Role of tranexamic acid in management of dysfunctional uterine bleeding in comparison with medroxyprogesterone acetate

Currently, tranexamic acid (TXA) is used as 4 g/day in menorrhagia This prospective randomised study included 100 cases to assess efficacy and safety of 2 g/day TXA in dysfunctional uterine bleeding (DUB) vs cyclical 10 mg twice-daily medroxyprogesterone acetate (MPA) for 3 cycles. Follow-ups were made monthly for 3 months during therapy, then 3 months after. Mean pictorial blood loss assessment chart (PBAC) score decreased from 356.9 to 141.6 in the TXA group and from the pre-treatment 370.9 to 156.6 with MPA and mean reduction of blood loss was 60.3% with TXA and 57.7% with MPA after 3 months (p < 0.005 in both groups). Lack of response during treatment was seen in three patients (6.1%) TXA and in 13 patients (28.9%) with MPA (p = 0.003). In patients who reported 3 months after stopping the treatment, 66.7% in TXA group and 50% in MPA had recurrence of menorrhagia, (p = 0.155). During the 6 months study period more hysterectomies were performed in the MPA than in the TXA group (17.8% vs 4%; p = 0.002). We conclude that TXA in 2 g/day dosage is an effective and safe option in DUB.

Myomectomy during pregnancy: a feasible option

Myomectomy is rarely performed during an ongoing pregnancy because of fear of pregnancy loss and the risk of uncontrolled hemorrhage necessitating hysterectomy. Even now, few cases are performed during pregnancy and most cases have been performed at the time of Cesarean section. A case of successful myomectomy performed in the second trimester for a large subserous fibroid, weighing 3900 g and causing severe pressure symptoms and subacute intestinal obstruction, is described. The pregnancy continued uneventfully until term.

A review of total laparoscopic hysterectomy using LigaSure uterine artery-sealing device: AIIMS experience

STUDY OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of total laparoscopic hysterectomy (TLH) by using the Ligasure system for the sealing of uterine arteries.

DESIGN

We conducted a retrospective review of cases who underwent TLH over 1.5 years.

SETTINGS

This study was conducted in a tertiary care hospital setting, at the Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (New Delhi, India).

PATIENTS

A total of 110 patients of TLH done for uterine pathology [leiomyoma in 67 (60.9%), dysfunctional uterine bleeding in 34 (30.9%), and others in 9 (8.1%)].

INTERVENTIONS

Total laparoscopic hysterectomy, using the LigaSure system (Valleylab Inc., Boulder, CO), was done by the sealing of uterine arteries and Prashant Mangeshikar uterine manipulator for elevation of the uterus.

RESULTS

The mean age of the patients was 43.1 +/- 0.602 years and mean body mass index was 25.19 +/- 0.39 kg/m(2). The mean operating time was 116.91 +/- 3.4 minutes, mean intraoperative blood loss was 173.09 +/- 11.64 mL, and the mean weight of the removed uterus was 224.14 +/- 17.62 g. Six patients were converted from a laparoscopic to an open procedure (large myoma in 4 and dense adhesion in 2) and 1 was converted to laparoscopically assisted vaginal hysterectomy (tear in vaginal cuff). One patient (0.9%) developed lung emphysema during the intraoperative period. Postoperative complications included paralytic ileus in 3 (2.7%), retention of urine in 2 (1.8%), and febrile morbidity in 12 (10.9%) patients. There were no bladder or bowel injuries.

CONCLUSION

Laparoscopic hysterectomy by uterine artery sealing with LigaSure is a safe, efficient procedure with a low complication rate.

Fertility among women with classical congenital adrenal hyperplasia: report of seven cases where treatment was started after 9 years of age

BACKGROUND AND AIM

Androgen excess is believed to be one of the major factors responsible for poor fertility outcomes in females with congenital adrenal hyperplasia (CAH). Some believe that the adverse effect of androgens on fertility could have its origins as early as the antenatal years. To assess the impact of prolonged androgen exposure on fertility in CAH patients, we compiled the data of females with CAH followed in our clinic during the last 25 years who were sexually active and had not been initiated on steroids until age 9 years.

STUDY DESIGN AND PATIENTS

This was an observational case study on seven patients with classical CAH who fulfilled the inclusion criteria. The age at initiation of therapy in these females ranged from 9 years to 29 years.

