Abstract

In the wake of political upheaval, the Human Fertilisation and Embryo Authority (HFEA) has faced increasing insecurity over its future as a pivotal regulatory body of fertility practices in the UK. HFEA regulates activities by means of licensing, audit, and inspection of fertility centers and maintaining the Code of Practice, which ensures the optimum undertaking of licensed activities by fertility centers. In 2009, amendments to the 1990 Act came into force representing an amalgamation of cumulative proposals, debates, and changes in legislation, which have shaped the world of reproductive medicine. The medical world has, in many cases, adapted to righteous political and social demands, and continues to evolve at a rapid rate. The HFEA has faced many regulatory challenges and changes, and through this study, we aim to provide an overview of some of these changes, particularly those during the last 10 years and the implications that they may have had to fertility practices.

Abstract

Many countries across the world have made newborn screening (NBS) mandatory. It is a laboratory test which screens the newborns for metabolic & genetic disorders, some of which can be treated or modified if detected early in life, and thereby preventing potentially disastrous consequences and saving the baby’s life. The last four decades have witnessed rapid evolution in implementation & strategies used for NBS in US, Europe, Japan & other industrialised nations where NBS is well accepted public health policy. India is going through a progressive transitional phase of control over infant mortality & morbidity due to infections and emergence of genetic conditions. This is the right time to review NBS program in totality considering the global scenario of its initiation, growth, advances in technologies & its transfer from conventional to mass spectrometry techniques, as well as selection & nature of candidate NBS disorders. Nevertheless, the impact of this worldwide movement of NBS is inadequate in India; this review article discusses the various efforts required to successfully introduce this significant health service for population benefits as well as the lacunae & limitations still exist in 21st century in India. Based on the high-risk screening of congenital metabolic conditions using mass spectrometry in India, the first hand experience of more than a decade is shared here to provide better opportunities & guidelines to those who have serious urge to pursue NBS as an important preventive public health program, be it at government, public or private level for the masses of India.

Abstract

Objectives: Fetal growth restriction is defined as a patho-logic decrease in the rate of fetal growth. The most frequentetiology for late onset fetal growth restriction is uteroplacentaldysfunction which is due to inadequate supply of nutrients andoxygen to support normal aerobic growth of the fetus. How-ever, for symmetrical IUGR, fetal chromosomal anomalies,structural anomalies and fetal infections should be carefullyexcluded. Consequent to the uteroplacental vascular malad-aptation of endovascular trophoblastic invasion, there isincreased vascular resistance and decreased blood flow to theplacenta in the choriodecidual compartment.

Conclusions: This under perfusion of the placenta causesvillous damage; that is, total tertiary villous capillary bed isreduced leading to increased placental resistance. Thesechanges can be diagnosed by Doppler and characteristicchanges are seen in the uterine, umbilical, middle cerebralarteries and ductus venosus vessels. In severe cases,delivery of the fetus with optimum intrapartum surveil-lance, or caesarean section, is essential.

Abstract

Intra-uterine growth restriction (IUGR) is an important perinatal problem giving rise to increased morbidity and mortality in the growth restricted fetus. The aim of fetal medicine today, is to prevent the mere occurrence of IUGR in high risk pregnancies and to deliver the fetuses already afflicted with growth restriction, before they have suffered from the effects of hypoxia. The use of Doppler provides this information, which is not readily obtained from the other conventional tests of fetal well being. The Doppler patterns follow a longitudinal trend in the arterial and venous circulation of the fetus as well as the placental vasculature guiding management decisions regarding the appropriate time of delivery. Progressive knowledge of the fetal circulation and its adaptation when the fetus is subjected to hypoxia, has helped us recognize the early signs of IUGR thereby improving the prognosis of these complicated pregnancies. It has therefore become the gold standard in the management of the growth-restricted fetus.

Abstract

The standard of care for women with advanced stage epithelial ovarian cancer (EOC) involves surgery followed by adjuvant platinum-based combination chemotherapy. One of the goals of surgery is to resect all macroscopic disease. In this review we will discuss the justification for an aggressive surgical approach, including a discussion of factors limiting its implementation and suggestions for providing appropriate surgical intervention for all women with EOC.

