Ajog july sept 2011 by IJCP

Volume : 3 July-September 2011

Asian Journal of

Online Submission

Volume 3, July-September 2011

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

Dr KK Aggarwal CMD, Publisher and Group Editor-in-Chief Dr Veena Aggarwal Joint MD & Group Executive Editor

Contents from the Issue editor

From the desk of Group Editor-in-chief

CDC Guidelines for GBS Prophylaxis

Clinical Study

AJOG Speciality Panel

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 Dr Alka Kriplani Asian Journal of Obs & Gynae Practice

Dr M Paul Anand, Dr SK Parashar Cardiology

Dr VP Sood Asian Journal of Ear, Nose and Throat

Dr CR Anand Moses Dr Sidhartha Das Dr A Ramachandran Dr Samith A Shetty Diabetology

Dr Praveen Chandra Asian Journal of Clinical Cardiology Dr Swati Y Bhave Asian Journal of Paediatric Practice Dr Vijay Viswanathan The Asian Journal of Diabetology Dr KMK Masthan Indian Journal of Multidisciplinary Dentistry

Dr Ajay Kumar Gastroenterology

Umbilical Artery Doppler Study as a Predictive Marker of Perinatal Outcome in Gestational Hypertension

Dr Sidharth Kumar Das Rheumatology Dr V Nagarajan Neurology Dr Thankam Verma, Dr Kamala Selvaraj Obs and Gyne

Advisory Body Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions

Garima Kachhawa, K Maheshwari, V Kachhawa, S Mehta, R Desai, BS Jodha

Effects of Early Feeding after Cesarean Delivery Under Regional Anesthesia

Amitava Pal, Rabindranath Dalui, Raghunath Bhattacharya, Debasis Saha

Efficacy of Three Available Staining Modalities in Diagnosing Abnormal Lesions of Cervix

Saroj Singh, Mukesh Chandra, Richa Singh Arun Nagrath, Vatsala Parihar

Clinical Practice

Role of Misoprostol in Induction of Labor: Sublingual versus Vaginal

Laxmi Maru, Namrata Tiwari

Dr Koushik Lahiri Dermatology Dr Georgi Abraham Nephrology

KK Aggarwal

Anand Gopal Bhatnagar Editorial Anchor 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)

Alka Kriplani

Case Report

Primary Vaginal Carcinoma

Bandana Biswas, Prosenjit Sarkar, JK Saha, Mallika Datta

Short Course in Genetics is Must for Obstetricians: A Case Report on Meckel Gruber Syndrome

Monika Sharma

Vaginal Leiomyoma: Mimicking Uterine Prolapse Amrita Chaurasia, Vishal Dhingra, Astha Singh

Asian Journal of Volume 3, July-Septemeber 2011

Contents

Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Pvt. Ltd. and Published at E - 219, Greater Kailash, Part - 1 New Delhi - 110 048 E-mail: editorial@ijcp.com

Case Report

Double-headed Monster Delivered Vaginally

N Singh, S Barya, K Pandey, P Dubey, D Kumar

Printed at Ana Print O Grafix Pvt. Ltd., New Delhi

Vulvar Elephantiasis of Filarial Origin

ÂŠ Copyright 2011 IJCP Publications Pvt. 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 Pvt. Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

Rachan Chaudhary, Sudhir Rathi, Amit Maheshwari, Shipra Nigam

A Rare Case of Parasitic Fibroid Mimicking Ovarian Tumor

Madhu Patni Bhatt, Swati Kochar, Parul Prakash, Mahesh Gupta, Nidhi Binani

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.

Emedinews Section

From eMedinewS

44 Photo Quiz

Nutan Agarwal

Flow chart

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.

Gestational Diabetes Mellitus - Screening and Management

Reeta Mahey, Alka Kriplani

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from the issue editor

Dr Alka Kriplani

Professor and Head of Unit II Dept. of Obstetrics and Gynecology AIIMS, New Delhi E-mail: kriplanialka@gmail.com

Dear Reader This issue is a testimony of our commitment to disseminate recent and important information in the fast progressing field of Obstetrics and Gynecology. Smooth induction of labor is a pre-requisite to success of vaginal delivery. A successful induction of labor leads to vaginal delivery of a healthy baby, with minimal maternal discomfort, in an acceptable time frame. Labor induction with misoprostol has became an intensely investigative topic. A study â&#x20AC;&#x153;Role of misoprostol in induction of labor: sublingual versus vaginalâ&#x20AC;? aims to evaluate the comparison between sublingual versus vaginal use of misoprostol in induction of labor. Carcinoma cervix is a very common cancer in women especially in developing countries. Proper screening and early detection in preinvasive stage can largely reduce the burden of the disease as has been done in the developed world. A study conducted by Prof. Saroj Singh from Agra compared used of toluidine blue test with other established methods of staining in diagnosing preinvasive cervical lesion and found it more sensitive and specific as compared to acetic acid and Lugolâ&#x20AC;&#x2122;s iodine. Umbilical artery Doppler study appears to assist clinicians in identifying and distinguishing earlier those fetuses at risk of adverse perinatal outcome. This use of Doppler ultrasound has helped in better management of patients with gestational hypertension. A clinical study on role of Doppler in predicting perinatal outcome in cases of gestational hypertension re-emphasizes the role of Doppler in these patients. Traditionally, patients are kept fasting following cesarean delivery until return of bowel sounds. A study on effect of early feeding after cesarean section concludes that early feeding in well-tolerated with lesser need of intravenous fluid supplementation, hence is a patient-friendly approach. The present issue also contains our regular columns like interesting Case Reports, eMedinewS Section, Photo Quiz and Flow Chart. I am sure this issue will make for an interesting and informative reading. n

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

From the desk of group editor-in-chief

CDC Guidelines for GBS Prophylaxis

Dr KK Aggarwal

Padma Shri and Dr BC Roy National Awardee Sr Physician and Cardiologist, Moolchand Medcity President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group Editor-in-Chief, eMedinewS 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)

The Centers for Disease Control and Prevention (CDC) has published new algorithms for screening and treatment of group B streptococcus in pregnant women with preterm labor and preterm premature rupture of membranes. Screening for GBS in Preterm Labor before 37 Weeks

Patient admitted with signs and symptoms of preterm labor Obtain vaginal-rectal swab for GBS culture and start GBS prophylaxis Patient entering true labor? Yes

Continue GBS prophylaxis ultil delivery

Discontinue GBS prophylaxis Obtain GBS culture results

Positive

Not available prior to labor onset and patient still preterm

GBS prophylaxis at onset of true labor

Negative No GBS prophylaxis at onset of true labor; repeat vaginal-rectal culture if patient reaches 35-37 weeksâ&#x20AC;&#x2122; gestation and has not yet delivered

GBS: Group B streptococcus.

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

From the desk of group editor-in-chief Screening for GBS in PROM before 37 Weeks of Gestation

Obtain vaginal swab for GBS culture and start antibiotics for latency or GBS prophylaxis Patient entering labor? No

Yes Continue antibiotics until delivery

Continue antibiotics per standard of care if receiving for latency or Continue antibiotics for 48 hours if receiving for GBS prophylaxis

Obtain GBS culture results

Positive

Not available prior to labor onset

GBS prophylaxis at onset of true labor

Negative

No GBS prophylaxis at onset of true labor; repeat vaginal-rectal culture if patient reaches 35-37 weeksâ&#x20AC;&#x2122; gestation and has not yet delivered

Source: Centers for Disease Control and Prevention. Prevention of Perinatal Group B Streptococcal Disease. Revised Guidelines from CDC, 2010. MMWR 2010;59:No. RR-10.

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Clinical Study

Umbilical Artery Doppler Study as a Predictive Marker of Perinatal Outcome in Gestational Hypertension Garima Kachhawa*, K Maheshwari**, V Kachhawa**, S Mehta†, R Desai‡, BS Jodha‡

Abstract Aim: To evaluate the merit of umbilical artery Doppler study as a predictive marker of perinatal outcome in pregnancies affected by gestational hypertension. Material and Methods: A total of 50 patients at 28-36 weeks of gestational age (GA) who received antenatal umbilical artery Doppler velocimetry and delivered singleton infants with small-for-gestational-age (SGA) were recruited. The ratio of peak-systolic to end-diastolic blood flow velocities (S/D) in the umbilical artery was measured in each patient. The patients were divided into three groups: The normal group with S/D ratios of <95th percentile (n = 29), elevated S/D ratio group of ≥95th percentile (n = 19) and those with absent/reversed end-diastolic flow (n = 2). Maternal characteristics and neonatal outcomes of these groups were comparatively analyzed. Results: The GA at the time of delivery, and the mean birth weight showed statistically significant differences among three groups (p < 0.001). Also, poor perinatal outcome was significantly increased in infants with abnormal S/D ratio (13.4% vs 31.7% vs 67.4%, p < 0.001). Multivariate logistic regression analysis revealed umbilical artery Doppler study as a significant independent factor for prediction of poor perinatal outcome (p = 0.001). Conclusion: Antenatal umbilical artery Doppler velocimetry is shown as a significantly efficient marker in predicting perinatal outcome in preterm SGA infants. Key words: Perinatal outcome in gestational hypertension, Doppler velocimetry

he objective of antenatal care is to assure that every wanted pregnancy culminates in the delivery of a healthy baby without impairing the health of the baby. Although pregnancy may be classified as a normal physiological condition, it is fraught with considerable risk to both the mother and the fetus.1 Gestational hypertension is a pregnancyspecific syndrome characterized by reduced organ perfusion secondary to vasospasm and endothelial pathophysiology. This condition is a leading cause of maternal mortality and is responsible for considerable perinatal morbidity and mortality.2 As a result of impaired uteroplacental blood flow, manifestations of gestational hypertension may be seen in the fetal placental unit. These include intrauterine growth *Senior Research Associate **Professor Dept. of Obstetrics and Gynecology Regional Institute of Maternal and Child Health, Umaid Hospital attached to Dr SN Medical College, Jodhpur † Consultant Dept of Radiodiagnosis, Mehta Sonography Centre, Jodhpur ‡ Consultant Dept. of Obstetrics and Gynecology Regional Institute of Maternal and Child Health, Umaid Hospital attached to Dr SN Medical College, Jodhpur Address for correspondence Dr Garima Kachhawa F-57, West Ansari Nagar All India Institute of Medical Sciences, New Delhi - 110 029

restriction (IUGR), oligohydramnios, placental abruption and nonreassuring fetal status found on antepartum surveillance by Doppler ultrasound.3,4 The use of Doppler ultrasound has helped in better management of these patients. In the most extreme waveform abnormality, there is reversed (REDF) or absent end-diastolic flow (AEDF), which is considered a very ominous sign of placental compromise and is associated with high perinatal mortality rates.5 Antepartum assessment is based on the premise that identification and timed delivery of the hypoxic and acidotic fetus will prevent intrauterine fetal death and decrease the risk of long-term adverse effects. High flow resistance in the capillaries of the terminal villi leads to a low end-diastolic velocity in the umbilical artery and consequent hypoxia.6 Hence, a prospective study using umbilical artery flow velocimetry as diagnostic protocol to predict fetal and neonatal outcome in high-risk pregnancies was planned. Methodology The prospective study comprised 50 patients of gestational hypertension admitted in the Dept. of Obstetrics and Gynecology, Regional Institute of Maternal and Child Health, Umaid Hospital attached to Dr SN Medical College, Jodhpur. Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

clinical study These women either attended the Antenatal clinics with us or were referred to us in view of IUGR. The pregnancies were dated by a combination of the last menstrual period and first trimester-dating scan. Pregnant women with viable singleton pregnancies who had any gestational hypertension with or without IUGR, were included in the study. Pre-eclampsia was diagnosed according to the criteria of the International Society for the Study of Hypertension in Pregnancy: A previously normotensive woman with two repeated (4-hour apart) diastolic blood pressure measurements of >90 mmHg after the 20th week of pregnancy along with proteinuria of >300 mg/l in 24-hour urine.6 The pregnancy could be complicated by IUGR, defined as ultrasound-estimated fetal weight of <10th percentile for gestational age. The diagnosis of severe IUGR was made clinically and confirmed subsequently on ultrasound, when the fetal abdominal circumference was below the third centile. A detailed anomaly scan was performed on all fetuses and dysmorphic fetuses were excluded from the study. Karyotypically abnormal fetuses were also excluded from the study, besides patients with a positive TORCH test on screening. Mothers with chronic hypertension were also excluded from the study group. Clinical Assessment

Laboratory testing included complete blood count, liver function tests and kidney function tests. Ultrasound was carried out to determine composite ultrasound gestational age, estimated fetal weight (EFW), fetal biophysical profile.7 Umbilical artery flow was measured and Systolic/Diastolic ratio was calculated. Gestational age and fetal weight were determined on the basis of fetal biparietal diameter, abdominal circumference and femur length. Fetal weight was estimated according to Hadlock formula.8 Fetal biophysical profile (BPP) included fetal breathing, movements, tone fetal tonus, amount of amniotic fluid and nonstress test (NST).7 IUGR was defined as estimated fetal weight of <10th percentile for gestational age. The ultrasound machine used was Toshiba 140 A (Japan), with a Doppler unit and a 3.5 MHz convex linear probe. Umbilical artery Doppler resistance index was estimated on a free loop of cord. Waveforms of good quality were collected and analyzed in the absence of fetal breathing movements; on average, three separate readings were taken. During the examination, women were in a semi-recumbent position with the head and chest slightly elevated. Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

The recording was performed during periods of fetal apnea, because of the potential effect of fetal breathing movements on waveform variability. Statistical Analysis

Statistical analysis of categorical variables was performed by chi-square test with continuity correction or Fisher exact test when appropriate. The nonparametric MannWhitney U-test (for ordinal data) and Spearman rank correlation were used to determine the degree of correlation. Specificity and positive and negative predictive values were calculated for the diagnostic characteristics used to predict the outcome. All p values were two-tailed, and p < 0.05 was considered statistically significant. The SPSS/PC + statistical package (SPSS Inc. Chicago, IL, USA) was used for all analyzes. Results Fifty women met the inclusion criteria. Baseline characteristics of the study population are shown in Table 1. The average age of our study subject was 25.06 ± 4.22 years (19-35 years). Maximum (44%) were in the age group of 21-25 years. Fortyeight percent patients were primipara and 58% were primigravida. Average gestational age at admission was 34.72 ± 2.96 weeks and average gestational age at delivery was 36.52 ± 1.96 weeks. Out of 50 patients, 37 (74%) had gestational hypertension; 20 (40%) also had IUGR. Of these hypertensive patients, 42% had Table 1. Characteristics of Study Population Parameter Age GA at admission GA at delivery Birth weight Mode of delivery Vaginal LSCS Systolic BP (mmHg) Diastolic BP (mmHg) Hb (g/dl) FBS (mg/dl) Perinatal outcome Poor Good Perinatal death

Value ± SD 25.06 ± 4.22 34.72 ± 2.96 36.52 ± 1.96 2450 ± 2.66 23 (46%) 27 (54%) 140.56 ± 5.97 93.44 ± 9.49 10.2 ± 1.26 80.43 ± 18.56 29 (58%) 21 (42%) 8 (16%)

GA = Gestational age; LSCS = Lower segment cesarean section; BP = Blood pressure; Hb = Hemoglobin; FBS = Fasting blood glucose.

clinical study mild hypertension, 46% had moderate hypertension and 12% patients required immediate termination of pregnancy due to blood pressure >110 mmHg and not controlled on drugs. Fetal biometry to evaluate growth was done fortnightly. Uterine artery Doppler was performed at the baseline and fetuses were evaluated weekly/biweekly with the same, to decide management. Intensive fetal monitoring was performed with NST, liquor estimation on ultrasound and BPP. The frequency of these tests varied on the intensity of growth restriction, as judged in biometry and umbilical artery Doppler. With worsening, Doppler remote from term fetuses were monitored with NST and BPP every day. Decision to deliver was taken if gestational age >37 weeks, severe IUGR, oligohydramnios, poor BPP, abnormal fetal heart rate pattern, AEDF, REDF (Abnormal umbilical artery Doppler). Fifty-four percent had normal Doppler flow velocity waveforms while 46% had abnormal flow velocity waveforms. The results were analyzed according to the umbilical artery S/D ratio (UASD). Gestational age at the time of delivery was 36.0 ± 1.5, 34.4 ± 2.4 and 32.0 ± 2.2 weeks, respectively, for the groups with

UASD <3, UASD 3-4 and UASD >4, and it was the shortest in Group 3 (p < 0.001). Maximum number of patients delivered between 36-38 weeks. Newborns delivered spontaneously had higher birth weight (2,650 ± 125 gms) than those, in whom labor was induced (2,284 ± 375 gms). The mean birth weights of infants at the time of delivery in Group 1, 2 and 3 were 2,584 ± 320, 2,143 ± 345.1 and 1,300 g, respectively, Group 3 being the lowest (p < 0.001). The incidence of small for gestation fetus was 13.79%, 47.36%, 100% in the three groups, respectively (Table 2). The incidence of fetal distress (6.8%, 36.8%, 50%), NICU admission (10.3%, 42.10%, 100%), respectively were more in Group 2 and 3 than Group 1. There was no statistical difference between the groups in terms of neonatal gender; however, we were able to observe significant increase in the rate of <7 Apgar score at five minutes (10.34%, 31.57%, 100%), and perinatal death (3.44%, 26.30%, 100%) as Doppler index was becoming poorer (p < 0.001). Also, there was significant difference in poor perinatal outcome between Group 1, 2 and 3 (17.24%, 47.36% and 100%), respectively, p < 0.001 (Table 3).

