Invasive carcinoma of cervix during pregnancy--a case report and review of literature

Carcinoma of cervix is the commonest malignancy seen in Indian women in all age groups and therefore commonly seen in pregnancy. However, most of the cases remain in early stage and the occurrence of invasive cervical carcinoma is relatively uncommon in pregnant women. There is always a therapeutic dilemma faced by the gynaecologic oncologist and the maternal foetal specialist regarding management of pregnancy with cervical malignancy. A 30 years old, multiparous woman diagnosed to have squamous cell carcinoma of the cervix FIGO stage IB1 in the early second trimester was treated by radical hysterectomy followed by radiotherapy is being reported. The various therapeutic options and prognosis are discussed.

Recurrent ectopic pregnancy with heterotopic pregnancy in a patient of hypogonadotropic hypogonadism: a case report

BACKGROUND

Heterotopic pregnancy is the simultaneous occurrence of intrauterine and ectopic pregnancies. With an incidence reported to be between 1:8,000 and 1:30,000 pregnancies, heterotopic pregnancy is a rare entity. However, the increasing use of assisted reproductive techniques has contributed to the increasing incidence of heterotopic pregnancy during the past years.

CASE

This is a rare case of a hypogonadotropic hypogonadism in a patient with a heterotopic pregnancy six months after successful medical management of tubal ectopic pregnancy. The heterotopic pregnancy was managed expectantly with successful pregnancy outcome.

CONCLUSION

Heterotopic pregnancy should always be considered, especially in patients with prior history of ectopic pregnancy and those undergoing assisted reproduction. Its treatment is a challenge as serial beta-hCG is not useful in diagnosis or follow-up, and medical management with methotrexate is contraindicated with an intrauterine pregnancy. Heterotopic pregnancies in select cases can be managed expectantly with strict monitoring and serial ultrasounds, and the viable intrauterine pregnancy can be saved.

Identification of novel SRY mutations and SF1 (NR5A1) changes in patients with pure gonadal dysgenesis and 46,XY karyotype

Primary amenorrhea due to 46,XY disorders of sexual development (DSD) is complex with the involvement of several genes. Karyotyping of such patients is important as they may develop dysgerminoma and molecular analysis is important to identify the underlying mechanism and explore the cascade of events occurring during sexual development. The present study was undertaken for the genetic analysis in seven patients from five families presenting with primary amenorrhea and diagnosed with pure gonadal dysgenesis. Karyotyping was done and the patients were screened for underlying changes in SRY, desert hedgehog (DHH), DAX1 (NR0B1) and SF1 (NR5A1) genes, mutations in which are implicated in DSD. All the patients had 46,XY karyotype and two novel SRY mutations were found. In Family 1 (Patient S1.1) a missense mutation c.294G>A was seen, which results in a stop codon at the corresponding amino acid (Trp98X) and in Family 2 (Patients S2.1, S2.2 and S2.3), a missense mutation c.334G>A (Glu112Leu) was identified in all affected sisters. Both mutations were seen to occur in the conserved high mobility group box of SRY gene. One heterozygous change c.427G>A resulting in Glu143Lys in DHH gene in one patient and two heterozygous changes in the intronic region of SF1 (NR5A1) gene (c.244+80G>A+ c.1068-20C>T) in another patient were noted. One individual did not show changes in any of the genes analyzed. These results reiterate the importance of SRY and others, such as SF1 (NR5A1) and DHH, that are involved in the cascade of events leading to sex determination and also their role in sex reversal.

Peritoneal fluid leptin levels are increased but adiponectin levels are not changed in infertile patients with pelvic endometriosis

OBJECTIVE

Endometriosis is a leading cause of infertility, and recent studies suggest that leptin and adiponectin may have a role in its causation and progression. This study assessed levels of leptin and adiponectin in serum and peritoneal fluid (PF) in patients with endometriosis and infertility.

DESIGN AND SETTING

This cross-sectional study included women undergoing diagnostic and/or therapeutic laparoscopy for endometriosis with chief complaint of infertility. Following laparoscopy, patients diagnosed with endometriosis served as cases while patients with no endometriosis served as controls. Patients with polycystic ovarian syndrome, diabetes, thyroiditis and patients on prior therapy with danazol or leuprolide were excluded from the study. Leptin and adiponectin levels were analysed in blood and PF using commercially available ELISA kits.

