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ABSTRACTSVOLUME 69NUMBER 1January - February 2019


EDITORIAL

Post - reproductive Health : Window of Opportunity for Preventing Comorbidities

Suvarna Satish Khadilkar

Abstract

Post-reproductive health is a challenging issue as it is surrounded by many controversies. Menopausal hormone therapy (MHT) has witnessed a rise and fall over last several years. We do understand that comorbidities incidence rises beyond menopause and we need to prevent them. When MHT was used universally, the risk–benefit ratio became unfavorable. Hence, the use of MHT dropped drastically. But newer studies have introduced the concept of window of opportunity, wherein MHT does not have harmful effects, but in fact it will prevent comorbidities associated with menopause. This editorial focuses on the prevention of menopause- and MHT-related comorbidities.

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PRESIDENTIAL ADDRESS

Presidential Address

Nandita Palshetkar

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SYESTAMATIC REVIEW ARTICLE

Parenteral Versus Oral Iron for Treatment of Iron Deficiency Anaemia During Pregnancy and post-partum: A Systematic Review

Radhika A.G, Aparna Kandala Sharma, Vanamail Perumal, Anju Sinha, Vasumathi Sriganesh, Vidushi Kulshreshtha, Alka Kriplani

Abstract

Introduction : The burden of iron deficiency anaemia during pregnancy and post-partum continues to remain high especially in India. Challenges to treatment include gastrointestinal side effects and non compliance to oral iron therapy. Newer parenteral formulations need to be explored as alternatives.

Methods : Meta-analysis of randomized controlled trials published between years 2011 and 2018 comparing anaemic pregnant and post-partum women treated with intravenous iron sucrose versus oral iron was performed. The primary outcomes were mean maternal haemoglobin, serum ferritin and haematocrit at the end of 1st, 2nd, 4th and 6th weeks and comparison of adverse effects.

Results : Eighteen studies including 1633 antenatal women were randomly assigned to intravenous iron sucrose (n = 821) or oral iron [ferrous sulphate, ferrous ascorbate or fumarate] group (n = 812) in ten trials . Another eight studies compared iron sucrose infusion with oral iron in 713 post-partum women who were randomly assigned to intravenous iron sucrose group (n = 351) or oral iron group (n = 362). Cumulative analysis of all the time points indicates that the estimated mean values of Hb in the intravenous iron sucrose and oral iron groups were 10.11 g/dl and 9.33 g/dl, respectively, in antenatal group, while it was 10.57 g/dl and 9.74 g/dl in post-partum. The estimated mean ferritin level from first week to six weeks was 63.1 μg/l and 28.6 μg/l, respectively, in intravenous and oral iron groups. Cumulative estimate of haematocrit in the intravenous sucrose and oral iron over 6 weeks showed that the mean values in the respective groups were 30.5% and 29.5% in antenatal and 33.8% and 31.6%, respectively, in post-partum groups. Sensitivity analysis confirmed the reliability and consistency of the results. Oral iron was associated with significant gastrointestinal side effects. There was no significant difference in birthweight between the groups.

Conclusion : This meta-analysis demonstrates that intravenous iron sucrose is more effective than oral iron therapy for pregnant and post-partum women with iron deficiency anaemia. It is an effective and safe alternative to address the problem of iron deficiency especially in those who require rapid replacement of iron stores though medical personnel for intravenous administration of drug is required.

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ORIGINAL ARTICLES


OBSTETRICS

Neonatal Effects of Maternal Magnesium Sulphate in Late Preterm and Term Pregnancies

Prasad Madhva

Abstract

Aim
To compare the clinical, obstetric and neonatal parameters between patients with > 34-week gestation having severe preeclampsia receiving magnesium sulphate and those with > 34-week gestation with preeclampsia but not receiving magnesium sulphate.
Materials and Methods :
Single-centre prospective study studied 60 patients in each of the two groups. Magnesium sulphate was administered by Pritchard regimen as per standard protocol. Standard obstetric management was followed for both groups. In the severe preeclampsia/eclampsia group, maternal blood sample was analysed for serum magnesium levels. The duration of exposure, the amount of magnesium sulphate received and time elapsed between last dose of magnesium sulphate and delivery were all noted. Neonatal assessment was done. The various parameters including age, parity, blood pressure, mode of termination of pregnancy, NICU admission rate, incidence of hypotonia in the newborn and other neonatal parameters were tabulated and compared.
Results
The two groups were comparable with respect to age and parity. Need for induction of labour was higher in the group with severe preeclampsia/eclampsia. Rate of LSCS and birth weights were comparable between the two groups. NICU admission rate and incidence of hypotonia were higher in those who received magnesium sulphate. Amount of magnesium sulphate received and total duration of magnesium sulphate did not correlate with NICU admission rates.
Conclusions
Neonatal morbidity, in terms of higher NICU admission rates and hypotonia, is higher in patients receiving magnesium sulphate

