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Background: India has the world’s largest load of cervical malignancy. A lot of it can be attributed to lack of cervical cancer screening awareness among the general population. The Accredited Social Health Activists (ASHA) are grass root workers who have good reach in the remote areas, where health care facilities are lacking. Training these ASHAs may increase the general awareness about cervical cancer screening. The aim of the study was to train ASHA workers via lectures and question answer sessions and assess the training with pre and post tests. Methods: We organized two training programs of 500 ASHA workers in two tertiary care hospitals with aim of improving their knowledge and attitude about cervical cancer screening which will eventually improve their practice of training women in general population. It comprised of five lectures in language they understand, slogans, posters, question answer session etc. A test comprising of 17 questions was conducted before and after session to check their knowledge and attitude. Results: There was an overall improvement of 35% in knowledge of the ASHAs i.e. 48% answers were correct in pre-test and 78% were correct in post-test. Questions were pertaining to symptomatology, risk factors, screening methods, their utility and prerequisites of performing the screening tests, when and how often to repeat. Improvement was seen in all the areas. There was improvement in attitude too and most of them wanted themselves (98%), their relatives (100%) and the woman within their area (98%) to be screened for cancer cervix. Conclusion: It was a small initiative and successful result was obtained after the training session of ASHAs. These grass root workers may act as key link of awareness for cervical cancer prevention. They live in same community as the client and therefore, have better repo and communication as compared to medical personnel. Though, this study showed improved knowledge and motivation in ASHAs yet the impact on general population needs further evaluation.

The prognostic role of endometriosis amongst women with ovarian clear cell carcinoma (OCCC) remains debatable. The aim of this study was to ascertain the effect of endometriosis on the prognosis of OCCC. A retrospective review of the medical records of 94 women diagnosed and treated for OCCC at a tertiary gynaecological cancer centre in the UK, spanning the period 2010–2019. Women were divided into two groups according to the presence of endometriosis. Clinico-pathological characteristics, progression-free survival (PFS) and overall survival (OS) were collated between the two groups. Forty-six cases of endometriosis-free OCCC (Ef-OCCC) were collated with 48 cases of endometriosis-related OCCC (Er-OCCC). There was no significant difference between the two groups regarding age (p-value = 0.2), FIGO stage (p-value = 0.8), residual disease (RD) (p-value = 0.07), adjuvant chemotherapy agent (p-value = 0.4) or chemo-resistance (p-value = 0.9). The presence of endometriosis did not significantly affect either OS or PFS. The median OS in the Ef-OCCC and Er-OCCC was 55.00 (95% CI 32.00–189.00) and 71.00 (95% CI 47.00–97.00; log rank = 1.35, p-value = 0.2) months. The median PFS in the Ef-OCCC and Er-OCCC group was 39.00 (95% CI 19.00–143.00) and 39.00 (95% CI 19.00–62.00; log rank = 0.7, p-value = 0.4) months. Survival differences between the two groups were not significant after stratification analysis for independent prognosticators. Endometriosis was not independently associated with the prognosis of OCCC either in crude analysis or after stratification for stage and RD. Further larger, well-designed prospective studies are warranted to draw firmer conclusions on the intrinsic link between endometriosis and OCCC.

Cervical cancer is the fourth most common cancer in women in the world. To eliminate cervical cancer by 2030, the World Health Organization has given the target of 70 per cent coverage of twice lifetime screening. A multitude of screening methods are available, including cytology, human papillomavirus (HPV) DNA testing and visual inspection tests. Precision tests, including molecular and protein biomarkers such as DNA methylation, p16 immunostaining, and HPV mRNA testing help to enhance specificity of the screening. Worldwide HPV DNA testing with or without cytology is used as a screening method of choice, while in resource-poor settings, visual inspection tests are recommended. The major hurdle is a uniform and systematic implementation with a recall method in the population. Besides, controversies still exist regarding strategies to manage HPV-positive women and developing guidelines to screen the vaccinated population.

To study the accuracy of frozen section biopsy for endometrial pathology in high-risk women with abnormal uterine bleeding (AUB).A case-control study was conducted between November 2017 to April 2019, a total of 150 women with postmenopausal bleeding, perimenopausal AUB, and high-risk women of age 40 years with AUB were recruited. All women underwent transvaginal sonography and Doppler, based on age-appropriate endometrial thickness cut-offs 80 women then underwent hysteroscopy. Based on hysteroscopy, women suspicious of malignancy were taken as cases (n = 40) and those with benign findings as controls (n = 40). All cases and controls underwent dilatation and curettage (DC) with frozen section (FS) and routine histopathology.The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR), negative LR, and overall test accuracy of FS were 90.9%, 93.19%, 83.33%, 96.19%, 13.8, 0.1 and 86.25% respectively for diagnosing endometrial hyperplasia and cancer taking histopathology as the gold standard. Correlation between frozen section biopsy and histopathology was highly significant (p 0.001) on DC specimens and the level of agreement was good (K = 0.778).In women suspicious of malignancy on hysteroscopy, frozen section has high accuracy on DC specimen and can be used to diagnose endometrial hyperplasia and cancer in an effort to fast-track investigations and work-up for definitive treatment while awaiting final histopathology.