Table 2 Subject Distribution According to Umbilical Artery SD ratio Parameter

UASD <3

UASD >3

AEDF/REDF

No. of patient

29 (58%)

19 (38%)

2 (4%)

Birth weight

2,795 ± 218 g

2,711 ± 648 g

2,410 ± 275 g

AGA

25 (86.20%)

10 (28.57%)

SGA

4 (13.79%)

9 (71.43%)

2 (100%)

Normal outcome

24 (82.75%)

5 (17.24%)

Adverse outcome

5 (26.35%)

14 (73.68%)

2 (100%)

UASD = Umbilical artery systolic or diastolic ; AGA = Appropriate for gestational age; AEDF/REDF = Absent end-diastolic flow/reserved end-diastolic flow; SGA = Small for gestational age

Table 3 Adverse Perinatal Outcome by Umbilical Artery SD Ratio Parameter

UASD <3

UASD >3

REDF

Total

Fetal distress

2/29 (6.88%)

7/19 (36.84%)

1 (50%)

NICU admission

3/29 (10.34%)

8/19 (42.10%)

2 (100%)

Apgar <7 at 5 min

3/29 (10.34%)

6/19 (31.57%)

2 (100%)

2/19 (10.52%)

Neonatal death

1/29 (3.44%)

3/19 (15.78%)

2 (100%)

SGA

4/29 (13.79%)

9/19 (47.36%)

2 (100%)

IUD/SB

NICU = Neonatal intensive care unit; IUD/SB = Intrauterine death/still birth.

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

clinical study The multivariate regression analysis revealed that birth weight (2,632 ± 490 g vs 2,012 ± 117 g, p < 0.001) UASD ratio (3.07 ± 0.95 vs 4.61 ± 2.15, p < 0.001) were statistically significant independent factors for prediction of poor perinatal outcome. Discussion Accurate assessment of fetal condition in highrisk pregnancy is important if perinatal morbidity and mortality, as also unwarranted intervention in pregnancy and labor are to be reduced.7 Various studies have confirmed the clinical benefits of umbilical artery Doppler velocimetry in high-risk pregnancies, where this method has been compared with conventional NST, BPP and ultrasound fetometry.5,7,8 Doppler studies also allow more precise targeted prenatal monitoring and obstetric interventions, as pathological Doppler findings may be detected several hours to days before any abnormality, in cartiotocographic tracings.9 We observed that poor umbilical artery Doppler index in high pregnancies is associated with increased incidence of adverse perinatal outcome, and that umbilical artery Doppler index is an independent factor of prediction for perinatal outcome, irrespective of gestational age. In particular, subjects which showed AEDF/REDF, had the worst perinatal outcome which was in agreement with previously reported results.9-11 In the present study, there was a marked difference between the group with abnormal Doppler findings and the group with normal Doppler findings in the incidence of IUGR (54.55% vs 10.34%). On the other hand, the difference between the two groups in the incidence of low Apgar score at five minutes was less (30.4% vs 7.14%). This variation can be explained by the fact that in gestational hypertension, the decline in the nutritive placental functions that causes growth restriction, usually precedes fetal respiratory compromise, which causes low Apgar score.12 Previous studies showed that, in pregnancies accompanied by gestational hypertension and IUGR, the umbilical artery Doppler velocimetry can discriminate those at high-risk for adverse perinatal outcome and predict neonatal outcome.13-15 With normal UASD, only 17.24% had adverse outcome. As UASD ratio increased (>3), the incidence of adverse outcome increased (73.68%). The risk of adverse outcome increased to 100% in patients with REDF. Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Fetuses with normal umbilical artery flow velocity waveforms (UA FVWs) had better perinatal outcome as compared to fetuses with abnormal UA FVWs and worse in patients with REDF as shown in previous studies.13 Table 3 shows that with increasing grade of UASD ratio, the risk of adverse perinatal outcome increases. It has also been emphasized that IUGR with normal umbilical artery Doppler velocimetry is a disease entity different from those with abnormal umbilical artery Doppler blood flow,16 which may be managed by outpatient care17 and that small-for-gestationalage (SGA) fetuses with normal UASD ratios do not show increased morbidity compared to appropriatefor-gestational-age (AGA) pregnancies.18 In addition, it has been reported that, if the UASD ratio and amniotic fluid volume are normal, adverse outcomes will occur only during delivery of the baby, and therefore, close antenatal surveillance may be unnecessary.13 Furthermore, in cases of SGA fetuses with normal umbilical artery Doppler velocimetries, the frequency of fetal surveillance could be reduced from twice-weekly to fortnightly, because no differences in neonatal outcomes were detected between antenatal care provided twice a week and every two weeks.19,20 The present study had sensitivity of 72.72%, specificity of 82.14%, positive predictive value of 76.19% and negative predictive value of 79.31% for predicting adverse perinatal outcome in high-risk pregnancy by UASD ratio. Severe gestational hypertension with IUGR is associated with high placentofetal blood flow resistance, which leads to an absent end-diastolic or reverses enddiastolic flow. These conditions are associated with high perinatal morbidity and mortality and prolonged admission to NICU. In our study, there were two cases with REDF, both were delivered prematurely in an attempt to salvage the neonate but they both expired after 3-5 days of birth. Thus, the umbilical artery Doppler study appears to assist clinicians in identifying and distinguishing earlier fetuses at risk of having adverse perinatal outcome and hence requiring close fetal monitoring in antenatal period. 11

clinical study References 1. Benson RC. Current Obstetric and Gynecologic Diagnosis and Treatment. 5th edition, 1984:614. 2. Neilson JP, Alfirevic Z. Doppler ultrasound for fetal assessment in high risk pregnancies. Cochrane Database Syst Rev 2000;(2):CD000073. 3. Gagnon R, Van den Hof M; Diagnostic Imaging Committee, Executive and Council of the Society of Obstetricians and Gynaecologists of Canada. The use of fetal Doppler in obstetrics. J Obstet Gynaecol Can 2003;25(7):601-14; quiz 615-6. 4. Giles WB, Trudinger BJ, Baird PJ. Fetal umbilical artery flow velocity waveforms and placental resistance: pathological correlation. Br J Obstet Gynaecol 1985;92(1):31-8. 5. Konje JC, Bell SC, Taylor DJ. Abnormal Doppler velocimetry and blood flow volume in the middle cerebral artery in very severe intrauterine growth restriction: is the occurrence of reversal of compensatory flow too late? BJOG 2001;108(9):973-9. 6. Garite TJ, Clark R, Thorp JA. Intrauterine growth restriction increases morbidity and mortality among premature neonates. Am J Obstet Gynecol 2004;191(2):481-7. 7. Dekker GA, Sibai BM. Low-dose aspirin in the prevention of preeclampsia and fetal growth retardation: rationale, mechanisms, and clinical trials. Am J Obstet Gynecol 1993;168(1 Pt 1):214-27. 8. Baschat AA, Galan HL, Bhide A, Berg C, Kush ML, Oepkes D, et al. Doppler and biophysical assessment in growth restricted fetuses: distribution of test results. Ultrasound Obstet Gynecol 2006;27(1):41-7. 9. Almstrom H, Axelsson O, Cnattingius S, Ekman G, Maesel A, Ulmsten U, et al. Comparison of umbilicalartery velocimetry and cardiotocography for surveillance of small-for-gestational-age fetuses. Lancet 1992;340(8825):936-40. 10. Soregaroli M, Bonera R, Danti L, Dinolfo D, Taddei F, Valcamonico A, et al. Prognostic role of umbilical artery Doppler velocimetry in growth-restricted fetuses. J Matern Fetal Neonatal Med 2002;11(3):199-203.

11. Seyam YS, Al-Mahmeid MS, Al-Tamimi HK. Umbilical artery Doppler flow velocimetry in intrauterine growth restriction and its relation to perinatal outcome. Int J Gynaecol Obstet 2002;77(2):131-7. 12. Zelop CM, Richardson DK, Heffner LJ. Outcomes of severely abnormal umbilical artery Doppler velocimetry in structurally normal singleton fetuses. Obstet Gynecol 1996;87(3):434-8. 13. Karsdorp VH, van Vugt JM, van Geijn HP, Kostense PJ, Arduini D, Montenegro N, et al. Clinical significance of absent or reversed end diastolic velocity waveforms in umbilical artery. Lancet 1994;344(8938): 1664-8. 14. Baschat AA, Weiner CP. Umbilical artery Doppler screening for detection of the small fetus in need of antepartum surveillance. Am J Obstet Gynecol 2000;182(1 Pt 1):154-8. 15. Malhotra N, Chanana C, Kumar S, Roy K, Sharma JB. Comparison of perinatal outcome of growth-restricted fetuses with normal and abnormal umbilical artery Doppler waveforms. Indian J Med Sci 2006;60(8):311-7. 16. Baschat AA, Gembruch U, Weiner CP, Harman CR. Qualitative venous Doppler waveform analysis improves prediction of critical perinatal outcomes in premature growth-restricted fetuses. Ultrasound Obstet Gynecol 2003;22(2):240-5. 17. Burke G, Stuart B, Crowley P, Scanaill SN, Drumm J. Is intrauterine growth retardation with normal umbilical artery blood flow a benign condition? BMJ 1990;300(6731):1044-5. 18. Nienhuis SJ, Vles JS, Gerver WJ, Hoogland HJ. Doppler ultrasonography in suspected intrauterine growth retardation: a randomized clinical trial. Ultrasound Obstet Gynecol 1997;9(1):6-13. 19. Ott WJ. Intrauterine growth restriction and Doppler ultrasonography. J Ultrasound Med 2000;19(10): 661-5; quiz 667. 20. McCowan LM, Harding JE, Roberts AB, Barker SE, Ford C, Stewart AW. A pilot randomized controlled trial of two regimens of fetal surveillance for small-for gestational-age fetuses with normal results of umbilical artery Doppler velocimetry. Am J Obstet Gynecol 2000;182(1 Pt 1):81-6.

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Clinical Study

Effects of Early Feeding after Cesarean Delivery Under Regional Anesthesia Amitava Pal*, Rabindranath Dalui**, Raghunath Bhattacharya†, Debasis Saha‡

Abstract Objectives: To assess the effects of early introduction of fluid and/or food after cesarean delivery. Study design: A total of 150 women were selected and alternately assigned in the study (n = 75) and control (n = 75) groups delivered by cesarean section under regional anesthesia. Women with obstructed labor, medical complications and antepartum hemorrhage (APH) were excluded. In the study groups, oral hydration was started three hours after operation irrespective of bowel sounds. In the control groups, traditional regime of oral hydration after the appearance of bowel sounds and then gradual shift to the solid foods was adopted. The time of commencement of normal diet, time of discontinuation of intravenous (IV) fluid, time of hospital stay, time of ambulation and complications were recorded. Statistical analysis was done by z-test and chi-square test; p value of <0.05 was considered significant. Result: Women in study groups received a shorter IV fluid administration (9.6 ± 3.3 hours vs 23.92 ± 1.9 hours; p < 0.001) and more rapid return of regular oral diet (11.75 ± 0.82 hours vs 45.59 ± 0.92 hours; p < 0.001). Women who were fed early (study groups) had shorter hospital stays (4.16 ± 0.94 days vs 5.9 ± 0.83 days; p < 0.001) and shorter time interval from surgery to bowel movement (6.45 ± 0.61 hours vs 12.39 ± 1.85 hours; p < 0.01). There was no significant difference in gastrointestinal (GI) symptoms of both the groups. Conclusion: Early initiation of oral fluid and solid foods after cesarean section appears to be well-tolerated with a shorter hospital stay with no significant GI side effects compared with delayed feeding. Key words: Cesarean section, cesarean delivery, early feeding, paralytic ileus, regional anesthesia

raditionally patients were fasted following abdominal surgery until the return of bowel sounds or passage of flatus; intravenous (IV) line was maintained during this period. Peristalsis in the small intestine continues during anesthesia and surgery.1 The emphasis has lately shifted towards the benefit and safety of early oral hydration following cesarean section, which is generally a short duration operation involving minimal, if any bowel manipulation. Besides this, even with no stimulation by oral intake, 1-2 liters of gastric and pancreatic juices are present in the small bowel daily, which are absorbed immediately and do not need nasogastric suction.2 We therefore undertook a prospective study to assess the superiority of early feeding versus standard *Associate Professor **RMO † Senior Resident Dept. of Obstetrics and Gynecology ‡ Associate Professor Dept. of Anesthesiology, Burdwan Medical College, Burdwan Address for correspondence Dr Amitava Pal Vivekananda College More, Sadarghat Road Burdwan - 713 103, West Bengal E-mail: amitava.628@rediffmail.com

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

protocol with regard to tolerability, early ambulation and incidence of nausea and vomiting, paralytic ileus and hospital stay of patients. Material and Methods The study was conducted at Burdwan Medical College, Burdwan from March 2008 to February 2009, after necessary approval of Ethical Committee and subjects were enrolled in the study after adequate informed consent was obtained. A consecutive series of 150 women admitted for undergoing cesarean section for various reasons were alternatively allocated into two groups: Study groups and control groups (75 women in each). The study was not blind. All the women underwent lower segment cesarean section (LSCS) under regional anesthesia. The drugs used in perioperative period included anesthetic agents, oxytocics and antibiotics. Exclusion criteria were obstructed labor, chorioamnionitis, extensive intraabdominal surgery, medical disorders of pregnancy and antepartum hemorrhage (APH). Women with intraoperative complications like postpartum hemorrhage (PPH), necessitating blood transfusion or need for intensive care in postoperative period were dropped 13

clinical study from the study and next women were enrolled. Women in the study groups were managed with early oral hydration and they could have normal diet and ambulation within the day.

Data were represented as mean ± SD. Statistical analysis was done by z-test and chi-square test for comparison between two groups. A p value of <0.05 was considered significant.

In the control groups, the women were kept on IV fluid. The decision of taking clear fluid and regular diet was based on the presence of bowel sounds, passage of flatus and abdominal physical findings of the absence of distension.