RESULTS

All patients had varying degrees of genital ambiguity. The most common presenting complaints were genital ambiguity, non-development of secondary sexual characteristics, hirsutism and primary amenorrhea. Genital surgery was performed in all patients at ages ranging from 12 to 29 years, except for one patient who underwent surgery at age 5 years without a diagnosis of CAH being made. Breast development ensued within 2 to 12 months and periods started in all patients within 2-24 months of steroid initiation. There were 13 pregnancies (seven normal vaginal deliveries, two spontaneous abortions and four pregnancies were medically terminated).

CONCLUSIONS

Late initiation of steroid therapy did not affect fertility in our cohort of CAH women. Androgen excess in situations of subnormal cortisol may not adversely affect fertility in females with CAH.

Assessment of Fetomaternal Hemorrhage by Flow Cytometry and Kleihauer-Betke Test in Rh-Negative Pregnancies

OBJECTIVES

To assess the efficacy of flow cytometry (FC) in the detection and quantification of fetomaternal hemorrhage (FMH) in comparison to the Kleihauer-Betke test (KBT).

METHODS

25 unsensitized Rh-negative mothers who had delivered Rh-positive infants were included. Presence of FMH was determined by KBT and FC using FITC-labeled BRAD-3 antibodies.

RESULTS

FMH was detected in 19 (76%) patients by FC and 23 (92%) patients by KBT prior to delivery, and in 21 (84%) patients by FC and 23 (92%) patients by KBT after delivery. The mean volume of FMH in the post-delivery samples by KBT and FC were 0.34 +/- 0.26 ml (range 0.05-1.2 ml) and 0.37 +/- 0.57 ml (range 0.02-2.6 ml) respectively. The volume of post-delivery FMH estimated by KBT and FC correlated well (r = 0.75; ICC alpha = 0.73). A higher agreement between KBT and FC was seen in the 0.1-0.5 ml range (kappa = 0.65; p < 0.01).

CONCLUSIONS

Both manual KBT and FC using FITC-BRAD-3 antibodies show good sensitivity in detecting and quantifying fetal red cells. There is a good correlation between the methods in the 0.1- to 0.5-ml range of FMH.

Comparative evaluation of smear cytology & hybrid capture II for the diagnosis of cervical cancer

BACKGROUND & OBJECTIVES

There is no ideal screening method for cervical cancer in India with the role of human papilloma virus (HPV) detection yet to be established. This study was undertaken to compare the diagnostic accuracy of HPV testing by hybrid capture II (HC-II) with conventional cervical smear cytology for squamous intraepithelial lesions (SIL).

METHODS

This prospective study was conducted at New Delhi during 2003-2004 with patients selected from the gynaecology out patients of the All India Institute of Medical Sciences. Initial screening by a questionnaire and per-speculum examination were used to select high-risk patients. Patients, in whom conventional cytology, HC-II test and colposcopy-directed biopsy were done, formed the basis of this study.

RESULTS

Of the 133 patients included in the study, incidence on biopsy of low grade SIL (L-SIL) was 6.77 per cent, high grade SIL (H-SIL) was 8.27 per cent and carcinoma was 3.00 per cent. Sensitivity and specificity of cytology for detection of H-SIL and above lesions was 93.33 and 83.49 per cent while for HC-II it was 93.33 and 90.83 per cent, respectively. HC-II had higher diagnostic accuracy of 91.13 per cent versus 84.68 per cent for cytology. Kappa for HC-II was higher (0.67) than cytology (0.52). Among patients diagnosed to have atypical squamous cells (ASC-US & ASC-H) and L-SIL, HC-II helped to select patients who had significant lesions on biopsy.

INTERPRETATION & CONCLUSION

The main utility of HC-II is in the triage of patients with cytology smear diagnosis of ASC-US, ASC-H or L-SIL, for referral to colposcopic examination. HC-II alone has the best diagnostic accuracy but owing to high cost it is unsuitable for general screening in developing countries. Combining HC-II with cytology will refer smaller numbers for colposcopy,improving efficient utilization of available resources.