RESULTS

Of the 50 patients (aged 22-41 years), 15 had endometriosis (cases) while 35 had no endometriosis (controls). The median PF leptin level was significantly higher in cases as compared to controls (27.7 vs. 15.6 ng/ml, p = 0.019), and this remained significant even when PF leptin was BMI-normalised (p = 0.004). However, median serum leptin and adiponectin levels remained comparable between the two groups.

CONCLUSIONS

This study confirmed the role of PF leptin in causation and progression of endometriosis. However, this would have been definitive if healthy fertile females were included in this study.

Efficacy of mifepristone in reducing intermenstrual vaginal bleeding in users of the levonorgestrel intrauterine system

OBJECTIVE

To evaluate the efficacy of mifepristone to reduce intermenstrual bleeding in levonorgestrel intrauterine system (LNG-IUS) users.

METHOD

In this prospective, open-label, comparative study, 36 women using the LNG-IUS for menorrhagia received 100mg of mifepristone every 30 days for 3 months (group 1). Fifty age-matched LNG-IUS users who did not receive any drugs were used as the comparison group (group 2). Menstrual bleeding days, pictorial blood loss assessment chart (PBAC) score, and intermenstrual bleeding/spotting days were compared between the 2 groups at 3 months (during treatment) and at 6 months (3 months post treatment).

RESULTS

Baseline characteristics were comparable between the groups. At 3 months, median duration and episodes of intermenstrual bleeding/spotting were significantly lower in group 1 compared with group 2 (6 vs 12.5 days, P=0.01; 2.5 vs 3, P=0.05, respectively). More women were satisfied with the LNG-IUS in the mifepristone group compared with the control group (75% vs 44%; P=0.004). At 6 months, the median duration of intermenstrual bleeding/spotting was significantly lower in group 1 compared with group 2 (6 vs 15 days; P=0.008).

CONCLUSION

Mifepristone was effective in reducing the number of episodes and duration of intermenstrual bleeding/spotting in LNG-IUS users.

Utility of pH test & Whiff test in syndromic approach of abnormal vaginal discharge

BACKGROUND & OBJECTIVE

In India, National AIDS Control Organization (NACO) introduced syndromic approach to treat patients with abnormal vaginal discharge without a need for laboratory tests. Simple tools like pH test and Whiff test can be done without high expertise, microscope and even speculum. This can improve diagnostic value of syndromic approach of abnormal vaginal discharge. The present study was conducted to evaluate sensitivity and specificity of pH test and Whiff test in diagnosis of abnormal vaginal discharge, considering microscopic diagnosis as gold standard.

METHODS

This prospective hospital-based study included 564 women with abnormal vaginal discharge. All women were subjected to gynaecological examination, pH test and Whiff test. The findings were compared with microscopic examination. Statistical analysis was done by calculating proportions, percentage, sensitivity and specificity.

RESULTS

Vaginitis was diagnosed in 301 (53.37%) women. Bacterial vaginosis (BV) was the commonest type of vaginitis (39.01%). Cervical erosion was the second most common cause (17.91%) and physiological discharge was the third (14.36%). pH >or= 4.5 and positive Whiff test had sensitivity of 94.09 per cent and specificity 87.5 per cent in diagnosing BV. Similarly pH < 4.5 and positive or negative Whiff test had sensitivity of 83.72 per cent in diagnosing candidiasis.

INTERPRETATION & CONCLUSION

pH test and Whiff test can improve diagnostic value of speculum examination where microscope facilities are not available.

Prevalence of human papillomavirus infection among young women in North India

BACKGROUND

The number of women infected with human papillomavirus (HPV) and the distribution of the HPV genotypes vary across populations and with age.

OBJECTIVE

To determine the prevalence and genotype distribution of HPV in young married women aged 16-24 years.

METHODS

1300 women residing in an urban slum in Delhi donated samples of exfoliated cervical cells that were collected by the Digene((R)) kit and tested for the presence of HPV DNA by two techniques in parallel, i.e., PCR using PGMY consensus primers for all HPV types and the Digene HPV test (Hybrid Capture 2 (HC2) Probe B for high-risk (hr) types. Genotyping was done on all HPV positive samples using the Roche reverse line blot assay.