Results

In the early feeding groups, oral fluid was encouraged three hours after surgery. Only two factors were considered in commencing oral feeding; firstly, the alertness of the patient and secondly, the absence of nausea. At first clear fluid was given and if it was tolerated, free intake of fluid was encouraged. A normal diet including, biscuit, puffed rice, rice with pulses and vegetables, bread was allocated at the time of next major meal and then onwards. IV fluid was discontinued when oral intake was wellestablished without nausea and vomiting; IV cannula was removed upon completion of three doses of antibiotics or hydration, whichever was later. Attempts were made to eliminate postoperative pain by inserting diclofenac sodium suppositories at the end of the operation. The drug was inserted after confirmation of well-contracted uterus and absence of uterine bleeding. Baseline data about the duration of IV fluid administration, time of initiating oral fluid, ambulation and duration of stay in hospital was recorded and postoperative complications were also noted. The nurses who took care of patients particularly in the study also answered a questionnaire regarding their satisfaction with patient under the research protocol.

Both the groups had similar baseline demographics (Table 1). Emergency cesarean section was done in majority of cases. The prevalence of repeat cesarean section was similar in both the groups. Table 2 shows that the duration of IV fluid in study group was 9.6 ± 3.3 hours and in the control groups it was 23.92 ± 1.9 hours. Compared with controls, women in the early feeding groups had significantly more rapid initiation of oral fluid (3.52 ± 1.8 hours vs 14.56 ± 3.06 hours; p < 0.001). The mean time of initiating normal diet from the time of surgery was four times longer in control groups when compared to study groups. The hospital stay in the control groups Table 1. Patient Profile Profile

Study groups (n = 75)

Control groups (n = 75)

Age (years)

21.9 ± 5.2

20.28 ± 3.06*

Parity

2.0 ± 0.8

2.1 ± 1.06**

GA (weeks)

38.0 ± 1.6

39.0 ± 2.5***

Elective LSCS

23 (31)

19 (25)

Emergency LSCS

44 (59)

43 (57)

Repeat LSCS

08 (10)

13 (18)

Longitudinal incision

07 (9.3)

09 (12)

Pfannenstiel incision

68 (90.7)

66 (88)

Results are expressed mean ± SD, n (%), z-test- *p > 0.01 (ns), **p > 0.01 (ns), ***p < 0.01 (s) GA = Gestational age; LSCS = Lower segment cesarean section; ns = Nonsignificant; s = Significant.

Table 2. Selected Study Results Character Initiation of oral fluids (hours)

Study (n = 75) 3.52 ± 1.80

Control (n = 75) 14.56 ± 3.08

9.6 ± 3.3

23.92 ± 1.9

Time of first normal meal (hours)

11.75 ± 0.82

45.59 ± 0.92

Postoperative hospital stay (days)

4.16 ± 0.94

5.9 ± 0.83

Discontinuation of IV fluids (hours)

MD (95% CI) 11.04 (10.98-11.10) 14.32 (14.24-14.39) 33.84 (33.82-33.86) 1.74 (1.72-1.76)

p value* <0.001 <0.001 <0.001 <0.001

Mean ± SD, MD = Mean difference, (95% CI of mean difference),*z-test, highly significant

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

clinical study Table 3. Comparison of Bowel Functions and Mobilization Character

Study

Control

(n = 75)

p value*

Appearance of bowel sounds (hours)

6.45 ± 0.61

12.39 ± 1.85

5.94 (5.72-6.14)

<0.01

Passage of flatus (hours)

12.29 ± 0.92

20.01 ± 2.74

7.72 (7.39-8.05)

<0.01

Bowel evacuation (hours)

24.72 ± 2.01

33.37 ± 3.96

8.65 (8.15-9.15)

<0.01

Sitting on bed (hours)

5.09 ± 0.29

11.21 ± 1.95

6.12 (5.89-6.36)

<0.01

Ambulation (hours)

13.12 ± 1.12

25.26 ± 9.97

12.14 (10.98-13.30)

<0.01

Results are expressed as mean ± SD; MD = Mean difference (95% confidence interval of MD); * z-test: Significant difference were found

Table 4. Comparison of Postoperative Complications Complications

Study (n = 75)

Control (n = 75)

p value*

Nausea

09 (12)

25 (33)

0.36 (0.0-1.32)

11.26

Vomiting

07 (09)

05 (07)

1.50 (0.05-2.33)

0.34

Paralytic ileus

01 (01)

06 (08)

0.13 (0.0-2.53)

3.72

Wound sepsis

02 (03)

01 (01)

3.00 (0.0-4.03)

0.34

Fever

06 (08)

02 (03)

2.67 (0.0-3.13)

2.11

UTI

02 (03)

04 (05)

0.6 (0.0-2.48)

0.69

01 (01)

1.006

Thrombophlebitis

UTI = Urinary tract infection; n (%); RR = Relative risks (95% confidence interval of RR) , *Chi-square test, nonsignificant (p > 0.05)

was higher (5.9 ± 0.83 days) than study groups and it was statistically significant (p < 0.001). Table 3 shows comparison of bowel function and mobilization after operation in the study and control groups. In the study groups, the mean duration of appearance of bowel sound was 6.45 ± 0.61 hours and in the control groups was 12.39 ± 1.85 hours, p < 0.01). The 95% CI of mean in the study and control groups was 6.45 ± 0.14 hours and 12.39 ± 0.42 hours, respectively. The mean duration passage of flatus in the study and control groups were 12.29 ± 0.92 hours and 20.01 ± 2.74 hours, respectively. The 95% of CI of mean in the study and control groups was 12.29 ± 0.21 hours and 20.01 ± 0.62 hours (the difference was statistically significant as p < 0.01). The first bowel evacuation occurred in the study and control groups at a mean of 24.72 ± 2.01 hours and 33.37 ± 3.96 hours. The mean duration of sitting in the study groups was 5.09 ± 0.29 hours and in the control groups was 11.21 ± 1.95 hours (95% CI of mean in the study and control groups was 5.09 ± 0.7 hours and 11.21 ± 0.44 hours, respectively and the difference was statistically significant as p < 0.01). Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Postoperative complications are shown in Table 4. Cases in the control groups had higher percentage of nausea as compared to those in the study groups; 33% versus 12%, respectively. Six women in the control groups developed paralytic ileus; all recovered with conservative management. Fifteen nurses who were engaged for postoperative care of such patients were given a questionnaire at the end of the study. All nurses reported that the work load decreased when they took care of patients who received early feeding because of shorter duration of IV fluid and more rapid mobilization. Discussion Early feeding after laparoscopic surgery has been widely accepted as safe.3 It is customary to restrict oral intake following cesarean section until the bowel function returns to prevent gastrointestinal tract (GIT) complications. Early feeding after careful evaluation and strict vigilance not only improves the bowel activity but is also beneficial regarding hydration and nutrition (positive calories and nitrogen balance) to hasten the recovery of postoperative period and early discharge from hospital. 15

clinical study

Control groups Study groups

Initiation of oral fluid*

Discontinuation of IV fluid*

First normal meal*

Sitting***

Ambulation**

Hospital stays*

100

120

140

160

Mean postoperative hours

Figure 1. Showing postoperative durations of both groups. All comparisons were statistically significant (*p < 0.001; **p < 0.01)

The oral fluid was initiated within three hours in our study and found good result regarding bowel activity, ambulation and acceptability concerned. Recent studies have also suggested that early feeding seems to be beneficial and well-tolerated in patients who have undergone laparotomy and cesarean section.2,4,5 In our series, bowel sounds were noted six hours earlier, flatus was passed eight hours earlier and bowel evacuation occurred nine hours earlier in the study groups. Figure 1 shows that postoperative durations for both groups and comparisons were statistically significant (p < 0.001 and p < 0.1) in our study. Disbrow et al showed that gastrointestinal motility returned earlier in groups receiving suggestions of early feeding when compared to the groups that received nonspecific advice. Time to discharge was 6.5 versus 8.1 days.6 16

Bhuiyan et al reported that mean time for introduction of solid food was 11.78 Âą 0.46 hours,7 which was comparable to our present study and there is a definite benefit in maintaining perioperative nutritional status after surgery.5 We found that early feeding has been advocated not only for its nutritional values, but also for its positive effects on GIT (bowel movement 6.45 hours vs 12.39 hours; p < 0.01). Subjective assessment of women clearly demonstrated that early fluid intake minimized the discomfort due to thirst and women were happier in the study group protocol.8 Several other investigations have shown that women may tolerate early solid food after cesarean delivery; none have demonstrated an impact on the duration of hospital stay.2,4,5 In our study, the mean hospital stay of women who were given solid food after cesarean section was shorter by nearly 48 hours (96 hours vs 144 hours). The economic impact of early discharge from the hospital after an uncomplicated cesarean section cannot be overlooked. Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

clinical study Nausea was higher in the control groups while there was no statistical difference of paralytic ileus between the two groups in our study. Mangesi and Hofmeyer reported a trend towards decreased abdominal distension in participating women (within the first 24 hours after cesarean section) taking early oral intake. No significant differences were identified with respect to nausea, vomiting, time of bowel action/passing flatus or paralytic ileus.9 Early prospective feeding also reduces hospital stay, which is economic and reduces the load on infrastructure.10 There is also reported data that early feeding after abdominal surgery may stimulate intestinal motility resulting in decreased incidence of paralytic ileus.11,12 Acknowledgement We are indebted to nursing staffs and the personnel of the Dept. of Obstetrics and Gynecology and Anesthesiology for their enthusiastic participation in this program.

References 1. Senanayake H. A retrospective study of patient-controlled early feeding and diet expansion after caesarean section. Sri Lanka J Obstet Gynaecol 1997;19:23-5. 2. Bufo AJ, Feldman S, Daniels GA, Lieberman RC. Early post operative feeding. Dis Colon Rectum1994;37(12):1260-5. 3. Binderow SR, Cohen SM, Wexner SD, Nogueras JJ. Must early postoperative oral intake be limited to laparoscopy? Dis Colon Rectum 1994;37(6):584-9.

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

4. Soriano D, Dulitzki M, Keidar N, Bakari G, Mashiach S, Seidman DS. Early oral feeding after cesarean delivery. Obstet Gynecol 1996;87(6):1006-8. 5. Burrows WR, Gingo AJ Jr, Rose SM, Zwick SI, Kosty DL, Dierker LJ Jr, et al. Safety and efficacy of early postoperative solid food consumption after cesarean section. J Reprod Med 1995;40(6):463-7. 6. Disbrow EA, Bennett HC, Owings JT. Effect of preoperative suggestion on postoperative gastrointestinal motility. West J Med 1993;158(5):488-92. 7. Bhuiyan SN, Begum R. Early oral feeding after caesarean section. Avd Obstet Gynecol 2002;1(6):352-4. 8. Malhotra N, Khanna S, Pasrija S, Jain M, Agarwala RB. Early oral hydration and its impact on bowel activity after elective caesarean section - our experience. Eur J Obstet Gynecol Reprod Biol 2005;120(1):53-6. 9. Mangesi L, Hofmeyr GJ. Early compared with delayed oral fluids and food after caesarean section. Cochrane Database Syst Rev 2002;(3):CD003516. 10. Patolia DS, Hilliard RL, Toy EC, Baker B. Early feeding after cesarean section: randomized trial. Obstet Gynecol 2001;98(1):113-6. 11. Schippers E, Holscher AH, Bollschweiler E, Siewert JR. Return of interdigestive motor complex after abdominal surgery. End of postoperative ileus? Dig Dis Sci 1991;36(5):621-6. 12. Teoh WH, Shah MK, Mah CL. A randomized controlled trial on beneficial effects of early feeding post cesarean delivery under regional anaesthesia. Singapore Med J 2007;48(2):152-7.

Clinical Study

Efficacy of Three Available Staining Modalities in Diagnosing Abnormal Lesions of Cervix Saroj Singh*, Mukesh Chandra**, Richa Singh†, Arun Nagrath‡, Vatsala Parihar#

Abstract Aims and objectives: To estimate sensitivity and specificity on visual inspection by application of acetic acid, Lugol’s iodine and toluidine blue in the diagnosis of abnormal cervical lesions, followed by colposcopic evaluation and biopsy. Material and methods: The present cross-sectional study was conducted in the Dept. of Obstetrics and Gynecology, SN Medical College and Hospital, Agra, over the period from July 2008 to September 2010. Symptomatic women (n = 100) of age group 20-49 years coming to Gynecology OPD were selected for study group. The study group was subjected to detailed history, physical examination, Pap smear, visual inspection test followed by colposcopy and biopsy. Results: In our study, out of 100 women, acetowhite areas were seen in 60% women. Visual inspection with Lugol’s iodine (VILI) test was positive in 53%, while toluidine blue positive areas were present in 48% women (p > 0.05), so, there is no significant difference among the findings on three visual inspection tests. Out of 60 women who showed acetowhite areas on visual inspection with acetic acid (VIA test), 35 had biopsy proven preinvasive lesions. So, sensitivity of acetic acid is 58.33% and specificity is 87.5%. Out of 53 women who had VILI test positive (iodine-negative area), 33 had biopsy-proven preinvasive lesion. Thus, the sensitivity and specificity of Lugol’s iodine is 62.26% and 85.11%, respectively. On visual inspection after toluidine blue, 48 women had positive test; out of which 34 had biopsy-proven preinvasive lesion, thus the sensitivity and specificity of toluidine blue is 70.83% and 88.46%, respectively. Conclusion: Based on this study it can be concluded that toluidine blue is a more sensitive and specific stain as compared to acetic acid and Lugol’s iodine in diagnosing preinvasive cervical lesions. So, it can be used routinely as a screening modality for preinvasive cervical lesions. But, concentration of toluidine needs to be standardized for this purpose. Key words: Abnormal cervical lesions, visual inspection test

stains and acetic acid have been used. These stains carry the disadvantage of highlighting the cellular cytoplasm by virtue of which abnormal activity may be missed.1

To aid the macroscopic and magnified colposcopic images of cervix and vagina, to identify abnormal areas on the cervix and to obtain colposcopic directed biopsies, various stains like Lugol’s iodine, immunofluorescent

Aims and Objectives

quamous cell carcinoma of the cervix fulfills the model for a classic multistage disease beginning with the acquisition of a precursor lesion, morphologic progression of the precursor during the course of time and in some cases the development of invasive carcinoma. The fact that this process takes as much as 20 years to evolve has been the basis for screening programs targeting the detection of preinvasive disease.

**Professor and Head **Professor † Associate Professor ‡ Former Professor and Head # Junior Resident - Third Year Dept. of Obstetrics and Gynecology, SN Medical College, Agra Address for correspondence Dr Richa Singh Associate Professor 1/120-G, Delhi Gate, Agra - 282 002 E-mail: chauhan.richavishal@gmail.com

Though nuclear stains like toluidine blue have been used in the diagnosis of buccal lesions, there is no report of this stain being used in vivo in the cervix or vagina. This stain shows promise because of its nuclear staining properties and may have the potential of more sensitivity and specificity in the diagnosis of preinvasive cervical lesions.

