. Per vaginum findings at the time of admission were also similar in both the groups. Mean cervical dilatation was 4.30 cm in epidural group and 4.50 cm in control group, with mean effacement of 43.33% and 50.33%, respectively (Table 1). Head was at -1 station in most of the parturients in both groups and membranes were intact in all of them. The mean time for onset of analgesia after first dose of epidural ropivacaine was 13.13 minutes. The VAS score was 74.57 mm before giving epidural analgesia and 13.5 mm at 30 minutes and 17.17 mm at one hour after giving epidural ropivacaine. Thus, the degree of pain relief was statistically significant (p < 0.05). In the epidural group, 14 women (46.67%) needed two top up doses, while 12 (40%) needed one and three women (10%) needed three top up doses. One woman did not need any top up dose. Table 1. Clinical Characteristics of the Women on Admission Group A (Epidural group) (n = 30)
Group B (Control group) (n = 30)
P value
Mean age (years)
23.60
23.43
0.83
Mean height (cm)
154.90
156.43
0.11
Mean weight (kg)
52.80
52.60
0.82
Mean gestational age (weeks)
39.30
39.03
0.55
Mean cervical dilatation (cm)
4.30
4.50
0.53
Mean effacement (%)
43.33
50.33
0.53
Mean fetal heart rate on admission (bpm)
140.67
142.67
0.21
Clinical characteristics
Per vaginum findings on admission
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ORIGINAL ARTICLE As shown in Table 2, the mean duration of first and second stages of labor were slightly prolonged in the epidural group than the control group but the difference was not statistically significant. Maternal parameters (pulse rate, blood pressure, respiratory rate) at the time of admission and one hour after receiving epidural ropivacaine showed no significant changes in either group (Table 3). During intrapartum CTG monitoring in epidural group, FHR was normal (110-160) in 85.67% cases, tachycardia (>160 bpm) was seen in 10% cases and bradycardia (<110 bpm) in only one case (3.33%). In the control group, FHR was normal in 93.3% cases, tachycardia was seen in 6.67% cases with no case of bradycardia. In the epidural group, beat-to-beat variability was normal (5-25 bpm) in 96.67% cases and <5 bpm (for 40-90 min) in one case, while in the control group all cases had normal beat-to-beat variability. In the epidural group, there was absence of acceleration in one case (3.33%) and early decelerations in four cases (13.3%). In the control group, none of the cases showed absence of acceleration while early decelerations were seen in two cases (6.67%). None of the women in either group had late decelerations. (Table 4). In the study, 83.3% cases Table 2. Duration of Various Stages of Labor Duration of labor
Group A (Epidural group) (n = 30)
Group B (Control group) (n = 30)
P value
Primipara Stage I (min)
331.67
315.32
0.32
Stage II (min)
41.11
35.45
0.23
Stage III (min)
10.22
8.91
0.058
Stage I (min)
215.42
172.00
0.078
Stage II (min)
35.87
32.50
0.131
Stage III (min)
7.58
2.33
0.078
Multipara
in the epidural group and 90% in the control group had normal CTC tracing during intrapartum period, while suspicious CTC findings were found in 16.7% and 10%, respectively. The difference was not significant. None of the cases had pathological CTG tracings. The mode of delivery was vaginal in maximum women in both the groups (26/30 [87.7%] vs 28/30 [93.3%]). In epidural group, forceps were applied in one case (3.33%) because of nonrotation of head, while none of the cases in the control group were delivered instrumentally. Three women (10%) in the epidural group had cesarean section because of nonprogression of labor or fetal distress, while two women (6.67%) in the control group had cesarean section for non- progression of labor. Thus, there was no statistically significant increase in rate of instrumental delivery or cesarean section rate with epidural ropivacaine (p = 0.53) (Fig. 1). Table 4. Intrapartum CTC Changes CTG findings Group A Group B (Control (Epidural group) group) (n = 30) (n = 30) Number Percent Number Percent (%) (%) Fetal heart rate (bpm) 110-160 26 85.67 28 93.33 >160 3 10 2 6.67 <110 1 3.33 Beat to beat variability 5-25 bpm 29 96.67 30 100 <5 (40-90 min) 1 3.33 bpm <5 (>90 min) bpm Absence of 1 3.33 acceleration Presence of deceleration Early 4 13.33 2 6.67 Late -
Table 3. Effect of Ropivacaine on Maternal parameters Maternal parameters
On admission Epidural group Control group
Mean pulse rate (per min)
One hour after admission P value
Epidural group Control group
P value
84.60
83.07
>0.05
89.67
88.20
>0.05
Systolic (mmHg)
124.20
124.53
>0.05
121.0
122.33
>0.05
Diastolic (mmHg)
86.40
85.07
>0.05
81.73
83.27
>0.05
16.13
15.73
>0.05
17.67
16.73
>0.05
Mean blood pressure
Mean resiratory rate (per min)
12
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
ORIGINAL ARTICLE Table 5 compares the neonatal outcome in the two groups. Eighty percent cases in epidural group and 67% cases in control group had birth weight between 2.5-3 kg. There was no statistically significant difference in the mean birth weight in both the groups (2.710 kg in epidural group and 2.703 kg in control group; p = 0.93). Mean Apgar score at one minute in epidural group was 8.07 and in control group was 8.23. Mean Apgar score at five minutes was 9.07 and 9.33, respectively, while at 10 minutes it was 9.73 and 9.83 in the epidural and control group, respectively. The difference in the two groups was not statistically significant. Three neonates (10%) in the epidural group and one (3.33%) in control group required NICU admission due to physiological jaundice and were discharged after conservative treatment. On statistically analyzing the difference it was found not significant. There was no neonatal mortality in either group. 30 25
26
28
20 15
Epidural group Control group
10 5 0
1 Vaginal
0
Instrumental
3
2
Cesarean
Figure 1. Mode of delivery.
Table 5. Comparison of Neonatal Outcome Neonatal outcome
Group A Group B P (Epidural group) (Control value (n = 30) group) (n = 30)
Mean Apgar score At 1 minute
8.07
8.23
0.33
At 5 minutes
9.07
9.33
0.06
At 10 minutes
9.73
9.83
0.36
Mean neonatal birth weight (kg)
2.710
2.703
0.93
NICU admission (hours) -
-
24-48
<24
1 (3.33%)
-
>48
2 (6.67%)
1 (3.33%)
-
-
Neonatal mortality
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
Most evident maternal side effects with epidural ropivacaine were nausea, vomiting, headache and backache, occurring in <50% women. None of them were serious enough to discontinue the therapy. Overall patient satisfaction rate with epidural ropivacaine was excellent in 16 cases (53%), good in nine (30%) and average in five cases (17%). Discussion Use of epidural analgesia has gained popularity in many obstetric clinics. Ropivacaine and bupivacaine are the most commonly used local anesthetic agents in labor analgesia. Ropivacaine can be administered at various doses either as a bolus or as continuous epidural infusion. In our study, we have administered 10 ml of 0.1% ropivacaine as bolus dose and top up doses on parturient’s request. The mean time of onset of analgesic action after epidural ropivacaine in our study was 13.13 minutes, which is comparable to 12.8 minutes found by Clement et al,6 and 10 minutes by Stienstra et al.7 The degree of pain relief, measured by VAS at 0 and 30 minutes was 74.57 mm and 13.5 mm, which was comparable to other studies.6-8 The duration of first stage of labor varies from 276 to 545 minutes and that of second stage from 63 to 102 minutes in various studies.8-10 In our study, it was 331.67 minutes and 41.11 minutes respectively. The outcome of labor was not significantly affected and incidence of cesarean section and instrumental delivery was not increased by use of epidural ropivacaine. The cesarean section rate of our study (10%) was comparable to 10.2% cesarean rate of Litwin et al.1 The cesarean section rate varies from 5 to 20%8,9 and instrumental delivery rate varies from 1.66 to 32%1,8,9 in different studies. Overall patient satisfaction rate was excellent in 53% and good in 30% women in our study. Similar results were seen by Mousa et al,9 i.e., excellent patient satisfaction rate in 65% cases and good in 55% cases. According to Lee et al,10 good/ excellent satisfaction rate was 95% which was similar to our study (83%). In the present study, one case (3.33%) had fetal bradycardia with ropivacaine while four (13.33%) had early decelerations and one (3.33%) had decreased variability. Owen et al8 had one case of fetal bradycardia which was managed by ephedrine.
13
ORIGINAL ARTICLE Tugrul et al11 found no significant change in terms of neonatal breathing rate, umbilical cord CO2, O2, pH levels and Apgar scores with 0.2% ropivacaine. The present study also did not find any significant adverse effect on neonatal outcome with ropivacaine. A variety of changes of FHR parameters have been attributed to epidural anesthesia. Epidural anesthesia with lidocaine may cause tachycardia in a small percentage of women and decreased FHR variability in others. No changes in baseline FHR have been observed after epidural anesthesia with bupivacaine. The FHR changes with ropivacaine are still being studied. In general, epidural anesthesia in the absence of maternal hypotension or uterine hypertonus causes minimal changes in the FHR parameters. Those changes that do occur are neither universal nor predictable. Therefore, any alteration in FHR monitoring parameters occurring in a patient receiving epidural anesthesia should be evaluated and acted upon in the same fashion and by the same methods one would employ if the patient was not receiving epidural anesthesia.12 Conclusion From our study, we can conclude that epidural analgesia with ropivacaine provides rapid and significant pain relief. It provides excellent patient satisfaction during labor with no major side effects. The duration of various stages of labor are slightly longer with epidural analgesia but it is not significant enough to alter the final outcome of labor. There is no increase in cesarean sections or instrumental delivery rate. There is no adverse effect on maternal parameters, intrapartum CTG findings or perinatal outcome. Thus, the use of ropivacaine in epidural labor analgesia is efficacious and safe for the mother as well as the baby. References 1. L itwin AA. Mode of delivery following labor epidural analgesia: influence of ropivacaine and bupivacaine. AANA J. 2001;69(4):259-61.
14
2. Merson N. A comparison of motor block between ropivacaine and bupivacaine for continuous labor epidural analgesia. AANA J 2001;69(1):54-8. 3. Writer WD, Stienstra R, Eddleston JM, Gatt SP, Griffin R, Gutsche BB, et al. Neonatal outcome and mode of delivery after epidural analgesia for labour with ropivacaine and bupivacaine: a prospective meta-analysis. Br J Anaesth 1998;81(5):713-7. 4. Boehm FH, Woodruff LF Jr, Growdon JH Jr. The effect of lumbar epidural anesthesia on fetal heart rate baseline variability. Anesth Analg 1975;54(6):779-82. 5. National Institute of Clinical Excellence. The use of electronic fetal monitoring. Inherited Clinical Guideline C 2001:p.1-27. 6. Clément HJ, Caruso L, Lopez F, Broisin F, Blanc-Jouvan M, Derré-Brunet E, et al. Epidural analgesia with 0.15% ropivacaine plus sufentanil 0.5 microgram ml-1 versus 0.10% bupivacaine plus sufentanil 0.5 microgram ml-1: a double-blind comparison during labour. Br J Anaesth 2002;88(6):809-13. 7. Stienstra R, Jonker TA, Bourdrez P, Kuijpers JC, van Kleef JW, Lundberg U. Ropivacaine 0.25% versus bupivacaine 0.25% for continuous epidural analgesia in labor: a double-blind comparison. Anesth Analg 1995;80(2): 285-9. 8. Owen MD, Thomas JA, Smith T, Harris LC, D’Angelo R. Ropivacaine 0.075% and bupivacaine 0.075% with fentanyl 2 microg/mL are equivalent for labor epidural analgesia. Anesth Analg 2002;94(1):179-83, table of contents. 9. Mousa WF, Al-Metwalli RR, Mostafa M. Epidural analgesia during labor--0.5% lidocaine with fentanyl vs. 0.08% ropivacaine with fentanyl. Middle East J Anesthesiol 2010;20(4):521-7. 10. Lee BB, Ngan Kee WD, Ng FF, Lau TK, Wong EL. Epidural infusions of ropivacaine and bupivacaine for labor analgesia: a randomized, double-blind study of obstetric outcome. Anesth Analg 2004;98(4):1145-52, table of contents. 11. Tugrul S, Oral O, Bakacak M, Uslu H, Pekin O. Effects of epidural analgesia using ropivacaine on the mother and the newborn during labor. Saudi Med J 2006;27(12):1853-8. 12. Lavin JP.The effects of epidural anesthesia on electronic fetal heart rate monitoring. Clin Perinatol 1982;9(1):55-62.