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An Observational Study to Evaluate the Maternal and Foetal Outcomes in Pregnancies Complicated with Jaundice

Pradnya Changede • Niranjan Chavan • Neha Raj• Priyanka Gupta• A. Gupta•

Abstract

Background :Incidence of jaundice in pregnancy, including underlying chronic liver diseases, is 3–5%. However, the maternal mortality rate in some conditions can be as high as 18% in acute fatty liver of pregnancy and 22% in hepatitis E in pregnancy.

Objectives : This is an observational study of the demographics, obstetrical profile, aetiology, maternal morbidity, mortality and neonatal outcomes in pregnancies complicated with jaundice.

Materials and Methods : This is an observational study conducted in Department of Obstetrics and Gynaecology of a tertiary care hospital, situated amidst the biggest urban slum in Mumbai spanning over 1 year from January 2016 to December 2016. All registered, unregistered and transferred patients with abnormal liver function tests excluding patients with chronic liver diseases were included in this study.

Results : Most of the cases of jaundice in pregnancy were seen in primigravida (51%) and age group of 20–30 years (58%). Fifty-three percentage of cases were referred or transferred from periphery hospitals. Hepatitis E was the most common cause (42%) of jaundice in pregnancy. Complications like disseminated intravenous coagulopathy, postpartum haemorrhage, hepatic encephalopathy and hepatoportal hypertension were seen in 65% of cases. Maternal mortality rate and perinatal mortality rate were as high as 40 and 37%, respectively, in our study.

Conclusions: Incidence of jaundice in pregnancy, mainly due to viral hepatitis, is very high in lower socio-economic, densely populated urban slums. Special efforts should be made to counsel and educate the mothers about initial symptoms and preventive measures for viral hepatitis. Patients along with the relatives should be informed about the severe features of pre-eclampsia to combat these preventable causes of maternal mortality.

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Current Practices of Cervical Ripening and Induction of Labour in Intrauterine Foetal Demise: An Observational Study

Kinnari V. Amin• Anahita R. Chauhan• Anchal Goel• •

Abstract

Background:Objectives of the current study were to find the most effective method of induction of labour in case of intrauterine foetal death (IUFD), with efficacy described as least induction-to-delivery time, and the agent with the best safety profile, i.e. least maternal complications.

Methods: This was a prospective observational descriptive study carried out between January and November 2015 in a tertiary care centre. Hundred consecutive cases of IUFD after 20 weeks of gestation requiring induction of labour and fulfilling inclusion criteria were selected. The method of induction decided by each consultant was noted, and results were analysed. As this was a purely observational study, all agents used for induction of labour (misoprostol, dinoprostone gel, intracervical Foley catheter) and all dose variations

Results: The induction-to-delivery interval was shortest with dinoprostone (12.52 h) followed by Foley catheter (13.28 h) and misoprostol (15.82 h). However, the p value (0.301) was not statistically significant. Misoprostol was used more often in second trimester, while dinoprostone gel was most commonly used in third trimester. Failure occurred in 3 cases; all required lower segment caesarean section (LSCS). No significant complications were associated with any of the methods.

Conclusion Dinoprostone gel, misoprostol and Foley catheter are safe for induction of labour in all cases of IUFD, even for those with previous LSCS with IUFD

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The Impact of Incidental Ultrasound Finding of Subchorionic and Retroplacental Hematoma in Early Pregnancy

Ayser Hashem• Samar Dawood Sarsam •

Abstract

Background: Chorionic hematomas can be caused by the separation of the chorion from the endometrium, with an incidence of 3.1% of all pregnancies. It is the most common sonographic abnormality and the most common cause of first-trimester bleeding

Objectives: To evaluate the impact of subchorionic and retroplacental hematomas detected by ultrasound in the first trimester of pregnancy

Patients and Methods: A prospective observational case-control study was conducted at Elwiya Maternity Teaching Hospital on 100 pregnant ladies with subchorionic or retroplacental hematoma shown in ultrasound compared with 200 pregnant ladies without hematoma in the first trimester. The demographic feature, course of pregnancy, obstetric outcome, and neonatal outcome were analysed

