Ajog oct dec 2012 by IJCP

Volume : 4 October-December 2012

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Asian Journal of

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Volume 4, October-December 2012

Contents

An IJCP Group Publication Corporate Panel Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal Group Editor-in-Chief

from the issue editor

Alka Kriplani

From the desk of group editor-in-chief

Dr Veena Aggarwal MD, Group Executive Editor

Tdap and Flu Vaccinations During Pregnancy

AJOG Specialty Panel

KK Aggarwal

Dr Alka Kriplani Editor Consultant Editor Dr Urmil Sharma Assistant Editors Dr Nutan Agarwal (Delhi) Dr Neera Aggarwal (Delhi) Dr A Biswas (Singapore) Dr CS Dawn (Kolkata) Dr Gauri (Delhi) Dr Suneeta Mittal (Delhi) Dr S Mehra (Delhi) Dr Prashant Mangeshikar (Mumbai) Dr Prakash Trivedi (Mumbai) Dr Gita Ganguly Mukherjee (Kolkata)

Dr (Mrs) Prabha Arora (Delhi) Dr Hema Divakar (Bangalore) Dr Kamini A Rao (Bangalore) Dr Deepti Goswami (Delhi) Dr Neerja Bhatla (Delhi) Dr Bhawna Malhotra (Delhi) Dr Biswas Nicholas (Australia) Dr Sudhaa Sharma (Jammu) Dr Jaibhagwan Sharma (Delhi) Dr Veena Mathur (Agra) Dr Pradeep Garg (Delhi)

Clinical Study

Vaginal Estrogen Therapy in Postmenopausal Overactive Bladder

Manidip Pal, T Deb

Saline Infusion Sonography: Can it Add on Sonographic Endometrial Assessment in Cases of Abnormal Uterine Bleeding

Rupita Kulshrestha, Saroj Singh, Shikha Singh

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

ENT Dr Jasveer Singh

Cardiology Dr Praveen Chandra Dr SK Parashar

Gastroenterology Dr Ajay Kumar

Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses Dr Sidhartha Das Dr A Ramachandran Dr Samith A Shetty

Dentistry Dr KMK Masthan Dr Rajesh Chandna

Dermatology Dr Hasmukh J Shroff Neurology Dr V Nagarajan Journal of Applied Medicine and Surgery Dr SM Rajendran Dr Jayakar Thomas

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

Cryotherapy and Carbon Dioxide Laser Management of Benign Cervical Lesions: A Controlled Comparative Study

Richa Singh, Saroj Singh, Mukesh Chandra, Shikha Singh, Roohi Parveen

To Compare the Efficacy of Cryotherapy, Electrocautery and Laser Vaporization in Treatment of Benign Cervical Lesions

Urmila Karya, Pooja Arora, Abhilasha Gupta

Outcome of Prelabor Rupture of Membranes in a Tertiary Care Center in West Bengal 28 Barunoday Chakraborty, Tamal Mandal, Subhankar Chakraborty

Asian Journal of Volume 4, October-December 2012

Contents

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

Case Report

Conjoined Twins Requiring Abdominovaginal Approach for Delivery

Printed at Nikeda Art Printers Pvt. Ltd., Mumbai

Chandrakant S Madkar, Hemant G Deshpande

© Copyright 2012 IJCP Publications Ltd. All rights reserved. The copyright for all the editorial material contained in journal, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

Anton’s Syndrome and Cortical Blindness

Srikant R Gadwalkar, Deepa DV, P Rama Murthy, Ravi Dhar

Prolapsed Huge Cervical Fibroid with Acute Red Degeneration Mimicking Uterine Inversion

Editorial Policies The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article. Note: Asian Journal of Obs & Gynae Practice does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature in this issue.

Neerja Varshney, Meenakshi Sharma, Vandana Jain

Maternal Death due to Medical Abortion

Premalatha

photo quiz

Nutan Aggarwal

Flow Chart

Gestational Diabetes: Diagnosis and Management 47 Deepti Goswami, 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 collection of articles and case reports as part of our commitment to expand recent and important information in the fast progressing field of Obstetrics and Gynecology. Estrogen therapy, especially vaginal therapy which has fever systemic side effects than oral form, appears to be helpful in managing the prevalence of many bladder symptoms, such as frequency, urgency and incontinence (overactive bladder). This scenario is briefly discussed by Dr Manidip Pal in the article “Vaginal Estrogen Therapy in Postmenopausal Overactive Bladder”. The article “Saline Infusion Sonography: Can it Add on Sonographic Endometrial Assessment in Cases of Abnormal Uterine Bleeding” by Dr Rupita Kulshrestha and coauthors describes the role of SIS in diagnosing endometrial lesions causing abnormal uterine bleeding. Conjoined twins are an exceptional but the most multifarious congenital anomaly. Due to its rarity and interesting nature, we present this case of “Conjoined Twins Requiring Abdominovaginal Approach for Delivery” by Chandrakant S Madkar and Hemant G Deshpande. Cerebrovascular disease is the most widespread cause of cortical blindness. It occurs as a consequence of succeeding infarctions or from a single embolic or thrombotic occlusion. Dr Srikant R Gadwalkar and coauthors discuss this in their article “Anton’s Syndrome and Cortical Blindness”. We have lots of more articles in the issue which give vast knowledge in the field of gynecology. We also have our regular columns of Flowchart and Photo Quiz. We invite comments and correspondence from our readers to make the issue more reader-friendly.

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

From the desk of group editor-in-chief

Tdap and Flu Vaccinations During Pregnancy

Dr KK Aggarwal Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist, Moolchand Medcity, New Delhi President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS National Vice President-Elect, IMA Chairman Ethical Committee, Delhi Medical Council Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http//twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)

he prevalence of pertussis in US is increasing. Infants younger than three months of age are at highest risk. Vaccination of the mother can decrease the risk of infant exposure, and placental transfer of maternal antibodies may additionally provide a degree of passive protection to the infant for 2-6 months.

In 2013, the United States Advisory Committee on Immunization Practices (ACIP) has recommended that all pregnant women receive the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine during each pregnancy, optimally between 27 and 36 weeks of gestation, regardless of prior vaccination status. Previously, Tdap was recommended only for pregnant women who had not previously received the acellular pertussis vaccine during adulthood.1 Influenza vaccination is recommended in pregnancy as both mother and fetus are at increased risk. Maternal vaccination provides passive protection to the infant. The safety and efficacy of vaccination of pregnant women has been confirmed in a retrospective analysis of over 1,00,000 pregnancies during the 2009 influenza A (H1N1) pandemic in Norway.2 All women who are pregnant or will be pregnant during influenza season should receive the inactivated influenza vaccine, regardless of pregnancy trimester. References 1.

Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedules for Persons Aged 0 Through 18 years and Adults Aged 19 Years and Older - United States, 2013. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm62e0128a1. htm?s_cid=mm62e0128a1_e (Accessed on January 29, 2013).

Håberg SE, Trogstad L, Gunnes N, Wilcox AJ, Gjessing HK, Samuelsen SO; et al. Risk of fetal death after pandemic influenza virus infection or vaccination. N Engl J Med 2013;368(4):333-40. 

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

Clinical Study

Vaginal Estrogen Therapy in Postmenopausal Overactive Bladder Manidip Pal*, T Deb**

Abstract Objective: To assess the efficacy of vaginal estrogen therapy in postmenopausal overactive bladder (OAB). Study design: It is an OPD (outpatient department) based prospective study. Postmenopausal women attending gynecology OPD with complaints of OAB were enrolled for the study. Women fulfilling the criteria for the study were given estradiol 2 mg vaginal tablet everyday for two weeks, then weekly twice for 10 weeks. Patients were assessed by 3-day bladder diary, patient global impression scale before and after the therapy. Results: Ninety-three patients completed the study. Increased frequency of micturition was cured in 92.5% cases; urgency and urge incontinence were cured in 74.2% cases. Patient’s subjective feeling of improvement scale revealed that only 12.9% women felt either no change or little better; rest all were happy. Conclusion: Local estrogen therapy in postmenopausal women with OAB resulted in a good outcome. Key words: Overactive bladder, estrogen, vaginal

enopause causes different types of morbidity in women’s life - urinary incontinence is one of them. Postmenopausal women many at times complain of frequency, urgency, urge incontinence overactive bladder (OAB). While evaluating them, ruling out of infectious etiology (urinary tract infection) is very important. Next to infection hypoestrogenism is thought to be the major etiological factor. Present study evaluates the efficacy of local estrogen in treating postmenopausal OAB. Material and Methods The study was conducted in the Dept. of Obstetrics and Gynecology, College of Medicine and JNM Hospital, Kalyani, Nadia, West Bengal from April 2010 to March 2012. It was an OPD (outpatient department) based prospective study. Postmenopausal women attending gynecology OPD with complaints of OAB were enrolled for the study. Inclusion criteria were:

*Associate Professor Dept. of Obstetrics and Gynecology **Assistant Professor Dept. of Pharmacology College of Medicine and JNM Hospital, Kalyani, Nadia, West Bengal Address for correspondence Dr Manidip Pal Dept. of Obstetrics and Gynecology College of Medicine and JNM Hospital Kalyani, Nadia, West Bengal E-mail: manideep2b@yahoo.com

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

1) Patient should be at least one year postmenopausal; 2) increased frequency of micturition and nocturia (normal voiding habits ≤8 episodes/day and ≤2 episodes/night)1 and 3) urgency of urination ± urge incontinence. Exclusion criteria were: 1) Undiagnosed vaginal bleeding; 2) endometrial hyperplasia, and other estrogen- dependent diseases specially malignancy; 3) hypertension (blood pressure systolic >160 mmHg, diastolic >100 mmHg); 4) previous thromboembolic episodes; 5) liver disease and 6) estrogen therapy within last six months. Informed consent was obtained from all patients. All patients underwent a detailed history and clinical examination including breast, per abdominal, per vaginal examination, blood pressure measurement, etc. Complete blood count, liver and renal function tests, coagulation profile, Pap smear, pelvic ultrasonography was done for all the cases. Mid-stream urine culture and sensitivity was done routinely before starting estrogen therapy. If infection was present, it was cured with respective sensitive antibiotic. After that, if OAB symptoms still persisted then only vaginal estrogen therapy started. Urodynamic study could not be done as there was no such facility in our setup. Patients were asked to maintain a 3-day bladder diary before starting therapy and also at the end of the therapy at 12 weeks. Estradiol vaginal tablet 2 mg was inserted in the posterior fornix every night for first two weeks; followed by twice weekly for 10 weeks. Total 12 weeks of therapy was given.

clinical study To evaluate the effect of treatment on patients’ perception of urgency, each patient completed a threepoint urgency perception scale at baseline and after 12 weeks’ treatment. Patients were asked to describe their typical experience when they felt the desire to urinate. The possible response options were as follows: 1) “I am usually not able to hold urine”; 2) “I am usually able to hold urine until I reach the toilet” and 3) “I am usually able to ﬁnish what I am doing before going to the toilet.”2 Patient’s feelings were also assessed by patient Global Impression scale3 at the starting of the study. Patient Global Impression of Severity (PGI-S) scale measures the subjective feeling about the severity of her condition: 1) normal, 2) mild, 3) moderate and 4) severe. Result of the treatment is assessed by Patient Global Impression of Improvement (PGI-I) scale at 12 weeks. This scale measures the patient’s own feeling of her OAB condition after the treatment, whether

improved or not: 1) Very much better, 2) much better, 3) a little better, 4) no change, 5) a little worse, 6) much worse and 7) very much worse. Result One hundred women were enrolled for the study. Four were unfit for estrogen therapy after investigations. Three were lost to follow-up. Total 93 women completed the trial. At the beginning of the study, increase in frequency of micturition >20 times was present in 15.6% cases, nocturia in 17.7% cases and nocturnal enuresis in 5.2% cases. Eighty-four (87.5%) patients had urge incontinence. Patient’s subjective feeling revealed 21.9% had severe problem. At the end of 12 weeks vaginal estrogen therapy 92.5% women had no more increase frequency of micturition. There was no case of nocturnal enuresis. Urgency and

Table 1. Improvemet in Frequency of Micturition after 12 weeks of Therapy Frequency of micturition

Nocturia No.

At starting

No.

At starting

9-15 times

39.6

3-4 times

13.5

16-20 times

44.8

5-6 times

4.2

>20 times

15.6

Total

17.7

Total

96 2

11.8 (2/17)

At starting

5.2

After 12 weeks of therapy

< 8 times

92.5

3-4 times

9-15 times

7.5

Nocturnal enuresis

Total

Table 2. Improvement in Urgency and Urge Incontinence after 12 weeks of Therapy Urgency and urge incontinence

No.

