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ABSTRACTSVOLUME 68NUMBER 5SEPTEMBER - OCTOBER 2018

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EDITORIAL

Scientific Misconduct

Suvarna Satish Khadilkar

Abstract

In today’s world, evil appears to be all pervading. Medical publication is no exception. Scientific misconduct in medical writing is slowly becoming a global concern, especially over the last few decades. While the occurrence of such events is certainly rare, every researcher and reader should be aware of this entity. The researcher should ensure that no inadvertent error is construed as misconduct, and should take every effort to guard against it, and the reader should have a critical eye for the same. This article looks into various aspects of scientific misconduct and encourages awareness regarding the same.

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SYSTEMATIC REVIEW / META ANALYSIS

Effect of Orlistat Versus Metformin in Various Aspects of Polycystic Ovarian Syndrome: A systematic Review of Randomized Control Trials

Soumya Ranjan Panda • Madhu Jain • Shuchi Jain• Riden Saxena • Smrutismita Hota •

Abstract

Background Polycystic ovarian syndrome (PCOS), a commonly prevalent endocrinopathy among reproductive age group women, is most often associated with obesity. Increased insulin resistance appears to be the central pathophysiologic mechanism responsible for various complications of PCOS. This makes ‘weight loss’ as the first-line treatment approach in PCOS. So various trials have tried to compare metformin (an insulin-sensitizing agent) and orlistat (an anti-obesity drug) aiming to achieve weight loss and hence higher ovulation rate for the group of obese PCOS patients. Keeping an eye on all these background facts, we designed this systematic review and metaanalysis to compare the effects of metformin andorlistat on various aspects of PCOS and to pick the better among the two drugs.

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INVITED MINI REVIEW ARTICLE

Difficult Deliveries in Caesarean Section

Dr. Sujata Dalvi •

Abstract

Cesarean section rate has been on the rise. It is commonly perceived as a simple and safe alternative to difficult vaginal birth. However, there are situations during C section where delivery of fetus may be difficult. This can cause maternal and fetal complications. To avoid such mishaps, anticipation of potential difficulties and planning in advance can be fruitful. This amounts to mobilization of a good team of anesthetist, assistant and skilled neonatologist. Proper technical skills are needed not only to use the equipment but to deal with such situations for safe delivery of the fetus. The training in technical skills can be imparted through drill protocols under C section skills. This way, one should try and accomplish safe atraumatic fetal delivery.

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ORIGINAL ARTICLES


OBSTETRICS

Role of Ultrasonographic Placental Thickness in Prediction of Fetal Outcome: A Prospective Indian Study

Kashika Nagpal • Pratima Mittal • Shabnam Bhandari Grover •

Abstract

Background Information Placenta is the connecting organ between the mother and the fetus. It supplies oxygen and all the necessary elements for the growth and development of the fetus. In normal pregnancy, the growth of the placenta remains concordant with the growth of the fetus. The sonographic assessment of placenta can give information about the nutritional status of the fetus. It is known that normal placental thickness approximately equals gestational age. It is historically documented that placental weight is one-fifth of the fetal weight and abnormally thin or thick placenta is associated with increased incidence of perinatal morbidity and mortality. However, there are very few studies correlating placental thickness with Neonatal outcome.Objectives To correlate ultrasonographic placental thickness at 32 and 36 weeks pregnancy with neonatal outcome. To propose placental thickness as a simple test for prediction of neonatal outcome.Methods Placental thickness at 32 and 36 weeks was measured by ultrasound, in 130 pregnant mothers with confirmed dates and uncomplicated singleton pregnancy. Placental thickness was categorized as normal (10th–95th percentile), thin (\10th percentile) and thick ([95th percentile) at each stage and was correlated with birth weight and neonatal outcome.Results Neonatal outcome was good in women with normal placental thickness (10th–95th percentile) at 32 and 36 weeks and was compromised in women with thin (\10th percentile) and thick ([95th percentile) placentae.Conclusion Placental thickness at 32 and 36 weeks corresponds well with gestational age and is a good prognostic factor in assessing neonatal outcome. Therefore, placental thickness should be measured in addition to biometric parameters in antenatal women undergoing ultrasoundKeywordsPlacental thickness on ultrasound Birth weight Neonatal outcome Thick and thin placentae.

