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Volume 1, Number 4, October-December 2017

ISSN 0971-8788

Asian Journal of

Obstetrics &

Gynaecology Practice In this Issue Obstetrical and Neonatal Outcome of Pregnancy in Women with Previous One Cesarean Section: A Prospective Study Low-dose Spinal Anesthesia: A Safe Option in Molar Pregnancy with Thyrotoxicosis Bilateral Endometriomas with Deep Infiltrating Endometriosis in Infertility: An Increasing Trend (Case Series) Sheehanâ&#x20AC;&#x2122;s Syndrome: A Case Report An Unusual Case of Uterine Anomaly, Surgically Corrected with a Fruitful Pregnancy At Last A Hole in Fundus of Primigravid Uterus: An Unusual Finding at Cesarean Section Unexpected Intruder: An Interesting Case of Placenta Incretan News and View

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Volume 1, Number 4, October-December 2017

An IJCP Group Publication Corporate Panel Dr Sanjiv Chopra Prof. of Medicine and Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor Dr KK Aggarwal Group Editor-in-Chief IJCP Group, eMedinewS and eMediNexus Dr Veena Aggarwal MD, Group Executive Editor AJOG Specialty Panel Dr Alka Kriplani Editor Consultant Editor Dr Urmil Sharma Assistant Editors Dr Nutan Agarwal (Delhi) Dr Neera Aggarwal (Delhi) Dr A Biswas (Singapore) Dr CS Dawn (Kolkata) Dr Gauri (Delhi) Dr Suneeta Mittal (Delhi) Dr S Mehra (Delhi) Dr Prashant Mangeshikar (Mumbai) Dr Prakash Trivedi (Mumbai) Dr Gita Ganguly

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 Garima Kachhawa

CONTENTS FROM THE ISSUE EDITOR

Maternal Antibiotic Exposure During Pregnancy and Hospitalization with Infection in Offspring

Alka Kriplani

FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF

Heart Attack with Normal Angiography or Normal Post Mortem

KK Aggarwal

REVIEW ARTICLE

Obstetrical and Neonatal Outcome of Pregnancy in Women with Previous One Cesarean Section: A Prospective Study

Navneet Kaur, Gurdeep Kaur, Paramjit Kaur, Ruby Bhatia

Editorial Board

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

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

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

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

CASE REPORT

Low-dose Spinal Anesthesia: A Safe Option in Molar Pregnancy with Thyrotoxicosis

Bhavna Sriramka, Ranjita Acharya

Bilateral Endometriomas with Deep Infiltrating Endometriosis in Infertility: An Increasing Trend (Case Series)

Parmjit Kaur, Ruby Bhatia, Aman Dev, Santosh Kumari

Sheehanâ&#x20AC;&#x2122;s Syndrome: A Case Report Shikha Singh, Rekha Rani, Dibya Singh

Asian Journal of Volume 1, Number 4, October-December 2017

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

An Unusual Case of Uterine Anomaly, Surgically Corrected with a Fruitful Pregnancy At Last

Printed at Bon Graphics, Chennai Copyright 2017 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.

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

Sumitra Yadav, Anita Singh, Niyati Jain

A Hole in Fundus of Primigravid Uterus: An Unusual Finding at Cesarean Section

Rekha Rani, Shikha Singh, Urvashi Verma, Ruchika Garg, Divya Yadav, Saroj Singh, Surendra Kumar, Shweta Chauhan, Ragini

Unexpected Intruder: An Interesting Case of Placenta Increta

HN Rukshana, Sowbarnika, Jayanthi Mohan

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GM: General Manager Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

FROM THE ISSUE EDITOR

Maternal Antibiotic Exposure During Pregnancy and Hospitalization with Infection in Offspring

Dr Alka Kriplani

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

new study published in the International Journal of Epidemiology investigated the relationship between maternal antibiotic exposure before and during pregnancy, and risk of childhood hospitalization with infection. This study used population-based Danish national databases for pregnancies between 1995 and 2009. Infants were followed from birth until either their first infectionrelated hospitalization, 14th birthday, emigration, death or maximally up to 2009. The findings revealed that 18% of the mothers had at least one antibiotic prescription during pregnancy, while 29.4% were exposed in the 18 months before pregnancy. On the other hand, of the 776,657 live-born singletons, 443,546 infection-related hospitalizations occurred 28.6% of the children. Pregnancy antibiotic exposure was associated with increased risk of childhood

infection-related hospitalization. Meanwhile, in mothers prescribed antibiotics only during pregnancy and whose child did not receive pre-hospitalization antibiotics, this association was present only in those born vaginally. However, higher risks of infectionrelated hospitalization occurred when pregnancy antibiotic prescriptions were closer to birth and in mothers receiving more pregnancy antibiotics. Additionally, children born to mothers exposed to antibiotics before (but not during) pregnancy also had increased risk of infection-related hospitalization. From the results, it was inferred that antibiotic exposure before or during pregnancy was associated with increased risk of childhood hospitalized infections. It was speculated that the probable contributory mechanisms could be alteration of the maternally derived microbiome and shared heritable and environmental determinants.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF

Heart Attack with Normal Angiography or Normal Post Mortem

Dr KK Aggarwal

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

he death of actress Sridevi was due to accidental drowning in a bath tub following loss of consciousness in a hotel in Dubai. This was the conclusion of the post-mortem report and foul play has been ruled out. Dubai police said that the case has been closed. However, the cause of unconsciousness has not yet been conclusively found. Traces of alcohol were found in blood, and it has been suggested that this may have led to the accidental drowning. Though the post mortem has ruled out heart attack, it still remains the most likely initiating event for loss of unconsciousness or gasping, which may have been due to ventricular tachycardia/fibrillation. So, can one have a normal angiography or normal post-mortem after a heart attack? The answer is yes.

There are two types of heart attacks: Type I versus type II heart attack. Most patients with acute heart attack will have obstructive (blockages) atherosclerotic (cholesterol deposition) coronary artery stenoses (narrowing) with acute thrombosis (clot) as the underlying pathology. However, some patients (up to 28%) will not have significant epicardial coronary artery disease when coronary angiography is performed or post mortem is done. These patients are defined as having a type 2 heart attack, which is defined as a heart attack consequent to increased oxygen demand or decreased supply (coronary endothelial dysfunction, coronary artery spasm, coronary artery embolus, tachy / bradyarrhythmias, anemia, respiratory failure, hypertension, or hypotension).

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

REVIEW ARTICLE

Obstetrical and Neonatal Outcome of Pregnancy in Women with Previous One Cesarean Section: A Prospective Study Navneet Kaur*, Gurdeep Kaur†, Paramjit Kaur‡, Ruby Bhatia†

ABSTRACT Objective: Rising trends in number of post cesarean pregnancies is being observed in day-to-day obstetric practice, since there is tremendous increase in primary cesarean section rates due to multifactorial reasons. The present study was conducted to observe the maternal and the neonatal outcome in women with previous one cesarean section. Material and methods: This prospective study was conducted on 100 pregnant women with previous one cesarean section admitted to emergency labor room of Dept. of Obstetrics and Gynecology, Govt. Medical College and Rajindra Hospital, Patiala. Patients were evaluated thoroughly by history and clinical examination. Mode of delivery was decided. Women were given TOLAC (trial of labor after cesarean section) after informed consent. Labor was continuously monitored for any complications to decrease the maternal and perinatal morbidity and mortality. Results: A total of 100 pregnant women with previous cesarean were enrolled in the study. Eighty-five (85%) women had repeat cesarean section and 15 (15%) had vaginal delivery. Sixty-five (76.47%) women had emergency cesarean section and 20 (23.53%) had an elective cesarean. Nonprogress of labor was the most common indication for repeat cesarean section (25). Birth weight of babies were ≤2,500 g in 26 (26%) women, 42 (42%) had weight of 2,600-3,000 g and 32 (32%) had >3,000 g. There was no maternal or perinatal mortality in our study. Conclusion: The trial of labor after cesarean section should be conducted in carefully selected patients after informed consent explaining all the risks with everything ready for cesarean section with availability of blood, anesthetist, neonatologist and continuous maternal and fetal monitoring. The women who don’t fit into the criteria should be kept for elective cesarean section. Keywords: Cesarean section, vaginal birth after cesarean section, TOLAC, pregnancy, labor

esarean section has been a part of human culture since ancient times and there are tales in both western and eastern cultures of this procedure resulting in live mothers and offsprings.1 In today’s obstetric practice, we encounter increasing number of post cesarean pregnancies because of rise in primary cesarean due to multifactorial reasons. There is increasing concern by obstetricians for managing these cases for medical and legal point of view.2 In past 20 years, the rate of cesarean delivery has steadily increased from about 5% to more than 20%.3 With

*Senior Resident † Associate Professor ‡ Professor Dept. of Obstetrics and Gynecology Govt. Medical College and Rajindra Hospital, Patiala, Punjab Address for correspondence Dr Navneet Kaur 267, SST Nagar/Sunder Nagar Near Guru Harkrishan Public School, Patiala - 147 001, Punjab E-mail: nav_neetu8@yahoo.in

present techniques and skill, the incidence of cesarean scar rupture in subsequent pregnancies is very low. The strength of the uterine scar and its capacity to withstand the stress of subsequent pregnancy and labor cannot be completely assessed or guaranteed in advance.3 Planned vaginal birth after cesarean (VBAC) is contraindicated in women with previous uterine rupture or classical cesarean scar and in women who have other absolute contraindications to vaginal birth that apply irrespective of the presence or absence of a scar (e.g., major placenta previa). In women with complicated uterine scars, caution should be exercised and decisions should be made on a case-by-case basis by a senior obstetrician with access to the details of previous surgery. The success rate of a trial of labor after cesarean (TOLAC) ranges between 50% and 85%.4 Vaginal delivery is associated with fewer risks, requires less anesthesia, poses a lower potential for postpartum morbidity, involves a shorter hospital stay, is more affordable and encourages earlier and better bonding between mother and infant.5 Uterine rupture is the most catastrophic complication of a trial of labor

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CLINICAL STUDY after previous cesarean delivery. Other complications include scar dehiscence, febrile illness, infections, thromboembolic events and bleeding due to morbidly adherent placenta. The incidence of uterine rupture with VBAC in a mother who has had a low transverse incision is approximately 0.2-0.5%.6 Material and Methods This was an observational prospective study conducted in pregnant women at ≥35 weeks with previous one cesarean section who came to labor room of Dept. of Obstetrics and Gynecology, Govt. Medical College and Rajindra Hospital, Patiala in emergency. The study included a total of 100 pregnant women at ≥35 weeks gestation with previous one cesarean section admitted in emergency labor room. Patients were evaluated thoroughly by a detailed history, general physical and local examination with special emphasis on vitals/any evidence of scar tenderness. The maternal parameters taken were name, age, obstetric history, gestation, indication for previous cesarean (recurrent/nonrecurrent) (elective/emergency), time elapsed since previous cesarean. The place of previous cesarean section and postpartum complication if any were was also noted. The mode of delivery (TOLAC/ lower segment cesarean section [LSCS]) was decided after taking into consideration the risk factors in present pregnancy. Patients were kept for TOLAC provided they fulfilled all the desired criteria after taking the informed consent from the patient. Labor was constantly monitored by partogram and patients were immediately taken up for emergency cesarean in event of fetal distress, scar tenderness or nonprogress of labor. Patients not fulfilling the criteria were taken up for elective cesarean section as per departmental protocol. After the delivery, birth weight, Apgar score of baby and intrapartum or postpartum complications, if any were noted.

