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Abstracts of Papers Presented At The 111th Research Meeting of The Medical Research Centre of Bombay Hospital
Convenor Dr. HL Dhar
 
1. Importance of Repeat Angiogram in Non-Traumatic Subarachnoid Haemorrhage
 
Gunjan Aeron, Anand Alurkar, DB Modi, Anil Karapurkar
Most cases of non-traumatic subarachnoid haemorrhage are caused by rupture of an arterial aneurysm or an arteriovenous malformation. The first angiogram, performed within a week of clinical presentation, may be negative in 10-30% cases of spontaneous SAH documented on CT scan, MRI and/or lumbar puncture. A repeat angiogram done about 2 weeks to 3 months after the bleeding may reveal the origin of the haemorrhage in 5-10% cases. Reasons for false negative angiogram include technical and interpretation factors, vasospasm etc.

A 45 year old female was admitted in Bombay Hospital with complaints of severe headache and neck pain. She had no neurological deficit. Two days prior to admission she had subarachnoid haemorrhage. Clinically she was in Grade I of SAH (Hunt-Hess classification). CT scan showed SAH and blood in the fourth ventricle. Four vessel DSA was done on the 17th of July 2003. Bilateral vertebral artery angiography revealed tortuous hypoplastic right vertebral artery. The left vertebral artery was also tortuous. Basilar artery was hypoplastic. Both the posterior cerebral arteries filled from the internal carotid artery and not from the basilar artery. No aneurysm was seen. Repeat DSA was recommended and the patient was discharged. She continued to have severe headache which was relieved after 2 lumbar punctures. No readmission, repeat DSA was done on the 13 th of August 2003 which revealed a small round 2 mm diameter aneurysm on left vertebral artery at its junction with the posterior inferior cerebellar artery. The fundus of the aneurysm was directed upwards. Endovascular treatment was advised as surgical treatment for posterior circulation is associated with high morbidity and mortality. The risks of endovascular treatment were explained. These occur in less than 2% of the cases and include 1) perforation 2) thromboembolism 3) parent artery occlusion. Satisfactory endovascular treatment was done using 2 mm x 2 cm GDC coil.
 
2. Traumatic Dissection of Carotid Artery
 
Chetan Panchal, Anand Alurkar, Anil Karapurkar, DB Modi
The incidence of traumatic dissection of the carotid artery is 0.5% of total post traumatic injuries. Following increasing incidence of road traffic accidents and use of seat belts this incidence is increasing. Delay in the diagnosis is common because of lack of awareness. Late detection increases the risk of morbidity and mortality. Increasing awareness and proper management reduces the morbidity and mortality.

A 25 year old lady was admitted following road traffic accident. She was unconscious on admission but rapidly recovered. CT scan showed left frontal depressed fracture. She was operated and depressed fracture was elevated. Several hours later she developed mild weakness of right upper limb and dysphasia. She later worsened further. Repeat CT scan showed hypodense area in the left MCA territory suggestive of ischaemia or infarction. This increased further on follow up CT scan. Clinically there were bruises on the left side of the neck. Angiography showed subtotal occlusion with a thin sreak extending upwards upto the cavernous ICA suggesting ICA dissection. The neurological deficit was probably due to multiple episodes of repeated embolism. After documenting adequate collateral flow through anterior and posterior communicating artery, therapeutic occlusion was done to prevent further embolism. Following this the patient improved clinically and CT scan 72 hours later showed marked reduction in the hypodense area.
 
3. Role of Radiation Therapy in Soft-tissue Sarcoma
 
Avtar Raina, AJ Chaudhary
Soft-tissue Sarcomas are highly heterogenous group of tumours, arising from non-epithelial extra-skeletal tissue of the body like-voluntary muscles, fat, fibrous tissues and also peripheral nervous tissues, and constitute about 1% of entire cancer burden.

Soft-tissue sarcomas are highly aggressive tumours, having the potential of spreading locally, as well as to distant sites, lungs being the most common site of metastasis (about 50%). Lymph node metastasis is seen in less than 5%. About 60% of soft-tissue sarcomas arise in the extremities, 30% in trunk and about 10% in head and neck region.