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CLINICAL STUDY
Incidence of First Trimester Miscarriage among Women Undergoing ICSI According to Origin of Sperm for Male Factor and Non-male Factor Alka Gahlot*, ML Swarankar**, Ravikant Soni†
ABSTRACT Prior to the development of intracytoplasmic sperm injection (ICSI), azoospremic and severely oligospermic men had little to no chance of having a biological child. In this study, ICSI outcome in 212 transfers with ejaculated spermatozoa and 44 transfers with surgically retrieved spermatozoa were evaluated. Material and methods: The 68 singleton gestations achieved by ICSI were segregated according to underlying infertility etiology, with 54.41% having male factor and 45.59% having female factor. None of the patients had coexisting infertility factor. Results: The miscarriage rate of all ICSI singleton gestations during the first trimester was 19.12%. There were no significant differences in early pregnancy loss (EPL) rate by infertility factor. Among patients undergoing ICSI because of male factor, there were no significant differences in early pregnancy loss using ejaculated or nonejaculated sperm. Regardless of etiology, women aged ≥35 years had significantly higher early pregnancy loss (36.36%). Conclusion: Our preliminary results demonstrate that first trimester miscarriage rates of ICSI gestations are not affected by underlying infertility etiology but are affected by maternal age. Key words: Intracytoplasmic sperm injection, infertility, miscarriage, pregnancy
I
ntracytoplasmic sperm injection (ICSI) has gained an increasing popularity due to its consistent fertilization rate and high pregnancy outcome. ICSI has been used largely to treat male factor infertility, with fertilization and pregnancy rates being comparable to those obtained in couples with good semen parameters undergoing standard in vitro insemination. The evident ability of ICSI to achieve high fertilization and pregnancy rates regardless of ejaculated semen parameters has extended its application to azoospermic patients. Injected epididymal and testicular spermatozoa have been used to effect fertilization and pregnancies. Original concerns about ICSI relating to its aggressiveness and arbitrary sperm selection have been eased by reports on the outcome and follow-up of the ICSI newborns. The presence of a significant frequency of Y chromosome microdeletions and karyotypic anomalies in men with nonobstructive azoospermia *Associate Professor **Professor Dept. of Obstetrics and Gynecology † Senior Demonstrator Dept. of Bio-Chemistry Mahatma Gandhi University of Medical Sciences and Technology Jaipur, Rajasthan Address for correspondence Dr Alka Gahlot 170, Heera Nagar, DCM, Ajmer Road, Jaipur, Rajasthan - 302 021 E-mail: dralkagahlot@gmail.com; alkagahlot23@gmail.com
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
has raised concerns about the risks of treatment for these men. The etiology of azoospermia can be divided into obstructive and nonobstructive categories. The former is characterized by normal sperm production and is often caused by congenital maldevelopment of the vas deferens, a condition known to be associated with cystic fibrosis gene mutations. The treatment for obstructive azoospermia is microsurgical epididymal sperm aspiration (MESA), and when epididymal access is lacking testicular sampling is appropriate. Nonobstructive azoospermia is characterized by a varying degree of spermatogenic failure and at times is associated with an increased number of chromosomal abnormalities. The only method to retrieve spermatozoa from this form of azoospermia is by direct extraction of spermatozoa or germ cells from the testis. Women who are candidates for assisted reproduction technology have characteristics that may predispose them to an increased risk of miscarriage.1 Several studies have assessed miscarriage rates in In vitro fertilization (IVF) and ICSI pregnancies as well as the origin of spermatozoa utilized for assisted fertilization is considered in this regard.2 At present, almost half of fresh embryo transfers result from ICSI3 and ICSI has become a routine laboratory service. Since, chromosomal abnormalities (mostly aneuploidy) have 15
CLINICAL STUDY been reported to account for 50-75% of miscarriages during the first trimester of gestation,4 one measurable outcome to evaluate the safety of ICSI can be the rate of miscarriage among ICSI pregnancies. Conceivably, an increased rate of pregnancy loss may indicate an abnormal outcome related to ICSI as a technique. It is therefore important to document the survival rate of implanted gestations following ICSI and to compare these rates relative to underlying etiology of infertility. In this study, we report the first trimester survival rates of singleton gestations achieved by ICSI from patients with different types of infertility. Material and Methods The study was conducted prospectively from January 2012 to December 2012 at Jaipur Fertility Centre, Assisted Reproductive Technology (ART) Division of Mahatma Gandhi University of Medical Sciences and Technology, Jaipur, Rajasthan. Among the 256 patients who underwent ICSI, 68 (26.56%) were diagnosed as singleton gestations following embryo transfer. We excluded from this study all patients who had multiple gestation, monochorionic or heterotopic pregnancies or Frozen-Thawed embryo transfer. Couples having coexisting infertility factors or women with a history of recurrent pregnancy loss were also excluded from the study, as were couples known to have structural or numerical chromosomal aberrations. The remaining gestations were categorized according to the underlying etiology of infertility. Male factor cases were diagnosed according to the standards of the World Health Organization; tubal factor cases were diagnosed by either hysterosalpingogram or laparoscopy; polycystic ovarian syndrome (PCOS) was diagnosed by irregular menses, reversed folliclestimulating hormone (FSH): Luteinizing hormone (LH) ratio and sonographic appearance of ovaries; and all endometriosis cases were ≥II according to the American Fertility Society classification. Pregnancy was diagnosed as the presence of an intrauterine implanted embryo, defined as a gestational sac as determined by transvaginal ultrasonogram following ICSI and embryo transfer. A gestational sac was defined by the presence of an intrauterine hypoechoic area of ≥8 mm and covered by a double echogenic rim with a visible yolk sac (diameter ≥2 mm), as identified by a 6 MHz vaginal probe (Toshiba color Doppler N-10-30). 16
A miscarriage was defined as the cessation or lack of detection of cardiac activity in the gestational sac or the inability to detect a previously defined gestational sac after vaginal bleeding during the 12 weeks following embryo transfer. Gestations with trophoblast regression but without sonographic evidence of pregnancy were not considered as miscarriages. All patients underwent scanning by transvaginal ultrasonogram four weeks (28-30 days) after embryo transfer. None of the gestations evaluated started as a multiple type followed by subsequent vanishing of embryos. All patients continued to receive progesterone, 100 mg IM once or 200 mg vaginally 8-hourly daily as luteal phase support for 12 weeks after embryo transfer. All couples were thoroughly informed about the treatment procedures, and written informed consent was obtained from all patients. Statistical analyses were performed using the χ2 test, p < 0.05 was considered statistically significant. Result When we diagnosed infertility factors among the recruited couples with positive pregnancy, we found that 37 (54.41%) were due to male factor and 31 (45.59%) were due to female factors including tubal factor, endometriosis, PCOS, other factors as hyperprolactinemia, hypogonadotropic hypogonadism, myoma uteri, uterine dysconfiguration, genital tuberculosis or secondary infertility. The mean age of the women was 32.14 years, and the mean age of their spouses was 35.02 years. The miscarriage rates in singleton gestations did not significantly differ according to underlying infertility factor 21.62% versus 16.13% in male and female infertility, respectively (p > 0.05). During the first trimester overall 13 (19.12 %) patients experienced pregnancy loss (Table 1). Miscarriage rate was significantly higher in women aged ≥35 years than in younger women (36.36% vs 10.86%, p < 0.05). However, when the infertility categories were divided according to age (<35 vs ≥35 Table 1. Miscarriage Rates of Gestations by Infertility Factor No. of pregnancies
No. of miscarriage
Male factor
37/68 = 54.41%
8/37 = 21.62%
Female factor
31/68 = 45.59%
5/31 = 16.13%
68
13/68 = 19.12%
Total
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CLINICAL STUDY Table 2. Outcome of Gestations by Infertility Factor and Maternal Age <35 years
â&#x2030;Ľ35 years
P value
No. of pregnancy
No. of miscarriage
No. of pregnancy
No. of miscarriage
Male factor
25/46 = 54.35%
3/25 = 12%
12/22 = 54.55%
5/12 = 41.67 %
0.104 NS
Female factor
21/46 = 45.65%
2/21 = 9.5%
10/22 = 45.45%
3/10 = 30%
0.354 NS
46
5/46 = 10.86%
22
8/22 = 36.36%
0.030 S
Total
S = Significiant; NS = Not significiant.
Table 3. Miscarriage Rates among Women Undergoing ICSI according to Origin of Sperm for Male Factor and Non-male Factor No. of pregnancy
No. of miscarriage
Surgically retrieved spermatozoa
12
3/12 = 25%
Ejaculated spermatozoa (male factor)
25
5/25 = 20%
Ejaculated spermatozoa (non-male factor)
31
5/31 = 16.13%
Total
68
13/68 = 19.12%
years), older patient with male factor, had increased rates of miscarriage compared with younger patients, which is not statistically significant (Table 2). Among patients with male factor infertility, there was no significant difference in miscarriage rates when surgically retrieved sperm 25% or ejaculated sperm 20% were used for ICSI. Miscarriage rates also did not differ significantly in patients undergoing assisted reproduction treatment with ICSI because of female factor 16.13% (p > 0.05) (Table 3). Discussion Human reproduction is not efficient; with the majority of conceptions being lost very early in gestational life.5 Implanted embryos may undergo developmental arrest at any point during early gestational life. Pregnancies achieved by the use of ART, however, are easier to follow than those conceived spontaneously, offering the opportunity to observe early gestational life ultrasonographically. Miscarriage significantly reduces the initial success and efficacy of assisted reproduction treatment, as well as increasing the psychological burden on patients. Couples who are planning assisted reproduction pregnancies should be informed of the potential hazards of these methods, enabling them to be aware of any potential risk factors that may cause miscarriage. Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
Several studies have reported miscarriage rates in ICSI pregnancies, and have compared rates in IVF and spontaneous pregnancies. Whereas, most have found no significant differences in early miscarriage rates, one study found that the early pregnancy loss rate was significantly lower in ICSI (11%) than in IVF (24%) pregnancies.6 Although, there are no randomized data on miscarriage rates following ICSI and IVF,7 early pregnancy and perinatal outcomes of ICSI gestations appear not to be different from those of IVF gestations.8 In addition, no clinical effects of ICSI severe enough to cause a miscarriage during the first trimester have been reported.9 It has been suggested that offspring from ICSI carry an increased rate of chromosomal aberrations.10 Those abnormalities, however, seem to be related to the underlying parental risk of abnormality and not to the ICSI procedure itself. Although patients undergoing assisted reproduction treatment have a higher rate of miscarriage than do fertile patients, these differences in loss rates are not completely understood and may originate from predisposing factors that are more prevalent in patients suffering from infertility.1 Some studies recently reported that prenatal karyotypes of fetuses in pregnancies achieved by ICSI for male factor infertility did not differ from fetal karyotypes in pregnancies achieved by ICSI for non-male factor infertility.11 Furthermore, IVF and ICSI pregnancies that aborted during the first trimester showed no significant differences in the incidence of embryonic anomalies.12 In the majority of reports, ICSI procedures have been performed in cases of male factor infertility, which may eventually pose a risk to the offspring. Therefore, we studied segregated gestations according to male and female factor infertility. Male factor infertility was further subdivided into groups in which ejaculated sperm and nonejaculated sperm were used. The impact of sperm origin and quality on miscarriage rates was assessed among ICSI pregnancies. No differences 17
CLINICAL STUDY in miscarriage rates have been reported in patients undergoing ICSI for male factor or IVF for non-male factor, and semen origin was found not to affect the miscarriage rate in both sets of patients.13 In support to our findings, the miscarriage rate has been reported to be higher in gestations using surgically retrieved sperm than in those using ejaculated sperm,14 although others have reported similar results for both groups.15 Our results confirm that first trimester survival rates of singleton gestations did not differ when patients with non-male factor infertility underwent ICSI. In agreement with previous studies, we observed an increased risk of miscarriage with increasing maternal age.16 The current study differs in two ways from similar studies evaluating miscarriage rates in ICSI pregnancies. The earlier studies used the demonstration of a fetal heartbeat to define pregnancy. This method, however, may miss a significant number of implanted embryos following transfer, which would have been detected by the presence of a gestational sac, even in the absence of cardiac motion. In other words, this method may underestimate the lifespan of earliest stage implanted embryos, which would have been detected by ultrasonographic visualization. A study recently demonstrated vanishing embryos in multiple gestations by using the presence of a gestational sac as a landmark17 indicating that this approach would better evaluate the intrauterine fate of implanted ICSI embryos. In contrast to most other studies evaluating miscarriage rates in ICSI pregnancies, we evaluated miscarriage rates only in singleton gestations. Most of the earlier studies assessing early pregnancy loss in ICSI pregnancies did not account for multiple fetuses and defined abortion as the total miscarriage of the pregnancy. During early gestational life, a significant number of multiple gestations can have spontaneous reductions, which should be considered in calculations of abortion rates.17 In addition, the survival rates of singleton gestations differ from those of multiple gestations during the first trimester.18 Data support the idea that performing ICSI in all cases of assisted reproduction is not advantageous, and probably it is only more expensive and time consuming.19 Conclusion We have shown that first trimester miscarriage rates in singleton gestations achieved by ICSI were not affected 18
by the underlying infertility factor, but were affected by maternal age. References 1. Ezra Y, Schenker JG. Abortion rate in assisted reproductiontrue increase? Early Pregnancy 1995;1(3):171-5. 2. Schieve LA, Tatham L, Peterson HB, Toner J, Jeng G. Spontaneous abortion among pregnancies conceived using assisted reproductive technology in the United States. Obstet Gynecol 2003;101(5 Pt 1):959-67. 3. Human Fertilisation and Embryology Authority. For Patients; Information and Guide. URL: http:// wwwhfeagovuk. 2000. 4. Philipp T, Philipp K, Reiner A, Beer F, Kalousek DK. Embryoscopic and cytogenetic analysis of 233 missed abortions: factors involved in the pathogenesis of developmental defects of early failed pregnancies. Hum Reprod 2003;18(8):1724-32. 5. Macklon NS, Geraedts JP, Fauser BC. Conception to ongoing pregnancy: the ‘black box’ of early pregnancy loss. Hum Reprod Update 2002;8(4):333-43. 6. Orvieto R, Ben-Rafael Z, Ashkenazi J, Yoeli R, Messing B, Perri T, et al. Outcome of pregnancies derived from assisted reproductive technologies: IVF versus ICSI. J Assist Reprod Genet 2000;17(7):385-7. 7. van Rumste MM, Evers JL, Farquhar CM. ICSI versus conventional techniques for oocyte insemination during IVF in patients with non-male factor subfertility: a Cochrane review. Hum Reprod 2004;19(2):223-7. 8. Kozinszky Z, Zádori J, Orvos H, Katona M, Pál A, Kovács L. Obstetric and neonatal risk of pregnancies after assisted reproductive technology: a matched control study. Acta Obstet Gynecol Scand 2003;82(9):850-6. 9. American Society for Reproductive Medicine; Society for Assisted Reproductive Technology Registry. Assisted reproductive technology in the United States: 1999 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry. Fertil Steril 2002;78(5):918-31. 10. Bonduelle M, Van Assche E, Joris H, Keymolen K, Devroey P, Van Steirteghem A, et al. Prenatal testing in ICSI pregnancies: incidence of chromosomal anomalies in 1586 karyotypes and relation to sperm parameters. Hum Reprod 2002;17(10):2600-14. 11. Jozwiak EA, Ulug U, Mesut A, Erden HF, Bahçeci M. Prenatal karyotypes of fetuses conceived by intracytoplasmic sperm injection. Fertil Steril 2004;82(3):628-33. 12. Causio F, Fischetto R, Sarcina E, Geusa S, Tartagni M. Chromosome analysis of spontaneous abortions after Cont’d on page 23...