Results A total of 100 pregnant women at ≥35 weeks gestation with previous one cesarean delivery were included in the study. Of these, 85 (85%) women underwent cesarean section and 15 (15%) had TOLAC (Table 1). Out of total 85 pregnant women who had cesarean delivery, 65 (76.47%) had an emergency cesarean section due to one or other indication, while 20 (23.53%) had an elective cesarean. In 75 (88.24%) women, repeat cesarean section was done for recurrent indication, while 10 (11.76%) had nonrecurrent indication for previous cesarean section. Five (5%) women with previous cesarean section were ≤20 years of age, out of whom 2 (40%) had vaginal delivery. Forty (40%) women were in age group of 21-25 years, 48 (48%) in 26-30 years of age group. Seven (7%) women came at >30 years of age and they had cesarean section. Ten (10%) women came at 35-37 weeks, 75 (75%) women at 37-40 weeks of gestation and 6 (6%) came at >40 weeks. One woman with >40 weeks gestation in labor had a vaginal delivery and rest 5 (83.33%) had cesarean section. Out of a total of 25 patients who were multiparous, 5 (20%) had a vaginal delivery and 20 (80%) had cesarean section (Table 2). In our study, total 10 patients (who fulfilled all the desired criteria for VBAC) were induced for TOLAC, only 5 (33.33%) of them had VBAC and remaining 5 had cesarean section done due to NPOL, which was otherwise the most common indication for cesarean section in the study. Fifteen (15%) patients were referred in labor and they had cesarean section due to NPOL. Fourteen (14%) women came with pregnancy-induced hypertension, 55 (55%) had severe anemia, 2 (2%) had gestational diabetes mellitus, 12 (12%) women had fetal growth restriction with oligohydramnios. One patient

Table 1. Total Number of Cesarean Section and Vaginal Births (n = 100) Total

VBAC (n = 15) Spontaneous

100

Cesarean section (n = 85)

Induced

Elective

Emergency

Recurrent indication

Nonrecurrent indication

No.

66.67

33.33

23.53

76.47

88.24

11.76

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CLINICAL STUDY Table 2. Demographic Profile of Patients (n =100) Total

LSCS

VBAC

No.

<20

21-30

86.34

13.64

>30

100

â&#x2030;Ľ35

36-40

13.33

86.67

>40

83.33

16.67

Literate

Illiterate

58.33

41.67

Lower

66.67

33.33

Middle

82.35

17.65

Upper

56.25

43.75

Rural

82.35

17.65

Urban

71.88

28.12

Age (years)

Gestation (weeks)

Literacy

Socioeconomic status

Residence

Table 3. Indications of Repeat Cesarean Section (n = 85 = 100%) Indications

No.

CPD

MSL

Transverse lie

NPOL

Scar tenderness

FGR with oligohydramnios

Severe pre-eclampsia

Twins

Abruptio

Placenta previa

CPD = Cephalopelvic disproportion; MSL = Meconium-stained liquor; NPOL = Nonprogress of labor; FGR = Fetal growth restriction.

each came with abruptio placentae, breech in labor and transverse lie and all had cesarean section. In half of the 20 (23.53%) women who had an elective cesarean section,

intraoperatively scar was thinned out. In 10 (10%) women with repeat cesarean, previous cesarean section was done due to cephalopelvic disproportion. Thirteen (13%) women had meconium-stained liquor with fetal distress for which emergency cesarean was done and 9 (9%) women had an emergency cesarean section due to scar tenderness. Four (4%) women who were admitted due to placenta previa with previous cesarean section had an elective cesarean (Table 3). Forty-three (43%) women in the study came with previous cesarean in labor, out of them, 10 (66.67%) had vaginal delivery and rest all had an emergency cesarean section due to either scar tenderness or fetal distress. Five (33.33%) women had a vaginal delivery were augmented with Pitocin. The patients kept were continuously monitored for any complication. None of the patient with previous LSCS for TOLAC had scar rupture during our study. Two patients were referred with rupture uterus to our hospital during the study period.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CLINICAL STUDY Table 4. Birth Weights of Babies Born to Women with Previous Cesarean Section (n = 100) Birth weight (gms)

n = 100 = 100% No.

% No.

No.

<2,500

2,500-3,000

3,100-3,500

>3,500

Sixteen women came with scar tenderness on admission in whom cesarean section was immediately done in emergency. In 2 women, classical cesarean section was done and one had an upper segment cesarean due to very dense adhesions. Birth weight of babies were â&#x2030;¤2,500 g in 26 (26%) women, 42 (42%) had weight of 2,600-3,000 g and 32 (32%) had >3,000 g (Table 4). There was no stillbirth or neonatal death. One women in the TOLAC group with baby birth weight >3,000 g had a successful vaginal delivery. The Apgar score of newborn babies at 1 and 5 minutes were good in all patients with TOLAC except for 2 patients each with preterm vaginal delivery and preeclampsia with fetal growth restriction. Twenty (20%) women had atonic postpartum hemorrhage, which was managed conservatively with 6 women requiring blood transfusions. No maternal mortality was reported in the study group. Discussion Good candidates for planned TOLAC are those women in whom the balance of risks (as low as possible) and chances of success (as high as possible) are acceptable to the patient and the healthcare provider.7 In our study, patients with previous LSCS fulfilling the criteria, were taken up for TOLAC after informed consent. Patients with recurring indications were taken up for repeat elective LSCS as per departmental protocol. In our study, 85% women had cesarean section and it was similar to the study by Rahman et al (85%).1 In their study, they took 126 women and out of them, 26 dropped out. So, 100 women were studied and compared. In the study by Balachandran et al, cesarean section rate was 16.5% which was quite less.8 The high percentage in our study (85%) is because ours is a tertiary care center and percentage of high risk who 10

LSCS

VBAC

Jani et al

Present study

13 10

7 5

0 NPOL

Fetal distress

CPD

1 1

Scar S PIH Abruptio Placenta tenderness previa

Figure 1. Comparison of indications of cesarean section.

are referred is quite large, so the patients are managed very vigilantly to avoid complications and without taking any undue risks. The most common indication for elective cesarean section in our study was unknown scar type as the patients donâ&#x20AC;&#x2122;t bring their previous surgery records along with them and a very limited information could be extracted from history. The TOLAC rate in our study was 15% and in the study by Singh et al, it was 67.6%.9 The most common indication for cesarean section was NPOL (25%) as compared to the study by Bangal et al3 and Singh et al,9 where it was fetal distress (46%). In our study, 14% women came with pre-eclampsia and all had cesarean section, whereas in the study conducted by Jani et al2 only 5.26% came with pre-eclampsia. They took only 50 women and the study was conducted in a private hospital, so the number of high risk women were less in their study (Fig. 1).

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CLINICAL STUDY Current obstetric opinion is that the LSCS is not a contraindication for the use of oxytocin for induction and augmentation of labor; however, the role of prostaglandins is controversial. To determine the impact of labor induction on both the success and safety of a trial of labor in women who were candidates for TOLAC, a prospective observational analytical study was conducted at the Medical University of South Carolina. The vaginal delivery rate was significantly higher (77.1% vs. 57.9%) in the spontaneous labor group compared with the induced labor group6 and the similar result was found in our study (66.66% vs. 33.33%). So, these studies conclude that induction of labor in women attempting VBAC is associated with a significantly reduced rate of successful vaginal delivery. A study was conducted by Hendler et al in which effect of prior TOLAC was studied to see the obstetric outcome and it was seen that the rate of successful trial of labor was quite high in women with prior TOLAC (93.1% vs. 70.1%),10 but such an observation was not seen in our study because we had 5 women with prior TOLAC and all had cesarean section either due to scar tenderness or severe pre-eclampsia with fetal growth restriction with fetal distress. In one of the study by Anwar et al11 which also involved 100 women, 59 (59%) gave birth to neonates with birth weight 2.5-3 kg, while 25 (25%) had birth weight 3.1-3.5 kg and only 16 neonate (16%) had birth weight 3.6-4 kg as compared to 48 (48%), 27 (27%) and 4 (4%), respectively in our study. The chances of success of VBAC section increases with lower birth weight as seen in our study, where 100% women had cesarean section in whom birth weight of newborns were >3,500 g and it was similarly found by Birgisdottir et al in their study that the trial of labor was less likely to succeed if the infant’s birth weight was >4,000 g compared with <4,000 g.12 Conclusion For successful delivery after a previous cesarean section, the obstetrician requires to have the expertise to carefully select the patients, for trial of vaginal birth because rupture of scar can endanger the life of the mother and the child. The spontaneous onset of labor, average-sized babies and increasing parity are the other factors having a positive impact on the successful outcome of TOLAC. Planned TOLAC after informed

consent is appropriate for and may be offered to the majority of women with a singleton pregnancy of cephalic presentation at 37+0 weeks or beyond who have had a single previous lower segment cesarean delivery, with or without a history of previous vaginal birth (RCOG). The informed consent for VBAC should be taken before the trial of labor and it should be conducted in the institution equipped with all the facilities for emergency cesarean section with constant maternal and fetal monitoring. Acknowledgment I am highly thankful to all my teachers and my family who encouraged me in every aspect of my life. I am thankful to Dr Paramjit Kaur, Dr Ruby Bhatia and Dr Gurdeep Kaur who helped me in collecting the material and writing on this topic. This paper has been possible due to joint effort of my co-authors as well. I really appreciate the work of juniors who helped me in this topic a lot. This study has been conducted prospectively and no harm has been inflicted upon the patients involved in the study.

References 1. Rahman R, Khanam NN, Islam N, Begum KF, Pervin HH, Arifuzzaman M. The outcome of vaginal birth after caesarean section (VBAC): a descriptive study. J Med Today. 2013;25(1):14-7. 2. Jani RS, Munshi DS. Management of pregnancy with previous lower segment caesarean section in modern obstetric practice. NHL J Med Sci. 2013;7(2):59-63. 3. Bangal VB, Giri PA, Shinde KK, Gavhane SP. Vaginal birth after cesarean section. N Am J Med Sci. 2013;5(2):140-4. 4. Martel MJ, MacKinnon CJ; Clinical Practice Obstetrics Committee, Society of Obstetricians and Gynaecologists of Canada. Guidelines for vaginal birth after previous caesarean birth. J Obstet Gynaecol Can. 2005;27(2):164-88. 5. Ugwu GO, Iyoke CA, Onah HE, Egwuatu VE, Ezugwu FO. Maternal and perinatal outcomes of delivery after a previous cesarean section in Enugu, Southeast Nigeria: a prospective observational study. Int J Womens Health. 2014;6:301-5. 6. Islam A, Ehsan A, Arif S, Murtaza J, Hanif A. Evaluating trial of scar in patients with a history of caesarean section. N Am J Med Sci. 2011;3(4):201-5. 7. American College of Obstetricians and Gynecologists. ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol. 2010;116 (2 Pt 1):450-63.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CLINICAL STUDY 8. Balachandran L, Vaswani PR, Mogotlane R. Pregnancy outcome in women with previous one cesarean section. J Clin Diagn Res. 2014;8(2):99-102. 9. Singh N, Tripathi R, Mala YM. Maternal and foetal outcomes in patients with previous caesarean section undergoing trial of vaginal birth at a tertiary care centre in North India. J Preg Child Health. 2014;1(1):1-5. 10. Hendler I, Bujold E. Effect of prior vaginal delivery or prior vaginal birth after cesarean delivery on obstetric outcomes

in women undergoing trial of labor. Obstet Gynecol. 2004;104(2):273-7. 11. Anwar S, Ahmad S, Abbasi N, Anwar MW. Effect of birth weight on success of vaginal birth after caesarean delivery. Gomal J Med Sci. 2015;13(1):46-8. 12. Birgisdottir BT, Hardardottir H, Bjarnadottir RI, Thorkelsson T. Vaginal birth after one previous cesarean section. Laeknabladid. 2008;94(9):591-7.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

REVIEW ARTICLE

Low-dose Spinal Anesthesia: A Safe Option in Molar Pregnancy with Thyrotoxicosis Bhavna Sriramka*, Ranjita Acharya†

ABSTRACT Hydatidiform mole often has an association with thyrotoxicosis. Molar pregnancy usually presents with severe vaginal bleeding requiring emergency suction evacuation and time for proper treatment of thyrotoxicosis may not be available making perioperative management of these patients difficult. We recently had an encounter of a 26-year-old female of hydatidiform mole associated with thyrotoxicosis presenting with vaginal bleeding, which was successfully managed with low-dose spinal anesthesia under cover of antithyroid medication, steroids and b blockers. Patient was then shifted to intensive care unit in the postoperative period and later to the ward after 2 days. Eventually, she was discharged on the fifth postoperative day with near normal thyroid profile and completely asymptomatic. Timely diagnosis with a high degree of suspicion of thyrotoxicosis association, proper anesthesia plan and vigilant postoperative management is essential in dealing such a dreadful situation. We recommend low-dose spinal anesthesia as a safe option in such situation. Keywords: Hydatidiform mole, thyrotoxicosis, low-dose, spinal anesthesia, safety

estational trophoblastic disease is an abnormal proliferation of trophoblastic epithelium of which hydatidiform mole is a result of malformation of chorionic vilosities predisposing to malignant neoplasia. Curry et al described it as a pregnancy usually lacking an intact fetus, in which the placental villi are characterized by edema and loss of vasculature, and showing varying degrees of trophoblastic proliferation.1 It may present with many complications, of which trophoblastic thyrotoxicosis is life-threatening.2 Complete moles have prevalence of hyperthyroidism as high as 7%.3 Thyrotoxicosis and hemorrhage have overlapping signs and many times can be missed. We hereby present a case where a molar pregnancy associated with hyperthyroidism presented with vaginal bleeding and was posted for emergency dilatation and curettage. It highlights the perioperative management and optimization of hyperthyroid state prior to surgical evacuation of the hydatidiform mole.

