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ABSTRACTSVOLUME 68NUMBER 6NOVEMBER - DECEMBER 2018

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EDITORIAL

The Plague of Plagiarism: Prevention and Cure!!!

Suvarna Satish Khadilkar

Abstract

Plagiarism is a serious form of scientific misconduct. Literal meaning of the Latin word ―to Plagiare ‖ is ―to steal or to kidnap‖. The act of taking the writings of another person and passing them off as one’s own is plagiarism. It implies intellectual theft in the world of medical writing. The ―copy and paste‖ culture is becoming rampant all over the world after the advent of electronic publications, and Indian medical literature is no exception. This editorial will enlighten aspiring authors and readers about various forms of plagiarism and reasons for engaging in plagiarism. More so, it will also elaborate on how to prevent and cure this plague. Possible consequences that authors may face on detection of the plagiarism are also discussed. I am concluding my editorial series on medical writing with this last editorial of the year. I since rely hope that these editorials helped authors and readers and this journal continues to receive high - quality papers written with the greatest honesty and integrity.

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INVITED MINI REVIEW ARTICLE

Cesarean Myomectomy: Necessity or Opportunity?

Anahita Chauhan

Abstract

Fibroids in pregnancy are increasingly common, due to advanced maternal age, better diagnostic tools and use of assisted reproductive techniques. Cesarean section (CS) is the commonest mode of delivery in these patients. Cesarean myomectomy (CM) is the term used to describe the removal of fibroids at CS; it has always been a controversial topic, with two schools of thought. Some obstetricians advise against it due to the traditional fear of massive obstetric hemorrhage and its att endant complications. However, recent literature advocates elective or opportunistic myomectomy in well - selected cases during CS. This is especially valuable in low - resource settings where the patient may be spared a repeat surgery and problems of anesthes ia and cost associated with it. This review examines the recent published data on CM, its indications, technique, safety and applicability in modern obstetrics.

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ORIGINAL ARTICLES


OBSTETRICS

Prenatal Diagnosis of Single Umbilical Artery: Incidence, Counselling and Management in Indian Scenario

Nupur Shah

Abstract

Purpose
The objective of this study is to report the incidence of single umbilical artery (SUA) on prenatal diagnosis and formulate protocol for counselling and its management in Indian scenario.
Method
A total of 1024 cases were screened for Single umbilical artery (SUA) between 12 and 20 weeks gestation during the 1 year period from May 2016 to April 2017. Targeted anomaly scan was performed for all cases at 18 – 20 weeks. Those with addi tional structural anomalies were subjected to invasive genetic testing. Serial growth monitoring starting from 28 weeks was done.
Results
Out of ten cases diagnosed with SUA, five had isolated SUA. Two out of five cases of isolated SUA developed FGR in thi rd trimester. Out of the remaining, three cases with additional structural anomalies had normal foetal karyotype, whereas other two cases showed chromosomal abnormalities (12pder and trisomy 18). Conclusion Targeted anomaly scan is must in all cases of SUA. Invasive genetic testing must be offered in case of associated anomalies. Serial growth monitoring in third trimester is an important part of protocol.

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Pregnancy Check Point for Diagnosis of CKD in Developing Countries

A. Kaul• D. Bhaduaria• M. Pradhan • R. K. Sharma• N. Prasad• A. Gupta•

Abstract

Objective :Evidences suggest that females with CKD are associated with high risk of maternal and fetal complications. Early referral in CKD with pregnancy for specialist care may prove useful for maternal and fe tal outcome.

Material : Study looked for assessment of impact of CKD detection at the time of pregnancy and its impact on fetal and maternal outcome.

Results: A total of 465 females were retrospectively evaluated for renal status during their pregnancies, 172 females were unaware about their renal illness at the time of pregnancy, while 208 females were under regular obstetrical and nephrological follow - up during their pregnancy. 44.1% of these females in both groups had GFR < 60 ml/min. Preeclampsia was observ ed in 17.6% of planned pregnancies, while it was observed in 47.5% of unplanned pregnancies. Worsening of renal failure during and following pregnancy was observed among all stages of CKD, and there was greater decline in GRF with progression to ESRD earli er during or after pregnancy among unplanned pregnancies. Planned pregnancy group had better fetal outcome. Low birth babies weighing < 2500 g in unplanned group were much higher than in planned pregnancies.