RESULTS

HPV infection was detected in 91/1300 (7%) samples by PCR and 110/1300 (8.4%) samples by HC2. Genotyping identified 20 high-risk and 11 low-risk types. HPV16 was the commonest high-risk type (3%) followed by HPV52 (1.2%) and HPV51 (0.8%). Among low-risk types, HPV62 was the commonest (0.8%), followed by HPV84 and HPV89 (0.5% each). Multiple infections were found in 3% of the HPV positive samples.

CONCLUSION

A wide spectrum of HPV genotypes is seen in this young population. Knowledge about HPV types prevalent in communities in different regions of India would be useful in devising the optimum strategy for cervical cancer prevention.

Aetiology & risk factors of recurrent vaginitis & its association with various contraceptive methods

BACKGROUND & OBJECTIVES

Women who do not seek treatment for recurrent vaginitis have risk to acquire other sexually transmitted infections. Besides proper antibiotic treatment, male condom acts as a barrier to various infections. Present study was done to assess type of vaginitis, its association with various contraceptive methods and need of male condom in prevention of recurrent vaginitis.

METHODS

Prospective hospital based cohort study with a total of 400 women with recurrent vaginitis was done. Wet mount and Gram's staining examination were done to diagnose type of vaginitis. After treatment, proper counselling about good hygiene and use of male condom for 4 months in addition to their contraceptive method was advised. Patients were called after four months or when they developed symptoms of vaginitis.

RESULTS

Tubal ligation (38.8%) and non contraceptives (34.0%) were the most common methods used by recurrent vaginitis patients. Bacterial vaginosis (BV, 53.8%) and mixed infection (36.8%) were commonly seen infections. BV was not observed in OC pill users. Overall post-treatment cure was 89.1 per cent. INTERPRETATION CONCLUSIONS: Our findings showed that male condom use provided protection against recurrent vaginitis and its use should be promoted with other contraceptive methods in high risk cases. Female condom may be another option.

Abstract C59: Human papillomavirus genotype distribution in northern India: Implications for vaccination

Background: Cervical cancer caused by human papilloma virus (HPV), is the commonest cancer in Indian women, with an estimated 132000 new cases and 76000 deaths annually. More than 100 HPV genotypes have been identified in humans of which at least 40 HPV types are found in the genital tract. Several high-risk HPV types are known to cause the disease. There are only limited data available on the genotype distributions in this region.

Methods: During the period three different cross-sectional studies were carried out: (1) a hospital-based cross-sectional study in which 106 women presenting with invasive cervical cancer; (2) a hospital-based cross-sectional study in which 524 women presenting to have an unhealthy cervix were invited to participate; (3) a community-based cross-sectional study in which 465 women also underwent HPV testing. HPV typing in these studies was done by using L1 consensus PCR followed by reverse line blot hybridization assay (Roche).

Results: In the hospital-based population, among 106 invasive cervical cancers the six commonest HPV types were HPV-16, -18, -45, -59, -33 and 73. HPV-16/18, singly or in combination, were seen in 83% of cases. (2) In the hospital-based population, among the 524 symptomatic hospital subjects, the overall HPV prevalence was 15.5 % and the six commonest HPV types were as follows: HPV -16, -89, -39, -52, -33 and 18. Among the HPV positive women accounted for HPV-16/18 were associated with 34.3%, 45.4% and 65.7% of normal, low-grade and high-grade disease respectively. Among (3) the community-based women, the overall HPV prevalence was 7 % and the six commonest HPV types were as follows: HPV- 16, - 45, -52, -31, -66, and -18.

Conclusions: A wide spectrum of HPV types is seen in north Indian women, with HPV-16/18 are the commonest types in all populations. However, thereafter there is considerable variation. It is estimated that the HPV -16/18 vaccine would reduce over 75% of the total cancer burden in this region. The community population is from a confined geographical area whereas the hospital population includes not only residents of Delhi and neighbouring areas but also further states of North India as well as neighboring countries of Nepal and Bangladesh. Thus more studies are required to establish the true picture of HPV type-distribution in this large and diverse region.

Citation Information: Cancer Res 2009;69(23 Suppl):C59.

Can human papillomavirus DNA testing of self-collected vaginal samples compare with physician-collected cervical samples and cytology for cervical cancer screening in developing countries?

BACKGROUND

To determine human papillomavirus (HPV) types by polymerase chain reaction (PCR)-reverse line blot assay and examine the concordance between HPV by Hybrid Capture 2 (HC2) and PCR on self-collected vaginal and physician-collected cervical samples and cytology.