Results: There was statistically significant difference between both groups regarding maternal and neonatal outcome. In regard to maternal outcome, there is increasing rate of miscarriage (20%, P = 0.004), preterm labor (18%, P = 0.005), intrauterine growth restriction (7%, P < 0.001), abruption (9%, P = 0.001), and cesarean section (60%, P < 0.001) compared to control group. Regarding neonatal outcome, there is increasing rate of low gestational age at birth (P = 0.004), low birth weight (P = 0.003), low Apgar score at 1 & 5 min (P < 0.001, P = 0.002, respectively), and more admission to NICU (P = 0.015) in study group when compared to control group

Conclusion: 1. The presence and the characteristic of an intrauterine hematoma during the first trimester may identify a population of patients at increased risk of adverse pregnancy outcome as miscarriage, preterm delivery, IUGR, abruption, low birth weight, cesarean section rate, low Apgar score at 1 and 5 min, and NICU admissions in patients with intrauterine hematoma
2. The miscarriage rate with retroplacental hematoma is significantly higher than with subchorionic hematoma. The size of the hematoma is significantly greater in the miscarriage group
3. All subchorionic hematomas disappeared, but 2% of retroplacental hematomas did not disappear until the end of second trimester

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A Call for Eminence Obstetrics Care by Way of “Neonatal Near Miss” Events (NNM): A Hospital-Based Case–Control Study

Bhavesh D. Shroff• Nittal H. Ninama •

Abstract

Background:A neonatal near miss (NNM) case would refer to an infant who nearly died but survived during birth or within 28 days of extra-uterine life. The near miss concept is being increasingly used as a tool to evaluate and improve the quality of care, especially obstetric care. All “near miss” should be inferred as free lesson and opportunities to improve the quality of service endowment.

Methods:A hospital based case control study was conducted in a tertiary care hospital of central Gujarat to measure factors associated with NNM events. Mothers of those new-borns, who had been admitted for critical care, and survived, were included as cases, after their discharge. Controls were selected from same settings who were not falling into defined criteria of NNM. Various antenatal factors were compared among the two groups.

Results:The number of neonatal near miss events were 291 (109 newborns with birth weight less than 1500 g, 169 APGAR score < 7 and 13 with gestational age < 30 weeks). The neonatal near miss rate was 86.7 per 1000 live births. Less number of antenatal visits, history of referral and hospitalisation during ante natal period were adversely associated with near miss events.

Conclusions:Incorporation of near miss events into the confidential enquiry system is worthwhile for corrective interventions like quality antenatal care, timely screening and referral of pregnant women into the primary health care system.

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Long-Term Outcome of Fetuses with Soft Marker and Without Genetic or Structural Abnormality

Migraci Tosun• Emel Kurtoglu Ozdes• Erdal Malatyalioglu• Erhan Yavuz• Handan Celik• Fatma Devran Bildircin• Kubilay Canga• Arif Kokcu• Gonul Ogur •

Abstract

Purpose : To determine long-term outcome of infants with isolated or multiple soft markers but no structural or chromosomal abnormalities.

Methods:A retrospective study of 78 pregnant women who were referred for amniocentesis and found to have soft markers including echogenic intracardiac focus/foci (EIF), echogenic bowel (EB), unilateral or bilateral choroid plexus cysts, (UCPCs or BCPCs) mild pyelectasis and single umbilical artery but no structural anomalies and outcomes of the liveborns with a 4- to 9-year follow-up was conducted.

Results:Among 28 fetuses with EIF, allergic asthma and epilepsy were diagnosed in two liveborns. We followed up nine pregnancies with EB, epilepsy was present in one case. Allergic asthma was detected in both UCPCs and BCPCs, whereas epilepsy and attention-deficit/hyperactivity disorder (ADHD) were diagnosed in two liveborns with BCPCs. Twelve liveborns with multiple soft markers were evaluated; no pathology was detected in most of them except one case of allergic asthma, one case of hearing impairment and one case of ADHD.

Conclusion:This study shows longer-term favorable outcomes of the liveborns with isolated or multiple soft markers without any aneuploidy and may provide insight into this debated point.

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An Evaluation of Applicability of Salivary Uric Acid Measurement in Preeclampsia and Normal Pregnancy and Its Correlation with Serum Uric Acid

Urmila Singh • Vandana Solanki • Seema Mehrotra • Ruchita Sharma •

Abstract

Purpose :Hypertensive disorders complicate 5–10% of all pregnancies and contribute greatly to maternal morbidity and mortality. There are various biomarkers for detection of preeclampsia. Several studies have reported that positive correlation exists between serum uric acid (UA) levels and adverse maternal and fetal outcome. Significant advances have been made toward validation of salivary biomarkers. We conducted this study to determine levels of salivary UA and its correlation with serum UA normal pregnancy and preeclampsia.

