Physician heal thyself - ‘Mental health is a universal human right’. Abstract World mental health day is an important health awareness event celebrated every year on 10 October to create acceptance, awareness, healing and promote the importance of sound mental health in one's life and society. This day aims to educate people including physicians about the stigma of mental illness, and encouraging people around the world to support and help the cause, and establish a healthy environment in all aspects of life. Preventive Tips & Effective ways to promote Mental Health Awareness in practising gynaecologists

1. Be Vocal if you identify anyone with mental health issues and have open (accepting) mindset towards Mental Health Issues.
2. Keep yourself informed about the warning Signs and Symptoms of Mental Illnesses. Some of the prominent indications includes changes in sleep and eating patterns, persistent sadness, antisocial behaviour and mood changes.
3. Be kind and compassionate towards others working with you.
4. Don't hesitate to avail and promote free mental health screening.
5. Participate in Awareness campaign and support the cause.
6. Learn and implement proper healthy lifestyle to improve the mental wellbeing of your family and yourself. 
7. Encourage and support the affected one to get diagnosed and avail proper mental health programs based on their signs and symptoms.

Background Multiple pregnancies have increased with the use of assisted reproduction, and we expect more women reporting with Rh isoimmunization among multiple gestation in near future. Intrauterine transfusion in singleton itself is technically difficult and requires a lot of skill and precision. Performing double/triple transfusion in twins/triplets is expected to be more demanding.

Aim To create awareness on the technical difficulties encountered in intrauterine transfusion in twins and triplets.

Methodology We report a case series of four Rh-isoimmunized twins/triplets in 5 years who presented with severe anemia requiring intrauterine transfusion.

Results Each of the four sets of cases had their own intricacies that needed to be pondered before tackling them as not much was available in the literature. In Case 1, the first twin intrauterine transfusion in our 20-year-long experience, the difficulty in the approach to the first twin due to a posteriorly placed placenta has been highlighted. Case 2 was rare due to the concomitant presence of atypical antibodies in the mother in addition to Rh-D isoimmunization that made it difficult to cross match any donor blood for intrauterine transfusion. The third case was exclusive due to its monochorionic–diamniotic nature of the twins where the impact of inter-twin anastomosis on the transfusion was to be taken into consideration. Fourth case was a triplet gestation where the difficulty of which cord to be assigned to which fetus, the crowded space for intervention, as well as the risk of prolonged operative time and associated risk of preterm/premature rupture of membranes were our concern. Conclusion Intrauterine transfusion (IUT) in twins/triplets is challenging. Difficulties encountered during IUT in multifetal gestation are due to different or uncertain chorionicity, intraplacental anastomosis between vessels, different degree of anemia in twins, difficult to ascertain cord–fetus relationship and difficulty to reach placental insertion site due to crowding by multiple fetal parts.

Fetal anemia · Intrauterine transfusion · Rh isoimmunization · Twin transfusion · Twin intrauterine transfusion

Background This objective of this study was to diagnose Obstructive Sleep Apnoea (OSA) in pregnant women using Questionnaire-based methods and to determine any association of Sleep-Disordered Breathing (SDB) with Hypertensive Disorder of Pregnancy (HDP). Additionally, the study aimed to identify factors associated with OSA.

Methods This case–control study was conducted in department of Obstetrics in tertiary care hospital in Delhi. We Identified SDB using Berlin Questionnaire and Modified Stop-Bang Questionnaire in 100 pregnant women with Hypertension and 100 normotensive controls. We compared the groups using appropriate statistical analysis.

Results The mean age of women with HDP (25.46 ± 4.38) was found to be slightly higher than controls (24.13 ± 3.89) (p value-0.02). Sleep apnoea as depicted by the presence of either high-risk STOP Bang or Berlin score was seen more often in hypertensive women in 45% as compared to controls in 8% (p value < 0.001). Higher pre-pregnancy weight (58.58 ± 9.77 vs. 53.0 ± 6.59), higher BMI (24.03 ± 5.89 vs. 20.68 ± 1.49), higher mean neck circumference (14.97 vs. 14.27 inches) weight gain more than 11 kg during pregnancy (55.6% vs. 38.2%) were the high-risk factors more commonly associated with SDB as seen in women with OSA in hypertensive women. On logistic regression analysis, the presence of OSA was singularly responsible for development of Hypertension (Odds Ratio–13.014, 95% CI 5.237–32.337) (p value < 0.001).

Conclusion Gestational hypertension appears to be strongly associated with the presence of obstructive sleep apnoea. The recognition and treatment of OSA during pregnancy may lead to improved outcomes.