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CLINICAL STUDY
The Usefulness of Ultrasound Guidance in Fresh Embryo Transfers: A Retrospective Study Alka Gahlot*, ML Swarankar**, Ravikant Soni†
ABSTRACT Objective: To evaluate retrospectively the efficacy of ultrasound guided embryo transfer method on pregnancy and implantation rate and compare with clinical touch method. Material and methods: The results of 582 cycles from our in vitro fertilization and embryo transfer (IVF-ET) program conducted at Jaipur Fertility Centre, an Infertility Unit of Mahatma Gandhi University of Medical Sciences and Technology, Jaipur, Rajasthan were analyzed retrospectively and comparison was made between those carried out using ultrasound guidance and those by clinical touch method. Results: Higher pregnancy and implantation rate (37.19% and 19.66%, respectively) were found in the group using the transabdominal ultrasound guidance during ET compared with those in the group using the clinical touch method (30.92% and 16.22%, respectively). The difference was not statistically significant. Conclusion: Older women (>35 years) and in the subgroup when the clinician rated the transfer procedure as easy with some difficulty, there appeared to be a substantial improvement in the pregnancy rate and the difference was statistically significant. We believe that ultrasound-guided ET should be used in these subgroups. Key words: Clinical-touch, embryo transfer, in vitro fertilization, retrospective study, ultrasound-guided, air bubble.
T
ransabdominal ultrasound-guided embryo transfer (ET) has been described by various authors since 1985 to improve the pregnancy rate.1-4 However, significantly higher pregnancy rates following transabdominal ultrasound guidance have not been consistently demonstrated. Lindheim et al, first reported that ultrasound guidance improved pregnancy outcome only in easy transfer.5 Subsequently, two studies demonstrated significant differences between the clinical touch method and transabdominal ultrasound-guided ET retrospectively6 and prospectively.7 Most studies trying to address the issue of whether ultrasound guidance is beneficial to ET conclude that although pregnancy rates may not be significantly raised, ultrasound guidance provide both the clinicians and patients with the greater
*Associate Professor **Professor Dept. of Obstetrics and Gynecology † Senior Demonstrator Dept. of Bio-Chemistry Mahatma Gandhi University of Medical Sciences and Technology Jaipur, Rajasthan Address for correspondence Dr Alka Gahlot 170, Heera Nagar, DCM, Ajmer Road, Jaipur, Rajasthan - 302 021 E-mail: dralkagahlot@gmail.com, alkagahlot23@gmail.com
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
degree of confidence in the ET procedure.3,4,8 We divided our study population according to: i) Number of embryo transferred; ii) age of patient and iii) ease of transfer to delineate a subgroup of patients that would particularly benefit from their embryo being transferred under ultrasound guidance. Material and Methods A retrospective study of in vitro fertilization and embryo transfer (IVF-ET) cycles from June 2011 to August 2012 was performed. Between June 2011 to December 2011 the clinical touch method had been adopted for 262 cycles in our IVF-ET program. Between January 2012 and August 2012, 320 cycles of IVF-ET were performed under transabdominal guidance. During both periods, there is no change in ovarian stimulation method, oocyte retrieval, culture media and culture system. For ET Wallace and Cook echo tip catheters were used. Exclusion criteria was; age >45-year-old, more than three previous assisted conception cycles and transfer requiring general anesthesia for the patients. One clinician and three ultrasonographer were involved in the study. All ultrasonographer were specialist in infertility. An ultrasound machine with 3.75 MHz transabdominal probe was used on all women in ultrasound group. 19
CLINICAL STUDY Controlled ovarian hyperstimulation (COH) was carried out in more than 85% of patients with recombinant follicle-stimulating hormone (FSH) and human menopausal gonadotropin (hMG) with halfdose of gonadotrophin-releasing hormone (GnRH) agonist after down regulation with GnRH agonist in the preceding late luteal phase. Rests of the patients were induced by short protocol with GnRH agonist along with recombinant FSH or hMG. Follicular growth was followed by transvaginal ultrasonography and once adequate follicular maturation was obtained, human chorionic gonadotrophin (hCG) was administered and oocyte retrieval was performed about 36 hours later under transvaginal sonographic guidance and general anesthesia. ET was carried out on Day 3 or Day 5 after oocyte retrieval. Frozen ETs were excluded from the study. The Embryo Transfer Procedure We carried out all the ET in the operation theater. Three embryos were usually prepared for transfer. In case, where numbers of embryos formed are less than three less number of embryos i.e., one or two were transferred. The patients arrived with semifilled bladder in ultrasound-guided group and with empty bladder in clinical touch group. In both clinical touch and ultrasound group, the clinicians started the ET in the same way, i.e., cleaning the external genitalia with a dry swab before insertion of a sterile speculum into the vagina. The external cervical os was than cleaned with a dry cotton swab and mucus in the cervical canal was removed with a mucus extractor. Embryos were loaded into Wallace sure view and cook echo tip catheter. The catheter was then handed over to the clinician who inserted it through the cervical canal. At this stage, there was a difference between the two groups. In the clinical group, when the clinician was satisfied with that he had placed the catheter as close to the fundus as possible without touching it, the plunger was depressed; but in the ultrasound group, the ultrasonographer used a transabdominal ultrasound to guide the clinician in the positioning of the tip of the catheter to ~15 mm from the fundus of the uterine cavity. The plunger was then depressed and the air bubbles observed to be expelled from the catheter tip. The embryos were injected over 30Â seconds, allowing observation of the movement of the air bubbles into uterine cavity. Removal of the catheter was also monitored by ultrasound and retention 20
of the air bubbles were observed in the fundal position. The catheter was carefully checked under microscope and the embryo retained within the lumen or adherent to the surface of the catheter were reharvasted. The embryo can be clearly identified by air bubbles inserted on either side, which are seen as bright echoes on the ultrasound image. The clinician was then required to rate the ET procedure in terms of ease of transfer before they left the ET room. The rating system guidelines was: zz Very easy: Transfer catheter went straight through the cervix. zz Easy with some difficulty: Required the separation of the transfer catheter to advance the sheath of a stiffer catheter to facilitate the transfer. zz Difficult: Required in tenculum in addition to those requirement in easy category. A positive pregnancy outcome was a positive blood pregnancy test performed two weeks after the ET and an ultrasound scan showing at least one sac in the uterine cavity two weeks after the positive pregnancy test. Statistical analysis: A p value < 0.05 was considered to be statistically significant. Table 1. Clinical Data of IVF Cycles in Clinical Touch and Transabdominal Group Variables
Age in years
Clinical touch (n = 262)
Ultrasoundguided (n = 320)
34.2
33.9
142/262 = 54.2
165/320 = 51.6
6.0
5.6
Unexplained (%)
44/262 = 16.8
63/320 = 19.7
Male (%)
92/262 = 35.1
112/320 = 35
Only female (%)
98/262 = 37.4
127/320 = 39.7
Combined (%)
Primary infertility (%) Mean infertility duration in years Cause of infertility
28/262 = 10.7
18/320 = 5.6
Mean number of embryos available
7.8
6.9
Mean number of embryos transferred
2.56
2.37
Mean number of oocyte retrieved
13.2
12.3
Days after retrieval
3.1
3.2
No significant difference was observed between the two groups.
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CLINICAL STUDY Table 2. Outcome of Embryo Transfers Performed with Clinical Touch and Ultrasound Guidance Clinical touch (n = 262)
Ultrasound-guided (n = 320)
P value
Pregnancy rate (%)
81/262 = 30.92%
119/320 = 37.19%
0.134 NS
Implantation rate (%)
109/672 = 16.22%
149/758 = 19.66%
0.103 NS
NS = Not significant
Table 3. Outcome of Embryo Transfer in Subgroups Pregnancy rate in subgroups
Clinical touch (n = 262)
Ultrasoundguided (n = 320)
P value
One
3/21 = 14.3%
15/55 = 27.27%
0.327 NS
Two
15/72 = 20.8%
24/92 = 26.1%
0.549 NS
Three
63/169 = 37.3%
80/173 = 46.24%
0.116 NS
≤35-year-old
53/141 = 37.6%
69/186 = 37.1%
0.981 NS
>35-year-old
28/121=23.14%
50/134 = 37.31%
0.021 S
Number of embryo transferred
Age of patients
Ease of embryo transfer Very easy
65/174 = 37.4%
85/225 = 37.8%
0.986 NS
Easy with some difficulty
12/62 = 19.35%
25/68 = 36.8%
0.045 S
Difficult
4/26 = 15.38%
9/27 = 33.33%
0.231 NS
S = Significant
Table 4. Pregnancy Rate According to the Position of the Air Bubbles Distance of air bubbles from fundus (mm) 0-5
6-10
11-15
16-20
21-25
No air bubbles
Total
26-30
Total
13
34
49
14
6
5
4
125
Pregnancy
4
13
21
5
2
1
0
46
30.77
38.24
42.86
35.71
33.33
20
0
36.8
Pregnancy rate (%)
Results The pregnancy rate and implantation rate appeared higher in the ultrasound-guided group but not significant statistically (Tables 1 and 2). When the analysis was performed controlling for the number of embryo transferred, there was no significant difference in the two groups whether one, two, three embryos are transferred. When controlled for age of women (≤35 and >35 years old) again the results were not significantly different in ≤35 years of age group but they were statistically significant in age group >35 years old (23.14% vs 37.31%, respectively). Pregnancy rate in ‘easy with some difficulty’ ultrasound group was 36.8% versus 19.35% in comparison to clinical touch group (statistically significant p < 0.05), Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
may be due to precise recognition of position of uterus in ultrasound-guided cases. If we only examined the cases, which are rated ‘difficult’ the difference in favor of the ultrasound group appeared nonsignificant (Table 3). Out of 320 ultrasoundguided ET in 125 patients’ distance of air bubbles from fundus was noted. Pregnancy rate according to the position of the air bubbles was calculated. Maximum pregnancy rate was achieved when the distance of air bubble was between 11-15 mm from the fundus. Four cycles were excluded from this analysis because there was no description of the location of air bubbles in these cases (Table 4). Discussion Since, the IVF pregnancy was achieved some aspects of the technique have remained largely unchanged, 21
CLINICAL STUDY whilst other have been constantly evolving, the most significant development being in ovulation induction, the use of intracytoplasmic sperm injection (ICSI) and in the development of culture media. Despite these improvements, the majority of the transferred embryos fail to implant. This failure may be due to poor quality embryo, lack of uterine receptivity or the technique of ET itself.9 Defining the factors that are important for successful ET after IVF has been a major issue. Based on the questionnaires distributed amongst highly experienced IVF clinical, Kovacs summarized the answers.10 The factor that got highest votes was the need to remove hydrosalpinx before treatment. The other important factor in order of absence of bleeding, blood on the catheter used, not touching the fundus, avoid the use of a tenaculum, removal of all mucus from the cervix, ultrasound details of the cavity before treatment, leaving the catheter in place for at least one minute, 30 minutes rest after transfer, dummy transfer before treatment, ultrasonic monitoring of transfer and antiprostaglandins to prevent contractions. Although the clinician rated the importance of ultrasound guidance as 11th of 12 factors the role of ultrasound monitoring during transfer should receive more emphasis. The cause of low priority of this factor might be due to the inconvenience and inaccuracy of transabdominal ultrasound guidance. Generally, the positions of air bubble indicate the position of the embryos. It was recommended that the tip of the catheter be positioned 15 mm from the fundus of the uterine cavity to avoid placement of embryos close to the uterine fundus.7 In our study, the point of placement of embryo was also 15 mm from the fundal limit of the uterine cavity. We could transfer the embryos to the precise place under transabdominal ultrasound guidance. There was no pregnancy in four cases in which air bubbles could not be identified. It is likely that these embryos are misplaced probably due to uterine contractions or technical errors. In two cases embryos remained in the lumen of catheter. In other cases, we suppose that the catheter was inadvertently abutting the internal tubal os and the bubbles disappeared in the tubal canal. Furthermore, we experienced some cases in which the air bubbles moved towards the cornue or the cervix from the position of the tip of the catheter. These observations also suggest the adequate monitoring by ultrasound guidance is very important during ET. 22
Evidence emerging from 17 to 20 randomized controlled trials comparing ultrasound guidance versus the ‘clinical touch’ method for ET was evaluated in the meta-analysis.7,11,12 In all three of them, clinical pregnancy rates were found to be statistically significant higher (odd ratio [OR] 1.31-1.50) with transabdominal ultrasound guidance. It was reported that tactile assessment of catheter placement was unreliable.13 The outer guiding catheter inadvertently abutted the fundal endometrium or the internal tubal os and intended the endometrium. The transfer catheter was seen to be embedded within the endometrium. Transabdominal ultrasound-guided ET can minimize these endometrial traumas and thus reduce the uterine contractions. As transabdominal ultrasound can supply fine picture of the flexion of the uterus and the curve of the uterine endometrial midline, the clinician can insert the catheter smoothly without endometrial trauma under the monitoring, and stop the catheter before reaching the fundus. If the curve of the uterine endometrial midline is sharp, we stop the outer sheath before intending the endometrium and advance only the inner catheter, which is softer than the outer sheath, upto 15 mm from the uterine fundus. These atraumatic procedures probably contributed to successful ET in the present study because bleeding from the endometrium or the uterine cervix is a significant negative factor for ET, as suggested by Kovacs.10 The procedure was readily accepted by the patients who were reassured by the visualization of the transfer process. The acceptance by the clinician was also high with no significant added time, and the procedure was done with more confidence as the catheter is advanced to the fundus of the uterus under ultrasound scan guidance. Furthermore, ultrasoundguided ET may have two additional advantage over clinical touch ET when considering that: i) Blind catheter placement has been shown to result in a malposition of the catheter in >25% of cases, thus indicating that tactile assessment of ET catheter position is unreliable13 and ii) the depth of the embryo replacement into the uterine cavity influences implantation rates, with high pregnancy rates obtained when the embryos are replaced 15-20 mm from the fundal endometrial surface.7 All the above, the notion that ultrasound assistance in the ET is a pivotal tool for improving pregnancy rate in assisted reproduction irrespective of whether embryos are fresh or frozen and replaced in Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CLINICAL STUDY spontaneous, stimulated or artificially prepared cycles. A very recent report showing that ultrasoundguided ET improve outcome in patients with previous failed IVF cycles provides further evidence in this regards.11 Conclusion There was no significant difference in the pregnancy rate when the number of embryo transferred was controlled. Based on the results obtained from the present study, transabdominal ultrasonography guidance appear to be an essential factor for improving the results of ET especially in case of easy with some difficulty ET and in older women. References 1. Al-Shawaf T, Dave R, Harper J, Linehan D, Riley P, Craft I. Transfer of embryos into the uterus: how much do technical factors affect pregnancy rates? J Assist Reprod Genet 1993;10(1):31-6. 2. Kan AK, Abdalla HI, Gafar AH, Nappi L, Ogunyemi BO, Thomas A, et al. Embryo transfer: ultrasound-guided versus clinical touch. Hum Reprod 1999;14(5):1259-61. 3. Leong M, Leung C, Tucker M, Wong C, Chan H. Ultrasound-assisted embryo transfer. J In Vitro Fert Embryo Transf 1986;3(6):383-5. 4. Strickler RC, Christianson C, Crane JP, Curato A, Knight AB, Yang V. Ultrasound guidance for human embryo transfer. Fertil Steril 1985;43(1):54-61. 5. Lindheim SR, Cohen MA, Sauer MV. Ultrasound guided embryo transfer significantly improves pregnancy rates in
women undergoing oocyte donation. Int J Gynaecol Obstet 1999;66(3):281-4. 6. Wood EG, Batzer FR, Go KJ, Gutmann JN, Corson SL. Ultrasound-guided soft catheter embryo transfers will improve pregnancy rates in in-vitro fertilization. Hum Reprod 2000;15(1):107-12. 7. Coroleu B, Carreras O, Veiga A, Martell A, Martinez F, Belil I, et al. Embryo transfer under ultrasound guidance improves pregnancy rates after in-vitro fertilization. Hum Reprod 2000;15(3):616-20. 8. Prapas Y, Prapas N, Hatziparasidou A, Prapa S, Nijs M, Vanderzwalmen P, et al. The echoguide embryo transfer maximizes the IVF results. Acta Eur Fertil 1995;26(3):113-5. 9. Speirs AL. The changing face of infertility. Am J Obstet Gynecol 1988;158(6 Pt 1):1390-4. 10. Kovacs GT. What factors are important for successful embryo transfer after in-vitro fertilization? Hum Reprod 1999;14(3):590-2. 11. Anderson RE, Nugent NL, Gregg AT et al. Transvaginal ultrasound guided embryo transfer improves outcome in patients with failed IVF cycles. Presented at the 49th annual meeting of the Pacific Coast Reproductive Society, California, USA. Fertil Steril (Suppl.), 2001;S9-10. 12. Fanchin R, Righini C, Olivennes F, Taylor S, de Ziegler D, Frydman R. Uterine contractions at the time of embryo transfer alter pregnancy rates after in-vitro fertilization. Hum Reprod 1998;13(7):1968-74. 13. Woolcott R, Stanger J. Potentially important variables identified by transvaginal ultrasound-guided embryo transfer. Hum Reprod 1997;12(5):963-6.