Introduction/Background Circulating tumor DNA found in women with malignancy, enters plasma due to lysis of cells at the interface between the primary tumor and the circulation. The primary objective of this study was to isolate and quantify cell-free DNA (cfDNA) from peripheral blood, analyze p53 mutations and correlate with tumor burden in epithelial ovarian malignancy. Secondary objective was to study the degree of agreement between cfDNA p53 mutations and tissue p53 immunohistochemistry. Methodology This prospective case-control study was carried out over 18 months from November 2018 to April 2020 at a tertiary teaching institution. Considering the exploratory nature of the study, study group (n=20) comprised women with epithelial ovarian malignancy. Control groups were women with borderline tumors (n=10) and benign epithelial ovarian tumors (n=10). 58 women who were treatment naive and admitted for surgery entered the study but only those with a final histopathology of epithelial ovarian tumor (malignant, borderline and benign) were included. Peritoneal carcinomatosis index (PCI), surgical complexity score and cytoreductive score was calculated in women undergoing primary cytoreduction. Plasma samples for cfDNA was collected just before surgery and stored at -20oC. cfDNA was extracted from plasma serum using a DNA isolation kit and quantified with Nanodrop Spectrophotometer. ARMS PCR was used to detect a point mutation in Exon 8, codon 239 of p53 using primer pairs. p53 immunostaining was performed on tissue samples using monoclonal antibody directed against p53. Statistical analysis was done using SPSS version 21. Results In women with malignant ovarian cancer isolated cfDNA was highest (1330 ng/mL) in comparison to those with benign or borderline ovarian tumors (748.5 ng/mL and 448.5 ng/mL, respectively) reaching statistical significance, p=0.023. Quantity of cfDNA also correlated well with the histopathological grade of the tumor and stage of the disease, p Analysis of cfDNA p53 mutation in exon 8 showed that 55% of the women diagnosed with malignant ovarian tumor harboured this mutation (p=0.043). Correlation of tissue p53 with cfDNA p53 mutation was statistically significant, p=0.007. All women with malignant ovarian tumor in whom cfDNA p53 mutation was present at codon 239 of exon 8 stained positive for tissue p53 mutation. Conclusion cfDNA p53 mutation in exon 8 was detected at higher frequency in women with malignant epithelial ovarian cancer. Significant correlation was seen between tissue p53 and cfDNA p53 mutation suggesting that mutational analysis of cfDNA could act as biomarker for the diagnosis of ovarian tumors. Disclosures Shalini Rajaram – No conflict of interest Aanchal Verma - No conflict of interest Rajarshi Kar - No conflict of interest Vinod Arora - No conflict of interest Bindiya Gupta - No conflict of interest Sandhya Jain - No conflict of interest

Introduction/Background Women with endometriosis carry an increased risk for ovarian clear cell ovarian carcinoma (OCCC), also referred to as ‘endometriosis-associated ovarian carcinoma’. Considered as the precursor lesion of a subset of OCCC, the prognostic role of endometriosis amongst women with OCCC remains a field of contention. Few studies have evaluated the prognostic significance of the concurrent endometriosis with conflicting results. The aim of this study was to ascertain the effect of endometriosis on the prognosis of OCCC. Methodology This was a retrospective cohort study, from 2000 to 2019. Population-based prospectively collected data on OCCC with or without concurrent endometriosis were retrieved via the Pan-Birmingham Gynaecological Oncology database. Ninety-four women with a primary diagnosis of OCCC have been divided into groups based upon the detection of cancer arising from ovarian endometriosis (n=48, 51.1%) or not (n= 46, 48.9%) according to Samson and Scott criteria. Chi-squared test, t-test, and univariate/multivariate Cox regression were used. Survival curves were plotted via the Kaplan-Meier method, whilst survival differences were examined via the log-rank test for categorical variables or Cox regression for continuous variables. All reported p-values were two-tailed. Statistical significance was set at p-value Results Women with OCCC arising from endometriosis had significantly lower levels of pre-operative CA-125 (434.63 ± 1135.57 Vs 867.30 ± 1609.67, p-value=0.02) and significantly lower incidence of post-operative residual disease (RD) (p-value=0.02). Age, post-menopausal status, FIGO stage and incidence of capsule rupture were not statistically significant. The mean overall survival (OS) and overall progression free survival (PFS) were 86.35 (95% CI 69.47 – 103.22) and 115.97 (95% CI 98.77 – 133.17) months, respectively. The presence of endometriosis did not affect neither the OS (87.99 Vs 75.30, p-value=0.25) nor the PFS (111.13 Vs 117.42, p-value=0.48). In univariate analysis, the FIGO stage II-IV and RD were correlated with poorer OS, whilst capsule rupture (CR) with poorer PFS. In multivariate analysis, FIGO stage [HR=2.86 (95% CI 1.47 – 5.55), p-value=0.002] and RD [HR=2.52 (95% CI 1.28 – 4.94, p-value=0.007) were found independent predictors for OS, whilst CR [HR=0.3 (95% CI 0.11 – 0.82), p-value=0.02] for PFS, respectively. No factors affected OS after stratification by stage. Conclusion In this cohort concurrent endometriosis was not a predictive factor for the survival of OCCC women. Further studies are warranted to ascertain whether OCCC with or without coexisting endometriosis develop via distinct pathogenic pathways. Disclosures Nil to disclose.