Conservative surgical excision and adjuvant radiotherapy achieves a high degree of local control with improved cosmetic and functional results.

Radiotherapy can be delivered either by external beam alone or combining external RT with brachytherapy.

External radiotherapy treatment encompasses the tumour site with 5-8 cm margins on either side, sparing a generous long strip of normal tissue, upto dose of 60-65 Gy. Lymph node regions normally not treated.

Intraoperative brachytherapy with Ir-192 plays a major role in the management of STS. Plastic tubes placed over the tumour-bed following the surgical excision, are used to deliver the required dose to the bed. Total dose generally ranges between 20-40 Gy.

Our study using brachytherapy with or without external radiotherapy has been extermely satisfactory in terms of local control and complications and are comparable to the data in literature.
 
4. Successful Endovascular Embolisation of Spontaneous Retroperitoneal Haematoma Complicating Low Molecular Weight Heparin Therapy
 
Gunjan Aeron, Sundeep Punamiya
Low molecular weight heparins are widely used anticoagulants. However their liberal use is not without incident. Major bleeding may occur as a complication in 5.2% cases. We report three cases of spontaneous retroperitoneal haematoma complicating low molecular weight heparin managed successfully by endovascular embolisation.

Three patients in the age group between 55 and 75 years underwent angiographic evaluation for retroperitoneal haematoma complicated by haemodynamic collapse while undergoing LMW heparin therapy. Anticoagulation was indicated post angiographic stenting in two patients and for management of ischaemic cerebrovascular disease in one patient. Clinically all the three patients presented with haemodynamic collapse, flank pain and abdominal mass within two to ten days of initiation of anticoagulant therapy. The diagnosis of retroperitoneal haematoma was confirmed on computed tomography/sonography. Digital angiography was done for further evaluation and management. The origin of the bleed - the lumbar arteries, deep circumflex iliac artery and the ilio-lumbar artery in respective cases - was identified and selective endovascular embolisation done. Microcoil embolization using gelfoam/PVA successfully controlled extravasation in all patients, with stabilization of haemodynamic parameters.

Very few published reports are available on spontaneous retroperitoneal haemorrhage complicating LMW therapy and its management. We conclude that although rare, the possibility of LMW heparin therapy related bleeding must be considered in patients on anti-coagulation presenting with haemodynamic collapse particularly so in elderly patients.

Early diagnosis and management by selective transcatheter embolization may be a viable life-saving option in spontaneous retroperitoneal haemorrhage complicating low molecular weight heparin therapy.
 
5. Pictorial Essay of Mri in Orbital Pathologies
 
Dinesh S Baviskar, Inder Talwar, Sunila Jaggi
Orbital pathologies have non-specific clinical presentation and symptomatology, which mandates imaging, nonionising nature, excellent soft tissue resolution and non-invasive nature plays a vital role in imaging of the orbit.

Advent of higher field strength magnets (1.5 T) and surface coil have heralded a new era in orbital imaging. MRI helps in determining the extent of the lesions and differentiating lesions of the globe, optic nerve, intraconal and extraconal pathologies, lacrimal gland and eyelid. MRI not only acts as a diagnostic modality but also helps us to determine the response to treatment as in cases of thyroid ophthalmopathy and orbital pseudotumour which shows change in signal characteristics in response to steroid treatment.

Noninvasive vascular studies; i.e.; MR Angiography is useful in cases of carotid cavernous fistula where a dilated superior ophthalmic vein can be demonstrated. Contrast enhanced MRI demonstrates various orbital pathologies with excellent details.

Optic nerve pathologies such as optic nerve glioma, meningioma of sheath of optic nerve, optic neuritis and optic atrophy have characteristic MR features. Orbital and periorbital vascular pathologies like capillary and cavernous haemangioma, venous varix and eyelid haemangioma are demonstrated by MR Angiography and contrast enhanced MRI. MRI also helps to differentiate Graves ophthalmopathy from pseudotumour and lymphoma, which cause proptosis. Orbital neoplasm’s like melanoma, retinoblastoma and metastases can also be evaluated using MRI.