I am usually not able to hold urine

87.5

I have to go the toilet immediately but am usually able to hold urine until I reach there

12.5

I am usually able to ﬁnish what I am doing before going to the toilet

At starting

96 After 12 weeks of therapy I am usually not able to hold urine

24.7

I have to go the toilet immediately but am usually able to hold urine until I reach

1.1

I am usually able to ﬁnish what I am doing before going to the toilet

74.2

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study Table 3. Patient Global Impression Scale PGI-S scale (at the beginning) Normal Mild Moderate Severe Total PGI-I scale (after 12 weeks of therapy) Very much better Much better A little better No change A little worse Much worse Very much worse Total

urge incontinence was cured in 74.2% cases. Patientâ&#x20AC;&#x2122;s subjective feeling of improvement scale revealed only 12.9% women felt either no change or little better; rest all were happy (Tables 1-3). Discussion Local estrogen therapy in postmenopausal women resulted in a good outcome in relation to their improvement in OAB problem. Hypoestrogenism affects the sensory threshold of the urinary tract, which leads to reduction in the volume and time needed to change the first sensation to void into the feeling of imminent micturition, and in some subjects causes involuntary detrusor contraction.4 This could be the reason why estrogen therapy helped in reducing the OAB symptoms in postmenopausal women. Various studies have demonstrated that estrogen replacement can improve, or even cure, urinary stress and urge incontinence. High dose estrogen can reduce the total number of voids in 24 hours, including nocturnal voids.5 Cochrane database review 20096 also revealed that estrogen therapy can cure or improve urinary incontinence in women, especially urge incontinence. In evaluation of estradiol absorption from vaginal tablets in postmenopausal women it was found that absorption of the drug is not that high so as to cause systemic side effects. Over 12 weeks of therapy also Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

No. 0 19 56 21 96 69 12 7 5

% 19.8 58.3 21.9

74.2 12.9 7.5 5.4

absorption patterns remained consistent, and women did not have accumulations of circulating E2.7 Cardozo et al8 had performed a systematic review of the effects of estrogen therapy on symptoms suggestive of OAB in postmenopausal women. Eleven randomized trials were identified, which included a total number of 430 subjects. Estrogen (estriol, estradiol, conjugated estrogens or combination of estradiol and estriol), systemic or local versus placebo was reviewed. Overall, all the outcome variables, which included diurnal and nocturnal frequency, urgency, number of incontinence episodes, first sensation to void, and bladder capacity, were significantly improved in patients given active treatment compared with those taking placebo. When the authors analyzed data separately for systemic and local therapies, however, they found that only numbers of incontinence episodes and first sensation to void were significantly improved in patients taking systemic treatment, whereas local treatments had beneficial effects on all outcomes. Based on these findings, it was concluded that estrogen therapy may be effective in alleviating the symptoms suggestive of OAB, but local administration may be the most beneficial route of administration. Based on current evidence, it would appear preferable to use vaginal estrogens rather than systemic as part of the management of menopause-related bladder problems.9 In our study, though 100 patients were initially recruited, 93 could complete the whole course.

clinical study Other studies on effect of vaginal estrogen on urinary incontinence in postmenopausal women had sample sizes of 40 (Enzelsberger et al,10 used estriol cream 1 mg/day, 3 mg/day), 59 (Nelken et al,11 estradiol vaginal ring vs oral oxybutynin) and 110 (Cardozo et al,12 used 17-b estradiol tablet) cases.

Yalcin I, Bump RC. Validation of two global impression questionnaires for incontinence. Am J Obstet Gynecol 2003;189(1):98-101.

Fantl JA, Wyman JF, Anderson RL, Matt DW, Bump RC. Postmenopausal urinary incontinence: comparison between non-estrogen-supplemented and estrogensupplemented women. Obstet Gynecol 1988;71(6 Pt 1):823-8.

McCully KS, Jackson S. Hormone replacement therapy and the bladder. J Br Menopause Soc 2004;10(1):30-2.

Moehrer B, Hextall A, Jackson S. Oestrogens for urinary incontinence in women. Cochrane Database Syst Rev 2009;(4):CD001405.

Notelovitz M, Funk S, Nanavati N, Mazzeo M. Estradiol absorption from vaginal tablets in postmenopausal women. Obstet Gynecol 2002;99(4):556-62.

Cardozo L, Lose G, McClish D, Versi E. A systematic review of the effects of estrogens for symptoms suggestive of overactive bladder. Acta Obstet Gynecol Scand 2004;83(10):892-7.

Hillard T. The postmenopausal bladder. Menopause Int 2010;16(2):74-80.

Conclusion The bladder and its surrounding structures are rich in estrogen receptors and there are demonstrable physiological and anatomical changes that occur around and immediately after the menopause. The prevalence of many bladder symptoms, such as frequency, urgency and incontinence (OAB) does seem to increase around the menopause. Hence estrogen therapy, especially vaginal therapy which has less systemic side effect than oral form, appears to be helpful in managing OAB. Acknowledgments

We express our sincere thanks to the Principal and Medical Superintendent of College of Medicine and JNM Hospital, Kalyani, Nadia, West Bengal, India to allow us to do this study and publish the work. References

10. Enzelsberger H, Kurz C, Schatten C, Huber J. The effectiveness of intravaginal estriol tablet administration in women with urge incontinence. Geburtshilfe Frauenheilkd 1991;51(10):834-8.

Kovac SR. Surgical treatment of urinary incontinence. In: Clinical Gynecology. 1st edition, Bieber EJ, Sanfilippo JS, Horowitz IR (Eds.), Elsevier, Churchill Livingstone: Philadelphia 2006:p.341-53.

11. Nelken RS, Ozel BZ, Leegant AR, Felix JC, Mishell DR Jr. Randomized trial of estradiol vaginal ring versus oral oxybutynin for the treatment of overactive bladder. Menopause 2011;18(9):962-6.

Freeman R, Hill S, Millard R, Slack M, Sutherst J; Tolterodine Study Group. Reduced perception of urgency in treatment of overactive bladder with extended-release tolterodine. Obstet Gynecol 2003;102(3):605-11.

12. Cardozo LD, Wise BG, Benness CJ. Vaginal oestradiol for the treatment of lower urinary tract symptoms in postmenopausal women - a double-blind placebo-controlled study. J Obstet Gynaecol 2001;21(4):383-5. 

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

Clinical study

Saline Infusion Sonography: Can it Add on Sonographic Endometrial Assessment in Cases of Abnormal Uterine Bleeding Rupita Kulshrestha*, Saroj Singh**, Shikha Singhâ&#x20AC;

Abstract Aims: To study and compare the accuracy of endometrial assessment by transvaginal sonography (TVS) alone with saline infusion sonography (SIS) in patients with abnormal uterine bleeding (AUB) and to compare their diagnostic accuracy taking histopathology as gold standard. Study design: Prospective comparative study. Material and methods: Sixty outpatients coming to Dept. of Obstetrics and Gynecology with complaints of AUB were taken for the study. All patients underwent TVS followed by SIS in same sitting and histopathology as endometrial biopsy or hysterectomy was taken within 14 days of procedure. Results were analyzed statistically. Results: Most common menstrual complaint was menorrhagia and most common endometrial lesion was submucous myoma. Overall sensitivity and specificity for TVS was 77.77% and 75.75% and for SIS was 88.88% and 81.82%, respectively. SIS was more accurate in diagnosing endometrial lesions as compared to TVS alone. Commonest histopathological lesion was submucous myoma followed by endometrial hyperplasia. Conclusion: SIS is more sensitive and specific than TVS alone in diagnosing endometrial lesions causing AUB with high positive and negative predictive values. SIS findings are more in agreement with histopathological findings than TVS alone. Key words: Abnormal uterine bleeding, transvaginal sonography, saline infusion sonography

bnormal uterine bleeding (AUB) accounts for 15% of office visits and 25% of gynecological surgeries.1 The current concepts of the AUB conclude that it is most likely due to local causes in the endometrium. Local causes include fibroids, endometrial polyps, chronic pelvic inflammatory diseases, cervical polyp and endometrial carcinoma. Submucous myomas and polyps account for more than 40% of cases of AUB in premenopausal women.2 The management of AUB is often associated with failure and final resort is hysterectomy. Anything that can significantly improve the accuracy of diagnosing the cause of bleeding will guide the proper line of management. Transabdominal ultrasound is a modality that is used most commonly and is easily available for diagnosis of AUB. The recent development and application of transvaginal sonography (TVS) probes have greatly *Junior Resident III **Professor and Head â&#x20AC; Assistant Professor Dept. of Obstetrics and Gynecology SN Medical College, Agra, UP Address for correspondence Dr Rupita Kulshrestha 29, Sarlabagh, Dayalbagh, Agra - 282 005 E-mail: rupita.kulshrestha@gmail.com

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

enhanced sonographic depiction of endometrium over conventional transabdominal scan.3 But, some cases may still be missed by this technique. Saline infusion sonography (SIS) is a technique, which involves instillation of fluid into uterus coupled with transvaginal probes that allows tremendous diagnostic enhancement. It is inexpensive, simple, noninvasive and well-tolerated office procedure.4 SIS has several advantages like simplicity, decreased cost, minimal invasiveness, lack of ionizing radiation and high level of diagnostic accuracy with an ability to more accurately characterize the lesion within the endometrial cavity.5 The present study has been designed to study the accuracy of endometrial assessment by TVS along with SIS in cases of AUB. Aims and Objectives To study and compare the accuracy of endometrial assessment by TVS alone with SIS in patients with AUB and to compare their diagnostic accuracy taking histopathology as gold standard. Material and Methods This study was conducted in the Dept. of Obstetrics and Gynecology, Sarojini Naidu Medical College, Agra, 11

clinical study a tertiary care hospital, during the period of November 2009 to September 2011.

through the catheter under continuous sonographic monitoring.

Sixty outpatients presenting with complaint of AUB marked enough to warrant further investigation were taken in this study. After taking consent, all patients were subjected to TVS and SIS in the same sitting. Histopathological sample either as endometrial biopsy or hysterectomy was taken within 14 days of procedure. All patients enrolled for study were subjected to detailed history, general and local examination.

Uterus was scanned in sagittal and coronal planes in both TVS and SIS to delineate the entire uterine cavity and appropriate images were recorded. The endometrial cavity was examined for the presence of polyps, submucous fibroids, focal endometrial thickening or any other endometrial pathology.

The calculations for the likelihood ratios (LR) were as follows:  Positive LR = sensitivity/(100-specificity)  Negative LR = (100-sensitivity)/specificity LR represent a score that allows the categorization of test results. A positive LR of 2-5 indicates a fair clinical test, 5-10 is good and above 10 is excellent. A negative LR of 0.5-0.2 indicates a fair clinical test, 0.2-0.1 is good and <0.1 is excellent. Exclusion Criteria 

    

 

Patients with clinically demonstrable organic cause Unmarried females Patients with narrow vagina Patients with stenosed cervix Pregnant patients Patients with any evidence of active infection of genital tract Patients with cervicitis Patients not giving consent for the procedure

TVS (By Medison India Pvt. Ltd.; Model SA 8000 LIVE) with endovaginal probe of 5 MHz, was used to examine both the adnexa and the uterus. For SIS, sterile speculum was inserted into the vagina and the cervix was cleaned with antiseptic solution (10% iodine-based solutions). Anterior lip of cervix was held with valsellum and a Foley’s balloon catheter (5 Fr) was introduced into utero-cervical cavity at the level of internal os and balloon was inflated with 5 ml of saline to seal the external os to prevent retrograde leakage of saline into vagina. The speculum was then removed and transvaginal probe was inserted into the vagina. Ten milliliter of sterile saline was injected slowly 12

Histopathology specimens were obtained from all the patients by endometrial biopsy in 27 patients and 33 patients were treated by hysterectomy and their uteri were sent for histopathology within 14 days of TVS and SIS procedure. Pathologists were blinded to TVS or SIS findings. The samples were examined both grossly and microscopically. On gross examination, the presence of polyps, myomas, synechiae and carcinoma were recorded. Presence of atrophic, proliferative or secretory endometrium without any other abnormality at examination was considered as normal uterus. A final pathologic diagnosis was made by using the results of both the procedures and histopathologic analysis. Result and Discussion Majority of patients (46.67%) were in age group of 41-50 years. Mean age of patients was 41.16 ± 6.57 years. Majority (38.33%) of patients were either Para-3 or Para-4. None were nulliparous. Most common complaint was menorrhagia (58.33%) followed by metrorrhagia (15%), menometrorrhagia (11.67%), postmenopausal bleeding (10%) and polymenorrhea (5%) (Table 1). These findings are similar to previous studies. The duration of menstrual complaint was found to be 6-9 months in majority of patients (26.67%) followed by 3-6 months in 25%. Most of cases (62.85%) of menorrhagia were seen in 31-40 years age group while the majority of cases of metrorrhagia, menometrorrhagia and polymenorrhea were seen in 41-50 years age group. TVS showed 31 cases to be normal. In the rest 29 cases, the most common lesion found was endometrial hyperplasia (23.33%) followed by submucous myoma (15%) and endometrial polyp (10%) (Table 2). SIS diagnosed 30 cases as normal. In the rest 30, most common lesion was submucous myoma (21.67%) Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study Table 1. Demographic Details of AUB Patients in Study Group Most common age group

41-50 years (Mean group = 41.16 Âą 6.57 years)

Most common complaints

Menorrhagia (58.33%), metrorrhagia (15%)

Most common duration of menstrual complaints

6-9 months (26.67%), 3-6 months (25%)

Most common parity among AUB patients

Para-3 or 4 (38.33%)

Table 2. Endometrial Pathologies as Diagnosed by TVS, SIS and Histopathological Examination Endometrial pathology

TVS

Sis

Histopathological findings

(%)

(Sub types)

51.67

Proliferative

28.33

31.67

Secretory

13.33

16.67

Atrophic

8.33

6.67

Endometrial polyp

11.67

Endometrial hyperplasia

23.33

18.33

Submucous myoma

18.33

Total

100

Normal

Table 3. Sensitivity, Specificity, PPV and NPV in Different Endometrial Pathologies Histopathological findings

Sensitivity

Specificity

TVS PPV

NPV

Sensitivity

Specificity

PPV

NPV

Submucous myoma

81.82

91.92

81.82

95.92

90.91

95.92

83.33

97.92

Endometrial hyperplasia

77.78

90.19

58.33

95.83

88.89

94.12

72.72

97.96

Endometrial polyp

71.43

88.11

83.33

96.3

85.71

98.11

85.71

98.11

followed by endometrial polyp (16.67%) endometrial hyperplasia (11.67%) (Table 2).