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Efficacy of Antiviral Therapy in HBsAg-Positive Pregnant Women to Reduce Mother-to-Infant Transmission of Hepatitis B Virus

Jyoti Ramesh Chandran• Sajala Vimal Raj • Monica Saraswat

Abstract

Background :Higher-order multiple (HOM) pregnancies are associated with increased incidences of pregnancy complications mainly abortions, pre-eclampsia, preterm delivery and fetal death. Multifetal reduction (MFR) during first trimester and subsequent delivery of twins can reduce pregnancy associated morbidities. This study was conducted to evaluate the maternal and fetal outcomes of MFR procedure in patients with HOMs those managed in a tertiary care hospital.

Methods and Material : It was a prospective observational study carried out in a tertiary care military hospital, India, and all women with higher-order multiples (triplets or more) conceived spontaneously or after infertility treatment (ovulation induction, intra-uterine insemination, or in vitro fertilization) during the 3-year period from Jan 2014 to Dec 2016 were included for MFR. Demographic and clinical data, and obstetric and neonatal outcomes were tabulated.

Results: TThe study included 32 HOM pregnancies which underwent MFR. 16% patients had pre-eclampsia and 12% patients had gestational diabetes. The study had 2 pregnancy losses before 24 weeks period of gestation (POG). 70% patients underwent cesarean delivery with mean gestational age of 35.5 weeks. Average birth weight of newborn was 1820 gm and 80% of them required NICU admission. Conclusion Favorable pregnancy outcomes can be achieved after multifetal reductions during first trimester in higher-order multiples, but the procedure is not totally safe.

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New Evidence to Support Antibiotic Prophylaxis in Meconium- Stained Amniotic Fluid in Low-Risk Women in Labor a Prospective Cohort Study

Kavitha Abraham• Elsy Thomas• Jessie Lionel •

Abstract

Background: Purpose of study To assess the maternal and perinatal complications associated with meconium-stained amniotic fluid (MSAF) in low-risk women in labor. Methods This prospective cohort study was conducted at CMC Hospital, Vellore, India. Two hundred low-risk women who had artificial or spontaneous rupture of membranes after admission with MSAF were included in MSAF in labor established in our study strongly supports the use of prophylactic antibiotics in these women to prevent immediate and long-term consequences.

Keywords Meconium-stained liquor Chorioamnionitis Endomyometritis Respiratory distress syndrome Meconium aspiration syndrome Neonatal sepsis

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Prenatal Diagnosis of Choroid Plexus Cyst: What Next?

Nupur Shah •

Abstract

Introduction and Objective Fetal choroid plexus cysts (CPC) are often detected on prenatal ultrasounds and pose a need to formulate protocol for management and counseling.

MethodologyA total of 1024 unselected cases between gestational ages 11 and 20 weeks were sonologically screened for CPC in 1-year period. On ultrasound, CPC are seen as sonolucent spaces in the echogenic choroid plexus of lateral ventricles of brain measuring at least 2–3 mm in diameter. Those diagnosed with CPC were subjected to thorough anomaly scan. Prenatal karyotype was offered in cases of associated anomalies. Results The incidence of CPC is 1% (10/1024) in this study. Associated anomalies were found in 20% (2/10) of cases, which were offered invasive testing for fetal karyotype. All the cases with isolated CPC had good outcome. Conclusions Isolated CPC with low-risk biochemical screening for aneuploidies are now considered normal variants rather than a pathology, need no invasive testing and carry a good prognosis. CPC associated with other anomalies warrant invasive testing and are more likely to be associated with Trisomy 18.