...Cont’d from page 18
in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Eur J Obstet Gynecol Reprod Biol 2002;105(1):44-8.
16. Nybo Andersen AM, Wohlfahrt J, Christens P, Olsen J, Melbye M. Maternal age and fetal loss: population based register linkage study. BMJ 2000;320(7251):1708-12.
13. Palermo GD, Neri QV, Hariprashad JJ, Davis OK, Veeck LL, Rosenwaks Z. ICSI and its outcome. Semin Reprod Med 2000;18(2):161-9.
17. Ulug U, Jozwiak EA, Mesut A, Berksoy MM, Bahceci M. Survival rates during the first trimester of multiple gestations achieved by ICSI: a report of 1448 consecutive multiples. Hum Reprod 2004;19(2):360-4.
14. Anderson AR, Wiemer KE, Weikert ML, Kyslinger ML. Fertilization, embryonic development and pregnancy losses with intracytoplasmic sperm injection for surgically-retrieved spermatozoa. Reprod Biomed Online 2002;5(2):142-7. 15. Göker EN, Sendag F, Levi R, Sendag H, Tavmergen E. Comparison of the ICSI outcome of ejaculated sperm with normal, abnormal parameters and testicular sperm. Eur J Obstet Gynecol Reprod Biol 2002;104(2):129-36.
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
18. Tummers P, De Sutter P, Dhont M. Risk of spontaneous abortion in singleton and twin pregnancies after IVF/ICSI. Hum Reprod 2003;18(8):1720-3. 19. Borini A, Gambardella A, Bonu MA, Dal Prato L, Sciajno R, Bianchi L, et al. Comparison of IVF and ICSI when only few oocytes are available for insemination. Reprod Biomed Online 2009;19(2):270-5.
23
CLINICAL STUDY
Aquadissection in Nondescent Vaginal Hysterectomy: A Comparative Study of Intraoperative and Postoperative Parameters Mohita Agarwal*, Saroj Singh**, Arun Nagrath**
ABSTRACT Objectives: Vaginal hysterectomy is a common surgical procedure in gynecology. Nondescent vaginal hysterectomy has its own advantages. Supplementation of tumescent anesthesia or aquadissection, whereby fluid with an anesthetic and a vasoconstrictor agent is pushed into the fascial spaces, has further added upto the benefits by reducing the associated morbidity. Material and methods: The study was carried out in the Dept. of Obstetrics and Gynecology, SN Medical College, Agra, UP on 100 cases planned to undergo nondescent vaginal hysterectomy for different indications. Fifty cases were operated conventionally and the other 50 were supplemented with aquadissection. Results: The cases in the aquadissection group has lesser blood loss, shorter operating time, earlier ambulization, short hospital stay and fewer intraoperative and postoperative complications as compared to the conventional group. Conclusion: Aquadissection techniques supplemented to vaginal hysterectomy is advantageous. Key words: Nondescent vaginal hysterectomy, aquadissection, tumescent anesthesia
H
ysterectomy is the commonest major surgical procedures in gynecology. Among the spectrum of approaches available for removing the nonprolapsed uterus vaginal route is preferred over abdominal route as it has a shorter operating time and hospitalization, less morbidity and good cosmetic results. Tumescent anesthesia was first described by Jeffrey Klein for liposuction. It is technique for delivery of local anesthesia that maximizes safety by using pharmacokinetic principles to achieve extensive regional anesthesia of skin and subcutaneous tissue.1 The subcutaneous infiltration of a large volume of very dilute lidocaine and epinephrine causes the targeted tissue to become swollen and firm, or tumescent, and permits procedures to be performed on patients without subjecting them to the inherent risks of local anesthesia and blood loss.2 The injection of large amounts of normal saline, which makes the surgical field bloodless and paves the way for proper planes of dissection. The use of fluid to ease out surgical
*Lecturer **Professor Dept. of Obstetrics and Gynecology SN Medical College, Agra, UP Address for correspondence Dr Mohita Agarwal Dept. of Obstetrics and Gynecology SN Medical College, Agra, UP E-mail: bestmolly@gmail.com
24
dissection justifies the procedure to be referred to as ‘Aquadissection’. It was introduced in vaginal surgery with the aim of further enhancing the benefits of this route. Infiltration of normal saline creates edema in the fascial spaces and in the process the bladder anteriorly and the pouch posteriorly is adequately dissected. Moreover, the presence of large quantities of normal saline in the fascial spaces exerts mechanical pressure on the blood vessels, thus acting as a compression and reduces intraoperative bleeding. Hence, the name ‘water tourniquet’. The introduction of supplementation of tumescent anesthesia into the technique of vaginal hysterectomy has made surgical dissection easier and safer and intraoperative blood loss is also minimized. It allows dissection over larger areas than previously possible with considerable ease. It uses direct infiltration of saline-based or similar solution to deliver lidocaine, epinephrine and other medications into the subcutaneous and submucosal areas. The presence of very dilute epinephrine in the range of 1:1,000,000 causes vasoconstriction locally. This in turn reduces during and after the procedure, the local anesthetic effects of lidocaine are prolonged and systemic absorption of lidocaine is delayed, permitting larger doses to be administered than could be safely done without epinephrine. Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CLINICAL STUDY Material and Methods The study was conducted in the Dept. of Obstetrics and Gynecology, SN Medical College, Agra, UP on 100 women who were planned for nondescent vaginal hysterectomy for various gynecological complaints like dysfunctional uterine bleeding, fibroid, adenomyosis, dysplasias, etc. A detailed history of the case regarding chief menstrual complaints, personal, obstetric and medical especially cardiovascular symptoms was obtained. General, systemic and bimanual examinations were done. Cases of more than 40 years with a mobile uterus of <12 weeks size with preferably no abdominal scar were selected for the study. Those with acute pelvic inflammatory disease (PID), restricted uterine mobility, limited vaginal space, adnexal pathology, fistula repairs, cervix flushed with vagina and carcinoma cervix were excluded. The cases were divided into study group and control group of 50 cases each. Control group underwent nondescent vaginal hysterectomy by the standardized technique. In the study group, 150-200 ml of aquadissection solution was infiltrated into the paracervical space. Aquadissection solution is prepared my adding 20 ml of 1% lignocaine and 1 mg of adrenaline (1:1,000,000) to 200 ml of normal saline. The concentration of lidocaine is kept below the safe limit of 60 mg/kg body weight. After a brief massage to accelerate distribution of the tumescent fluid, surgery was performed by the standardized technique. The difference in duration of surgery, blood loss during surgery as assessed by the number and extent of sponges soaked and intraoperative and postoperative morbidity were assessed in both groups. The following parameters were considered as morbidity. zz Duration of surgery - more than 45 minutes zz Intraoperative blood loss - more than two completely soaked sponges zz Postoperative duration of intravenous fluid infusion - more than 48 hours zz Postoperative mobilization - after more than 48 hours zz Postoperative urinary complications - urinary retention, incontinence, dysuria, etc. zz Postoperative febrile morbidity - fever of more than 100.40F on two consecutive days (after first 24 hours of operation) Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
zz
zz
Presence of any vaginal discharge - both white discharge pervaginum and bleeding pervaginum Duration of hospital stay - more than seven days
Results Aquadissection in itself is not a new concept. It has been tried in a number of operations in different indications, wherein, liquid substances like normal saline is injected into the fascial spaces, which comprise of loose areolar tissue. The introduction of large amounts of fluid in the fascial spaces leads to separation of the tissues or what we can term dissection of the fascial spaces. Thereafter, separating the vital tissues from their immediate relations becomes relatively easy because of tissue edema that has been produced as a result of the introduction of large amounts of water. The multidirectional force of the fluid can create a plane of cleavage by way of the path of least resistance. The present study was carried out to identify the extent of utility of aquadissection in reducing the morbidity associated with conventional nondescent vaginal hysterectomy (NDVH). The maximum number of patients in both groups was between 36-40 years with a parity of three in Group B and four or more in Group A and the most common complaints of polymenorrhagia (cause dysfunctional uterine bleeding [DUB]) in both groups (Table 1). Maximum cases in the aquadissection group required not more than 35 minutes for surgery, which was significantly less than the conventional group, where the maximum cases required more than 45 minutes for completion of surgery (Table 2). Most cases carried out by the aquadissection technique were completed with a moderately soaked one sponge, whereas in the conventional group more than one sponge got completely soaked with blood. Table 1. Patient Profile Parameter
Age
Group A (conventional NDVH)
Group B (aquadissection)
40.6 years
38.16 years
Parity
≥ P4
≥ P4
Diagnosis
DUB
DUB
DUB = Dysfunctional uterine bleeding
25
CLINICAL STUDY Table 2. Intraoperative and Postoperative Parameters Parameter
Group A (conventional NDVH)
Group B (aquadissection)
P value
Time taken for surgery (minutes)
44.50
36.40
<0.01
Duration of catheterization(hours)
42.42
21
<0.01
Postoperative intravenous drip (hours)
30.96
26.88
>0.01
Acceptance of oral sips (hours)
16.32
14.66
>0.01
Postoperative mobilization (hours)
42.48
27.12
<0.01
Duration of hospital stay (days)
8.38
6.58
<0.01
Table 3. Comparison of Blood Loss During Surgery Amount of blood loss
Group A (conventional NDVH)
Group B (aquadissection)
-
24
Moderately soaked one sponge
10
58
Completely soaked one sponge
42
16
More than one completely soaked sponge
48
02
Slightly soaked one sponge
Chi-square 55.929: p < 0.01
Intraoperative morbidity was significantly less in the aquadissection group (Table 3). Six cases in the conventional group required blood transfusion postoperatively due to intraoperative bleeding, whereas one case in the aquadissection group required blood transfusion. In one case of the conventional group, vaginal route had to be abandoned in favor of abdominal route because of morbid adhesions encountered during surgery (Table 4). Maximum number of cases undergoing NDVH by the aquadissection technique required postoperative catheterization for less than 24 hours after which they could void normally while cases undergoing conventional NDVH required postoperative catheterization for 36-48 hours as only few patients required indwelling catheterization. Therefore, urinary problems associated with catheterization were also minimized. Only two cases of aquadissection group complained of urinary burning and one case developed urinary frequency, whereas in the conventional group 10 cases complained of urinary burning and four cases developed frequency (Table 4). 26
Table 4. Intraoperative and Postoperative Complications Morbidity
Group A (conventional NDVH)
Group B (aquadissection)
Discharge P/V
12
2
Low backache
42
6
Febrile morbidity
20
4
Vaginal bleeding
8
0
Subileus
0
0
Hemorrhage requiring blood transfusion
12
2
Urinary tract infection
8
2
Urinary retention
0
0
Conversion to abdominal route
2
0
Bladder injury
0
0
Bowel injury
0
0
Ureteric injury
0
0
Mortality
0
0
Minor
Moderate
Severe
In our study, bowel sounds appeared within 13-24 hours in maximum number of patients in both groups and they adequately accepted oral sips of clear liquid. These findings were not statistically significant (Tableâ&#x20AC;Ż2). Most cases of aquadissection were ambulatory in 24-36 hours postoperatively with a mean of 27.12 hours as against the conventional group, where maximum cases took 37-48 hours before being ambulatory. The mean was 42.48 hours and the difference was statistically Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CLINICAL STUDY Table 5. Intraoperative and Postoperative Morbidity Chi-square P value test Intraoperative problems
7.156
<0.05
8.691
<0.05
Bowel injury Bladder injury Hemorrhage Conversion to abdominal route Postoperative complaints Burning/Dysuria Urinary retention Frequency Incontinence Urinary tract infection Febrile morbidity Discharge P/V Follow-up complaints Discharge P/V
49.662
<0.01
Low backache Bleeding P/V Urinary complaints
significant. Febrile morbidity was higher in the conventional group as compared to the aquadissection group. None of cases in the aquadissection group developed discharge per vaginum. There was one case of urinary tract infection. On the other hand, in the conventional group three cases developed discharge per vaginum and there were four cases of urinary tract infection. Maximum numbers of cases in the aqua dissection group were discharged within a week, whereas most of the cases in the conventional group stayed for nine days. The difference was statistically significant. During follow-up, 21 cases of the conventional group complained of low backache as against one in the aquadissection group. Other complaints like discharge or bleeding per vaginum were also significantly more in the conventional group. No mortality was observed in either group (Table 5). Discussion Supplementation of aquadissection to the conventional technique has reduced the preoperative blood loss so much so that in most cases a single small-sized sponge would suffice. Easy identification of fascial spaces and Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
ligaments ensures minimal dissection and therefore less time consuming. In a study conducted by Rajesh Modi on the use of aquadissection during performing myomectomy in 157 cases he reported a significant reduction in blood loss and operating time in all cases.3 Sizzi et al4 conducted an Italian multicenter study of complications in 2,050 laparoscopic myomectomies, which had the use of vasoconstrictive agent in 37% cases to reduce the operative time. The conclusion was that the operating time for the enucleation of a fibroid was reduced with the use of vasoconstrictive agent. Aquadissection is not related to the intraoperative problems encountered due to intraperitoneal adhesions. The action of aquadissection is limited to paracervical spaces anteriorly, posteriorly and laterally and the need for laparotomy because of dense intraperitoneal adhesions cannot be attributed either to the use of aquadissection or otherwise. It has been observed that bowel sounds appear earlier in cases that underwent surgery under general anesthesia as compared to regional anesthesia. So, the method of performing vaginal hysterectomy has little or no effect on bowel sound appearance. Under the effect of local anesthetic and adrenaline used in the aquadissection solution, there is lesser pain postoperatively and minimal need for indwelling catheterization using aquadissection study hence the cases can be ambulated earlier. Zullo et al5 enrolled 60 premenopausal women with uterine leiomyomas in a randomized controlled design and intraoperatively treated them with injection of bupivacaine plus epinephrine (Group A) or saline solution (Group B) during laparoscopic myomectomy. Blood loss, total operative and enucleation time, and degree of surgical difficulty were significantly (p < 0.05) lower in Group A than in Group B. The number of vials of pain medication used postoperatively was significantly (p < 0.05) lower in Group A than in Group B. Causes of postoperative febrile morbidity in vaginal hysterectomy are infection at the operative site, increased amount of blood loss and urinary tract infection. Two out of the three causes were observed to be significantly less in the latter group. Thereby lesser predisposition to develop fever postoperatively could be explained. The main concern with the use of vasoconstrictive agent is that it causes sudden rise in blood 27
CLINICAL STUDY pressure, if it is accidentally injected directly into a blood vessel. This complication can be avoided by simply aspirating before injecting. There are concerns regarding the cardiac effect of adrenaline. Myocardial vessel constriction may mimic transient myocardial ischemia. This will manifest as decrease in T-wave amplitude and a long QT interval on ECG monitoring.6 This may last for upto 20 minutes, till the effect of adrenaline wears off. However, ECG changes were not seen intraoperatively with the use of adrenaline at our center. If we only use 400Â ml of saline without adrenaline, then the effect of hemostasis will only be effective for 5-10 minutes, during which time it is washed out from the tissues and bleeding starts, while the surgery is still on.
