Journal of Obstetrics and Gynecology of India最新文献

The concept of foetal viability has evolved significantly and has been influenced by advancements in neonatal care and legal frameworks. This review explores the complexities of defining foetal viability in India's contemporary medical landscape, particularly in light of the recent extension of the Medical Termination of Pregnancy (MTP) Act to 24 weeks. The article examines the confusion surrounding the classification of extreme preterm births, Medical Termination of Pregnancy (MTP) Act, and prenatal documentation during sonography. It addresses the challenges in distinguishing between preterm birth and abortion and proposes solutions to standardize definitions and practices.

Endometriosis affects about 10 percent women in the reproductive age group globally and approximately 42 million in India. Managing the patient's pain symptoms associated with endometriosis appears to be the cornerstone in endometriosis disease management. The ideal medical treatment in endometriosis would be suppressing estradiol enough to alleviate symptoms of endometriosis but maintain sufficient levels to mitigate hypoestrogenic side effects. NSAIDs are generally prescribed for the initial management of pain symptoms in endometriosis along with hormonal agents like progestogens or combined oral contraceptive pills (COCPs). Injectable depot gonadotropin-releasing hormone (GnRH) agonists such as leuprolide acetate and letrozole are effective as second-line agents in the management of endometriosis-associated pain. Dienogest is a 19-nortestosterone derivative which has a high specificity for progesterone receptors and improves endometriosis-related symptoms and the overall quality of life. Dydrogesterone is quite effective in the treatment of endometriosis-associated pelvic pain without causing suppression of ovulation. GnRH agonists and GnRH antagonists both have been used in the treatment of endometriosis. Elagolix a first oral, non-peptide gonadotropin-releasing antagonist for the management of moderate to severe pain associated with endometriosis is successfully used. Aromatase inhibitors are used as second-line drugs in the management of endometriosis-associated pelvic pain. They prevent the conversion of steroid precursors to estrogens, both at the periphery and at the ovarian level. Tamoxifen, raloxifene and bacidoxifen have an anti-proliferative effect and regress the endometriotic implants. Mifepristone (progesterone receptor antagonist) and Ulipristal acetate (SPRM) have been used for medical management of endometriosis. LNG-IUS is emerging as a good option for patients with endometriosis who are not desirous of conception. Hormonal management is one of the effective management options in endometriosis. One has to be mindful of molecule-specific adverse effects while prescribing drugs.

Peripartum mental health is an underdiagnosed and undertreated entity; obstetricians are in a dilemma when patients present with signs of any mental disturbance. The peripartum period is fraught with triggers that can cause, or exacerbate, mental illness, and obstetricians need to be aware of diagnoses and treatment of blues, depression, psychosis and other problems. Key strategies that can be adopted are discussed in this review, along with the scenario in India.

Background: Approximately 20% of women develop an ovarian cyst or pelvic mass at some point in their lives. Due to high false positivity of CA-125, women with various benign ovarian tumors simulating malignant masses undergo extensive debulking surgery resulting in increased morbidity. Serum HE4 is a useful test for better discrimination of benign or malignant nature of pelvic masses in preoperative period. Our study gives an update on the biological markers specifically CA-125 and a novel tumor marker HE4 and aims to reduce the debulking surgeries done for benign pathology.

Materials and methods: The total study population (n = 302) included women who were operated with suspicious ovarian malignant mass (n = 238) with benign (n = 98), borderline (n = 6), and malignant (n = 134) ovarian tumors. Cutoff of CA-125 was 35 U/mL, and for HE4 140 pM for postmenopausal and 70 pM for premenopausal women were calculated at 86% and 81% accuracy, respectively. Statistical analysis was done using SPSS version 20.

Results: The cutoff values of CA-125 were able to differentiate between benign, borderline, and malignant tumors with statistical significance (p < 0.05), whereas the cutoff values of HE4 significantly (p < 0.05) differentiated benign tumors from the malignant tumors, but not from the borderline tumors. Serum CA-125 has significantly higher sensitivity and NPV (95%, 72%, respectively) compared to HE4 (81%, 52%) and combined HE4 plus CA-125 (84%, 59%), whereas specificity, PPV, and AUC were higher for combined CA-125 plus HE4 (93%, 98%, 90%, respectively) compared to HE4 (83%, 95%, 88%) and CA-125 (48%, 88%, 87%).

Conclusion: Measuring serum HE4 along with CA-125 in preoperative diagnosis helps in excluding benign ovarian tumors in which CA-125 was falsely raised, especially in center where frozen section is not available, thus potentially decreasing morbid debulking surgeries done for benign ovarian tumors.

Preterm Labour leading to premature births has remained one of the longest unresolved conundrums in medicine. This "conundrum" of issues surrounding preterm labour and birth appears to be complex. While we continue to accept that preterm birth is difficult to predict, we are being faced with an increasing trend in preterm births owing to the preponderance of the known risk factors in the present day Obstetric population. Health care providers should know that the challenges in handling preterm births and the role of Obstetricians in improving the overall health scenario in this context has to extend beyond mere individual patient care. Adequate sensitisation of both the perinatal care team, smooth referral pathways and providing realistic choices to the family are all important in reaching a rational outcome. Optimising perinatal care for preterm babies will go a long way in achieving the sustainable development goal of ending preventable neonatal deaths.