Introduction/Background Embryonal rhabdomyosarcoma (RMS) of the cervix is a rare entity, encountered mainly in the first two decades of life. The literature consists mainly of case reports and few small case series, and no standard treatment guidelines are available. As this is a disease of adolescence, fertility preservation in well selected cases is of paramount importance. Methodology We report 3 cases of embryonal RMS of the cervix in adolescents, along with their clinical presentation, histopathological features, diagnosis, management tailored to individual cases. Results To date, two of the patients have been followed for 5 years and the remaining 1 for 2 years. They all remained asymptomatic, with no evidence of recurrent disease on clinical examination and MRI. Conclusion The embryonal type of cervical RMS is the most frequent type in this age group. Cervical RMS have good prognosis as usually they present early due to clinical features of bleeding or a mass protruding through the vagina. It should be considered as differential diagnosis for continuous vaginal bleeding in a teenager and should be investigated appropriately. The patients diagnosed with RMS should be managed by multidisciplinary team at cancer centre for best outcomes. Given the young age at diagnosis, fertility sparing treatment maintaining the oncological safety is of paramount importance and is associated with long term survival. Disclosures Nil to disclose.

Endometrial cancer is increasingly been diagnosed in women less than 40 years who are desirous of fertility preservation. These are usually type 1 well differentiated tumors with good prognosis. Endometrial biopsy and Magnetic resonance imaging are important for treatment palnning. Conservative mangement may be offered in women with grade 1 tumors confined to endometrium, with no lymphovascular space invasion and extrauterine disease. Progestins including Medroxy preogesterone acetate, megesterol acetate are used for treatment. All efforts should be made for conception once histological remmision is achieved.

Background Ovarian cancer is associated with a high relapse rate and is the fifth leading cause of cancer deaths in women. The genetic profile of a tumor is responsible for deciding response to chemotherapeutic agents. In this study, we investigate the relation between survivin and p53 expression and response to chemotherapeutic agents of primary cultures of ovarian cancer cells established from ascitic fluid. Materials and Method Ascitic fluid and Dulbecco’s modified Eagle medium was mixed in equal proportion in culture flasks and incubated to establish primary culture. The cells were treated with different combinations of carboplatin and paclitaxel with and without survivin small interfering RNA transfection. Cell survival was estimated by MTT assay. Survivin and p53 expression was quantified by real-time polymerase chain reaction. Results Out of 19 ascitic fluid samples, 13 primary cultures of ovarian cancer cells were established. The half maximal inhibitory concentration doses of carboplatin (≥70 μg/mL) and paclitaxel (≥18 μg/mL) were high for 10/13 and 5/13 patients, respectively. Survivin messenger RNA expression was significantly downregulated on treatment with carboplatin (100 μg/mL), paclitaxel (12.5 μg/mL), and a combination of carboplatin (50 μg/mL) and paclitaxel (6.25 μg/mL). Only paclitaxel-treated ovarian cancer cells showed decrease in expression of p53. Survivin small interfering RNA increased sensitivity of the primary cultures to chemotherapeutic agents. Conclusions The present study highlights the fact that establishing primary cultures from ascitic fluid may help to develop personalized treatment regime for individual patients based on their molecular profile. Our study also shows that supplementing taxols drugs with survivin inhibitors may prove to be beneficial in the treatment of ovarian cancer patients.

H1N1 is a novel influenza A strain. Although it is more common in younger population who mostly observe a mild flu, it can cause serious illness in extreme of ages in less than 5 and more than 65-year-old people and in pregnant women. Understanding the effect of viral infection on pregnancy and also the effect of vaccination is essential for improving health outcomes for mother and baby. Antiviral therapy and vaccination are safe during pregnancy.

Primary pelvic lymphoma is an uncommon tumor. An isolated adnexal or pelvic mass seldom raises the suspicion of lymphoma. They can mimic cancer of ovary, endometrium, cervix or sarcoma. Diagnosis is very important as management changes completely. We report a case of pelvic Non-Hodgkin’s lymphoma masquerading as an adnexal mass and posing dilemma in diagnosis. Diagnosis was made on biopsy. She received 6 cycles of chemotherapy. Unfortunately, she developed recurrence after 1 year.

To test the clinical utility of biomarkers p16/Ki-67 expression in cervical cytology smears as a marker for transforming HPV infection. Experimental study at a tertiary care hospital. Women who were screened positive on Pap and visual inspection tests (n = 280) underwent colposcopy and biopsy. p16/Ki-67 immunostaining was performed in abnormal Pap smears (n = 86), and HPV DNA testing was also performed in the same women. Sensitivity, specificity, negative predictive value, positive predictive value and likelihood ratios were calculated for each biomarker separately and in combination. McNemar test and receiver operating characteristic (ROC) curves were used to compare sensitivity and specificity of biomarkers with HPV DNA. Areas under the ROC curve (AUC) were compared using the Chi-square test. Eighty-six women with abnormal cytology were evaluated with p16/Ki-67 immunocytochemistry; 20.9% (n = 18) and 18.6% (n = 16) were positive for each biomarker, while dual marker was positive in 15% (n = 13). In all smears, the sensitivity of p16INK4a/Ki-67 in detecting CIN 2+ lesion was 76.9% and specificity was 95.8%. For ASCUS (n = 42) and LSIL (n = 23) smears, specificity and negative predictive value of p16/Ki-67 for CIN 2+ were 100% with a likelihood ratio (LR+) of 27 and 25, respectively, suggesting good diagnostic accuracy. In comparison with HPV DNA testing, combined marker p16/Ki-67 was significantly more specific (p = 0.003); AUC was 0.734 and 0.635, respectively. p16/Ki-67 evaluation in cervical cytology is a valuable biomarker in triaging for CIN 2+ disease in ASCUS and LSIL smears.