Conclusion
In our experience in the past selected cases of nondescent vaginal hysterectomy have been discharged from the hospital within 24 hours. This has resulted in the recognition of NDVH as an outpatient surgery or a day care surgery. These cases have to fulfill certain criteria laid down for the purpose before they can be included in this group. This only goes to show that postoperative stay in the hospital may not necessarily be the result of surgical trauma and the disability and morbidity thereof but more of a cautious concern on the part of the surgeon to ensure that these difficult cases are allowed to remain under observation for a longer period of time.
1. Shiffman MA, Giuseppe AD. Liposuction: Principals and Practice. Springer: Germany; 2006.
Very little published literature is available on different aspects of NDVH. Perhaps, one of the understandable reasons is the preference of the abdominal routes or the use of operative endoscopy to carry out hysterectomy. Therefore, not much studies are available for comparison.
28
Thus, the relative advantages and disadvantages of the NDVH by two different methods were evaluated and compared for difference in various intraoperative and postoperative parameters. Minimal handling of the bladder, ease in performing anterior and posterior colpotomy, dramatic reduction in the amount of bleeding during the course of dissection of the paracervical tissues, reduction in the need for transfusion of blood/blood products, lesser pain postoperatively hence earlier ambulation, and shorter duration of stay in the hospital makes aquadissection technique more advantageous than the conventional one. References
2. De Jong RH. Tumescent anesthesia lidocaine dosing dichotomy. Int J Cosmet Surg and Aesth Dermatol 2002;4(1):3-7. 3. Modi R. Laparoscopic myomectomy with aquadissection and barbed sutures. J Gynec Endosc Surg 2011;2(1):47-52. 4. Sizzi O, Rossetti A, Malzoni M, Minelli L, La Grotta F, Soranna L, et al. Italian multicenter study on complications of laparoscopic myomectomy. J Minim Invasive Gynecol 2007;14(4):453-62. 5. Zullo F, Palomba S, Corea D, Pellicano M, Russo T, Falbo A, et al. Bupivacaine plus epinephrine for laparoscopic myomectomy: a randomized placebo-controlled trial. Obstet Gynecol 2004;104(2):243-9. 6. Struthers AD, Reid JL, Whitesmith R, Rodger JC. Effect of intravenous adrenaline on electrocardiogram, blood pressure, and serum potassium. Br Heart J 1983; 49(1):90-3.
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CASE REPORT
Heterotopic Pregnancy Anshu Mishra*, Seema Dwivedi**, Neena Gupta*, Shefali Pandeâ&#x20AC;
ABSTRACT Heterotopic gestation, although common with assisted reproductive techniques, is very rare in natural conception. A high index of suspicion can help in timely diagnosis and appropriate intervention. We report a case of heterotopic pregnancy in a 25-year-old woman presented with hemoperitoneum from ruptured tubal pregnancy with live intrauterine gestation at 12 weeks of amenorrhea, diagnosed on ultrasound examination. Key words: Adnexal mass, assisted conception, heterotopic
H
eterotopic pregnancy is defined as the coexistence of intrauterine and extrauterine gestation. The incidence of heterotopic pregnancy is very low. The frequency was originally estimated on theoretical basis to be one in 30,000 pregnancies. We present a rare case of heterotopic pregnancy with live intrauterine gestation and ruptured left ectopic pregnancy in natural conception.
Ruptured left tubal ectopic with gestational sac in situ
Case Report A 25-year-old woman, G4P2L2A1, with 10-12 weeks of amenorrhea presented to our department with chief complaints of acute pain in abdomen for two hours and acute onset breathlessness for one hour with clinical features of shock with very low general condition.
Figure 1.
Ruptured left tubal ectopic
On examination, her general condition was very poor, her blood pressure was 60 systolic, pulse rate was 160/min, respiratory rate 34/min, afebrile, pallor +++; Per abdominal examination revealed distended tense abdomen with tenderness.
Bulky pregnant uterus
Per speculum examination: Slight blood mixed discharge was present Urine pregnancy test was positive. Transabdominal ultrasound revealed single live intrauterine fetus of approximately 11 weeks with *Professor **Lecturer â&#x20AC; Senior Resident Dept. of Obstetrics and Gynecology GSVM Medical College, Kanpur, UP
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
Figure 2.
variable presentation. A complex left adnexal cystic mass (showing fetal node of 10 weeks with cardiac activity) was present. There was moderate amount of free fluid in peritoneal cavity-? Hemoperitoneum. Gaseous distended bowel loops were present. 31
CASE REPORT zz zz
Fetus with gestation sac
zz
zz
zz
Figure 3.
Provisional diagnosis of a heterotopic pregnancy with ruptured left ectopic gestation was suggested in view of clinical history, moderate amount of free intraperitoneal fluid and an intrauterine gestation. The patient underwent emergency exploratory laparotomy. There was ruptured left-sided tubal pregnancy with alive fetus with hemoperitoneum and left-sided salpingectomy was performed; the intrauterine live gestation was allowed to continue. Discussion A heterotopic gestation is difficult to diagnose clinically. Typically, laparotomy is performed because of tubal pregnancy. At the same time, uterus is congested, softened and enlarged; ultrasound examination can nearly always show gestational products in uterus. The incidence was originally estimated on theoretical basis to be one in 30,000 pregnancies. However, more recent data indicate that the rate is higher due to assisted reproduction and is approximately one in 7,000 overall and as high as one in 900 with ovulation induction.1,2 The increased incidence of multiple pregnancy with ovulation induction and in vitro fertilization (IVF) increases the risk of both ectopic and heterotopic gestation. The hydrostatic forces generated during embryo transfer may also contribute to the increased risk.1 There may be an increased risk in patients with previous tubal surgeries.3 Heterotopic pregnancy can have various presentations. It should be considered more likely: 32
After assisted reproduction techniques. With persistent or rising chorionic gonadotropin levels after dilatation and curettage for an induced/ spontaneous abortion When the uterine fundus is larger than for menstrual dates When more than one corpus luteum is present in a natural conception When vaginal bleeding is absent in the presence of signs and symptoms of ectopic gestation.4
A heterotopic gestation can also present as hematometra and lower quadrant pain in early pregnancy.5 Most commonly, the location of ectopic gestation in a heterotopic pregnancy is the fallopian tube. However, cervical and ovarian heterotopic pregnancies have also been reported.6,7 Majority of the reported heterotopic pregnancies are of singleton intrauterine pregnancies. Triplet and quadruplet heterotopic pregnancies have also been reported, though extremely rare.8,9 It can be multiple as well.4 They can be seen frequently with assisted conceptions. Intrauterine gestation with hemorrhagic corpus luteum can simulate heterotopic/ectopic gestation both clinically and on ultrasound.10 Other surgical conditions of acute abdomen can also simulate heterotopic gestation clinically and hence the difficulty in clinical diagnosis. Bicornuate uterus with gestation in both cavities may also simulate a heterotopic pregnancy. High resolution transvaginal ultrasound with color Doppler will be helpful as the trophoblastic tissue in the adnexa in a case of heterotopic pregnancy shows increased flow with significantly reduced resistance index.2 The treatment of a heterotopic pregnancy is laparoscopy/laparotomy for the tubal pregnancy.4 The illustrated case did not have any risk factor for the heterotopic gestation and presented with ruptured tubal pregnancy with hemodynamic instability due to hemoperitoneum. Conclusion A heterotopic pregnancy, though extremely rare, can still result from a natural conception; it requires a high index of suspicious for early and timely diagnosis; a Contâ&#x20AC;&#x2122;d on page 35...
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CASE REPORT
A Rare Case of Secondary Abdominal Pregnancy with Placental Implantation between Leaves of Broad Ligament Seema Dwivedi*, Neena Gupta**, GN Dwivedi†, Shefali Pande‡
ABSTRACT Abdominal pregnancy is a relatively uncommon condition. The incidence of abdominal pregnancy is one in 10,000 live births and the incidence of advanced abdominal pregnancy is approximately one in 25,000 births.1 The overall mortality rate associated with abdominal pregnancy is 0.5-8.0%.2 Delay in diagnosis is mainly due to difficulties in clinical assessment caused by variance in presentation.3 It usually occurs after tubal abortion or rupture.4 Very rarely, it occurs following rupture of rudimentary horn. Continuation of pregnancy is very rare without manifestation of hemoperitoneum. We report a case of secondary abdominal pregnancy following rupture of cornual pregnancy. Key words: Abdominal, tubal, pregnancy
A
bdominal pregnancy has historically been defined as an implantation in the peritoneal cavity, exclusive of tubal, ovarian or intraligamentary pregnancy.5 Abdominal pregnancy is a rare obstetric complication with high maternal mortality and even higher perinatal mortality, and it can be primary or secondary with the latter being the most common type. Primary peritoneal implantation is rare. Studdiford established three criteria for diagnosing primary peritoneal pregnancies: 1) Normal bilateral fallopian tubes and ovaries; 2) the absence of uteroperitoneal fistula and 3) a pregnancy-related exclusively to the peritoneal surface and early enough to eliminate the possibility of secondary implantation following a primary nidation in the tube.6 Secondary abdominal pregnancy is a condition, where the embryo or fetus continues to grow in the abdominal cavity after its expulsion from the fallopian tube or other seat of its primary development. Secondary abdominal pregnancy almost always follows early rupture of a tubal ectopic pregnancy into
*Lecturer **Professor, Dept. of Obstetrics and Gynecology † Associate Professor, Dept. of Pediatrics ‡ Senior Resident, Dept. of Obstetrics and Gynecology GSVM Medical College, Kanpur, UP Address for correspondence Dr Seema Dwivedi D-22, Medical College Campus GSVM Medical College, Kanpur, UP E-mail: dr.shefali04@gmail.com
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
the peritoneal cavity with the incidence being one in 10,000 live births.7 Advanced abdominal pregnancy is rare and accounts for one in 25,000 pregnancies.8 Risk factors for abdominal pregnancy are the same as for ectopic pregnancy and, when it is recognized, immediate laparotomy with removal of the fetus is usually recommended. As it is a life-threatening condition, expectant management carries a risk of sudden life-threatening intra-abdominal bleeding and a generally poor fetal prognosis.9 Case Report Mrs. S, 32-year-old lady, third gravida with 2 live issues presented with eight months pregnancy with intrauterine death, ascites and poor general condition. During her antenatal period patient complained of pain abdomen at two months of gestational age, for which she consulted some general practitioner and sonography was advised. Her ultrasonography (USG) report showed eight weeks live gestation, fetal pole, fetal cardiac activity and fetal movements were seen. Mild free fluid was present in pelvis. Inflamed bowel loops were present. After this, patient continued to have dull aching pain abdomen throughout her pregnancy, with acute exacerbations off and on. She gave history of acute pain abdomen in October 2011, for which she showed again to some general 33
CASE REPORT practitioner and repeat USG was done. USG report showed single live fetus of 23 weeks with regular cardiac activity and placenta in right lateral position, Grade 1. Moderate amount of free fluid was present in peritoneal cavity. Then she experienced a third episode of exacerbation of pain abdomen on 30th December 2011. Patient presented in emergency with history of severe pain abdomen, two episodes of vomiting and abdominal distention for one day. Her USG report showed a single dead fetus of 31 weeks in breech presentation and maternal ascites with a few septations. Obstetric history: Her previous two deliveries were term vaginal deliveries at home, 8 and 4 years back, respectively. On examination, patient was dyspneic and unable to lie down due to pain abdomen. Her pulse rate was 120/min, blood pressure was 110/70 mmHg with respiratory rate of 30/min. Her temperature was 98.4째F and pallor was +++ with no edema. On per abdominal examination, uterus was 34 weeks size. Tenderness was present in epigastrium and right lumbar area, fetal parts could not be assessed and fetal heart sounds could not be heard. On per speculum examination no bleeding seen. On per vaginal examination, os was closed and cervix was found to be firm, tubular and posteriorly placed. Here, patient was admitted in emergency and after routine investigations, induction of labor was started with prostaglandin E2 (PGE2) gel and misoprost 50 ug per vaginally 4-hourly, which was unsuccessful. After
Dead fetus along with placenta
Figure 1.