Hypertensive disorders of pregnancy (HDP) · Preeclampsia · Sleep-disordered breathing (SDB) · Obstructive sleep Apnoea (OSA) · Stop-Bang Questionnaire · Berlin Questionnaire

Background/Purpose This study aims to assess lifestyle-related factors such as diet, physical activity and sleep along with common myths, beliefs, and barriers to a healthy lifestyle and resultant postpartum weight retention. It has also explored the association of the aforementioned factors with socio-demographic variables.

Methods A cross-sectional survey was conducted using a comprehensive pre-validated questionnaire on a convenience sample of postpartum women using a telephonic interview schedule.

Results A total of 505 postpartum women were recruited with median postpartum weight retention of 5 kg. More than half of the participants had incorrect dietary practices with less than one-tenth of women indulging in low/moderate-intensity physical activity. Postpartum women had poorer diet (p < 0.05) and sleep (p < 0.01) in the initial phase postpartum as compared to late postpartum. These women were also less physically active in the initial months and as the postpartum period progressed their physical activity also improved significantly (p < 0.001). Socio-demographic variables such as socio-economic status, education, and employment status were significantly associated with unhealthy lifestyle practices. Common barriers were lack of knowledge, time constraints, lack of childcare support and cultural myths and beliefs.

Conclusion The findings of the study will help in developing a comprehensive women-centric weight management module focusing on practical guidelines for lifestyle, breastfeeding and other confounding factors associated with postpartum weight management.

Postpartum period · Overweight · Obesity · Lifestyle · Weight management

Introduction As the pregnancy advances beyond term, the risk of perinatal morbidity and mortality increases. Hence to prevent these complications associated with postterm pregnancy, induction of labor is done, as per our institution protocol between 40 and 41 weeks of gestation. Induction has its own drawback, so it is essential to identify the women with high chances of failure of induction of labor, to prevent the morbidities associated with induction failure.

Aim To study the role of ultrasonographic fetal adrenal gland enlargement for the prediction of success of labor induction among primigravida beyond 40 weeks gestation.

Material and Methods Low-risk primigravidas beyond 40 weeks gestation, scheduled for induction of labor, were enrolled for the study. Fetal adrenal gland dimensions were measured by using abdominal probe Philips HD 7XE and general electronics logiq P6 pro or any ultrasound machine equipped with 7.5–10 MHz linear array probe and 3.5–5 MHz curved array probe.

Results The fetal adrenal gland length, width and ratio were statistically significant between the successful versus failed induction groups. The cutoff fetal zone ratio > 0.36 for the prediction of successful induction of labor had 90% sensitivity, 89% specificity, 93% PPV and 75% NPV.

Conclusion Fetal zone enlargement (fetal zone ratio > 0.36) is a strong predictor of successful induction of labor as compared to TVL and Bishop’s score. It can be used for screening the women, who are destined for induction failure, so that adverse effects of induction of labor can be avoided.

Postterm pregnancy · Fetal adrenal gland · Fetal gland ratio · Fetal zone ratio · Fetal adrenal gland enlargement

Context Carcinoma Cervix is one of the leading prevalent cancers in India especially in rural population and causes a significant mortality. WHO has launched many projects for prevention, screening and treatment plans. Even after many projects, Cervical Cancer persists as a heavy burden public health problem in rural India.

Aims To calculate survival of cancer cervix patients in a rural population-based RCC and to discuss the factors affecting it.

Methods and Material A hospital-based gathering of retrospective data of the patients diagnosed with carcinoma cervix over 5 years from January 2013 to December 2017 (single institution analysis). We included 751 patient’s data from our cancer registry for analysis. Data related to demographics, treatment and follow up records were taken and statistical analysis done.

Results The survival rates were 64.0%, 50.0%, 36.9% and 17.5% for Stage I, Stage II, Stage III and Stage IV, respectively. The best survival outcomes were for those treated with only surgery. Involvement of nodes had poor survival than those with no involvement. Various patient-related factors like Religion, Education and Marital status are found to be non-significant factors even-though they have survival differences. STAGE of the disease emerged as a significant prognostic factor.

Conclusion Our study concluded that higher stage and nodal involvement had poor outcomes and also lower survival compared to Western and Indian literature. We should also address all the socio-economic factors that affects survival. Randomized prospective studies are needed to evaluate the effect of socio-economic factors on survival.

Cervical cancer · Rural · Socio-economic · Stage · Survival

Introduction Endometriosis is the condition in which there are ectopic endometrial tissues outside the uterine cavity. The use of nerve sparing technique has been well established in the field of oncology, leading to better quality of life following radical oncologic procedures without compromising on the long-term survival. The objective of this study is to compare the quality of life in terms of sexual function and urinary function in women undergoing nerve sparing surgeries for endometriosis and those undergoing non-nerve sparing surgeries.