*Senior Resident † Associate Professor Dept. of Anesthesia and Critical care IMS and Sum Hospital, Bhubaneswar, Odisha Address for correspondence Dr Bhavna Sriramka 106-Mahadev Orchid, Cosmopolis Road, Dumduma, Bhubaneswar - 751 019 E-mail: bhavna.sriramka@gmail.com

Case Report A 26-year-old patient weighing 48 kg with body mass index (BMI) 26.2 was admitted to the Dept. of Obstetrics and Gynecology with complaints of amenorrhea of 12 weeks, abdominal pain and vaginal bleeding. She was febrile (101.6°F), tachypneic (respiratory rate [RR]-26), tachycardiac (127 bpm), hypertensive (160/92 mmHg), with pale mucous membranes and dehydrated. Urine pregnancy test was positive. Thyroid gland was palpable and of normal size. Cardiorespiratory examinations were normal. Laboratory investigations upon admission were hemoglobin - 8.2 g/dL, hematocrit - 30.3%, leukocytes - 13,800, platelets - 3.04 lacs, with normal coagulation profile, decreased thyroid-stimulating hormone (TSH) - 0.08 (range 0.35-5.5) and raised total T3 - 388 ng/dL (range = 80-150 ng/dL). The levels of human chorionic gonadotropin (hCG) were 6,38,000 UI/L. Abdominal pelvic ultrasound showed uterine volume of 1,680 cm3 with multiple anechoic cystic vesicles compatible with complete hydatidiform mole. She was shifted to the operating room on the same day of hospitalization to undergo an emergency uterine curettage due to severe vaginal bleeding. A high risk informed and written consent for anesthesia and surgery was taken and availability of postoperative intensive care unit (ICU) care was ensured. A low-dose

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REVIEW ARTICLE spinal anesthesia was planned. The goals were to reduce temperature, tachycardia, hypertension and proper oxygenation with adequate anesthesia. One hour prior to the surgery - tablet propylthiouracil 150 mg was given followed by injection dexamethasone 2 mg IV, injection dexmedetomidine started @1 μg/kg for 10 minutes followed by 0.4 μg/kg/hr and along with it infusion of injection esmolol started @1 mg/kg IV over 30 seconds and then 0.2 mg/kg/min titrated according to heart rate and blood pressure. Injection acetaminophen 500 mg was given for temperature control. Hydration was maintained with Ringer lactate.

The glycoprotein hormone hCG has a structural analogy with TSH and so can cause cross-reactivity with their receptors.9 For every 10,000 mU/mL increase in serum hCG, FT4 increases by 0.1 ng/dL and TSH decreases by 0.1 mIU/mL.10 Hyperthyroidism may be a result of this significant rise in hCG levels in hydatidiform mole, which calls for a prompt treatment that is uterine evacuation thereby decreasing the hCG values. Hyperthyroidism can co-exist with anemia secondary to vaginal bleeding and their clinical presentations are often overlapping. Tachycardia, tachypnea with fever and hypertension calls for a suspicion of thyroid storm.

Spinal anesthesia was given with intrathecal 2 mL of bupivacaine (0.5% H) and 25 μg of fentanyl given after clear aspiration of cerebrospinal fluid (CSF) in L2-L3 space. After 8 minutes, the motor block was Grade 2 (Bromage scale) and sensory block was T8. Patient was lightly sedated and comfortable. Vitals were stable with heart rate reduced to 98/min, blood pressure reduced to 134/86 mmHg and RR 14/min, temperature dropped to 100°F maintaining SpO2 99%. She was allowed to breath in venturimask with FiO2 of 0.5. Surgeons were then allowed to perform uterine curettage. One unit of whole blood was transfused. Surgery went uneventfully and then patient was shifted to the ICU, where she was continued on tablet propylthiouracil 100 mg 8-hourly for 1 day and dexamethasone was tapered over 4 days. Tablet propranolol 10 mg 8-hourly was given for 2 days. Patient was hemodynamically stable in the postoperative period, was shifted to the regular ward after 2 days and from the hospital after 5 days.

High output cardiac failure, thyroid storm, hypertension, embolization of pulmonary arteries, hypovolemia, DIC and pulmonary edema are the anesthetic challenges to be aware of when dealing with molar pregnancy.11,12 Goals of anesthetic management are to ensure hemodynamic stability and maintain proper oxygenation thereby providing adequate anesthesia for surgery. Both regional and general anesthesia have been described in the literature for management of molar pregnancy.13

Discussion Complete hydatidiform mole, most commonly presents with vaginal bleeding occurring at 6-16 weeks of gestation in 80-90% of cases, followed by hyperemesis and hyperthyroidism.2,4,5 Acute respiratory distress syndrome (27%) has also been reported as a result of trophoblastic embolization, sepsis, amniotic fluid embolism and transfusion related acute lung injury.6 Consumption coagulopathy is yet another complication which may be due to factors released by the molar tissue that could trigger the coagulation cascade, resulting in disseminated intravascular coagulation (DIC) and multiorgan failure.7 Clinical hyperthyroidism in a patient with hydatidiform mole was first reported in 1955 by Tisne et al.8 14

In hypotensive patients with bleeding, the choice is general anesthesia. Regional anesthesia is a safer option in stable patients with emergency surgeries with full stomach having the advantages of no tocolytic effect on the uterus and avoiding airway instrumentation but is contraindicated in DIC.3,14 Our patient diagnosed with hyperthyroidism having hypertension, and severe bleeding was stabilized in the limited time available with antithyroids, steroids, sedatives, blood transfusion and IV fluids and planned for a low-dose spinal anesthesia to prevent hemodynamic instability. Conclusion Anesthesiologists need to be vigilant of the perioperative complications associated with a molar pregnancy. A detailed work-up, optimization of the patient, careful selection of anesthesia with postoperative intensive care management is of paramount importance when dealing any case of molar pregnancy. References 1. Curry SL, Hammond CB, Tyrey L, Creasman WT, Parker RT. Hydatidiform mole: diagnosis, management, and long-term follow up of 347 patients. Obstet Gynecol. 1975;45(1):1-8.

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REVIEW ARTICLE 2. Celeski D, Micho J, Walters L. Anesthetic implications of a partial molar pregnancy and associated complications. AANA J. 2001;69(1):49-53.

8. Tisne L, Barzelatto J, Stevenson C. Study of thyroid function during pregnancy-puerperal state with radioactive iodine. Bol Soc Chil Obstet Ginecol. 1955;20(8-9):246-51.

3. Dave N, Fernandes S, Ambi U, Iyer H. Hydatidiform mole with hyperthyroidism - perioperative challenges. J Obstet Gynecol India. 2009;59(4):356-7.

9. Yoshimura M, Hershman JM. Thyrotropic action of human chorionic gonadotropin. Thyroid. 1995;5(5):425-34.

4. Lurain JR. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. Am J Obstet Gynecol. 2010;203(6):531-9. 5. Garner EI, Goldstein DP, Feltmate CM, Berkowitz RS. Gestational trophoblastic disease. Clin Obstet Gynecol. 2007;50(1):112-22. 6. Chantigan RC, Chantigan PD. Problems of early pregnancy. In: Chestnut DH (Ed.). Obstetric Anaesthesia Principles and Practice. 2nd Edition, St Louis, Mo: Mosby; 1999. pp. 263-78. 7. Egley CC, Simon LR, Haddox T. Hydatidiform mole and disseminated intravascular coagulation. Am J Obstet Gynecol. 1975;121(8):1122.

10. Glinoer D. The regulation of thyroid function in pregnancy: pathways of endocrine adaptation from physiology to pathology. Endocr Rev. 1997;18(3):404-33. 11. Erol DD, Cevryoglu AS, Uslan I. Preoperative preparation and general anaesthesia administration with Sevoflurane in a patient who develops thyrotoxicosis and cardiogenic dysfunction due to a hydatidiform mole. Int J Anesthesiol. 2003;8(1). 12. Wissler RN. Endocrine disorders. In: Chestnut DH (Ed.). Obstetric Anesthesia Principles and Practice. 3rd Edition, Philadelphia: Elsevier Mosby; 2004. pp. 744-9. 13. Khanna P, Kumar A, Dehran M. Gestational trophoblastic disease with hyperthyroidism: anesthetic management. J Obstet Anaesth Crit Care. 2012;2(1):31-3. 14. Solak M, Aktürk G. Spinal anesthesia in a patient with hyperthyroidism due to hydatidiform mole. Anesth Analg. 1993;77(4):851-2.

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CASE REPORT

Bilateral Endometriomas with Deep Infiltrating Endometriosis in Infertility: An Increasing Trend (Case Series) Parmjit Kaur*, Ruby Bhatia†, Aman Dev‡, Santosh Kumari#

ABSTRACT Endometriosis affects 8-10% of women of reproductive age; in 30% of the women, the condition is associated with primary or secondary infertility. Deep infiltrating endometriosis (DIE) is a particular form of endometriosis that extends >5 mm under the peritoneal surface. These lesions develop in the form of retroperitoneal nodules that consist histologically of endometrial epithelium and stroma, surrounded by muscular hyperplasia and fibrosis. In addition to infertility, it is commonly associated with symptoms such as dyspareunia, dysmenorrhea, bladder/bowel symptoms and chronic pelvic pain. Medical therapies may temporarily alleviate painful symptoms, but recurrence rates after their discontinuation are high. Radical surgical excision of DIE lesions is the mainstay of treatment. Ovarian endometriomas, a localized form of endometriosis are large, fluid-filled cysts that form on, and may even encapsulate, the ovaries. They are highly common and may be present in up to 30-40% of women with the disease. We report a series of 5 cases with bilateral large endometriomas with DIE associated with infertility. Keywords: Endometriosis, deep infiltrating endometriosis, endometriomas, infertility, radical surgical excision

ndometriosis is a clinical and pathological entity characterized by the presence of tissue resembling functioning endometrial gland and stroma outside the uterine cavity. It is 7-10 times more common in infertile women and encountered in 70% of women with chronic pelvic pain. The most common sites of endometriosis, in decreasing order, are the ovaries, anterior/posterior cul-de-sac, broad ligaments and uterosacral ligaments, uterus, fallopian tubes, sigmoid colon and appendix. The growth of the implants is dependent on ovarian produced steroids. It is a disease that most severely affects women in the age group 25-35 years.1 In addition to infertility, it is commonly associated with symptoms such as dyspareunia, dysmenorrhea, bladder/bowel