To estimate sensitivity and specificity on visual inspection by application of acetic acid, Lugol’s iodine and toluidine blue in the diagnosis of abnormal cervical lesions, followed by colposcopic evaluation and biopsy. Material and Methods The present cross-sectional study was conducted in the Dept. of Obstetrics and Gynecology, SN Medical College, Agra over the period from July 2008 to September 2010. One hundred symptomatic women Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

clinical study of age group 20-49 years coming to Gynecology OPD were selected as the study group. After taking informed consent, the study group was subjected to detailed history, physical examination, Pap smear, visual inspection test followed by colposcopy and biopsy. After analyzing the data by chi-square test, results were assessed for comparison between three stains. Results Women in study group were between 20-49 years. Mean age was 36.30 Âą 6.20 years. Most of the women in study were multipara (65%). Vaginal discharge and lower abdominal pain were the most common complaints. On per speculum examination, nabothian follicles + hypertrophy were the most common findings (22%) followed by erosion + hypertrophy + nabothian follicles (20%), erosion + hypertrophy (16%), congestion (10%), hypertrophy (8%), erosion (4%), ulcer (3%) and nabothian follicle (2%). Per speculum findings were normal in 15% women (Table 1). Pap smear was normal in 20%; low-grade squamous intraepithelial lesion (LSIL) was present in 24%, highgrade squamous intraepithelial lesion (HSIL) in 15%, and findings suspicious of carcinoma cervix were seen in 2% women (Table 2). On visual inspection using the three stains, visual inspection with acetic acid (VIA) was positive in 60% women, visual inspection with Lugolâ&#x20AC;&#x2122;s iodine (VILI) Table 1. Distribution of Subjects According to Per Speculum Findings

Perspeculum findings

Number of subjects

Normal

Congestion

Hypertrophy

Erosion

Erosion + hypertrophy

Nabothian follicle

Nabothian follicle + hypertrophy

Erosion + hypertrophy + nabothian follicle

Ulcer

Total

100

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Table 2. Distribution of Subjects According to Pap Smear Findings

Pap smear findings

Number of subjects Normal 20 Inflammatory 20 Reactive/reparative 05 Koilocytosis 04 ASCUS 10 LSIL 24 HSIL 15 Suspected carcinoma cervix 02 Total 100

% 20 20 05 04 10 24 15 02 100

Table 3. Comparison of Visual Inspection Tests

Test Positive Negative Total

VIA 60 40 100

VILI 53 47 100

Toluidine blue test 48 52 100

c2 = 1.63; d.f. = 2; p-value = 0.442 p > 0.05

Table 4. Distribution of Subjects According to Colposcopic-guided Biopsy

Biopsy findings Normal Chronic cervicitis Condyloma acuminata CIN-I CIN-II CIN-III Carcinoma in situ Total

Number of subjects 27 30 03 21 14 03 02 100

% 27 30 03 21 14 03 02 100

was positive in 53% while toluidine blue test was positive in 48% (p > 0.05) (Table 3). On biopsy, 27% women showed normal findings, 30% had chronic cervicitis, 3% had condyloma acuminata, 21% had cervical intraepithelial neoplasia (CIN)-I lesions, 14% had CIN-II, 3% had CIN-III and 2% showed carcinoma in situ (Table 4). Out of 60 women, who had acetowhite area on VIA, only 35 had biopsy-proven preinvasive lesions, so sensitivity of acetic acid to detect preinvasive lesion is 19

clinical study Table 5. Relation between VIA and Biopsy

Biopsy (Preinvasive lesion) Present (n = 40) Absent (n = 60)

VIA test

VILI test

Positive 35 (58.33%)

Negative 5 (12.5%)

Positive 33 (62.20%)

Negative 7 (14.89%)

Positive 34 (70.83%)

Negative 6 (11.54%)

25 (41.6%)

35 (87.5%)

20 (37.74%)

40 (85.11%)

14 (29.16%)

47 (88.46%)

58.33% and specificity is 87.5%. Out of 53 women who had VILI test positive, only 33 had biopsy-proven preinvasive lesion so sensitivity of Lugol’s iodine is 62.26% and specificity is 85.11%. Out of 48 women, who had positive toluidine blue test, 34 had biopsy-proven preinvasive lesion; so, sensitivity and specificity of toluidine blue is 70.83% and 88.46%, respectively (Table 5). Discussion The current study was undertaken to evaluate the diagnostic efficacy of acetic acid, Lugol’s iodine and toluidine blue in diagnosing abnormal cervical lesion. In our study, out of 100 women, 60 had acetowhite areas on VIA test. Out of those 60 women, 35 showed biopsy-proven preinvasive lesions. So, sensitivity and specificity of acetic was 58.33% and 87.5%, respectively (Tables 3 and 5). According to a study published in Trop Doct, the sensitivity of visual inspection after acetic acid was 55% and specificity was 71.39%.2 According to Sankaranarayanan et al, the sensitivity of VIA to detect CIN lesions was 88.6% and specificity was 86.5%.3 In our study, the sensitivity of VILI was 62.26% and specificity was 85.11% (Tables 3 and 5). In a cross-sectional study of 4,444 women, sensitivity of VILI was 87.2% and specificity was 84.7%.4 The sensitivity and specificity of toluidine blue was 70.83% and 88.46% in our study (Tables 3 and 5). Epstein et al reported a sensitivity of 87.5% and positive predictive value of 92%, respectively and increase in specificity values when toluidine blue and Lugol’s iodine were used in assessment of oral premalignant lesions.5 These three stains have special properties; acetic acid and Lugol’s iodine are cytoplasmic stains while toluidine blue is a nuclear stain. So, toluidine blue is more specific to identify preinvasive lesions.

Toluidine blue test

In our study, the study group was not so large, so the diagnostic efficacy of any one stain cannot be accepted. The toluidine blue used in this study was of low concentration, which had poor staining property. Toluidine blue needs to be used in higher concentrations of the stain to know its proper sensitivity and specificity. Conclusion Based on this study, it can be concluded that toluidine blue has proved to be a more sensitive and specific stain as compared to acetic acid and Lugol’s iodine in diagnosing preinvasive cervical lesions. But to determine the accurate diagnostic efficacy, toluidine blue should be further studied in larger population and it should also be used in different concentration so that proper concentration of toluidine blue for optimum result can be determined. References 1. Love R, Liles RH. Differentiation of nucleoproteins by inactive protein-bound amino groups and staining with blue and ammonium molybdate. J Histochem Cytochem 1959;7(3):164-81. 2. Qureshi S, Das V, Zahra F. Evaluation of visual inspection with acetic acid and Lugol’s iodine as cervical cancer screening tools in a low-resource setting. Trop Doct 2010;40(1):9-12. 3. Sankaranarayanan R, Wesley R, Thara S, Dhakad N, Chandralekha B, Sebastian P, et al. Test characteristics of visual inspection with 4% acetic acid (VIA) and Lugol’s iodine (VILI) in cervical cancer screening in Kerala, India. Int J Cancer 2003;106(3):404-8. 4. Sankarnarayanan R, Rajkumar R, Arrossi S, Theresa R, Esmy PO, Mahé C, et al. Determinants of participation of women in a cervical cancer visual screening trial in rural south India. Cancer Detect Prev 2003;27(6);457-65. 5. Epstein JB, Scully C, Spinelli J. Toluidine blue and Lugol’s iodine application in the assessment of oral malignant and lesions at risk of malignancy. J Oral Pathol Med 1992;21(4):160-3.

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Clinical practice

Role of Misoprostol in Induction of Labor: Sublingual versus Vaginal Laxmi Maru*, Namrata Tiwari**

Abstract Introduction: A successful induction of labor leads to vaginal delivery of a healthy baby, in an acceptable time frame with minimum maternal discomfort or side effects. Objectives: To compare the efficacy and safety of sublingual and per vaginal 25 µg misoprostol for labor induction. Primary outcome measures were the number of cases delivering vaginally. Secondary outcome measures included the interval of induction to labor, induction to delivery, number of doses of misoprostol, oxytocin requirement, the incidence of meconium-stained liquor, number of cesarean deliveries, the incidence of hyperstimulation/ tachysystole, maternal adverse effects and neonatal outcomes. Material and methods: A prospective study was conducted in Dept. of Obstetrics and Gynecology, MGM Medical College and MY Hospital, Indore. Indications were reviewed; 416 women randomly received misoprostol 25 µg vaginally and sublingually every three hourly for maximum three doses. Outcomes were analyzed accordingly. Results: The number of cases who successfully delivered vaginally was greater in the sublingual group. The induction to vaginal delivery interval was significantly shorter in sublingual group. The incidence of tachysystole and meconium-stained liquor were more in the vaginal than in the sublingual group. The mean doses, mode of delivery, oxytocin augmentation and maternal outcomes were significantly favorable in sublingual group. No significant difference is seen in neonatal outcome. Conclusions: Sublingual misoprostol 25 µg administered three hourly for labor induction has better efficacy as compared to 25 µg of vaginal misoprostol. Key words: Misoprostol, tachysystole, meconium stained liquor, cervical ripening

n the modern era of day-care obstetrics, a smooth timely delivery and return to the routine activity is desired by everyone with the wide acceptance of active management of labor. The concern over the problem of labor induction has justifiably grown over the year. Induction of labor near term is required in 10-20% of women. Medications that ripen the cervix within a short period of time play an important role in modern obstetrics. A successful induction of labor leads to vaginal delivery of a healthy baby, in an acceptable time frame with minimum maternal discomfort or side effects.1 A timely induction is advantageous both to the obstetrician as well as the patient. Induction of labor means initiation of uterine contraction (after the *Professor and Head **Postgraduate Resident Dept. of Obstetrics and Gynecology MGM Medical College and MY Hospital, Indore (MP) Address for correspondence Dr Namrata Tiwari C/o: Dr MK Tiwari 106, Post Office Road Mhow, Indore, MP E-mail: dr.namrata28@gmail.Com

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

period of viability) by any method medical, surgical or combined for the purpose of achieving vaginal delivery. It is done with the aim of achieving vaginal delivery whenever, the continuation of pregnancy presents a threat to the life or well-being of the mother and her unborn child. Before induction one must ensure the gestational age as well the pulmonary maturity of the fetus. Rarely, preterm induction may have to be done. Modern obstetrics techniques have greatly increased the safety and reliability of induction of labor so that, it can be performed with greater confidence of success. The transition from pregnancy to labor is a gradual process marked by prelabor changes such as increased uterine contractility and cervical ripening. A ripe soft cervix requires a lower quantum of uterine work compared to an unripe hard and rigid one.2 The drugs commonly available for the purpose of induction are oxytocin, dinoprostone gel and recently misoprostol. Misoprostol, the most fascinating synthetic prostaglandin E1 analog has recently been the focus of attention amongst various laborinducing agents. Misoprostol was originally made for the healing of gastric ulcers induced by nonsteroidal 23

clinical practice anti-inflammatory drugs (NSAIDs).3,4 They also potentiate the action of oxytocin on the myometrium. Prostaglandins act as the ‘ultimate uterine stimulant’. Unlike spontaneous labor, induction of labor carries the possibility of uterine hyperstimulation, rupture and fetal distress.5 Labor induction with misoprostol has become an intensely investigated subject. Objectives The present study aims to evaluate, the comparison between sublingual tablets 25 µg of misoprostol versus vaginal 25 µg of misoprostol in cervical ripening and induction of labor. Material and Methods The present study was carried out in the Dept. of Obstetrics and Gynecology, Mahatma Gandhi Memorial Medical College and Maharaja Yeshwant Rao Hospital, Indore from September 2009 to August 2010 on 416 pregnant women having indication for induction of labor. They were selected randomly for preinduction cervical ripening and induction of labor either with 25 µg of sublingual versus vaginal 25 µg of misoprostol. Women enrolled in the study fulfilled the following inclusion criteria:  Singleton pregnancy at gestational age 37 weeks or more  Obstetrics indication for induction  Vertex presentation  Unfavorable cervix (Bishop’s score <6)  No cephalopelvic disproportion  No history of bronchial asthma, glaucoma, serious cardiovascular disorders, renal diseases, metabolic or endocrinal disorders or allergy to misoprostol  Nulliparous and multiparous women (parity <5)  Reassuring fetal heart tracing (since admission)  Intrauterine death The patients with the following clinical history or findings were excluded from this study:  Transverse lie or presentation other than cephalic  Previous operation on uterus  Known hypersensitivity to prostaglandins  Placenta previa, abruption or unexplained vaginal bleeding 24

  

Patient of known hemoglobinopathy Grand multiparity Significant fetal or maternal conditions that make induction necessary under continuous monitoring (e.g., severe pre-eclampsia, severe IUGR), renal or hepatic dysfunction.

Among 416 women enrolled, 208 women received sublingual tablet and 208 women received vaginal misoprostol. Pre-treatment Data

Cases were randomized into two groups: Group I (sublingual) and Group II (vaginal). The following procedure was adopted:  A written consent of patient  A thorough physical examination  Complete obstetrical examination which included: n Per abdomen examination n Fetal heart rate was auscultated every hour throughout the 1st stage of labor and every five minutes during the 2nd stage of labor. n Uterine contraction was monitored every 30 minutes. Hemoglobin, blood group, urine analysis were done in all patients. Subsequent doses were given after every three hours till the patient developed adequate uterine contractions, the cervical dilatation reached ≥4 cm and spontaneous rupture of membranes or upto maximum of three doses. Vaginal examination was done every three hours. Oxytocin augmentation was commenced six hours after the last dose of misoprostol if the patient was not yet in established labor (after artificial rupture of membranes [ARM], using an standard oxytocin regime of 1, 2, 8, 16 U in 500 ml of 5% dextrose at 15, 30, 60 drops per minute (2, 4, 8, 6 and 32 mU 64 m% per minute, respectively) increments at 20-minute intervals. Adverse effects (like nausea, vomiting, etc.) if present were noted and treated accordingly. All events of labor were graphically recorded in the form of Partogram. ‘Failed induction’ was considered when no progress following three doses of misoprostol, ARM and oxytocin drip acceleration. If labor in active phase did not end within 12 hours spontaneously it was considered as Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

clinical practice ‘failure to progress’ and other methods of termination of pregnancy were looked for. Fetal outcome in terms of live or stillbirth, weight, Apgar scoring at one minutes and five minutes, etc. were recorded. Both mother and the baby were observed for at least 48 hours. The results were represented as statistically modified ‘t’ test.

This clinical observation is strengthened by the study of Zieman et al who found a maximum plasma concentration at 34 minutes after oral dosing and 80 minutes after vaginal administration by misoprostol.6 Medication-delivery Interval

The present study was conducted in the Dept. of Obstetrics and Gynecology, MGM Medical College and MY Hospital, Indore from September 2009 to August 2010 on 416 pregnant women with indication for induction of labor.

In the present study, 62.5% patient in the vaginal group and 75% in the sublingual group delivered within 12 hours. It was statistically significant (Table 2). The mean induction to delivery interval was less in the sublingual group compared to the vaginal group. The mean induction to delivery interval was less in sublingual than vaginal group in the study by Bennett.7

Age

Doses

In the present study, 170 (81.74%) patients in the sublingual group and 162 (77.89%) patients in vaginal group level were in the age group 20-25 years.

Majority of cases (134) in sublingual misoprostol group delivered with one dose of misoprostol compared to 102 of cases in vaginal group, which is statistically significant. This may be because of the systemic bioavailability of sublingual administered misoprostol, which avoids first-pass metabolism. Vaginal secretions also decrease the local effect of vaginal route.

Results and Discussion

Gravidity

In the present study, 112 patients in the sublingual group and 107 patients in the vaginal group were primigravida; 96 patients in sublingual group and 101 patients in the vaginal group were multigravida. Medication-labor Interval

Our results show that in equivalent doses, the sublingual route of administration of misoprostol resulted in shorter induction to labor interval (Table 1). Labor was established within six hours in 78.85% of patients in sublingual group and 63.47% patients in vaginal group. Sublingual misoprostol was more effective than vaginal misoprostol in inducing labor.

Mode of Delivery

In the present study, there is significant difference in mode of delivery in either group; 19.71% in sublingual group and 34.62% in vaginal group required abdominal delivery and 80.28% in sublingual group and 65.38% in vaginal group delivered vaginally (Table 3). In one study, 152 women were analyzed (Carlan2002).8 Eighteen out of 73 patients in the sublingual group versus 28 out of 79 patients in the vaginal

Table 1. Distribution of Patients According to Medication to Pain Interval (In Minutes) Duration Total interval

Sublingual group (n = 208)

Vaginal group (n = 208)

1,597.96 ± 813.16

1,954.14 ± 924.7

Table 2. Distribution of Patients According to Medication to Delivery Interval Delivery interval

Sublingual group (n = 208)

Vaginal group (n = 208)

No.