Keywords Choroid plexus cyst Prenatal Fetal Trisomy 18.

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Umbilical Coiling Index Assessment During Routine Fetal Anatomic Survey: A Screening Tool for Fetuses at Risk

Hiralal Konar • Richa Sharma• Gita Radhakrishnan• Smita Manchanda• Shilpa Singh

Abstract

BackgroundThe umbilical cord is the lifeline of the foetus as it supplies water, nutrients, and oxygen. Protection of these blood vessels is needed and provided by Wharton’s Jelly, amniotic fluid and the helical pattern, or coiling, of the umbilical cord vessels.Aim To establish the relationship between antenatal umbilical cord coiling index (aUCI) measured at 18–20 weeks along with level II USG and adverse perinatal outcomes.

Methods:A cross-sectional study was conducted on 408 antenatal women, enrolled at the time of fetal anatomic survey, and their cord coiling index (aUCI) was measured, and its association with perinatal outcomes was observed. Umbilical coiling index was classified as Hypocoiled if UCI \10th percentile, hypercoiled [90th percentile, normocoiled between 10th and 90th percentile.

Results:408 antenatal women were enrolled for the study. Mean aUCI was 0.43 ± 0.30 (normocoiled group),0.18 ± 0.4 (hypocoiled), and 0.53 ± 0.05 (hypercoiled group). The average gestational age at delivery in hypocoiled group was 36.8 ± 2.34 weeks, and it was shorter than 38.3 ± 1.82 weeks of the normocoiled group and 38.9 ± 1.72 weeks of the hypercoiled group. Mean birth weight observed was 2055 ± 744 (hypocoiled group), 3049 ± 564 (hypercoiled), and 3102 ± 564 (normocoiled) p\0.001. Preterm births 52 (59%) and low birth weight 76 (69%) were significantly associated with hypocoiling. Conclusion Abnormal umbilical cord coiling index, detected at the fetal ultrasound anatomic survey in the second trimester (18–20 weeks), can be used potentially as a screening or as a predictive tool for adverse antenatal or perinatal events.

Keyword Hypocoiled Hypercoiled Normocoiled Perinatal outcome.

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Comparison of Efficacy and Safety of Intravenous Labetalol Versus Hydralazine for Management of Severe Hypertension in Pregnancy

Purvi Patel• Deepika Koli• Nandita Maitra• Tosha Sheth• Palak Vaishnav •

Abstract

BackgroundThere is no consensus about the better intravenous drug between Hydralazine and Labetalol to control hypertension in cases of severe hypertension in pregnancy. Both drugs have their own advantages and disadvantages. Methods This is a prospective randomized controlled trial comparing the efficacy and safety of intravenous Labetalol versus Hydralazine for management of severe hypertension in pregnancy. A total of 152 eligible subjects were randomised in two groups consisting 76 subjects each by envelope method. Both the groups were comparable with respect to systolic, diastolic and mean arterial blood pressure at admission. One group received Labetalol and the other Hydralazine. The number of drug doses, the time taken to achieve target blood pressure and side-effects were noted.

Methods:With a single dose, Labetalol (81.5%) was able to achieve target blood pressure in a significantly higher number of cases as compared to Hydralazine (69.5%). Labetalol could help in achieving the target blood pressure faster than Hydralazine. The incidence of maternal adverse effects was comparable between the groups. Fetal outcome was comparable in both groups.

Conclusion:Hydralazine and Labetalol both were found to be equally efficacious in reducing blood pressure in cases of severe hypertension in pregnancy. Labetalol achieved the target blood pressure faster than Hydralazine. The adverse effects of both the drugs were comparable.

Keywords: Severe hypertension in pregnancy Hydralazine Labetalol.