OBJECTIVE To compare the AV Magnivisualizer with colposcopy to detect cervical intraepithelial neoplasia (CIN) using the Swede scoring system. METHODS Cross-sectional study conducted in a tertiary care hospital from May 2017 to March 2018. One hundred women with positive results at visual inspection with acetic acid underwent cervical inspection using the Magnivisualizer followed by a colposcope. Biopsies were taken if the Swede score was greater than 4. Pregnant women, women with an obvious cervical growth, acute cervicitis, or prior cervical surgery were excluded. Diagnostic accuracy of the Magnivisualizer and colposcope was calculated for high-grade lesions (CIN 2/CIN 2+) and agreement was compared between the two modalities. RESULTS The sensitivity, specificity, and positive and negative predictive values of the Magnivisualizer were 88.2%, 70.0%, 50.0%, and 94.6%, respectively, to detect high-grade lesions at a Swede score cutoff of 5 or more. The area under the curve for the Magnivisualizer was 0.80 (95% CI, 0.67-0.92), which was comparable with colposcopy (AUC 0.86; 95% CI, 0.76-0.96). There was very good agreement between the Magnivisualizer and colposcopy (κ=0.865, P

Background: To estimate the prevalence of genital tuberculosis in women with idiopathic chronic pelvic pain on laparoscopy, correlate laparoscopic findings with microbiological and histological diagnosis of tuberculosis and assess the response to anti tubercular treatment (ATT) in these cases. Method: In a prospective cohort study, fifty women with idiopathic chronic pelvic pain were enrolled. Diagnostic laparoscopy was done in all women and fluid from pouch of Douglas and/or saline washings were sent for acid fast bacilli (AFB) smear, conventional and rapid culture and DNA polymerase chain reaction (PCR) analysis for diagnosis of genital TB. The results of these tests were analyzed and agreement with laparoscopy was assessed using Kappa statistics. Pain scores using visual analogue scale were compared before and after treatment. Results: Pelvic pathology was present in 44 (88%) women of idiopathic chronic pelvic pain, with a 34% prevalence rate of genital tuberculosis. Pelvic inflammation was associated with positive peritoneal fluid PCR (n=4) and AFB culture (n=3). Acid fast bacilli PCR had substantial agreement (kappa statistics=0.716) with visual findings at laparoscopy. There was a significant reduction in pain scores after treatment. Conclusion: Genital tuberculosis contributes to one-third cases of chronic pelvic pain. Pelvic inflammation is an early feature of genital TB and peritoneal fluid PCR has the best co-relation with laparoscopic findings of genital tuberculosis.

Highlights • Embryonal rhabdomyosarcoma (RMS) of the cervix. • Subtypes of embryonal RMS. • Disease of adolescence. • Fertility preservation. • Lack of standard treatment., Embryonal rhabdomyosarcoma (RMS) of the cervix is a rare entity, encountered mainly in the first two decades of life. The literature consists mainly of case reports and few small case series, and no standard treatment guidelines are available. As this is a disease of adolescence, fertility preservation in well selected cases is of paramount importance. We report 3 cases of cervical RMS, in adolescents highlighting the clinical presentation, diagnosis and management.

Background: Squatting posture may appear outdated and primitive, but in the antenatal period, it is an important resistance exercise to strengthen the abdominal and pelvic floor muscles which are believed to potentially prepare the women for a more natural delivery. No study till date has evaluated the effect of type of toilet seat regularly used during pregnancy. This was a pilot study to assess obstetric outcomes in antenatal women using squat versus western style sitting toilet seat.Methods: In an observational prospective pilot study, low risk primigravida at 28-32 weeks gestation were recruited from the outpatient department and divided into two groups after matching baseline characteristics. Group I (n=50) included women regularly using squatting type toilet seat and group II (n=50) comprised women using western style toilet seat. Pregnancy was followed till delivery; obstetric and neonatal outcomes were noted.Results: Squatting group, as compared to sitting type seat users, had lower incidence of vaginal discharge (10% vs 16%), urinary tract infection(12% vs. 24%), constipation (2% vs. 6%), labor induction (52% vs. 58%), shorter second-stage duration (0.60 vs. 1.24 hours) and a higher incidence of normal vaginal delivery (94% vs. 86%), albeit not statistically significant. NICU admissions (16% vs. 20%) and mean birth weight (2.83 vs. 2.97 kg) were comparable in the two groups.Conclusions: Squatting type toilet seat users had many favourable obstetric outcomes, especially a higher incidence of normal vaginal delivery; although, the difference was not statistically significant. Large community based surveys in this regard can reveal the true effects of squatting type toilet seat on pregnancy and labour outcomes.

Objective To compare the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and platelet indices between women with pre-eclampsia and normotensive pregnant women. Methods A cross-sectional study conducted from January to July 2017 at a tertiary care hospital in Delhi, India. The study compared pregnant women aged 18-40 years with pre-eclampsia diagnosed at term with healthy pregnant women matched for gestational age. Venous blood samples were drawn and complete blood count was analyzed. The parameters recorded were hemoglobin, red cell distribution width (RDW), platelet count, mean platelet volume (MPV), plateletcrit, and platelet distribution width. Results There were 67 women included in each group. NLR was higher in women with pre-eclampsia compared with the control group (6.8 ± 7.6 vs 3.0 ± 0.98; P=0.001). Both PLR (14.18 ± 14.4 vs 9.54 ± 3.6; P=0.012) and MPV (9.45 ± 1.19 vs 9.02 ± 1.1; P=0.029) were higher in the study group compared with the control group. Platelet count was lower in pre-eclamptic women compared with the control group (188 ± 89.7 vs 200.1 ± 62.36; P=0.014). RDW was also higher in the study group (P=0.025). Conclusions The present study found that the inflammatory markers NLR, PLR, RDW, and MPV were higher in women with pre-eclampsia. Measuring NLR and PLR may be useful in predicting pre-eclampsia among women at high risk during prenatal follow-up.