*Professor † Associate Professor ‡ Civil Surgeon # Postgraduate Student Dept. of Obstetrics and Gynecology Govt. Medical College and Rajindra Hospital, Patiala, Punjab Address for correspondence Dr Parmjit Kaur Professor Dept. of Obstetrics and Gynecology Govt. Medical College and Rajindra Hospital, Patiala, Punjab E-mail: dr.parmjit.obg@gmail.com

symptoms and chronic pelvic pain. We report a series of 5 cases with bilateral large endometriomas with deep infiltrating endometriosis (DIE) associated with infertility. Case Reports Case 1

A 19-year-old unmarried female admitted with chief complaint of subacute pain and lower abdomen mass of 16-18 weeks size of pregnant uterus. Her menstrual cycle was 7-8/22 with excessive flow and severe congestive dysmenorrhea. She visited our OPD 7 years back with complaint of menorrhagia and dysmenorrhea. Her USG pelvis done that time showed nulliparous uterus with 2.5 cm cyst in right ovary (Fig. 1). She was put on nonsteroidal anti-inflammatory drugs (NSAIDs) and oral contraceptives but she was lost to follow-up and had presented now with large abdominal mass. She was thin built (body mass index [BMI] 17), with depressive personality and a school dropout. Thyroid-stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), erythrocyte sedimentation rate (ESR), alfa-fetoprotein (AFP) and beta human chorionic gonadotropin (β-hCG) were normal. All required investigations were done. UPT was negative and cancer antigen-125 (CA-125) was 60 U/mL. Computed tomography (CT) abdomen and

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CASE REPORT pelvis showed well-defined 9 × 7.2 cm smooth walled round to oval right adnexal mass with thickened and diffuse internal echoes displacing gut loops superiorly and laterally. Another small hypodense cystic lesion of 2.8 × 1.7 cm was seen adjacent to the aforementioned adnexal mass (Fig. 2). Another well-defined smoothly marginated round mass 7.5 × 5.3 cm was seen in left adnexa CT abdomen and pelvic organ (Fig. 3). Exploratory laparotomy confirmed bilateral fetal head size endometriomas with DIE. Dense areas with peritubal and periovarian adhesions present in pelvis, bladder, bowel and ligaments attaching uterus to pelvis. Bilateral excision of endometriomas and extensive Figure 3. CT whole abdomen and pelvis showing well-defined

thin walled cystic mass 7.5 × 5.3 cm in left adnexal region (Case 1).

endometriotic implants was done. Only minimal ovarian tissue could be reserved on both sides. Histopathological examination (HPE) confirmed extensive endometriosis. Long-term oral contraceptive pill (OCP) started after 3 weeks and continued for 1 year. On follow-up patient is comfortable with regular menstrual cycle till date.2 Case 2

Figure 1. Longitudinal and transverse USG sections of uterus showing cystic lesion of 2.5 cm in right adnexa (Case 1).

Figure 2. CT whole abdomen and pelvis showing right adnexal mass 9 × 7.2 cm (Case 1).

A 31-year-old female presented in OPD with chief complaint of primary infertility for 10 years with menorrhagia associated with passage of clots. She is a known case of hypothyroidism, took tablet eltroxin 50 μg for 6 months but stopped herself since last 1 year. Her menstrual cycle was 7 days, heavy flow associated with clots in every 24-26 days. P/A was soft to firm in consistency with a nontender midline mass of 14 weeks size of pregnant uterus arising out of pelvis felt with regular margins and smooth surface. Bimanual pelvic examination revealed a nontender soft to firm 10 × 10 cm mass in right fornix and another mass of 6 × 5 cm of similar consistency was felt in left adnexa. Uterus was retroverted, exact size could not be made out. USG confirmed 16 × 10 cm mass in right adnexa and 15 × 10 cm cystic mass in left adnexa. CA-125 was 46 IU/mL. On exploratory laparotomy, bilateral large endometriomas 20 × 10 cm left adnexa and 7 × 5 cm right adnexa were seen with dense adhesions between uterus, transverse colon and omentum. Uterine surface was irregular and pouch of Douglas was obliterated. Dark cherry-colored chocolate fluid was aspirated from both

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CASE REPORT the endometriomas. Both of the endometriomas had daughter cysts. Most of the ovarian tissue was replaced by endometrioma. There was Grade IV endometriosis. Conservative surgery was done with removal of the endometriomas and conservation of ovarian tissue. Postoperatively, she was put on injection gonadotropinreleasing hormone (GnRH) agonist (injection leuprolide 3.75 mg IM monthly for 3 months) and was advised in vitro fertilization (IVF). Case 3

A 31-year-old female was admitted with complaint of chronic lower abdomen pain and primary infertility for 10 years. All required investigations were done. CA-125 was 75 IU/mL. CT whole abdomen showed a welldefined thin walled cystic lesion 7.3 × 4.9 cm in right adnexa with septa 3 mm with right ovary 1.5 × 2.5 cm in size was seen. Left ovary was enlarged, 3.5 × 4.9 cm in size with multiple cystic lesions of variable sizes. Within it a well-defined cystic tubular structure 6.2 × 2.7 cm was seen lying along the ovary. Uterus was normal in shape and size with endometrial thickness (ET) 8 mm, 2 well-defined hypoechoic masses 1.5 × 1.5 cm and 0.9 × 0.9 cm were seen in anterior myometrium suggestive of fibroids. Exploratory laparotomy was done after informed consent. On exploratory laparotomy, uterus was seen buried in dense adhesions along with bilateral 7 × 7 cm large endometriomas. There were dense peritubal and periovarian adhesions along with gut specially rectum and omentum and posterior surface of uterus. Uterosacral ligament was studded with endometriotic implants. HPE: right

Figure 4. Histopathological examination showing hemosiderin

laden macrophages (Case 3).

ovarian aspirate cytology confirmed hemosiderin laden macrophages features suggestive of chocolate cyst ovary. Left ovarian cyst cytology showed degenerated cells with necrotic debris in background (Fig. 4). Case 4

A 24-year-old unmarried female was admitted with complaint of congestive dysmenorrhea for 2-3 months. She had normal menstrual cycles with 4 days moderate flow associated with severe pain. She was a known case of hypothyroidism who had been taking tablet eltroxin 50 μg but had discontinued taking them 2 years back. USG confirmed normal shape size uterus with ET 10 mm irregular walled cystic lesion with internal echoes and few septa 4.75 × 5.25 cm in left adnexa with another cystic lesion 2.5 × 1.93 cm with internal echoes in right adnexa suggestive of right hemorrhagic ovarian cyst. A tubular multiseptate structure with internal echoes was seen in right adnexa suggestive of pyosalpinx or hematosalpinx. On diagnostic laparoscopy, both the ovaries were replaced by endometriomas. Posterior surface of uterus was found densely adhered to gut and omentum. Burn match stick endometriotic patches were seen over ovarian fossa, tubes and uterine surface. Conservative surgery was done with aspiration of endometriomas and adhesiolysis and fulguration of endometriotic patches. There was Grade IV endometriosis with DIE. She was put on OCP for 1 year after surgery. Case 5

A 45-year-old P1L1 female landed up in High Dependency Unit, Obstetrics and Gynecology with chief complaint of acute abdominal pain. She was in shock, blood pressure (BP) 90/60 mmHg and pulse rate (PR) 120/min. Her USG whole abdomen and pelvic organ showed a large 20 × 10 cm cystic mass in left adnexa with uterus 14 cm in size, multiple fibroids with fluid in peritoneum and cul-de-sac. On needling, hemoperitoneum was confirmed. She was in shock. Immediate exploratory laparotomy was done. There was rupture of right-sided large endometrioma (10 × 8 cm) with hemoperitoneum of about 3 liters with 8 × 8 × 5 cm endometrioma on left side. There were bilateral large hematosalpinx with dark tarry chocolate material pouting out of fimbrial end. There was gross picture of DIE with dense adhesions of uterus and endometriomas with bladder, gut and omentum.

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CASE REPORT Total abdominal hysterectomy and removal of endometriomas with bilateral salpingectomy was done. Uterus was 10 weeks size, studded with fibroids. On cut section, uterus was also filled with dark tarry fluid. Note is made that during the time period of this case series, though magnetic resonance imaging (MRI) which is diagnostic modality of endometriomas (characteristic hyperintensity on T1-weighted images and hypointensity on T2-weighted images) was not available in our hospital, so CT scan was done instead of MRI. Discussion Endometriosis, though traditionally is diagnosed after the 2nd or 3rd decade, approximately one-third of the patients with confirmed endometriosis experience their 1st symptom before 15 years of age.3 Women who have a first-degree relative affected by the disease have a 7 times higher risk of developing endometriosis than women who do not have a family history of the disease.4 Pelvic anatomy becomes distorted and fecundity is reduced via mechanical disruptions such as pelvic adhesions. These disruptions impair oocyte release or pick-up, alter sperm motility, cause disordered myometrial contractions, as well as impair fertilization and embryo transport.5 IVF studies have suggested that women with more advanced endometriosis have poor ovarian reserve, low oocyte and embryo quality and poor implantation.6,7 Both eutopic and ectopic endometrium have been shown to be resistant to progesterone, causing an unopposed estrogen state, which is likely not suitable for implantation.8,9 Many factors must be taken into account including but not limited to distorted pelvic anatomy, patientâ&#x20AC;&#x2122;s ovarian reserve, partner semen analysis, age, presence of endometriomas and length of infertility.10 Depending on the patient, current treatment options may include expectant management, surgical removal of implants, ovulation induction or IVF. For women with suspected stage III/IV endometriosis, IVF is recommended. Current treatment of endometriosis-associated infertility focuses on improving fecundity by removing or reducing ectopic endometrial implants and restoring normal pelvic anatomy.11 Current research is also examining novel promising nonhormonal treatment options for endometriosis such as immunoconjugate, vascular endothelial growth factor antagonists and stem

cells, which may also prove to increase fecundity by decreasing the extent of ectopic implants or improving the eutopic endometrium.12,13 Other trends in the treatment of endometriosis include the use of aromatase inhibitors, cyclooxygenase-2 inhibitors, omega-3 fatty acids and cannabinoid agonists.14 Prolonged GnRHa treatment prior to IVF may improve fertility rates in advanced endometriosis.15-17 Laparoscopic surgery is preferred to laparotomy; it is more cost-effective, has a shorter hospital stay and shorter recovery.18 A 2008 Cochrane review examined, the current literature regarding laparoscopic ablation versus excision of endometriomas and found that excision of the cyst was associated with a subsequent increased spontaneous pregnancy rate in women who had documented prior subfertility (odds ratio [OR] 5.21; confidence interval [CI] 2.04-13.29). Resection was clearly superior when compared to drainage or ablation. IVF is currently the most effective treatment of endometriosis-associated infertility. Conclusion Treatment of endometriomas with DIE-associated infertility should focus on improving fecundity by conservative laparoscopic surgery by removing or reducing ectopic endometrial implants and restoring normal pelvic anatomy followed by hormonal therapy and IVF. Early diagnosis and treatment during adolescence may decrease disease progression, prevent subsequent infertility and such catastrophic sequelae. References 1. Olive DL, Schwartz LB. Endometriosis. N Engl J Med. 1993;328(24):1759-69. 2. Kaur P, Bhatia R, Singh KD, Bhatia SK, Kaur S, Singh AD. Bilateral fetal head size endometriomas with deep infiltrating endometriosis in an adolescent girl. Med Res Chron. 2015;2(3):425-9. 3. Ballweg ML. Impact of endometriosis on womenâ&#x20AC;&#x2122;s health: comparative historical data show that the earlier the onset, the more severe the disease. Best Pract Res Clin Obstet Gynaecol. 2004;18(2):201-18. 4. Simpson JL, Elias S, Malinak LR, Buttram VC Jr. Heritable aspects of endometriosis. I. Genetic studies. Am J Obstet Gynecol. 1980;137(3):327-31. 5. Holoch KJ, Lessey BA. Endometriosis and infertility. Clin Obstet Gynecol. 2010;53(2):429-38.