34
24 hours of induction patient was taken up for lowersegment cesarean section (LSCS). On opening the abdomen, about 3.5 liters of hemoperitoneum was found. Dead macerated fetus of approximate 30 weeks gestational age was found in abdominal cavity. Whole of the placenta was adherent and going into leaves of the broad ligament on right side with right cornual defect with healed margins and no active bleed from that side. Bladder was badly adherent to anterior surface of uterus. Placenta was found implanted between the leaves of broad ligament, bleeding was present from placental site. Decision for hysterectomy was taken and hysterectomy was done. Discussion The patient probably had a cornual pregnancy, which ruptured around eight weeks, when she experienced pain abdomen. Due to rupture, free fluid was present in pelvis and bowel loops were inflamed. After the rupture, placenta got implanted between the two leaves of broad ligament, while the fetus continued to grow intra-abdominally in an intact amniotic sac. Abdominal pregnancy is a rare obstetric complication with high maternal and perinatal mortality. Ultrasound, magnetic resonance imaging (MRI), computed tomography (CT) scan and laparotomy can help in differentiating between primary and secondary abdominal pregnancy.10 As early rupture of tubal ectopic pregnancy is the usual antecedent of a secondary abdominal pregnancy, a suggestive history can usually be obtained. These include spotting or irregular bleeding along with abdominal pain, nausea, vomiting, flatulence, constipation, diarrhea and abdominal pain, all in varying degrees. Fetal malpresentation, extreme anterior displacement of the cervix, failure of spontaneous onset of labor and failure of artificial induction of labor are common complications. Small fetal parts may be palpated through the vaginal fornices and identified clearly outside the uterus.9 As in this case, despite repeated USG diagnosis was not made, so we should have a constant suspicion in our mind, while dealing with such cases. About 50% of diagnoses are missed on ultrasound11 but MRI and CT are both excellent diagnostic tools to diagnose secondary abdominal pregnancy.7,9 Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CASE REPORT Proper preoperative evaluation with appropriate diagnostic techniques can help with a timely diagnosis, and preoperative treatment such as methotrexate administration to minimize blood loss at surgery can facilitate maximal placental removal. As the placenta continues to grow throughout the pregnancy methotrexate is recommended at all gestational ages. Conclusion Treatment with preoperative systemic methotrexate with subsequent laparotomy for removal of the fetus and placenta may minimize potential blood loss, and would be a reasonable approach in the care of a patient with an abdominal pregnancy with placental implantation to the abdominal viscera and blood vessels. This treatment option should be considered in the management of this potentially life-threatening condition. During surgery, if the placenta is attached to vital organs it should be left behind. Early diagnosis can help in reducing associated maternal morbidity and mortality. References 1. Cunningham FG, Gant NF, Leveno KJ et al (Eds.). Williams Obstretrics. 21st edition, McGraw Hill: New York 2001:p.899.
2. Shaw HA, Ezenwa E. Secondary abdominal pregnancy in a Jehovah’s Witness. South Med J 2000;93(9):898-900. 3. Rahman MS, Al-Suleiman SA, Rahman J, Al-Sibai MH. Advanced abdominal pregnancy - observations in 10 cases. Obstet Gynecol 1982;59(3):366-72. 4. Martin JN Jr, Sessums JK, Martin RW, Pryor JA, Morrison JC. Abdominal pregnancy: current concepts of management. Obstet Gynecol 1988;71(4):549-57. 5. Worley KC, Hnat MD, Cunningham FG. Advanced extrauterine pregnancy: diagnostic and therapeutic challenges. Am J Obstet Gynecol 2008;198(3):297.e1-7. 6. Studdiford WE. Primary peritoneal pregnancy. Am J Obstet Gynecol 1942;44:487-91. 7. Atrash HK, Friede A, Hogue CJ. Abdominal pregnancy in the United States: frequency and maternal mortality. Obstet Gynecol 1987;69(3 Pt 1):333-7. 8. Lastra Lastra A, Ruiz Bedoya JA, Jiménez Balderas EA, Manrrique Ochoa LA. Abdominal pregnancy with fetal survival. A report of 2 cases. Ginecol Obstet Mex 1993;61:348-50. 9. Cunningham GF, Levine KJ, Bloom SI. Williams Obstetrics. 22nd edition. Prentice Hall International (UK); 2005:p.265-6. 10. Alto WA. Abdominal pregnancy. Am Fam Physician 1990;41(1):209-14. 11. Costa SD, Presley J, Bastert G. Advanced abdominal pregnancy. Obstet Gynecol Surv 1991;46:515-25.
...Cont’d from page 32
timely intervention can result in a successful outcome of the intrauterine fetus.11 References 1. Lyons EA, Levi CS, Sidney M. In: Dashefsky in Diagnostic Ultrasound. Volume 2, 2nd edition, Rumak CM, Wilson SR, Charboneau WK (Eds.), Mosby 1998:p.999. 2. Glassner MJ, Aron E, Eskin BA. Ovulation induction with clomiphene and the rise in heterotopic pregnancies. A report of two cases. J Reprod Med 1990;35(2):175-8.
6. Hirose M, Nomura T, Wakuda K, Ishiguro T, Yoshida Y. Combined intrauterine and ovarian pregnancy: a case report. Asia Oceania J Obstet Gynaecol 1994;20(1):25-9. 7. Peleg D, Bar-Hava I, Neuman-Levin M, Ashkenazi J, Ben-Rafael Z. Early diagnosis and successful nonsurgical treatment of viable combined intrauterine and cervical pregnancy. Fertil Steril 1994;62(2):405-8. 8. Alsunaidi MI. An unexpected spontaneous triplet heterotopic pregnancy. Saudi Med J 2005;26(1):136-8.
3. Gruber I, Lahodny J, Illmensee K, Lösch A. Heterotopic pregnancy: report of three cases. Wien Klin Wochenschr 2002;114(5-6):229-32.
9. Sherer DM, Scibetta JJ, Sanko SR. Heterotopic quadruplet gestation with laparoscopic resection of ruptured interstitial pregnancy and subsequent successful outcome of triplets. Am J Obstet Gynecol 1995;172(1 Pt 1):216-7.
4. Ectopic Pregnancy, Textbook of -Williams Obstetrics. 21st edition, Multifetal Ectopic Pregnancy. Chapter 34; pp. 888-9.
10. Sohail S. Hemorrhagic corpus luteum mimicking heterotopic pregnancy. J Coll Physicians Surg Pak 2005;15(3):180-1.
5. Cheng PJ, Chueh HY, Qiu JT. Heterotopic pregnancy in a natural conception cycle presenting as hematometra. Obstet Gynecol 2004;104(5 Pt 2):1195-8.
11. Espinosa Picazo M, Alcántar Mendoza MA. Heterotopic pregnancy: report of a case and review of the literature. Ginecol Obstet Mex 1997;65:482-6.
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
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CASE REPORT
Post Cesarean Vaginal Omental Prolapse Asavari Ashok Bachhav
ABSTRACT Vaginal evisceration following lower-segment cesarean section is a rare occurrence. There is no documented case report available although omental prolapse following third stage of labor have been reported due to old uterine perforation following multiple curettage and uterine rupture in multi-gravid patients, respectively. This is a life-threatening complication diagnosed only afterâ&#x20AC;Ża high index of suspicion and a thorough clinical examination. We report a case of post cesarean vaginal omental prolapse in a primigravida. Key words: High-risk pregnancy, complications, omental prolapse
Case Report A 26-year-old primigravida was admitted with us from 34 weeks onwards as a case of hypothyroidism with mild pre-eclampsia for observation and further in-patient management. On admission, her blood pressure was 150/100 mmHg, urine albumin was +2 by dipstick method with no premonitory signs or symptoms. On general examination, bilateral pedal edema with facial puffiness was present and deep tendon reflexes were normal. On per abdominal examination uterus was 30-32 weeks gestation with mild abdominal ascites. She had been diagnosed as hypothyroid in her first trimester and was on thyroxine for the same. She was started on antihypertensives. Laboratory investigations for pre-eclampsia were within normal limits. Obstetric ultrasonography (USG) showed evidence of fetal growth retardation (FGR) with oligohydramnios with amniotic fluid index (AFI) of 4-5. Doppler ultrasound showed bilateral uterine artery notching with no evidence of uteroplacental insufficiency. Patient was managed conservatively with steroids being given for fetal lung maturity, weekly investigations being monitored and blood pressure stabilized at 140/90 mmHg.
Ex-Assistant Professor KEM Hospital and Seth GSMC, Mumbai, Maharashtra Consultant, Tulsi Hospital, Nasik, Maharashtra Address for correspondence Dr Asavari Ashok Bachhav Tulshi Hospital, ND Patel Road, Nasik - 422 001, Maharashtra E-mail: asavari.b@gmail.com
36
She went into spontaneous labor at 36 weeks of gestation and liquor being thick meconium stained, a decision for emergency lower-segment cesarean section (LSCS) in view of severe fetal distress was taken. LSCS was done with midline infraumbilical incision taken in view of severe fetal distress being done in late first stage of labor and a preterm, FGR male child was delivered by vertex. Mild-to-moderate ascites was present. As the LSCS was done in late first stage of labor, there was an extension of the uterine incision on the right side to the lower-segment. Consequently, the rightsided uterine artery ligation was done and hemostasis satisfactorily achieved. The uterus was sutured in two layers with the visceral and parietal peritoneum being closed separately followed by abdominal closure in layers. The neonate required urgent resuscitation and was admitted to the neonatal intensive care unit (NICU) for further management. In early postoperative period, patient had pyrexia for which high grade antibiotics were started. Despite antibiotic coverage, patient developed a full length wound gape on Day 10. The wound gape was managed conservatively with daily wound dressing with full asepsis and antibiotic coverage according to microbial sensitivity. The wound healed satisfactorily and the patient was discharged on Day 25. On discharge, her blood pressure was within normal limits and was continuing thyroxine. Patient followed up after three months of surgery with complaints of something coming out of vagina since one week, which increased on straining and was not Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CASE REPORT
Cervix
Uterus
Omentum Omentum being retracted from rent
Figure 1. Omental prolapse throligh cervix.
Figure 2. Omentum being extracted through rent in uterus.
reposited on rest (Fig. 1). There was no history of any foul smelling discharge or fever following discharge from hospital.
postulated to be the site of right uterine artery ligation. The omentum was gently retracted through the opening and was transfixed and resected. The rent was closed with interrupted sutures with delayed absorbable vicryl. The left-sided ovary and tube could not be visualized due to dense adhesions and right-sided ovary and tube were densely adherent to each other. The abdomen was closed in layers after confirming hemostasis. The postoperative course was uneventful. A delayed suture removal was done on Day 14, the wound was healthy and the patient was discharged.
On examination, the patient was apprehensive but her vitals were stable. General physical examination and systemic examination was normal. On per abdomen examination, the abdomen was soft with no mass or tenderness and hernial orifices were normal. Speculum examination revealed an irregular, fleshy, thick mass coming through the cervix. It was 5 × 1 cm in size and did not bleed on touch. Vaginal examination showed same mass/growth palpable on gloved finger with slight bleeding. No abnormality was detected on per rectal examination. Routine laboratory investigations were normal except for a decreased hemoglobin of 8 g/dl for which one pint of blood transfusion was given. USG of pelvis and abdomen showed increased endometrial thickness with no other abnormality in the pelvis and abdomen. Decision for examination under anesthesia/SOS exploratory laparotomy was taken. Intraoperatively, a tongue-shaped fleshy mass simulating omentum, lying in the vagina, protruding from the cervix was seen. The mass was gently pulled down till a normal looking omentum came out, which was identified. Decision for exploratory laparotomy was taken. Intraoperatively, multiple thick bands of adhesions were present. After sharp and blunt dissection, the uterus was visualized and on the right posterior aspect of the isthmus, a rent of 0.5 × 0.5 cm was visualized through which the omentum earlier adherent had gained entry to the uterine cavity and herniated through the vagina (Fig. 2). It was Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
Discussion The incidence of cesarean sections in obstetric practice has undoubtedly increased in the past few years. Women are now four times more likely to have a cesarean birth than 30 years ago. There is also a wide variation in surgical techniques used worldwide and even in different hospitals. Also, the advances in neonatal care with increase in the survival rates at lower gestational ages have made cesarean section a preferred option over preterm birth and the resultant neonatal morbidity and mortality. In our case, the pregnancy being a high-risk with preterm labor and severe fetal distress made a cesarean section an obvious choice for mode of delivery. The intraoperative complication was satisfactorily managed by unilateral uterine artery ligation. Bilateral uterine artery ligation (O’Leary stitch) has become the first-line of management in managing postpartum hemorrhage (PPH) during laparotomy. Although primarily used for laceration of uterine 37
CASE REPORT arteries, it can also be used for bleeding due to other etiologies. It is preferable to internal iliac artery ligation because the uterine arteries are more readily accessible, the procedure is technically easier, and there is less risk to major adjacent vessels and the ureter.1 Post cesarean omental prolapse in a previously unscarred uterus is an exceedingly rare complication and no such case has been previously reported although omental prolapse following third stage of labor have been reported due to old uterine perforation following multiple curettage and uterine rupture in multi-gravid patients, respectively.2,3 In our patient, it was surmised that the due to the hemostatic suture, there was infarction followed by necrosis abetted by the wound infection that followed postoperatively. As a result, the omentum being the â&#x20AC;&#x2DC;guardian of the abdominal cavityâ&#x20AC;&#x2122; moved in to seal the uterine wound and in the process, adhesion followed by herniation through the necrosed wound followed. Uterine artery ligation as a method of controlling traumatic PPH during cesarean section is commonly done in hospitals worldwide and is also taught to
38
postgraduates as a routine procedure. This hitherto unknown complication brings forth to us that the procedure needs to be carefully taught with the proper technique and precautions. Also, any postoperative wound infection needs to aggressively managed to prevent further complications like chronic pelvic pain, infertility and as the above case demonstrates, rare but dangerous complications like omental incarceration. A high-degree of vigil and suspicion is required in such cases for diagnosis and appropriate management of the patient to prevent further morbidities. References 1. Oâ&#x20AC;&#x2122;Leary JA. Uterine artery ligation in the control of post cesarean hemorrhage. J Reprod Med 1995;40(3):189-93. 2. Marsden DE. Omentum presenting at the vulva after a normal labor and delivery. An unusual late complication of induced abortion.Acta Obstet Gynecol scand 1984;63(3):277-8. 3. Singhal SR, Singhal SK, Gupta P. Bowel and omentum prolapse into the vagina after third stage: an unusual presentation of ruptured uterus. Acta Obstet Gynecol Scand 2008;87(5):577-8.