Methods :Present cross-sectional study was conducted in tertiary care teaching hospital in North India. One hundred and fifty participants were divided into control group (50 healthy non-pregnant females), study group I (50 normotensive pregnant females), study group II (50 pregnant females with preeclampsia), and both salivary and serum UA was estimated at the same time.

Results :Saliva UA of study group II (4.86 ± 2.37 mg/dl) was significantly higher (p < 0.001) than that of control group (2.09 ± 1.33 mg/dl) and study group I (3.32 ± 1.77 mg/dl). Serum UA of study group II (6.63 + 2.78 mg/dl) was significantly higher (p < 0.001) than that of control group (2.94 + 1.94 mg/dl) and also study group I (5.18 + 2.31 mg/dl) (p = 0.0006).

Conclusion :UA is present in the saliva of women with preeclampsia and has linear correlation with serum UA. Therefore, salivary UA can be used in place of invasive serum UA to monitor women with preeclampsia. Saliva collection is easy, non-invasive and cost-effective. Salivary UA testing may be useful for monitoring preeclampsia at home-based and hospital setting.

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GYNECOLOGY

Can LBC Completely Replace Conventional Pap Smear in Developing Countries

Vasundhara Kamineni • Priti Nair • Ashok Deshpande •

Abstract

Background : A number of screening techniques have been developed to reduce the incidence of cervical cancer, most common of which is conventional Pap smear (CPS) being overtaken by liquid-based cytology (LBC) in most of the developed countries. There are a number of studies with conflicting results, and no method has been shown superior in terms of all parameters. LBC was introduced in our hospital in 2014, and we planned to do a study and compare results of the two techniques. This study aims to compare the two methods in terms of sensitivity, specificity, positive predictive value and negative predictive value, turnover time, cost-effectiveness, sample adequacy. This study has been done in 100 women with unhealthy cervix to increase the output.

Method : This was a prospective observational study. A total of 100 women fulfilling the inclusion criteria were subjected to screening test. In first 50 cases, first conventional Pap smear was taken and then LBC, and in remaining 50 cases, first LBC and then conventional Pap smear were taken; this was done to remove bias.

Results : The number of unsatisfactory slides was reduced with LBC, and turnover time was less for LBC. The detection of ASCUS was increased with LBC, but the detection of higher-grade lesions (HSIL and SCC) was equal with both tests.

Conclusion : The superiority of LBC with respect to reduction in the number of unsatisfactory slides and less turnover time is being offset with increased detection of low-grade lesions subjecting women to further testing increasing the cost of programme and anxiety among women. It is difficult to say that it can completely replace conventional Pap smear in low-resource settings.

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Comparison of Metformin and N Acetylcysteine on Clinical, Metabolic Parameter and Hormonal Profile in Women with Polycystic Ovarian Syndrome

Nidhi Chandil• Shubha Pande• Shashwati Sarkar Sen• Durgesh Gupta •

Abstract

Objective : Comparison of metformin and N acetylcysteine on clinical, metabolic parameter and hormonal profile in women with polycystic ovarian syndrome.

Design : Prospective comparative study.

Setting : Obstetrics and Gynecology department in Kamala Nehru Memorial Hospital Allahabad.

Patient(s) : On the basis of inclusion and exclusion criteria, 100 patients of PCOS were selected for study and assigned randomly in two groups to receive either metformin (1500 mg/day) (group M) or N acetylcysteine (1800 mg/day) (group N) for 24 weeks.

Intervention(s) : Metabolic parameter and hormonal profile were determined before and after the treatment.

Main Outcome Measure(s) : Metabolic parameters, fasting glucose, fasting insulin and testosterone changes.

Result(s) : Forty-five patients of both groups were ultimately evaluated. There was a significant improvement of body mass index, waist circumference and waist–hip ratio in group N, but there was no significant difference found in weight reduction among two groups. The biochemical marker of insulin resistance like fasting insulin, fasting glucose/insulin ratio improved significantly in group N. Greater reduction of total testosterone was observed in group N.

Conclusion(S) : Better improvement of metabolic and hormonal profile was observed in N acetylcysteine group. Because of its less side effect comparing to metformin, NAC can be used as a substitute for insulin-sensitizing agent in treatment of PCOS.

