Atul Marwah, Shefali Gokhale, Sunita Tarsarya

Purpose :To evaluate the role of 18F-FDG PET/CT scan as an infection imaging modality in patients with pyrexia of unknown origin.

Methods : A total of 12 patients, 7 males and 5 females with age ranging between 17 and 60 years (referred between April 2005 and September 2006). All patients with fever of unknown origin as a main symptom and a variety of non contributive former investigations with or without potential diagnostic clues were included in the study. The patients underwent FDG - PET/CT scanning. We performed dual phase (early and delayed) imaging protocol, the patient was fasted for 6 hrs prior to the injection of FDG with commencement of early phase imaging approximately 45 minutes post i.v. administration of 10 mCi of 18F-FDG and delayed phase imaging was performed 3 hours post injection.

Result : Ten (83%) patients had positive FDG - PET findings. Patients with positive (true positive) FDG - PET scan findings were subsequently evaluated. Lymphoma was confirmed in one patient, adeno-carcinoma of lung in one patient, pyelonephritis in one patient, subcutaneous device infection (pacemaker) in one patient, infection of hip replacement in one patient, infection of knee replacement in one patient, surgical site infection in one patient, infective portocaval lymphnode (nodal Kochs) in one patient, prostatic abscess in one patient, ileal Kochs in one patient and thrombophlebitis in one patient. In none of the patients the findings were falsely positive. Two patients had a negative FDG - PET finding, in this group, the method was regarded as unhelpful in determining a diagnosis, however no other investigation could lead to the diagnosis. Sensitivity of the FDG PET/CT scan for infection imaging by the study is approximately 83% and the specificity was 90%.

Conclusion : 18F-FDG PET/CT is a useful imaging modality in localizing focus of infection in patients with PUO. It is also helpful in evaluating response to therapy.

Atul Marwah, Shefali Gokhale, Sunita Tarsarya, Rajnath Jaiswar

Aim :The aim of this study was to assess the role of functional brain imaging as a clinical tool in the management of neurologic and psychiatric diseases.

Material and Methods : Fifteen patients (8 males and 7 females, range 19-67 years) were considered. These patients underwent functional brain imaging, either Brain SPECT with Tc-99m ECD/Tc-99m MIBI or Brain PET with FDG for the purpose of diagnosis, prognosis assessment, evaluation of response to therapy, risk stratification and choice of therapy. Millennium VG Hawkeye coincidence imaging dual head gamma camera was used. Images of all patients were evaluated visually in a prospective manner.

Results : Functional brain imaging influenced further management in thirteen out of the fifteen patients. In two patients, functional brain imaging did not contribute to further management. Functional brain imaging was instrumental in guiding or changing management in 86.6% of patients.

Conclusion : Functional brain imaging proved to be a powerful adjunct in the assessment and treatment of neurologic and psychiatric diseases.

BK Goyal, R Kawar, BC Kalmath, A Sharma, S Deshpande, P Manokar

Background :Drug eluting stents have emerged as the latest new offering in percutaneous interventions in coronary artery disease in the new millennium.

Methods : We prospectively evaluated the short term safety and feasibility of use of drug eluting stents in our institute from January 1, 2004 to December 31st 2005 (two year period) in management of coronary artery disease.

Inclusion Criteria : 1) Exclusive use of one or more drug eluting stent in treatment of coronary artery disease.

Exclusion Criteria : 1) Use of a bare metal stent as part of the revascularisation strategy in any vessel during the index hospitalisation. 2) Instent restenosis. 3) Any contraindication to prolonged dual anti-platelet therapy.

Aims of Study : 1) To assess the feasibility of drug eluting stents in all complex subsets of patients, clinical presentations and lesion morphologies. 2) To assess the short term safety (30 day mortality) of drug eluting stents. 3) To study the incidence of subacute stent thrombosis.

Results : A total of 545 patients fulfilled the inclusion and exclusion criteria for participation in the study. The average age of patients was 50.2 ± 7.4 years. There were 426 males (78.2%) and 119 females (21.8%). The risk factor profile of the patients were as follows Diabetes Mellitus (n=184, 33.75%), Hypertension (n=106, 19.4%), Dyslipidaemia (n=76, 13.9%), Smoking (n=130, 23.85%). Cardiac history included history of previous Q wave MI (n=190, 34.9%), non Q wave MI (n=64, 11.7%), previous PTCA (n=25, 4.5%) and Previous CABG (n=12, 2.2%). Present cardiac status warranting the percutaneous intervention were acute myocardial infarction (n=90, 16.5%) unstable angina (n=204, 37.4%), stable angina (n=230, 42.2%), silent ischaemia (n=21, 3.8%). A total of 630 vessels were stented. The distribution being LAD (n=232, 36.8%), RCA (n=201, 31.9%), LCX (n=166, 26.3%), Left main (n=11, 1.7%), Radial graft (n=2, 0.31%), SVG graft (n=18, 2.8%). The number of ostial lesions were (n=67, 10.6%), bifurcation lesions (n=54, 8.5%), small vessel disease (< 2.5 mm) (n=30, 4.7%). TIMI flow (O=60, I=28, II=108, III=434), Lesion Class (ACC/AHA Classification) (A=120, B1=183, B2=196 C=131). A total of 664 drug eluting stents were used for stenting these vessels. The drug eluting stents used were CypherTM (n=60, n=9%). A procedural success was achieved in 540 patients (99.80%). There was one intraprocedure death (n=1, 0.18%). There was inability to establish TIMI 3 flow with stenting necessitating emergency coronary artery bypass surgery in four patients (n=4, 0.7%). There were 5 post procedural deaths, (n=5, 0.91%), 2 patients (no reflow phenomenon), 2 patients (subacute stent thrombosis), 1 patient (contrast induced renal failure). Other major adverse cardiac events included stent thrombosis (n=10, 1.8%), the incidence of post procedural myocardial infarction were ST elevation (n=13, 2.4%) and NSTEMI (N=7, 1.3%). Five patients developed post procedure renal dysfunction of which one patient died and one improved with intermittent dialysis, the remaining three recovered with conservative treatment. Major haematoma requiring blood transfusion was present in 2 patients (n=2, 0.4%).