Haemostatic material made of oxidized cellulose is a bio-absorbable fabric used widely for intraoperative haemostasis and adhesion prevention in surgery. The knit mesh facilitates platelet adhesion and aggregation during surgery. However, rarely it may cause a foreign-body reaction, which is indistinguishable from abscess or granuloma formation. This report describes a case of a local tissue reaction due to oxidized regenerated cellulose followed by vault erosion and vaginal bleeding, mimicking pelvic sepsis post hysterectomy. The signs and symptoms resolved completely following removal of the oxidized cellulose fabric.

Acute intermittent porphyria is a rare autosomal dominant disease caused by a mutation in the gene coding for the porphobillinogen deaminase enzymes in heam biosynthesis. The disease manifests as acute attacks of neuropsychiatric dysfunction and neurovisceral manifestations presenting as acute abdomen. In pregnancy, 54% patient has exacerbation of attacks in the form of seizures and acute abdomen occurs due to hormonal changes. Prevalence of acute intermittent porphyria is 1-2/200000 in general. Here we report a case of 36 year old women, G4P1L2A2 presenting at 10+4 weeks of gestation requesting pregnancy termination. Patient was diagnosed as case of acute intermittent porphyria with porphyic polyneuropathy 6 months back. At that time her main symptoms were acute pain abdomen with numbness and weakness in all four limbs. Her urinary porphobillinogen and 5 ALA raised. Her CECT of brain and nerve conduction studies were normal. Since then she is on Tablet Gabapentin 300 mg H.S. She underwent successful pregnancy termination by suction and evacuation under spinal anesthesia and she refused for copper-T insertion. Only safe drugs were used for procedure and she was discharged with advice of barrier contraception.

Hemoperitoneum resulting from various gynecological emergencies can be life threatening and ruptured corpus luteal cyst is one of the causes Here we are reporting a case of yrs women with history acute pain abdomen on th day of her mentstrual cycle Ultrasound showed collection in pelvic cavity mainly around right adnexa After few hours of observation she was taken for laparotomy because of tense and tender abdomen Intraoperative there was hemoperitoneum of around cc with ruptured corpus luteal cyst of right ovary Ruptured corpus luteum cyst should be kept in differential diagnosis of acute abdomen in women of reproductive age group especially in secretory phase Timely diagnosis and management can save patient life

Genetic causes involving changes in the parental or fetal chromosomes are an important etiology for recurrent pregnancy loss. 3–6% of Recurrent miscarriages are due to chromosomal abnormalities of one of the two partners. Chromosomal trisomies are the most common cause, while single most specific cause is monosomy X. Numerical abnormalities and single gene defects are other important genetic abnormalities. Translocations are present in 2.2% of couples after one miscarriage, 4.8% after two miscarriages, and 5.7% after three miscarriages. Once a genetic defect is identified by parental or fetal karyotype, genetic counseling should be offered to the couple. There is insufficient evidence to support the use of available strategies to minimize the risk of having an affected child like preimplantation genetic screening and diagnosis.

Unexplained recurrent miscarriage indicates that there is no underlying cause for this condition and up to 50% of patients remain without a diagnosis. The most common cause is the factor of chance alone which constitutes the type 1 pregnancy losses. Other suggested mechanisms are endogenous factors like poor oocyte, sperm and embryo quality, and environmental risk factors constituting the type 2 unexplained RPL group. Treatment includes psychological and supportive care, and role of drug therapy is still not proven.

The role of cerclage in recurrent pregnancy loss is in patients of true cervical incompetence which complicates less than 1% of all pregnancies. Cervical cerclage may be offered in women with history of three or more second-trimester pregnancy losses or extreme premature deliveries or in women with two or less midtrimester losses if cervical length is less than 2.5 cm before 24 weeks. Cerclage may be transvaginal or transabdominal; the latter is preferred preconceptionally in select cases with failed vaginal cerclage.

Vaginal route is a feasible and safe option for various indications of hysterectomy like fibroid, adenomyosis, abnormal uterine bleeding, cervical intraepithelial neoplasia III, cervical carcinoma in situ in older women and Stage I endometrial cancer. The contraindications are mainly based on factors like uterine size, mobility, descent, vaginal width, need for concomitant salpingo-oophorectomy, multiple previous surgeries, skill and experience of the surgeon. Vaginal hysterectomy is considered the safest of all hysterectomies and must be considered the first choice whenever applicable.