Gestational trophoblastic disease: Experience at a tertiary care center from a developing country

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Background: We retrospectively analyzed case records of patients diagnosed to have Gestational Trophoblastic Disease (GTD) to determine clinical characteristics, risk groups, treatment outcome, and reproductive function post treatment. Methods: Between Jan 1991 to Dec 2005, 102 patients (mean age: 28.2 years, range 19–50) were diagnosed to have GTD. 35 patients were nulliparous and 8 had prior molar pregnancy. Vaginal bleeding was the most common presenting symptom (77.5%). The antecedent pregnancy was vesicular mole in 50%, abortion - 34.3%, ectopic pregnancy - 4% and term pregnancy in 11.8% patients. The mean value of B hCG was 1225386 mIU/ml. The histopathology (n=85) was complete mole in 30, partial mole - 28, invasive mole- 9, PSTT -1 and choriocarcinoma in 17 patients. 68(66.7%) patients had non-metastatic disease. Sites of metastasis were - lung (38.2%), vagina (11%), brain (8.8%), liver (6.9%) and kidney, Urinary bladder and peritoneum in one patient each. According to modified WHO risk scoring - 78(76.5% had low risk and 24 (23.5%) were high risk. Results: Eighty-seven (85.3%) patients received chemotherapy using methotrexate with leucovorin (n=63), EMA/CO (n=19) and BEP (n=5). 77/87 (89.5%) achieved complete remission (CR) ; the response rate was higher in non-metastatic GTD (p<0.05). Two of 7(28.6%) patients with liver and 5/9 (55,6%) of brain metastasis achieved CR. Two patients had grade III oral mucositis and diarrhoea with methotrexate. One patient died of Methotrexate hypersensitivity. 19 patients received second line chemotherapy using EMA/CO (n=11), EMA/EP (n=2), BEP (n=1), actinomycin-D (n=1) and MAC (methotrexate, actinomycin D and Cyclophosphamide) n=1; 14 patients achieved CR. At a mean follow up of 180 months, 5-year survival for patients with low risk is 100% and that of high risk is 95%. Eight patients had recurrent disease including recurrent molar pregnancy in four. 16 patients had 24 successful deliveries after completion of treatment and 10 of them were primiparae. No fetal abnormalities were found. We did not observe second malignancy or other therapy related sequele. Conclusions: Present study confirms excellent outcome for patients with gestational trophoblastic disease. The potential for childbearing is well maintained.

No significant financial relationships to disclose.

Efficacy, acceptability and side effects of the levonorgestrel intrauterine system for menorrhagia

OBJECTIVE

To evaluate the efficacy, acceptability, and possible side effects of a levonorgestrel-releasing intrauterine system for menorrhagia.

METHODS

Sixty-three women with menorrhagia but without uterine enlargement, endometrial hyperplasia with atypia, or endometrial carcinoma were enrolled in this prospective, open, nonrandomized clinical trial. An intrauterine system releasing 20 microg/day of levonorgestrel (LNG-IUS; Mirena, Shering, Finland) was inserted in the postmenstrual phase. Menstrual pattern, number of bleeding days, and subjective and objective estimation of menstrual blood loss using a pictorial blood loss assessment chart (PBAC) were recorded before insertion and at specific intervals for 4 years. Hemoglobin levels and endometrial thickness were evaluated at baseline and at 12 months. Treatment continuation and hysterectomy rates were noted as well as side effects.

RESULTS

The device was expelled spontaneously in 6 patients (9.52%) and removed prematurely in 9 patients (14.3%); 3 patients (4.8%) were lost to follow-up; and 45 patients (71.4%) continued with the LNG-IUS. Menorrhagia was cured in 35 (77.7%) of these 45 patients at 3 months and in all patients at 36 months. There was a significant decrease in the mean number of bleeding days (P=0.01) and PBAC score (P=0.00) at 1 month, and the decrease continued with treatment duration. The subjective blood loss reduction was considerable as well, and at 12 months the mean+/-SD rise in hemoglobin concentration was 1.06+/-1.7 g/dL (P=0.000). Endometrial thickness was decreased by 3.4+/-3.53 mm (P=0.0001) at 12 months. The most common side effect was intermenstrual spotting during the first 6 months, and 18 patients (28.57%) developed amenorrhea.

CONCLUSION

Using the LNG-IUS is an effective and well-accepted option overall for the medical management of menorrhagia.

Detection of fetomaternal hemorrhage following chorionic villus sampling by Kleihauer Betke test and rise in maternal serum alpha feto protein

OBJECTIVES

To assess incidence and volume of fetomaternal hemorrhage (FMH) after chorionic villus sampling (CVS) by Kleihauer Betke test (KBT) and rise in maternal protein (MSAFP).

