Abstract

The increasing incidence and mortality rates of breast cancer have led to the necessity of initiating and developing clinical practice guidelines in order to optimize cancer control and provide patients with the best care. These guidelines are either national or issued by reputed relevant European societies—like European Society for Medical Oncology. Many of the recommendations are concordant in-between the guidelines. However, there are still considerable discrepancies to be noted between guidelines from diferent European countries, which could hinder physicians from implementing their recommendations. The present paper summarizes and compares the recommendations included in the various European guidelines.

Abstract

Background The intersection of ART and molecular genetic science is fast growing. It is now possible to utilize the advances in molecular genetics for clinical application to detect chromosomal aberrations in preimplanting embryos. As molecular genetic techniques have improved, it is now possible to test the complete characterization of human genome variation with reasonable accuracy. In this article, we have tried to summarize the common current indications of chromosomal analysis of preimplanting embryos in couples having various chromosomal dominant or chromosomal recessive heritable disorders leading to the birth of a new born baby with chromosomal aberrations or leading to repeated miscarriage.

Conclusion The currently available techniques of embryo biopsy have their advantages and shortcomings. Today, preimplantation genetic testing to diagnose a euploid embryo is widely used in clinical practice in couples undergoing IVF ET treatment. By eliminating the transfer of aneuploid embryos, the pregnancy rate improves per embryo transfer and it shortens the time of conception from the start of IVF treatment. We have also discussed the current scenario of the place of PGT-A for routine use in IVF treatment procedure in view of the possible risk of losing euploid embryos due to the shortcoming of the embryo biopsy procedure.

Abstract

Pelvic organ prolapse (POP) is a very common condition which can greatly impact a woman’s quality of life. Treatment options are individualized and typically involve a combination of physiotherapy, pessary insertion and surgical treatments. It is well known that nulliparous prolapse in India constitutes 1.5–2% of genital prolapse, while the incidence is even higher (5–8%) for young women who have delivered one or two children, thus making it one of the highest rates in the world. This has necessitated the development of numerous conservative surgical treatment options for POP, which allows women to retain their sexual and reproductive function and therefore allows for subsequent pregnancies. With the controversy surrounding the use of mesh, a variety of surgical treatment options should be considered. Such alternative treatments include the use of surgical sling procedures, which have been used widely in Indian practice for the treatment of POP for over 60 years. This review outlines some of the well-established conservative treatment options for POP. It also highlights the unique contribution of Indian Obstetricians in the development of these conservative surgical treatment options, from prominent Indian Gynecologists including Dr VN Shirodkar, Dr BN Purandare, VN Purandare, RP Soonawala, Brigadier SD Khanna and Dr RM Nadkarni.

Stress urinary incontinence (SUI) is a common type of urinary incontinence adversely affecting the quality of life of women. For mild SUI, life style changes, pelvic floor exercises and medical treatment with duloxetine may help. Most patients of moderate to severe SUI usually require surgical treatment. Various surgical treatment options include Kelly’s plication, Burch colposuspension, bulking agents and sling surgeries. Although, suburethral fascial slings including the autologous rectus fascia slings were in vogue before 1990, they were overtaken by minimally invasive, faster and easier artificial midurethral slings (tension free vaginal tape and transobturator tape). However, observation of serious long-term and life changing complications of synthetic midurethral slings like mesh erosion, chronic pelvic pain and dyspareunia led to their adverse publicity and medico legal implications for the operating surgeons. This led US FDA (Food and Drug Administration) to issue a warning against their use. Currently, their use has significantly decreased in many countries, and they are no longer available in some countries. This has led to renaissance of use of natural autologous fascial sling, especially rectus fascia for surgical management of SUI. Although performing rectus fascia sling surgery is technically more challenging, takes longer, has more short-term morbidity like voiding dysfunction, their long-term success is high with very little risk of serious complications like mesh erosion, chronic pelvic pain and dyspareunia. However, multicentric trials and longer follow ups are needed before it’s routine recommendation This review discusses the role of autologous fascial sling (especially rectus fascia) for the surgical management of SUI in the current time and the need of ongoing training of this procedure to gynecology residents and urogynecology fellows.