ObjectiveOvarian cancer is the seventh leading cause of cancer death worldwide. This is mainly due to late diagnosis and high rate of relapse and resistance following chemotherapy. In the present study, we describe simple and cost-effective method to establish primary culture from ascitic fluid and solid tumor obtained from epithelial ovarian carcinoma patient, which may provide a better tool for in vitro testing of drug sensitivity and designing individualized treatment protocol.MethodsComplete Dulbecco modified Eagle medium (DMEM) was prepared by supplementing DMEM with 10% fetal bovine serum and antibiotics (ciprofloxacin and amphotericin B). Establishment of primary culture of ovarian cancer cells from ascites fluid and solid tumor was done by using complete DMEM media.ResultsPrimary cultures of ovarian cancer cells were established from ascitic fluid and solid tumor tissue. Of the 7 ascitic fluid samples, we were able to establish 5 primary cultures of ovarian cancer cells. All the 7 samples were diagnosed as serous papillary adenocarcinoma. Some fibroblasts were also attached to culture flask on day 4; they were removed by exposing them to trypsin for a brief period. On day 7, grape-like clusters were visualized under inverted microscope. The cells became confluent on the 10th and 11th day and showed cobblestone appearance, which is a hallmark of ovarian cancer cells. Senescent irregularly shaped cells that have ceased dividing were seen after 8 to 10 passages.ConclusionThis study highlights the fact that establishing primary cultures from ascitic fluid or solid tumor tissue may help us to understand the molecular profile of the cancer cells, which allow us to select the best chemotherapeutic agent for ovarian cancer patients and thus take a step toward patient-tailored therapy so that patients are not exposed to drugs to which they are not likely to respond.

Collision tumours are defined by co-existence of two tumours in the same or adjacent organs which are topographically and histologically distinct with minimal or no histological admixture. Collision tumours have been described in many organs notably thyroid, brain, adrenal gland, stomach and rarely uterus. Most of the collision tumours reported in uterus have two components; an adenocarcinoma and a sarcoma. We report a case of a 60-year-old lady who presented with complaints of post-menopausal bleeding. A cervical biopsy was performed which showed a non-keratinizing squamous cell carcinoma of cervix. Intra-operatively the uterus was bulky with a 6 cm x 5 cm polypoidal mass in the endometrial canal along with a 2 cm friable cervical growth. The fleshy uterine cavity mass was a spindle cell tumour with moderate pleomorphism and frequent mitosis. It was immunopositive for CD10 and negative for smooth muscle actin and cytokeratin 5/6. The other growth showed non-keratinizing squamous cell carcinoma which was positive for cytokeratin 5/6. Based on the distinct topographical location and limited areas of tumour admixture of the two tumours, a diagnosis of collision tumour of uterus comprising of endometrial stromal sarcoma (high grade) uterus and squamous cell carcinoma cervix was made.

Levetiracetam (LEV) is a relatively newer anticonvulsant drug used to treat epilepsy and is approved by United States Food and Drugs Administration (USFDA). The drug binds to a synaptic vesicle glycoprotein and inhibits presynaptic calcium channels, thus reducing neurotransmitter release. Commonly reported side effects include drowsiness, weakness, unsteady gait, mood changes and loss of appetite. Like most other antiepileptics, it is a Category C drug in pregnancy. We report the first case of facial dysmorphism in the neonate of a mother taking LEV antenatally. A 30-year-old lady, G2 P1 L1 presented at 38 weeks gestation with history of previous caesarean and leaking per vaginum. She was a known epileptic, taking carbamazepine since three to four years. She was switched over to LEV at fifth week of pregnancy. Her antenatal period was uneventful. Basic investigations including anomaly scan were normal. Unfavourable cervix necessitated caesarean section. Neonate (female) had dysmorphic facies with bilateral preauricular appendages and lateral cleft. Infantogram was suggestive of bifid vertebra in thoracic region. Computed Tomography (CT) scan chest revealed bifid vertebral body at D5 level with fusion of spinous process of D5 and D6 vertebra on left side. This is the first case of LEV induced facial dysmorphism, highlighting the need of further studies on LEV safety during pregnancy.

Birth asphyxia leading to acidosis comprises 20–60 % of perinatal mortality. Nuchal cord (NC) is one of the possible causes of birth asphyxia. Majority of fetuses who are antenatally detected to have nuchal cord are able to achieve successful vaginal birth. The purpose of this study was to analyze the effect of nuchal cord on fetal acid base status and perinatal outcome in vaginal deliveries. 150 parturients were equally divided into three groups after vaginal delivery based on no NC, single and multiple loops. Umbilical cord arterial blood was analyzed for biochemical markers i.e. pH, PO2, SPO2, PCO2, HCO3 −, standard base excess and lactate for acidosis. Labor complications like abnormal FHR, meconium-stained liquor, prolonged second stage, instrumental vaginal delivery, third stage complications were compared. In neonates, birth weight, Apgar score ≤7 at 5 min, NICU admission and other morbidity and mortality during hospital stay were compared among groups using suitable statistical tests. Above parameters were also compared between tight and loose loops. Nuchal cord groups had significantly higher frequency of labor complications than no NC group, especially tight loops. Neonates with NC had significantly higher frequency of meconium-stained liquor, Apgar score ≤7 at 5 min, deranged biochemical markers, NICU transfer. However, none of the neonate had pH in acidosis range and majority were discharged in healthy condition. Patients with NC are likely to have uneventful labor and delivery as cord compression is transient and most fetuses are able to compensate for reduce umbilical blood flow. Routine antenatal ultrasound scan is not advisable, as mode of delivery and labor management does not change with detection of NC antenatally. Therefore, vaginal delivery with routine labor protocol can be allowed in cases of nuchal cord.

A collision tumor is defined by the presence of two separate tumors in one organ on gross, microscopic, and immunohistochemical studies and they should be distinguished from malignant mullerian mixed tumors. A 60 year old lady P8L8 presented with blood stained vaginal discharge and post menopausal bleeding. Examination revealed a 1 x 2 cm cervical growth which was reported as squamous cell carcinoma cervix. Imaging revealed myohyperplasia with normal uterine cavity. The patient underwent Type III radical hysterectomy, bilateral salphingo-oophorectomy and bilateral pelvic lymphadenectomy. The uterine corpus revealed 5 cm growth in uterine cavity which was reported as high grade endometrial stromal sarcoma and the cervical growth was non keratinising squamous cell carcinoma infiltrating the former. The lymph nodes, parametria and vaginal cuff were free of tumor. The patient was referred for adjuvant chemotherapy and radiation therapy.