MR imaging features of the various orbital pathologies were described and a comparative study of MRI V/S CT imaging was done in 15 patients which revealed that MRI is better as compared to CT in 14:1 cases.
 
Abstracts of Papers Presented at The 112th Research Meeting of The Medical Research Centre of Bombay Hospital, Convenor Dr. HL Dhar
 
1. De Novo Tuberculosis in Renal Allograft Recipients - Our Experience
 
HK Shah, SD Bichu, P Namboodiri, V Dodke, UG Oza, AL Kirpalani

To study the prevalence, clinical profile and outcome of de novo post transplant tuberculosis (TxTB).

56/610 renal allograft recipients with TxTB between 1985 and 2003 were retrospectively analysed. These patients (pts) received either Pred+Aza or Pred+Aza+CycA or Pred+MMF+CycA. 13 pts received antirejection therapy (Methylpred - 13; OKT3-2) for acute rejection.

The mean age was 34.3 ± 7.4 years. 18 pts. were diabetic and 12 pts. had either Hepatitis B or C. 41 pts (73%) got TxTB in their first year after treatment. Common sites of involvement were Pulmonary - 27, Lymphadenopathy - 14, Pleural effusion - 6, Disseminated TB - 6, Pericardial - 3, Meningeal - 2, GI tract - 2, Spine-1, Palate-1; TB granuloma of renal allograft-1 and PUO which responded to empirical AKT-5.11 pts (20%) had involvement of more than 1 site at the time of presentation. The diagnosis was made by following methods: Radiological - 44, Bacteriological - 15, Serous fluid Biochemistry - 12; Histopathology - 10. All pts. received INH, ETB and PZA. 25 pts. got Streptomycin, 19 Fluoroquinolones and 10 Rifampicin in addition. 40/56 pts (71%) responded to ATT which was given for 6,12 or 18 months. 10/56 pts (18%) expired during the course of treatment due to other causes. One patient had relapse. 3 pts received second line ATT for suspected drug resistant TB. ATT induced hepatitis occurred in 11 pts (19%) of whom 6 had preexisting chronic liver disease.

The prevalence of TxTB was 9.2% in our centre. In contrast to other studies extrapulmonary TB was more common than pulmonary and majority of cases occurred within the first year of transplant. Predisposing factors for TxTB were : PTDM (25%), Hepatitis B/C (23%) and antirejection therapy (23%). TxTB can be successfully treated without Rifampicin.

 
2. Hyperhomocysteinaemia in Chronic Kidney Disease
 
Vidya Dodke, N Pravin, Hardik Shah, B Shrirang, AL Kirpalani
1. To study the incidence of hyperhomocysteinaemia in Chronic Kidney Disease (CKD) patients (pts) on MHD and on conservative treatment (Early CKD).

2. To study the effect of high dose Folate and haemodialysis in reducing and normalising S. Homocysteine (Hcy) levels.

25 pts with CKD on MHD and 10 pts wit CKD on conservative treatment (ECKD) who were on 5 mg of folate daily were included. Pts with Vit. B-12 deficiency and those on folate antagonists were excluded from the study. All pts with hyperhomocysteinaemia (S. Hcy > 15 mmol/l) were given folate in high doses i.e. 60 mg/d for 4 wks and repeat Hcy levels done pre and postdialysis to see the effect of high dose folate on S. Hcy levels.

The conventional 5 mg folate was able to keep only 8%, pts normohomocysteinaemic. High dose folate increased the percentage of normohomocysteinaemic pts from 8 to 28% predialyis and 32 to 68% postdialysis. 50% of the pts receiving high folate reduced Hcy levels by at least 5 mmols. High dose folate reduced Hcy levels by 22.6% in MHD group and by 33.47% in ECKD group.

