JOURNAL CLUB

MODERATOR : DR. NEERJA GOEL

PRESENTER: DR. SHIVANGINI SAHAY
 IOTA Simple Ultrasound Rules for Triage of
Adnexal Mass: Experience from South India
• The Journal of Obstetrics and Gynecology of India (July–August 2019)
69(4):356–362
• Jyothi Shetty, Aruna Saradha ,Deeksha Pandey , Rajeshwari Bhat, Pratap Kumar ,
Sunanda Bharatnur
 INTRODUCTION
• A woman presenting with an adnexal mass is a common clinical problem.
Correctly characterizing ovarian tumors is critical, as this ensures
appropriate referral of patients with cancer to specialized surgeons, which
is crucial to optimize patient care and survival .
• By correctly recognizing benign ovarian masses, conservative
management may be adopted, leading to reduced morbidity.
 CLINICAL CHARACTERISTIC

BENIGN MALIGNANT
• Reproductive age group • Extremes of age
• Pain + • Painless

• Unilateral • Bilateral

• Cystic in consistency • Variable solid cystic firm to hard and

fixed .
• Tender • Non tender
 SCREENING
Screening for ovarian malignancy
• Clinical – vague GI symptoms (nausea, vomiting, early satiety, bloating)
• Per vaginum – palpable ovary in post menopausal women.
• At TAH a clinical finding of malignancy such as -
Bilaterality ,solid cystic areas , ruptured capsule , omental caking , nodules
in POD, extra genital extensions and haemmorhage in the ovary
• INVESTIGATION OF CHOICE : TVS
• A systematic review in 2009 concluded that the risk of malignancy
index is the best available test to triage patients with ovarian tumors for
the referral to the gynecologic oncologist.
M

RMI
• >200 HIGH RISK
• 25-200 INTERMEDIATE RISK
U
• <25 LOW RISK

U*M*C
• However, RMI which relies heavily on serum CA 125 for its prediction
may not be useful in diagnosing germ cell malignancy in which other
tumor markers such as AFP and LDH are elevated.
• Another assessment can be done by ROMA (RISK OF OVARIAN
MALIGNANCY ALGORITHM)
• This includes (HE4 LEVELS , CA-125 , MENOPAUSAL STATUS)
 IOTA RULES
• In 2008, IOTA group proposed simple ultrasound rules for the diagnosis
of ovarian cancer. These rules are based on demonstration of certain
sonographic findings, indicative of benignity (B features) and some of
which are suggestive of malignancy (M features).
 AIM
• To assess the diagnostic performance of International Ovarian Tumor
Analysis (IOTA) simple ultrasound rules to discriminate adnexal masses
as benign or malignant.
 METHOD
• Prospective cross-sectional study.
• The protocol was approved by the ethics committee.
• All women gave informed consent.
 CRITERIA

