Diagnostic approach to Perimenopausal bleeding by Pipelle or Dilatation and Curettage

Perimenopausal bleeding, is a very common problem, which is an alarming symptom for both; women and their doctors because of the rising fears of cellular changes or tumor of endometrium. In our study we tried to prove that collecting endometrial samples using the outpatient method of Pipelle is as effective as collecting the endometrial samples in the traditional method of Dilation and Curettage (DandC) in operation theatre which necessitates general anesthesia. Ninety four patients more than 40 years old were included in the study, all of them were complaining of abnormal uterine bleeding (pregnant ladies and ladies using hormonal contraception were excluded from the study) and endometrial samples were collected first in outpatient clinic using the Pipelle and labelled as A samples and secondly in the theatre under general anesthesia by dilatation and curettage and labelled as B samples, all samples were sent for histopathology without informing the pathologist about the method of sample collection and patients past medical history. Then, the reports of histopathological examination were compared between Pipelle and DandC samples (group A and group B). From the results we can conclude that samples of endometrium using Pipelle could replace the traditional method of DandC, with high specificity and sensitivity in detecting endometrial carcinoma and endometrial hyperplasia.

Is there any role of antibiotic as a post procedure prophylaxis in dilatation and curettage? A comparative single centre study at tertiary care centre

Background: Dilatation and curettage (D and C) is one of commonest procedure in the gynaecology. There are still two schools of thoughts pertaining to whether to administer antibiotic as a pre and post procedure prophylaxis or not to administer and hence study planned to evaluate the incidence of infection in patients after dilation and curettage with and without prophylactic antibiotics.Methods: Adults (>18 years) (n=100) who underwent dilatation and curettage procedure for any indication were included and patients with prior history of infection were excluded from the study. Patients were divided into 2 groups; group 1 (n=50) received prophylactic antibiotics and group 2 (n=50) received no prophylactic antibiotics as per the discretion of treating doctor.Results: Infection in both the groups was 2% and there is no statistically significant difference between the groups (p>0.349).Conclusions: Appropriate use of antibiotics can be a cost-effective strategy which can minimize the chances of development of antibiotic resistance and other side effects. Antibiotic are not necessary for pre and post procedure prophylaxis in D and C.

Bleeding Patient with Anti-PP1Pk – Revisiting Autologous Frozen Red Blood Cells

Introduction/Objective A 34-year-old Amish woman G11P8A2L8, with a known PP1Pk antibody, presented to her OB with vaginal hemorrhage secondary to an incomplete spontaneous abortion. Despite medical treatment, her hemoglobin decreased from 12 g/dL to 8.4 g/dL. She was air transferred to a tertiary care hospital for further management and antigen negative RBC transfusion. Upon arrival, her hemoglobin had decreased to 7.1 g/dL and her BP decreased to 92/64 mm Hg. Additional blood draws were discontinued to save blood wastage. Her blood pressure continued to decrease over the next several hours to a low of 78/36. The patient was briefly stabilized, and a successful dilation and curettage was performed. Methods/Case Report A national search was conducted for PP1Pk antigen negative blood. Her RBC phenotype: C+, c-, E-, e+, K-k-, Fy(a + b-), Jk(a+ b+), MN+, p, Le(a-b-). There was no history of blood product transfusion and the prior miscarriages where thought to be the source of alloimmunization. There was no known family history of the p (P- P1- Pk-) phenotype. Results (if a Case Study enter NA) One unit of PP1Pk antigen negative PRBCs was located approximately 48 hours after the patient’s admission, however, the consulting hematology team suggested withholding transfusion due the possibility of alloimmunization from other blood groups complicating future transfusions. She was treated with IV iron and discharged four days later with a hemoglobin level of 6 g/dL. She was asymptomatic upon discharge. Conclusion Anti-PP1Pk is a rare antibody (5.8 per 1 million people). In the Amish population, the incidence is approximately 1 in 5000 individuals. Our patient is planning for future pregnancies. Upon our suggestion, the patient was encouraged to consider frozen autologous blood donation after recovery and before the next pregnancy as well as close monitoring in high-risk maternal fetal medicine settings. In a patients and donors with anti PP1PK, we recommend advance planning including frozen autologous blood donation and family members RBC antigen studies. They should be encouraged to become regular blood donors for themselves and others.