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CASE REPORT
Pregnancy with Eisenmenger Syndrome: A Challenge to Obstetrician Kiran Pandey*, Shefali Pande**
ABSTRACT Eisenmenger syndrome is defined as the development of pulmonary hypertension in response to a left-to-right cardiac shunt with consequent bidirectional or reversal (right-to-left) of shunt flow. Maternal mortality in the presence of Eisenmenger syndrome is reported to be 30-50%. If the patient continues her pregnancy against advice, a well co-ordinated multidisciplinary team approach is advocated. Here we report a case of pregnancy with Eisenmenger syndrome and its successful outcome. Key words: Pregnancy, Eisenmenger’s, maternal mortality
C
ongenital heart disease patients are reaching reproductive age due to improved healthcare facilities and more of them are conceiving. Eisenmenger’s syndrome consists of pulmonary hypertension with a reversed or bidirectional shunt at the atrial, ventricular or aortopulmonary level.1 Eisenmenger’s syndrome in pregnancy is usually associated with high mortality rates (30-50%).2 Such patients are advised against pregnancy or to interrupt pregnancy before 10th gestational week but if they continue pregnancy against advice a well organized multispecialist care is required. Here we report a successful pregnancy in a woman with Eisenmenger’s syndrome.
Past history: She had no history of dyspnea previously. She had a previous uneventful cesarean section. Her symptoms were much worse in this pregnancy. Recently diagnosed with pulmonary arterial hypertension (PAH) and atrial septal defect (ASD).
Case Report
Systemic examination: Cardiovascular system (CVS): S1 normal, S2 single-narrow split, pulmonary ejection systolic murmur, enlarged right heart. P/A: Uterus 36 weeks size, longitudinal, cephalic, moderate contractions, FHS + tachycardia, scar tenderness present.
Patient XYZ, G3P1A1, aged 30 years, gestational age 36 weeks, presented to our setting with chief complaints of pain abdomen for six hours and breathlessness (dyspnea on less than ordinary activity and orthopnea) for three days. She had marked limitation of physical activity (New York Heart Association [NYHA] Class 3). Obstetric history: Previous lower-segment cesarean section (LSCS) four years back (Indication - CPD) miscarriage in first trimester three years back. *Professor and Head **Senior Resident Dept. of Obstetrics and Gynecology GSVM Medical College, Kanpur, UP Address for correspondence Dr Kiran Pandey New Type IV/7, Medical College Campus, Kanpur - 208 002 E-mail: dr.kiranpandey@gmail.com
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
Echocardiography revealed: Moderate-sized ASD, severe PAH, moderate pulmonary regurgitation (PR) and tricuspid regurgitation (TR). Routine antenatal investigations were within normal limits. General examination: Blood pressure (BP) - 124/80 mmHg, pulse rate (PR) - 92/-, pallor +, edema-, cyanosis ++.
As per cardiological review, she was treated with propped up position, oxygen inhalation. Injection ampicillin 2 g and injection gentamicin 80 mg were given as infective endocarditis prophylaxis. Decision for emergency LSCS was taken. Her cesarean section was performed. A healthy baby of weight 2.9 kg was born. Her bilateral tubal ligation was performed. Intraoperative and postoperative period uneventful. Continuation of same cardiac treatment was done. Patient discharged on 8th post-op day in a good condition with a healthy baby. 39
CASE REPORT Discussion The hemodynamic changes occurring in pregnancy are usually poorly tolerated in women with Eisenmenger syndrome. Most women with Eisenmenger syndrome are in a precariously balanced state and an important principle of care is not to disrupt this balance. In women with Eisenmenger syndrome and a low cardiac output state, the compromised right ventricle may not meet the demands of increasing blood volume and cardiac output associated with pregnancy. In addition, a fixed pulmonary vascular resistance with a resulting inability to increase pulmonary blood flow may not accommodate an increase in cardiac output. Similarly, large fluctuations in blood volume both preand postpartum may not be tolerated by an already compromised CVS. The fall in peripheral vascular resistance that occurs during pregnancy can augment right-to-left shunting, worsening maternal hypoxemia and cyanosis.2 Pregnancy is a cause of significant mortality in women with Eisenmenger syndrome. A systematic review of published studies from 1978 to 1996 examined maternal mortality rates in women with Eisenmenger syndrome and demonstrated mortality rates of 56%.3 The degree of maternal hypoxemia is the most important predictor of fetal outcome; prepregnant levels of arterial oxygen saturation of 85% or less are associated with rates of live births as low as 12%, while saturation of 90% or more results in 92% of live births.4 This is explained by a high incidence of spontaneous abortions, a 30-50% risk of premature delivery and low birth weights.2,4,5 Maternal mortality in the presence of Eisenmenger´s syndrome is reported as 30-50%.1,4 Gleicher et al reported a 34% mortality associated with vaginal delivery and a 75% mortality associated with cesarean section. Because of the high mortality associated with continuing pregnancy, abortion is the treatment of choice for women with Eisenmenger’s syndrome. For the patient with a continuing gestation, hospitalization in the second trimester is highly recommended.3 Intrauterine growth restriction is seen in 30% of pregnancies as a result of maternal hypoxemia. Premature labor is found in 50-60% of instances and the high perinatal mortality rate (28%) is due mostly to prematurity. In one study of women with Eisenmenger syndrome, 47% delivered at term, 33% between 32 and 36 weeks, and 20% before 31 weeks of gestation.3 40
Continuous administration of oxygen, anticoagulation and pulmonary vasodilator is controversial. Although, there aren’t any controlled trials, a Brazilian series of 13 pregnancies6 reported improved maternal mortality (23%) with a regimen of oxygen, heparin before delivery and warfarin after 48 hours. Sixty percent of infants were live births, mostly premature. There is no evidence to support the choice of either vaginal or cesarean delivery for cardiac reasons: Vaginal delivery is associated with a lower average blood loss but also increased maternal effort.7 The mortality of patients with Eisenmenger’s syndrome who become pregnant remains high. Appropriate advice regarding contraception should be given to all patients. If a patient becomes pregnant, therapeutic termination should be offered. If pregnancy continues against medical advice, treatment strategies as outlined above may be helpful, with prolonged hospital care both preand postpartum. Conclusion Although pregnancy should be discouraged in women with Eisenmenger’s syndrome, it can be successful with careful monitoring and a well co-ordinated multispecialist care as elucidated in this case. References 1. Wood P. Pulmonary 1952;8(4):348-53.
hypertension.
Br
Med
Bull
2. Buckshee K, Biswas A, Mittal S, Agarwal N. Eisenmenger’s syndrome with pregnancy: a rare obstetrical problem with successful outcome. Asia Oceania J Obstet Gynaecol 1988;14(3):323-5. 3. Gleicher N, Midwall J, Hochberger D, Jaffin H. Eisenmenger’s syndrome and pregnancy. Obstet Gynecol Surv 1979;34(10):721-41. 4. Weiss BM, Zemp L, Seifert B, Hess OM. Outcome of pulmonary vascular disease in pregnancy: a systematic overview from 1978 through 1996. J Am Coll Cardiol 1998;31(7):1650-7. 5. Presbitero P, Somerville J, Stone S, Aruta E, Spiegelhalter D, Rabajoli F. Pregnancy in cyanotic congenital heart disease. Outcome of mother and fetus. Circulation 1994;89(6):2673-6. 6. Avila WS, Grinberg M, Snitcowsky R, Faccioli R, Da Luz PL, Bellotti G, et al. Maternal and fetal outcome in pregnant women with Eisenmenger’s syndrome. Eur Heart J 1995;16(4):460-4. 7. Head CE, Thorne SA. Congenital heart disease in pregnancy. Postgrad Med J 2005;81(955):292-8.
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CASE REPORT
A Case of Displaced Intrauterine Contraceptive Device Preeti Lewis*, Som Subhro Biswas*
ABSTRACT Intrauterine contraception is a widely used, highly effective method of birth control. Uterine perforation is a serious albeit rare complication with the use of an intrauterine device (IUD). We report here a case of a copper intrauterine contraceptive device (IUCD) perforating the posterior uterine wall and its management. Key words: IUCD, hysteroscopy, misplaced copper T
T
intermittent spotting. She had three children, all normal vaginal deliveries with last child birth two years ago when copper IUCD was inserted three days postpartum.
Case Report
On examination, her general condition was fair and vitals were stable. On per abdomen examination, abdomen was soft, with no guarding, tenderness or rigidity. On per speculum examination, copper IUCD thread was not seen. Cervix and vagina was healthy. On per vaginal examination, uterus was normal in size. It was retroverted, bilateral fornices were free and nontender. Patient was admitted and ultrasonography was repeated, which showed elongated hyperechoic density in posterior wall of uterus 20 mm in length.
he incidence of intrauterine device (IUD) perforation is 0.87/1,000 insertions.1 An IUD may perforate through the uterine wall into the pelvic or abdominal cavity or into adjacent organs. Contrary to what one might assume, perforation is often silent and the wayward device is either detected after further sequelae or found incidentally by imaging.2 The accepted treatment for displaced IUDs is surgical removal because of the putative risk of adhesion formation or of damage to the intestine or urinary bladder.3 Considerable comfort and minimal hospital stay associated with endoscopic procedures should offer these as the firstline attempt to remove a misplaced intrauterine or extrauterine translocated device.4
A 26-year-old female, married since nine years, parity 3 living 3, with copper intrauterine contraceptive device (IUCD) inserted two years back, came with complaints of pain in abdomen since two months. She had no other complaints. She was referred from a private hospital with ultrasonography suggestive of copper IUCD in posterior wall of uterus. Her menstrual cycles were regular and she had no complaints of
*Assistant Professor Dept. of Obstetrics and Gynecology Grant Medical College and Sir JJ Group of Hospitals, Mumbai Address for correspondence Dr Som Subhro Biswas C/o: Dr TK Biswas F-199, Raghunath Vihar, Khargar, Sector -14 Navi Mumbai, Maharashtra - 410 210 E-mail: tonitedeschi@gmail.com
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
Uterus was normal in size. Endometrial thickness was 69 mm and no copper IUCD was seen in the endometrial cavity. Minimal free fluid was present in Pouch of Douglas. Bilateral ovaries, fallopian tubes and adnexae were normal. X-ray of pelvis reconfirmed the presence of copper IUCD outside the uterine cavity. Her all routine investigations were within normal limits. Patient was posted for hysteroscopic copper IUCD removal. Patient underwent hysteroscopy, which showed part of copper IUCD perforating the uterus at two sites, first at the cornua and second in the body. Hysteroscopic removal was not possible due to firm insertion and risk of damaging other structures due to nonvisibility of the ends of the copper IUCD. Based on these findings decision to do laparoscopy was taken. On laparoscopy copper IUCD was 41
CASE REPORT Discussion The recommended management of a misplaced IUCD by the manufacturers is laparoscopic removal.5 However, individual case scenario can differ in presentation. As in this case, sometimes it is impossible to remove the IUCD hysteroscopically or laparoscopically due to its abnormal presentation and firm embedment into the uterine wall and the surgeon needs to recourse to an open abdominal removal. References Figure 1. Copper T protruding from uterine cornua into abdominal cavity.
seen perforating the uterus at the posterior wall and the cornua (Fig. 1). Laparoscopic removal was not successful and so decision to proceed with laparotomic removal was taken as it appeared to be firmly embedded. Pfannelstein incision was taken and copper IUCD was removed gently with artery forceps. There was no hemorrhage, abdomen was closed and patient withstood operation well. Her postoperative course in ward was uneventful. Sutures were removed on Day 9 and 10, wound was healthy. Patient was discharged.
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1. Haimovâ&#x20AC;?Kochman R, Amsalem H, Adoni A, Lavy Y, Spitz IM. Management of perforated levonorgestrelmedicated intrauterine device - a pharmacokinetic study: case report. Hum Reprod 2003;18(6):1231-3. 2. Levsky JM, Herskovits M. Incidental detection of a transmigrated intrauterine device. Emerg Radiol 2005; 11(5):312-4. 3. Markovitch O, Klein Z, Gidoni Y, Holzinger M, Beyth Y. Extrauterine mislocated IUD: is surgical removal mandatory? 2002;66(2):105-8. 4. Mittal S, Kumar S, Roy KK. Role of endoscopy in retrieval of misplaced intrauterine device. Aust N Z J Obstet Gynaecol 1996;36(1):49-51. 5. Gowri V, Mathew M. Ultrasound Location of Misplaced Levonorgestrel Releasing Intrauterine System (LNG-IUS) is it easy? Oman Med J 2009;24(1):54-5.
