Prelims

DC Dutta's Clinics in GYNECOLOGY

Cover Image

FIG: Unruptured tubal ectopic pregnancy, salpingectomy was done. The specimen is cut open to show the embryo of 7 weeks gestation (see discussion Chapter 46)

DC Dutta's Clinics in GYNECOLOGY

DC Dutta MBBS DGO MO (Cal) Professor and Head, Department of Obstetrics and Gynecology Nilratan Sircar Medical College and Hospital, Kolkata, India Edited by Hiralal Konar (Hons; Gold Medalist) MBBS (Cal) MD (PGI) DNB (India) MNAMS FACS (USA) FRCOG (London) Professor and Head, Department of Obstetrics and Gynecology, KPC Medical College and Hospital, Kolkata, India FOGSI Representative to Asia Oceania Federation of Obstetricians and Gynecologists (AOFOG) Member, Oncology Committee of AOFOG Chairman, Indian College of Obstetricians and Gynecologists (2013) Formerly Professor and Head, Department of Obstetrics and Gynecology Agartala Govt. Medical College and GB Pant Hospital, Tripura, India Professor, Department of Obstetrics and Gynecology Calcutta National Medical College and Hospital, Kolkata Professor and Head, Department of Obstetrics and Gynecology Midnapore Medical College and Hospital, West Bengal University of Health Sciences, Kolkata Rotation Registrar in Obstetrics, Gynecology and Oncology Northern and Yorkshire Region, Newcastle-upon-Tyne, UK Examiner National: MBBS, DGO, MD and PhD of different Universities and National Board of Examination, New Delhi International: Royal College of Obstetricians and Gynaecologists (MRCOG), London Royal College of Physicians of Ireland (MRCPI) Recipient, “Pride of FOGSI” award – 2019, for exemplary efforts toward upliftment of Women's Health in India

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DC Dutta's Clinics in Gynecology

First Edition: 2022

9789354651397

Printed at:

those who strive relentlessly

to develop quality care

for

women's health

Professor DC Dutta

Professor DC Dutta was an Obstetrician, Gynecologist, a teacher par excellence and above all a noble human being. He came out with his first book entitled, Textbook of Obstetrics in 1983, while he was the Professor in Obstetrics and Gynecology at Sir Nil Ratan Sircar Medical College and Hospital, Kolkata, India. He was the first author in Obstetrics and Gynecology to remove the complexity of management with a most simple approach of the text information and the management flowchart, based on science and available resources. Textbook of Obstetrics soon became very popular Nationally and Internationally for which he received many accolades. DCD, as he was known to all his colleagues and students, was the doyen in Obstetrics and Gynecology in his era. His ‘Textbook of Gynecology’ was published in 1989 from the same institute and department while he was the Professor and Head. This book also fetched more name and fame.

His deep interest in emergency obstetric care, is reflected by his several publications in the national journals. Presently, the best publication award, under the Federation of Obstetric and Gynecological Societies of India (FOGSI), every year, goes by his name. He is well-known for his fast surgical skill. He retired from the same institution in 1993, after a long and distinguished career. He died on 29th December 1995. His charming personality and the profound knowledge, made him very popular to the generations of students, professionals, practitioners and the patients. His legacy continues. He is remembered with great affection and professional respect by all, who knew him.

PREFACE

Dutta's Clinics in Gynecology is an up-to-date comprehensive review for the postgraduates. The current edition has been made more widened and prepared with recent advances in gynecology extensively. This book was previously published as Manual of Obstetrics and Gynecology for the Postgraduates.

Approach for this book is entirely different from a standard textbook. Any attempt to cover the entire subject of gynecology is presently impossible for anyone in the discipline. Technology driven advances from embryo biopsy to robotics for gynecology oncology, have given us a huge new insight. The topics are selected depending on the necessity to learn and practice with the available resources.

This book has been designed for all categories of medical students and the residents that they are striving to keep themselves abreast with the progress of science and technology for improved patient care. Practicing gynecologists will equally be benefitted to update themselves for the quality care. This book focuses on all the practical aspects of clinical diagnosis and management. The book covers several hundreds of problems in Gynecology, in a concise mode of discussion within a well-deigned structured framework.

As the concept of precision medicine is the trend, attempts have been made to provide a comprehensive summary of each subject under the subspecialty. My sincere attempt was to provide a global view for the standard of teaching, training and evaluation. A framework for the international standard of postgraduate examinations have been provided. This book is enriched with a good number of illustrations, numerous charts, tables, boxes, photographs of rare variety. Suggested Reading has been added for additional information to know the other management options.