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CLINICAL STUDY CASE REPORT 6. Brosens I. Endometriosis and the outcome of in vitro fertilization. Fertil Steril. 2004;81(5):1198-200. 7. Olivennes F. Results of IVF in women with endometriosis. J Gynecol Obstet Biol Reprod (Paris). 2003;32(8 Pt 2): S45-7. 8. Lessey BA, Ilesanmi AO, Castelbaum AJ, Yuan L, Somkuti SG, Chwalisz K, et al. Characterization of the functional progesterone receptor in an endometrial adenocarcinoma cell line (Ishikawa): progesterone-induced expression of the alpha1 integrin. J Steroid Biochem Mol Biol. 1996;59(1):31-9. 9. Lessey BA, Yeh I, Castelbaum AJ, Fritz MA, Ilesanmi AO, Korzeniowski P, et al. Endometrial progesterone receptors and markers of uterine receptivity in the window of implantation. Fertil Steril. 1996;65(3):477-83. 10. Senapati S, Barnhart K. Managing endometriosis-associated infertility. Clin Obstet Gynecol. 2011;54(4):720-6. 11. Ozkan S, Murk W, Arici A. Endometriosis and infertility: epidemiology and evidence-based treatments. Ann N Y Acad Sci. 2008;1127:92-100. 12. Taylor HS, Osteen KG, Bruner-Tran KL, Lockwood CJ, Krikun G, Sokalska A, et al. Novel therapies targeting endometriosis. Reprod Sci. 2011;18(9):814-23.

13. Petracco RG, Kong A, Grechukhina O, Krikun G, Taylor HS. Global gene expression profiling of proliferative phase endometrium reveals distinct functional subdivisions. Reprod Sci. 2012;19(10):1138-45. 14. Rocha AL, Reis FM, Petraglia F. New trends for the medical treatment of endometriosis. Expert Opin Investig Drugs. 2012;21(7):905-19. 15. Guo YH, Lu N, Zhang Y, Su YC, Wang Y, Zhang YL, et al. Comparative study on the pregnancy outcomes of in vitro fertilization-embryo transfer between long-acting gonadotropin-releasing hormone agonist combined with transvaginal ultrasound-guided cyst aspiration and longacting gonadotropin-releasing hormone agonist alone. Contemp Clin Trials. 2012;33(6):1206-10. 16. Ozkan S, Arici A. Advances in treatment options of endometriosis. Gynecol Obstet Invest. 2009;67(2):81-91. 17. Surrey ES, Voigt B, Fournet N, Judd HL. Prolonged gonadotropin-releasing hormone agonist treatment of symptomatic endometriosis: the role of cyclic sodium etidronate and low-dose norethindrone “add-back” therapy. Fertil Steril. 1995;63(4):747-55. 18. Busacca M, Fedele L, Bianchi S, Candiani M, Agnoli B, Raffaelli R, et al. Surgical treatment of recurrent endometriosis: laparotomy versus laparoscopy. Hum Reprod. 1998;13(8):2271-4.

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CASE REPORT

Sheehan’s Syndrome: A Case Report Shikha Singh*, Rekha Rani†, Dibya Singh‡

ABSTRACT Sheehan's syndrome is postpartum hypopituitarism caused by necrosis of the pituitary gland, which usually result of severe hypotension or shock caused by massive hemorrhage during or after delivery. Patients with Sheehan's syndrome have varying degrees of anterior pituitary hormone deficiency, the basic event seems to be an infarct in the anterior pituitary due to decreased blood volume. Enlargement of pituitary gland, small sella size, disseminated intravascular coagulation and autoimmunity have been suggested to play a role in its pathogenesis. We report a case of a 26-year-old para 1 female who presented with amenorrhea since past 7 years. She gave a history of vaginal delivery at home followed by heavy bleeding for which she was managed conservatively along with 3 units of blood transfusion at a local hospital. She was thoroughly investigated and she was diagnosed to be suffering from Sheehan's syndrome. She was managed by cyclical hormone replacement therapy with positive outcome. Her menses have become regular with normal flow and duration and she is now planning for infertility treatment. Keywords: Sheehan's syndrome, postpartum pituitary necrosis, intrapartum or postpartum hemorrhage, hormone replacement, growth hormone deficiency

heehan’s syndrome, first described by Sheehan in 1937,1 is postpartum hypopituitarism caused by intrapartum or postpartum hemorrhage. The damage to pituitary tissue may require lifelong hormone replacement.

Pituitary damage unrelated to pregnancy is called Simmonds’ disease.2 In a study of 1,034 symptomatic adults, Sheehan’s syndrome was found to be the sixth most frequent etiology of growth hormone deficiency, being responsible for 3.1% of cases (vs. 53.9% due to a pituitary tumor).3 Although the pathogenesis of Sheehan’s syndrome is not clear, the basic event is infarct in the anterior pituitary due to decreased blood volume.4 It is not clear whether this infarct is due to vasospasm, thrombosis or a vascular compromise.

*Assistant Professor † Lecturer ‡ Junior Resident Dept. of Obstetrics and Gynecology SN Medical College, Agra, Uttar Pradesh Address for correspondence Dr Shikha Singh 23, Jaipur House, Agra - 282 010, Uttar Pradesh E-mail: drshikhasingh.shikha@gmail.com

Pituitary volume increases twofold during pregnancy. This is due to hyperplasia of prolactin secreting cells from elevated estrogen secretion. Enlarged pituitary gland may be compressing the blood vessels supporting it or there may be a predisposition in pregnant women compared with nonpregnant women or these two conditions may concur. Pituitary gland doesn’t have ability to regenerate. Scar tissue substitutes the necrotic cells. Presence of 50% of pituitary gland suffices the maintenance of normal functions.4 Partial or total hypopituitarism develops with necrosis of 70-90%.5 We report our experience in diagnosing and managing a case of Sheehan’s syndrome. Case Report A 26-year-old para 1 female presented with amenorrhea for 7 years. There was history of vaginal delivery at home followed by heavy bleeding for 2 days, for which she was admitted to some local hospital managed conservatively along with 3 units of blood transfusion. She did not resume her menses for 5 years post-delivery and did not breastfeed her baby due to insufficient milk production. In 2010, she took advice from some local practitioner and got investigated. Her serum prolactin level was 0.63 mg/ dL, triiodothyronine (T3) - 0.25 mg/dL, thyroxine (T4) - 1.30 mg/dL, thyroid-stimulating hormone

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CASE REPORT (TSH) - 2.13 mg/dL and estradiol - 23.92 pg/mL. She was prescribed many medications but did not resume her menses at all. She became hopeless and left treatment. Two years after this treatment failure, she presented to us with same complaints and additionally with cold intolerance for 2 years. On general examination, she was thin built of short stature (height 142 cm) with weight of 46 kg; pulse rate was 88/min and blood pressure (BP) was 132/86 mmHg with mild pallor. Her facial skin was dry, rough, discolored and few fine wrinkles were seen. Her systemic examination was within normal limits. Per speculum examination was within normal limits. On per vaginal examination, uterus was anteverted, hypoplastic, mobile, nontender, bilateral adnexa were clear and nontender. She was again investigated and results were: zz zz zz zz zz

Free T3 (FT3) - 0.40 pmol/L Free T4 (FT4) - 0.50 pmol/L TSH - 2.130 µIU/mL Serum prolactin - 0.48 ng/mL Growth hormone - 4.15 µIU/mL.

Blood picture of our patient showed - hemoglobin - 9.8 gm%, total leukocyte count (TLC) - 4,500/ dL, differential leukocyte count (DLC) - P74L26, platelet count - 2,80,000/dL, GPB - normocytic normochromic mild anisocytosis, no HP seen. Lipid profile was triglyceride - 112 mg%, cholesterol - 159 mg%, high-density lipoprotein (HDL) - 45%, lowdensity lipoprotein (LDL) - 91 mg%, very low-density lipoprotein (VLDL) - 23 mg%. On USG → Hypoplastic uterus was found. Ovaries were within normal limits. No adnexal mass was noted. Magnetic resonance imaging (MRI) was done, which showed partially empty sella suggestive of pituitary necrosis. Dynamic pituitary tests could not be done due to financial constraints of the patient. All her investigations were suggestive of Sheehan’s syndrome. She was prescribed cyclical hormones in the form of ethinyl estradiol 0.05 mg o.d. (Day 1 to Day 21) and norethindrone acetate 5 mg b.i.d. (Day 16 to Day 25) and referred to Medicine Department for other supplementary hormonal therapy. There she was advised tablet prednisolone - 20 mg o.d., levothyroxine 50 µg o.d. for 1 month. 22

After 1 month, she resumed her menses with average flow and duration. Meanwhile hormonal doses were changed, she was kept on tablet prednisolone 10 mg for 15 days f/b 7.5 mg. Dose of levothyroxine was increased to 75 µg for 1 month. Estrogen and progestins were continued in the same dose. She again had her menses at an average interval, flow and duration. After 2 months of treatment, her thyroid profile was FT3 - 3.33 pmol/L (within normal limit), FT4 - 10.37 pmol/L (within normal limits) and TSH - 1.770 µIU/mL (within normal limits). Her cold intolerance and lethargy improved and skin texture was better. Earlier she was hopeless with the treatment but after having positive results she is willing for infertility treatment. She will be planned for infertility treatment in future. Discussion Known as postpartum pituitary necrosis, diagnosis of Sheehan’s syndrome is based upon medical history of the patient, clinical findings, detection of low level of pituitary and target gland hormones and visualizing partial or complete empty sella by imaging procedures. Sheehan’s syndrome is one of the leading causes of hypopituitarism in developing countries.6,7 Pituitary insufficiency in Sheehan’s syndrome may be in the form of partial or complete hormone insufficiency.8 Symptoms and signs of Sheehan’s syndrome are generally due to insufficient levels of hormones secreted from the anterior pituitary. The skin is dry, pale and light-colored and face is wrinkled. Axillary and pubic hair decrease and amenorrhea develops as a result of insufficiency of gonadotropins. Thyioid gland is shrunk as thyroid stimulation is ceased. Sufficient milk cannot be produced because of hypoprolactinemia.9 The patients with Sheehan’s syndrome usually are presented to emergency services due to situations such as “coma of hypothyroidism, adrenal insufficiency, hypoglycemia and hyponatremia following a serious stressful event”.10 Hyponatremia is the most common electrolyte disorder in Sheehan’s syndrome. It develops due to volume depletion, cortisol insufficiency, hypothyroidism and probably syndrome of inappropriate antidiuretic hormone secretion (SIADH). It may merge in postpartum period as well as several years after delivery.10-13

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT Anemia may develop in Sheehan’s syndrome due to cortisol deficiency, hypothyroidism and hypogonadism.14 Sheehan’s syndrome patient may present with hyperlipidemia due to hypothyroidism and growth hormone insufficiency. It is believed that functions most frequently affected in Sheehan’s syndrome are prolactin and growth hormone secretion. However, the secretion of other hormones may also be affected adversely. In our patient, prolactin level was very low. In regard to basal hormone levels, our patient had low T3, T4 and normal TSH level. This suggested that situation was secondary to hypothyroidism. Studies show that sella volume of patient with Sheehan’s syndrome are smaller than normal controls.15,16 Our patient had partially empty sella on MRI. Sheehan’s syndrome may be acute or chronic, it’s acute form is rare. Sheehan’s syndrome diagnosis is usually made several years after the postpartum bleeding. The interval may be as long as 15-20 years.9 Our patient was diagnosed much earlier with disease duration of 7 years. Conclusion Sheehan’s syndrome is more common in rural parts of our country. Considering the duration of disease, one may conclude that diagnosis and treatment are delayed. This may be originating from natural course of disease and also because of delay in diagnosis. Though rare but also it is frequently missed because of lack of awareness on the part of treating clinician. So keeping in mind, a women coming in postpartum period with history if heavy bleeding during or after child birth, signs and symptoms suggestive of deranged hormonal profile should be investigated for early diagnosis and treatment of Sheehan’s syndrome. References 1. “Postpartum necrosis of the anterior pituitary”, by H.L. Sheehan, Journal of Pathology and Bacteriology, vol. 45, pp. 189-214, 1937. Am J Obstet Gynecol. 1971;111(6):851.