Conclusion : Drug eluting stent use is safe, feasible in complex patient and lesion subsets.

Chitwan Dubey, Prema Kania, Sadhana Desai

For all couples who have suffered recurrent pregnancy loss the first step is evaluation to identify any predisposing factor. When a likely cause can be defined specific counselling and treatment can improve the prognosis for successful pregnancy outcome. But when no specific cause is found, reassurance and encouragement combined with supportive management along with empirical treatment have proven valuable.

The incidence of unrecognized pregnancy loss is between 30 and 60%. Miscarriage risk increases with the number of previous pregnancy losses, but rarely exceeds 40 to 50%. Thus obstetrician has a chance to play with the 40 to 50% and give a successful outcome to their patient.

Risk of pregnancy loss increases with increasing maternal age moderately after 35 years of age and more rapidly after 40 years.

Here I am presenting 2 cases one of which is a 41 year old female with a bad obstetric history GRAVID4 PARA2 Still Birth 1 Abortion 1 MTP 1 and another 27 year old female GRAVIDA 5 Abortion 4.

Both of these cases were of unexplained recurrent pregnancy loss. Empirical treatment with exogenous progesterone in early pregnancy followed by duvadilan in the later half, low dose aspirin and low molecular weight heparin to counteract the thrombogenic effect found in every pregnancy, were instituted and successful outcome achieved. Thus establishing the fact that supportive empirical therapy has an excellent role in giving a successful outcome in unexplained recurrent miscarriage.

Sonal Yadav, Chitwan Dubey, Prema Kania, Sadhana Desai

Systemic lupus erythematosus (SLE) is an idiopathic chronic disease that affects skin, joints, kidney, liver, serous membrane, nervous system, and other organs of the body.

Lupus nephritis is a common complication of SLE. (Incidence 50%).

Most of the studies till date have discouraged pregnancy in women with lupus nephropathy. The reports suggest it as a contributor to serious maternal mortality and morbidity. Studies on pregnancy outcome in SLE are scarce due to above reasons.

However, more recent series suggest that pregnancy in women with lupus nephropathy can result in favourable outcome, if the disease is well-controlled and renal function well preserved.

An interesting case of Gravid 2 Para 1 Still birth 1 with 28 weeks gestation a known case of lupus nephritis was admitted with us for safe confinement in view of lupus nephritis with a previous still birth.

The first pregnancy was a stillbirth at 7 months gestation in view of IUGR and oligohydramnios.

The patient was kept on immunosuppressive agents and a strict monitoring for renal deterioration and hypertension, risk of SLE exacerbation, risks associated with immunosuppressive therapy and obstetric complications, like pregnancy loss, preterm birth, IUGR and neonatal lupus.

This case study is being presented to emphasize that although lupus can be life threatening to both mother and foetus - infant but successful outcome can be achieved as in our case with the clinician being vigilant of the development of life threatening dangers.

Namita Patil, Chitwan Dubey, Prema Kania, Sadhana Desai

“Postpartum haemorrhage is the description of an event, not a diagnosis” as, mentioned in Williams obstetric text book.

More than half of the maternal death from haemorrhage is due to postpartum events.

Accurate estimation of blood loss, prompt recognition of clotting disorder, early involvement of experienced clinician, availability of experienced anaesthetist, appropriate fluid replacement, appropriate blood and blood product replacement and adequate physiologic management are factors that govern maternal survival.

We had a case of primary post partum haemorrhage in a primigravida with twins where we came across all the possible complications of primary post partum haemorrhage.

Protracted haemorrhage led to exhaustion of coagulation factors, a fullblown DIC. The patient was given adequate volume of whole blood, blood substitutes to maintain volume and tissue perfusion. Ultimately factor VII had to be given to control the DIC and finally ended up in obstetric hysterectomy as a life saving measure.

The purpose of presenting this case is to emphasize the unpredictability of obstetric haemorrhage and the importance of protocols to deal with massive haemorrhage.