Conclusions: Chronic kidney disease is often clin ically silent until renal impairment is advanced. Pregnancy can be a check point for detection of renal disease and managed appropriately for better maternal and fetal outcome.

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A Review of Outcomes in Pregnant Women with Portal Hypertension

Anisha Ramniklal Gala• Tarakeswari Surapaneni• Nuzhat Aziz• Sailaja Devi Kallur•

Abstract

Background:The course of pregnancy in a woman with portal hypertension is a difficult one as it is associated with complications like variceal bleeding, splenic artery rupture and coagulopathy. All these pose a threat to a woman’s life. Although this condition is rare, every obstetrician should have a high index of suspicion when an antenatal mother presents with splenomegaly, thrombocytopenia or hematemesis. Hence, we aimed to revi ew maternal and fetal outcomes in pregnant women with portal hypertension.

Methods In a retrospective observational study, 41 women and 47 pregnancies were evaluated, from January 2000 – December 2015 at Fernandez Hospital, a tertiary referral perinatal cent er. Maternal outcomes studied were variceal bleed during pregnancy, surgical procedures, morbidity and mortality. Neonatal variables were gestational age at delivery, birth weight and morbidities.

Results Mean maternal age was 26.4 years. Average gestation al age at delivery was 36.5 weeks. Mean birth weight was 2507.5 g. There were three maternal deaths out of 47 deliveries, the cause of death was massive variceal bleed in one, the second one was due to cardiac arrest on MRI table, and the third death was d ue to splenic hilar vessel bleed. There was one stillbirth, and no neonatal deaths.

Conclusion A multidisciplinary approach is essential to improve perinatal outcomes in pregnancy complicated by portal hypertension. Surgical measures to reduce portal venous pressure done before pregnancy or beta blockers during pregnancy might help reduce sudden variceal bleeds.

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Analysis of Proteinuria Estimation Methods in Hypertensive Disorders of Pregnancy

Hanumant V. Nipanal• Dilip Kumar Maurrya• S. Susmitha• P. N. Ravindra •

Abstract

Purpose of the Study The gold - standard 24 - h urine collection method for protein estimation is inconvenient and is associated with a delay in laboratory analysis. This study was undertaken to compare sulphosalicylic acid test, urine d ipstick test, urine protein - to - creatinine ratio with 24 - h urine protein estimation in pre - eclampsia cases

MethodsThis is a comparative study and consists of a single group of 764 subjects. This study was conducted in the Department of Obstetrics and Gynaecology in collaboration with the Department of Biochemistry, JIPMER, Pondicherry, India, from February 2011 to January 2014. The subjects included were 764 pre - eclampsia women. A first voided morning sample was obtained for sulphosalicylic acid test, dipstick test, urine protein and creatinine estimation and urine culture, and subsequent urine samples were collected for the 24 - h urine protein estimation.

Main Findings For significant proteinuria, sulphosalicylic acid test with 1 + proteinuria has sensi tivity, specificity, PPV and NPV of 59, 48, 39, 67, whereas with 2 + has sensitivity, specificity,PPV and NPV of 44, 88, 75 and 67%, respectively, dipstick test with 1 + proteinuria has sensitivity, specificity, PPV and NPV of 71, 52, 54 and 70%, whereas w ith 2 + has sensitivity, specificity,PPV and NPV of 49, 87, 75 and 69%, respectively. The spot urine protein - to - creatinine ratio and 24 - h urine protein were significantly correlated ( r = 0.98; p < 0.0001). The cut - off value for the protein - to - creatinine ra tio as an indicator of protein excretion ≥ 300 mg/day was 0.285. The sensitivity, specificity PPV and NPV were 100, 99, 100 and 99%, respectively.

Conclusion The spot urine protein - to - creatinine ratio is a better method for estimation of proteinuria in pre - eclampsia.

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Prospective Comparative Study of Oral Versus Vaginal Misoprostol for Second - Trimester Termination of Pregnancy

Suyash S. Bhandekar• Anahita R. Chauhan• Arun Ambadka•

Abstract

BackgroundVarious medical methods for second - trimester medical termination of pregnancy (MTP) exist. Misoprostol alone has been used with myriad variations in route and dosage. Comparison between oral and vaginal routes of misoprostol forms the basis of this study.

