Common Medical Devices with Uncommon Complications

Medical devices and materials commonly used in management of common gynecological conditions or during surgical procedures may present with acute or chronic complications due to incorrect application, improper use and lack of follow up. We present two interesting cases highlighting this problem. A strong index of suspicion is very crucial in early diagnosis and successful management.

Salivary progesterone as a biochemical marker to predict early preterm birth in asymptomatic high-risk women

OBJECTIVE

To evaluate salivary progesterone as a predictor of early preterm birth (PTB) and compare it with transvaginal sonographic (TVS) cervical length in asymptomatic high-risk women.

DESIGN

Prospective study.

SETTING

Departments of Obstetrics and Gynaecology and Biochemistry at UCMS & GTBH, Delhi, India.

SAMPLE

Ninety pregnant women.

METHODS

The progesterone concentration in saliva of asymptomatic pregnant women at high risk for preterm delivery was estimated by immunoassay, and cervical length was measured by TVS, at the first antenatal visit at 24-28 weeks of gestation, and then repeated 3-4 weeks later.

MAIN OUTCOME MEASURES

Early PTB, mean and critical cut-off values of salivary progesterone, and a diagnostic value comparison of salivary progesterone with TVS cervical length.

RESULTS

The mean value of salivary progesterone was significantly lower in all women who delivered at <37 weeks of gestation (n = 38), compared with the term group (n = 52; P < 0.001). Salivary progesterone decreased significantly from the first to the second visit, with the maximum decrease observed in women who delivered at <34 weeks of gestation (29.6%, 95% CI 17.8-41.4%, P < 0.002). The single predictive critical cut-off value for salivary progesterone was 2575 pg/ml, below which more than 80% of women delivered prematurely before 34 weeks of gestation, with sensitivity, specificity, and positive and negative predictive values of 83% (95% CI 58.6-96.4%), 86% (95% CI 75.9-93.1%), 60% (95% CI 38.6-78.8%) and 95% (95% CI 87.1-99.0%), respectively. The TVS cervical length decreased significantly (P < 0.001) in the women who delivered prematurely.

CONCLUSIONS

Low salivary progesterone concentration can be used for predicting early PTB in asymptomatic high-risk women.

A case control study of gene environmental interaction in fetal growth restriction with special reference to organochlorine pesticides

OBJECTIVES

Organochlorine pesticides (OCPs) and oxidative stress are reported to be associated with adverse reproductive outcomes. Glutathione S-transferase (GST) is a polymorphic supergene family involved in the detoxification of numerous toxins including OCPs. OCPs are endocrine disrupter and prenatal exposure to them may be associated with fetal growth restriction (FGR). The objectives of the present study were (i) to determine the frequencies of polymorphic alleles of GSTM1 and GSTT1 genes in women with idiopathic FGR, (ii) to analyze the maternal and cord blood levels of the OCPs, and (iii) to identify the gene environment interaction that increases the risk of FGR.

STUDY DESIGN

Maternal and cord blood samples of 50 FGR cases (birth weight <10 percentile for gestational age as per Lubchenco's growth chart) and equal number of normal pregnancies who were occupationally non exposed to OCPs and excluding all the known high risk factors such as anemia, hypertension, antiphospholipid antibody syndrome, medical disease, dietary habit, living style, parity, and BMI. The collected samples at the time of delivery/after delivery were analyzed for OCPs levels by gas chromatography and polymorphic analysis for GSTM1/GSTT1 gene using multiplex PCR.

RESULTS

Significantly higher levels of α,β,γ-HCH and p,p'-DDT were found in maternal blood and significantly higher levels of β and γ-HCH and p,p'-DDT were found in cord blood of FGR cases as compared to controls. The genotypic distribution of GSTM1/GSTT1 was almost similar in both the groups, but the frequency of GSTM1-/GSTT1- (null) genotype was significantly higher in FGR cases as compared to controls (p<0.05, OR=6.42). When interaction between GSTM1/GSTT1 genes polymorphism-OCPs levels and birth weight (gene-environment interaction) was ascertained, a significant association was seen between β-HCH and GSTM1- genotype with reduction in birth weight of 213g.

CONCLUSION

Higher levels of OCPs in pregnant women may be considered as an important aetiological factor in 'idiopathic' FGR. GST polymorphism can influence the relationship between prenatal exposure to pesticides and FGR. The present study provides evidence that polymorphism in xenobiotic metabolising genes may modify the effect of environmental health hazards and increase the risk of FGR.

Mature ovarian dermoid cyst invading the urinary bladder

Mature ovarian dermoid cysts are common lesions, accounting for up to 10-25% of all ovarian neoplasms. Uncomplicated dermoid cysts are often asymptomatic and are relatively easy to diagnose on imaging and to treat. Symptoms develop once complications set in and these may cause diagnostic dilemmas. Torsion (16%) is the most common complication, while rupture, suppuration and malignant transformation are relatively uncommon. Of all these complications, spontaneous rupture into the urinary bladder is least common. The diagnosis of this condition has been through the use of cystoscopy or laparotomy in all cases reported so far. We report a case of a 30-year-old patient with pyuria and dysuria, where ultrasound examination clearly demonstrated an ovarian dermoid cyst invading the urinary bladder. A clear-cut imaging diagnosis helped to allow planning of surgery in advance and a mucosa-sparing partial bladder resection could be performed.

Rupture uterus--changing Indian scenario

A total of 60 cases of rupture uterus managed in last five years in the department of obstetrics and gynaecology at the University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi were reviewed. Of these 77% cases reported to the hospital with rupture uterus while in 23% cases rupture occurred after admission. The factor responsible for rupture in admitted patients was either oxytocin induction/augmentation in scarred uterus or obstetrical manipulation in unscarred uterus; 80% cases were totally unsupervised during antenatal period. Previous uterine scar was responsible for rupture in as high as 63.3% cases. The commonest previous surgery was caesarean section mostly for non-recurrent causes. Obstructed labour was responsible for rupture in 26.6% cases while traumatic rupture was seen in 10% cases. Repair of uterine rent was performed in 54% cases while rest required hysterectomy. Bladder injury was associated in 9 cases and was repaired at the time of laparotomy. Maternal mortality was 3.33% and foetal mortality was 78.66%. The changing trends observed in the present study are those of low maternal mortality and decreasing incidence of obstructed labour in the aetiology of rupture uterus.

A case report on radiotherapy in choriocarcinoma: a life saving procedure

Radiation therapy was tried to control hemorrhage from uterine cavity in a case of choriocarcinoma in which surgery was not practically possible due to the presence of a large nodule extending from suburethral region up to anterior fornix involving the entire anterior vaginal wall and patient being in a very critical condition. Radiotherapy was found to be successful and life saving.

Acute abdominal pain in gynaecology

Fifty female patients with acute abdominal pain were studied. High risk factors helping in clinical diagnosis were evaluated and 7(14%) cases with clear cut surgical indications were immediately operated on while 43 (86%) were kept under active observation. In doubtful cases, culdoscopy and diagnostic laparoscopy were found to be helpful in confirming the diagnosis and another 26% were operated later on. The delay in surgery did not increase the morbidity and mortality and only one patient (2%) underwent unnecessary laparotomy. Hence, it was concluded that active observation in cases of acute abdominal pain of doubtful origin is a safe and effective approach.