Abstract

Cesarean section once performed, paves the way for a repeat cesarean often, which in turn results in multiple disadvantages. An attempt is made to view the place of vaginal birth after cesarean against the consequences of not giving such a trial and choosing to perform a repeat cesarean section. The aftermath and repercussions of a previous cesarean section on future obstetric and gynecological outcomes are hereby presented.

Abstract

The control of cervical cancer has been on the agenda of health care workers all over the world for several years. It is more of a problem in the developing world as 80% of all cases are seen in low resource setting. Approximately 1.2 lakh cases occur in India each year out of these 80,000 present with advanced disease and succumb within a year. However, the scenario changed dramatically in the 20th century. With the introduction of radiotherapy, the concept of precancer, and routine use of Pap smear in the developed world the disease is finally getting under control. Although it has been known since centuries that cervical cancer was in some way related to sexual activity no definite carcinogen was implicated. It was in the 1970s that Zur Hausen 1 in Germany implicated that the human papillomavirus was the causative organism which led to the development of cervical cancer. Further developments were rapid. Over a 100 different types of HPV specific to human beings were discovered. At least 30 of these affect the genital mucosa. They are further divided into high oncogenic potential and low oncogenic potential HPV. Cervical cancer is the first solid tumor associated with virus infection. It is a spherical Zur Hausen’s 2 research resulted in a monumental work which explained molecular pathogenesis of cancer cervix and its causation by a virus, which radically changed our thinking. However, it is only in the last 30 years that there have been substantial changes in the understanding of the disease and major changes in the concepts of control.

Abstract

Women with polycystic ovaries (PCOS) frequently present with reproductive dysfunction. However, when these women do finally achieve pregnancy, after intensive treatment, they are faced with a substantially high risk of miscarriage in the first trimester. This review deals with the pathophysiology and management of pregnancy loss in women with PCOS.

Recurrent miscarriage, described as the loss of three or more consecutive pregnancies, affects 1% of couples trying to conceive. Amongst the various causes , PCOS is the most commonly identified ultrasound abnormality amongst women with recurrent pregnancy loss 1. Its incidence ranges from 40 to 56% of women with recurrent pregnancy loss. Conversely, rate of early pregnancy loss is reported to be 30 to 50% in women with PCOS, which is 3 fold higher than the rate of 10 to 15% in normal women 2.

It is clear that a fully functional CL is an important prerequisite for both nidation and the normal progress of early pregnancy. Normal formation and function of the CL and optimal endometrial preparation for implantation of the conceptus depend on a number of factors, a deficiency of any one of which may result in luteal phase inadequacy and thereby predispose to early pregnancy wastage.

The duration of luteal function in the nonfertile menstrual cycle is limited to no more than 10 to 15 days 3. Theoretically, each menstrual cycle is potentially a fertile one. The mechanism responsible for spontaneous luteolysis, viz., the timely and inevitable demise of the CL when pregnancy fails to occur, remains unknown despite considerable investigations. An important feature of the endocrinology of the early pregnancy is the prolongation or maintenance of luteal function, a process commonly known as CL rescue. Luteal support remains essential until approximately the seventh week of gestation, presumably the time when the trophoblast has acquired sufficient steroidogenic capacity to support the pregnancy by itself. Lutectomy induces abortion in most women if performed prior to 7 weeks of gestation whereas removal of the CL after that time has no effect.