INCLUSION CRITERIA EXCLUSION CRITERIA

• Women with at least one adnexal • Pregnancy
mass were recruited into the study. • Refusal of transvaginal
• In the case of bilateral adnexal ultrasonography
masses, the mass with the most • Failure to undergo surgery within 120
complex ultrasound morphology days of the ultrasound examination
was included in the analysis.
 METHOD
• Transvaginal ultrasonography was performed using one of the available
Voluson P8 or Phillips machines.
• Transabdominal ultrasonography was performed if a large mass could not
be fully assessed trans vaginally.
• During the examination, assessment of sonographic morphology of the
masses together with Color Doppler study was performed to characterize
the masses.
• Examiner evaluated the mass for the presence or absence of each benign
or malignant ultrasound feature
 CLASSIFICATION OF MASS
• At the end of the examination, the mass was classified as benign if one or
more B features were present in the absence of M features.
• The mass was classified as malignant if one or more M features were
present in the absence of B features.
• If both B rules and M rules were applied or none were present, the mass
was classified as inconclusive .
• Surgery was performed in the case of a mass classified as persistent (i.e.,
still present 12 weeks after the initial scan).
• In cases of symptomatic masses, suspected malignancy, or at the patient’s
request, surgery was performed more quickly, either by laparoscopy or
laparotomy according to the surgeon’s judgment.
• Histopathologic diagnosis of all patients was noted postoperatively.
• The masses with the pathological diagnosis of borderline tumors were
categorized in the malignant group
 RESULT
• In total, the simple rules yielded a conclusive result for 183(89%) of the
tumors.
• In 174 cases, at least one B feature was present, and in 155 (88%) of these no
M features were present.
• Of the 155 masses predicted to be benign by the simple rules, 93% (144)
were benign according to histopathology.
• In 51 cases, at least one feature for a malignant tumor was present, and in 28
(55%) of these no B feature was present.
• Of the 28 masses predicted to be malignant by the simple rules, 93% (26)
were malignant according to histology
• Among the tumors for which the simple rules yielded an inconclusive
result, pattern recognition was used as the second-stage test.
• In the 22 cases which were inconclusive by simple rules, 19 (86.4%)
masses exhibited one B feature and one M feature and three masses did
not exhibit any feature.
 DISCUSSION
• Results show that these rules are reasonably reproducible among
observers with different levels of experience.
• This study indicates that the main advantage of simple rules is that they
are user-friendly and does not require complicated computer software.
• Experienced ultrasound examiners take clinical and ultrasound
information into account when they estimate the risk of malignancy in an
adnexal mass, and they subconsciously apply a set of rules—based on
their previous observations—when evaluating a tumor.
 LIMITATION AND STRENGTH
• The limitation of this technique is that approximately 10% were
inconclusive results, which needed further evaluation by pattern
recognition.
• The reason for better diagnostic performance in this study may be due to
the extensive training imparted to the residents before embarking on the
study.
 CONLUSION
• IOTA simple rules have high diagnostic performance in differentiating
between benign and malignant adnexal masses.
• IOTA rules were able to correctly characterize about 89% of adnexal masses.
• If we use simple rules as a triage test and pattern recognition by an
experienced ultrasound examiner as a second-stage test in those masses for
which the simple rules result was inconclusive, we obtain the same
diagnostic performance as when pattern recognition is used in all masses.
• Therefore, the use of simple rules has the potential to reduce the burden of
work on experienced ultrasound examiner.
THANKYOU
JOURNAL CLUB
MODERATOR : DR. NEERJA GOEL
PRESENTER: DR. SHIVANGINI SAHAY
Impact of the Coronavirus Infection in Pregnancy:
A Preliminary Study of 141 Patients
• The Journal of Obstetrics and Gynecology of India (July-August 2020)
70(4):256–261
• Arun Harishchandra Nayak , Deepali Swapnil Kapote, Michelle Fonseca ,
Niranjan Chavan , Rahul Mayekar , Meenal Sarmalkar , Amarjeet Bawa
 INTRODUCTION
• The novel coronavirus infection (COVID-19) is a global public health emergency.
• The first case of coronavirus infection was identifed in Wuhan, Hubei province of
China and was notifed to the WHO on 31st December 2019.
• By 30th of January 2020, the coronavirus disease was declared as a Public Health
Emergency of International Concern (PHEIC)
• 1,83,14,234 cases globally have been reported with 6,94,235 deaths in 215 countries
• 6.76 million cases have been recorded in India with crossing over 1,05,000 deaths.
 INTRODUCTION
• The mode of transmission is by droplets which can occur when the patient
sneezes or coughs. The incubation period varies from 2 days to 2 weeks
following exposure to the virus.
• The period from the onset of COVID-19 symptoms to death ranged from
6 to 41 days with a median of 14 days with a case fatality rate of 2.3% -
6%.
 INTRODUCTION
• The patient can present with an array of symptoms, most commonly
presenting with complaints of cold, cough, fever, malaise, headache,
diarrhoea , anosmia, itching or watering in the eyes .
• However, patients may also present with gradual worsening of respiratory
discomfort or multiorgan failure.
• During pregnancy the symptoms can be mild (80%), severe (15%), and
critical (5%)
 INTRODUCTION
• The diagnosis of current infection relies on tests to detect the presence of virus in
various body fluids.
• The standard test being done presently is detection of the viral RNA by RT-PCR
(Reverse Transcriptase Polymerase Chain Reaction) from the nasopharyngeal mucosa
as recommended by the ICMR (Indian Council of Medical Research).
• Antibody tests on blood are used to confirm past infection and presumed immunity to
repeat infection, although effectiveness of such tests is not yet known .
• The ancillary tests include CBC , LFT , KFT, IL-6, Ser. Ferritin , electrolytes,
coagulation studies, ECG, HRCT
 RECOMMENDED TREATMENT
• MLID CASES – Azithromycin 500mg OD 3-5 days, HCQS(400mg BD then 200mg BD for 2-5
Days ) and Ivermectin(12mg OD for 3 days)
• SEVERE CASES – Dexamethasone 6mg 4 times a day for 7-10 days (if hypoxia present)
If there is coagulopathy then thromboprophylaxis is given.
SEVERE CASES WITH PROPOSED HIGH VIRAL LOAD – Remdesevir(200mg IV day 1 followed by
100mg IV for 2-10 days )
is given .
• CRITICAL CASE WITH HIGH IL-6 – Prone ventilation and Tocilizumab (400mg in 20ml NS IV single dose) is given .
• CRITICAL CASE NOT RESPONDING TO MEDICAL THERAPY – Plasma therapy.
Vaccine is yet to come but it will be a mRNA recombinant sub unit vaccine.
 AIM
• To assess the effects of COVID-19 infection on the maternal morbidity
and mortality as well as the effects on newborn in the 141 pregnant
women diagnosed with COVID infection in the early phase of the
pandemic.
 Materials and Methods
• A retrospective observational analytical study done in the Department of
Obstetrics and Gynaecology at Tertiary Care Hospital attached to a
Medical College, located in Central Mumbai
• A total of 977 pregnant women were included in the study
• DURATION : from 1st April to 15th May 2020
• There were 141 women who tested COVID positive and remaining 836
patients were included in the COVID negative group.
• Details about the patients like age, parity, gestational age, address, history of
contact, any comorbid conditions, mode of delivery/outcome, baby details,
APGAR score and treatment given were noted.
• For COVID positive patients, chest X-ray was done and they were started on oral
or parenteral antibiotics along with tablet Hydroxychloroquine (HCQ) treatment
in the dose of 400 mg BID on first day and later 200 mg BID for 4 days.
• Symptomatic patients requiring oxygen or ventilatory support were managed in a
separate ward in consultation with the physician.
• Asymptomatic positive patients were discharged or transferred to COVID care
center (CCC) on day 5. Neonatal swabs were sent within 24 h and rooming-in
was recommended.
• Direct breastfeeding was encouraged in these patients. Mothers were instructed
to wear a medical mask, when they were near their baby and perform hand
hygiene before close contact with the baby
 Statistical Analysis
• All the maternal and neonatal parameters were analyzed using descriptive
statistics i.e. percentages and proportions were calculated.
• The Chi-square test was used to compare categorical variables in COVID
positive and negative groups.
• p value of less than 0.05 was considered significant.
 RESULTS
• A total of 977 pregnant women were included in the study period of 45 days,
from 1st April to 15th May 2020.
• Of these, there were 141 women who tested COVID positive and the
remaining 836 patients were COVID negative.
• Thus giving the incidence of COVID infection in pregnancy as 14.43%.
• Among COVID positive cases, only 8 patients gave a history of contact with
patients diagnosed with COVID-19 infection and 133 were community
acquired cases.
 DEMOGRAPHIC PROFILE