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A Prospective Study of Minimally Invasive Paravaginal Repair of Cystocele and Associated Pelvic Floor Defects: Our Experience

Kavitha Yogini Duraisamy• Devi Balasubramaniam• Amrutha Kakollu• Palanivelu Chinnusamy• Kodeeswari Periyasamy •

Abstract

Aims and Objectives : To assess the outcome of minimally invasive paravaginal repair of symptomatic cystocele and to correlate postoperative outcome with preoperative presentation. The primary outcome was the anatomical outcome measured by postoperative physical examination and the functional outcome was assessed by subjective symptoms and questionnaires. The secondary outcomes were perioperative and postoperative complications.

Materials and Methods : In this longitudinal prospective observational study, 44 women underwent laparoscopic or robotic paravaginal cystocele repair from January 2016 to July 2016 and they were followed up to 1 year after surgery in a tertiary advanced laparoscopic center. All patients had a symptomatic lateral cystocele ≥ grade 2 according to Baden–Walker classification. Other coexisting defects like apical cystocele or combined defects were corrected concomitantly. The anatomical outcome was measured by physical examination and functional outcome was assessed by questionnaires—Pelvic Organ Prolapse Distress Inventory 6 and Urinary Distress Inventory 6 preoperatively and during postoperative follow-up.

Results : All 44 patients were followed up to 12 months after surgery. The anatomical cure rate for cystocele was 97.7%. There were no major complications. All subjective symptoms and quality of life scores improved significantly during postoperative follow-up. The anatomical recurrence rate in our study was 2.3%.

Conclusion : Minimally invasive paravaginal repair of cystocele is an effective advanced laparoscopic procedure. It can be concomitantly performed with other surgical procedures to correct coexisting defects. The anatomical and functional results were outstanding with minimum perioperative morbidity and encouraging long-term outcome.

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CASE REPORT


GYNECOLOGY


Gonadal Vein Graft for Maintaining Renal Circulation After a Complication During Para-Aortic Nodal Dissection

Pesona Grace Lucksom • Jaydip Bhaumik • Gautam Biswas • Sujoy Gupta • Basumita Chakraborti •

Abstract

A 39 year old female underwent staging laparotomy for carcinoma endometrium. During para aortic node dissection the left renal vein (LRV) was accidentally injured. The patency of the LRV after rent repair was not adequate for functioning of the left kidney. Nepherectomy was considered but plans for saving the kidney was discussed by the joint team of surgeons. The venous blood of the left kidney was diverted through an anastomosis of the left gonadal vein with the venacava. Patency of the anastomosis was checked and was found to be adequate for keeping the left kidney functional. Doppler of the renal veins done on post-operative day three was normal and she was fit for discharge on day four.

Conclusion: Gonadal veins can be used to replace renal vein in case of injury during para aortic node dissection, hence, it should be left long until the end of surgery.

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Benign Ovarian Edema Masquerading as Malignancy

Shalini Singh• Kameswari Surampudi• Meenakshi Swain •

Abstract

Solid ovarian masses in young age can pose significant diagnostic and therapeutic challenges to the clinician. A young 16 year old girl presented with irregular cycles, pain abdomen and reportedly bulky ovaries with calcifications. Examination was unremarkable. Ultrasound scan revealed bilateral complex ovarian masses suggestive of neoplasm. MRI confirmed a solid right ovarian mass with normal left ovary. Tumour markers were normal. Option of frozen section followed by complete surgery if malignant or two stage procedure including staging laparotomy and if necessary a second surgery were discussed. Parents opted for the latter. At midline laparotomy, free fluid from abdomen was sent for cytology. Right ovary was irregular and enlarged measuring 10 x 8 cm with unruptured white capsule and no torsion. Left ovary was normal. Right salpingo-oophorectomy with omental and peritoneal biopsies were performed. Cytology was benign and histopathology showed massive ovarian edema which was a surprise and relief. Massive ovarian edema is a unique condition with tumour like enlargement of the ovary mimicking neoplasm on imaging leading to overtreatment of patients. Knowledge of this condition allows for fertility sparing procedures.

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PICTORIAL ESSAY

Deep Infiltrating Ureteral Endometriosis with Hydroureteronephrosis : A Case Report

Meenakshi Sundaram• Rachita Munjal• Juhul Patel •

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LETTER TO EDITOR

Methylene Blue Use: Is It Safe?

Urvashi Miglani• Poonam Laul• Harsha Rajpal• V. K. Kadam• Gargi Chowdhary •

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