Methods:This was a prospective comparative study of m isoprostol for second - trimester (14 – 20 weeks) MTP, comparing oral versus vaginal routes. Sixty patients were randomly allotted to two groups; 30 received oral misoprostol 400 μg 4 h up to a maximum of five doses (2000 μg), and 30 received vaginal misoprost ol in the same dose and duration. In both groups, oxytocin infusion was started if abortion did not occur. Efficacy of oral versus vaginal misoprostol, induction – abortion interval (AI) and need for surgical intervention were analyzed.

Results:Both groups were well matched in terms of age, parity, previous LSCS, mean gestational age and indication for MTP. Overall mean induction – abortion interval was 19.59 h (21.66 vs. 18.57 h, oral vs. vaginal, respectively), with vaginal group taking lesser ti me ( p 0.09). Sixty percentage in oral group required five doses, while 70% in vaginal group required 3 – 4 doses of misoprostol ( p 0.010). 23.7 versus 6.7% in oral versus vaginal group required check curettage ( p 0.038). There were no major complications, an d there was only one failure in oral group.

ConclusionsThough both oral and vaginal misoprostol are safe, vaginal route appears to be more efficacious for second - trimester MTP.

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Single Nucleotide Polymorphism - Based Noninvasive Prenatal Testing: Experience in India

Ishwar Chander Verma• Ratna Puri• Eswarachary Venkataswamy• Tulika Tayal• Sheela • Nampoorthiri• Chitra Andrew• Madhulika Kabra• Rashmi Bagga• Mamatha Gowda• Meenu Batra• Sridevi Hegde• Anita Kaul• Neerja Gupta• Pallavi Mishra• Jayshree Ganapathi • Subramanian• Shruti Lingaiah• Riyaz Akhtar• Francis Kidangan• R. Chandran• C. Kiran• G. Ravi Kumar• V. L. Ramprasad• Priya Kadam•

Abstract

IntroductionNoninvasive prenatal testing (NIPT) has revolutionized prenatal screening for chromosomal aneuploidies in some countries. Its implementation has been sporadic in developing countries. Given the genetic variation of the people in different countries, we eva luated the performance of the SNP - based NIPT in India .

Materials and Methods:The Panorama NIPT was performed in 516 pregnancies, which had tested intermediate - to - high risk on conventional first and second trimester screening. Results were confirmed eithe r by invasive diagnostic testing or by clinical evaluation after birth.

Results:Of 511 samples analyzed, results were obtained in 499 (97.7%). Of these, 480 (98.2%) were low risk and 19 were high risk. A sensitivity of 100% was obtained for detection of tr isomies 21, 18, 13 and sex chromosomal abnormalities. The specificity ranged from 99.3 to 100% for abnormalities tested. Taken together, the positive predictive value for trisomies 21, 18, 13 and monosomy X was 85.7%. The average fetal fraction was 8.2%, w hich is lower than the average observed elsewhere.

Conclusion:This is the first report of detailed experience with NIPT in India and demonstrates comparable performance in all aspects of testing to the results elsewhere

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Interstitial and Cornual Ectopic Pregnancy: Conservative Surgical and Medical Management

Mamta Dagar • Mala Srivastava • Indra ni Ganguli • Punita Bhardwaj • Nidhish Sharma • Deepak Chawla •

Abstract

BackgroundInterstitial and cornual ectopic pregnancy is rare, accounting for 2 – 4% of ectopic pregnancies and remains the most difficult type of ectopic pregnancy to diagnose due to low sensitivity and specificity of symptoms and imaging. The classic triad of ectopic pregnancy — abdominal pain, amenorrhea and vaginal bleeding — occurs in less than 40% of patients. The site of implantation in the intrauterine portion of fallopian tube and invasion through the uterine wall make this pregnancy difficult to differentiate from an intrauterine pregnancy on ultrasound. The high mortality in this type of pregna ncy is partially due to delay in diagnosis as well as the speed of hemorrhage.

MethodsThree cases of interstitial pregnancy were retrospectively analyzed.

ResultSuccessful laparoscopic cornuostomy and removal of products of conception were performed in t wo cases, while one case was successfully managed by local injection with KCL and methotrexate followed by systemic methotrexate.

ConclusionEarly diagnosis and timely management are key to the management of interstitial and cornual ectopic pregnancy. With expertise in ultrasound imaging and advances in laparoscopic skills progressively, conservative medical and surgical measures are being used to treat interstitial and cornual ectopic pregnancy successfully.