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
CASE REPORT
Hysterosalpingographic Findings in a Case of Genital Tuberculosis Som Subhro Biswas*, Tara Sharma**
ABSTRACT Tuberculosis is pretty common in India. But sometimes the patient does not give history and genital tuberculosis is caught on hysterosalpingography. This is a case report of a patient whose hysterosalpingographic findings were suspicious of genital tuberculosis even though she did not give history of tuberculosis. It was confirmed with diagnostic tests thus reaffirming the fact that in India, primary genital tuberculosis is still a common cause of infertility. Key words:
G
enital tuberculosis is a common cause of infertility in India, causing significant uterine and tubal pathologies.1 Although genital tuberculosis is a condition that is prevalent worldwide, it is still a diagnostic dilemma.2 Conventional methods of diagnosis namely, histopathologic examination (HPE), acid-fast bacilli (AFB) smear and culture have low sensitivity. Polymerase chain reaction (PCR) was found to be useful in diagnosing early disease as well as confirming diagnosis in clinically suspected cases.3 Laparoscopy is a superior method for the research of tubal and pelvic pathologies in the evaluation of infertility. However, hysterosalpingography is a more economical and elementary method suitable for evaluation of endometrial and tubal pathologies and laparoscopy is an appropriate method for examining the external part of tubae, fimbriae, the relation of tuba and ovary, endometriosis, adhesions, tuberculosis and other pathologies. Therefore, these two methods are not alternative, but complementary.4
*Assistant Professor **Associate Professor and Unit Head Dept. of Obstetrics and Gynecology Grant Medical College and Sir JJ Group of Hospitals, Mumbai Address for correspondence Dr Som Subhro Biswas C/o: Dr TK Biswas F-199, Raghunath Vihar, Khargar, Sector -14 Navi Mumbai, Maharashtra - 410 210 E-mail: sombiswas1@gmail.com
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
Case Report A 25-year-old female came with complaints of infertility since six years of marriage. Her menstrual cycles were regular. She had no other complaints. She had no past history or family history of tuberculosis. Her general and genital examination was normal.
Figure 1.
43
CASE REPORT All her blood investigations for infertility and routine chest X-ray were normal and husbandâ&#x20AC;&#x2122;s semen analysis was normal. She underwent hysterosalpingography to rule out congenital defects in uterus or fallopian tubes. Hysterosalpingographic findings showed extravasation of dye into vasculature suggestive of tuberculosis (Fig. 1). Patient underwent tuberculosis-PCR, which turned positive for tuberculosis. Patient has been started on antituberculosis drugs. Discussion Genital tuberculosis is an important cause of female infertility in developing countries like India, Nepal, Bangladesh and Pakistan.5 A patient who does not give history of tuberculosis in past or in the family and whose chest X-ray is normal can still have primary genital tuberculosis. Though hysterosalpingography is contraindicated in such patients it is difficult to
44
suspect in absence of other findings. Antituberculosis drugs should be promptly started in all such patients. References 1. Khanna A, Agrawal A. Markers of genital tuberculosis in infertility. Singapore Med J 2011;52(12):864-7. 2. Thangappah RB, Paramasivan CN, Narayanan S. Evaluating PCR, culture & histopathology in the diagnosis of female genital tuberculosis. Indian J Med Res 2011;134:40-6. 3. Sakar MN, Gul T, Atay AE, Celik Y. Comparison of hysterosalpingography and laparoscopy in the evaluation of infertile women. Saudi Med J 2008;29(9):1315-8. 4. Mondal SK, Dutta TK. A ten year clinicopathological study of female genital tuberculosis and impact on fertility. JNMA J Nepal Med Assoc 2009;48(173):52-7. 5. Sharma JB, Pushparaj M, Roy KK, Neyaz Z, Gupta N, Jain SK, et al. Hysterosalpingographic findings in infertile women with genital tuberculosis. Int J Gynaecol Obstet 2008;101(2):150-5.
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
45 1. 2. 3. 4.
Asian Journal of Obs and Gynae Practice, Vol. 1, January-March 2013
Answers
This film is an MRI of brain showing microadenoma pituitary on lateral margin of anterior lobe. Patient can have symptoms like oligomenorrhea, secondary amenorrhea, galactorrhea and infertility. Diagnosis is made on the basis of high serum prolactin twice, with MRI showing focal area in pituitary of <10 mm in size. Neurological and ophthalmic evaluations are required. Medical therapy with cabergoline or bromocriptine (if wish to conceive) is indicated. Prolactin has to be monitored at 3, 6 12 months with imaging annually. Withdrawal of therapy should be done two years after normalization of serum prolactin and resolution of lesion. Further one year follow-up is required as recurrence rate is high at this time.
4. How will you manage this patient? 3. What are the diagnostic criteria? 2. What can be the gynecological symptoms in this patient? 1. What is this film depicting?
Questions
Photo Quiz
Dr Nutan Agarwal Additional Professor Dept. of Obstetrics and Gynecology AIIMS, New Delhi
PHOTO QUIZ
FLOW CHART Carcinoma Endometrium
Introduction
It is the most common malignancy of the female genital tract in the west, with an incidence of 22/1,00,000. In India, it is the third most common gynecological malignancy with an incidence of 4.4/1,00,000 population. The lifetime risk of developing endometrial carcinoma is 2-3%. The median age at diagnosis is 63 years. Primarily occurs in postmenopausal females and is increasingly virulent with advancing age.
Risk Factors
Most of the identified risk factors are related to prolonged, unopposed estrogen stimulation of the endometrium. Characteristic
Relative risk
Characteristic
Relative risk
Nulliparity
2-3
Anovulation, PCOD
3
Early menarche and late menopause 2-3
Tamoxifen therapy
2-3
Obesity
Unopposed estrogen therapy
4-8
21-50 lb overweight
3
>50 lb overweight
10
Atypical endometrial hyperplasia
8-29
2.8
HNPCC syndrome
20
Diabetes mellitus
HNPCC: Hereditary non-polyposis colorectal cancer
Pathology WHO histological classification of endometrial carcinoma Endometrioid adenocarcinoma – commonest: 80-90%
Mixed carcinoma
Mucinous carcinoma
Transitional-cell carcinoma
Serous carcinoma: 10-15%*
Small-cell carcinoma
Clear-cell carcinoma: 5%*
Undifferentiated carcinoma
Clinical Presentation
Most often occurs in sixth and seventh decades of life. Vaginal bleeding occurs in 80-90% of women and accounts for 10% of postmenopausal bleeding. Some experience pelvic pressure or discomfort. Less than 5% are asymptomatic.
Diagnosis
•• Routine screening is not recommended. •• Transvaginal sonography (TVS); (Sn = 96%, Sp = 81%); endometrial thickness >4
••
mm taken as cut-off for evaluation by endometrial aspiration; markers suggestive of malignancy on TVS are: Endometrial cavity fluid collection, irregularity of the myometrial endometrial surface, inhomogenity of the endometrium. Endometrial aspiration (Sn = 81-99%, Sp = 98%) D&C: Samples about 50% of cavity Hysteroscopy Cytology from a Pap smear or endometrial brush (has limited accuracy for the diagnosis of endometrial cancer in an asymptomatic population). MRI is useful for pre-op evaluation of disease
Types of Endometrial Carcinoma Type I More common In younger perimenopausal females Body habitus obese Unopposed estrogen exposure present Begins as hyperplastic endometrium Better differentiated Good prognosis Mutation in PTEN and K-ras Endometrioid adenocarcinoma most common Superficial invasion Nodal metastasis infrequent
Type II Less common In older postmenopausal females Thin habitus No source of unopposed estrogen stimulation Occurs in a background of atrophic endometrium Less differentiated Bad prognosis Mutation in p-53 Papillary serous and clear cell carcinoma most common Deep invasion Nodal metastasis frequent
Staging (FIGO 2009)
Stage I: Tumor confined to the corpus uteri
•• IA: No or less than half myometrial invasion •• IB: Invasion equal to or more than half of the myometrium
Stage II: Tumor invades cervical stroma, but does not extend beyond the uterus Stage III: Local and/or regional spread of the tumor •• IIIA: Tumor invades serosa of corpus uteri and/or adnexae# •• IIIB: Vaginal and/or parametrial involvement# •• IIIC: Metastases to pelvic and/or para-aortic lymph nodes#, IIIC1; Positive pelvic nodes, IIIC2; Positive para-aortic lymph nodes with/without positive pelvic lymph nodes. Stage IV: Tumor invades bladder and/or bowel mucosa, and/or distant metastases •• IVA: Tumor invasion of bladder and/or bowel mucosa •• IVB: Distant metastases, including intra-abdominal metastases and/or inguinal lymph nodes Positive cytology has to be reported separately without changing the stage.
#
Work-up
•• History, physical examination including pelvic examination, endometrial biopsy or •• •• •• ••
*Research Associate, **Senior Research Associate
Prof. Alka Kriplani
Professor and Head of Unit II Dept. of Obstetrics and Gynecology, AIIMS, New Delhi
Treatment Surgery followed by radiotherapy except in Stage I (Grade 1 and 2). Extended surgical staging is done. (Exploratory laparotomy through a vertical midline incision, peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy or omental biopsy, peritoneal biopsies and pelvic and para-aortic lymph node sampling). Indications of retroperitoneal lymph node sampling: Myometrial invasion >½ thickness; size of growth >2 cm; cervix-isthmus extension; extrauterine spread; serous, clear cell, squamous or undifferentiated cell types; enlarged lymph nodes; high-grade histology on EA/ECC. No evidence of benefit of pelvic lymphadenectomy in early Endometrial carcinoma in terms of overall or recurrence free survival (ASTEC Trial). Postoperative management according to stage: STAGE IA: Grade 1, 2- Observation alone; Grade 3- EBRT/IVBT/Brachytherapy alone; STAGE IB: G1- Observation/IVBT alone/ EBRT; G2- Observation/IVBT ± EBRT; G3- EBRT + IVBT; STAGE IC, STAGE II: All grades – EBRT+ IVBT; STAGE III: EBRT + IVBT + chemotherapy; IVBT for IIIA: Upper half to upper two-thirds of vagina; IIIB: Entire vaginal length; EBRT-Pelvic EBRT; extended field RT (Para-aortic); whole abdominal RT (30 Gy-whole abdomen, 45 Gy-paraaortic, 50 Gy-pelvis); STAGE IV: The options are exenteration; Palliative chemotherapy ± hormonal therapy. *EBRT: External beam radiotherapy
Radiotherapy
Benefits in: Cervical involvement; Pelvic LN + extrauterine disease Grade 3 tumor >50% myometrial invasion >2 cm tumor with superficial myometrial invasion lymphovascular space invasion. Postoperative radiotherapy significantly decreased the risk of loco-regional recurrence without affecting overall survival (PORTEC trial). •• •• •• •• ••
Chemotherapy
Squamous-cell carcinoma* *Poor prognosis
•• •• •• ••
Dr Sumita Agarwal*, Garima Kachhawa**
aspiration curettage Chest X-ray hMG, LFT, KFT CT scan, MRI or ultrasound abdomen Optional: Cystoscopy, sigmoidoscopy, IVP, barium enema, CA125
Indicated in advanced or recurrent cancers; may improve prognosis in women with early stage cancer who have high-risk of relapse; single agent therapy: Doxorubicin; combination chemotherapy: Doxorubicin + Cisplatin + Paclitaxen is the most effective regimen with response rates of 30-60%.
Hormonal Therapy
Indicated in early stage well-differentiated endometrial adenocarcinoma in young women who want to preserve their uterus •• Progestins (high-dose medroxyprogesterone acetate 200 mg/day or megestrol acetate 160 mg/day) •• SERMs •• GnRH agonists •• Aromatase inhibitors
Fertility-preserving Options
In young women who have not completed their families and have well-differentiated adenocarcinoma •• Progestational agents •• GnRH agonists •• Progesterone containing intrauterine devices (Mirena).
Follow-up
•• First 2 years: Pelvic examination with/without vaginal cytology every 3 months; CXR
annually; CT/MRI if needed
•• Next 3 years: Pelvic examination every 6 months; vaginal cytology annually •• Thereafter: Annually CA125 in patients with high-risk
Prognostic Variables
•• •• •• •• •• •• •• •• •• •• •• •• ••
Age Histologic type and grade Myometrial invasion Lymphovascular space invasion Isthmus-cervix extension Adnexal involvement Lymph node metastasis Intraperitoneal tumor Tumor size Peritoneal cytology Hormone receptor status (progesterone receptor positive status has better survival); DNA ploidy/proliferative index (mortality higher in tumors with aneuploid cells) Genetic/Molecular markers (presence of K-ras mutations; reduced expression of E-cadherin, overexpression of HER-2/neu oncogene; alteration of p53 gene are associated with bad prognosis).
Recurrence
•• Approximately 13% of all patients with endometrial cancer develop recurrent disease;
50% by 2 years and 75% by three years
•• 32% asymptomatic - detected during follow-up •• Symptoms: Vaginal bleeding, pelvic pain, hemoptysis, abdominal distention,
seizures, etc.
•• Prognosis better if: Vaginal mass is isolated; initial disease was well-differentiated and
if recurrence is after three years of therapy
•• Management options: Surgery; radiotherapy; systemic treatment consisting of hormone
therapy or chemotherapy.
Five-year Survival
(According to surgical stage) Stage I: 87% Stage II: 76% Stage III: 59% Stage IV: 18%
•• •• •• ••
Guidelines for Authors The Asian Journal of Obstetrics and Gynaecology is a quarterly journal with wide circulation. The journal provides a medium for the publication of review and update articles on any aspect of Obstetrics and Gynecology practice. It welcomes original articles, case reports, dilemmas of clinical practice, new investigations and surgical techniques in the field of Obstetrics and Gynecology. All communications should be submitted to Editor, Asian Journal of Obstetrics and Gynaecology Practice, E-219, Greater Kailash, Part -1, New Delhi - 110 048.
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References must be numbered in the order in which they first appear in the text. Identify references in text, tables and legends by arable numerals in parentheses. The style of reference and abbreviated title of journals must follow that of Index Medicus. For journal references, list all authors when 6 or less, when 7 or more list only first three and add et al. The title of the manuscript will be printed after the author’s names, before the abbreviated title of the journal e.g.,: De Cherney AH, Diamond MP, Lavy G and Polan ML. Endometrial ablation for intractable uterine bleeding. Obstet. Gynecol. 1987;70: 668-670. For book reference list all authors of the book, title, edition, city of publication, publisher, year of publication, chapter and page in that order. Goldrath MH and Garry R. Nd:YAG laser ablation of the endometrium In: Endoscopic Surgery for Gynaecologists 2nd Edition, Sutton C and Diamond N (Eds.), WB Saunders, London 1993:16-21. References should be limited to 20 except for the possible exception of special review articles, The editorial board of the journal has decided to adopt the Vancouver style of uniform requirements for manuscripts submitted to biomedical journals (N. Engl. J. Med. 1991;324:421-428) These notes for contributors confirm with the Vancouver style. Figures
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