• Majority of the patients were found in the

age group of 21–25 years.
• More number of women in our study were
multigravida and had gestational age of
≥37 weeks.
 ASSOCIATED COMORBIDITIES

• 27 (19.14%) COVID positive patients and 161(19.25%)

women in COVID negative group had comorbidities.
• Anaemia, pregnancy-induced hypertension and eclampsia
were the most common comorbidities in both the groups.
 MODE OF DELIVERY

• number of patients who were

delivered by LSCS in COVID
positive group (50%) was higher
as compared to COVID negative
group (47%) but the difference
between the two groups was not
statistically signifcant, (p>0.05).
 MATERNAL COMPLICATIONS
• First case was a Primigravida
with
35 weeks of gestation with
sepsis
and hepatitis
• Day 2 of normal delivery with
severe anaemia with pneumonia
with cardiogenic shock with
HELLP syndrome
• Post LSCS patient with sepsis
and acute kidney injury (AKI).
There were 8 maternal deaths in
the
COVID negative group.
 NEONATAL OUTCOME

• APGAR score was normal (7–10) in most

of the neonates in both the groups, (>0.05). Low
APGAR i.e. 0–3 was observed in 2 (1.52%)
neonates of COVID positive mothers and in 15
(1.91%) neonates of COVID negative mothers.
• In both the groups, majority of neonates had
birth weight between 2.5 and 2.9 kg, (<
0.05).
 NEONATAL COMPLICATIONS

Out of 24 babies of COVID positive mothers in

NICU,
• 16 babies went to NICU due to low birth
weight (LBW),
• 2 for low APGAR score,
• 6babies due to various reasons like neonatal
seizures, meconium aspiration syndrome and
ABO incompatibility.
Out of total 131 babies tested, only 3 babies
were tested positive on first swab and all of
them tested negative on day 5
 DISCUSSION
• Viral pneumonia is believed to be the most common non obstetric infectious disease
during pregnancy associated with maternal and neonatal morbidity and mortality .
• There is a very limited data currently available on maternal outcomes in COVID-19
infection in pregnancy.
• However, as per the data from other viral illnesses such as influenza, SARS and
MERS, pregnant women are more likely to develop viral pneumonitis, with higher
morbidity and mortality because of immunosuppression.
• However women with comorbidities have worse outcome can have maternal death due
to cardiomyopathy and MSOF.
 DISCUSSION
• The emergence of a disease with respiratory implications in the third
trimester of pregnancy is usually associated with a higher risk of LSCS,
preterm births, low Apgar indexes, and low birth weight.
• Recent literature tends to lean towards LSCS; however, much depends on
woman’s comorbidities.
• Certain generalized viral infections, such as HIV are predisposed to
intrapartum neonatal transmission. For COVID-19, data is limited.
 CONCLUSION
• Research on the effects of COVID-19 infection during pregnancy is still in its initial
stages as only few case reports are available.
• The results of the study suggested that there is almost negligible effect of COVID 19
infection on maternal and perinatal outcome. However more studies are needed to
conclude on this issue.
• The majority of the women were discharged without any major complications and
there was no evidence of vertical transmission of the COVID-19 infection but on
reviewing the literature 3 case reports of neonatal positivity have been found within
18hrs of birth.
THANKYOU