In India, cervical cancer is the second most common cause of cancer-related fatalities and the fourth most common malignancy worldwide affecting women. India accounts for 25% of all cervical cancer-related deaths worldwide each year. The main drawbacks of clinical staging were the imprecise estimation of tumor size and the challenge of determining the involvement of pelvic and para-aortic lymph nodes with the few studies that FIGO allowed to be done for staging of cancer cervix. The use of 2009 staging approach showed that when many cases were operated based only on clinical findings, they subsequently required adjuvant therapy; hence, treatment-related morbidity was negatively impacted by these errors. Changes have been made to the staging of cervical cancer according to the 2018 revised International Federation of Gynecology and Obstetrics (FIGO) guidelines. Correction to cancer of the cervix staging was published recently in 2024. The horizontal extent (lateral extent) of the disease is not taken into consideration for staging in cases of microinvasive disease. Three subgroups have been identified based on the stratification of tumor size: IB1 ≤ 2 cm, IB2 > 2- ≤ 4 cm, and IB3 > 4 cm. Pathology and imaging modalities are added to clinical diagnosis for staging of cancer cervix. The involvement of lymph nodes (LNs) is now classified based on pathology (p) or imaging (r) which specifies that lymph node involvement is diagnosed using pathology (p) or imaging (r). Stage IIIC has been added [IIIC1 (involvement of pelvic nodes) and IIIC2 (involvement of para-aortic nodes)] is assigned to the case in the event of lymph node positive status. Pathological assessment takes precedence over radiological and clinical findings. The involvement of vascular/lymphatic spaces should not change the staging. The lower staging should be assigned when there is doubt about stage. Overall, the revised FIGO staging of cancer cervix (2024) has a number of advantages, including the inclusion of imaging and pathology, tumor size and LN-based categorization. More studies on staging of cancer cervix in different populations using revised staging of cancer cervix will help to prognosticate use of this staging.

Background: Cervical cancer (CC) is the second most common cancer among women in India and in Sikkim. Screening helps in prevention and early detection of the disease; however, pelvic examination for smear collection is not preferred by many. Self-sampling method can be a good alternative for collection of smears, thus increasing screening uptake. Therefore, a study was conducted to evaluate perception about self-sampling method of screening among women in Sikkim.

Methodology: A total of 210 women who consented for this study were screened for cervical cancer using Pap smear and HPV DNA. Women were taught to collect their self-sample for HPV DNA test. Questionnaires were used to assess their attitude toward self-sampling prior to collection of samples and perception, post-collection.

Results: Seventy-percent women knew that CC is the most common cancer among women in Sikkim. 73% knew that it could be prevented, but only 57% had knowledge about screening facilities in Sikkim. 50% women knew about HPV vaccination program in Sikkim. 96% women had never done a self-sampling, while 67% had never heard about it. There was a significant change (p value < 0.00001) in perception toward self-sampling after the procedure. Comparative analysis showed that women found self-collection easier than expected. If they had a choice, they would prefer self-sampling over physician sampling; however, due to their trust in physicians they still believed physician collected sample would be better.

Conclusion: Self-sampling is a socially acceptable screening technique and can increase compliance among socially shy community.

Introduction: The use of transrectal ultrasound (TRUS) is established in prostate cancer but remains limited in cervical cancer. This systematic review aims to aggregate and describe the current use and advancements of TRUS in cervical cancer to identify gaps in the literature.

Methods: This study follows a protocol registered in the PROSPERO database (CRD42024520099). It includes cervical cancer patients confirmed by histopathological analysis, where TRUS was used for diagnosis or as an adjunct to therapeutic procedures. Cross-sectional, case-control, cohort, or randomized controlled trials published in any language were included. The risk of bias was assessed using the Newcastle Ottawa Scale (NOS).

Results: From an initial pool of 3380 articles, 50 duplicates were removed, leaving 3330 unique articles. After screening titles and abstracts, 2932 articles were excluded, resulting in 31 studies included in the review. These studies involved 1635 women with cervical cancers, with a mean age of 52.9 years. Histopathologically, 81.2% were squamous cell carcinoma (SCC), and 39.6% were at FIGO stage IIB. Nineteen studies were prospective, five retrospective, and fourteen used consecutive sampling. Only 10 articles had a fair rating, while the rest received poor ratings. Complications from post-TRUS included pain (N = 106), haemorrhage (N = 59), and perforations (N = 10). TRUS was used in seven areas, including cancer extension and pre-operative assessment. It showed a strong correlation with MRI but had lower sensitivity. TRUS was useful in staging, diagnosis, and guiding brachytherapy, demonstrating comparable accuracy to MRI in several instances.

Conclusion: The recommended use of TRUS in cervical cancer is still limited in formal guidelines, and clinical research remains insufficient.

Supplementary information: The online version contains supplementary material available at 10.1007/s13224-024-02047-8.