<12

156

75.00

130

62.50

12-24 hours

13.46

17.31

>24 hours

11.54

20.19

Total

208

100

208

100

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

clinical practice Table 3. Distribution of Patients According to Mode of Delivery Mode of delivery

Sublingual group (n = 208)

Vaginal group (n = 208)

No.

Vaginal

167

80.28

136

65.38

Abdominal

19.71

34.62

Total

208

100

208

100

group had cesarean deliveries. The sublingual route was associated with slightly fewer cesarean sections. Most of the cesareans in vaginal group were due to fetal distress (19%) compared to 12% in sublingual group. Higher incidence of fetal distress in vaginal group was due to higher rate of hyperstimulation, which requires a more cautious approach in the vaginal administration of misoprostol group.

In the present study, it was comparable in both groups. Tachysystole and Hyperstimulation

In the present study, tachysystole and hyperstimulation developed in 32 (15.4%) patients in the sublingual group and 76 (36.54%) in the vaginal group. Sublingual misoprostol mimics the efficacy of the vaginal route by having a similar pharmacokinetic profile, while causing less hyperstimulation by avoiding the cervical effects.9 Sublingual group Vaginal group

180

160

Preinduction Bishop Score

164

In the study done by Shetty et al, there were five tachysystoles and 14 hyperstimulations in the vaginal group and two tachysystoles and eight hyperstimulations in the 10 sublingual group.

146 140 128 120 104

104

Meconium-stained Liquor

100

62 60 44 40

30 18

0 Clear

Thin/Thick MSL

Oxytocin required

Oxytocin not required

GIT side effects (D+V)

Shivering and pyrexia

Figure 1. Number of patients according to color of liquor, oxytocin requirement and maternal adverse effects in sublingual and vaginal groups. D+V = Diarrhea + Vomiting

There were 38.46% cases of meconium-stained liquor in the vaginal group compared to 21.15% in the sublingual group which may be due to the higher incidence of hyperstimulation and tachysystole in the vaginal group (Fig. 1). Oxytocin-augmentation Requirement

In the present study, oxytocin was required more commonly in the sublingual group (n = 62; 29.8%) than in vaginal group (n = 104; 50%) (Fig. 1).

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

clinical practice Maternal Complications



In the present study, maternal side effects were more in the vaginal group; 29.94% in the vaginal group and 14.57% in the sublingual group had adverse effects of misoprostol (Fig. 1). According to Carlan 2002,8 maternal complications were significantly more in vaginal group.



Neonatal Outcomes

In the present study, there were no significant differences in the Apgar score at 1- or 5-minute and passage of meconium in either group. Neonatal admissions were more in the vaginal group (24%) as compared to sublingual group (19%). Hyperbilirubinemia was observed in nine neonates in vaginal group and seven in sublingual group. Septicemia was seen in eight neonates in vaginal group and 6 neonates in sublingual group. Apgar score was <7 at 1-minute in 4 patients in sublingual group and in six neonates in vaginal group. Apgar score was <7 at 5-minute in six neonates in sublingual group and 8 neonates in vaginal group. Meconium aspiration syndrome was observed in 16 neonates in sublingual group and 18 neonates in vaginal group. In the study by Carlan-2002,8 11 cases in the sublingual and 10 in pervaginal group had neonatal complications (p = 0.67). Recent studies have found that sublingual administration of misoprostol is very effective for induction of labor.11-17 Conclusion The aim of the study was to compare safety and efficacy of 25 µg sublingual misoprostol versus vaginal misoprostol for preinduction cervical ripening and induction of labor. The following conclusions were drawn:  In the present study, majority of the patients were in the age group 20-25 years. Patients admitted had an unfavorable cervix (Bishop’s score <6). Patients with Bishop’s score >6 at admission were not included in the study.  The number of booked and emergency cases and distribution of cases according to gravidity were comparable in the two groups.  The number of cases was comparable with respect to mean gestational age. Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011



The most common indications for inducing labor in the two groups were premature rupture of membrane or leaking, pregnancy-induced hypertension and postdatism. The distribution of cases according to preinduction Bishop scores was comparable. There was a significant difference in medicationestablished labor interval in both groups. The average interval from start of induction to established labor was shorter in sublingual than vaginal group. There was a significant difference in medicationdelivery interval. It was significantly shorter in sublingual group. There was also a significant difference in the route of delivery in both groups. Forty-one patients delivered abdominally in the sublingual group versus 72 patients in the vaginal group. Significantly fewer doses were required in the sublingual group than in the vaginal group. Tachysystole (≥6 uterine contractions in 10 minutes for two consecutive 10-minute periods) or hyperstimulation developed in 15.38% patients in sublingual group and 36.54% patients in vaginal group. There was significant difference in tachysystole and hyperstimulation in the two groups. The response to a single dose of misoprostol was more in the sublingual group (n = 134) than the vaginal group (n = 102). The incidence of meconium-stained liquor was more in the vaginal group 38.46% (n = 80) as compared to the sublingual group 21.15% (n = 44). The incidence of maternal complications like diarrhea, nausea, shivering and pyrexia were more in the vaginal (28.74%) as compared to the sublingual group (14.57%). There was no significant difference in neonatal outcome in either group.

The secret of success in labor induction lies on replicating the process of spontaneous parturition as closely as possible. Sublingual misoprostol as compared to vaginal misoprostol proves to be an effective and better method for cervical ripening and induction of labor when combined with judiciously timed amniotomy achieving more vaginal deliveries in women with unfavorable cervix. Misoprostol is a 27

clinical practice less invasive and more natural agent which sometime requires intravenous oxytocin infusion. Sublingual misoprostol has minimal maternal systemic side effects and fetal distress. To conclude, misoprostol is a promising drug for labor induction. Sublingual misoprostol is better than when used vaginally. References 1. Ramsey PS, Ogburn PL Jr, Harris DY, Heise RH, Ramin KD. Effect of vaginal pH on efficacy of misoprostol for cervical ripening and labour induction. Am J Obst and Gynaecol 2000;182(6):1616-9. 2. Oâ&#x20AC;&#x2122;Brien WF. Cervical ripening and labor induction: progress and challenges. Clin Obstet Gynecol 1995;38(2):221-3. 3. Sanchez Ramos L, Gaudier FL, Kauntiz AM. Cervical ripening and labor induction, Clin Obstet Gynecol 2000;43(3):513-23. 4. Hofmeyer GJ, Gulmezoglu AM, Alfirevic Z. Misoprostol for induction of labour: a systemic review. Br J Obstet Gynaecol 1999;106(8):798-803. 5. American College of Obstetricians and Gynaecologists. Induction and augmentation of labor. ACOG Technical Bulletin No. 217. Washington, DC: ACOG, 1995. 6. Zieman M, Fong SK, Benowitz NL, Banskter D, Darney PD. Absorption kinetics of misoprostol with oral or vaginal administration. Obstet Gynecol 1997;90(1): 88-92. 7. Bennett KA, Butt K, Crane JM, Hutchens D, Young DC. A masked randomized comparison of oral and vaginal administration of misoprostol for labor induction. Obstet Gynecol 1998;92(4 Pt 1):481-6.

8. Carlan S, Blust D, Oâ&#x20AC;&#x2122;Brien.W. Buccal versus intravaginal misoprostol administration for cervical ripening. Am J Obstet Gynaecol 2002;186:229-33. 9. Shetty A, Danielian P, Templeton A. Sublingual misoprostol for the induction of labor at term. Am J Obstet Gynecol 2002;186(1):72-6. 10. Shetty A, Danielian P, Templeton A. A comparison of oral and vaginal misoprostol tablets in induction of labour at term. BJOG 2001;108(3):238-43. 11. Bartusevicius A, Barcaite E, Krikstolaitis R, Gintautas V, Nadisauskiene R. Sublingual compared with vaginal misoprostol for labour induction at term: a randomised controlled trial. BJOG 2006;113(12):1431-7. 12. Caliskan E, Bodur H, Ozeren S, Corakci A, Ozkan S, Yucesoy I. Misoprostol 50 microg sublingually versus vaginally for labour induction at term: a randomized study. Gynecol Obstet Invest 2005;59(3):155-61. 13. Feitosa FE, de Amorim MM, Alencar CA Jr, Coutinho IC, Sampaio ZS. New formulation of sublingual misoprostol (25mcg) for induction of labor. (Article in Portugese). Rev Assoc Med Bras 2006;52(4):251-5. 14. Feitosa FE, Sampaio ZS, Alencar CA Jr, Amorim MM, Passini R. Sublingual vs vaginal misoprostol for induction of labor. Int J Gynaecol Obstet 2006;94(2):91-5. 15. Moraes Filho OB, Albuquerque RM, Pacheco AJC, Ribeiro RH, Cecatti JG, Welkovic S. Sublingual versus vaginal misoprostol for labor induction of term pregnancies. (Article in Portugese). Rev Bras Ginecol Obstet 2005;27(1):24-31. 16. Wolf SB, Sanchez-Ramos L, Kaunitz AM. Sublingual misoprostol for labor induction: a randomized clinical trial. Obstet Gynecol 2005;105(2):365-71. 17. Nassar AH, Awwad J, Khalil AM, Abu-Musa A, Mehio G, Usta IM. A randomized comparison of patient satisfaction with vaginal and sublingual misoprostol for induction of labour at term. BJOG 2007;114(10):1215-21.

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Case Report

Primary Vaginal Carcinoma Bandana Biswas*, Prosenjit Sarkar**, JK Saha†, Mallika Datta‡

Abstract Primary vaginal carcinoma is the rarest of rare cases. We present herewith a case of primary vaginal carcinoma of FIGO Stage 2 with histological feature of nonkeratinizing squamous cell carcinoma, currently being treated with radiotherapy. Key words: Human papilloma virus, vaginal carcinoma, radiotherapy

rimary vaginal carcinoma is a rare type of carcinoma occurring in only 0.42/1,00,000 women.1 Each case is a milestone in a clinician’s life. Primary vaginal carcinoma is defined as cancerous growth arising solely from vagina with no involvement of the external cervical os superiorly or the vulva inferiorly. About 80% of vaginal carcinoma are metastatic with the primary growth being either cervical or endometrial.2 Case Report Mrs. LS, a 42-year-old lady with history of irregular acyclic bleeding associated with white discharge per vaginal since last two months presented to our OPD. She was admitted to our institute on March 16, 2010. Her previous menstrual history was unremarkable. She had no significant medical comorbidity or history of surgical intervention. She was nulliparous, nulligravida with history of marriage and cohabitation for four years. She did not report any history of sexual exposure since the age of 22 years, when she was abandoned by her husband and started living at the home for restitutes, where she is currently residing. *Professor **2nd Year DGO PGT † Associate Professor ‡ Assistant Professor Dept. of Obstetrics and Gynecology Medical College, Kolkata Address for correspondence Dr Bandana Biswas Professor, Dept. of Obstetrics and Gynecology Medical College, Kolkata Res.: 69, Chandi Ghosh Road, Kolkata - 700 040, West Bengal

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

On examination, she had mild pallor and a lump on her left breast with no palpable lymph nodes. Her other parameters like blood pressure, pulse, etc. were within normal limits. Pelvic examination was performed under general anesthesia. A growth was seen involving the posterior wall, extending from the vault till upper part of lowerthird of vagina (Fig. 1). Anteriorly and posteriorly the growth involved both upper and middle third of vagina. The growth was fungating in nature, friable and bled to touch. Cervix was flushed with vagina. No growth could be seen arising from the cervix. Uterus was of normal size, anteverted and mobile. Per rectal examination revealed growth involving posterior wall of vagina. Mackenrodt’s and uterosacral ligaments were bilaterally free. Rectal mucosa was uninvolved. Clinically the vaginal carcinoma was staged as International Federation of Gynecology and Obstetrics (FIGO) Stage 2.

Cervix

Vaginal growth

Figure 1. Photograph of actual vaginal growth.

Case Report

Sheets of invasive nonkeratinizing malignant squamous cells

Figure 2. Picture showing the hematoxylin and eosin stained histopathological slide of the vaginal tissue under 400x high power magnification.

Investigations: Routine blood counts, chest X-ray and other metastatic work ups came back with reports within normal limits. CECT scan of whole abdomen revealed bulky uterus and cervix. A rounded structure was seen on the posterolateral aspect of uterus suggestive of an enlarged lymph node. It seemed to be a case of primary vaginal carcinoma.

Survival

Histopathology: Biopsy taken from cervix showed no malignancy or atypia with features suggestive of chronic cervicitis. Biopsy taken from vaginal tissue showed features of nonkeratinizing invasive squamous cell carcinoma. The mass from her left breast was subjected to fine-needle aspiration cytology (FNAC) and the reports proved it to be a benign fibroadenoma (Fig. 2).

Overall survival as calculated by 5-year mortality data is about 42%. In Stage 1 it is <72% and Stage 2 is 45.8%.7

The recommended treatment for Stage 2 and most other higher stages is radiotherapy. The patient is currently undergoing radiotherapy. She has received 25 cycles of teletherapy with 2 cGY of radiation dose in each cycle. Total radiation dose received is 50 cGY.

2. Hilborne LH, Fu YS. Intraepithelial, invasive and metastatic neoplasms of the vagina. In: Pathology of the Vulva and Vagina. Wilkinson EJ, (Ed.), Churchill Livingstone: New York, NY 1987:184.

Discussion Squamous cell carcinoma is the commonest histological variety of primary vaginal carcinoma occurring in about 80-90% of cases. The etiology of squamous cell carcinoma is unknown. Human papilloma virus types 16 and 18 have been isolated from 80% of precursor lesions and 60% of actual cases.3,4 In addition, 30% of women with vaginal carcinoma have history of being treated for cervical carcinoma within previous five years.5,6 Primary vaginal carcinoma usually spreads into adjacent soft tissues and organs by direct extension. Distant spread occurs only in very advanced stages. 30

International Federation of Gynecology and Obstetrics (FIGO) Staging of Vaginal Cancer • Stage 0 Carcinoma in situ, intraepithelial carcinoma. • Stage I The carcinoma is limited to the vaginal wall. • Stage II The carcinoma has involved the subvaginal tissue but has not extended to the pelvic wall. • Stage III The carcinoma has extended to the pelvic wall may (or may not) have spread to adjacent lymph nodes but has not spread to distant sites. • Stage IV The carcinoma has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum. Spread of the growth to adjacent organs. • IVa • IVb Spread to distant organs.

References 1. Ragni MV, Tobon H. Primary malignant melanoma of the vagina and vulva. Obstet Gynecol 1974;43(5):658-64.