Background Placental site trophoblastic tumors are rare forms of gestational trophoblastic neoplasia. Due to the rarity, atypical presentation and relative chemoinsensitive nature, they pose both a diagnostic and therapeutic challenge. We present two cases of this rare tumor.

A retrospective study was conducted to review incidence, clinical practice, surgical management and histology of adolescent ovarian masses in order to audit and improve future practices. Complete hospital records of all adolescents between 10 and 20 years who had undergone surgery for ovarian masses were analysed between November 2006 to 2014. Parameters analysed were age, clinical features, diagnosis, operative procedure and histopathology. Ninety-four patients were included in the study and among them, 37 had non-neoplastic masses, 30 had benign neoplasms while 27 had malignant tumors. The main clinical presentations were abdominal pain (54%) and abdominal mass (41%). Dermoid was the most common benign neoplasm while germ cell tumor was the most common malignant mass; dysgerminoma being the commonest (68%). Malignancy was more common in early adolescence (12 ± 4.8 years) while non-neoplastic masses were seen more frequently in late adolescence (17.7 ± 2.2 years). There was a fair correlation between ultrasound and histopathological diagnosis.

Background: Antiphospholipid antibody syndrome (APAS) is regarded as the most frequently acquired risk factor for thrombophilia. The obstetric manifestations of APAS include early or late pregnancy losses and complications like preeclampsia and fetal growth restriction. Its timely diagnosis and treatment can improve maternal and neonatal outcome. Aims: To study the pregnancy outcome of patients with APAS treated with heparin and aspirin. Settings and Design: This was a retrospective study of pregnancy outcome in 42 consecutive women with APAS, treated with heparin and aspirin. Materials and Methods: The case records of 42 diagnosed cases of APAS with pregnancy, over a 3-year period, were studied. The pregnancy outcome in this group was compared before and after treatment with heparin and low-dose aspirin in terms of abortions, intrauterine deaths and live birth rate. The outcome of the present pregnancy in terms of fetal and maternal complications was analyzed. Results: The mean age and average parity of women with APAS were 30.1±4.1 years and 3.2±1.2, respectively. Among the treated patients of APAS, 13 (30.9%) had preeclampsia and 9 (21.4%) had intrauterine growth restriction (IUGR). There were 2 (4.7%) intrauterine deaths, 4 (9.5%) missed abortions and 3 (7.1%) abruptio placentae. Women with APAS had a live birth rate of 4.6% before treatment and 85.7% in the index pregnancy after treatment. Conclusion: Treatment of pregnant women with APAS results in marked improvement in the live birth rate (4.6-85.7%). However, complications like preeclampsia and IUGR occur even after treatment, requiring strict monitoring and timely delivery.

Objectives: To study and compare the efficacy and side effects of drotaverine hydrochloride and hyoscine-N-butylbromide in the augmentation of labor. Methods: A prospective randomized trial of 150 women in active labor included 50 women given drotaverine (group 1), 50 women given hyoscine-N-butylbromide (group 2), and 50 women given no medication (group 3). Duration of labor, rate of cervical dilation, mode of delivery, side effects, and neonatal outcome were compared among the groups. Results: The mean duration of the active phase of labor was 4.48 ± 2.26 h, 3.9 ± 2.42 h, and 3.6 ± 2.07 h in groups 1, 2, and 3, respectively. The mean rate of cervical dilation was 2.6 cm/h, 2.4 cm/h, and 2.5 cm/h, respectively. The differences were not statistically significant. There was no difference in the duration of the second and third stages of labor. No adverse maternal or fetal outcomes were noted. Conclusion: Drotaverine hydrochloride and hyoscine-N-butylbromide do not have a role in augmentation of labor.

Endometrial cancer is increasingly being diagnosed in women

Routine surveillance is aimed to detect recurrence early and institute treatment In addition, follow-up also helps to diagnose treatment complications and provide psychological support for the patient. Most of the endometrial cancer recurrences, mostly vaginal cuff, occur within 3 years of diagnosis of primary tumor and 50–80 % of them are symptomatic [7–9]. The surveillance guidelines are more intensive for the first 5 years posttreatment.

This article describes a rare case of early onset severe preeclampsia presenting with loss of vision in both eyes due to retinal detachment. Retinal detachment has been mainly reported in late onset preeclampsia unlike in this case. Though, some authors believe that occurrence of maternal retinal detachment in cases of preeclampsia has no prognostic implication to the fetus, in this case, presence of retinal detachment was associated with foetal demise.

Bony fragments in the uterus occur after second trimester termination of pregnancy following retained fetal bones. Very rarely, they can form following first trimester loss. Clinical symptoms range from pain, menstrual symptoms, and infertility. Ultrasound shows a hyperechoic shadow, and treatment is by curettage or hysteroscopic removal.

