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ABSTRACTSVOLUME 68NUMBER 4JULY - AUGUST 2018

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EDITORIAL

Rejection Blues : why do papers get rejected?

Suvarna Satish Khadilkar

Abstract

It is really disheartening when your paper gets rejected by a journal. Authors work very hard to conduct research. They present their work in the form of platform presentation in a conference and or as a research article for publication. When their platform presentations get applauded by the audience, researchers feel encouraged to publish it. However, it may not be appreciated by editors and reviewers when the research is submitted to a journal for publication. One should not get disappointed by rejections. Most top journals have almost 80 % rejection rates. This editorial will take a brief review of reasons for rejection and advise how to deal with rejections.

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INVITED REVIEW ARTICLE

Ovulation Induction for the General Gynecologist

SSteven R. Lindheim • Tanya L. Glenn • Megan C. Smith • Pascal Gagneux

Abstract

The practice of ovulation induction often falls to the reproductive endocrinology and infertility specialist. However, attitudes toward the evaluation and treatment of infertility has shifted among general obstetrician-gynecologists (OB-GYN). This review discusses the underlying scientific basis of anovulation and clinical guidelines regarding the use of different medications for the purpose of promoting follicular recruitment and ovulation for the general OB-GYN.

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INVITED MINI REVIEW ARTICLE

Is LNG-IUS the One-Stop Answer to AUB?

Jayashree Nayar • Sobha S. Nair • Nisha Annie George •

Abstract

A systematic search of the literature available on the use of Levonorgestrel intra-uterine system (LNG-IUS) in women with abnormal uterine bleeding was done. This included PubMed searches up to February 2017 as well as references available with the authors. LNG-IUS usage in other situations was not included in the study. Each relevant published article was evaluated as to whether it served the purpose of this review. Available data show that LNG-IUS is certainly the one-stop answer to AUB, providing a safe and cost-effective treatment and being a substitute for hysterectomy in most women with AUB.

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ORIGINAL ARTICLES


OBSTETRICS

Impact of Gestational Weight Gain on Cesarean Delivery Risk, Perinatal Birth Weight and Gestational Age in Women with Normal Pre-pregnancy BMI

Reza Omani-Samani • Mahdi Sepidarkish • Saeid Safiri • Arezoo Esmailzadeh • Samira Vesali • Farahnaz Farzaneh • Amir Almasi-Hashiani

Abstract

Background :Gestational weight gain (GWG) proportional to body mass index before pregnancy is one of the factors on maternal and neonatal outcomes. The aim of the current study was to assess association between GWG, and cesarean section, birth weight and gestational age at birth in women with normal BMI prior to pregnancy.

Methods:This was a cross-sectional study carried out in 103 hospitals in Tehran, the capital of Iran, from July 6 to 21, 2015. The data were extracted by 103 trained midwives. Finally, 2394 pregnant women with normal BMI before pregnancy and singleton birth were examined. GWG was categorized based on Institute of Medicine (IOM) recommendations.

Result:Prevalence of low birth weight (LBW) was 5.41% and prevalence of macrosomia was 2.18%. The prevalence of LBW in women with GWG less than the weight gain recommended by IOM was 2.13 times [95% confidence interval (CI) 1.13–4.02, P = 0.019] more than in women with GWG equal to the weight gain recommended by IOM. There was no statistically significant difference in the prevalence of LBW between women with GWG more than recommended weight gain by IOM and women with GWG equal to the weight gain recommended by IOM (OR = 1.21, 95% CI 0.61–2.38, P = 0.580).

Conclusion :After controlling for confounding variables, the prevalence of cesarean section and preterm birth had no significant difference at various levels of GWG. Accordingly, the prevalence of LBW among women with GWG less than the recommended weight gain by IOM was significantly 2.13 more than that among women with GWG equal to the recommended weight gain by IOM.

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Outcomes of Multifetal Reduction: A Hospital-Based Study

Madhusudan Dey • 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: The 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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Feto-maternal Outcomes in Pregnancies Complicated by Thermal Burns

Pratima Mittal• Shankar Kripa • Anjum Ara • Vinay Kumar Tiwar

Abstract

Background: Burns in pregnancy can be a potentially life-threatening condition for both mother and baby. Human physiology is altered during pregnancy and burns add further stress leading to diminished maternal reserves. Very few studies have been reported for management of such patients.

Materials and Methods : This was a prospective based study carried out in Department of Burns and Plastic Surgery in collaboration with Department of Obstetrics and Gynaecology and Department of Pediatrics for a period of 20 months from December 2011 to July 2013. Pregnant women with thermal injuries more than 15% TBSA were included in the study. Patients with coexisting obstetrics complications and burns other than thermal were excluded.