The endometrium is a dynamic target organ in a woman’s reproductive life. It undergoes cyclical change regulated by the fine balance between oestrogen and progesterone. The endometrial thickness (ET) varies according to the phases of the menstrual cycle. Endometrium contains both oestrogen and progesterone receptors, which respond to above hormones, irrespective of whether the woman is in reproductive or menopausal phase. Abundance of oestrogen leads to endometrial hyperplasia, and paucity causes endometrial atrophy. The initial best modality of assessing ET or aberration is high resolution transvaginal ultrasonogram. Thickened endometrium is always a clinical conundrum. Dilemma does remain as to the thickness of endometrium which requires intervention, mostly in symptomatic pre and perimenopausal women. In post-menopausal women with bleeding, the cut-off of ET that warrants investigation is almost defined. However, the cut-off value of ET in asymptomatic postmenopausal women; beyond which intervention is required, is still debated. Dilemma also exists about the cut-off of ET in both symptomatic and asymptomatic women on HRT and Tamoxifen. This article will discuss the above issues and reach at some consensus about the cut-off of ET after critical analysis of evidence and experience and will help clinicians in arriving at a proper decision in dealing with such clinically confounding situations.

Medical Termination of pregnancy is a common gynaecological procedure. Unlike other procedures, this procedure has ethical, moral and legal overtones. Medical termination of pregnancy is governed strictly by the Medical Termination of pregnancy Act (MTP Act). One of the legally accepted indications for termination is substantial foetal anomaly. But the law does not allow termination is the pregnancy has crossed twenty weeks. This poses serious dilemma to the gynaecologist. Judicial activism by the author has paved way to significant relaxations to the law. It has enabled woman and their care givers to provide for legal termination of pregnancy even after twenty weeks cut off. The law in the field in evolving and soon likely to be amended by the Parliament.

Female genital tuberculosis (FGTB) is an important cause of significant morbidity and infertility.

Gold-standard diagnosis by demonstration of acid fast bacilli on microscopy or culture or detection of epithelioid granuloma on histopathology of endometrial or peritoneal biopsy is positive in only small percentage of cases due to its paucibacillary nature. Use of gene Xpert on endometrial or peritoneal biopsy has improved sensitivity of diagnosis. Composite reference standard (CRS) is a significant landmark in its diagnosis in which combination of factors like AFB on microscopy or culture, positive gene Xpert, epithelioid granuloma on endometrial or peritoneal biopsy, demonstration of definite or probable findings of FGTB on laparoscopy or hysteroscopy. There have been many advances and changes in management of FGTB recently. The program is now called National Tuberculosis Elimination Program (NTEP), and categorization of TB has been stopped. Now, patients are divided into drug-sensitive FGTB for which rifampicin (R), isoniazid (H), pyrazinamide (Z) and ethambutol (E) are given orally daily for 2 months followed by three drugs (rifampicin, isoniazid and ethambutol (RHE) orally daily for next 4 months. Multi-drug-resistant FGTB is treated with shorter MDR TB regimen of 9–11 months or longer MDR TB regimen of 18–20 months with reserved drugs. In vitro fertilization and embryo transfer have good results for blocked tubes and receptive endometrium, while surrogacy or adoption is advised for severe grades of Asherman’s syndrome.

Globally reproductive health services such as contraception and abortion are impacted and are not accessible to a considerable population. The International Planned Parenthood Federation reported anticipated shortage of contraception as the lockdown measures led to reduction in the manufacturing of contraceptives. A recent analysis by the Guttmacher Institute estimated the potential effects of the pandemic. It was found that a 10% decline of sexual and reproductive health services due to COVID-19, would mean an additional 15.4 million unintended pregnancies, over 3.3 million unsafe abortions and 28,000 maternal deaths. The UN Secretary General has issued a call to continue the delivery of sexual and reproductive health services even without prescription. The focus is now to provide vaccines, and therefore, a number of research organizations and pharmaceutical industries are working on their production. One of the reasons for vaccine refusal is the concern that it may affect female and male reproductive functions. However, it is important to correct this misunderstanding as vaccination does not affect fertility. In most cases, vaccination during pregnancy and lactation can be considered safe and effective.

This narrative review is aimed to practically review and evaluate the existing evidence and illuminate the effectiveness of physical activity, yoga, and exercise for postpartum and midlife weight management. A comprehensive review was conducted using electronic databases such as PubMed and google scholar using search terms physical activity, exercise, yoga, postpar- tum, midlife, weight loss, weight reduction, and all the probable terms. This helped in generating evidence-based information and formulating practical physical activity prescriptions to be used by obstetricians, general clinicians, nutritionists, and other allied healthcare personnel. Overweight and obesity in postpartum and midlife women present long-term health risks and complications. Indulging in optimum physical activity comprising exercise and yoga will help in weight management, increasing muscular strength, and endurance thus improving overall health and well-being.