SIS

and

Histopathological examination confirmed endometrial pathologies in 27 patients. Out of which most common lesion was submucous myoma in 18.33% followed by endometrial hyperplasia (15%) and endometrial polyp (11.67%) (Table 2). Rest 33 were reported as normal on histopathology. On comparing TVS findings with histopathology, it was noticed that out of 31 cases in which TVS detected no endometrial pathology, 25 patients were true negative and six were diagnosed as false negative. Out of the six Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

false negative cases were diagnosed as two cases each of endometrial polyp, endometrial hyperplasia and submucous myoma on histopathology. On comparing SIS findings with histopathology it was noticed that out of 30 cases where SIS detected no endometrial pathology, 27 were true negative and three cases were diagnosed as false negative. They were diagnosed as one case each of endometrial polyp, endometrial hyperplasia and submucous myoma on histopathological analysis. On further evaluation, both positive and negative LRs were found to be fairly higher in SIS when 13

clinical study Table 4. comparison of LRs of Tvs/sis in Detecting Different Endometrial Pathologies Histopatho-

TVS

SIS

logical findings

LR+

LR -

LR +

LR-

Submucous myoma

20.05

0.19

22.3

0.09

Endometrial hyperplasia

7.93

0.25

15.1

0.12

Endometrial polyp

0.29

70.02

84.03

0.14

Table 5. Comparison of Accuracy of TVS and SIS in Different Studies Author

Year

Procedure

Sensitivity (%)

Specificity (%)

PPV (%)

NPV (%)

Duohelm et al6

2001

TVS

SIS

TVS

SIS

TVS

65.5

SIS

TVS

77.77

75.75

72.41

80.64

SIS

88.88

81.82

80.0

Ryu et al

2004

Reddi Rani et al Present study

2010 2011

compared to TVS alone in detection of all the three types i.e. submucous myoma, endometrial hyperplasia and endometrial polyp (Table 4). The present study showed that SIS has higher sensitivity and specificity when compared with TVS alone. Similar findings were seen in studies by Ryu et al,7 Reddi Rani et al8 and Duohelm et al (Table 5).6 The increased sensitivity and specificity of SIS is due to the fact that on instillation of fluid into uterine cavity the opposing uterine walls get separated from each other and there is creation of fluid endometrium interface, which causes submucous myoma and endometrial polyp like lesions to be visualized better. These lesions may be misinterpreted as endometrial hyperplasia on TVS. Thus, SIS is found to be more accurate than TVS in visualizing the endometrial cavity and it is a better alternative. Summary SIS is found to be more accurate than TVS alone in visualizing the endometrial cavity. The increased sensitivity and specificity of SIS is due to the fact that on instillation into uterine cavity the opposing 14

uterine walls get separated from each other and there is creation of fluid endometrium interface, which causes submucous myoma and endometrial polyp like lesions to be visualized better. These lesions may be misinterpreted as endometrial hyperplasia on TVS. TVS alone can not distinguish endometrial hyperplasia from polyps as both cause endometrial thickening, are hyperechoic and can contain cystic spaces; whereas, SIS can detect focal lesions from diffuse thickening. Hence, SIS is a better alternative. Conclusion TVS is a simple, minimally invasive, low cost technique and it should be the first diagnostic method of choice in evaluating AUB. The appropriate place for sis is a second-line diagnostic procedure in evaluation of AUB if TVS findings are inconclusive. SIS is highly sensitive and specific for diagnosing submucous myoma, endometrial hyperplasia and endometrial polyps. It is an alternative to diagnostic hysteroscopy with additional advantage of evaluating myometrium and adnexal pathology besides being less invasive and cost-effective. Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study References 1.

Laughead MK, Stones LM. Clinical utility of saline solution infusion sonohysterography in a primary care obstetric-gynecologic practice. Am J Obstet Gynecol 1997;176(6):1313-6; discussion 1316-8.

Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. Am Fam Physician 2004;69(8):1915-26.

Shah PK, Noronh S. Dysfunctional uterine bleeding. An Update. “Ultrasonography in DUB” 6:66.

Goldstein SR. AUB: Role of ultrasound. In:Textbook of Ultrasonography in Obstetrics and Gynecology. 5th edition. Callen PW (Ed.), Elsevier: New Delhi 943-934.

Lindheim SR, Sprague C, Winter TC 3rd. Hysterosalpingo-

graphy and sonohysterography: lessons in technique. AJR Am J Roentgenol 2006;186(1):24-9. 6.

Dueholm M, Forman A, Jensen ML, Laursen H, Kracht P. Transvaginal sonography combined with saline contrast sonohysterography in evaluating the uterine cavity in premenopausal patients with abnormal uterine bleeding. Ultrasound Obstet Gynecol 2001;18(1):54-61.

Ryu JA, Kim B, Lee J, Kim S, Lee SH. Comparison of transvaginal ultrasonography with hysterosonography as a screening method in patients with abnormal uterine bleeding. Korean J Radiol 2004;5(1):39-46.

Reddi Rani P, Lakshmikantha G. Transvaginal sonography and saline infusion sonohysterography in the evaluation of abnormal uterine bleeding. J Obstet Gynecol India 2010;60(6):511-5. 

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

Clinical Study

Cryotherapy and Carbon Dioxide Laser Management of Benign Cervical Lesions: A Controlled Comparative Study Richa Singh*, Saroj Singh**, Mukesh Chandra†, Shikha Singh‡, Roohi Parveen#

Abstract Objective: To compare the clinical efficacy of cryotherapy versus carbon dioxide (CO2) laser therapy for the treatment of benign cervical lesions and complications during and after each procedure. Material and methods: A prospective randomized controlled study was performed on 100 women with benign cervical lesions attending the OPD of Obstetrics and Gynecology. Study Group I comprising of 50 women were subjected to cryotherapy and study Group II also comprising of 50 women were subjected to CO2 laser therapy. Both groups were matched regarding age, parity and other factors. Response to therapy and complication rates in each group were compared Student ‘t’ test was used for statistical analysis. Results: The results of treatment were not significantly different for cryotherapy and CO2 laser therapy; failure rate was 16% for cryotherapy and 8% for CO2 laser therapy. Treatment results were identical for Grade 1+ and Grade 2+ cervical intraepithelial neoplasia (CIN), whereas Grade 3+ CIN responded comparatively better to laser (failure rate 14%) than cryotherapy (failure rate 37.5%) (p = 0.30). Complications were fewer with CO2 laser therapy. Conclusions: Based on this study, it was concluded that cryotherapy is a cost-effective treatment modality for benign cervical lesions, cryotherapy and CO2 laser are equally effective for small lesions but for larger lesions, CO2 laser appears to be better than cryotherapy with faster healing and fewer side effects. Key words: Cervical intraepithelial neoplasia, cryotherapy, carbon dioxide laser

quamous cell carcinoma of the cervix fulfills the model for a classic multistage disease beginning with 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 cytologic screening programs targeting the detection of preinvasive disease and treatment of these conditions with conservative methods. Since, the introduction of colposcopy for the triage of patients with abnormal Papanicolaou smears, many clinicians have turned to outpatient treatment

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

modalities to manage cervical intraepithelial neoplasia (CIN) in patients in whom invasive cancer has been ruled out. Modalities have included electrocoagulation, radical electrodiathermy and cryotherapy, but a series of patients treated with carbon dioxide (CO2) laser have also begun to appear in the literature in larger numbers and advocates of each technique have described benefits and drawbacks. In this series, subjects were treated alternately by cryotherapy or CO2 laser therapy and carefully followed to compare the end results and the advantages and disadvantages of each method. Aims and Objectives To compare the clinical efficacy of cryotherapy versus CO2 laser therapy for the treatment of benign cervical lesions and complications during and after each procedure. Material and Methods The study was a prospective randomized controlled trial to compare the results of management of cervical lesions with cryotherapy versus CO2 laser in as objective way as possible by alternating cases randomly in so far as possible on the basis of histologic grade and lesion size. Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study Table 1. Patient Characteristics Age

Study Group I

Study Group II

Cases for cryotherapy

Cases for CO2 laser

Number

Percent (%)

Number

Percent (%)

15-25

26-35

36-45

Mean age

29.6

30.86

Parity Paral

Para 2-3

Para 4-5

>Para 5

Table 2. Distribution of Cases according to Pap Smear Findings before Cryotherapy/CO2 Laser Treatment Cytological findings

Study Group I

Study Group II

Cases for cryotherapy

Cases for CO2 laser

Number

Percent (%)

Number

Percent (%)

Inflammatory

Reactive/Reparative

ASCUS

CIN I

CIN II

CIN III

SCC

Total

100

Table 3. Distribution of Cases according to Colposcopic Findings before Cryotherapy/CO2 Laser Treatment Colposcopic findings

Study Group I

Study Group II Cases for CO2 laser

Cases for cryotherapy Number

Percent (%)

Number

Percent (%)

Acetowhite areas

Iodine negative areas

Abnormal vascularity

Normal

One hundred patients presenting to our OPD of Obstetrics and Gynecology from April 2010 to March 2011 with symptoms suggestive of abnormal cervical lesions like persistent vaginal discharge, lower abdominal pain, contact bleeding or low backache Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

were recruited for study. Study Group I comprised of 50 cases of benign cervical lesions treated by cryotherapy and study Group II comprised of 50 cases of benign cervical lesions managed by CO2 laser therapy. 17

clinical study Table 4. Distribution of Cases according to Grading of Lesion on Colposcopy Grading of lesion

Study Group I

Study Group II

Cases for cryotherapy

Cases for CO2 laser

Number

Percent (%)

Number

Percent (%)

Grade 1+

Grade 2+

Grade 3+

Table 5. Distribution of Cases according to Impression on Cervical Biopsy Impression on cervical biopsy

Study Group I

Study Group II

Cases for cryotherapy

Cases for CO2 laser

Number

Percent (%)

Number

Percent

Normal

CIN I

CIN II

CIN III

Table 6. Cryotherapy and Laser Treatment Results by Grade of Cervical Lesions on Colposcopy Size

Study Group I

Study Group II

Cases for cryotherapy

Cases for CO2 laser

Number treated

Failure

Number treated

Number

Percent (%)

Number

Percent (%)

37.5

Total

The women included in the study were those who were found to have an unhealthy cervix on per speculum examination. They were subjected to detailed history, clinical examination, Pap smear, colposcopy, cervical biopsy and endocervical curettage. All the patients selected in this series were in whom invasion had been ruled out consistently by colposcopy, cytology and histology, in whom the endocervical curettage was negative and in whom the lesion could be seen in its entirety. The lesions were subdivided histologically into CIN Grades 1, 2 or 3. The lesions size was graded as 1+, 2+ 18

Failure

or 3+ by the following criteria: If the colposcopically visible CIN lesion covered 25% or less of the surface area of the ectocervix, it was considered a 1+ lesion; if it covered 50% it was graded 2+ and if it covered 75% or more, it was graded as 3+. Patients were treated in a prospective fashion and treatment was alternated with respect to lesion size as closely as possible. All the patients managed by cryotherapy were treated with a nitrous oxide gun type unit using a 18 mm flat tipped probe and a single freeze thaw cycle. The therapeutic endpoint was that Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study the ice ball extended at least 5 mm beyond the edge of the colposcopically abnormal appearing epithelium. In large lesions, multiple applications were usually necessary, and each application was overlapped with the others in order that the entire lesion was frozen with a sufficient extension beyond its limits to ensure a complete freeze. The treatment time varied from 2.5 to 9 minutes depending on lesion size. For laser therapy patients were treated with AZURYT CTL 1401 Medical unit, which is based on active media in the form of CO2 with radiation wavelength of 10,600 mm. The spot size was 2 mm and power density of 500 w/cm2 was used. The approach was designed to destroy the lesion and the entire transformation zone as well. The lesion to be vaporized was delineated by marking with the laser beam at the anterior (12 O’clock), the posterior (6 O’clock) and both lateral sides (3 and 9 O’clock), then these 4 dots were connected to make a circle that surrounded the area to be vaporized with an

adequate margin. The nonlesion bearing transformation zone was vaporised down to a depth of 2-3 mm; then the lesion was vaporized continuously by the beam to a depth of 6-7 mm. A bivalve speculum with a dull surface was used to prevent laser reflections, and all the vapors were evacuated by a filter. The treatment time varied from 2 to 6 minutes. All the subjects in both cryotherapeutic and CO2 laser series were treated as outpatients. None received anesthesia or analgesia before or during therapy. All subjects were seen for follow-up at six weeks following the treatment session for evaluation of side effects and epithelial healing. Each patient was seen again at three months, when a Pap smear was taken and each was examined colposcopically. Any patient who had an abnormal Pap Smear discovered after treatment during the course of the study was re-evaluated colposcopically and by multiple punch biopsy and endocervical curettage. Any patient found

Table 7. Distribution of Cases according to the Type of Cytological/Pap Smear Findings after Cryotherapy/CO2 Laser Treatment (After 3 Months) Type of cytological/Pap smear findings