3. Oldham RK, Greco FA. Small-cell lung cancer. A curable disease. Cancer Chemother Pharmacol 1980;4(3): 173-7. 4. Sheets EE, Berman ML, Hrountas CE, Liao SY, DiSaia PJ. Surgically treated, early-stage neuroendocrine small-cell cervical carcinoma. Obstet Gynecol 1988;71(1):10-4. 5. Lenehan PM, Meffe F, Lickrish GM. Vaginal intraepithelial neoplasia: biologic aspects and management. Obstet Gynecol 1986;68(3):333-7. 6. Herman JM, Homesley HD, Dignan MB. Is hysterectomy a risk factor for vaginal cancer? JAMA 1986;256(5):601-3. 7. Data compiled from Benedet et al, 1983 (98); Rubin et al, 1985 (200); Kucera et al, 1985 (221); Houghton and Iversen, 1982 (222); Eddy et al, 1991 (223) and Pride et al, 1979 (224). Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Case Report

Short Course in Genetics is Must for Obstetricians: A Case Report on Meckel Gruber Syndrome Monika Sharma

Abstract Birth defects and disability have become a major cause of concern. The causes of birth defects are poverty, malnutrition and inadequate healthcare. Equity in healthcare requires that the burden of birth defects on the individual, family and community be recognized. Every year 7.9 million (6%) of total births worldwide are born with a serious birth defect of genetic origin, especially in developing countries. This is due to consanguineous marriages, childbearing at advanced maternal ages and a higher rate of carrier status for certain mutations associated with hemoglobinopathies and glucose-6-phosphatase dehydrogenase (G6PD) deficiency where malaria is endemic. In India, the prevalence of birth defects per 1,000 live births is 64.3/1,000. The field of fetal and genetic medicine is at an early stage of development in India. Though Fetal Medicine Clinics are in tertiary centers, our rural and less privileged class does not have access to these facilities. In todayâ&#x20AC;&#x2122;s scenario, an obstetrician should have knowledge of clinical genetics so that they can diagnose genetic and fetal disorders. They should learn the principles of genetic counseling, sample required, method to do genetic tests, interpretation of results. This is a case report on Meckel Gruber syndrome, that I was able to diagnose and refer to geneticist. Key words: Meckel Gruber syndrome, genetic counseling, encephalocele, polydactyly, autosomal recessive inheritance, enlarged kidneys

eckel Gruber syndrome (MGS) is a wellknown syndrome characterized by occipital meningoencephalocele, bilateral enlarged kidneys with multicystic dysplasia, fibrotic changes of the liver in the portal area with ductal proliferation and postaxial polydactyly. Intra- and inter-familial clinical variability have been recognized. Other frequent malformations include microphthalmia, cleft lip and cleft palate, bowing of long bones, situs inversus, heart defects and genital anomalies. The incidence of the disease ranges from 1/13,250 to 1/1,40,000 births. In Finland, the prevalence of the disease averages 1/9,000 births. MGS is caused by mutation in a gene encoding a component of the flagellar apparatus basal body proteome (MKS1).1 Genetic heterogeneity has been described. The other genes causing MGS are TMEM67, CEP290, RPGRIPIL and CC2D2A. There are some loci, with a locus (MKS1) in 100 kb region of Consultant Gynecologist and Obstetrician Nirmala Medical Centre, New Delhi Address for correspondence Dr Monika Sharma 65, Uday Park, August Kranti Marg, Opp. Ansal Plaza New Delhi - 110 049 E-mail: monikanavneetam@yahoo.co.in

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

17q21-q24, a second-locus (MKS2) at chromosome 11q132 and a third (MKS3) at chromosome 8q24, Meckel-like cerebrodigital syndrome (MKS4) at 12q21.31 (mutation in CEP290 gene). The mode of inheritance is autosomal recessive and risk of recurrence in a sibling of a proband is 25%. Surprising clinical variability of the clinical features exist. In a study of affected siblings of probands, 100% had cystic dysplasia of the kidneys. However, 63% had occipital encephaloceles and only 55% had polydactyly; 18% had no brain anomaly. Salonen proposed that cystic dysplasia of kidneys with fibrotic changes of liver and occipital encephalocele or some other manifestation should be minimal criteria of Meckel syndrome.3 Case Report Mrs. X is a case of bad obstetrics history. She is married since 2002. Consummation of marriage done since 2004. Her obstetrics history is as follows: ď Ź A1 - Spontaneous abortion of two months not followed by dilation and curettage (D&C) ď Ź A2 - Abortion-induced in August 2008 for large occipital encephalocele and bilateral large multicystic kidneys with absent liquor at 22 weeks 31

Case Report

ď Ź

pregnancy. At that time no investigations were done by the obstetrician. No further advice was given. A3 May 2009; 19 weeks intrauterine pregnancy with occipital encephalocele with bilateral enlarged kidneys. This time, as I had a brief training in Fetal Medicine and Clinical Genetics, I could refer her to the Dept. of Genetic and Fetal Medicine. Abortion was induced with prostaglandins and the cord blood samples were sent for karyotyping, fetus was sent for autopsy. Male fetus weighing 375 g; occipital encephalocele identified, both lower limbs and right upper limb showed polydactyly (6 digits). On cutting open, all organs were in anatomical position. Bilateral adrenals were absent. The kidneys were enlarged and showed features of polycystic kidney disease. Sections examined from other visceral organs were within normal histological limits for age. No analyzable metaphases were seen in cord blood sample. At the Genetics Clinic, karyotyping of both partners was done; it was normal. Clinical diagnosis of MGS was made and in view of autosomal recessive inheritance, recurrence rate of 25% was explained to patients. A4 May 2010; 22 weeks pregnancy with occipital encephalocele with bilateral enlarged cystic kidneys with polydactyly with oligohydramnios. Abortion was induced. Cord blood samples were sent for examination but reports not available.

Patient is now currently on folic acid. Prenatal Diagnosis As many genes cause MGS, mutation analysis is a difficult and costly task. Ultrasound is a valuable tool. 10 weeks: Abnormal anechoic cystic intracranial image. 13 weeks: Defect in occipital area, enlarged kidneys, elevated alpha-fetoprotein level when there is encephalocele. Differential Diagnosis Hydrolethalus syndrome: Refers to hydramnios, hydrocephalus and lethality. Autosomal recessive with gene focus assigned to 11q23-25 associated with

polydactyly and micrognathia. There is polyhydramnios; in MGS, there is usually oligohydramnios. Smith Lemli-Opitz syndrome: Postaxial polydactyly of hands and less often feet, microcephaly. Joubert syndrome: Cerebellar vermis hypoplasia with hypotonia, developmental delay; occipital encephalocele and polydactyly have occasionally been described in Joubert syndrome. Goldston syndrome: Meckel syndrome type 7 caused by mutation in NPHP3 gene.4 Autosomal recessive with enlarged kidneys and CNS abnormalities resulting in perinatal death. Occipital encephalocele and polydactyly are not described in literature. Goldston syndrome is a variant of Meckel syndrome of which Dandy-Walker syndrome may be a component.4 Trisomy 13: Holoprosencephaly with microphthalmia, cleft lip and cleft palate, polydactyly of hands and feet, polycystic kidneys. Genetic Counseling In patients with bad obstetrics history, it is really difficult to counsel the patient as consecutive events lower the morale of the patient. Each pregnancy is a separate event and 25% recurrence means that she still has 75% chance of having a normal child. Early diagnosis by ultrasound is possible, mutation study in parents and their extended families followed by prenatal diagnosis from chorionic villus sampling (CVS) sample can be offered if parents are able to afford. References 1. Roume J, Ma HW, Le Merrer M, Cornier-Daire V, Girlich D, Genin E, et al. Genetic heterogeneity of Meckel syndrome. J Med Genet 1997;34(12): 1003-6. 2. Roume J, Genin E, Cormier-Daire V, Ma HW, Mehaye B, Attie T, et al. A gene for Meckel syndrome maps to chromosome 11q13. Am J Hum Genet 1998;63(4): 1095-101. 3. Salonen R. The Meckel syndrome: clinicopathological findings in 67 patients. Am J Med Genet 1984;18(4): 671-89. 4. Walpole IR, Goldblatt J, Hockey A, Knowles S. DandyWalker malformation (variant), cystic dysplastic kidneys, and hepatic fibrosis: a distinct entity or Meckel syndrome? Am J Med Genet 1991;39(3):294-8.

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Case Report

Vaginal Leiomyoma: Mimicking Uterine Prolapse Amrita Chaurasia*, Vishal Dhingra**, Astha Singh†

Abstract Vaginal leiomyoma is a rare clinical entity which has different clinical presentations. Although, it may be asymptomatic initially but may produce various symptoms like dyspareunia, pressure symptoms and discharge per vaginum with its growth. When large enough, it may come out of the introitus and mimic uterine prolapse. Surgical excision is the treatment of choice. The excised material should be examined histopathologically for establishing the diagnosis and ruling out malignancy. Key words: Leiomyoma, uterine prolapse, surgical excision

enign tumors arising from the vagina include papilloma, hemangioma, mucous polyp and rarely, leiomyoma. Although rare, the most common mesenchymal neoplasm of the vagina is the leiomyoma. The mean patient age at detection of a vaginal leiomyoma, is approximately 40 years, with a reported range between 19 and 72 years. Vaginal leiomyomas vary from 0.5 to 15 cm in diameter, averaging approximately 3-4 cm in size.1 When such a tumor arises from upper vagina, it may be mistaken for cervical fibroid. This rare tumor usually shows variable clinical presentation and broad differential diagnosis that can lead to preoperative misdiagnosis. Careful histological examination of these tumors is essential to establish diagnosis and to exclude malignancy such as leiomyosarcoma.2 Although, these rare lesions are often asymptomatic, larger tumors may be associated with pain, pressure symptoms and dyspareunia. Symptoms may develop with the growth of tumor. With further growth, it may come out of the introitus and very often may have necrotic, ulcerated and distorted surface. Hence, at a glance, it may often be confused with uterine prolapse if not properly examined clinically. The tumor is usually encountered in the middle anterior vaginal wall but rarely unusual locations are reported.1 Surgical enucleation via a vaginal approach is the treatment of choice and the recurrence rate of leiomyoma of *Assistant Professor, Dept. of Obstetrics and Gynecology **Assistant Professor, Dept. of Pathology † Junior Resident, Dept. of Obstetrics and Gynecology MLN Medical College, Allahabad Address for correspondence Dr Amrita Chaurasia 44, Saray, Khuldabad, Allahabad, UP E-mail: dr.amrita.chaurasia@gmail.com

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the vagina after removal is very low. We report this case due to its rarity and apparent similarity with uterine prolapse. Case Report Mrs. JS, a 36-year-old female, parity 2+0 was referred to Dept. of Obstetrics and Gynecology, Swaroop Rani Nehru Hospital, Allahabad with a probable diagnosis of incarcerated, irreducible uterine prolapse with an ulcer on cervix. Patient’s chief complaint was something coming out of vagina for one year and foul-smelling, blood stained discharge for three months. Her menstrual history was normal. On examination, a globular mass of approximately 5 × 5 cm, was seen coming out through introitus with ulcerated surface, covered with slough. It was firm in consistency, tender and irreducible (Fig. 1). Due to tenderness, further examination could

Figure 1. Vaginal leiomyoma mimicking prolapsed uterus.

Case Report not be performed, and so examination under anesthesia (EUA) was planned. Her blood and urine investigations were sent, ulcer discharge was sent for culture and sensitivity and ultrasonography of the abdomen and pelvis was done. Ultrasonography of pelvis revealed a parous uterus, bilateral adnexa were normal thus confusing the clinical picture. So EUA was performed. On examination, the mass was firm with wellcircumscribed margins, irreducible and arising from the anterior vaginal wall. Cervix was at its normal position and uterus was anteverted, parous size, mobile with bilateral adnexa free. Biopsy was taken from the growth, and it revealed a benign lesion with nonspecific inflammatory changes with no identification of cervical tissue. Culture and sensitivity of discharge showed heavy growth of Klebsiella. Enucleation of mass was planned for after infection cleared following antibiotic treatment. It was done after indwelling catheterization to take care of urethra and urinary bladder. Enucleation was carried out vaginally with use of blunt and sharp dissection. The mass had very clear planes of dissection, but its bed bled heavily during the procedure, which was obliterated and vaginal flaps were approximated after cutting the redundant portion. The mass was sent for histopathological examination. Postoperative blood transfusion and antibiotic coverage as per culture and sensitivity report were given. Patient recovered well. The histopathology report showed ‘highly vascular leiomyoma of the vagina’ (Figs. 2 and 3).

Figure 3. H&E stain (×400) showing vaginal leiomyoma with cells having uniform oval/spindle nuclei and numerous blood vessels.

Discussion Majority of leiomyomas arise from uterus and sometimes from cervix. Rare extrauterine sites are broad ligament, round ligament, uterosacral ligaments, etc. Leiomyoma of vagina is extremely rare and the rarity of the tumor can be judged by the fact that <300 cases have been reported in literature.3 The earliest reference contributed to such a tumor is attributed to Deneys De Leyden in 1733. Leiomyomas constitute 4.5% of all the solid tumors of vagina.1 Lesions are usually single and located in the anterior vaginal wall. Their size varies from 0.5 to 15 cm, majority measuring approximately 3-4 cms.1 Gowri et al have reported a case of vaginal leiomyoma arising from the right lateral wall.4 The largest vaginal leiomyoma recorded till date measured 20 cms in diameter.5 The lesions arise from outer coat of smooth muscles surrounding the vagina. When large, they may extend on to the broad ligament and ischiorectal fossa. The usual presenting symptoms are urinary symptoms, dyspareunia, discharge and protrusion of mass from vagina. In many cases, ulceration of overlying epithelium may occur, followed by subsequent necrosis and purulent discharge and bleeding. The diagnosis is seldom made preoperatively.6 It is only confirmed after removal of the mass and its histopathological examination. Upon microscopy, these tumors consist of fascicles of uniform smooth muscle cells having typical spindle configuration with

Figure 2. H&E stain (×100) showing vaginal leiomyoma with uniform oval/spindle nuclei and numerous blood vessels.

Cont’d on page 43... Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Case Report

Double-headed Monster Delivered Vaginally N Singh*, S Barya**, K Pandey†, P Dubey‡, D Kumar#

Abstract Double-headed monster is a rare and interesting variety of twin pregnancy. In this report we present a case of a 26-year-old, G3P2+0, who was referred to our center with delivered head since one hour and failure to deliver the rest of the body. The rest of the body with second head was delivered vaginally using McRobert’s maneuver with only few vaginal lacerations to the mother. Key words: Conjoined twin, double-headed monster, monozygotic twin

ne of the most interesting and rare anomalies of multiple pregnancies is conjoined twin and double-headed monster is one of them. This disorder affects 1:200 of monozygotic twin pregnancies, 1:900 of twin pregnancies and 1:25,0001:1,00000 of births. Conjoined twinning results from incomplete fission of inner cell mass in early gestation, after development of embryonic plate and before second week of fertilization. Conjoined twins are classified according to the site of union i.e., ventral (87%) and dorsal (13%). Ventral union includes thoracopagus (19%), omphalopagus (18%), ischiopagus (11%) and craniopagus (11%). The dorsal union includes craniopagus (5%), pyopagus (6%) and rachipagus (2%). Antepartum diagnosis is usually missed and if it could be made, helps in management as decision of termination or continuation of pregnancy can be taken and if pregnancy is continued safe place and mode of delivery can be decided. Case Report A 26-year-old, G3P2+0, was referred to our center with delivered head since one hour and failure to deliver rest of the body. She was an unbooked case and *Lecturer **Senior Resident † Professor and Head ‡ Professor Dept. of Obstetrics and Gynecolgy GSVM Medical College, Kanpur (UP) # Lecturer CSM Medical University, Lucknow (UP) Address for correspondence Dr N Singh D-20, GSVM Medical College Campus, Kanpur, UP E-mail: smitabgoy@gmail.com, drneetusingh.73@gmail.com

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admitted to our side with chief complains of labor pains for four hours and leaking per vaginum for 12 hours following term pregnancy for which she went to nearby primary health care (PHC) where vaginal delivery was attempted. There the head of the baby was delivered normally but rest of the body could not be delivered for half an hour despite all efforts. She was then referred to us for further management. At the time of admission, her general condition was fair, pulse rate was 124/min, BP was 106/70 mmHg; mild pallor and mild dehydration were present. Systemic examination revealed no abnormality. On per abdominal examination, uterus size corresponded to 36 weeks of pregnancy and it was tonically contracted, fetal heart sound could not be detected and the delivered head was deeply congested. She was diagnosed as a case of full-term pregnancy with intrauterine fetal death with shoulder dystocia. She was prepared for delivery under general anesthesia (GA) or cesarean section if required. Intravenous (IV) fluids and IV antibiotics were started. Under GA, McRobert’s maneuver was tried and with one effort of gentle traction on head, the second head was delivered and rest of the twisted trunk delivered normally. The head, upper limbs and lower limbs were two in number in the delivered fetus. There was a single trunk of unusual shape (as division of trunk was started but could not be completed) and a tail-like structure. The cervical and vaginal tears were stitched, intravaginal packing was done for vaginal lacerations and Foley’s catheterization was done. Her postnatal period was uneventful. She was discharged on 7th postnatal day in satisfactory condition. Follow-up period was uneventful. 35