Results:Out of 3397 female patients of burns admitted, 1382 patients were in reproductive groups, 1116 were married and 67 were pregnant; these were enrolled. Maternal and fetal outcome is inversely linked with the TBSA of the mother (p < 0.001). In TBSA group 15–30%, there was no maternal and fetal mortality, but in TBSA >30–50% maternal mortality was 44%, and in 50–70% maternal mortality was 83% and no mother survived in >70%. In TBSA 30–50%, fetal mortality was 72%. Only one baby survived in 50–70% TBSA group and one in >70% TBSA group after intensive care in NICU for prematurity. Fetal survival was also dependent on gestational age, and there are better outcomes in late trimesters.

Conclusions:Maternal and fetal outcome are directly related to TBSA of mother, and best care can be offered to such patients with a multidisciplinary team-based approach.



Predicting Successful Trial of Labor After Cesarean Delivery: Evaluation of Two Scoring Systems

Mayur Dilipbhai Patel • Nandita Maitra • Purvi K. Patel • Tosha Sheth • Palak Vaishnav

Abstract

Background:Attempting vaginal birth after cesarean section (VBAC) places women at an increased risk of complications. Trial of labor after cesarean (TOLAC) calculators aim to predict the chance of successful vaginal birth after cesarean (VBAC) based on the patient’s preexisting demographic and clinical factors.

Objective:To assess the rate of successful TOLAC using two calculators: FLAMM and the Grobman calculator, and to compare the performance of the two calculators in the successful prediction of VBAC.

Methods: Prospective cohort study in subjects with previous one caesarean section using well-defined inclusion and exclusion criteria.

Results:A total of 280 subjects with previous one cesarean section were enrolled. One hundred thirty-nine subjects consented for TOLAC, 90 (67%) underwent successful trial of vaginal birth, and 49 (32.8) required cesarean section. Cervical dilatation (p < 0.0001) and effacement (p < 0.0001), and any prior vaginal delivery (p < 0.02) were significantly associated with a successful outcome. At a cutoff score of 5, the sensitivity of the FLAMM score was 72% and specificity was 76%. For the Grobman calculator, the best sensitivity (69%) and specificity (67%) were seen at a cutoff score of 85%.

Conclusion:Both prediction models, the FLAMM and the “close to delivery” nomogram, recommended by Grobman et al. are easy to use and could successfully estimate the chances of vaginal birth in previous caesarean, in this small cohort. The decision for women opting for TOLAC can be individualized, and patient-specific chances of success can be predicted by the use of these prediction models.

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Association of Thyroid Dysfunction and Autoimmunity in Pregnant Women with Diabetes Mellitus

Hiralal Konar • Madhutandra Sarkar • Manas Roy

Abstract

Purpose:This study was undertaken to find out the proportion of women with thyroid dysfunction in pregnancy complicated by diabetes mellitus; to find out the association, if any, of thyroid dysfunction and of antithyroid peroxidase (anti-TPO) antibodies during pregnancy in women with pregestational (PGDM) and gestational diabetes mellitus (GDM); and to find out the maternal and perinatal outcomes of pregnancies complicated by both diabetes mellitus and thyroid dysfunction.

Methods:A cross-sectional observational study was conducted in a tertiary care teaching hospital in Kolkata, India, for a period of 1 year. Sixty-four pregnant women with diabetes, both PGDM and GDM, were recruited from the antenatal clinic. They were managed and followed up till 6 weeks postpartum. Their plasma glucose levels were estimated, and thyroid function was evaluated periodically. All relevant data were recorded and analyzed statistically.

Results:Most (81.25%) women had GDM. Forty percent women suffered from some form of thyroid disorder, mostly (37.5%) hypothyroidism. Thyroid dysfunction was not associated with the type of diabetes mellitus (GDM or PGDM) (p > 0.05). The higher rate of anti-TPO titers was observed in pregnancies with PGDM compared to pregnancies with GDM; however, this difference was not statistically associated (p > 0.05). All pregnant women with combined endocrinopathy delivered by cesarean section, and the most common neonatal complication observed was jaundice.

Conclusion: Thyroid disorders are quite common during pregnancy complicated by diabetes mellitus. The study findings warrant routine screening for thyroid abnormalities in diabetic pregnant women. These women have increased rate of maternal and neonatal complications.

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Role of PDW and Plateletcrit in the Assessment of Nonthrombocytopenic Preeclampsia and Eclampsia

Abha Singh • Ruchi Varma

Abstract

Objectives:To evaluate the role of platelet indices in preeclampsia and eclampsia.