clinical characteristics, dosing and safety. Clin Endocrinol (Oxf ). 1999;50(6):703-13. 4. Kovacs K. Sheehan syndrome. Lancet. 2003;361(9356): 520-2. 5. Aron DC, Finding JW, Tyrell BJ. Hypothalamus and pituitary. In: Greenspan FS, Strewler GJ (Eds.). Basic and Clinical Endocrinology. 5th Edition, Stanford CT, USA: Appleton & Lange; 1997. pp. 95-156. 6. Dash RJ, Gupta V, Suri S. Sheehan’s syndrome: clinical profile, pituitary hormone responses and computed sellar tomography. Aust N Z J Med. 1993;23(1):26-31. 7. Ozbey N, Inanc S, Aral F, Azezli A, Orhan Y, Sencer E, Molvalilar S. Clinical and laboratory evaluation of 40 patients with Sheehan’s syndrome. Isr J Med Sci. 1994; 30 (11):826-9. 8. Haddock L, Vega LA, Aguiló F, Rodríguez O. Adrenocortical, thyroidal and human growth hormone reserve in Sheehan’s syndrome. Johns Hopkins Med J. 1972;131(2):80-99. 9. De Groot LJ. Textbook of Endocrinology. 2nd Edition, Philadelphia, Pa: Saunders; 1989. pp. 431-2. 10. Kageyama Y, Hirose S, Terashi K, Nakayama S, Komatsuzaki O, Fukuda H. A case of postpartum hypopituitarism (Sheehan’s syndrome) associated with severe hyponatremia and congestive heart failure. Jpn J Med. 1988;27(3): 337-41. 11. Shoji M, Kimura T, Ota K, Ohta M, Sato K, Yamamoto T, et al. Cortical laminar necrosis and central pontine myelinolysis in a patient with Sheehan syndrome and severe hyponatremia. Intern Med. 1996;35(5):427-31. 12. Umekawa T, Yoshida T, Sakane N, Kondo M. A case of Sheehan’s syndrome with delirium. Psychiatry Clin Neurosci. 1996;50(6):327-30. 13. Boulanger E, Pagniez D, Roueff S, Binaut R, Valat AS, Provost N, et al. Sheehan syndrome presenting as early post-partum hyponatraemia. Nephrol Dial Transplant. 1999;14(11):2714-5. 14. Bayram F, Ünlühızarcı K, Keleştimur F. A retrospective investigation of the patients with Sheehan’s syndrome seen in Erciyes University Medical School Hospital during the last 7 years. Tur JEM. 1996;6(3):279-91.

2. Pituitary (Hypoestrogenic Amenorrhea). In: First Aid for the Obstetrics and Gynecology Clerkship. p. 226.

15. Bakiri F, Bendib SE, Maoui R, Bendib A, Benmiloud M. The sella turcica in Sheehan’s syndrome: computerized tomographic study in 54 patients. J Endocrinol Invest. 1991;14(3):193-6.

3. Abs R, Bengtsson BA, Hernberg-Stâhl E, Monson JP, Tauber JP, Wilton P, et al. GH replacement in 1034 growth hormone deficient hypopituitary adults: demographic and

16. Sherif IH, Vanderley CM, Beshyah S, Bosairi S. Sella size and contents in Sheehan’s syndrome. Clin Endocrinol (Oxf ). 1989;30(6):613-8.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT

An Unusual Case of Uterine Anomaly, Surgically Corrected with a Fruitful Pregnancy At Last Sumitra Yadav*, Anita Singh†, Niyati Jain‡

ABSTRACT Fusion anomalies of uterus results in a variety of uterine shapes which cause increased incidence of miscarriage, poor fetal growth, malpresentation and abnormal placental adherence in such cases. Prevalence of uterine anomalies in general population is 7-8%. We are presenting a case report of a 20-year-old P0 patient who presented with acute abdomen. Ultrasonography revealed a hemorrhagic cyst. On laparotomy, it was found to be unicornuate uterus with hematometra in the noncommunicating arm. She was subjected to surgical correction which led to a bicornuate uterus and thereafter she was conceive twice successfully. Keywords: Endometriosis, deep infiltrating endometriosis, endometriomas, infertility, radical surgical excision

usion anomalies of the uterus results in a variety of uterine shapes which cause increased incidence of miscarriage, poor fetal growth, malpresentation and abnormal placental adherence in such cases.1-3 Prevalence of uterine anomalies in general population is 7-8%. Now, because of better availability of diagnostic modalities like transvaginal sonography, hysterosalpingography and laparoscopy, better detection of such anomalies is possible.4 Reproductive outcomes can be improved with early diagnosis and proper surgical correction. We are reporting a case of unicornuate uterus with a noncommunicating horn which after surgical correction became a bicornuate and resulted in successful pregnancy outcome. Case Report A 20-year-old married female was admitted with acute abdominal pain and vomiting for 1 day in MY Hospital, Indore on May 2008. As per patient, her menses lasted for 1 day only. Her ultrasonography (USG) showed a cyst of size 7.47 × 4.17 cm in right adnexal region with

*Associate Professor † Senior Resident ‡ 3rd Year PG Student MY Hospital and MGM Medical College, Indore, Madhya Pradesh Address for correspondence Dr Sumitra Yadav 30, Nayapura, Aerodrome Road, Indore, Madhya Pradesh - 452 005 E-mail: drsumitrayadav@yahoo.co.in

internal echo and absent right-sided kidney. Color Doppler showed acute hemorrhage in right ovary. Emergency laparotomy was done. Intraoperatively, there was a globular swelling on left side, which was connected to uterus (Figs. 1 and 2). Uterus was small of about 4 × 3 cm with tubes and ovary on right side only. So, it was diagnosed to be a unicornuate uterus having noncommunicating horn with hematometra (Fig. 3). Hematometra was drained and the unicornuate uterus surgically corrected to a bicornuate uterus by modified Strassman’s method. Her cervical os was pin-pointed and dilation was done. On follow-up, her menstrual history showed that her cycles now lasted for 5-6 days with good flow as compared to previous scanty menses. Hysterosalpingography showed bicornuate uterus with 2 separate cavities. Cervix was common and seen in continuation of right horn with patent fallopian tube.

Figure 1. Globular swelling on left side.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT and a male baby of 2.26 kg with maturity of around 36 weeks was delivered through emergency LSCS and this time tubectomy was also done. Discussion Developmental failure of one mullerian duct while the other develops normally results in unicornuate uterus5 and accounts for approximately 20% of mullerian duct anomalies. A unicornuate uterus may be isolated, manifested in 35% patients, although it is usually associated with variable degree of a rudimentary horn. A rudimentary horn without endometrium is seen in 33% of cases and that with endometrium is seen in 32%. A rudimentary horn is designated communicating if there is communication with the endometrium of contralateral horn (10%) and noncommunicating, if there is no such communication (22%).

Figure 2. Globular swelling connecting to uterus.

Conclusion Various studies show that it is better to remove rudimentary horn with hematometra.6 In this case report, an experimental surgery has been done in which rudimentary horn with hematometra after drainage was joined with a small uterus that resulted in a fruitful pregnancy. References Figure 3. Unicornuate uterus having noncommunicating horn.

1. Propst AM, Hill JA 3rd. Anatomic factors associated with recurrent pregnancy loss. Semin Reprod Med. 2000; 18(4):341-50. 2. Patton PE, Novy MJ. Reproductive potential of the anomalous uterus. Semin Reprod Endocrinol. 1988;6:217-33.

Outcome She conceived after 1½ years and her last menstrual period was 20th October 2009 with expected delivery date 27th July 2010. She was admitted at 32 weeks with complaint of backache. She was kept on tocolytics and given decadron. After 1 month of ward admission, she had pain in lower abdomen and persistent tachycardia. She finally landed up in emergency lower segment cesarean section (LSCS) on 20th June 2010. A female baby of 1.5 kg with maturity around 35 weeks was delivered. She conceived second time after 1 year

3. Heinonen PK. Unicornuate uterus and rudimentary horn. Fertil Steril. 1997;68(2):224-30. 4. Carrington BM, Hricak H, Nuruddin RN, Secaf E, Laros RK Jr, Hill EC. Müllerian duct anomalies: MR imaging evaluation. Radiology. 1990;176(3):715-20. 5. Buttram VC Jr, Gibbons WE. Müllerian anomalies: a proposed classification. (An analysis of 144 cases). Fertil Steril. 1979;32(1):40-6. 6. Rock John A, Jones Howard W III. TeLinde’s Operative Gynaecology. 10th Edition, 575 (Andrews and Johnes).

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT

A Hole in Fundus of Primigravid Uterus: An Unusual Finding at Cesarean Section Rekha Rani*, Shikha Singh†, Urvashi Verma‡, Ruchika Garg*, Divya Yadav#, Saroj Singh$, Surendra Kumar¥, Shweta Chauhan¶, Ragini¶

ABSTRACT The spontaneous rupture of the primigravid uterus before the onset of labor is an obstetric rarity. Invariably, there is a history of antecedent scarring. A case of uterine rupture or defect in uterine musculature, an unusual finding at cesarean section, is reported. The probable mechanism of rupture/defect in fundus is discussed. Admission at 32 weeks and cesarean section at 36 weeks is recommended in the next pregnancy. Keywords: Fundal defect, rupture uterus, primigravid uterus, pregnancy, cesarean section

ncomplicated uterine perforation has been considered a benign event. Since the advent of operative hysteroscopy, there have been several reports of uterine rupture during pregnancy in patients who have undergone that procedure when complicated by known or unsuspected uterine perforation. Large fundal defects without rupture have also been reported. In general, a small midline or fundal injury with a blunt instrument does not have clinically significant sequelae if bleeding is minimal, but large rents or those caused by sharp or electrosurgical instruments may result in a need for diagnostic laparoscopy to completely evaluate the patient for bleeding or visceral injury. Lateral perforations involve risk of injury to vessels and should

be further inspected with diagnostic laparoscopy or interventional radiology, angiography.

*Associate Professor † Professor Dept. of Obstetrics and Gynecology ‡ Associate Professor Dept. of Pediatric Surgery # Assistant Professor $ Professor and Head ¥ Consultant Anesthesia ¶ Junior Resident (3rd Year) Dept. of Obstetrics and Gynecology SN Medical College, Agra, Uttar Pradesh Address for correspondence Dr Rekha Rani Associate Professor Dept. of Obstetrics and Gynecology SN Medical College, Agra, Uttar Pradesh - 282 002 E-mail: drrekha.gynae@gmail.com

On examination at admission, her vitals were stable. The uterus was at term, relaxed, with the fetus in breech presentation and with absent liquor. The fetal heart beat was regular. Per vaginum examination showed that the cervix was long and os closed. Her pelvis was borderline. All antenatal investigations were within normal limits. Her ultrasonography (USG) showed single live intrauterine pregnancy of 41 weeks 3 days with frank breech with absent liquor. The patient was admitted and in view of her precious post-dated pregnancy with frank breech and absent liquor and previous infertility treatment. The decision was taken for an emergency cesarean section. Her cesarean section was done and after delivery of

Whenever electrical or laser injury to the bowel or bladder is suspected, laparoscopy or laparotomy is required for complete evaluation. The risk of peritonitis, sepsis and death are most often associated with unrecognized and untreated thermal injuries to the viscera. Case Report A 24-year-old primigravida, married for 4 years, was admitted as a referred patient at term. She had a history of 4 years of infertility, having conceived following infertility treatment. She had a prior diagnostic laparoscopy for infertility 2 years back. The patient had no complaints. There was no abdominal pain, nor any bleeding/leaking per vaginum. The patient’s gestational age at admission was 41 weeks.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT

2-3 cm defect in uterus Defect covered by right fallopian

Figure 1. A 2.5 × 3 cm defect seen in the fundal part of the

uterus.