Case Report Discussion Dicephalic fused twin or double-headed monster is a variety of conjoined twin with fused thorax and abdomen. The incidence of dicephalic fused twin is not well-established. It is rare for such type of twins to survive. The classic examples being the Scottish brothers who lived upto the age of 28 years, Rita-Christina born in Sardina in 1829 and Tocci brothers born in Italy in 1877.2 Goel and Goel3 also reported a case of twins having two heads, two arms, a single body and two lower limbs delivered by cesarean section. Nagaria also reported a case of dicephalic twin with three upper limbs; the central one having 2 palms, single body and two lower limbs.4 Postdelivery X-ray, USG, CT scan of the fetus were also done in our case. This type of conjoined twin is rare to be found. As this was an unbooked case with no antenatal check-up, a safe mode and place of delivery was not preplanned. With the help of early diagnosis, early termination of pregnancy was an option to reduce maternal morbidity and mortality. As reviewed by van den Brand and associates,5 the diagnosis of conjoined twins can frequently be made at midpregnancy using USG, which allows parents to decide between termination or continuation of pregnancy. It is possible if an effort is made to rule out this condition in all monozygotic twin gestations. A comprehensive USG between 18-22 weeks may be useful to determine to anatomy of the shared organs and to detect associated malformations.6 Twins facing each other, the heads at the same level and plane, the thoracic cages in unusual proximity,

both fetal heads hyperextended and no change in the relative position of the fetuses with movement, manipulation or in repeat examination obtained hours or days later, are the USG findings that increase the probability of conjoined twins. Cardiac connections between the twins can be diagnosed by repeated 2D and 3D USG, CT and MRI scanning. Parents should be counseled after proper evaluation of point of connection between twins. Termination of pregnancy is better considered when vital organs like heart or brain are shared. Surgical separation of nearly completely joined twins may be successful when organs essential for life are not shared and when it can be performed on a planned as opposed to emergency basis.7 References 1. Spencer R. Anatomic description of conjoined twins: a plea for standardized terminology. J Pediatr Surg 1996; 31 (7):941-4. 2. In: Munro Kerrâ&#x20AC;&#x2122;s Operative Obstetrics. 10th edition, Bombay KM Verghese Co. 1982:117. 3. Goel S, Goel M. Asian J Obstet Gynecol Pract 1999; 3:34-5. 4. Nagaria T. Conjoined twins delivered vaginally. J Obstet Gynecol India 2006;56(4):348-9. 5. van den Brand SF, Nijhuis JG, van Dongen PW. Prenatal ultrasound diagnosis of conjoined twins. Obstet Gynecol Surv 1994;49(9):656-62. 6. Multifetal gestation. In: Practical guide to high risk pregnancy and delivery. 3rd edition, Arias, Daftary, Bhide, 2007:306-7. 7. Spitz L, Kiely EM. Conjoined twins. JAMA 2003;289 (10):1307-10.

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Case Report

Vulvar Elephantiasis of Filarial Origin Rachan Chaudhary*, Sudhir Rathi**, Amit Maheshwari†, Shipra Nigam‡

Abstract Lymphedema is the accumulation of lymph in the soft tissue due to obstruction of lymphatics. Filariasis caused by Wuchereria bancrofti and Brugia malayi is one of the secondary causes of lymphedema. Long-standing lymphedema can lead to ‘elephantiasis’. Elephantiasis of female genitalia is extremely rare. We present one such case of a 40-year-old lady who had giant vulvar elephantiasis of filarial origin and was managed successfully by surgery (vulvectomy with vulvoplasty). Key words: Vulvar elephantiasis, vulvectomy for vulvar elephantiasis

ymphedema can be defined as swelling of soft tissues which is the result of accumulation of protein-rich interstitial fluids caused by a low output failure of lymph.1 This leads to proliferation of fibroblasts and mast cells, organization of the edema fluid and sclerosing fibrosis of the subcutaneous tissue giving rise to the firm, nonpitting and irreversible swelling. Hyperkeratosis, verrucous and condylomatous changes are features of long-standing lymph stasis and are collectively termed ‘elephantiasis’.2 The legs, arms and genitalia are commonly involved. Elephantiasis can be filarial or nonfilarial in origin. Filariasis results from infection with Wuchereria bancrofti and Brugia malayi. While Wuchereria infection has only been noted in humans, Brugia infection has been noted in both man and animals. Filarial elephantiasis of female genitalia is extremely uncommon; a rough estimate of its incidence would not be more than 1-2% of total cases of filarial elephantiasis.3 We present a case of vulval elephantiasis due to underlying filarial etiology. Case Report This case report describes a 40-year-old lady P3+0 who came to our center with complaint of mass in genital area with associated dragging pain and difficulty in coitus, difficulty in walking and psychological distress for last three to five years. There was no history of chronic cough, chyluria or any lymphadenopathy. She weighed 68 kg, attained menarche at 13 years; *Assistant Professor, Dept. of Obstetrics and Gynecology **Associate Professor and Head, Dept. of Surgery † Assistant Professor, Dept. of Medicine ‡ Postgraduate Student, Dept. of Obstetrics and Gynecology LLRM Medical College, Meerut, UP

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

a healthy lady with all normal systemic examinations. All previous pregnancies were uneventful resulting in normal vaginal delivery and live births. There was no history of lymphedema in any family member. Laboratory findings: Hemoglobin 11 gm%, leukocyte count 6,400 cells/mm3, neutrophilia 80% and absolute eosinophil count 200. Patient was hepatitis B positive (HBsAg). On examination, there were two nontender irreducible huge well-defined bosselated vulval masses, right and left measuring 45 × 38 cm and another 22 × 20 cm in size, respectively (Fig. 1). There were multiple nodular swellings on the outer surface on each mass. Excision of both masses with vulvoplasty was done in single stage (Figs. 2 and 3). The two large masses weighed 15 and 8 kg each and measured 48 × 40 × 10 cm and 26 × 25 × 7 cm in size, respectively with multiple nodular swellings on outer surface measuring 2.5 × 0.5 cm in size. Postoperatively the patient was kept on amoxicillin-clavulanate and amikacin prophylaxis. The postoperative period was uneventful. Histopathology: Key histological features were stratified squamous epithelium showing acanthosis

Figure 1. Pre-op picture

Figure 2. Immediate post-op picture

Case Report

Figure 3. Excised vulval mass

of mass with vulvoplasty was done. Excision plays a role for better qualityof-life and improved cosmesis by making the patient perform better her sexual activity and daily needs (Fig. 5).

Figure 5. Post-op day 30

References

Figure 4. Histopathology

and hyperkeratosis, underlying stroma showed dermal fibrosis and collagenization with mixed inflammatory infiltrate in the form of eosinophils, polymorphs, lymphocytes, macrophages and plasma cells (Fig. 4). Discussion Vulval lymphedema can be caused by radiotherapy4 and as a postoperative complication after vulvectomy and inguinofemoral lymphadenectomy.5 Vulval lymphedema can be a rare extra-intestinal manifestation of Crohn’s disease,6,7 but the ulcer in such cases shows epithelioid and giant cell granulomas. Clinically, vulval lymphedema may mimic genital warts.8 Lymphangioma circumscriptum9 was ruled out since it has an early onset at birth with initial presentation of thin translucent vesicles, which may become verrucous later on. Microscopically it may mimic aggressive angiomyxoma but lacks true thick-walled vessels and contains ectatic tortuous lymphatics.10 As per recommendations, most lymphedema patients can be treated with a combination of limb elevation, a high-quality compression garment, complex decongestive physical therapy and compression pump therapy and if necessary surgery.11 Surgical intervention is used only in extreme cases in order to reduce the weight of the affected organ, to help minimize the frequency of inflammatory attacks, to improve cosmesis and to potentially reduce the risk of secondary angiosarcoma.12,13 Our patient came with complaint of vulval swelling with inability to walk, with difficulty in coitus. Excision 38

1. Mortimer PS. Disorders of lymphatic vessels. In: Rook, Wilkinson, Ebling’s Textbook of Dermatology. 6th edition, Champion RH, Burton JI, Burns DA, et al. (Eds.), Blackwell Science, Oxford 1998:2277-96. 2. Pandhi RK, Sood A. Disease of arteries, veins and lymphatics. In: IADVL Textbook and Atlas of Dermatology. 2nd edition, Valia RG, Valia AR (Eds.), Bhalani Publishing House, Mumbai 2001:576-95. 3. Khanna NN, Joshi GK. Elephantiasis of female genitalia. Case report. Plast Reconstr Surg 1971;48(4):379-81. 4. Bradbury AW, Murie JA. Lymphatic system In: Bailey and Love’s Short Practice of Surgery. 23rd edition, Russel RCG, Williams NS, Bulstrode CJK (Eds.), Arnold, London 2000:250-69. 5. Gaarenstroom KN, Kenter GG, Trimbos JB, Agous I, Amant F, Peters AA, et al. Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions. Int J Gynecol Cancer 2003;13(4):522-7. 6. Schulman D, Beck LS, Roberts IM, Schwartz AM. Crohn’s disease of the vulva. Am J Gatroenterol 1987;82(12): 1328-30. 7. Fenniche S, Mokni M, Haouet S, Ben Osman A. Vulvar Crohn disease: 3 cases. Ann Dermatol Venereol 1997;124(9):629-32. 8. Mu XC, Tran TA, Dupree M, Carlson JA. Acquired vulvar lymphangioma mimicking genital warts. A case report and review of literature. J Cutan Pathol 1999;26(3):150-4. 9. Esquivias-Gomez JI, Miranda-Romero A, Cuadrado Valles C, Bajo del Pozo C, Sánchez Sambucety P, Martínez Fernández M, et al. Lymphangioma circumscriptum of the vulva. Cutis 2001;67(3):229-32. 10. Vang R, Connelly JH, Hammill HA, Shannon RL. Vulvar hypertrophy with lymphedema. A mimicker of aggressive angiomyxoma. Arch Pathol Lab Med 2000;124(11):1697-9. 11. In: Park’s Textbook of Social and Preventive Medicine. Park K, 19th edition, 2007:220-5. 12. Miller TA, Wyatt LE, Rudkin GH. Staged skin and subcutaneous excision for lymphedema: a favorable report of long-term results. Plast Reconstr Surg 1998;102(5): 1486-98; discussion 1499-501. 13. Kim DI, Huh SH, Hwang JH, Joh JH. Excisional surgery for chronic advanced lymphedema. Surg Today 2004;34(2):134-7. Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

clinical study

Case Report

A Rare Case of Parasitic Fibroid Mimicking Ovarian Tumor Madhu Patni Bhatt*, Swati Kochar*, Parul Prakash*, Mahesh Gupta**, Nidhi Binani†

Abstract Leiomyomas are the most common benign uterine tumors. Parasitic fibroids are very rare. This case illustrates that an adnexal mass with an unusual presentation and location should be evaluated carefully. In the differential diagnosis, extremely rare conditions must be considered preoperatively. Key words: Parasitic fibroid, ovarian tumor, acute abdomen

eiomyomas are the most common benign uterine tumors. They can be intramural, subserosal or submucosal in location. Subserosal leiomyomas may be beneath the uterine surface or exophytic or pedunculated. If a pedunculated subserosal leiomyoma develops an extremely long and tenous stalk, it is called a wandering or migrating leiomyoma.1 Occasionally, such tumors become adherent to surrounding structure such as broad ligament or omentum and develop an auxiliary blood supply. These leiomyomas lose their original attachment to the uterus and are then called parasitic leiomyoma.1,2 Parasitic fibroids are very rare. Rarely, a parasitic leiomyoma may become torsive and cause an acute abdomen.3 We report a rare case of parasitic fibroid attached to small intestine mimicking an ovarian tumor.

intermittent pain abdomen. She was hospitalized twice in the surgery ward for these episodes and was treated conservatively as a case of subacute intestinal obstruction. There was no history of medical or surgical illness or any malignancy in her family.

Case Report

All routine blood and urine investigations were normal. Subsequent ultrasound revealed findings suggestive of a pelvic mass, which was predominantly hypoechoic of approximately 83 × 63 mm size with central calcification.

A 50-year-old patient, P9L9A0, came to our OPD in February 2009 with chief complaint of pain in lower abdomen off and on since three months. She had reached menopause four years back. There was no history of postmenopausal bleeding, anorexia, weight loss, abdominal distension or urinary complaint. Patient gave history of previous episodes of severe *Assistant Professor **Junior Resident Dept. of Obstetrics and Gynecology † Senior Demonstrator, Dept. of Pathology SP Medical College, Bikaner Address for correspondence Dr Parul Prakash H-2, PBM Hospital Campus Bikaner - 334 003, Rajasthan E-mail: parulprakash@ymail.com

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Her general condition was satisfactory with mild pallor. On per abdominal examination, no mass was palpable. There was mild tenderness on palpation in right hypochondriac region. There was no ascites or hepatosplenomegaly. On per speculum examination, the cervix and vagina were healthy. Per vaginal examination revealed a small atrophic uterus which was anteverted and anteflexed. A firm, mobile, nontender mass, 8 × 8 cm, was palpable in right adnexa. The left fornix was free. There was no nodularity in pouch of Douglas on per rectal examination.

On the basis of the above findings, a provisional diagnosis of ovarian mass was made and decision of laparotomy was taken. Abdomen was opened by subumbilical midline longitudinal incision. There was no ascites. Uterus and both adnexa were identified. They were normal. A mass firm in consistency and of 8 × 5 × 4 cm size was found in abdominal cavity attached to small intestine (Fig. 1). It was excised and ligated. The mass did not have any peduncle or attachment to the uterus. The surface of the uterus was normal. The mass was removed from the intestine by sharp dissection with the help of a surgeon. The mass had only superficial attachment to intestinal serosa and 41

Case Report

Figure 1. Operative findings showing parasitic leiomyoma attached to the intestine.

Figure 3. Microscopic appearance of parasitic leiomyoma showing hyaline degeneration.

Figure 2. Microscopic appearance of the parasitic leiomyoma.

Figure 4. Cut section of the parasitic leiomyoma with hyaline degeneration.

was not infiltrating the intestinal wall. Intestinal serosa was closed by interrupted sutures with 3-0 silk. After achieving hemostasis, abdominal cavity was closed in layers. Patient stood the procedure well. Postoperative period was uneventful and stitches were removed on the 8th day.

misdiagnosed as an ovarian tumor. Other differential diagnoses for these masses include:

Histopathological examination revealed that tumor had interlacing bundles of smooth muscle cells separated by a greater or lesser well-vascularized connective tissue (Fig. 2). Stroma contained scattered lymphocytes. Areas of hyaline degeneration were also visualized (Figs. 3 and 4). Since, only serosa of intestine was involved, it was most likely a parasitic fibroid. Discussion Parasitic fibroids can mimic a variety of adnexal masses. Due to their unusual and rare presentation they can be 42

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Inflammatory lesion of fallopian tube such as gonococcal or chlamydial salpingitis or granulomatous salpingitis (mycobacterial, fungal, sarcoidosis, Crohn’s disease, etc.)4 Tubal malignant tumor (e.g. adenocarcinoma or tubal gestational choriocarcinoma)4 Tumors in broad ligament such as papillary cyst adenoma (Wolffian duct origin), Mullerian carcinoma, teratoma,4 leiomyosarcoma5 and malignant fibrous histiocytoma.6 Parasitic infections such as dracunculosis7 (guinea worm disease), which have also been called “parasitic leiomyomas” but in fact represent parasites in fibrous tissue.7 Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Case Report  

Endometriosis Ectopic pregnancy

Conclusion Pedunculated or parasitic fibroids are separate from the uterus and are mostly found attached to omentum or broad ligament. The present case is unique as the parasitic fibroid was attached to intestine. These types of fibroids pose a great diagnostic challenge. This case illustrates that adnexal mass with an unusual presentation and location should be evaluated carefully. Extremely rare conditions must be thought preoperatively in the differential diagnosis. References 1. Robbin SL, Cotran RS, Kumar V. Pathologic basis of disease. 3rd edition, WB Sweden, Philadelphia 1984:p 1109.