Weight retention and weight gain during the postpartum and midlife periods subsequently increase the risk of chronic health conditions, thereby deteriorating the overall health. Dietary intervention is the pivotal component of sustainable weight management. However, in resource restricted settings, where dietitians may not be present, other healthcare professionals such as physicians, obstetricians and paediatricians should play a vital role in providing timely weight management advice to these women. Therefore, this article provides dietary advice including the setting of realistic weight loss goals, identifying an individual's calorie needs, distribution of macronutrients and consideration of important micronutrients. Healthcare professionals can follow the stepwise approach to prescribe dietary advice to postpartum and midlife women for their weight management. Various dietary principles such as cultural and regional preferences of an individual, portion size, hypocaloric diets, and nutrient-dense meals, eating habits, cultural beliefs and myths along with co-morbid conditions should be taken into consideration by healthcare professionals while providing the dietary prescription.

Introduction The World Health Organization defines obstetric (maternal) sepsis as organ failure caused by infection during pregnancy, childbirth, post-abortion or postpartum period. It is the third most prevalent reason for maternal death. According to statistics, sepsis caused 11 percent of maternal fatalities worldwide.

Discussion Physiological changes related to pregnancy may imitate the start of sepsis, which makes definitive diagnosis difficult. The definition of sepsis is gradually amended over decades. Various diagnostic tools and criteria are available.

Conclusion Prevention, early diagnosis, and appropriate management can reduce sepsis related maternal mortalities and morbidities. To reduce unnecessary maternal mortality, future policy development in the area of evaluation and care of obstetric sepsis is essential.

The regulatory vacuum in the field of ART in India was filled when in December 2021, the Assisted Reproductive Technology (Regulation) Act, 2021 (ART Act) (https:// egaze tte. nic. in/ Write ReadD ata/ 2021/ 232025. pdf) and the Surrogacy (Regulation) Act, 2021 (SR Act) were passed. We surveyed medical professionals to understand their knowledge, attitude and perception towards the Acts and to offer an initial, snapshot assessment of their impact on the medical community. The government has already signalled its intent to implement the Acts and has published several notifications/gazettes to clarify and amend the issues surrounding the Acts (https:// artsu rroga cy. gov. in/ Natio nalAr tSurr ogacy/ faces/ HomeP age. xhtml#). We hope that these responses will help to voice the thoughts, concerns and suggestions from of ART service providers for ART to further clarify and rationalise the laws. Infertility is already a much stigmatised problem which deserves to be a higher public health priority. While the laws are a welcome step, changes in both laws is are the need of the hour to make ART more accessible, available and affordable to the millions of couples who need these services and for the health care providers who to be able to deliver them.

The decision regarding oophorectomy during gynaecological surgeries, especially in perimenopausal and postmenopausal women, has historically posed a significant dilemma. Traditionally, it was widely believed that conserving the ovaries held no benefits, leading to a common practice of recommending Bilateral Salpingo-oophorectomy alongside hysterectomy for benign conditions in women aged 40–45 and above. Given our evolving comprehension of postmenopausal ovarian function and the genetic susceptibility to ovarian epithelial cancers, the decision regarding oophorectomy poses a dilemma. Oophorectomy is recommended for women with a higher risk of ovarian cancer and ovarian conservation is necessary with women with higher risk of co-morbidities. This paper reviews the available literature on these aspects of oophorectomy. Despite a wealth of literature narrating the advantages and disadvantages of oophorectomy, covering aspects such as ovarian cancer risk, myocardial infarction incidence, and post-oophorectomy peritoneal cancer, there is a notable absence of a comprehensive evaluation system for risk stratification. The objective of the present paper is to address this gap by consolidating existing literature into a risk stratification system. This system will provide treating physicians a tool that facilitates more informed, case-specific decisions in collaboration with patients and their families. While recognizing that the ultimate decision must be tailored to the individual case and agreed upon mutually by the surgeon, patient, and family, the proposed system seeks to streamline risk stratification. This, in turn, should aid in determining the most suitable course of treatment that maximizes benefits for the patient.

Pruritus is a commonly described symptom during pregnancy. Despite its high prevalence, it is often considered trivial but causes significant patient discomfort. It is important to assess and investigate the patient thoroughly as some conditions have a detrimental outcome for both mother and fetus. There is extensive literature on pruritus due to pregnancy-specific dermatoses, however, the evaluation of pruritus merits a broader approach. Various other conditions such as certain infections, systemic diseases, and pre-existing dermatological conditions should also be considered. Awareness of these conditions in obstetricians will also ensure adequate treatment and timely referral, if necessary. The purpose of this article is to describe the etiology, clinical features, diagnostic approach, and management of pruritus in pregnancy.