Trends in patient profile, clinical presentation, diagnosis, management options and outcome of abnormally invasive placenta (AIP) were retrospectively evaluated at a tertiary care centre from 2001 to 2010. AIP was diagnosed when confirmed by ultrasound or MRI, when complete manual removal of placenta was not possible or when histological confirmation was achieved in a hysterectomy specimen. The first and second halves of the time period were compared. The total number of cases was 56 and the incidence increased significantly in the second half. Main risk factors were placenta previa and previous cesarean section. Antenatal diagnosis by ultrasound was made in 72% in the second half, compared with 35% in the first half (p = 0.009). Maternal mortality was 29% in the first half and 21% in the second half. Hysterectomy was the mainstay in management; elective procedures being significantly higher in the second half.

Primary umbilical endometriosis accounts for 0.5–1% of extragenital endometriosis. Clinical presentation is typical and treatment involves complete excision. It is important to consider it in differential diagnosis of an umbilical nodule.

Uterine rupture is a potential obstetric catastrophe. We report a case of a gravida 2 para 1 with intrapartum unscarred uterine fundal rupture. Immediate resuscitation, laparotomy and hysterectomy, was done with maternal survival. History of passive cocaine smoke exposure elicited postoperatively was the possible etiology leading to complete fundal rupture. This case is an eye opener as regards to ill effects of drug abuse even though passive. A careful history of drug abuse must be elicited when the common causes of uterine rupture have been excluded or the rupture site is unusual.

Fetal warfarin syndrome (warfarin embryopathy) is a consequence of maternal ingestion of warfarin during pregnancy. Warfarin fetotoxicity comprises wide range of manifestations including dysmorphology in neonate with characteristic classical features of nasal hypoplasia and stippling of epiphyses.Here we present a case of a neonate whose mother was on unsupervised warfarin prophylaxis throughout pregnancy. A brief review of literature with suitable options for anticoagulation during pregnancy is discussed.The final consensus over LMWH and warfarin in the first trimester is yet to be finalised. The treatment of warfarin embryopathy is symptomatic. Long term sequels in survivors are still not known.

A 13-year-old unmarried virgin reported to our gynaecological out patient department with continuous right-sided lower abdominal pain of one-month duration, with increasing severity since last 24 h. It was not associated with fever, but with mild nausea and vomiting. She attained menarche at 11 years of age, had regular menstruation and her last menstrual period occurred 10 days previously. On examination, vitals were stable with a tender suprapubic cystic mass corresponding to 14–16 weeks size of gravid uterus with restricted mobility. Bowel sounds were normal. On rectal examination, a right-sided tender mass was felt measuring approximately 5 £ 6 cm, which was conWrmed by ultrasound. She had undergone ultrasound (USG) guided cyst aspiration for the same mass 3 months back at our institute. Two hundred ml of straw colored Xuid was drained and cytology revealed only blood cells and occasional histiocytes. Tumor markers were within normal limits. Repeat USG scan a month later due to a similar episode of acute pain abdomen showed recurrence of the cyst, measuring 5.6 £ 4.8 cm with no solid areas and normal doppler Wndings. USG done at this visit showed a right ovarian unilocular cyst measuring 11.2 £ 8.2 £ 6.1 cm, with no septae or suspicious areas. Her haemoglobin value was 10.6 g/dl and white blood cell count was 9,800 mm. Her symptoms did not resolve on conservative management. A diagnostic laparoscopy was performed which showed a right sided elongated hydrosalpinx measuring 8 £ 8 cm, twisted twice on its pedicle with moderate congestion (Fig. 1). The left fallopian tube, ovaries, uterus and appendix all looked grossly normal; there were no adhesions in pelvis. Right salpingectomy was performed after taking informed consent from the relatives. The patient recovered well postoperatively and was discharged on postoperative day 2. Cytology of the Xuid drained from hydrosalpinx showed sheets of mesothelial cells in a haemorrhagic background; polymerase chain reaction (PCR) and acid fast bacillus (AFB) stain for mycobacterium tuberculosis was negative. Histopathological sections examined conWrmed our diagnosis of fallopian tube torsion with a hydrosalpinx.

We thank Prof. Gursoy et al. [1] for going through our study [2] in depth and we welcome their comments. However, here we could like to correct them regarding comment, ‘‘pathological range pH and lactate in non nuchal group in our study’’. In our study, Nuchal cord group had slightly lower pH as compared to non-nuchal cord group; however, neonate in neither of the group had pathological range pH suggesting that presence of NC interrupt umbilical blood flow to some extent causing some biochemical derangement, however, most with adequately functioning placenta are able to compensate quickly, this may lead to slight fall in pH but rarely pathological range acidosis in those who are able to sustain vaginal delivery. However, among NC group who were not able to compensate for the reduced blood flow must have had fetal distress and undergone secondary cesarean section. Since we have not included cases of cesarean section in our study, at moment we are not able to comment on this aspect. Regarding excluding nuchal cord cases delivered by cesarean section. At the start of our study, we purely wanted to evaluate the effect of NC on outcome parameters of vaginal delivery. Second to avoid bias, as the most common indication for emergency caesarean sections are fetal distress which could be due to meconium staining, non-progress of labour, uterine inertia, second stage arrest, cephalopelvic disproportion, if associated with presence of NC, then NC could be labelled as cause of fetal distress and as indication of caesarean section. NC could be the reason for secondary cesarean section in some cases. Since we only followed vaginal delivery we do not have data on cesarean section due to NC. Further research is underway in our department, after which we can comment on this aspect in a better way.

Genital tract tuberculosis is usually secondary to extragenital tuberculosis. The upper genital tract is usually involved; involvement of cervix and vulva is very uncommon. We present two such rare cases of vulval and cervical tuberculosis diagnosed on histopathology and treated with antitubercular chemotherapy.