2. Ritchie AC. Boyd’s Textbook of Pathology. Vol. II, 9th edition, Lea & Febiger, Philadelphia 1990:1953. 3. Brody S. Parasitic fibroid. Am J Obstet Gynecol 1953;65(6):1354-6. 4. Thor AD, Young RH, Clement PB. Pathology of the fallopian tube, broad ligament, peritoneum, and pelvic soft tissues. Hum Pathol 1991;22(9):856-67. 5. Cheng WF, Lin HH, Chen CK, Chang DY, Huang SC. Leiomyosarcoma of the broad ligament: a case report and literature review. Gynecol Oncol 1995;56(1):85-9. 6. Mai YL, Wu MY, Lin YH, Chen RJ, Chuang SM, Huang SC, et al. Malignant fibrous histiocytoma of broad ligament. Gynecol Oncol 1994;54(3):362-4. 7. Allaire AD, Majmudar B. Dracunculosis of the broad ligament. A case of a “parasitic leiomyoma”. Am J Surg Pathol 1993;17(9):937-40.

...Cont’d from page 34 indistinct cell border and abundant pale eosinophilic cytoplasm.7 In this case, histopathology showed numerous blood vessels in substance of myoma making it highly vascular (Figs. 2 and 3).

References

The practical approach to such a vaginal mass entails careful excision through the vaginal route.4 Huge tumors may require combined abdominal and perineal approach and may necessitate hysterectomy, though morcellation of tumor might render surgery through vaginal route easier.4 Local recurrences are not common. Nel and Tiltman found no recurrence in a follow-up period that varied from eight months to 20 years. There is a single study that has reported chance of recurrence and sarcomatous change.7

2. Horn LC, Fischer U, Reuter S, Pyttel C. Leiomyosarcoma and leiomyoma of the vagina. Zentralbl Gynekol 1998;120(1):38-41.

Conclusion

6. Imai A, Furui T, Hatano Y, Suzuki M, Suzuki N, Goshima S. Leiomyoma and rhabdomyoma of the vagina. Vaginal myoma. J Obstet Gynaecol 2008;28(6):563-6.

Vaginal leiomyomas are rare entities which can be confused with many other conditions and hence misdiagnosed. Therefore, while distinguishing a vaginal mass, a vaginal leiomyoma should be borne in mind.

1. Sangwan K, Khosla AH, Hazra PC. Leiomyoma of the vagina. Aust N Z J Obstet Gynaecol 1996;36(4):494-5.

3. Ruggieri AM, Brody JM, Curhan RP. Vaginal leiomyoma. A case report with imaging findings. J Reprod Med 1996;41(11):875-7. 4. Gowri R, Soundararaghavan S, Oumachigui A, Sistla SC, Iyengar KR. Leiomyoma of the vagina: an unusual presentation. J Obstet Gynaecol Res 2003;29(6):395-8. 5. Moghissi K. Myoma of the vagina: report of a case and review of literature. Obstet Gynecol 1960;15:235-6.

7. Qian J, Zheng F, ShiY. Clinical analysis of 25 cases of leiomyoma of vagina. Zhonghua Fu Chan Ke Za Zhi 2001;36(3):156-8.

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Emedinews section

From eMedinewS

15 Eggs Magic Number for Best Results in IVF The odds of achieving a live birth after in vitro fertilization (IVF) increased steadily with the number of eggs retrieved after ovarian stimulation, topping out at about 15, data from a large IVF registry showed. The estimated live birth rate reached 40% after retrieval of 15 eggs from women ages 18-34, as reported online in Human Reproduction.

Infertility Update How is a sperm donor selected?

The following guidelines may be recommended: 

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Source: Medpage Today

Mesh Better Tx for Pelvic–organ Prolapse but Riskier For women with pelvic-organ prolapse, a transvaginal mesh kit improves treatment success rates compared with traditional colporrhaphy, but comes at a cost of more surgical complications and adverse events, a randomized trial showed. Women treated with the mesh kit were more likely to be free of prolapse a year later as defined by both objective and subjective measures (60.8% vs 34.5%, P < 0.001), according to Daniel Altman, MD, PhD, of Danderyd Hospital in Stockholm, and colleagues. But adverse events were more frequent in the mesh group both in the hospital and during follow-up, they reported in the May 12 issue of the New England Journal of Medicine. Source: Medpage Today

Lab Update Iron Deficiency Anemia In iron deficiency anemia, the serum iron concentration is reduced, and the level of transferrin, also measured as total iron binding capacity (TIBC), is elevated; the latter finding reflects the reciprocal relationship between serum iron and transferrin gene expression in most nonerythroid cells. —Dr Arpan Gandhi and Dr Navin Dang

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The main qualities to seek in selecting a donor for TDI are an assurance of good health status and the absence of genetic abnormalities. The donor should be of legal age and, ideally, less than 40 years of age, because increased male age is associated with a progressive increase in the prevalence of aneuploid sperm. Selection of donors with established fertility is desirable but not required. Psychological evaluation and counseling by a qualified mental health professional is recommended strongly for all sperm donors. No owner, operator, laboratory director, or employee of a facility performing TDI may serve as a donor in that practice. Neither the patient’s physician nor the individual performing the actual insemination can be the sperm donor. —Dr. Kaberi Banerjee, Director, Precious Baby Foundation

Medifinance Update Personal Accident - Individual During the first year of the operation of insurance cover, the expenses on treatment of diseases such as cataract, benign prostatic hypertrophy, hysterectomy for menorrhagia or fibromyoma, hernia, hydrocele, congenital internal diseases, fistula in anus, piles, sinusitis and related disorders are not payable if these diseases (other than congenital internal diseases/ defects) are pre-existing at the time of proposal that will not be covered even during subsequent period of renewal too. If insured is aware of the existence of congenital internal diseases/defects before inception of policy it will be treated as pre-existing. —Dr GM Singh

Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Answers 1. Picture A shows echogenic bowel and picture B is depicting large placenta. 2. Causes of this condition may be aneuploidy, CMV infection, cystic fibrosis. In 68% of cases, fetus is normal. 3. Isolated findings of echogenic bowel is seen in 0.6% of normal fetuses and 1.4% risk of aneuploidy. It can be found in 12% of Down syndrome fetuses. If it is associated with other soft markers, risk of aneuploidy increases upto 15%. There is also risk of developing IUGR (15%) and fetal demise 5%. 4. Invasive testing is required if associated with other soft markers of aneuploidy and also for torch infection. In this case, as large placenta is seen with echogenic bowel, torch testing is required.

Photo A

Photo B 4. Does she require invasive testing? 3. What is the significance of these findings? 2. What are the causes of the condition in picture A? 1. What are these pictures (A and B) showing?

Questions

Quiz

Photo

Dr Nutan Agarwal Associate Professor Dept. of Obstetrics and Gynecology AIIMS, New Delhi

Photo Quiz

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Asian Journal of Obs and Gynae Practice, Vol. 3, July-September 2011

Flow Chart

Gestational Diabetes Mellitus - Screening and Management Introduction • • •

Insulin therapy

Most common medical complication during pregnancy, responsible for high perinatal morbidity and mortality. Incidence varies according to ethnicity and selection criteria. Overall incidence is 1-14% (5-8% among Asians). Gestational diabetes mellitus (GDM) constitutes approximately 87.5% of all diabetic cases during pregnancy. Type 1 DM is 7.5% and type 2 is responsible for 5% of cases. But due to lifestyle factors and dietary habits, incidence of type 2 DM is increasing these days. Of all GDM patients, >50% develop type 2 DM in later life.

Screening for GDM

Low risk factors • Age <25 years • Normal weight before pregnancy (BMI <25) • Member of ethnic group with low GDM prevalence • No history of abnormal glucose tolerance • No history of diabetes in first-degree relatives • No history of poor obstetric outcome

Intermediate-acting insulin

1/3 (20 U)

2/3 (40 U)

Evening (30 U)

½ (15 U, before dinner)

½ (15 U, HS)

With intermediate-acting insulin, there is more chance of delayed hypoglycemia. So, rapid insulin (shortacting) is preferred nowadays and is used more frequently during pregnancy. It provides better control over blood sugar and thus improved maternal and fetal outcome.

at 32 weeks onwards.

GDM on insulin

Antepartum fetal surveillance is done as in patients with pregestational diabetes. Elective induction is done at 38 completed weeks.

Management of pregestational diabetes mellitus in pregnancy Special investigations during pregnancy First trimester:

HbA1C levels, biochemical screening (10 weeks) - PAPP-A, β-hCG, USG (11-12 weeks) for nuchal translucency

Second trimester: Triple screen (16-18 weeks), level II scan (18-22 weeks) fetal echocardiography (20-22 weeks), growth and liquor volume (26-28 weeks) Third trimester: USG for growth parameters Antepartum fetal monitoring to prevent IUD and plan delivery

No testing required if all present

Timing of delivery • Plan for induction at 38.5 weeks. • Elective LSCS if EFW ≥4.5 kg.

Methods for screening and diagnosis Two step method (Glucose challenge test followed by glucose tolerance test) (Recommended by ADA) • Glucose challenge test: Irrespective of previous meal, patient is given 50 g glucose load and blood glucose levels are tested after 1 hour value ≥140 mg/dl is taken as cut-off for doing GTT. • Glucose tolerance test

100 g (Carpenter and Coustan)

Short-acting insulin Morning (60 U)

GDM on diet • Induction at 38-40 weeks POG depending upon monitoring. • History of stillbirth, hypertension, uncontrolled blood sugars - biweekly nonstress test (NST) is started

ACOG and WHO recommend universal screening at 24-28 weeks. Patients with risk factors should be screened as early as possible.

Glucose load

Calculate total dose = (2/3 in morning + 1/3 in evening) (e.g., 90 U = 60 U + 30 U).

Obstetrical management

High risk factors • Obesity (>200 lbs or >15% of nonpregnant ideal body weight) • Positive family history • History of diabetes in previous pregnancy • History of stillbirth or unexplained neonatal death • ≥3 abortions in Ι or ΙΙ trimester • History of delivery of large infant (>4 kg) • History of traumatic delivery with neurological disorder in infant • History of congenital anomaly in previous baby • History of pre-eclampsia as multipara • Chronic hypertension • Recurrent severe moniliasis • Recurrent UTI • Polyhydramnios • Diagnosis of PCOS

ADA*

Dr Reeta Mahey Senior Resident Prof. Alka Kriplani Professor and Head of Unit II Dept. of Obstetrics and Gynecology AIIMS, New Delhi

Thresholds (mg/dl) (venous plasma) Fasting

1-hour

2-hour

3-hour

≥95

≥180

≥155

≥140

75 g

≥95

≥180

≥155

ACOG*

100 g (NDDG)

≥105

≥190

≥165

WHO°

75 g (WHO)

≥126 (7.0 mmol/l)

≥145

≥140 (7.8 mmol/l)

*Two or more glucose values must meet threshold. °One or more glucose value must meet threshold.

One step diagnosis of GDM WHO recommends one step approach for diagnosis of GDM to avoid inconvenience to patients due to repeated blood testing. Patient is given 75 g glucose load after overnight fasting. Glucose challenge test is not required for this method.

Management of diabetes in pregnancy Medical management 1. Medical nutrition therapy: Primary therapy for 30-90% of women diagnosed with GDM. Blood sugar monitoring should be done after 1-2 weeks of starting diabetic diet till 36 weeks, then weekly. 2. Exercise: 3-4 times weekly for 20-30 min/session. Recommended glycemic goals in patients on diet

Elective LSCS of a diabetic patient is planned early morning. • Usual night-time dose of insulin is given and morning dose is omitted. • Patient is kept NPO. • Fasting blood sugar and urine testing (sugar and ketones) is done. If FBS is <70 mg/dl, 5% dextrose is started. If FBS is >100 mg/dl, insulin infusion with DNS is started. • Regular RBS monitoring is continued.

Intrapartum management • Insulin dose is omitted on day of induction. • Regular glucose monitoring is done every 2-3 hourly in latent phase and every 1-2 hourly in active phase • • • •

of labor. Urine testing for sugar and ketones is also done. Patient is kept well-hydrated. Regular insulin is given to meet the maternal requirement during labor. Insulin is given in form of low-dose infusion form depending upon blood sugar levels.

Postpartum management Vaginal delivery GDM patients on diet do not need any monitoring. Those who are on insulin, blood sugar (fasting and postprandial) should be done before discharge. Pregestational diabetes: Patient is started on diabetic diet. Insulin is decreased to half of prepregnancy dose or 1/3-1/2 of pregnancy dose (if prepregnancy dose not available) Cesarean section Blood sugar monitoring is done 4-6 hourly. Regular insulin is given if RBS is >140-150 mg% in first 24-48 hours. Once patient starts taking regular diet, insulin dose is adjusted.

Postpartum glucose testing

Patients who are diagnosed to have GDM during pregnancy are subjected to oral glucose tolerance test with 75 g glucose. Normal

Diabetes mellitus

Impaired glucose tolerance

FBG (<110 mg/dl)

≥7.0 mmol/l (126 mg/dl)

6.1-7.0 mmol/l (110-125 mg/dl)

2-hour (<140 mg/dl)

≥11.1 mmol/l (200 mg/dl)

≥7.8 mmol/l (140-199 mg/dl)

Venous plasma (mg/dl) 2-hour postprandial Fasting

<95

1-hour postprandial

<140

2-hour postprandial

<120

If ≥50% values are deranged, then insulin should be started along with diabetic diet. Calorie calculation - 24-hour calories recommended • BMI - 19-27.5 kg/m²: 30-35 kcal/kg of ideal body weight • Underweight women (BMI <19 kg/m²): 35-40 kcal/kg/day • Overweight women (BMI >35 kg/m²): 25-30 kcal/kg/day2 Composition of diet - It should include carbohydrates (50-55%), proteins (20-30%) and fats (20-30%) with saturated fat <10%. Indications to start insulin therapy • MNT therapy fails to achieve glycemic goals within two weeks. • Fetal abdominal circumference (AC) at 29-33 weeks is more than 75 percentile. Target glucose levels in patients on insulin

Depending upon whether the patient has impaired glucose tolerance or frank diabetes, she is adviced for diabetic diet, oral hypoglycemics, insulin, benefits of weight control, exercise and regular physician evaluation to control and prevent the long-term complications of diabetes mellitus.

Oral hypoglycemic agents in pregnancy Biguanides (Metformin) • Studies have shown that it reduces the incidence of first trimester spontaneous abortions in these patients • • •

Sulfonylureas (Glyburide) • Most widely studied drug in pregnancy. • Transplacental transfer is minimal and no fetal complications have been reported. • Increases insulin secretion and is effective till fasting blood sugar is ≤140 mg/dl. • Initial dose is 2.5 mg/day. Maximum upto 20 mg/day can be given.

Contraception

Fasting (BBF)

60-90

• •

Before lunch, dinner, bedtime snack

60-105

•

Time

and is not associated with any major congenital malformations. Dose is usually started with 500 mg HS, and is slowly increased upto 2,250 mg/day. Contraindicated in presence of renal disease. Insulin is added if glycemic control is not achieved.

Venous plasma glucose levels (mg/dl)

After meals (2-hour)

<120

2:00-6:00 am

>60

•

Barrier methods have high failure rates. Intrauterine devices (copper containing and LNG containing) - considered ideal for diabetic women. These do not affect glucose metabolism. Progesterone only pills (POPs): Avoid in lactating women because of risk of decrease in glucose tolerance and insulin sensitivity. These should be used only when estrogen is contraindicated that too in nonlactating women. Women who have completed their family should be offered ligation when possible.

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, Daryacha, 39, Hauz Khas Village, New Delhi - 110 016. Editorial Policies

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F/DXO/AJOG/III/2/2011-12