Study Group I

Study Group II

Cases for cryotherapy

Cases for CO2 laser

Number

Percent (%)

Number

Percent (%)

Normal

Reactive

Inflammatory

CIN I

CIN II

Table 8. Distribution of Cases according to Colposcopic Findings after Cryotherapy/CO2 Laser Treatment (After 3 Months) Colposcopic findings

Study Group I

Study Group II

Cases for cryotherapy

Cases for CO2 laser

Number

Percent (%)

Number

percent (%)

Normal

Acetowhite area

Iodine negative area

Abnormal vascularity

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study Table 9. Distribution of Cases according to Complications During and after Cryotherapy or CO2 Laser Treatment Complication

Study Group I

Study Group II

Cases for cryotherapy

Cases for CO2 laser

Number

Percent (%)

Number

Percent (%)

Headache

Abdominal pain

Bleeding

Vasovagal attack

Vaginal discharge

100

Bleeding

Abdominal pain

Weakness

During procedure

After procedure

Table 10. Comparative Analysis of Success Rate with Different Studies Cryotherapy (%)

CO2 laser ablation (%)

Our study (2011)

Townsend and Richart (1985)

Ferenczy A (1985)

62.1

Jobson and Homesley (1984)

89.7

90.5

Mitchell et al (1998)

to have a persistent CIN was offered retreatment. No patient was lost to follow-up. Results The present prospective randomized cross-sectional study was conducted over a period of one year. Every patient treated by cryotherapy complained of abnormal sensation during the course of the treatment. Eightyfour percent complained of abdominal pain and 36% of headache, 4% had light-headedness. They had to be kept indoor for half an hour following treatment till they felt better. Among the patients treated with CO2 laser, 8% complained of abdominal pain and 4% of headache. Two patients had slight bleeding during the procedure, which was managed by laser itself. None of the laser treated patients had vasomotor symptoms. All of them left shortly after treatment. 20

Post-treatment all patients treated with cryotherapy experienced watery discharge 80%, describing it as profuse and requiring 2-4 pads/day for its control. The discharge lasted for 10-14 days in 80% women. There was no significant bleeding after cryotherapy. Among the laser patients, 36% complained of discharge but only slight in amount. Two patients had slight bleeding per vaginum for initial 2-4 days, which subsided spontaneously. Among patients treated with cryotherapy the cervix became epithelialized and reached normal limit at six weeks in 26%. In the remainder, cervix had healed at the time of the three month examination. Of the eight patients, who failed with cryotherapy, six had to be taken for laser and remaining underwent hysterectomy as they also had coexistent abnormal uterine bleeding. Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study In patients treated by CO2 laser, 90% of the cervical wounds healed at six weeks and remaining by three months. Of the four patients who failed with laser therapy, three were given repeat laser and cervical lesions healed in them. One patient opted for hysterectomy. Discussion An experienced team composing of a clinician, a cytologist and a pathologist is required for an outpatient approach to be used safely as ruling out an invasive cancer is a must for outpatient management techniques of cervical lesions. The side effects associated with outpatient management techniques generally are minor and certainly fewer than those associated with conization or hysterectomy. In the present study, majority of the women in both the study groups were in between 26-35 years. The mean age of the study Groups I was 29.6 years and study Group II was 30.86 years. Both the groups were comparable in age, parity and socioeconomic status. On the basis of per speculum examination, Pap smear and colposcopic examination at three months after the treatment, the failure rate was 16% for cryotherapy and 8% for CO2 laser therapy in our study. The results were not statistically significant (p > 0.05) (Table 6). The therapeutic success decreased with increasing lesion size and histological grade, lesion size being more important variable. Cryotherapy and laser treatment results were identical for Grade 1+ and Grade 2+ CIN; whereas, Grade 3+ CIN, responded comparatively better to laser (failure rate 14%) than cryotherapy (failure rate 37.5%) (p value 0.30) (Table 6). Similar findings were reported by Townsend and Richart who concluded that results of treatment were not significantly different for cryotherapy and CO2 laser therapy, with failure occurring in 7% of patients treated with cryotherapy and 11% of those treated with CO2 laser therapy. Therapeutic success decreased with increasing lesion size.1 Ferenczy reported that cryotherapy and CO2 laser treatment results were identical for Grade 1 and 2 lesions, whereas Grade 3 + CIN responded comparatively better to laser (94%) than cryotherapy Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

(61%) (p < 0.1). In large lesions, cryotherapy failures (38%) were considerably higher than laser failures (8%).2 Jobson and Homesley3 and Mitchell et al4 also reported comparable cure rates for both cryotherapy and CO2 laser ablation. In our study, healing was faster in patients treated with CO2 laser therapy than patients treated with cryotherapy. Similar conclusions have been reported by Townsend and Richart1 and Ferenczy.2 In our study, abdominal pain (84%) and headache (36%) was the main complaint by patients during cryotherapy while patients treated with laser had less abdominal pain (8%) and headache (4%). Only two patients treated with laser had slight bleeding during the procedure. In our study, vaginal discharge was present in all the patients treated with cryotherapy and in only 36% patients treated with COÂ2 laser therapy (p < 0.05). Patients treated by CO2 laser had a greater risk of bleeding during and after the procedure as compared to patients treated with cryotherapy. Similar findings were reported by Townsend and Richart,1 Ferenczy2 and Berget et al.5 Conclusion Based on this study, it can be concluded that cryotherapy is a cost-effective treatment modality for benign cervical lesions, but in a government institution like ours where both treatment modalities are available and cost of treatment is not an issue, the lesion should be graded, according to the size and distribution and accordingly the best modality for the outpatient treatment should be chosen. Cryotherapy appears to be treatment of choice for CIN lesions <2.5 cm. The remaining lesions, >2.5 cm or those with limited endocervical extension may be managed with laser. The use of laser is also recommended for CIN lesions that have failed after two cryotherapies. Laser has the advantage of faster healing and fewer side effects. After laser therapy the squamo-columnar junction is positioned appropriately at the external os for future screening. 21

clinical study References 1.

Townsend DE, Richart RM. Cryotherapy and carbon dioxide laser management for cervical intraepithelial neoplasia: a controlled comparison. Obstet Gynecol 1985;61(1):75-8.

Ferenczy A. Comparison of cryo- and carbon dioxide laser therapy for cervical intraepithelial neoplasia. Obstet Gynecol 1985;66(6):793-8.

Jobson VW, Homesley HD. Comparison of cryosurgery and carbon dioxide laser ablation for treatment of cervical intraepithelial neoplasia. J Gynecol Surg 1984;1 (3):173-80.

4. Mitchell MF, Tortolero-Luna G, Cook E, Whittaker L, Rhodes-Morris H, Silva E. A randomized clinical trial of cryotherapy, laser vaporisation and loop electrosurgical excision for treatment of squamous intraepithelial lesions of the cervix. Obstet Gynecol 1988;92(5): 737-44. 5. Berget A, Andreasson B, Bock JE, Bostohe E, Hebjorn S, Isager-Sally L, et al. Outpatient treatment of cervical intraepithelial neoplasia. The CO2 laser versus cryotherapy, a randomized trial. Acta Obstet Gynecol Scand 1987;66(6): 531-6. 

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

Clinical study

To Compare the Efficacy of Cryotherapy, Electrocautery and Laser Vaporization in Treatment of Benign Cervical Lesions Urmila Karya*, Pooja Arora**, Abhilasha Gupta†

Abstract Aims and objectives: To compare and evaluate the efficacy of different ablative modalities i.e., cryotherapy, electrocautery and laser vaporization in treatment of benign cervical lesions. Methods: The study was conducted on 300 patients who attended Gyne OPD of LLRM Medical College, Meerut with benign symptomatic cervical lesions. They were randomly allocated into three treatment groups i.e., cryotherapy, electrocautery and laser vaporization. Three different modalities were compared and evaluated for efficacy of treatment, intraoperative acceptability, tolerance, postoperative side effects and healing time taken by different modalities. Results: Result shows that patients in all groups tolerated procedures well. Mean healing time was minimum for laser vaporization i.e., four weeks and for cryotherapy and electrocautery is eight weeks with p value <0.001. Intraoperative and postoperative side effects were least with laser vaporization in terms of pain, bleeding and discharge with p value <0.001. Conclusion: Laser vaporization is best method to treat benign cervical lesion with minimum healing time four weeks and least side effect. Key words: Benign cervical lesions, cryotherapy, electrocautery, laser vaporization

enign cervical lesions i.e. chronic cervicitis, cervical erosions, cervical polyps are one of the most common disorders encountered in gynecological OPDs in day-to-day practice. Benign lesions are mostly asymptomatic but these can increase morbidity of the patient when they are associated with distressing symptoms such as excessive discharge per vaginal (PV), intermenstrual bleeding, postcoital bleeding, dysmenorrhea, dyspareunia, etc. These lesions have potential to progress to cervical cancer precursors. So, early diagnosis and treatment of these lesions decreases patient’s morbidity by relieving distressing symptoms and also prevent their progression into cancer precursors. Various treatment modalities such as laser vaporization, cryotherapy and electrocautery can be used to cure these benign cervical lesions. This study was done to evaluate these modalities in terms of patient’s acceptability and tolerance and to compare their efficacy in treatment of these lesions. *Professor **PG Student † Associate Professor Dept. of Obstetrics and Gynecology LLRM Medical College, Meerut, UP Address for correspondence Dr Urmila Karya Associate Professor Dept. of Obstetrics and Gynecology LLRM Medical College, Meerut, UP E-mail: urmila726@gmail.com

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

Aims and Objectives To compare and evaluate the efficacy of different ablative modalities i.e., cryotherapy, electrocautery and laser vaporization in treatment of benign cervical lesions. Methodology This study was a prospective randomized clinical trial to determine efficacy of ablative therapeutic modalities i.e., laser vaporization, cryotherapy and electrocautery in treatment of benign cervical lesions. This study was conducted at Dept. of Obstetrics and Gynecology, LLRM Medical College, Meerut from September 2010 to December 2011. Three hundred women aged 20-60 years attending gynecological OPD with symptomatic benign cervical lesions were recruited for study. Exclusion criteria were women who were pregnant, women using OCPs and those having obvious invasive cancer at time of clinical evaluation. After detailed history and examination informed written consent was obtained from each patient for participation in the study. Randomization was done by using computer generated random numbers and with use of opaque sealed envelopes, women were randomly 23

clinical study

Figure 1. Before treatment.

Figure 2. Lesion stained with VIA + VLI.

Figure 3. After laser vaporization at 12 weeks.

Figure 4. Outlined lesion with cautery.

Figure 5. After cautery.

Figure 6. With cryoprobe.

Figure 7. Completed iceball.

allocated one of three ablative modalities. Pap smear and visual inspection with acetic acid was done in all the patients (Figs. 1 and 2). CO2 laser vaporization was done in minor OT under cervical block at 12, 4 and 7â&#x20AC;&#x2122;O clock position using doris plus CTL 1401 laser medical unit (Fig. 3). Cervical lesions were ablated by continuous laser beam using power density of 20-25 watts. Depth of beam was 5 mm. Cryocautery was done in minor OT without any anesthesia by using Appaswamy Cryostat using nitrous oxide as refrigerant

(Figs. 4-7). The cervical probe was kept in place till ice ball spread 2-3 mm beyond the lesion on to normal cervix. This takes 2-3 minutes. Electrocautery was performed in minor OT under cervical block. The whole lesion was cauterized by cautery point giving linear strokes starting from inside cervical canal to over eroded area. None of the patients were hospitalized; they were sent home two hours after the procedure. No local Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study Results

medication, douching or packing was allowed. Patients were advised to abstain from intercourse for six weeks. Patients were prescribed prophylactic antibiotics for five days.

A total of 300 patients with symptomatic benign cervical lesions were enrolled in the study and were randomly assigned to three study groups. A total of 100 (33.3%) patients were allocated in each group depending upon mode of treatment. In Group I, laser vaporization was utilized as the mode of treatment while in Group II, cryotherapy was performed. In Group III, the treatment modality was electrocautery. Baseline demographic and obstetrics history were comparable in all three groups as listed in Table 1. The distribution of different cervical lesions was comparable as shown Table 2.

Intraoperative pain was evaluated on ‘Verbal Rating Scale (VRS)’. In VRS patient was asked to rate their pain on a scale, which is illustrated as 0 - No pain, 5 - Moderate pain, 10 - Worst pain ever. Patients were advised to come for regular follow-up at 2, 4 and 8 weeks. All groups were followed and observed for postoperative complications i.e., pain, bleeding PV, discharge PV; cure of disease by direct visualization and Pap smear after three months; time taken for healing of lesions; incomplete healing: Requirement of other therapies and secondary treatment of lesion after three months.

None of the subjects in Group II had bleeding. Majority of subjects in Groups I and III had mild bleeding. None of the subjects in any group had severe bleeding. There were 16

Table 1. Demographic and Obstetric History Variable

Group I (n = 100)

Group II (n = 100)

Group III (n = 100)

Significance of difference

34.26 ± 7.42 (21-48)

32.96 ± 5.98 (22-48)

33.34 ± 6.96 (23-54)

F = 0.481; p = 0.619 (ANOVA)

Hindu

78 (78%)

72 (72%)

74 (74%)

χ2 = 4.625; p = 0.328

Muslim

22 (22%)

28 (28%)

22 (22%)

Others

4 (4%)

Primi (P1)

12 (12%)

2 (2%)

10 (10%)

Multi (P2-4)

80 (80%)

76 (76%)

66 (66%)

8 (8%)

22 (22%)

24 (24%)

Condom

16 (16%)

8 (8%)

14 (14%)

IUCD

14 (14%)

6 (6%)

14 (14%)

Ligation

16 (16%)

26 (26%)

30 (30%)

None

54 (54%)

60 (60%)

42 (42%)

Mean age ± SD (Range) Religion (No., %)

Parity (No. %)

Grandmulti (P4+)

χ2 = 8.425; p = 0.077

Contraceptive method χ2 = 7.033; p = 0.318

Table 2. Per Speculum Findings at Enrolment Finding

Group I (n = 100)

Group II (n = 100)

Group III (n = 100)

Significance of difference

No.