Material and Methods Data of 51 patients operated for endometriosis at Galaxy Care Laparoscopic Institute, Pune, India between 1st January 2020 till 31st December 2020 were collected and analysed. We included patients in age group between 38 and 44 years in monogamous relationship, with moderate to severe endometriosis (Revised American Society of Reproductive Medicine r-ASRM score of 16 and above 5), being operated for hysterectomy along with ureterolysis and/or bowel resection (including shaving of rectal endometriosis, discoid resection, segmental resection), and excision of large ovarian endometriomas (> 3 cm size) with cul-de-sac obliteration.

Results The patients were evaluated for the following factors: age, parity, nature of surgery done, immediate intraoperative complications (bowel injury, bladder injury, ureteric injury), operative time in minutes, average blood loss, length of hospital stay, days to removal of foley’s catheter and postoperative urinary and sexual function which were assessed on follow up visit and a 1-year follow up interview. We found that the urinary and sexual function in the group undergoing nerve sparing surgeries was significantly better than the patients undergoing non-nerve sparing surgeries.

Conclusion Laparoscopic nerve sparing approach for clearance of endometriosis has allowed better quality of life post surgery. Proper understanding and demonstration of pelvic neuroanatomy has made this approach feasible and achievable in carefully selected patients.

Endometriosis · Laparoscopy · Nerve sparing · Hypogastric plexus

Introduction Retained products of conception (RPOC) generally results after first half of pregnancy termination and also may occur after the vaginal or cesarean delivery. It frequently presents with irregular or continuous vaginal bleeding, lower abdominal and pelvic pain, and discharge per vaginum due to infection; it can also cause late complications like formation of intrauterine adhesions and subfertility. The diagnosis of the RPOC with the symptoms is generally supported by ultrasonog- raphy with or without colour Doppler. The patient also undergoes uterine vasculature assessment to diagnose arteriovenous malformation (AVM). The management of RPOC has been conventionally done with blind dilation and suction curettage (D and C); however, expectant management, uterine artery embolization, and hysteroscopic resection of RPOC are safe and efficient alternatives. Materials and methods In this review, we analyse the current available evidence regarding the clinical presentation, diagnosis and treatment of RPOC comparing the sensitivity, specificity, outcomes, pros and cons of various methods. Conclusion RPOC is common complication associated with early and late complications. The judicious use of antibiotics along with interventional radiology and hysteroscopy forms the backbone for the treatment of this condition.

Retained products of conception · Hysteroscopy · Intrauterine adhesions · Uterine arteriovenous malformation

 Introduction This study was done to assess and compare the efficacy and safety of mifepristone and misoprostol combination versus misoprostol alone for second trimester termination of pregnancy in relation to induction abortion interval, average amount of misoprostol required in each group, success rate and side effects.

Materials and Methods This randomised control study was conducted on 100 women admitted in the Department of Obstetrics & Gynaecology, S.C.B. Medical College & Hospital, Cuttack, for second trimester termination of pregnancy, divided into two groups, Group A and Group B of 50 patients each. Group A patients received 200 mg of oral mifepristone followed by 400 mcg of vaginal misoprostol after 48 h, and then 400 mcg of vaginal misoprostol every 3 hourly until complete expulsion or up to a maximum of 6 doses. Group B patients received 400 mcg of vaginal misoprostol every 3 hourly until complete expulsion or up to maximum 6 doses.

Results Complete abortion was seen in 92% and 72% cases in Group A and Group B, respectively. Mean induction abortion interval was 11.59 ± 2.71 h in Group A and 15.57 ± 2.27 h in Group B (p value < 0.001). The average dose of misoprostol required was less in combination regimen, i.e. 1128 ± 384 mcg compared to 1680 ± 302 mcg in misoprostol alone group (p value < 0.001). Side effects like nausea, vomiting and diarrhoea were less in combination regimen than misoprostol alone group.

Conclusion Mifepristone and misoprostol combination is more effective and safer alternative than misoprostol alone in second trimester termination of pregnancy.

Second trimester termination of pregnancy · Mifepristone · Misoprostol · Induction–abortion interval

Study objective To measure pain using a visual analogue scale (VAS) and analyse its relationships with variables such as menopausal status, parity, uterine and cervical pathology, procedure length, and anxiety in patients undergoing ambulatory hysteroscopy (AH). Design Prospective observational study. Setting Dr DY Patil Medical Hospital and Research Centre, Dr.D.Y. Patil Vidyapeeth, Pimpri, Pune. Patients Seventy-five women. Intervention Ambulatory hysteroscopy(AH).

Methodology AH was performed in seventy-five patients using vaginoscopic approach. At the end of the procedure, the intensity of pain was assessed using the visual analogue scale (VAS), from the score of 0 (no pain) to 10 (intolerable pain). The factors determining pain were assessed.