Methods:An observational analytical study was conducted in Department of Obstetrics and Gynaecology, Ambedkar Hospital, Pandit Jawaharlal Nehru Memorial Medical College, Raipur. It was performed on 150 women between March 2015 and February 2016; among them, 42 were taken as controls, 36 were preeclampsia and 72 were eclampsia. Their platelet count and platelet indices were done, analyzed and compared.

Results:In our study, we found that mean platelet count and mean plateletcrit showed a significant decrease while mean MPV and mean PDW showed a significant increase with increasing severity of disease. Also, we observed that 66.7% preeclampsia and 51.4% eclampsia were nonthrombocytopenic. Among these women, a decrease in the values of plateletcrit and an increase in PDW were seen in a significantly higher number of eclampsia patients. So these two platelet indices can become the new marker for an adverse outcome in preeclampsia and eclampsia even in women presenting with normal platelet counts.

Conclusion:Platelet indices showed a significant variation along with the severity of the disease. Platelet indices, especially PDW and plateletcrit, can be used along with platelet count to evaluate the severity of preeclampsia and eclampsia instead of relying on platelet count alone.

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A Randomized, Open-labelled, Interventional Study to Evaluate the Incidence of Infection with or Without Use of Prophylactic 4 Antibiotics in Patients of Episiotomy in a Normal Vaginal Delivery

Amrita N. Tandon • Asha R. Dalal

Abstract

Aim:The aim of this study was to compare the incidence of infection in patients of episiotomy with or without the use of prophylactic antibiotics and to compare other morbidities associated with episiotomy and the role of antibiotics in their prevention and treatment.

Design:This open-labelled, randomized, interventional study was conducted in the Department of Obstetrics and Gynaecology at BYL Nair Charitable Hospital, Mumbai, Maharashtra, from October 2014 to October 2015. Three hundred women subjected to episiotomy during normal vaginal delivery in the labour ward from BYL Nair Charitable Hospital fulfilling specific criteria were enrolled in this study and randomly divided into two study groups A and B. In group A, 5-day course of prophylactic antibiotics including tablet cefixime 200 mg BD and tablet metronidazole 400 mg TDS was given, and in group B, prophylactic antibiotics were not given. The two groups were followed up for a period of 5 days postpartum and observed for signs and symptoms of infection.

Main Outcome:Presence of infection, i.e. presence of any positive finding including redness/pain/swelling/wound discharge or wound gape in group A (with antibiotics), was 0.7%, and in group B (without antibiotics) was 2%. The p value by Fischer’s exact test was 0.622 which is not significant. Hence, there was no increased incidence of infection in either group, whether antibiotics were given or not.

Conclusion:To summarise, in our study, it was seen that prophylactic antibiotics did not decrease the incidence of infection in episiotomy following normal vaginal delivery in uncomplicated cases, but further studies are required to evaluate this topic and come to a more definitive conclusion.

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Frequency of Red Cell Alloantibodies in Pregnant Females of Navsari District: An Experience that Favours Inclusion of Screening for Irregular Erythrocyte Antibody in Routine Antenatal Testing Profile

Manoj Kahar

Abstract

Background:Alloimmunisation due to irregular erythrocyte antibodies is a recognised cause of hemolytic disease of the fetus and newborn (HDFN). Prior knowledge of red cell alloimmunisation in pregnant females guides the obstetrician to monitor the foetus for HDFN and if required for appropriated intervention. As limited data are available on prevalence of red cell alloimmunisation in pregnant females in India, the current study was carried out to know the prevalence of red cell alloimmunisation in pregnant females coming at our laboratory.

Methods:Screening for irregular erythrocyte antibodies was performed in 1960 pregnant females after obtaining informed consent between June 2015 and June 2016. MatrixTM screening and identification reagent red cells from Tulip Diagnostics (P) Ltd were used, and column agglutination technique was employed as a method for the test.

Results:Twenty antibodies (all of single specificity) were detected in 1960 samples giving a prevalence rate of alloimmunisation of 1.02%. Out of the 20 antibodies, 18 were identified to be anti-D, 1 was anti-c and 1 antibody was anti-H. The results obtained were then compared with those reported in the literature.

Conclusion:Red cell alloimmunisation is not uncommonly observed in pregnant females; the information gained can help the obstetrician to identify high-risk cases to timely start antenatal and post-natal treatment. Obstetricians should request screening for irregular red cell antibody desirably in all pregnant females; however, if limiting factors are there, it should be done at least in select group of pregnant females having bad obstetric history.