χ2

Cervical erosion

0.863

0.649

Hypertrophied cervix

1.068

0.586

Bleeds to touch

0.063

0.969

Multiple Nabothian cysts

2.568

0.277

Congested cervix

3.289

0.193

Cervical polyp

6.643

0.036

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study (32%) subjects in Group III who had moderate bleeding. Statistically, there was a significant difference among the groups (p < 0.001) (Table 3). None of the subjects in Group II had any pain. The mean pain score in Group I was 1.46 ± 0.86 (Range 0-4), whereas the mean pain score in Group III was 3.48 ± 1.39 (Range 0-6). Statistically, there was a significant difference among the groups (p < 0.001) (Table 4). Postoperative vaginal discharge was excessive for 2-4 weeks and moderate upto six weeks in Table 3. Intraoperative Pain (VRS) Mean pain 1.46

SD 0.86

Min 0

Max

III

3.48

1.39

F = 171.466; p < 0.001

Table 4. Intraoperative Bleeding Grade

Group I (n = 100)

Group II (n = 100)

Group III (n = 100)

No.

None

100

Mild

Moderate

Severe

Survival Function

Table 5. Healing Status at Week 12 No. healed

100

III

100

Group 1 2 3

1.0

χ2 = 149.383 (df = 3); p < 0.001

Groups

Comparison of healing time showed median time to be same in Groups II and III (8 weeks), whereas in Group I it was only four weeks. Mean healing time was observed to be 4.42 ± 0.164 weeks in Group I, whereas the same was 7.52 ± 0.21 weeks in Group II and 9.52 ± 0.28 weeks in Group III (Table 6). KaplanMeier survival analysis was done to evaluate the healing time in three groups. The difference among groups was observed to be significant statistically (p < 0.001). At all the time intervals, a significant difference among groups was observed. It was observed that Group I had both, early response as well as early complete response. In Group II, the response was late as well as not complete. At eight week assessment, no significant difference was observed among the groups (p = 0.090).

0.8 Cum Unhealed

Group I

Group II. Statistically, there was a significant difference among the groups (p < 0.001). Cure rates were 100% in Group I and III while they were 96% in Group II (Table 5).

0.6 0.4 0.2 0.0 0

2 4 6 8 10 Time taken for healing of lesion

Figure 8. Time taken for leading lesion by the three treatment modalities.

χ2 = 4.054; p = 0.132

Table 6. Time Taken for Healing Group

Meana

Median

Estimate

Std. Error

95% CI

Estimate

Std. Error

Lower

Upper

4.420

0.164

4.098

7.520

0.211

9.520

Overall

7.153

95% CI Lower

Upper

4.742

4.000

0.143

3.719

4.281

7.107

7.933

8.000

0.116

7.773

8.227

0.283

8.965

10.075

8.000

0.661

6.705

9.295

0.215

6.732

7.574

8.000

0.208

7.592

8.408

Estimation is limited to the largest healing time if it is censored.

χ2 = 143.384 (df = 2); p < 0.001 (Log Rank Test)

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study By 12 weeks assessment all the subjects in Group I and Group III showed complete response, however, in Group II, three patients had slight discharge till 12 weeks interval. All the cases had normal findings on Pap smear at 12 weeks. At 12 weeks, all the patients in Groups I and III showed healing whereas in Group II, healing could be observed in 48 (96%) patients only. Statistically, there was no significant difference among the groups (Fig. 8). Discussion Benign cervical lesions are important cause of significant morbidity in female patients attending gynecological OPD. These can be precancerous as well. So, they should be treated as they are diagnosed or should be meticulously followed using modalities such as Pap smear, visual inspection with acetic acid (VIA) or colposcopy. In the Indian scenario, follow-up is difficult as patients are illiterate and ignorant towards the morbidity and progression of the disease, so they should be treated as soon as they are diagnosed by using various ablative methods. Kulkarni et al concluded that socioeconomic factors such as illiteracy and low literacy status, lower socioeconomic status, early age at marriage and high parity are contributory for the occurrence of cervical erosion. Efficacy in terms of cure rate was equal in all three groups with statistically no difference, but intraoperative and postoperative side effects were least with laser vaporization and mean healing time was also minimum for laser vaporization i.e. four weeks and for cryotherapy and electrocautery it was eight weeks with p value <0.001. Dalgic and Kuscu1 in their study presented 26 cases of chronic cervicitis managed with laser with a success rate of 93% and they advice this method to prevent the development of cervical intraepithelial neoplasm. Rubinstein.2 in their study revealed that all the treated women in the study exhibited preoperatively severe subjective symptoms for chronic cervicitis, and 32 out of 60 (53%) exhibited colposcopically atypical squamous epithelium. The women were examined 3, 6 and 12 months following laser surgery: 58 (97%) of them reported a decreasing intensity of their symptoms, and colposcopy revealed a normal post laser transformation zone as well as a decreasing edema of cervical epithelium. Kwikkel et al3 concluded that vaginal discharge, both in duration and amount, was significantly less in Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

patients treated with laser vaporization, compared with cryotherapy, but pain and bleeding occurred more often in patients treated with laser vaporization, however widespread introduction of laser facilities in smaller centers is not justified, because the success rates are not better than those of cryotherapy, and because the advantages of less discharge are outweighed by the high cost. Mitchell4 compared cryotherapy, laser vaporization and loop electrical excision for treatment of squamous intraepithelial lesions. They found a high success rate, with all three modalities. No significant difference in success rate was observed between the three treatments. Townsend and Richart5 studied the efficacy of carbon dioxide laser in the treatment of cervical intraepithelial neoplasia (CIN) and found it to be very effective. Berget et al6 compared the results of laser and cryosurgery for CIN after long-term follow-up. The cure rate after laser therapy was 97% and after cryotherapy was 99%. Conclusion Although laser vaporization is a costly modality, but if available, laser vaporization is the best modality among different ablative modalities in treating benign cervical lesions and early cervical cancer precursor with minimum mean healing time and least intraoperative and postoperative complications and side effects among all the three modalities. References 1.

Dalgic H, Kuscu NK. Laser therapy in chronic cervicitis. Arch Gynecol Obstet 2001;265(2):64-6.

Rubinstein E. CO2 laser vaporization for chronic cervicitis. Lasers Surg Med 1985;5(6):563-9.

Kwikkel HJ, Helmerhorst TJ, Bezemer PD, Quaak MJ, Stolk JG. Laser or cryotherapy for cervical intraepithelial neoplasia: a randomized study to compare efficacy and side effects. Gynecol Oncol 1985;22(1):23-31.

Mitchell FM, Cantor SB, Ramanujam N, Tortolero-Luna G, Richards-Kortum R. Fluorescence spectroscopy for diagnosis of squamous intraepithelial lesions of the cervix. Obstet Gynecol 1999;93(3):462-70.

Townsend DE, Richart RM. Cryotherapy and carbon dioxide laser in management of cervical intraepithelial neoplasia: a controlled comparison. Obstet Gynecol 1983;61(1):75-8.

Berget A, Andreasson B, Boik JE. Laser and cryo surgery for cervical intraepithelial neoplasia. A randomized trial with long-term follow-up. Acta Obstet Gynecol Scand 1991;70(3):231-5.

Clinical Study

Outcome of Prelabor Rupture of Membranes in a Tertiary Care Center in West Bengal Barunoday Chakraborty*, Tamal Mandal**, Subhankar Chakrabortyâ&#x20AC;

Abstract The etiology is unknown in majority of cases though bacterial infection, cervical incompetence, hypertensive disease, recent coitus, malpresentation, antepartum hemorrhage (APH), malnutrition are recognized causes of prelabor rupture of membranes (PROM). A study was conducted in our institution in 2011, where 478 cases out of a total obstetric admission of 9,637 presented with PROM. Spontaneous rupture of membranes after 28 weeks of gestation before the onset of labor is called PROM. When it occurs before 37 completed weeks of gestation it is called preterm PROM (pPROM). The term PROM cases were induced after waiting for 24 hours for a spontaneous onset of labor. The preterm population were divided in three groups and were given treatment as; Group A: with beta-mimetic, antibiotic, steroid, iron and folic acid (IFA); Group B: With steroid, antibiotic, natural progesterone and IFA; Group C: With only antibiotic and IFA. Observed neonatal mortality in the very preterm group (<34 weeks) was 10% as compared to 5.8% in preterm (34-37 weeks) and nearly 3% among term pregnancies. Treatment of pPROM cases with steroid and antibiotic compared with addition of natural progesterone with or without beta-mimetic did not show any significant difference in terms of Apgar score, need for resuscitation in absence of maternal infection. Elective lower segment cesarean section (LSCS) showed a zero neonatal mortality, better Apgar score and significantly lesser requirement of neonatal resuscitation compared to emergency LSCS. It was concluded that gestational age at the time of delivery is the main determinant of neonatal body weight as well as survival among PROM cases. Beta-mimetics and progesterone showed no role to prolong pregnancy in PROM cases. Key words: PROM, pPROM, Apgar score, neonatal mortality

relabor rupture of membranes (PROM) is defined as the spontaneous rupture of membranes any time beyond 28th week of pregnancy but before the onset of labor.1 Premature prelabor rupture of membranes (pPROM) is defined as the spontaneous rupture of membranes during the period from viability to 37 completed weeks prior to the onset of labor.2 PROM complicates 5-10% of all pregnancies. At least 60% cases of PROM occurs at term.3 PROM is one of the important causes of preterm labor and prematurity. Chance of ascending infection in PROM is more if labors fails to start within 24

*Associate Professor **2nd Year Student â&#x20AC; Rotating House Physician Dept. of Obstetrics and Gynecology Bankura Sammilani Medical College and Hospital, Bankura, West Bengal Address for correspondence Dr Barunoday Chakraborty Associate Professor Dept. of Obstetrics and Gynecology G-5/26, College Quarter, Bankura Sammilani Medical College Bankura - 722 102, West Bengal E-mail: c.subhankar@gmail.com

hours.1 Chorioamnionitis, cord prolapse, dry labor and neonatal respiratory distress syndrome (RDS) are the complications of PROM. Fetal pulmonary hypoplasia, especially in preterm PROM is a real threat when associated with oligohydramnios.1 The current study was conducted to investigate the efficacy of three different management protocols in cases with pPROM and to know the fetomaternal outcome. Review of Literature Review of available literature shows that rupture of membranes is related not only to bacterial infection but also to cervical incompetence, hypertensive disease, recent coitus, malpresentation, antepartum hemorrhage (APH), and inappropriate nutrition. PROM is also found more commonly in low socioeconomic class with inadequate prenatal care and inadequate weight gain during pregnancy.5 The etiology of pPROM is uncertain though probably multifactorial. The final common pathway usually Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study involves a subclinical chorioamnionitis, which is facilitated via cervical changes leading to a loss of integrity of the canal or particular organisms being present in the vagina allowing overgrowth of unwanted organisms. The effect is a cascade of biochemical changes in the fetal membranes and decidua which ultimately lead to prostaglandin and cytokine release and up regulation of intracellular messengers. In turn these changes lead to cervical ripening and membrane disruption. Increased uterine activity is often not far behind.3 The history of leaking fluid or gushing of water from vagina is diagnostic in over 90% cases. Different tests like nitrazine test, fern test, evaporation and diamine oxidase tests are done to confirm PROM. Now-adays, ultrasound examination is also a popular method of diagnosis of PROM.5 On examination, the fetal presentation needs to be assessed as there is high chance it may not be cephalic. A sterile speculum examination should be performed and high vaginal swab (HVS) to be taken. Per vagina (PV) examination should be avoided. Liquor is usually clear and colorless, though it may be pink. White cell count and C-reactive protein (CRP) have been investigated as possible better predictor of evolving chorioamnionitis but are not reliable.3 The microorganisms most commonly identified in the membranes and amniotic fluid of pregnancies complicated with spontaneous preterm labor with intact membranes are Ureaplasma urealyticum, Mycoplasma hominis, Gardnerella vaginalis, Mobiluncus, and bacteroides. The microorganisms most commonly associated with clinical chorioamnionitis and fetal infection after rupture membrane are Group Bstreptococci (GBS) and Escherichia coli. However, the association between preterm labor and lower genital tract colonization with these organisms is less clear. Upto 30% of pregnant women are colonized with GBS. GBS is the leading cause of neonatal sepsis and a substantial number of neonatal sepsis occurs among preterm infants.6 Birth asphyxia is the most common neonatal morbidity seen among PROM and reaches upto 40% followed by RDS seen nearly among 28% cases. Study carried out in West Bengal, India showed that 68% babies were healthy, 27% were asphyxiated and revived, 3.5% were asphyxiated and could not be revived and 1.5% are stillborn. The incidence of neonatal morbidity Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