Clinics in Gynecology provides a scholarly and updated answer for any question related to the subject as discussed in the different sections of subspecialty. While writing the book, I have tried my best to analyze critically the events, researches, trials and the literatures that appeared most clinically relevant. At the end, the author has expressed his experience and judgment as regard the care of an individual patient.

Hiralal Konar

ACKNOWLEDGMENTS

I am deeply indebted to my esteemed colleagues, residents and students, Department of Obstetrics and Gynecology of all the medical institutions of the country and abroad for their generous support while writing this book. I thank all the readers who have contacted me with suggestions and seeking explanations through e-mails. Their inputs have been invaluable and much appreciated. I wish I could mention their names individually.

I thank Professor Gautam Joarder, Principal, Professor Ashok Mondal, Chief Medical Director and Adviser to the Principal and Dr Saurav Ghosh, Medical Director, KPC Medical College and Hospital, Kolkata, India for the support.

I sincerely thank World Health Organization Regional Office of South-East Asia (WHO-SEARO) for supporting me to include the important chapter “Safe Abortion Service and WHO Guidelines” in the book. I also sincerely acknowledge the valuable inputs and contributions of Dr Neena Raina, Senior Advisor, Maternal, Child and Adolescent Health and Aging and Dr Meera Thapa Upadhyay, Technical Officer, Reproductive Health, WHO-SEARO and technical experts from Sexual and Reproductive Health (SRH)/Prevention of Unsafe Abortion (PUA) unit at WHO, Geneva.

I sincerely acknowledge the help specially Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr MS Mani (Group President) and Dr Madhu Choudhary (Publishing Head–Education) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi for all round support as and when needed.

I thank, Md Jakir Hossain MSc, BEd, ADCA, Consultant Software for the technological support while composing the draft.

I am grateful to Dr Arindam Halder, Associate Professor, Dinajpur Medical College and Hospital, Dr (Mrs) Picklu Choudhury, Professor and Head, Department of Obstetrics and Gynecology, Rampurhat Medical College and Hospital, Dr Pallab Mistri, Associate Professor, Medical College, Kolkata, Prof Malabika Misra, JIMSH, Kolkata, Dr Chandrachur Konar, Assistant Professor SDUMC, Dr Roshini P, Senior Resident MVJ Medical College and Dr Lisley Konar, Resident, SDUMC for their tireless efforts to review the manuscripts.

I am ever grateful to Mrs Madhusri Konar for her sincere secretarial job and the all round support for this project.

At the end, I am grateful to all who have taught me most—all the patients and my beloved students.

I always welcome the views of the students, and the teachers through on line access to:

e-mail: h.kondr@gmail.com and websites: hirlalkonar.com and dcdutta.com

ABBREVIATIONS AACE:

American Association of Clinical Endocrinology

AC:

Abdominal Circumference

ACA:

Anticardiolipin Antibodies

ACE:

Angiotensin Converting Enzyme

ACHOIS:

Australian Carbohydrate Intolerance Study

ACOG:

American College of Obstetricians and Gynecologists

ACS:

Acute Chest Syndrome

ACTH:

Adrenocorticotropic Hormone

ADA:

American Diabetes Association

AEDF:

Absent End-diastolic Flow

AEDs:

Antiepileptic Drugs

AFASS:

Affordable, Feasible, Accessible, Sustainable and Safe

AFC:

Antral Follicle Count

AFE:

Amniotic Fluid Embolism

AFP:

Alpha-fetoprotein

AFS:

American Fertility Society

AI:

Aromatase Inhibitors

AIDS:

Acquired Immune Deficiency Syndrome

ALT:

Alanine Transaminase

AMH:

Anti-Müllerian Hormone

APA:

Antiphospholipid Antibody

APAS:

Antiphospholipid Antibody Syndrome

API:

Association of Physicians of India

APS:

Antiphospholipid Syndrome

ARDS:

Acute Respiratory Distress Syndrome

ARM:

Artificial Rupture of the Membranes

ART:

Assisted Reproductive Technology

ASB:

Asymptomatic Bacteriuria

ASRM:

American Society for Reproductive Medicine

AST:

Aspartate Transaminase

ASTEC:

A Study in the Treatment of Endometrial Cancer

ATA:

American Thyroid Association

AUB:

Abnormal Uterine Bleeding

BBT:

Basal Body Temperature

BC:

Blood culture

BMD:

Bone Mineral Density

BMI:

Body Mass Index

BP:

Blood Pressure

BRCA:

BReast CAncer gene

BSO:

Bilateral Salpingo-oophorectomy

BTB:

Breakthrough Bleeding

CAH:

Congenital Adrenal Hyperplasia

C and S:

Culture and Sensitivity

CBAVD:

Congenital Bilateral Absence of Vas Deferens

CBC:

Complete Blood Count

CC:

Clomiphene Citrate

CCCT:

Clomiphene Citrate Challenge Test

CCU:

Clean Catch Urine

CDC:

Centers for Disease Control and Prevention

CDMR:

Cesarean Delivery on Maternal Request

CECT:

Contrast-enhanced Computed Tomography

CEE:

Conjugated Equine Estrogens

CEMACH:

Confidential Enquiry into Maternal and Child Health

cff-DNA:

Cell-free Fetal DNA

CFTR:

Cystic Fibrosis Transmembrane Regulator

CFU:

Colony-forming Unit

CGH:

Comparative Genomic Hybridization

CIN:

Cervical Intraepithelial Neoplasia

CIS:

Carcinoma in situ

CMV:

Cytomegalovirus

CNS:

Central Nervous System

CO:

Combined Obesity

COCs:

Combine Oral Contraceptives

COS:

Controlled Ovarian Stimulation

COX:

Cycloxygenase

CPD:

Cephalopelvic Disproportion

CPP:

Chronic Pelvic Pain

CPR:

Cardiopulmonary Resuscitation

CPR:

Cumulative Pregnancy Rate

CPT:

Complete Perineal Tear

CREST:

Calcinosis, Raynaud Phenomenon, Esophageal Dysmotility, Sclerodactyly, and Telangiectasia

CRH:

Corticotropin-releasing Hormone

CRS:

Congenital Rubella Syndrome

CS:

Cesarean Section

CSF:

Cerebrospinal Fluid

CSP:

Cesarean Scar Pregnancy

CT:

Computed Tomography

CTG:

Cardiotocography

CTPA:

Computed Tomographic Pulmonary Angiography

CVD:

Cardiovascular Disease

CVS:

Chorionic Villus Sampling

CZ:

Carbimazole

D and C:

Dilatation and Curettage

DF:

Dominant Follicle

DHEA:

Dehydroepiandrosterone

DHEAS:

Dehydroepiandosterone Sulphate

DIC:

Disseminated Intravascular Coagulation

DMPA:

Depot Medroxyprogesterone Acetate

DPG:

Diphosphoglycerate

DTIC:

Distal Tubal Intraepithelial Carcinoma

DVT:

Deep Vein Thrombosis

E2:

Estradiol

EC:

Endometrial Curettage

ECG:

Electrocardiogram

EGF:

Epidermal Growth Factor

EOCs:

Epithelial Ovarian Cancers

EPAU:

Early Pregnancy Assessment Unit

ESBL:

Extended-spectrum beta-lactamase

ESHRE:

European Society of Human Reproduction and Embryology

FBC:

Full Blood Count

FDP:

Fibrinogen Degradation Products

FET:

Frozen Embryo Transfer

FFP:

Fresh Frozen Plasma

FIGO:

International Federation of Gynaecology and Obstetrics

FISH:

Fluorescence in situ Hybridization

FL:

Femur Length

FOGSI:

Federation of Obstetricians and Gynecologists of India

FSH:

Follicle Stimulating Hormone

FVS:

Fetal Varicella Syndrome

G-6PD:

Glucose-6-phosphate dehydrogenase

GAS:

Group A Streptococcus (Streptococcus pyogenes)

GBS:

Group B Streptococci

GBS:

Group B Streptococcus (Streptococcus agalactiae)

GC:

Gonococcus (Neisseria gonorrhoeae)

GDM:

Gestational Diabetes Mellitus

GIFT:

Gamete Intrafallopian Transfer

GIT:

Gastrointestinal Tract

GnRH:

Gonadotropin Releasing Hormone

GO:

Generalized Obesity

GSI:

Genuine Stress Incontinence

GTD:

Gestational Trophoblastic Disease

GTN:

Gestational Trophoblastic Neoplasia

HAART:

Highly Active Antiretroviral Therapy

HAIR-AN:

Hyperandrogenism, Insulin Resistance and Acanthosis Nigricans

HAPO:

Hyperglycemia and Adverse Pregnancy Outcome

HAV:

Hepatitis A Virus

HbF:

Fetal Hemoglobin

HBV:

Hepatitis B Virus

HC:

Head Circumference

hCG:

Human Chorionic Gonadotropin

HCV:

Hepatitis C Virus

HDFN:

Hemolytic Disease of the Fetus and Newborn

HDL:

High Density Lipoprotein

HDR:

High Dose Radiation

HDU:

High Dependency Unit

HFEA:

Human Fertilization and Embryology Authority

hGH:

Human Growth Hormone

HGSOC:

High-grade Serous Ovarian Cancer

HIFU:

High Intensity Focused Ultrasound

HIV:

Human Immunodeficiency Virus

HLA:

Human Leukocyte Antigen

HMB:

Heavy Menstrual Bleeding

HMG:

Human Menopausal Gonadotropin

HPL:

Human Placental Lactogen

HPV:

Human Papilloma Virus

HRT:

Hormone Replacement Therapy

HVS:

High Vaginal Swab

HWY:

Hundred Woman Years (Pregnancy)

IAI:

Intra-amniotic infection (Chorioamnionitis)

IAP:

Intrapartum Antibiotic Prophylaxis

ICD:

International Statistical Classification of Disease

ICSI:

Intracytoplasmic Sperm Injection

ICU:

Intensive Care Unit

IDDM:

Insulin-dependent Diabetes Mellitus

IFA:

Immunofluorescence Assay

IGF:

Insulin-like Growth Factor

IOTA:

International Ovarian Tumor Analysis

IPV:

Inactivated Polio Vaccine

ISMINIM:

International Society for Minimally Invasive and Noninvasive Medicine

ITP:

Idiopathic Thrombocytopenic Purpura

ITS:

Indian Thyroid Society

ITU:

Intensive Therapy Unit

IUCD:

Intrauterine Contraceptive Device

IUD:

Intrauterine Device

IUI:

Intrauterine Insemination

IVC:

Inferior Vena Cava

IVF-ET:

In vitro Fertilization and Embryo Transfer

IVH:

Intraventricular Hemorrhage

IVIG:

Intravenous Immunoglobulin

LAC:

Lupus Anticoagulant

LARC:

Long-acting reversible contraceptives

LARVT:

Laparoscopic Assisted Radical Vaginal Trachelectomy

LAVH:

Laparoscopic Assisted Vaginal Hysterectomy

LBC:

Liquid-based Cytology

LDH:

Lactate Dehydrogenase

LDL:

Low Density Lipoprotein

LE:

Leucocyte Esterase

LFT:

Liver Function Test

LGSOC:

Low-grade Serous Ovarian Cancer

LH:

Luteinizing Hormone

LLETZ:

Large Loop Excision of the Transformation Zone

LMP:

Last Menstrual Period

LMWH:

Low Molecular Weight Heparin

LNG-IUD:

Levonorgestrel-intrauterine Device

LNG-IUS:

Levonorgestrel-intrauterine System

LOD:

Laparoscopic Ovarian Drilling

LOS:

Laparoscopic Ovarian Surgery

LPD:

Luteal Phase Defect

LSCS:

Lower Segment Cesarean Section

LUF:

Luteinized Unruptured Follicle

LVS:

Low Vaginal Swab

LVSI:

Lymphovascular Space Involvement

MAHA:

Microangiopathic Hemolytic Anemia

MAP:

Mean Arterial Pressure

MC:

Monochorionic

MCA:

Middle Cerebral Artery

MCA-PSV:

Middle Cerebral Artery Peak Systolic Velocity

MCDA:

Monochorionic Diamniotic

MCTP:

Monochorionic Twin Pregnancy

MDTA:

Multidisciplinary Team Approach

MEA:

Microwave Endometrial Ablation

MESA:

Microsurgical Epididymal Sperm Aspiration

MFR:

Monthly Fecundity Rate

MgSO4:

Magnesium Sulfate

MHV:

Mechanical Heart Valves

MMK:

Marshall-Marchetti-Krantz

MMR:

Maternal Mortality Rate

MNM:

Maternal Near Miss

MOM:

Multiple of the Median

MPGS:

Massively Parallel Genomic Sequencing

MRg FUS:

MR-guided Focused Ultrasound

MRI:

Magnetic Resonance Imaging

MRSA:

Meticillin-resistant Staphylococcus aureus

MSAFP:

Maternal Serum Alpha-fetoprotein

MSU:

Midstream urine

MTCT:

Mother-to-child Transmission

MTHFR:

Methylenetetrahydrofolate Reductase

MTP:

Medical Termination of Pregnancy

MTX:

Methotrexate

MVA:

Manual Vacuum Aspiration

Nitrites

NICE:

National Institute for Health and Clinical Excellence

NICHD:

National Institute of Child Health and Human Development

NIPT:

Noninvasive Prenatal Testing

NSAIDs:

Nonsteroidal Antiinflammatory Drugs

NTD:

Neural Tube Defects

OAB:

Overactive Bladder

OAT:

Oligoasthenoteratozoospermia

OGTT:

Oral Glucose Tolerance Test

OHSS:

Ovarian Hyperstimulation Syndrome

OP:

Occiput Posterior

OSCE:

Objective Structured Clinical Examination

OTA:

Oligoasthenoteratozoospermia

P-PROM:

Pre-term Premature Rupture of Membranes

PAPP-A:

Pregnancy Associated Plasma Protein-A

PCOS:

Polycystic Ovarian Syndrome

PCR:

Polymerase Chain Reaction

PDA:

Patent Ductus Arteriosus

PE:

Pulmonary Embolism

PESA:

Percutaneous Epididymal Sperm Aspiration

PET:

Positron Emission Tomography

PGD:

Prenatal Genetic Diagnosis

PID:

Pelvic Inflammatory Disease

PMB:

Postmenopausal Bleeding

PMS:

Premenstrual Syndrome

PO:

Post Operative

POC:

Product of Conception

POD:

Pouch of Douglas

POF:

Premature Ovarian Failure

POP:

Pelvic Organ Prolapse

POP:

Progestin only Pill

PORTEC:

Postoperative Radiation Therapy in Endometrial Cancer

PPA:

Primary Peritoneal Adenocarcinoma

PPIUCD:

Postpartum Intrauterine Contraceptive Devices

PR:

Pulse Rate

PRBCs:

Packed Red Blood Cells

PSOC:

Papillary Serous Ovarian Cancer

PSP1:

Pregnancy Specific Protein 1

PSTT:

Placental Site Trophoblastic Tumor

PT:

Prothrombin Time

PTD:

Postpartum Thyroid Dysfunction

PTT:

Partial Thromboplastin Time

PUL:

Pregnancy of Unknown Location

PVD:

Peripheral Vascular Disease

RALH:

Robotic Assisted Laparoscopic Hysterectomy

RCOG:

Royal College of Obstetrics and Gynecology

RCTs:

Randomized Controlled Trials

RMI:

Risk of Malignancy Index

ROMA:

Risk of Ovarian Malignancy Algorithm

RPL:

Recurrent Pregnancy Loss

RVT:

Radical Vaginal Trachelectomy

SAMM:

Severe Acute Maternal Morbidity

SCCA:

Squamus Cell Carcinoma Antigen

SCJ:

Squamocolumnar Junction

SGA:

Small for Gestational Age

SHBG:

Sex Hormone Binding Globulin

SIL:

Squamous Intraepithelial Lesion

SIS:

Saline Infusion Sonography

SLE:

Systemic Lupus Erythematosus

SOFA:

Sequential Organ Failure Assessment

SSI:

Surgical Site Infection

STIC:

Serous Tubal Intraepithelial Carcinoma

STIs:

Sexually Transmitted Infections

SUI:

Stress Urinary Incontinence

SUZI:

Subzonal Insemination

TAH:

Total Abdominal Hysterectomy

TBEA:

Thermal Balloon Endometrial Ablation

TCRE:

Transcervical Resection of Endometrium

TEC:

Thromboembolic Complications

TESE:

Testicular Sperm Aspiration

TIC:

Tubal Intraepithelial Carcinoma

TLH:

Total Laparoscopic Hysterectomy

TNFs:

Tumor Necrosis Factors

TOT:

Transobturator Tape

TPO:

Thyroid Peroxidase

TPOAbs:

Thyroid Anti-TPO Antibodies

TRAP:

Twin Reverse Arterial Perfusion

TRH:

Thyrotropin Releasing Hormone

TSHRAbs:

Thyrotropin Receptor Autoantibodies

TV:

Trichomonas Vaginalis

TVS:

Transvaginal Sonography

TVT:

Tension-free Vaginal Tape

TZ:

Transformation Zone

UAE:

Uterine Artery Embolization

UE3:

Unconjugated Estriol

UFH:

Unfractionated Heparin

UI:

Urinary Incontinence

USG:

Ultrasonography

UTI:

Urinary Tract Infection

VaIN:

Vaginal Intraepithelial Neoplasia

VAMA:

Very Advanced Maternal Age

VCB:

Vaginal Cuff Brachytherapy

VEGF:

Vascular Endothelial Growth Factor

VIA:

Visual Inspection using Acetic Acid

VKA:

Vitamin K Antagonist

VTE:

Venous Thromboembolism

VVF:

Vesicovaginal Fistula

WHO:

World Health Organization

WLTC:

Women with Life-threatening Condition

Chapter Notes