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Clinical Profile of Obstetric Patients Getting Admitted to ICU in a Tertiary Care Center Having HDU Facility: A Retrospective Analysis

Soumya Ranjan Panda• Madhu Jain• Shuchi Jain•

Abstract

BackgroundThe critically ill obstetric patient represents a challenge that usually requires a multidisciplinary approach. Lack of awareness and the absence of regular antenatal care make the critically ill patients to be referred late and sometimes in moribund conditions. The objective of the present study is to determine the incidence, predictors and outcome of obstetric ICU admissions.

MethodsThis retrospective study was conducted over a period of 2 year from July 2015 to June 2017 in Department of Obstetrics and Gynecology at Institute of Medical Sciences, BHU, Varanasi, India

Results:Out of a total of 4986 deliveries, 756 patients underwent HDU admission, while 92 obstetric patients were admitted to ICU during this study period. Maximum number of patients (73.91%) were in the age - group of 20 – 35 years, 64.13% of patients constitute lowe r socioeconomic status group, 68.47% of patients reside in rural area and there was inadequacy in receiving antenatal care in case of 60.86% of patients. Maximum number of patients were admitted for a period of 4 – 7 days. Blood transfusion (64.1%), the use of inotropic drugs (45.6%), central line placement (44.5%) and mechanical ventilation (26.08%) were the major interventions performed in ICU. Obstetric hemorrhage was found to be the most frequent clinical diagnosis leading to ICU admission (31.5%) followe d by hypertensive disorders (25%).

Conclusion In addition to timely referral, health education and training of health professionals may improve clinical outcome and better obstetric practice, especially in countries like India. Obstetric ICU dedicated for the management of only obstetric patients should be constructed in order to compensate for heavy burden critically ill women.

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Labor Pattern Among Primigravida in Local Population

Nivethitha Pitchaimuthu• Shanta Bhaskaran •

Abstract

Objectives:In this study, we tried to make the customized labor curve by studying the labor pattern among the primigravidas and we compared the cervicograph with Zhang’s and Suzuki’s curves. This study may be a motivator for future research to create own labor norms for our Indian population which may help in reducing the cesarean section rates, principally in primigravidas.

Materials and Methods:It was a prospective observational study, which included 156 primigravidas with uncomplicated term singleton pregnancy with spont aneous onset and progression of labor, who had normal vaginal delivery with good maternal and neonatal outcome.

Results:The shape of the labor curve of this study was similar to Zhang’ and Suzuki – Horiuchi’s curves which had slower progression. The active phase started from 5 to 6 cm of cervical dilatation onwards which was similar to Suzuki – Horiuchi’s curve. In the present study, the mean rate of cervical dilatation in the active phase was 1.5 cm/hour in contrast to Friedman’s study which had a mean rate of cervical dilatation of 3 cm/hour with lower limit of 1.2 cm/hour as 5th centile.

Conclusion:In the present study the mean rate of cervical dilatation in active phase in Indian women was approximately equivalent to the lowest acceptable rate of cervica l dilatation in Friedman’s study. If we continued to follow Friedman’s labor norms, it could result in increasing c - sections. Hence, it would be prudent to create a customized labor curve for the local population served based on their individual characteri stics features.

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Ectopic Pregnancy: Risk Factors, Clinical Presentation and Management

G. Geovin Ranji• G. Usha Rani• Sri Varshini•

Abstract

BackgroundEctopic pregnancy is increasing in incidence. Nevertheless, there is wide availability of tools for early diagnosis and advances in management. Though it is not a leading cause of maternal mortality, it significantly causes morbidity and jeopardizes reproductive outcome in women desirous of fertility.

Aims:To determine incidence, risk factors, symptoms, signs, type of ectopic pregnancy and management.

Settings and Design:This is a one - year prospective, descriptive study conducted in Department of Obstetrics and Gynaecology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai

Results:Th ere were 119 ectopic pregnancies during the study period. The incidence of ectopic pregnancy is 2.81/100 deliveries. Ectopic pregnancy was common in 26 –30 years, the minimum age at diagnosis was 18 years and maximum age was 40 years. Fourteen women had pre vious one ectopic pregnancy. Four had previous two ectopic pregnancies. Previous cesarean and treatment for infertility were the commonest risk factors. The classic triad was present in only 27.7% of patients. Fourteen patients presented with shock. Five w omen were diagnosed even before they missed their periods. Success rate of medical treatment with methotrexate is 83.33%. Tubal pregnancy was the commonest type, and ampulla was the commonest site. Right side was affected more than left side. Thirty - three patients (27.7%) required blood transfusion. Seven developed morbidity. After 1 - year follow - up of 68 women who were desirous of fertility, five women have become pregnant subsequently with intrauterine gestation.