increases as duration of PROM increases. Apart from infection (pneumonia, meningitis, sepsis), pulmonary hypoplasia, limb and body deformities, umbilical cord compression or prolapse and abruptio placentae are occasional complications of PROM.5 The optimum management of PROM would be that, which minimizes the risk of both RDS and maternal and perinatal infection.4 The Cochrane review of over 6,000 randomized women shows that there is no difference in neonatal outcome from immediate induction of labor or waiting upto four days. There is no evidence that routine use of antibiotics improve neonatal outcome in absence of an indication for GBS prophylaxis.3 Random treatment of pregnant women of third trimester with oral erythromycin or placebo continuously for 10 weeks to treat GBS colonization, chlamydia and U. urealyticum resulted in no significant improvement of preterm delivery in pPROM. Majority of randomized control trials with antibiotic treatment of lower genital tract infections in cases of bacterial vaginosis (BV) have failed to show any significant benefit in terms of preterm labor and neonatal body weight. However, there is significant heterogeneity between studies. The Center for Disease Control (CDC) in USA notes in its guideline that evaluation of BV be conducted at the first prenatal visit for asymptomatic woman who are at risk of preterm labor. But current evidence does not support routine testing for BV.6 The practice in our center is to treat an woman with PROM with antibiotics e.g. amoxycillin, which aims at preventing neonatal sepsis and maternal postnatal morbidity. The use of progesterone administration to improve pregnancy outcome in threatened preterm labor dates back to as early as 1950s. The results of these early trials were summarized in two meta-analyses published in 1989 and 1990. One of these meta-analyses found positive efficacy of progesterone in reducing preterm delivery; whereas, the other did not find any. Erny et al in 1986 used 400 mg of micronized progesterone orally or a placebo in their patients with 30-36 weeks of gestation who were at risk of preterm labor. After one hour all their patients received intravenous ritodrine for tocolysis. The frequency of uterine contractions decreased in 76% of the progesterone group and 43% of the placebo group. Although progesterone treatment to prevent preterm delivery is not considered 29

clinical study standard of care now-a-days, many clinicians may, in their wisdom decide to use this drug for these specific groups of women.6 Although it is generally accepted that antenatal glucocorticoids reduce RDS in preterm pregnancies with intact membranes their use in pregnancies with PROM has been studied in limited number of prospective trials with conflicting results.8 In absence of fetal and maternal compromise, where the presentation is cephalic, vaginal delivery is usually indicated. Where the presentation is breech there is no evidence to suggest that cesarean section improves neonatal outcome. Generalization is difficult and decision needs to be individualized. Generally, outcome is related to the period of gestation, birth weight and fetal sex as with all preterm births. In pPROM particularly, fetal/neonatal sepsis will result in worse outcome.3 Aims and Objectives The objectives of the study were  To observe the perinatal and maternal outcome in PROM treated with  Isoxsuprine + antibiotic + iron and folic acid (IFA)  Natural progesterone+antibiotic + IFA  Only antibiotic + IFA  To note the perinatal outcome in different modes of delivery in PROM cases, e.g.  Elective lower segment cesarean section (LSCS)  Emergency LSCS after a failed induction of labor after six hours  Vaginal delivery Material and Methods The study was conducted at “Bankura Sammilani Medical College and Hospitals,” which is a tertiary care center in a district town in West Bengal. The duration of the study was six months during April to September, 2011. All the patients presented with PROM to the Dept. of Obstetrics and Gynecology, during that period were admitted. Then considering the previously set criteria mothers suitable for the study were included in the study population. The exclusion criteria were 30

 

   



Patient, in labor Pre-eclampsia/Pregnancy-induced hypertension (PIH) Multiple pregnancy Patients already suffering from fever Intrauterine fetal death Diagnosed cases of placenta previa and accidental hemorrhage Fetal congenital anomaly

As per the said design we got 478 pregnant mothers complicated with PROM out of a total obstetric admission of 9,637 mothers. All the participant mothers gave informed consents. Detailed history was taken from every case and period of gestation was noted. On clinical examination, we noticed maternal height, weight pulse, blood pressure temperature and condition of heart, lung, liver and spleen. We also noticed fetal heart rate and whether patient was in labor or not by per abdominal examination. Internal examination was done by a consultant or a senior resident to exclude any cord prolapse. A high vaginal swab was taken for bacteriological examination. Hematological investigations were done for Hb%, ABO and Rh-typing. Blood sugar estimation and VDRL testing were also done. Routine and microscopic urine examinations were also performed. Anaerobic culture specific for GBS is not a routine practice in our institution. Hence special arrangements to do the same failed due to official delay in face of a short notice and also prohibitive cost of the detection kit. Ultrasonography was prescribed in every case to determine feto-placental profile and liquor volume. Regarding treatment, we waited for 24 hours for spontaneous onset of labor in term PROM cases (e.g. 37 weeks of gestation). But in preterm cases we divided the study population in three groups for three different management protocols as namely  Group A: Isoxsuprine (10 mg TDS) + antibiotic (cap amoxycillin 500 mg TDS) + betamethasone (12 mg IM 12 hourly two such for 24 hours) + IFA  Group B: Natural progesterone (200 mg orally at bed time) + betamethasone (12 mg IM 12 hourly two such for 24 hours) + antibiotic (amoxycillin 500 mg cap TDS) + IFA  Group C: Only antibiotic+ IFA Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study But most of the consultants working here disagreed to prescribe isoxsuprine and natural progesterone and preferred only antibiotic. We followed up the cases till the onset of labor or termination by induction and subsequent events. The different modes of delivery i.e., spontaneous vaginal delivery, vaginal delivery following induction of labor and LSCS were noted in each case. Birth weight of the babies and Apgar score were recorded. Birth weight <1.5 kg and/or Apgar score <7 babies were sent to sick neonatal care unit (SNCU) attached to the same building. Any resuscitation measure undertaken on the neonate was recorded. We could not follow the mothers for three days following vaginal delivery due to heavy patient load and shortage of bed. Here, the practice is to discharge the patients with vaginal delivery after 24 hours. But, we followed mothers for seven days following cesarean section. Results During our study, we followed 9,637 pregnant mothers admitted in our department. Out of them, 478 mothers were included in our study as they fulfilled the inclusion criteria. Table 1 shows the distribution of PROM at different gestational periods. Thirty mothers (n1) were in between 28-34 weeks; 34 mothers (n2) were in between 34-37 weeks and finally 414 mothers (n3) presented beyond 37 completed weeks. There was three neonatal deaths

in the first group; 2 neonatal deaths occurred in group n2 and 13 deaths occurred in group n3. The neonates born to group n1 mothers had birth weights ranging from 0.7 to 2.6 kg. The second group of mothers (n2) had the neonates ranging from 2.2 kg to 3.1 kg and finally the n3 group had their neonatal birth weights ranging in between 2.75 kg to 3.3 kg. Table 2 shows the perinatal events among the 64 mothers (n1+ n2) who had a PPROM and received treatment according to previously set protocol, e.g.  Group A: Treated with isoxsuprine + antibiotic  Group B: Treated with natural progesterone + antibiotic  Group C: Treated with only antibiotic Group A consisted of 10 cases; their neonatal body weights varied in between 1.5-2.6 kg. Apgar score varied in between 4-7. Baby resuscitation was necessary in nine cases with bag mask ventilation (BMV) and oxygen inhalation. There were two neonatal deaths. Group B consisted of 14 cases with pPROM; their baby weights were in between 2.3-3 kg; Apgar score in between 4-8 and four babies required resuscitation in the form of BMV and oxygen and there was no perinatal mortality. Group C consisted of 40 cases, where the birth weights were in between 0.7-3.1 kg; Apgar scores between 2-9; baby resuscitation was necessary in 28 cases and there were nine neonatal deaths. Records regarding perinatal outcome in different modes of delivery has been tabulated

Table 1. Distribution of PROM of Different Gestational Periods Ge stational age Criteria

28-34 weeks (n1 = 30)

34-37 weeks (n2 = 34)

>37 weeks (n3 = 414)

Baby weight (kg)

0.7-2.6

2.2-3.1

2.75-3.3

Neonatal mortality

3 (10%)

2 (5.8%)

13 (3.14%)

Neonatal resuscitation required

27 (90%)

21 (61.7%)

49 (11.8%)

Table 2. Perinatal Events Among Mothers who Received Treatment for PROM Treatment protocol groups Criteria No of cases Neonatal body weight (kg) Apgar score

Group A

Group B

Group C

1.5-2.6

2.3-3.0

0.7-3.1

4-7

4-8

2-9

Baby resuscitation

Neonatal mortality

2 (20%)

9 (22.5%)

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study in Table 3. Total number of vaginal delivery performed were 351 among 478 study cases (73.4%) and rest (i.e., 127 among 478 cases) had been delivered by LSCS. Among these 127 cases, 46 mothers had been operated electively (36.22%) and rest 81 mothers had undergone emergency LSCS. The electively operated mothers had their neonatal body weights ranging between 1.75-3.1 kg, Apgar scores varied between 4-7 and 13 neonates in this group required resuscitation in the form of BMV and/or oxygen inhalation. There was no neonatal mortality. In emergency, LSCS cases neonatal body weights varied in between 1.2-3.0 kg, Apgar scores varied in between 2-7 and 32 neonates required resuscitation measures. There were eight neonatal deaths in this group. On the other hand, the 351 mothers who delivered vaginally had their babies with body weights ranging in between 0.7-3.3 kg, Apgar scores in between 2-10 and 48 newborns among them required neonatal resuscitation. Twenty neonatal death were recorded in this group. Observations and Discussion Table 1 shows the distribution of neonatal body weights at different gestational ages. The number of cases under the term prom (414) was considerably larger than the other two groups e.g. preterm (34-37 weeks - 34 cases) and very preterm (<34 weeks - 30 cases only). It is also obvious that gestational ages at delivery has shown the main impact on neonatal body weights, neonatal mortality and need for neonatal resuscitation. Observed neonatal mortality of 10% in the very preterm group against 5.8% in preterm and nearly 3% among term pregnancies when compared in pairs did not show any significance but there was much higher incidence of neonatal resuscitation among preterm neonates against their term counterparts - 90% in very preterm, 60% in preterm and only 11.8% among term

neonates. One reason for this might be nonavailability of electronic fetal monitoring (EFM) in all cases, which could have indicated the optimum timing for a caesarean section. Morales et al in their study, observed a neonatal mortality of 5-12% among preterm rupture of membrane below 34 weeks.4 Table 2 shows that addition of isoxsuprine with steroid and antibiotic (Group A) or isoxsuprine, steroid and natural progesterone with antibiotic (Group B) did not show any significant benefit in terms of Apgar score, need for neonatal resuscitation. There was no incidence of neonatal mortality in the natural progesterone group, which was obviously due to higher birth weights (2.3-3.0 kg) as compared to other two groups-the finding that reinforces our claim that it is the birth weight in absence of maternal infection that is the major determinant of neonatal survival. Paul J Meis and Ngina Connors in their review â&#x20AC;&#x153;Progesterone Treatment to Prevent Preterm Birthâ&#x20AC;? have concluded that all the successful trials reported have indicated therapy relatively early in gestation (at <24 weeks) in women who showed no symptoms of preterm labor. Trials of progesterone compounds to aid in halting the progression of labor have not been successful and the use of progesterone in women who have had symptoms or signs of labor should be discouraged.6 Table 3 indicates that planned elective LSCS showed a zero neonatal mortality, better Apgar score and significantly lesser requirement of neonatal resuscitation compared to emergency LSCS (28.3% against 39.5%). Hassan et al in their study at Lahore found nearly 30% neonatal intensive care admission after emergency LSCS and nearly 13% after elective LSCS.9 Compared to this a mild but significant higher resuscitation rate in our study may allude to greater degree of prematurity and lack of universal EFM.

Table 3. Comparative Results of Elective and Emergency LSCS Modes of delivery perinatal outcome Neonatal body weight (kg) Apgar score Neonatal mortality Resuscitation required

Elective cesarean section Emergency cesarean section (n = 46) (n = 81)

Vaginal delivery (n = 351)

1.75-3.1

1.2-3.0

0.7-3.3

4-7

2-7

2-10

8 (9.8%)

20 (5.7%)

13 (28.3%)

32 (39.5%)

48 (13.6%)

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

clinical study Conclusion The study clearly indicates that gestational age at the time of delivery is the main determinant of neonatal body weight as well as survival among PROM cases. Having said that obstetrician should consider elective LSCS in appropriate cases to avoid unnecessary emergencies to save a valuable child thanks to NICU support and antibiotic prophylaxis. Beta-mimetics and progesterone have no role to prolong pregnancy in PROM cases. Continuous EFM can help to decide an optimum timing of LSCS terminating a trial of vaginal delivery. Suggested Reading 1.

DC Dutta. Textbook of Obstetrics. 6th edition, New Central Book Agency (P) Ltd.8/1 Chittaranjan Das Lane, Calcutta 700009. Page 317.

Duff P. Premature rupture of the membranes at term. N Engl J Med 1996;334(16):1053-4.

Parry E. Managing PROM and PPROM. O&G 2006;8(4):35-8.

Gershenson DM, Kavanagh JJ, Copeland LJ, Stringer CA, Morris M, Wharton JT. Re-treatment of patients with recurrent epithelial ovarian cancer with cisplatin-based chemotherapy. Obstet Gynecol 1989;73(5 Pt 1):798-802.