Figure 3. The defect covered by fimbrial part of right fallopian

tube.

Gloved finger seen through defect

(Fig. 2). The defect was covered with fimbrial part of right fallopian tube (Fig. 3). However, in spite of the rent, there was no active bleeding from its edges. There was no tear into fresh uterine tissue. The scar tissue surrounding the hole in the uterus was excised and a two-layer closure was achieved. The lower segment of uterus and the abdomen were closed in the routine fashion. The patient made an uneventful recovery and was discharged on the 10th postoperative day. Discussion

Figure 2. Defect on the fundus communicating with the

uterine cavity.

the baby which was a healthy male child, weighing 3.44 kg, the uterus was exteriorized for examination. A 3 × 2.5 cm defect (Fig. 1) was found on the fundus anteriorly and communicating with the uterine cavity

The term ‘rupture uterus’ is used to denote a breach in the substance of the gravid uterus musculature from any cause after fetal viability.1 It constitutes a life-threatening obstetric emergency with significant effects on the reproductive function of women. Uterine rupture typically is classified as either complete when all layers of the uterine wall are separated, or incomplete when the uterine muscle is separated but visceral peritoneum is intact.2 The majority of cases of uterine rupture occur in a patient where pregnancy follows a previous cesarean section. Direct trauma to the uterus is another rare cause of uterine rupture. The signs and symptoms of rupture

IJCP SUTRA 108: Percutaneous mitral balloon valvotomy is indicated for selected asymptomatic patients with severe MS (MVA ≤1.5 cm2, stage C) with new onset atrial fibrillation (AF) and favorable valve morphology, absence of moderate to severe MR, and no left atrial thrombus. 2014 AHA/ACC Valve Guideline.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT of the uterus would manifest when the scar ruptures or the window extends in early labor. Silent rupture, dehiscence or windows should not be considered in the same category as true uterine ruptures. They represent no extension into fresh uterine tissue, lack symptoms, cannot be diagnosed, involve no blood loss or shock. The hazard to the mother or baby is minimal, as in this case. The uterine wall may be weakened by previous procedures like manual removal of the placenta or curettage with or without perforation for retained products of conception following abortion. At present maternal death as a consequence of uterine rupture occurs at a rate of 0-1% in developed nations and 5-10% in developing countries.3,4 In our case, the previous diagnostic laparoscopy may have caused trochar injury on the fundus.5 Rupture uterus is one of the worst obstetric emergencies in which the life of both mother and child are in danger, the incidence ranges from 0.2% to 0.6%. Factors that can predispose to uterine rupture are multiparity, advanced maternal age, a scarred uterus, malpresentations, contracted pelvis, misuse of oxytocic drugs and rarely obstetric maneuvers like external cephalic or internal podalic version, and following instrumental deliveries.6 Fetal morbidity invariably occurs because of catastrophic hemorrhage leading to fetal anoxia, with uterine rupture and expulsion of the fetus into the peritoneal cavity. The chance of fetal survival is minimal. Immediate diagnosis and delivery by laparotomy can save the baby.7

Conclusion We report this case to highlight the fact that although spontaneous rupture of the gravid uterus is a very rare complication in primigravid women. It can still occur and it should be diagnosed and treated promptly. Patients with a prior dilatation and curettage, diagnostic laparoscopy and other uterine interventions should be monitored and screened for myometrial thickness prior to conception and antenatally by ultrasound and magnetic resonance imaging. References 1. Ian Donald’s Practical Obstetric Problems. New Delhi: BI Publication Private Limited. 5th Edition; 1996. pp. 795-804. 2. Padhye SM. Rupture of the pregnant uterus - a 20 year review. Kathmandu Univ Med J (KUMJ). 2005;3(3):234-8. 3. Mokgokong ET, Marivate M. Treatment of the ruptured uterus. S Afr Med J. 1976;50(41):1621-4. 4. Rahman J, Al-Sibai MH, Rahman MS. Rupture of the uterus in labor. A review of 96 cases. Acta Obstet Gynecol Scand. 1985;64(4):311-5. 5. Nkwabong E, Kouam L, Takang W. Spontaneous uterine rupture during pregnancy: case report and review of literature. Afr J Reprod Health. 2007;11(2):107-12. 6. Ahmadi S, Nouira M, Bibi M, Boughuizane S, Saidi H, Chaib A, et al. Uterine rupture of the unscarred uterus. About 28 cases. Gynecol Obstet Fertil. 2003;31(9):713-7. 7. Mahbuba, Alam IP. Uterine rupture - experience of 30 cases at Faridpur Medical College Hospital. Faridpur Med Coll J. 2012;7(2):79-81.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT

Unexpected Intruder: An Interesting Case of Placenta Increta HN Rukshana*, Sowbarnika†, Jayanthi Mohan‡

ABSTRACT Placenta accreta, a condition with high morbidity, is anticipated in women with risk factors for the same. Danger when anticipated is easier handled than when taken by surprise. Here we report a case of placenta increta with an unusual presentation. Keywords: Placenta accreta, placenta increta, adherent placenta, severe morbidity, increasing cesarean section rates

dherent placenta is an abnormal attachment of the placental villi to the decidua and can present with varying degrees of invasion into the myometrium.1 Placenta increta is one of the rarer forms of adherent placenta. It is a serious condition associated with severe morbidity and even mortality. The risk factors include prior cesarean and uterine curettage.2 This condition affects 1 in 2,500 pregnancies.1 The increasing cesarean section rates has contributed to the alarming increase in adherent placenta but the risk remains low in an unscarred uterus. Here we discuss a case of placenta increta in a patient with no known risks for adherent placenta, who was successfully managed conservatively. Case Report Mrs SA, a 24-year-old primiparous lady was referred to our center with failed attempt at manual removal of placenta, after an uncomplicated vaginal delivery at term in a nursing home. On reviewing her history, she had been a second gravid with one previous spontaneous abortion at 2 months.

*Assistant Professor † Associate Professor ‡ Professor and Chief (Unit IV) Dept. of Obstetrics and Gynecology Sri Ramachandra University, Chennai, Tamil Nadu Address for correspondence Dr HN Rukshana No. 5, Kannadasan Street, Rangarajapuram, Kodambakkam, Chennai - 600 024, Tamil Nadu E-mail: rukshanahn@yahoo.com

She had no history of uterine curettage. The index pregnancy had been uneventful. She had spontaneous onset of labor at 39 weeks and delivered vaginally a healthy 2.7 kg boy baby. However, placenta failed to separate even 2 hours after the delivery. Manual removal was tried in that nursing home, which was unsuccessful. Hence, patient was referred for tertiary care to Sri Ramachandra Medical College, Chennai. On examination in the casualty, her general condition was satisfactory with a blood pressure (BP) of 110/70 mmHg. She had tachycardia with heart rate ~110130 bpm. On abdominal examination, uterus was 28 weeks in size and firm in consistency. On vaginal examination, os was closed with ~100 g of clots in the vagina. Ultrasound (Fig. 1) showed placenta at the fundus and post wall invading into the myometrium, with thinning of myometrium at the fundus. USG was followed by magnetic resonance imaging (MRI) (Figs. 2 and 3), which confirmed the earlier diagnosis of placenta increta with more than 60-70% of myometrial invasion; maximum thickness of the myometrium was 5 mm at the fundus. In view of placenta increta, we decided on uterine artery embolization (UAE) after counseling the patient and her family. The procedure was done under LA. Selective catheterization of both uterine arteries was done followed by embolization using graded polyvinyl alcohol (PVA) particles. Completion angiograms confirmed complete absence of abnormal blush and vascularity on either side.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT

Figure 1. Ultrasound showing adherent placenta.

Figure 3. MRI showing thinning of myometrium at the fundus.

Figure 2. MRI showing placenta increta.

Figure 4. The expelled placenta on Day 82.

After the embolization, patient was given one dose of intramuscular methotrexate 50 mg.

Patient has been following up on OP basis for the last 3 months. Clinical examination showed progressive involution of the uterus. Fundal height decreased from 28 weeks prior to the embolization to 14 weeks after 6 weeks and serial ultrasound has shown consistent decrease in the size of placenta from 8.6 × 6.0 to 8.0 × 5.8 at 3 weeks and 6.7 × 5.4 cm at 6 weeks with no flow on Doppler. BetahCG (human chorionic gonadotropin) returned to normal after 3 weeks. Eighty-two days after the procedure, patient expelled the placenta (Fig. 4)

Two days after the embolization, patient developed spikes of fever hemoglobin level progressively dropped from 8.4 mg/dL on D1 to 5.4 on D3 along with drop in total count from 17,000 to 4,500. Further doses of methotrexate was withheld because of pancytopenia. Three units of packed cell was transfused. Patient recovered well and was discharged on Day 7.

IJCP SUTRA 110: Percutaneous mitral balloon valvotomy is indicated for selected severely symptomatic patients (NYHA class III to IV) with severe MS (MVA ≤1.5 cm2, stage D) who have a suboptimal valve anatomy and who are not candidates for surgery or at high risk for surgery. 2014 AHA/ACC Valve Guideline.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT following 6 days of pain abdomen and moderate amount of bleeding per vaginum. Discussion A placenta accreta occurs when there is abnormally firm attachment of placental villi to the uterine wall with the absence of the normal intervening decidua basalis and Nitabuch's layer. There are 3 variants of this condition: 1) Accrete: The placenta is attached to the myometrium - incidence reported is 75%; 2) Increta: The placenta extends into the myometrium and is seen in 17% of patients with adherent placenta and 3) Percreta reported in 5-7% - the placenta extends through the entire myometrial layer and uterine serosa. About 88% of placenta accreta cases are associated with placenta previa and 78% have a history of previous cesarean birth.3 The risk of placenta accreta is 0.03% for primi, without placenta previa.4 Placenta accreta can be diagnosed using ultrasound or MRI. When one imaging modality is inconclusive, the other modality may be useful for clarifying the diagnosis.5 Sonographic features that have been associated with placenta accreta include:6 ÂÂ

Loss of normal hypoechoic retroplacental zone.

ÂÂ

Multiple vascular lacunae within placenta, giving “Swiss cheese” appearance.

ÂÂ

Blood vessels or placental tissue bridging uterineplacental margin, myometrial-bladder interface or crossing uterine serosa.

ÂÂ

Retroplacental myometrial thickness of <1 mm.

ÂÂ

Numerous coherent vessels visualized 3-dimensional power Doppler in basal view.

with

Serial MRI, in conjunction with β-hCG assays, has been shown to provide an accurate and noninvasive imaging modality to confirm ablation of residual trophoblastic tissue.7 When analyzing the role of conservative management of placenta accreta - it has been found to have a good success rate along with a reduction in the hysterectomy rate from 84% to 15%, proving that leaving the placenta in situ is a safe alternative to removing the placenta.8,9

Conservative management of placenta accreta with methotrexate although successful in uterine preservation, has not been found to be effective in prevention of significant delayed hemorrhage.10 UAE for placenta accreta has been found to be a safe and effective method for persistent but noncatastrophic obstetric bleeding11 and this modality has been well-established as an adjunctive treatment in cases, where the placenta is left in situ. Prophylactic UAE with PVA particles, to reduce uterine and placental blood flow, postoperatively has been found to be effective12 and subsequent fertility is not impaired by the procedure.13 Methotrexate has been used to accelerate reduction in placental mass and combination of methotrexate with UAE has also been reported.14 Expulsion of the retained placenta has been reported to occur as long as 7-8 weeks later.15 Conclusion Placenta increta occurs rarely in patients without risk factors nevertheless this condition must always be considered in women with retained placenta. UAE is a safe and effective nonsurgical method in the management of adherent placenta in a hemodynamically stable patient. References 1. ACOG Committee on Obstetric Practice. ACOG Committee opinion. Number 266, January 2002: placenta accreta. Obstet Gynecol. 2002;99(1):169-70. 2. De Lange M, Rouse GA. Ob/Gyn Sonography: An Illustrated Review. Pasadena, Calif: Davies Publishing Inc; 2004. 3. Armstrong CA, Harding S, Matthews T, Dickinson JE. Is placenta accreta catching up with us? Aust N Z J Obstet Gynaecol. 2004;44(3):210-3. 4. Silver RM, Landon MB, Rouse DJ, Leveno KJ Spong CY, Thom EA, et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107 (6):1226-32.