Comparison of Dexmedetomidine with Fentanyl and Pentazocine – Promethazine in patients undergoing dilation and curettage in monitored anesthesia care

Dilatation and curettage (D and C) is an essential and common minor surgery in obstetrics and gynecology. Sedation, hypnosis and analgesia are used in combination for such short procedures. These days conscious sedation is provided to patients for day care surgeries which includes analgesia, sedation and anxiolysis while rapid recovery is ensured without side effects. Dexmedetomidine is a highly selective alpha-2 agonist that provides anxiolysis and conscious sedation without respiratory depression. It was to study the effect of dexemedetomidine with fentanyl versus Pentazocine with promethazine on hemodynamic stability and recovery during sedation in dilatation and curettage procedure. The comparison included the hemodynamic data and recovery time. The effect of the drugs on hemodynamics and monitoring the occurrence of any complication were also done. In our study, 50 patients were randomly divided into 2 equal groups; group DF received dexmedetomidine loading dose 1 μg/kg over 10 min and followed by 0.5 μg/kg/hr infusion till completion of surgery and group PP received pentazocine 0.5 mg/kg (max 30mg) and Promethazine 12.5 mg slow intravenous Bolus. Dexmedetomidine is a safe drug which provides good hemodynamics and less recovery time. It also exerts sedative and analgesic effects without respiratory depression unlike most analgesic/sedative drugs, such as ketamine, pentazocine and benzodiazepines. This study demonstrates that dexmedetomidine is a safe drug with good hemodynamic and recovery profile. Dexmedetomidine administration showed better preservation of MAP and SpO2.

Cervical ectopic pregnancy

We performed dilation and curettage and cervical balloon placement in a cervical ectopic pregnancy after treatment with Methotrexate, KCI and bilateral uterine artery embolization. A minimally invasive approach was used in the case as the patient desired future fertility. We present the potential challenges in management of cervical ectopic pregnancy as well as approaches to treatment.

A rare case of placental site trophoblastic tumor

Placental site trophoblastic tumor (PSTT) is a very rare tumor of young women and unique form of gestational trophoblastic disease (GTD) representing a neoplastic transformation of intermediate trophoblastic cells that play a critical role in implantation. It accounts for 1-2% of all GTNs, incidence of it being 1 in 1,00,000 pregnancies. It displays a wide clinical spectrum from benign lesion within uterus to highly metastatic features with widespread features of metastasis and can be difficult to control even with surgery and chemotherapy. Unlike other forms of GTD, it is characterized by low β-hCG levels because it is a neoplastic proliferation of intermediate trophoblastic cells. PSTT can develop following all kind of pregnancies, whereas approximately 50% of PSTT cases occur after a normal pregnancy and other cases follow abortion, term delivery, ectopic pregnancy and molar pregnancy. Histopathologically, PSTT has proliferation of intermediate trophoblastic cells and absence of villi. It shows less invasion of vascular tissue and using immune histochemistry revealed that PSTT cells expressed HPL more than β-hCG, characterized by increased expression of the HPL in histological section as well as serum. The most common presenting symptoms of PSTT are irregular vaginal bleeding associated with uterine sub involution. Patient can also be presented with amenorrhea, nephritic syndrome, abdominal pain, galactorrhea and hemoptysis. Hence any case of unusual bleeding should be investigated with dilation and curettage and βHCG levels. Although the majority of patients of the non-metastatic PSTT are cured by hysterectomy but in metastatic cases, it requires aggressive treatment with chemotherapy and radiation. Due to its seldom occurrence and uncharacteristic clinical presentation, to reach a correct diagnosis and management is a surgeon’s nightmare and can be very challenging.

Study of endometrium by trans-vaginal sonography and it’s correlation with histopathology in perimenopausal women with abnormal uterine bleeding

Background: Objectives of the study were to study the endometrial patterns in cases of abnormal uterine bleeding (AUB) and anatomical (structural) lesions of uterus using transvaginal sonography (TVS) and endometrial histopathology and to determine the efficacy of TVS.Methods: Cross-section study of 50 perimenopausal age group with AUB in TNMC BYL Nair hospital from Nov 2017 to Nov 2018.Results: AUB was seen 40 to 45 years multiparous women TVS endometrial thickness (ET) T 6-10 mm (46%), ET 11-15 (22%), ET>15 mm (14%), <5 mm in (18%), showed 21 (42%) patients with endometrial hyperplasia on TVS, 12 (24%) simple hyperplasia 4 (8%) complex hyperplasia on histopathology fibroid 8%, adenomyosis 2%. endometrial polyp 6%.Conclusions: Endometrial lining exceeds 10 mm dilation and curettage to be done r/o endometrial hyperplasia, to study the endometrial patterns in cases of abnormal uterine bleeding and anatomical (structural) lesions of uterus using transvaginal sonography and endometrial histopathology.