Shrestha SR, Sharma P. Fetal outcome of pre-labour rupture of membranes. Nepal J Obstet Gynaecol 2006;1(2): 19-24.

Clinical Obstetrics and Gynecology; Indian Edition, Prevention of Preterm Birth, by Paul J. Meis, Lippincott Williams & Wilkins, April 2005/volume1/Number2; p.203-09.

Sanyal MK, Mukherjee TN. Premature rupture of membranes an assessment from a rural medical college of West Bengal. J Obstet Gynaecol India 1990;40(5):623-8.

Morales WJ, Diebel ND, Lazar AJ, Zadrozny D. The effect of antenatal dexamethasone administration on the prevention of respiratory distress syndrome in preterm gestations with premature rupture of membranes. Am J Obstet Gynecol 1986;154(3):591-5.

Hassan S, Javaid MK, Tariq S. Emergency Caesarean section: a comparative analysis. Professional Med J 2008;15(2):211-5. 

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

Case Report

Conjoined Twins Requiring Abdominovaginal Approach for Delivery Chandrakant S Madkar*, Hemant G Deshpande

Abstract Conjoined twin is a rare but most complex congenital anomaly. If it presents in undiagnosed condition in late gestational period and late stage of labor with features of obstructed labor, it creates a challenging situation, which is presented by us in this case report. We required abdomino-vaginal approach for delivery to save the life of mother. Due to its rarity and interesting nature we present this case. Key words: Conjoined twins, monozygotic twins, monochorionic monoamniotic twins, decapitation

onjoined twins (CJT) are monochorionic monoamniotic twins fused at some portion of body as a result of incomplete delayed division of inner cell mass taking place after 14th postfertilization day.1 This disorder affects one in 200 monozygotic twins, one in 900 twins and one in 25,000 - 1 lac birth. Saraiya et al has reported three cases2 and recently Singh et al have reported one case.3

At 10.30 pm, her cervix was fully dilated followed by delivery of head but failure to deliver rest of the body for three hours inspite of all efforts by the Dai. Her GC was poor with exhausted and anxious look. Pulse = 134 b/min, BP = 90/60 mmHg, dehydration +, pallor +, RS - NAD, CVS - NAD.

They are classified based on anatomical site of fusion e.g., thoracopagus, omphalophagus (combination being most common), craniopagus, ischiopagus, etc.

PA - Tonic tender uterus with stretched lower segment and edematous bladder. Fetal parts difficult to palpate. FHS - absent.

We are presenting this case due to its rarity and different approach required for management.

PV - Congested head outside introitus. Neck in the vagina with abnormal protrusion extending to right from root of neck.

Case Report An unregistered patient was referred at late mid-night (1.30 am), with features of obstructed labor. She was G4 P3 with 3FTND and no antenatal care for the current gestation. She was accompanied by a â&#x20AC;&#x153;Daiâ&#x20AC;? who gave history of 8 and 1/2 months amenorrhea and

*Associate Professor **Professor and Head Dept. of Obstetrics and Gynecology DY Patil Medical Collage, Pimpri, Pune, Maharashtra Address for correspondence Dr Chandrakant S Madkar 52/781, Suyog Society Lokmanyanagar Navi Peth, Pune - 411 030, Maharashtra E-mail: drcsmadkar @ gmail.com,

sudden leaking of excessive liquor at 6 pm followed by loss of fetal movements.

Lab: Hb = 7 g/dl, WBC = 13,200/mm3, hematuria. Diagnosis of obstructed labor due to anomalous fetus was done. She was immediately taken to OT for cesarean section due to critical condition of the patient. Midline vertical incision was preferred. LUS was stretched with hemorrhagic patches. After incising uterus, another head was seen impacted in right corner. Both fetuses were united in thoraco-abdominal region s/o thoracoomphalophagus. The head lying outside introitus was separated by decapitation due to inability to push it into pelvis. Remaining fetus was delivered by abdominal route. Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

Case Report Ideally, all MZ twins must be screened at 10 and 20 weeks by expert radiologist with help of color Doppler and fetal MRI if required.

Figure 1. Thoraco-omphalophagus with aligned decapitated head.

For on X-ray, Gray4 criteria and USG, Koontz et al5 criteria are valuable guidelines. Further management depends on anatomical complexities and medical facilities available. If there is sharing of major organs like brain/heart; MTP is preferred. If favorable prognosis is anticipated then monitoring upto term and delivery by elective LSCS with further shifting the neonate to wellequipped pediatric unit with all facilities is essential. By doing this same we can save three lives. References 1.

Saraiya U, Bhalerao S. Multiple Pregnancies: Diagnosis and Management: A Clinical Approach. Keith LG, Gandhi J (Eds.), Jaypee Brothers Publications 2002 (Edition 1): p.298-302.

Saraiya S, Jassawala MJ, Dastur Adi, et al. Bombay Hospital Journal 1995;37(2):297-9.

SR catheter and sutures were removed on 10th day. Wound healing was satisfactory.

Singh N, Barya S, Pandey K, Dubey P, Kumar D. Doubleblind monster delivered vaginally. Asian J Obstet Gynecol 2011;3:35-6.

Discussion

Gray CM, Nix HG, Wallace AJ. Thoracopagus twins; prenatal diagnosis. Radiology 1950;54(3):398-400.

Koontz WL, Herbert WN, Seeds JW, Cefalo RC. Ultrasonography in the antepartum diagnosis of conjoined twins. A report of two cases. J Reprod Med 1983;28(9): 627-30.

Hemostasis achieved. It was female CJT with 4.7 kg birth weight. Post-op two blood transfusions and broad-spectrum antibiotics, were given.

Retrospectively, this tragedy could have been prevented by early diagnosis of the anomaly and MTP was better option for this patient, which was however not possible in her case due to late presentation.



Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

Case Report

Anton’s Syndrome and Cortical Blindness Srikant R Gadwalkar*, Deepa DV**, P Rama Murthy*, Ravi Dhar**

Abstract Introduction: Anton’s syndrome is a rare form of acquired cortical blindness, where the patient is unaware of being blind and denies the problem even when it is pointed out to him. On the contrary, in cortical blindness patient is aware of his blindness and does not deny it. In both, bilateral lesions of the occipital lobes are seen. Case presentation: We present two cases of cortical blindness, Case 1 being consistent with diagnosis of Anton’s syndrome where patient denied of her blindness. Both cases revealed bilateral occipital lobe infarcts. Conclusions: Cerebrovascular disease is the most common cause of cortical blindness. These occur as a result of successive infarctions as seen in Case 1 or from a single embolic or thrombotic occlusion as seen in Case 2. First case is Anton’s syndrome with patient denying blindness; whereas, second case is cortical blindness. It is due to involvement of other cortical centers in Anton’s syndrome that patient denies blindness. Key words: Anton’s syndrome, cortical blindness, bilateral occipital lobe infarcts

nton’s syndrome is a rare form of acquired cortical blindness, where the patient is unaware of being blind and denies the problem even when it is pointed out to him. On the contrary, in cortical blindness patient is aware of his blindness and does not deny it. In both, bilateral lesions of the occipital lobes are seen. Case Presentation Case 1

was no history suggestive of any other cranial nerve involvement, motor deficits or sensory loss. There was no history of any bladder or bowel involvement. There was no history of previous medical illnesses or any visual abnormalities. Following this, she was taken to a general physician, where she was found to have high blood pressure and was prescribed antihypertensive medication and referred to the present hospital.

A 52-year-old married, right handed woman presented with history of headache and sudden, painless loss of vision since five days. Patient was apparently normal five days back, when she developed acute onset headache. After around five hours she started colliding into objects suggesting she was blind. Patient denied being blind and had no ocular symptoms like floaters, watering of eyes or ocular pain. She had no history of fever, seizures, trauma or any drug intake. There

*Professor and Head **Post Graduate Student Dept. of General Medicine, Vijayanagar Institute of Medical Sciences Bellary, Karnataka Address for correspondence Dr Srikant R Gadwalkar Professor and Head, Dept. of General Medicine, Vijayanagar Institute of Medical Sciences, Bellary, Karnataka E-mail: srikantbly@gmail.com

Figure 1. Radiological findings: Axial computed tomography brain plain showing ill-defined hypodensities in the right occipital and left temporoparietooccipital regions suggesting infarcts.

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

Case Report

Figure 2 and 3. Radiological findings: Axial sections of magnetic resonance imaging showing altered signals in the left temporoparietooccipital lobe and right occipital lobe suggestive of a large subacute infarct in the left temporoparietooccipital lobe involving P2 segment of posterior cerebral artery and a gliotic lesion (chronic infarct) in the right occipital lobe.

On arrival to the hospital, patient had a Glasgow Coma Scale score of 15 out of 15, but was agitated. Her blood pressure recording was 130/80 mmHg. On examination, patient had severe visual impairment with no perception of light. She walked into objects but denied of being blind. On asking her to describe the object in front of her, her reply was incorrect. Patient was oriented to time, place and person, speech, intelligence was normal but irritable in her behavior. There was no abnormality of any other cranial nerves. Pupillary reflexes were intact with normal fundus. Patient had normal power in all four limbs and no sensory loss. Cerebellar functions were normal. Skull and spine examination was normal. Rest of the examination was normal. The laboratory investigations revealed normal hemogram and biochemistry. Electrocardiogram and echocardiography, carotid and vertebral Doppler were normal. Computed tomography revealed ill

Figure 4. Radiological findings: Coronal sections of magnetic resonance imaging showing altered signals in the left temporoparietooccipital lobe and right occipital lobe suggestive of a large subacute infarct in the left temporoparietooccipital lobe involving P2 segment of posterior cerebral artery and a gliotic lesion (chronic infarct) in the right occipital lobe.

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

defined hypodensity in the right occipital region with surrounding edema and hypodensity in left temporoparieto-occipital regions (Fig. 1). Magnetic resonance imaging revealed altered signal in the left temporoparietooccipital lobe and right occipital lobe suggestive of a large subacute infarct in the left temporoparietooccipital lobe with a gliotic lesion (chronic infarct) in the right occipital lobe. Patient was given medication to reduce cerebral edema measures, which reduced her agitated behavior. Antiplatelet agents and statins were started. There was no significant improvement is her vision. Patient was discharged after seven days with focus on secondary prevention and rehabilitation. Case 2

A 60-year-old married, right handed man presented with history of sudden, painless loss of vision since one day. Patient was apparently normal on the previous day, when he developed sudden, painless loss of vision and had no ocular symptoms like floaters, watering of eyes or ocular pain. He had no history of fever, seizures, trauma or any drug intake. There was no history suggestive of any other cranial nerve involvement, motor deficits or sensory loss. There was no history of any bladder or bowel involvement. He was a known hypertensive on antihypertensive medication since the last eight years. He is married having two children. He was a smoker and alcoholic since 20 years. On arrival to the hospital, patient had a Glasgow Coma Scale score of 15 out of 15. His blood pressure recording was 160/92 mmHg. On examination, patient had severe visual impairment with no perception of light. 37

Case Report His higher mental functions were normal. There was no abnormality of any other cranial nerves. Pupillary reflexes were intact with normal fundus. Patient had normal power in all four limbs and no sensory loss. Skull and spine examination was normal. Cerebellar functions were normal. Rest of the examination was normal. The laboratory investigations revealed normal hemogram and biochemistry. Electrocardiogram, echocardiography, carotid and vertebral Doppler were normal. Computed tomography revealed ill-defined hypodensities in the right occipitotemporal and left occipital regions with surrounding edema. Patient was given medication to reduce cerebral edema, antiplatelet agents and statins were started. There was no significant improvement is his vision. Patient was discharged after four days with focus on secondary prevention and rehabilitation. With further follow-up, both patients had a slight improvement in vision though recovery in visual acuity remained low. Discussion The ability to recognize visually presented objects and words depends on the integrity not only of the visual pathways and primary visual area of the cerebral cortex (area 17 of Brodmann) but also of those cortical areas that lie just anterior to area 17 that is areas 18 and 19 of the occipital lobe and area 39 - the angular gyrus of the dominant hemisphere (visual association areas).1 Bilateral infarction in the distal posterior cerebral arteries (PCAs) produces cortical blindness (blindness with preserved pupillary light reaction). The patient is often unaware of the blindness or may even deny it (Anton’s syndrome). Tiny islands of vision may persist, and the patient may report that vision fluctuates as images are captured in the preserved portions. Rarely, only peripheral vision is lost and central vision is spared, resulting in ‘gun-barrel’ vision.2

Although cerebrovascular disease was the most common cause, surgery, particularly cardiac surgery and cerebral angiography were also major causes.3 We have presented two cases of cortical blindness due to infarcts in the posterior cerebral artery territory. The first case consistent with diagnosis of Anton’s syndrome had chronic infarct on the right side and acute infarct on the left side. She did not complain of any symptoms of visual loss related to the old infarct probably not noticed by the patient. This highlights the detailed examination of visual fields in all cases of suspected stroke as patient may have visual anasognosia and deny blindness. Less-complete bilateral lesions leave the patient with varying degrees of visual perception. There may also be visual hallucinations of either elementary or complex types. The mode of recovery from cortical blindness has been studied carefully by Gloning and colleagues, who describe a regular progression from cortical blindness through visual agnosia and partially impaired perceptual function to recovery. Even with recovery, the patient may complain of visual fatigue (asthenopia) and difficulties in fixation and fusion.4 In our cases, there has been no remarkable improvement in visual acuity. References 1.