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Role of Aspirin in High Pulsatility Index of Uterine Artery: A Consort Study

Nidhi Sharma• Sunayana Srinivasan• K. Jayashree Srinivasan• Kulasekaran Nadhamuni •

Abstract

Background:Preeclampsia is a heterogeneous disorder prevalent in 3–10% of pregnant women globally. The etiology is multifactorial. There is a initial stage of endothelial dysfunction and placental ischemia (Stage 1); this leads to maternal syndrome of hypertension, edema, and proteinuria (Stage 2). Drugs acting on immunomodulatory, anti-inflammatory, antioxidant and proresolving pathways can minimize the complications of preeclampsia. The therapeutic effect of aspirin is based on acetyl group and salicylate group. Both components have independent therapeutic effects on anti-inflammatory pathway and proresolving pathway.

Aims and ObjectivesThis study was designed to assess the effectiveness and safety of aspirin in prevention and treatment of symptoms and complications of preeclampsia in women at high risk of preeclampsia.

Methods:This is a prospective experimental study to evaluate the effectiveness of aspirin versus placebo in the prevention of maternal syndrome of preeclampsia in women with high risk of preeclampsia (G1 = 97, G2 = 92). Patients with age C 34, chronic hypertension, multiple pregnancies, gestational diabetes, and high pulsatility index of uterine artery were enrolled between 12 and 20 weeks of gestation and prescribed 75 mg aspirin daily till 34 weeks of gestation. Control group was not prescribed aspirin.

Observations and ResultsThere was a reduction in relative risk of preeclampsia in aspirin group as compared with control group. There was no significant increase in the number of cases of abruption placenta, preterm delivery, neonatal intraventricular hemorrhage, patent ductus arteriosus, and postpartum hemorrhage following aspirin therapy. Conclusion In patients with high mean pulsatility index of uterine arteries, low dose aspirin can be a useful intervention. Uterine artery Doppler is a simple and noninvasive test which can be used safely for the prediction of preeclampsia. Aspirin is safe, economical, and easily available commercially.

Keywords Acetylsalicylic acid Preeclampsia Uterine artery Doppler Ultrasound

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Vitamin D Status in Mothers and Their Newborns and Its Association with Pregnancy Outcomes: Experience from a Tertiary Care Center in Northern India

Saloni Arora• Poonam Goel• Deepak Chawla• Anju Huria• Adhi Arya

Abstract

Objective:Study was planned to know vitamin D status in mothers and their newborns and effect of vitamin D deficiency on pregnancy outcome. Study design: Two hundred consecutive pregnant women with singleton pregnancy admitted to the labor ward of a tertiary care center were recruited for the study. Maternal and cord blood samples were taken and analyzed for 25(OH) D level. Maternal and fetal outcomes were studied.

Results:High prevalence of hypovitaminosis D was found among pregnant women. Eighty-six percentage had vitamin D deficiency, 9.5% had insufficiency, and only 4.5% had sufficient vitamin D level. Women with preeclampsia had statistically significant vitamin D deficiency and insufficiency as compared to patients who had normal blood pressure levels (p = 0.04). Cesarean section rate was significantly higher in patients with vitamin D deficiency and insufficiency compared to sufficient group (p = 0.004). Cord blood 25(OH) D levels strongly correlated with maternal serum 25 (OH) D levels (p = 0.001, correlation coefficient r = 0.84).

Conclusion:This study showed a very high prevalence of hypovitaminosis D among pregnant women and excellent correlation between maternal and fetal 25(OH) D levels. Hypovitaminosis D was associated with preeclampsia, increased Cesarean rate, and low birth weight babies.

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Outcome of Pregnancy with Hemoglobinopathy in a Tertiary Care Center

Anahita Chauhan• Madhva Prasad •

Abstract

Purpose The objective was to observe the characteristics among pregnant patients with a diagnosed hemoglobinopathy and to study the obstetric and medical morbidity patterns during the antenatal and the perinatal periods in this group of patients.

Methods:A prospective observational study was conducted in a tertiary care center.