Results Patients who underwent AH reported mild pain in 66% of cases, moderate pain in 22%, and severe pain in 12% of cases. The most frequent reason for referral was abnormal uterine bleeding (AUB). In the moderate pain group, the bivariate analysis was statistically significant for menopausal status (P values < 0.001), cervical pathology (< 0.001), and duration of procedure (0.001) and in multivariate analysis nulliparity (0.001) and menopausal status (0.001) were the significant determining factors. In severe pain group, the bivariate analysis was statistically significant for cervical pathology (P value = 0.001) and in multivariate analysis cervical pathology (0.003) and uterine pathology (0.002) were the significant determining factors.

Conclusion Hysteroscopy is a safe, painless and a gold standard procedure. Pain experienced during AH was significantly influenced by cervical pathology. Gynaecologists in practise should receive training and start using AH to assess the endometrial cavity.

Ambulatory hysteroscopy · Factors · Pain

Human papillomavirus (HPV) infection, particularly infection with HPVs 16 and 18, is a major cause of cervical cancer. The current high-risk HPV screening or diagnosis tests use cytological or molecular techniques that are primarily based on qualitative HPV DNA detection. Comparative studies, however, revealed that different assays have varying sensitivities for detecting specific HPV types. Here, we developed and optimized a sensitive PCR (Polymerase Chain Reaction) assay for detection of high-risk HPV-16 and HPV-18. The PCR parameters were optimized, and analytical specificities were validated. Performance of developed PCR assay was evaluated in clinical samples (n = 100) which showed 100% specificity for both the assays and 96.97% and 94.12% sensitivity for HPV-16 and HPV-18, respectively. The developed assay demonstrated high sensitivity and specificity for detection of high-risk HPV-16 and HPV-18, making it applicable to routine HPV detection practices. Human papillomavirus · PCR · Detection · Cervical cancer

Introduction LNG-IUD although used extensively for its non-contraceptive indications like abnormal uterine bleeding (AUB), dysmenorrhoea and fibroid uterus, one of the major drawbacks is the high expulsion rates, especially among adenomyotic and fibroid uterus.

Material and Methods Altius Hospitals, Bangalore have developed a new technique of LNG-IUD fixation, which employs hystero-laparoscopy and usage of a long port closure needle with delayed absorbable sutures.

Conclusion. It ensures proper placement and fixation of the LNG-IUD to the uterine cavity, reduces the expulsion rates and has the advantages of being a day care procedure.

Abnormal uterine bleeding · Dysmenorrhoea · Intrauterine device expulsion · LNG-IUD · Hystero-laparoscopic fixation

Furcate and velamentous cord insertions are very rare. Furcate indicates forking of the cord vessels before it reaches the placental mass and, velamentous indicates insertion of cord into the membranes. This pictorial essay presents a case wherein both these entities were found together, diagnosed prenatally and confirmed postnatally.It briefs about the diagnostic features and its clinical implications.

Stillbirth is over-represented in lower and lower-middle-income countries and understandably this has motivated greater research investment in the development of prediction models. Prediction is particularly challenging for pregnancy outcomes because only part of the population is represented in observational research. Notably, unrecognised pregnancies and miscarriages are typically excluded from the development of prediction models and the consequences of such selection are not well understood. Other methodological challenges in developing stillbirth prediction models are within the control of the researcher. Identifying whether the intended model is for aetiological explanation versus prediction, attainment of a sufficiently large representative sample, and internal and external validation are among such methodological considerations. These considerations are discussed in relation to a recently published study on prediction of stillbirth after 28 weeks of pregnancy for women with hypertensive disorders of pregnancy in India. The predictive ability of this model amounts to the flip of a coin. Future screening based on such a model may be expensive, increase psychological distress among patients and introduce additional iatrogenic perinatal morbidities from over-treatment. Future research should address the methodological considerations described in this article. Stillbirth · Prediction models · Validation

The 10 edition of D C Dutta’s Obstetrics Textbook is released in 2023,within its due time frame. As before , this popular comprehensive textbook is aimed to serve the readers with the updated knowledge. It is enriched with the incorporation of contemporaneous guidelines and the recommendations of FOGSI and the other international academic bodies. Importantly, this 10 edition is written fulfilling the curriculum, as designed by the National Medical Commission (NMC) of India. The presentation and the language throughout the text is simple and unambiguous. It is enriched with huge number (more than 790) of illustrations, photographs, images ( USG, MRI), sketches, flowcharts, and boxes. The key points at the end of each chapter are of special value for quick revision before the examination. QR codes are there for more information. The video lecture series, case presentations, animations for procedures, and maneuvers are added for easy understanding and skill development . Author has given much emphasis on the changing trends in current obstetric practice in India and the world over . Current progress in diagnostic imaging, prenatal diagnosis, labor monitoring and maternal –fetal medicine, have been adequately highlighted. I feel, D C Dutta’s Textbook of Obstetrics, authored by Prof. Hiralal Konar, is an updated comprehensive textbook .This book is a must for all the medical students, residents, practicing Obstetricians and the midwives.