Ropper AH, Brown RH. Adams & Victor’s Principles of Neurology. 8th edition, The McGraw-Hill Companies: USA 2005;34:676.

Longo DL, Kasper DL, Jameson JL, Fauci AS, Hauser SL, Loscalzo S. Harrison’s Principles of Internal Medicine. 18th edition, Vol 2. The McGraw-Hill Companies: USA 2012; 370:p.3287.

Aldrich MS, Alessi AG, Beck RW, Gilman S. Cortical blindness: etiology, diagnosis, and prognosis. Ann Neurol 1987;21(2):149-58.

Ropper AH, Brown RH. Adams & Victor’s Principles of Neurology. 8th edition, The McGraw-Hill Companies: USA 2005;22:404-5. 

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

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Case Report

Prolapsed Huge Cervical Fibroid with Acute Red Degeneration Mimicking Uterine Inversion Neerja Varshney*, Meenakshi Sharma**, Vandana Jain†

Abstract Acute red degeneration in a large prolapsed cervical fibroid can mimic uterine inversion and presents as emergency where an emergency hysterectomy can be lifesaving. Key words: Prolapsed cervical fibroid, uterine inversion, emergency hysterectomy

ervical leiomyoma are usually single, interstitial or subserous but rarely become submucous and can rarely present as prolapsed or inverted uterus. We present a case report of huge prolapsed cervical fibroid with acute red degeneration requiring emergency hysterectomy. Case Report Mrs. X, 45 years, P3L3, presented in Gyne OPD with complaints of a painless mass coming out per vaginum for two months associated with offensive purulent discharge, menometrorrhagia, loss of weight and appetite. There was no history of bowel or bladder complaints or any history of significant medical or surgical illnesses in the past. The patient was thin built (body mass index [BMI] 17.15 kg/m2), pale and malnourished. The vitals and systemic examination were within normal limits. On abdominal examination, pelvic mass 14 weeks gravid uterus size was palpated in suprapubic region. Per speculum examination showed an oblong, 6 × 7 cm size, firm, nontender mass in vagina and a portion (3 × 4 cm) of it was lying outside the introitus. The mass was irreducible with areas of ulceration, hemorrhage and offensive purulent discharge.

*CMO, (NFSG), Incharge ** Junior Specialist † Senior Resident Dept. of Obstetrics and Gynecology Dr Hedgewar Arogya Sansthan Govt NCT, New Delhi

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

On bimanual examination, the mass was arising from right lip of cervix and posterior wall of uterus. The uterus was of multiparous size, distinct from the mass and bilateral fornices were free. Investigations showed hemoglobin (Hb) - 8.0 g/dl, total leukocyte count (TLC) -14,400/cm3, erythrocyte sedimentation rate (ESR) - 70 mm with microcytic hypochromic anemia. Transvaginal sonography (TVS) revealed enlarged uterus showing multiple hypoechoic lesions within the myometrium with submucosal component. Surgery was planned after controlling the local infection and blood transfusions. One day after admission patient complained of sudden acute increase in the prolapsed mass outside the vagina with bleeding from the fibroid. On examination, uterus was not palpable per abdomen

Figure 1. Prolapsed cervical fibroid.

Case Report and infarction. Postoperative period of patient was uneventful. Discussion Cervical leiomyoma may elongate, prolapse and present with emergency like acute retention of urine and hemorrhage. Prolapsed fibroid also has been reported after use of GnRH therapy1 and uterine artery embolization.2 In our case, there was an acute spontaneous increase in size of prolapse with hemorrhage requiring emergency hysterectomy.

Figure 2. Cut specimen with uterus.

and the prolapsed mass had increased in size upto 15 × 20 cm with active bleeding from the prolapsed mass. She was immediately taken up for emergency hysterectomy by a combined abdominoperineal route in view of the active bleeding and suspicion of uterine inversion. Intraoperatively uterus was bulky and the contour of fundus maintained. Ligation of uterine vessels was tried but it was not approachable because of the prolapsed mass pulling down the uterus. Vaginal myomectomy was performed and the rest of the hysterectomy was completed abdominally. Cut section of the uterus revealed cervical fibroid polyp of 15 × 20 cm with red degeneration arising from the posterior wall of uterocervical junction and weighing 1.1 kg. The histopathology of the resected specimen showed leiomyoma of uterus with areas of hemorrhage

Vaginal myomectomy has been recommended as the initial treatment of choice for prolapsed pedunculated submucous myoma, except in those cases in which other indications necessitate an abdominal approach.3 In patients requiring hysterectomy, vaginal route is preferable to abdominal route as the operating-time, cost, postoperative fever and need for analgesia are reported to be less without any significant difference in blood loss or other complications.4 In our case, abdominoperineal approach was used due to acute hemorrhage and the confusion in diagnosis with suspicion of uterine inversion and inaccessibility of the pedicle of cervical myoma by a solitary vaginal route. References 1.

Kriplani A, Agarwal N, Parul D, Bhatla N, Saxena AK. Prolapsed leiomyoma with severe haemorrhage after GnRH analogue therapy. J Obstet Gynaecol 2002;22(4): 449-51.

Pollard RR, Goldberg JM. Prolapsed cervical myoma after uterine artery embolization. A case report. J Reprod Med 2001;46(5):499-500.

Ben-Baruch G, Schiff E, Menashe Y, Menczer J. Immediate and late outcome of vaginal myomectomy for prolapsed pedunculated submucous myoma. Obstet Gynecol 1988; 72(6):858-61.

Benassi L, Rossi T, Kaihura CT, Ricci L, Bedocchi L, Galanti B, et al. Abdominal or vaginal hysterectomy for enlarged uteri: a randomized clinical trial. Am J Obstet Gynecol 2002;187(6):1561-5. 

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

Case Report

Maternal Death due to Medical Abortion Premalatha

Abstract I describe a young G2P1 aged 23 years with previous lower segment cesarean section (LSCS) with amenorrhea three months who developed septic shock having had an abortion medically induced with mifepristone and misoprostol seven days before admission at Hassan Institute of Medical Sciences (HIMS) on 1/10/2011 at 5.30 pm. After drug administration, patient had bleeding for two days and was fine for four days. After four days she was admitted in a PHC for mild pain abdomen, generalized uneasiness and weakness, where she was treated for a day and then referred to HIMS, when there was no improvement of general condition with IV fluids and antibiotics. Although, the patient was treated aggressively with evacuation of uterus for incomplete abortion with antibiotics and inotropics, death occurred with in 15 hours of admission on 2/10/2011 at 8.45 am. The death draws the attention for it’s unusual presentation like no fever, with little pain abdomen, rapid deterioration and refractory hypotension. Key words: Medical abortion, mifepristone, Clostridium sodellii, septic shock, maternal death

ifepristone is a progesterone receptor antagonist and abortifacient. Six hundred milligram of mifepristone is taken orally within 49 days of last menstrual period (LMP) followed by 600-800 µg of misoprostol after 48 hours. This medical regimen initiates the process of abortion with progesterone receptor blockage by mifepristone, which leads to a withdrawal of the progesterone effect from the placenta at its implantation site followed by prostaglandin analog misoprostol leading to uterine activity and expulsion of the products of conception. Complete abortion occurs in 90% of women. But 5-8% require surgical procedures for incomplete abortion, excessive bleeding or continuing of pregnancy. Effects of the regimen includes abdominal cramping and vaginal bleeding, headache, nausea and vomiting, and diarrhea. Rare but fatal cases of ruptured ectopic pregnancy have occurred.

abortion medically induced with mifepristone and misoprostol seven days earlier. On examination, the drug administration patient had bleeding for two days and was fine for four days. After four days, she was admitted in a PHC for mild pain abdomen, generalized uneasiness and weakness, where she was treated for a day and then referred to Hassan Institute of Medical Sciences (HIMS). Patient was conscious, afebrile, with blood pressure (BP) 90/50, tachycardia, tachypnea, with dry coated tongue, 100 ml urine output with adequate fluid replacement. In spite of IV fluids and antibiotics, she became more restless and irritable (signs of cerebral anoxia) became unconscious and developed subconjunctival hemorrhage suggestive of disseminated intravascular coagulation (DIC) and died. Inspite of insisting for autopsy patient’s husband refused.

Case Report

Minimum investigations done are Hb% - 9.7 gm%. blood group - A negative. Platelet count - 90,000 cells/mm3.

A young G2P1 aged 23 years with previous lower segment cesarean section (LSCS), with amenorrhea three months, presented to our institute on 1/10/2011 at 5.30 pm shock. The patient had an

This case shows that there is a need for the physicians to be aware of this syndrome and for further study of its association with medical abortion, and reporting of such cases.

Assistant Professor Dept. of Obstetrics and Gynecology Hassan Institute of Medical Sciences Hassan, Karnataka

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

Reason for Death

The death due to septic shock with toxins has been reported. A rare and serious infection of 43

Case Report Clostridium sordellii is related to, medical abortions. The other organisms are Peptostreptococcus, Klebsiella, C. perfringes, Escherichia coli, Staphylococcal and Streptococcal species. C. sordellii is a gram-positive anaerobic found ubiquitously in soil and as part of the human intestinal flora. Ten percent of women’s vagina are colonized. Infections are rare but have been reported in patients of all ages, with both intact and compromised immune system. Death is common. The organism produces an endotoxin and can produce two potent exotoxins. Sepsis may occur through effects on cortisol or cytokine responses. The characteristics of C. sordellii septic shock are:  Little or no fever  Generalized uneasiness  Abdominal pain, often mild  Rapid deterioration  Tachycardia  Refractory hypotension  Elevated hematocrit  Neutrophilia and multiple effusions Discussion

septic shock, eight had C. sordellii. All the women were young and healthy. It is now recognized that maternal death with mifepristone is 10 times greater than that of with surgical interventions; at under eight weeks gestation it is 1/1,00,000 to 0.1/1,00,000. At a panel sponsored by the CDC and FDA and NIH on 11th May 2006 in Atlanta nearly all the scientists agreed that there was evidence that RU 486 suppresses immune system. Conclusion The goal of any medical abortion program is to provide safe and effective services for women who choose to terminate a pregnancy. Women should be warned of the rare but potentially fatal adverse effect like serious infection and death. They should seek immediate attention if they have untoward symptoms like fever, severe abdominal pain, heavy bleeding, syncope or general malaise. Suggested Reading 1. 2.

During the 1990s, a new abortifacient drug mifepristone (RU 486) was developed. Mifepristone was originally investigated for its antiglucocorticoid effects as a potential treatment for Cushing’s syndrome. Medical termination of pregnancy with mifepristone was approved in the US in 2000 and is used in 31 countries worldwide. Approximately half of all abortions are performed with this method. In November 2004, the FDA called attention to potentially fatal complications like ruptured ectopic pregnancy and septic shock.

On April 30, 2011, the FDA released a report on 14 women who died in the US and other foreign countries that used mifepristone for termination of pregnancy. In USA, till 2003-2009 - seven deaths, Portugal in Europe in May 2011 - one death, 2001 in Canada one death have been reported.

Deaths have also been reported from UK, Sweden, Taiwan. Women who are known to have died from

5. 6.

Gilbert K. Portuguese girl dies of septic shock following RU-486 abuse. May 20, 2011. Murray S, Wooltorton E. Septic shock after medical abortions with mifepristone (Mifeprex, RU 486) and misoprostol. CMAJ 2005;173(5):485. Sinave C, Le Templier G, Blouin D, Léveillé F, Deland E. Toxic shock syndrome due to Clostridium sordellii: a dramatic postpartum and postabortion disease. Clin Infect Dis 2002;35(11):1441-3. Miech RP. Pathophysiology of mifepristone-induced septic shock due to Clostridium sordellii. Ann Pharmacother 2005;39(9):1483-8. The de Veber Institute for Bioethics and Social Research. WHAA-Ch 6 Maternal Mortality-revised. June 06.br2.rtf. Abdulla A, Yee L.The clinical spectrum of Clostridium sordellii bacteraemia: two case reports and a review of the literature. J Clin Pathol 2000;53(9):709-12. Fischer M, Bhatnagar J, Guarner J, Reagan S, Hacker JK, Van Meter SH, et al. Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion. N Engl J Med 2005;353(22):2352-60. U.S. Department of Health & Human Services. Drugs, Mifeprex (mifepristone) Information. FDA, U.S. Food and Drug Administration. [Online] July 19, 2011. [Cited: July 19, 2011.] http://www.fda.gov/drugs/drugsafety/ postmarketdrugsafetyinformationforpatientsandproviders/ ucm111323.htm. 

Asian Journal of Obs and Gynae Practice, Vol. 4, October-December 2012

45 Answers

1. Uterine torsion in a nongravid state with both fallopian tubes on same side of pelvis. Torsion of a nongravid uterus is extremely rare. 2. Most cases of uterine torsion occur during pregnancy. In approximately 80% cases dextrorotation (clockwise) is present and in 20% levorotation (counterclockwise). Torsion from 60 degrees to 720 degrees has been described. 3. Uterine torsion is observed in all age groups of the reproductive period and at all stages of pregnancy. The exact cause is not known but various abnormalities like myoma uteri, uterine and adnexal mass malformations have been associated with it. 4.�� The most usual symptoms of uterine torsion are birth obstruction, abnormal fetal presentation, abdominal pain, vaginal bleeding, shock, infertility and urinary and intestinal symptoms.

4. What are the symptoms? 3. What are the causes? 2. What is its significance? 1. What is the diagnosis?

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

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