Since each 5 mmol rise in Hcy levels has been shown by earlier studies to cause 50% increased risk of coronary artery disease (CAD), even the reduction of Hcy in the absence of normalisation could help in reducing morbidity and mortality due to CAD. On the basis of this finding we believe that the high dose of folate was beneficial to 50% of the pts receiving it. Hyperhomocysteinaemia of CKD seems to be refractory to even high doses of folate, suggesting that folate deficiency is not the only cause of high Hcy levels in this population.
 
3. Mycophenolate - An Initial Experience
 
P Namboodiri, SD Bichu, HK Shah, V Dodke, UG Oza, AL Kirpalani
This is a retrospective analysis of the clinical profile of 33 renal transplant recipients on MMF given either as primary immunosuppression (group A, n=25) or switch over therapy from azathioprine (group B, n=8). Patients with grafts < 3 months old were excluded. All patients also received Cyclosporine and Prednisolone and 11 patients received Basiliximab as induction.

In group A, the major complications were : acute rejection - 3(12%), graft losses - 4 (16%) [deaths - 3, graft thrombosis -1], post operative UTI-13 (52%), GI complaints - 12 (48%), Opportunistic infections - 11 (44%) [HZV infection-3; CMV disease-4, Pneumonia-2; Mucormycosis of paranasal sinuses-1; Pulmonary TB-1], Seizures of unknown cause-3 (12%), Leucopenia-2 (8%). MMF was discontinued in none. 3 patients (12%) needed readjustment of dose. In group B, (rescue therapy-5, other causes-3), the major complications were : GI complaints - 3 (37%), Opportunistic infections - 3 (37%) [CMV disease - 1, Pneumonia-2], Bronchiolitis obliterans-2 (25%), Leucopenia-1 (12.5%), while graft loss in 1 pt. (chronic rejection). There was no patient loss. MMF was withdrawn in 4 patients (50%) [bronchiolitis obliterans-2, leucopenia-1, GI complications-1].

When used as primary immunosuppression, the incidence of rejection was very low (12%) and no graft was lost due to acute rejection. In these patients, MMF was well tolerated with minor or no side effects in 72%. No patient needed withdrawal of the drug, 12% needed reduction of the dose. When used as rescue or switch over therapy from azathioprine patients did not experience acute rejections but 50% needed withdrawal of the drug due to side effects while one patient continued to have inexorable chronic rejection.
 
4. Post Transplant Renovascular Complications
 
H Shah, S Punamiya, S Bichu, P Namboodiri, V Dodke, UG Oza, AL Kirpalani
To study the incidence, clinical presentation and management of renovascular complications in renal allograft recipients.

This is a retrospective analysis of 523 consecutive renal allograft recipients (519 live and 4 cadaver) between May 1988 and May 2003. The incidence of different types of vascular complications, the clinical profile of these patients; the diagnostic and therapeutic approach adopted and their outcome were analysed. 490 patients received azathioprine and 33 received mycophenolate while 17 patients were given IL-2 Receptor antibodies as induction immunosuppression. All patients also received cyclosporine and prednisolone.

20/523 patients (3.8%) developed stenotic or thrombotic complications of which 14 patients (2.6%) had angiography proven transplant renal artery stenosis (TRAS) while 6 patients (1.2%) had thrombotic complications (3-venous; 3-arterial) with graft loss in all 6. The mean age of these patients were 35 ± 17 years. 4/14 patients (29%) with TRAS, presented with asymptomatic rise in S. Creatinine while 10/14 (71%) had concomitant resistant hypertension (requiring > 3 drugs). 10/14 patients (71%) presented within 6 months of the transplant; 2 patients between 6 months and 2 years after transplant while 2 patients got TRAS in the third year of their transplant. The severity of stenosis in our study was defined as follows: mild : < 50%; moderate : 50-70% and severe : > 70%. The commonest sites of stenosis were : (1) Renal artery branch stenosis - 1 patient (0.66%), which was severe (30 Pseudo TRAS i.e. just proximal to anastomosis - 4 patients (26.6%) of which 3 were severe and 1 mild and at external iliac artery - 2 patients which were moderate stenosis. Revascularisation (i.e. Percutaneous Transluminal Renal Angioplasty or Surgery) was done in 11 (85%) patients (PTRA - 10; Surgery - 1) while intervention was deferred in 3 (15%) because of patients refusal. Radiological success (i.e. < 40% residual stenosis post procedure with good intrarenal blood flow) was seen in 8 (80%) patients. One patient had partial success (i.e. > 40% residual stenosis) while 1 PTRA failed. A mean decrease in S. Creatinine by 40% at the end of 7 days was noted in six patients (54%) while 3 were lost to follow up. Restenosis of the revascularised segment was seen in 2 (18%) patients at the end of 6 months.