METHODS

A prospective study was conducted on 61 cases requiring CVS. FMH due to CVS was assessed by KBT and MSAFP.

RESULTS

Out of 61 cases, 60 (98.36%) cases showed FMH by MSAFP while all showed FMH by KBT. Median volume of FMH detected by MSAFP was 0.06 mL (25 to 75th interquartile (IQR) 0.01 to 0.12 mL) and by KBT was 0.45 mL (25 to 75th IQR 0.09 to 0.90). Mean volume of FMH detected by MSAFP was 0.1 + 0.1424 mL and by KBT was 0.58 + 0.637 mL. Significant FMH up to 0.1 mL was found in 20 (32.8%) and 45 (60.6%) by MSAFP and KBT respectively.

CONCLUSION

MSAFP and KBT are sensitive to detect FMH. KBT estimates more FMH than MSAFP. Fifty micrograms of anti-D is sufficient to cover FMH during CVS.

Fetal Intravenous Immunoglobulin Therapy in Rhesus Hemolytic Disease

Intrauterine blood transfusion is the mainstay of treatment of fetal rhesus hemolytic anemia with optimal perinatal outcome. Postnatal immunoglobulin therapy has been successfully used in the management of alloimmunized neonates and has shown to decrease the need for exchange transfusion. We report the first case series of fetal immunoglobulin therapy in the antenatal management of severe Rh incompatibility.

Human Papillomavirus Type Distribution in Cervical Cancer in Delhi, India

This hospital-based study in New Delhi, North India was performed to evaluate the prevalence of human papillomavirus (HPV) in cases of invasive cervical carcinoma (ICC). A total of 10 cases presenting with an obvious cervical growth were included in this study. 108 cases that was shown to be ICC on histology (101 squamous cell carcinomas, 4 adenocarcinomas, and one neuroendocrine carcinoma) were included in the analysis. DNA was extracted from tumor tissue and HPV genotype was determined by a consensus PCR assay using a reverse line blot hybridization assay. Of 106 evaluable cases, 104 (98.1%) were positive for HPV infection. Twelve different high-risk HPV types were found. There were 125 infections, 119 of which were high risk. Six cases had associated low risk infections. HPV 16 was the commonest type, seen in 73.6% cases followed by HPV 18 (14.2%) and 45 (11.3%). A vaccine with 100% efficacy in prevention of HPV 16 and 18 infections would theoretically reduce the total cancer burden in New Delhi by more than 75% (assuming 100% coverage). Increasing the genotype spectrum (e.g. valency) if the existing vaccines would be expected to have only a modest impact on the potential for cervical protection.

Evaluation of endometrial changes and p53 expression in tamoxifen treated women: comparison of various methods

OBJECTIVE

To compare transvaginal sonography (TVS), sonohysterography (SHG), hysteroscopy and endometrial aspiration (EA) and p53 expression in assessing endometrial abnormalities in women on tamoxifen.

METHODS

In a cross sectional study of 50 pre- and post-menopausal women receiving tamoxifen for > 2 years, all participants underwent TVS and EA. Those with endometrial thickness > 4 mm on TVS underwent hysteroscopy and SHG. Serum p53 antibody and p53 immunohistochemistry were tested in all women.

RESULTS

The sensitivity and specificity when compared with histopathology as the reference standard were as follows: TVS 100% and 33.3%, SHG 85.7% and 50%, hysteroscopy 92.8% and 80.8%, serum p53 50% and 83.3%, and p53 immunohistochemistry 57.1% and 61.1%. Prevalence of endometrial abnormalities was not significantly different in asymptomatic and symptomatic women.

CONCLUSION

Tamoxifen-users require routine testing for endometrial evaluation. TVS followed by hysteroscopy and biopsy is an effective option. p53 expression correlates with histological abnormalities.

Giant malignant ovarian tumor: a case report

Massive ovarian tumors are rare and occur less frequently today. The management of a patient with a large ovarian tumor weighing 74 kg is described. Preoperative paracentesis was resorted to. A multidisciplinary team approach helped combat the various associated complications of supine hypotension, technically difficult surgery, massive blood and fluid replacement, postoperative ventilatory failure, and wound dehiscence.