METHODS

This was a cross-sectional study of 546 sexually active women aged > or =30 years with persistent vaginal discharge, intermenstrual or postcoital bleeding or an unhealthy cervix. Participants self-collected vaginal samples (HPV-S) and physicians collected cervical samples for conventional Pap smear and HPV DNA (HPV-P) testing and performed colposcopy, with directed biopsy, if indicated. HPV testing and genotyping was done by HC2 and PCR reverse line blot assay. Concordance between HC2 and PCR results of self- and physician-collected samples was determined using a Kappa statistic (kappa) and Chi-square test.

RESULTS

Complete data were available for 512 sets with 98% of women providing a satisfactory self-sample. PCR detected oncogenic HPV in 12.3% of self- and 13.0% of physician-collected samples. Overall, there was 93.8% agreement between physician-collected and self-samples (kappa=76.31%, 95% confidence interval [CI]: 64.97-82.29%, p=0.04)-complete concordance in 473 cases (57 positive, 416 negative), partial concordance in seven pairs and discordance in 32 pairs. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of self-sampling for detection of cervical intraepithelial neoplasia (CIN)2+ disease were 82.5%, 93.6%, 52.4% and 98.4%, respectively; for physician-sampling they were 87.5%, 93.2%, 52.2% and 98.9%, respectively; and for cytology they were 77.5%, 87.3%, 34.1% and 97.9%, respectively. Concordance between HC2 and PCR was 90.9% for self-samples (kappa=63.7%, 95% CI: 55.2-72.2%) and 95.3% for physician-collected samples (kappa=80.4%, 95% CI: 71.8-89.0%).

CONCLUSIONS

Self-HPV sampling compares favourably with physician-sampling and cytology. A rapid, affordable, HPV self-test kit can be used as the primary method of cervical cancer screening in low-resource situations.

Metabolic properties of lactobacilli in women experiencing recurring episodes of bacterial vaginosis with vaginal pH >or= 5

While 60% of women experiencing recurring episodes of bacterial vaginosis (BV) with vaginal pH >or= 5 are depleted of resident probiotic lactobacilli, the remainder carry one or more strains of lactobacilli. Their ability to make D-lactic acid is, however, low (3.94 +/- 0.72 mM/L) compared to the D-lactic acid produced by strains from healthy vagina with vaginal pH approximately 4 (8.04 +/- 1.07 mM/L) culture supernatant of 0.5 McFarland concentration (P < 0.001).

Comparison of effect of daily versus weekly iron supplementation during pregnancy on lipid peroxidation

OBJECTIVES

To compare the effect of daily versus weekly iron supplementation on lipid peroxidation, hemoglobin levels and maternal and perinatal outcome in non-anemic pregnant women.

METHODS

Of 109 women randomly allocated into three groups, 90 completed the study. Group I (n = 30) received daily iron folic acid; Group II (n = 30) received weekly iron folic acid; Group III (n = 30) received daily iron (III)-hydroxide polymaltose complex. Hemoglobin levels, hematological indices, thiobarbituric acid reactive substances (TBARS) and glutathione levels were measured at baseline (14-16 weeks) and at 30-34 weeks. Statistical analysis was done using the anova test.

RESULTS

Group I had a highly significant increase in TBARS level (0.61 +/- 0.26 micromol/L, P = 0.000) compared to groups II and III in which the change in TBARS was not significant (0.02 +/- 0.06 and 0.007 +/- 0.06 micromol/L, respectively). There was an insignificant fall in glutathione levels in all groups. There was no significant difference in the mean period of gestation, pregnancy complications and neonatal outcome between the three groups. Among 22.2% of women who were non-compliant, Group I had significantly higher incidence of non-compliance (P = 0.016) and side-effects (P = 0.001). Final hemoglobin was higher in Group I than II (11.9 +/- 1.2, 11.3 +/- 0.9, respectively, P = 0.041). The TBARS level was not statistically different between preterm and term deliveries. Nine out of 11 patients who developed hypertension during pregnancy had preeclampsia. The final TBARS level was significantly higher in these women (P = 0.000).

CONCLUSIONS

Daily supplementation with ferrous sulphate results in greater lipid peroxidation than weekly supplementation, the latter is comparable with daily iron (III)-hydroxide polymaltose complex. Lipid peroxidation levels are significantly higher in preeclampsia.