The commonest vascular complication after renal transplant was TRAS. Thrombotic complication invariably led to graft loss. The commonest site of stenosis was at the anstomosis (with an angiographic success rate of 75%) although stenosis could occur at other parts as well. The incidence of anastomotic stenosis (which could be attributable to surgical technique) was acceptably low (1.5%) and comparable to other large international series.
 
5. Phaeochromocytoma : Our 10-year Experience of Laparoscopic Management
 
R Varma, DD Gaur, RK Garg, UP Acharya, KS Shivakumar, SJ Rizvi, A Arora, BK Jain
Adrenal or extra-adrenal phaeochromocytoma is usually managed laparoscopically at most centers throughout the world. We hereby present our ten year experience of management of phaeochromocytoma at our institute.

Since 1993 nine patients with phaeochromocytoma, including 2 extra-adrenal tumours underwent laparoscopic surgery for their excision. Three of the adrenal tumours were on the left and 5 on the right side. One patient had bilateral tumours. Retroperitoneal approach was used in 7 and transperitoneal approach in 3. The age range was 13 to 60 years and male to female ratio was 3 to 7.

The first three patients had a planned open conversion during the early part of our experience. There was no open conversion during our last 7 procedures. Adrenal tumours more than 5 cms and the extra-peritoneal ones were removed by the transperitoneal approach. Harmonic scalpel was required only in one patient with an 8.5 cm tumour. The mean operative time was 210 min and the mean blood loss 125 ml. The patients were discharged from the hospital between 2 and 10 days and there were no complications. Blood transfusion was required only in one patient. Significant blood pressure fluctuations were noted in only one patient, who did not receive preoperative phaenoxybenzamine.

Conclusions : With proper preoperative preparation of the patient, laparoscopic excision of phaeochromocytoma is a safe and feasible minimally invasive procedure. The retroperitoneal approach should be limited to tumours smaller than 5 cm.
 
6. Retroperitoneal Laparoscopic Live Donor Nephrectomy : Does A Phased Procedure Make It Safe?
 
SJ Rizvi, RK Garg, UP Acharya, KS Shivakumar, R Varma, A Arora, BK Jain, DD Gaur
Laparoscopic live donor nephrectomy is regularly being performed at many centres throughout the world. However, the fear of losing the kidney is a big deterrent for most laparoscopic surgeons. We, hereby, present our experience of a phased out procedure for laparoscopic live donor nephrectomy.

After having performed more than 50 simple laparoscopic nephrectomies, 20 live donors with single renal arteries were considered for retroperitoneoscopic nephrectomy. In the first 7 donors, the laparoscopic procedure was performed in a stepladder fashion starting from dissection of the ureter and posterior surface of the kidney to a complete dissection. In the next 13 donors a total retroperitoneoscopic procedure was planned. Balloon dissection was done in all and 3 to 4 ports were used.

There were no donor or graft complications during phase one. During phase two there were 2 open conversions for slow progress in 1 and renal vein tear in the other. The remaining 11 donors had an uneventful retroperitoneoscopic procedure. There were no complications except for lumbar vein bleeding in 2 donors. The mean operative time was 150 min, the mean blood loss 106 ml and the mean hospital stay 4.7 days.

In spite of a reasonably good laparoscopic nephrectomy experience, it is better to be cautious by performing live donor nephrectomies in a phased out procedure.
 