Abstract

The Influenza A H1N1 pandemic (A H1N1) occurred between June 2009 and August 2010. Although the pandemic is now over, the virus has emerged as the predominant strain in the current seasonal influenza phase in the northern hemisphere. The A H1N1 influenza is a novel strain of the influenza A virus and is widely known as swine flu. The virus contains a mixture of genetic material from human, pig and bird flu virus. It is a new variety of flu which people have not had much immunity to. Much has been learnt from the Pandemic of 2009/2010 but the messages about vaccination and treatment seem to be taken slowly by the clinical profession. Most people affected by the virus, including pregnant women, suffer a mild viral illness, and make a full recovery. The median duration of illness is around seven days. This influenza typically affects the younger age group i.e. from the ages of 5–65 years. Current experience shows that the age group experiencing increased morbidity and mortality rates are in those under 65 years of age. Pregnant women, because of their altered immunity and physiological adaptations, are at higher risk of developing pulmonary complications, especially in the second and third trimesters. In the United Kingdom, twelve maternal deaths were reported to be associated with the H1N1 virus during the pandemic and clear avoidable factors were identified (Modder, Review of Maternal Deaths in the UK related to A H1N1 2009 influenza (CMACE). www.cmace.org.uk, 2010). The pregnancy outcomes were also poor for women who were affected by the virus with a fivefold increase in the perinatal mortality rate and threefold increase in the preterm delivery rate (Yates et al. Health Technol Assess 14(34):109–182, 2010). There continues to be a low uptake of the flu vaccine and commencement of antiviral treatment for pregnant women.

Abstract

Introduction: There are more deliveries in India than any country in the world, according to World Health Report. Review of seven articles published in The Journal of Obstetrics and Gynecology of India suggests that the perinatal mortality (PNM) in the country is 92/1,000 (16,339/177,998) births and the cause is asphyxia in about one fourth of the cases.

Methods: We reviewed the evidencebased guidelines on intrapartum fetal surveillance from four countries (UK, USA, Canada, and Australia/New Zealand).

Results: Overall there were 72 recommendations and whether they were level A, B, C, or D varied significantly (p=0.021) for the four national guidelines. The composite summary of these recommendations indicates that no single guideline is comprehensive, the composite may be better than any singular.

Conclusion: Each country needs its own recommendations to ameliorate the PNM. Accounting for the varied setting childbirths occurring in the country, a national guideline for clinicians in India may decrease the PNM secondary to asphyxia.

Abstract

The presence of epithelial cells in the peritoneal cavity and within the myometrium was described during the second part of the 19th century and was given the name “adenomyoma”. Then, with the identification of peritoneal endometriosis in the 1920s, adenomyosis became a separate nosological entity. For decades, the two abnormalities have been considered separate benign proliferative conditions of the female reproductive tract with a different clinical profile. More recently, however, evidence has been accumulated indicating that these two diseases have in common an endometrial dysfunction involving both eutopic and heterotopic endometrium causing a reaction in the inner myometrium (the so-called myometrium junctional zone (JZ)). It therefore seems that adenomyosis and endometriosis share a common origin in an abnormal eutopic endometrium and myometrium JZ. It is therefore no surprise that both conditions are associated with obstetrical disorders, such as spontaneous preterm delivery and premature preterm rupture of the membranes, which may have roots in a disturbed decidualization and placentation process.

Abstract

Cervical cancer is a cause of significant disease worldwide. Human papillomavirus (HPV) infection is the cause of cervical cancer in almost 100% cases. HPV infection can also lead to genital warts, recurrent respiratory papillomatosis, vaginal, vulval, anal and penile cancers. HPV types 16 and 18 are responsible for more than 70% of HPV-related cancers whilst HPV types 6 and 11 cause approximately 90% of the cases of genital warts. Effective interventions to prevent HPV associated diseases can therefore prevent cervical cancers and genital warts.

Primary prevention of cervical cancer can be achieved by vaccination and secondary prevention by screening. Currently screening options of secondary prevention include visual inspection with acetic acid (VIA), cervical cytology and detection of high risk HPV-DNA viruses. Prophylactic HPV vaccines have been developed recently which will reduce the burden of HPV-related diseases in the community. For this primary preventive measure, two vaccines are available worldwide: quadrivalent HPV vaccine targeting HPV types -16, 18, 6 and 11 and a bivalent vaccine against HPV types 16 and 18. Clinical trials have shown that these vaccinations are safe, immunogenic and highly effective against type- specific HPV infections.