Barkha Jain, Kunjal Bhatija, Monica Agrawal, Preeti Kantak, Prema Kania

Introduction : Placenta accreta is morbid adhesion of the placenta into uterine wall. Of unknown aetiology, there are three grades depending on depth of the placental attachment. It is associated with considerable maternal and foetal morbidity and mortality. The incidence of placenta accreta has increased 10-fold in past 50 years and occurs with a frequency of 1 per 2,500 deliveries. Two or more caesarian deliveries with anterior or central placenta praevia increases risk of developing placenta accreta by 40%.

Case Report : Mrs. A, 35 years old primigravida (G1P0+0) a case of primary infertility, married since 12 years, with 7 1/2 months amenorrhoea (IVF concentration) with twin pregnancy with pregnancy induced hypertension with Rh negative pregnancy and a known case of diabetes mellitus was admitted to our hospital on 10-9-2006 for safe confinement. Patient was apparently asymptomatic and was being managed conservatively upto 18th Oct. 2006 when she complained of severe left abdominal pain. On examination uterus was relaxed and her emergency ultrasound was suggestive of intraplacental haematoma. The patient was taken up for emergency caesarean section and intraoperatively diagnosed to be a case of placenta accreta. In view of uterine atonicity and severe bleeding following caesarean section, placental bed suturing, vigorous uterine massage, intramuscular and intramyometrial prostaglandins, B-lynch sutures, bilateral uterine artery ligation were carried out in the same order. However, despite all the measures bleeding continued and patient became haemodynamically unstable, so a decision to go ahead with a obstetric hysterectomy as a life saving procedure was taken.

Summary : Placenta accreta is rare but associated with catastrophic obstetrical complications like haemorrhage, shock sepsis, perforation and rarely inversion. Previous uterine surgery and placenta praevia are the most common risk factors. Conservative treatment has a role in selected cases to preserve fertility. Hysterectomy is the choice in cases of uncontrolled bleeding with failed conservative treatment and also in haemodynamically unstable patients. What is required is anticipation in high risk cases, prenatal diagnosis, counselling, prompt diagnosis, effective and individualized treatment which will go a long way in reducing maternal and foetal morbidity and mortality.

Rahul Salunkhe, Asha Singhal

Introduction : Management of spontaneous labour is one of the most important issue of modern obstetrics, both in developing and developed nations. In developing countries like ours due to disparity in doctors patient ratio, labour is mostly monitored by health personnels other than doctors. This demands need to simple managerial tool for the early detection as well as appropriate management of prolonged labour and its sequelae. Emanuel A Friedman constructed a graphic representation of labour by plotting cervical dilatation and descent of the presenting part against time.

Material and Methods : We conducted a prospective study over a period of 1 year. In all about 100 cases of primigravida, without any high risk factor were randomly taken for study by using partogram.

Aims and Objectives : To demonstrate with the help of partogram active management not only shortens the length of normal labour but also reduces incidence of prolonged labour and its sequelae.

Observations : In this prospective study out of 100 cases, 60% patients had normal course of labour and 40% had an abnormal pattern. Out of 40 abnormal labour pattern cases because of early detection by partogram, in 24 cases active management in the form of amniotomy and oxytocin augmentation was carried out, leading to 60 and 40 per cent vaginal and caesarean delivery rates respectively. So we had an overall LSCS rate of 25%. In most tertiary teaching hospital rate of LSCS varies between 35%-50%. Thus it can be definitely said that use of partogram reduces the rate of LSCS.

Conclusion : Partogram leads to early detection of dystocia and is one of the most important approach to reduce maternal and neonatal mortality. Therefore, it is suggested that every woman in labour must be benefited by this scientific approach of labour.

Monica Agrawal, Asha Singhal

Introduction : Modified biophysical profile is a simple, less time consuming method and identifies group of patients at increased risk for adverse foetal outcome. It comprises of NST and AFI.

Aims : To evaluate the value of modified biophysical profile in predicting complications or distress going to develop during labour and correlating the findings of modified biophysical profile with foetal outcome parameters.

Methods : Two hundred subjects including both high and low risk singleton pregnancies of more than 3-4 weeks of gestation were randomly selected, registered and evaluated with modified biophysical profile during antenatal period within a week before delivery and foetal outcome was noted.

Result : With abnormal NST there was 4.95 and 5.57 times higher risk of Apgar < 7 and need for admission in NNU (P < 0.001). With low AFI (0-8 cms) there was 2.77 and 2.88 times higher risk of having Apgar < 7 and need for admission in NNU (P < 0.001). Both NST and AFI predicted independently for adverse foetal outcome. But if both AFI and NST were abnormal it imparted a further higher RR of 8.25 and 10.01 times for prediction of Apgar < 7 after 5 mins and need for admission in NNU respectively. Patients with abnormal modified biophysical profile had 9.19 times (RR) higher risk of passage of meconium during labour.

Conclusion : Modified biophysical profile can predict an adverse foetal outcome and need of good intensive neonatal care unit to salvage the babies.