7. Our Experience with The New Gaur Retroperitoneal Balloon Dissector
 
RK Garg, UP Acharya, KS Shivakumar, SJ Rizvi, R Varma, A Arora, BK Jain, DD Gaur
Since Gaur recently published his experience with a new cost saving reusable balloon dissector for expanding the retroperitoneal space, it has been successfully used in more than 50 patients. The fixation of the fingerstalls by the nut can sometimes be tricky and therefore, it has now been simplified.

In the old design, the fingerstalls get attached to the instrument by the screwing action of the retaining nut. This sometimes can be tricky and it can even cause twisting of the balloon over the shaft. The problem has been solved by a recent modification in this retaining nut.
The modified retaining nut now more easily slips over the fingerstalls and this prevents twisting of the balloon over the shaft. The retaining nut gets easily fixed over the fingerstalls by a simple pushing action. The new balloon dissector was successfully used in 5 patients undergoing retroperitoneoscopic procedures.

Gaur retroperitoneal balloon dissector is a safe, simple, reliable and cost saving instrument for expanding the retroperitoneal space. The newer version is more user friendly.
 
Abstracts of Papers Presented at The 113th Research Meeting of The Medical Research Centre of Bombay Hospital, Convenor Dr. HL Dhar
 
1. Synopsis of A Case of Congenital Diaphragmatic Hernia
 
A Tagare, S Khambayate, D Pawar, R Ramdwar, R Verma, Prem Sheth
An antenatally diagnosed case of congenital diaphragmatic hernia was admitted in NICU. Baby was delivered by an elective LSCS. Baby was full term/AGA. Baby was admitted in NICU and intubated. Early rescue surfactant therapy administered and baby was ventilated. Antenatal sonography and postnatal X-ray studies were suggestive of bilateral pulmonary hypoplasia due to abdominal viscera occupying thoracic cavity. Baby was operated on day 3 of life. All abdominal viscera was repositioned in abdominal cavity and diaphragmatic defect repaired. Left sided intercostals drain was kept. Baby was ventilated post operatively. Postoperatively both clinical and radiological findings suggested expansion of right lung, shift of mediastinum to left and some expansion of left lung. Baby was improving clinically and was put first on nasogastric feeds and then gradually oral feeds started. Baby was then put to breast and was sucking well. Baby was discharged from NICU and then from wards as baby had no respiratory problem, was sucking well and gaining weight gradually and consistently.
 
2. Case of Swelling in The Neck in A Newborn
 
R Dias, M Shinde, R Ramdwar, R Verma, Prem Sheth
10 day old male child presented in the OPD with a swelling in the left side of neck noted since the 8th day of life. Swelling was small in size and showed gradual increase in the size. It was round smooth surfaced and soft. It did not cause any feeding or breathing difficulty and the cry of the baby was normal. There was history of oil massage to neck over the next few days, there was an increase noted in the size and the cry hoarse.

OPD examination - a healthy term male neonate, vitals stable with a swelling in the middle of the left side of neck measuring 5*4* cms, soft cystic along the lateral border of the sternocleidomastoid freely mobile, fluctuant and transillumination + overlying skin normal. No other swellings in neck or other parts of body systemic examination was normal. D/D : 1. Cystic hygroma 2. Scm tumour 3. Bronchial cyst. CT scan neck cystic mass in the left side of neck which extended to the deeper structures-? cystic hygroma. Child took breast feeds well and was breathing comfortably despite the stridor. Baby was evaluated by Dr. Ravi Ramadwar and posted for surgical excision of the cyst which was done under GA the surgery lasted for 2 hrs and the cyst was removed in total. Post operatively baby was kept in the IPCU on pressure control ventilation and IV fluids for a day. 2nd day baby was extubated and started on tube feeds of ebm. By 3rd day, baby was able to take full tube feeds was active and alert. The surgical drains were removed thereafter and baby was slowly restored to breast feeds.
 