IJCP SUTRA 111: Mitral valve surgery is indicated for selected patients with moderate MS (MVA 1.6 cm2 to 2.0 cm2) with mitral valve anatomy unfavorable for percutaneous intervention (echocardiogram score and presence of MR) undergoing cardiac surgery for other indications. 2014 AHA/ACC Valve Guideline.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT 5. Dwyer BK, Belogolovkin V, Tran L, Rao A, Carroll I, Barth R, et al. Prenatal diagnosis of placenta accreta: sonography or magnetic resonance imaging? J Ultrasound Med. 2008;27(9):1275-81.

11. Uchiyama D, Koganemaru M, Abe T, Hori D, Hayabuchi N. Arterial catheterization and embolization for management of emergent or anticipated massive obstetrical hemorrhage. Radiat Med. 2008;26(4):188-97.

6. Publications Committee, Society for Maternal-Fetal Medicine, Belfort MA. Placenta accreta. Am J Obstet Gynecol. 2010;203(5):430-9.

12. El-Messidi A, Morissette C, Faught W, Oppenheimer L. Application of 3-D angiography in the management of placenta percreta treated with repeat uterine artery embolization. J Obstet Gynaecol Can. 2010;32(8):775-9.

7. Sonin A. Nonoperative treatment of placenta percreta: value of MR imaging. AJR Am J Roentgenol. 2001;177(6):1301-3. 8. Kayem G, Davy C, Goffinet F, Thomas C, Clément D, Cabrol D. Conservative versus extirpative management in cases of placenta accreta. Obstet Gynecol. 2004;104(3): 531-6.

13. Chauleur C, Fanget C, Tourne G, Levy R, Larchez C, Seffert P. Serious primary post-partum hemorrhage, arterial embolization and future fertility: a retrospective study of 46 cases. Hum Reprod. 2008;23(7):1553-9.

9. Sentilhes L, Ambroselli C, Kayem G, Provansal M, Fernandez H, Perrotin F, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526-34.

14. Sherer DM, Gorelick C, Zigalo A, Sclafani S, Zinn HL, Abulafia O. Placenta previa percreta managed conservatively with methotrexate and multiple bilateral uterine artery embolizations. Ultrasound Obstet Gynecol. 2007;30(2):227-8.

10. Mussalli GM, Shah J, Berck DJ, Elimian A, Tejani N, Manning FA. Placenta accreta and methotrexate therapy: three case reports. J Perinatol. 2000;20(5):331-4.

15. Chan BC, Lam HS, Yuen JH, Lam TP, Tso WK, Pun TC, et al. Conservative management of placenta praevia with accreta. Hong Kong Med J. 2008;14(6):479-84.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

JOURNAL SCAN

News and Views

Role of the Epidermal Growth Factor Network in Oocyte Growth, Maturation and Development A new study published in the Human Reproduction Update review outlines the role of the epidermal growth factor (EGF) network during oocyte development and regulation of the ovulatory cascade. This review focused on the effect of the EGF network on oocyte developmental competence. This study included peer-reviewed original and review articles concerning the EGF network form the PubMed database. The findings of this review confirmed that acute upregulation of the EGF network is an essential component of the ovulatory cascade as it transmits the luteinizing Hormone (LH) signal from the periphery of the follicle to the cumulus-oocyte complex (COC). It was reported that recent findings have elucidated new roles for the EGF network in the regulation of oocyte development. EGF signaling downregulates the somatic signal 3'5'-cyclic guanine monophosphate that suppresses oocyte meiotic maturation and concurrently provides meiotic inducing signals. In addition, the EGF network controls the translation of maternal transcripts in the quiescent oocyte, a process that is integral to oocyte competence. As a means of restricting the ovulatory signal to the Graffian follicle, most COCs in the ovary are unresponsive to EGFligands. Furthermore, the development of a functional EGF signaling network in cumulus cells requires dual endocrine (FSH â&#x20AC;&#x201C; follicle-stimulating hormone) and oocyte paracrine cues (growth differentiation factor 9 and bone morphogenetic protein 15), which occurs progressively in COCs during the last stages of folliculogenesis. Hence, it was stated that cumulus cell acquisition of EGF receptor responsiveness represents a developmental hallmark in folliculogenesis, analogous to FSH-induction of LH receptor signaling in mural granulosa cells. Similarly, this event represents a major milestone in the oocyte's developmental progression and acquisition of developmental competence. The results clarified that EGF signaling is obstructed in COCs matured in vitro. Thus, unraveling the fundamental

molecular and cellular mechanism by which the EGF network regulates oocyte maturation and ovulation can be expected to open new opportunities in assisted reproductive technology (ART). Estrogen Metabolism in Abdominal Subcutaneous and Adipose Tissue in Postmenopausal Women A new study published in The Journal of Clinical Endocrinology and Metabolism compared concentrations of and metabolic pathways producing estrone and estradiol in abdominal subcutaneous and visceral adipose tissue (AT) in postmenopausal women. Here, AT and serum samples were obtained from 37 postmenopausal women undergoing surgery for nonmalignant gynecological reasons. The results revealed that estrone concentration was higher in visceral than subcutaneous AT and correlated positively with body mass index (BMI). On the other hand, AT depots hydrolyzed estrone sulfate (E1S) to estrone, and visceral AT estrone and estradiol concentrations correlated positively with serum E1S. In comparison with visceral AT, subcutaneous AT produced more estradiol from estrone. In visceral AT, the conversion of estrone to estradiol increased with waist circumference. Besides, and estradiol concentration correlated positively with mRNA expression of 17Î˛-hydroxysteroid dehydrogenase (HSD17B7). It was concluded that both estrone and estradiol production in visceral AT increased with adiposity, but estradiol was produced more effectively in subcutaneous fat. While both AT depots produced estrone from E1S. Thus, it was stated that increasing visceral adiposity could increase overall estrogen exposure in postmenopausal women. Long-Term Effectiveness of the Quadrivalent Human Papillomavirus Vaccine. A new study published in Clinical Infectious Diseases assessed the long-term effectiveness of the quadrivalent human papillomavirus (qHPV) vaccine by monitoring the combined incidence of cervical intraepithelial

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

JOURNAL SCAN neoplasia (CIN2, CIN3), adenocarcinoma in situ (AIS), and cervical cancer related to HPV16 or HPV18. This study enrolled 2084 women from Denmark, Iceland, Norway, and Sweden who received a 3-dose regimen of the qHPV vaccine. Vaccine effectiveness against HPV16/18-related CIN2 or worse (CIN2+) was estimated by comparing the observed incidence with the expected incidence of CIN2+ in an unvaccinated cohort using historical registry data. It was observed that after the first 12 years, there were no breakthrough cases of HPV16/18 CIN2+ after 9437 person-years of follow-up. Statistical data confirmed that qHPV vaccine effectiveness remains above 90% for at least 10 years. It was reported that the number of person-years during the follow-up interval of 10-12 years is continuing to increase and shows a trend toward continuing effectiveness of the vaccine during that period. Thus, it was inferred that qHPV vaccine shows continued protection in women through at least 10 years, with a trend for continued protection through 12 years of follow-up. Polybrominated Diphenyl Ether Concentrations in Human Breast Milk Specimens Worldwide A new study published in Epidemiology aimed to summarize global research data on polybrominated diphenyl ether (PBDE) concentrations in human breast milk specimens, in recent years. This systematic review was conducted through PubMed search of original studies on PBDE concentrations in human individual breast milk specimens collected in the general population, over the recent 15-year period (2000-2015), worldwide. This study identified 49 eligible studies which included 7,505 study subjects. The results revealed that the pooled means of

total PBDE concentration in breast milk (ng/g lipid) were 66.8 in North America; 2.6 in Europe; and 2.8 in Asia. While the pooled means of median total PBDEs concentration in breast milk (ng/g lipid) were 40.0 in North America; 1.9 in Europe; and 2.2 in Asia. The high concentrations of total PBDEs in breast milk in North America were mainly due to high concentrations of brominated diphenyl ether-47 (BDE-47), BDE99, BDE-100, and BDE-153. However, there were too few studies from other continents (Africa, South America, and Oceania) for meaningful meta-analysis. Hence, it was inferred that total PBDE concentrations in breast milk in the recent 15-year period were over 20 times higher in North America versus Asia or Europe, whereas its concentrations were comparable in Europe and Asia.

Plasmodium Falciparum Infection Early in Pregnancy has Profound Consequences for Fetal Growth A new study published in The Journal of Infectious Diseases evaluated fetal growth by ultrasound and birth outcomes in women who were infected prior to their first antenatal visit (gestational age, GA<120 days), and not later in pregnancy. It was found that when compared to uninfected controls, women with early P. falciparum exposure had retarded intrauterine growth between a GA of 212 and 253 days, with a mean weight gain reduction of 107g; and shorter pregnancy length, with a mean reduction of 6.6 days. Additionally, the birth weight and the placental weight at term also declined. Hence, it was inferred that early exposure to P. falciparum, which are not prevented by current control strategies, has profound impact on fetal growth, pregnancy length, and the placental weight at term.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

Asian

Journal of

OBSTETRICS & GYNAECOLOGY Practice

Information for Authors

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

- -

The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper. Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors. Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript.

Manuscript - Three complete sets of the manuscript should be submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures). - The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures. - All pages should be numbered consecutively beginning with the title page. Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors. Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed, name of the corresponding authors, acknowledgment of financial support and abbreviations used.

The title should be of no more than 80 characters and should represent the major theme of the manuscript. A subtitle can be added if necessary.

A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included.

- The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page. -

A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text.

Summary - The summary of not more than 200 words. It must convey the essential features of the paper. - It should not contain abbreviations, footnotes or references. Introduction - The introduction should state why the study was carried out and what were its specific aims/objectives. Methods - These should be described in sufficient detail to permit evaluation and duplication of the work by others. - Ethical guidelines followed by the investigations should be described. Statistics The following information should be given: - The statistical universe i.e., the population from which the sample for the study is selected. -

Method of selecting the sample (cases, subjects, etc. from the statistical universe).

Method of allocating the subjects into different groups.

Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques.

Confidence intervals for the measurements should be provided wherever appropriate.

Results -

These should be concise and include only the tables and figures necessary to enhance the understanding of the text.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

Discussion -

This should consist of a review of the literature and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g. practicality and cost.

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses). At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution. Examples of common forms of references are:

Do not use clips/staples on photographs and artwork.

Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as ‘Fig.’. Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)_______________________________

Articles

2. Total number of pages ________________________

Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes. Q. J. Expt. Physiol. 1955;40:89-111.

3. Number of tables ____________________________

Books

Indian 1.____________Foreign 1.________________

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

2.____________ 2.________________

3.____________ 3.________________

Articles in Books

4.____________ 4.________________

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

7. All authors’ signatures________________________ 8. Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________

Tables -

These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table.

Legends - These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text. -

Figures - Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat. - All photomicrographs should indicate the magnification of the print. - Special features should be indicated by arrows or letters which contrast with the background. - The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen. - Color illustrations will be accepted if they make a contribution to the understanding of the article.

The legend must include enough information to permit interpretation of the figure without reference to the text.

4. Number of figures ___________________________ 5. Special requests _____________________________ 6. Suggestions for reviewers (name and postal address)

Online Submission Also e-issue @ www.ijcpgroup.com For Editorial Correspondence

Dr KK Aggarwal

Group Editor-in-Chief Asian Journal of Obstetrics and Gynaecology Practice E - 219, Greater Kailash, Part - 1, New Delhi - 110 048. Phone: 011-40587513 E-mail: editorial@ijcp.com, Website: www.ijcpgroup.com

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017

CASE REPORT

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 1, No. 4, Octover-December 2017