Results:Sixty patients were studied in 11 months. Primigravidae (43.3%) formed the highest percentage of patients. b Thalassemia trait was the most common hemoglobinopathy, seen in 81.66% of study subjects. The hemoglobin value ranged from 5.7 to 13.0, with an average of 9.2 g/dl. Thyroid problems were the most common associated medical disorder. Though IUGR and placenta previa were common, there were no major obstetric problems. There were 57 live births and 1 fresh stillbirth. Two patients had spontaneous abortion for which uterine curettage was done. LSCS was the most common obstetric outcome. Patients with sickle-cell disease required more blood transfusion than those with beta-thalassemia trait. There were 2 maternal mortalities, and both the patients were the diagnosed cases of sickle-cell disease.

Conclusion:While the perinatal outcomes among women with sickle-cell disease are poor, the outcomes in pregnant patients with beta-thalassemia trait were not a cause of major concern.

Keywaords:Hemoglobinopathy Beta-thalassemia Pregnancy outcomes Perinatal outcomes

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How Adequate are Macro- and Micronutrient Intake in Pregnant Women with Diabetes Mellitus? A Study from South India

Mini Joseph• Riddhi Das Gupta• Sahana Shetty• Roshna Ramachandran• Geethu Antony• Jiji Mathews• Santhosh Benjamin• Shajith Anoop• Jansi Vimala Rani• Nihal Thomas

Abstract

Background Diabetes is the most common condition in pregnancy with a worldwide prevalence of 16.9%. Aim To determine the adequacy of the nutrient intake of pregnant women with diabetes mellitus. Methods This is a cross-sectional study of 85 pregnant women who met the diagnostic inclusion criteria for diabetes mellitus (gestational and pre-gestational diabetes mellitus) and who were being managed at the outpatient clinic of a tertiary care teaching hospital. Their demography, clinical characteristics (from updated medical records), anthropometric measures (using standard procedures), nutrient intake and meal pattern (obtained using 24 h recall, food frequency and their log diaries) were collected.

Results:The mean age of the group was 29.9 ? 4.5 years, 54% were in the second trimester of pregnancy with a mean glycosylated haemoglobin level of 6.3 ? 1.4%. The mean BMI indicated that 47% of them were in the obese grade 1 category. Insulin was used in one-third of the population. The overall macronutrient and micronutrient intakes of the population were below the recommended daily allowances for Indians (60–70% of RDA). There was a deficit in the intake of calories, fibre, proteins, iron, calcium, carotene, folic acid, thiamine, riboflavin and niacin. Between the two groups, the pre-GDM women had a significantly better nutrient intake and this could be attributed to a greater exposure to nutrition counselling that they have received during the earlier part of their diabetes care.

Conclusion:The gestational period should be viewed as a window of opportunity to modify dietary patterns and introduce healthy lifestyle practices for the woman and her family

Keywaords:Nutrition Gestational diabetes Dietary pattern Macronutrients Micronutrients

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Sequential Versus Concurrent Use of Vaginal Misoprostol Plus Foley Catheter for Induction of Labor: A Randomized Clinical Trial

Ibrahim Abd Elgafor El Sharkwy• Elsayed Hamdy Noureldin• Ekramy Abd Elmoneim Mohamed• Sherine Attia Shazly

Abstract

Background To compare between the sequential and concurrent use of vaginal misoprostol plus Foley catheter for labor induction.

Methods:This single-center, non-blinded randomized study was conducted at the department of Obstetrics and Gynecology, Faculty of medicine, Zagazig University. A total of 160 women with full term singleton pregnancy, cephalic presentation and bishop score B 6 were randomized for labor induction with either concurrent or sequential use of vaginal misoprostol plus Foley catheter (80 cases in each group). The primary outcome measured was inductionto-delivery interval and secondary outcomes mesaured were vaginal delivery within 24 h, number of doses needed to induce labor, need of oxytocin for augmentation of labor, cesarean section rate, maternal or neonatal complications. Results The mean induction-to-delivery interval was 22.33 ± 13.28 h versus 18.45 ± 14.34 h (p = 0.041) in sequential and concurrent group, respectively. The percentage of women who completed vaginal delivery within 24 h was 51% versus 61% (p = 0.046) in sequential and concurrent group, respectively. Other maternal and neonatal outcomes were similar in both groups.