3. Unusual Case of Endometriosis in Umbilical Region - Misdiagnosed As Umbilical Hernia
 
Daksha Bhangui, PB Paidhungat
Endometriosis occurring in various unusual sites is well known. This is an unusual case of Umbilical Endometriosis. This patient Narasimah Prassana 47/F was admitted. In Bombay Hospital on 28th April 2003, with Chief Complaints of, 1. Swelling and blackening of umbilicus and periumbilical pain for 1 year 2. Discharge through the swelling (4 Days before, during and 3-4 days after menses). MH 3-4 /30, mod. flow, no dysmenorrhea LMP - 18/4/2003, OH P2L2A1. She had 2 previous FTLSCS and 1MTP. MED/SURG/H not significant O/E No Pallor. P-88/-BP-110/80 RS-NAD CVS - NAD PA uterus enlarged to 22 wks size. Mobile Umbilical blackening + Severe Periumbilical Tenderness + PS Cx Healthy. PAP SMEAR Taken PV Confirmed Abdominal Findings. USG Abd and pelvis done showed E/O Large fundal fibroid 9.5 X 7.5 X 8 cm. With mild (R) Hydronephrosis and hydroureter due to pressure effect. Rest abdominal findings normal. Rest all Preop investigations were WNL. Patient underwent DJ stenting of (R) ureter followed by total abdominal hysterectomy followed by umbilical excision on 29/4/2003. Post operative period was uneventful. Patient was discharged on POD8. HPR (1) Leomyomata (2) Proliferative Endometrium (3) Umbilical Endometriosis, No Granuloma, No atypia or malignancy.
 
4. Vaginal Removal of Fibroids more than 850 Gms Along with Vaginal Hysterectomy
 
Pradnya P Gujar, PB Pai-dhungat
Fibroid is one of the commonest indication for hysterectomy in patients with small symptomatic myomata, vaginal hysterectomy is treatment of choice. However, large fibroids are considered as contraindication for vaginal hysterectomy. We present two cases of large fibroids which were successfully removed vaginally with no operative complications with less morbidity and no mortality. Thus we conclude that large fibroid is not a contraindication to vaginal hysterectomy if performed at tertiary centre with good assistants and good anesthesia with few exceptions like uterus adherent to anterior abdominal wall due to previous surgery, highly pulled up cervix and cervical and ovarian malignancy.
 
5. NST in Relation to Cord Around The Neck, Indicating Decision for Caesarean Section - Case Presentation
 
Sulbha Arora, PB Pai-dhungat
NST is the simplest test which assesses the foetus at risk for uteroplacental insufficiency during pregnancy and helps in deciding the time as well as the route of delivery. Here we present two cases in which ominous NST pattern along with ultrasound finding of cord around the neck detected the decision for performing caesarean section was taken.

In both these cases presence of ominous changes in the NST were a deciding factor for caesarean section. Reactive NST suggests that the foetus is safe in utero for at least a week and expectant management might safely be pursued, while non-reactive pattern alerts the obstetrician well before the onset of labour regarding foetal risk in utero. In the case of cord around the neck as the foetus approaches term the chances of cord compression leading to foetal hypoxia increase and lead to subtle and momentary changes in FHR pattern which may be early indicators of foetal distress, and alert us to the need for timely intervention, so action can be taken before significant foetal compromise has actually occurred.
 
6. Systemic Lupus Erythematosus And Pregnancy
 
Preeti Lewis, SK Desai

31 year old Rhneg G3P1L1A1 with 26.1 weeks of gestation with c/o dyspnoea on exertion, puffiness of face, oedema feet, Headache since 1-2 months. H/o oliguria with dysuria and flank pain - since 10 days. Detected to be hypertensive, Investigations were done.

Management : With the help of nephrologists, haematologist, cardiologist, immunologist and ophthalmologist Pt was treated. Complete bed rest. UA, 1/O, BP, daily weight charting. Injectable antibiotics.

O+ve/male child/bwt=1.2 kg. baby on ventilator for respiratory distress. On iv maintenance and antibiotics. Details will be presented.