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E xternal Cephalic Version: A Dying Art Worth Reviving

Raj Lakshmi Nalam• Priya Chinnachamy• Paul Emmanuel•

Abstract

Purpose Breech presentation is the most common abnormal presentation occurring in 3 – 4% of all deliveries. Incidence of caesarean section for breech presentation has increased markedly in the last few decades. Attempting external cephalic version (ECV) reduces the chance of non - cephalic presentation at term, thus reducing the rate of caesarean sections.

Methods:Prospective study was conducted in secondary healthcare centre, in r ural set - up from August 2013 to August 2015. A total of 52 patients were enrolled into the study.

Results:ECV was successful in 32 out of 52 patients with overall success of 61.5%. Out of the 32 successful ECVs, 24 patients delivered vaginally (75%) ( p value 0.00), 6 patients delivered by caesarean section, and 2 patients were lost to follow - up. Transverse lie had 100% success rate for ECV ( p value 0.005). Gravidity, placental position, gestational age and use of tocolytics did not influence the success rate of ECV. Most common problem observed during the procedure was abdominal discomfort.

Conclusion:ECV is a safe procedure with high percentage of patients delivering vaginally after successful version. Hence, acquiring skills in ECV should be considered mandatory in the postgraduate training of future obstetricians.

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CASE REPORT


GYNECOLOGY

Ogilvie Syndrome with Caecal Perforation After Caesarean Section

K. Geethadevi• D. Gowthami• U. Chakrapani• R. S. Ramadevi•

Abstract

33yr old P3L3 after her third cesarean section developed abdominal distension and pain which was thought to be subacute intestinal obstruction or paralytic ileus and we treated her conservatively. On 7th pod CECT revealed colonic perforation. Emergency laparotomy was done with bowel re section and end to side anastamosis. Awareness of such an entity called Ogilvie syndrome and early CECT abdomen could diagnose colonic ditatation before perforation and prevent the morbidity.

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CASE REPORT


Osseous Metaplasia of the Vaginal Vault: A Case Report

Sajna V. M. Kutty• K. P. Kavitha• Nazer Thalamkandathil •

Abstract

Osseous metaplasia in the female genital tract has been reported in the cervix, endometrium and also vaginal vault after hysterectomy, of which this is the second reported case. The proposed impl icated factors predisposing to the metaplastic transformation of stromal cells to osteoblasts are varied although none have been proven effectively. Differentials to be ruled out include retained fetal parts after abortion, malignant mixed mullerian tumor, and systemic illnesses like hypervitaminosis and hypercalcemia.

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CASE REPORT


Heterotopic Quadruplet Pregnancy After ICSI Conception

Nupur A. Tamhane• Aditi Parikh• Vivek M. Joshi •

Abstract

Background: Heterotopic pregnancy (HP) is a condition characterized by co - existence of multiple fetuses at two or more implantation sites. It occurs in 1% of pregnancies after assisted reproductive techniques (ART). Presence of triplet intrauterine pregnancy with ectopic gestational sac is one of the rarest form of HP. Ectopi c pregnancy is implanted in the ampullary segment of the fallopian tube in 80% of cases. Most of the patients present with acute abdominal symptoms due to rupture of the tube. Case presentation: This article reports a case of quadruplet heterotopic pregnan cy after intracytoplasmic sperm injection (ICSI) with an ampullary ectopic pregnancy and intrauterine triplet pregnancies. The ruptured ampullary pregnancy was emergently managed by right salpingectomy. This was followed by embryo reduction at 12+6 weeks a nd successful outcome of intrauterine twin pregnancy.

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PICTORIAL ESSAY

Uterine Balloon Tamponade: A Savior in Ruptured Uterine Arteriovenous Malformation

Sandhya Gadre•

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LETTER TO EDITOR

Comments on Manuscript: Intrauterine Inflated Foley’s Catheter Balloon in the Management of Abnormally Invasive Placenta Previa: A Case – Control Study

Abbas Ahmed•

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