Conclusion:Concurrent use of vaginal misoprostol plus Foley catheter for labor induction was associated with shorter induction-to delivery interval compared to sequential use, and it increases the rate of vaginal delivery in the first 24 h.

Keywaords:Concurrent Foley catheter Induction Labor Misoprostol Sequential Vaginal

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CASE REPORT


OBSTETRIC

A Case of Recurrent First Trimester Miscarriages Due to Inherited Multifactorial Thrombophilia in an Otherwise Asymptomatic Patient: A Clinical Dilemma

Purnima Gupta• Madhavi M. Gupta

Introduction

Thrombophilias are haemostatic disorders and can be acquired, inherited or a combination of both. Inherited disorders include anti-thrombin III deficiency, protein S deficiency, protein C deficiency, factor V Leiden mutation, prothrombin gene G20210A mutation and methylenetetrahydrofolate reductase (MTHFR) mutation [1]. Protein S deficiency is a rare form of inherited thrombophilia, and its prevalence is only 0.2–0.3% in general population [1]. Its deficiency creates a hypercoagulable state and such condition predisposes a pregnant patient for risk of venous thromboembolism (VTE). The frequency of homozygous MTHFR mutation in the Asian women is 3.8% [2]. This mutation may also lead to a hypercoagulable state by increasing homocysteine levels in the blood. In the past, it was hypothesized that such inherited thrombophilias may lead to pregnancy loss by placental microthrombi and thrombosis. Due to lack of prospective data in untreated group, current guidelines do not recommend screening of patients with early pregnancy loss for inherited thrombophilias until they have any thrombotic complication in self or any family member in past or in present. Moreover, till date no studies have confirmed association of protein S deficiency with early pregnancy loss. Furthermore, there are only few case reports of multifactorial thrombophilia with recurrent first trimester miscarriages without any thrombotic complication in the patient or in any family member. We present such a rare case of concomitant protein S deficiency and MTHFR mutation, as a probable cause of recurrent first trimester pregnancy loss, without having any systemic thrombotic complication herself or in any family member, causing management dilemma.

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CASE REPORT


GYNECOLOGY

Nimotuzumab in the Management of Recurrent Endometrial Carcinoma: A Case Report

Shyamji Rawat •

Introduction

The majority of the cancers that affect the body of the uterus originate in the endometrial lining and are endometrial carcinomas. Globally, cancer of the body of the uterus is the sixth most common cancer among women, while in India, it is ranked as the tenth most common cancer accounting for 2.3% of all cancers among women and was responsible for an estimated 4773 cancer deaths (1.5% of total cancer deaths among women) [1].Survival is very poor with conventional treatment; especially in patients with advanced disease, targeted therapies have shown limited success in endometrial cancer patients. In this case report, we are sharing our experience with nimotuzumab, a novel monoclonal antibody, in the management of a recurrent case of endometrial carcinoma.

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PICTORIAL ESSAY

In-Bag Contained Power Morcellation Technique

Meenakshi Sundaram• Abdul Basith S. Fazal•

Abstract

Laparoscopic surgery has revolutionized gynecological surgery. No uterus or fibroid is too big that cannot be removed by laparoscopy. In addition to the benefits to the patients in terms of quick recovery and less pain, the new age surgeon finds laparoscopy better than open surgery as he is able to identify vital organs and structures better and with an increased magnification. All the new age tools with the varied energy sources have made laparoscopy the standard of care (Figs. 1, 2, 3, 4, 5).

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LETTER TO EDITOR

Intrapartum Hypomagnesemic Tetany: A Manifestation of an Ignored Element

Jainesh Doctor• Kunjal Bathija• Vibhor Pardasani

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