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ORIGINAL ARTICLES


GYNECOLOGY

Dienogest Versus Leuprolide Acetate for Recurrent Pelvic Pain Following Laparoscopic Treatment of Endometriosis

Ahmed Mahmoud Abdou • Islam Mohamed Magdi Ammar • Amr Abd Almohsen Alnemr • Amr Ahmed Abdelrhman

Abstract

Objective: To compare the efficacy and safety of dienogest (DNG) with depot leuprolide acetate (LA) in patients with recurrent pelvic pain following laparoscopic surgery for endometriosis.

Design: Prospective randomized trial.

Setting:Zagazig University hospitals, Egypt.

Patients:Two hundred and forty-two patients with recurrent pelvic pain following laparoscopic surgery for endometriosis.

Intervention:Dienogest (2 mg/day, orally) or depot LA (3.75 mg/4 weeks, intramuscularly) for 12 weeks.

Main Outcome Measures:A visual analogue scale was used to test the intensity of pain before and after the end of treatment.

Results:There was highly significant reduction in pelvic pain, back pain and dyspareunia in both groups with mean of difference in dienogest group (28.7 ± 5.3, 19.0 ± 4.3 and 20.0 ± 3.08 mm, respectively) and in LA group (26.2 ± 3.01, 19.5 ± 3.01 and 17.9 ± 2.9 mm, respectively). The most frequent drug-related adverse effects in dienogest group were vaginal bleeding and weight gain (64.5 and 10.8%, respectively) which were significantly higher than LA group (21.5 and 3.3%, respectively). While the most frequent drug-related adverse effects in LA group were hot flushes and vaginal dryness (46.3 and 15.7%, respectively) which were significantly higher than dienogest group (15.7 and 3.3%, respectively).

Conclusion:Daily dienogest is as effective as depot LA for relieving endometriosis-associated pelvic pain, low back pain and dyspareunia. In addition, dienogest has acceptable safety, tolerability and lower incidence of hot flushes. Thus, it may offer an effective and well-tolerated treatment in endometriosis.

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Thirteen Years of Experience with Opportunistic Bilateral Salpingectomy During TLH in Low-Risk Premenopausal Women

P. G. Paul • Sumina Mannur • Hemant Shintre • George Paul • Gunjan Gulati • Santwan Mehta

Abstract

Background: Opportunistic bilateral salpingectomy (OBS), also called as prophylactic salpingectomy or risk-reducing salpingectomy is the concurrent removal of the fallopian tubes in premenopausal women. Though there are some studies comparing the intraoperative complications and effect of salpingectomy on ovarian reserve, limited data are available on long-term follow-up after OBS.

Purpose of the Study:To evaluate the surgical outcome of routine bilateral salpingectomy during total laparoscopic hysterectomy (TLH) in terms of intraoperative and postoperative complications. We also evaluated the incidence and reoperation rate for adnexal pathology after TLH.

Methods:A retrospective study of 1470 patients undergoing total laparoscopic hysterectomy (TLH) with opportunistic bilateral salpingectomy (OBS) over 13 years was carried out at Paul’s Hospital.

Results:The mean age of the subjects was 43.6 ± 4.2 years, mean body mass index was 27 ± 5.4 kg/m2, and median parity was 2 (range 0–7). 43% of women had at least one previous surgery. The most common indication for surgery was fibroid uterus (67%, n = 985). The total complication rate was 4.4% (n = 65). One specimen showed paratubal borderline serous malignancy. The follow-up period ranged from 6 months to 13 years during which 17 (1.1%) women had adnexal pathology, and eight women (1.1%) needed resurgery for it. No ovarian malignancies were reported on follow-up.

Conclusion: OBS is a simple and short surgical step during TLH without increasing morbidity. OBS eliminates the risk of future diseases of tubal origin, and there might be a possible reduction in incidence and reoperation rate for future ovarian pathologies.

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CASE REPORT


OBSTETRIC

Chronic Uterine Inversion Following Mid-Trimester Abortion

Sujnanendra Mishra

Abstract

Uterine inversion during the postpartum period is a relatively rare but serious complication. It occurs as acute, chronic and sub-acute forms depending on time interval from delivery. In terms of onset of the inversion, acute describes the event occurring before cervical ring contraction. If the cervical ring has contracted, a subacute inversion has occurred. The inversion is classified as chronic if 4 weeks have elapsed before the event. Severe post-partum hemorrhage and shock result from the uterine inversion. If unrecognized, this obstetric emergency could cause serious morbidity or death. The reported incidence of uterine inversion varies considerably in the literature. Treatment options for this obstetric complication also varies from patient to patient and depends upon Surgeon’s familiarity with the procedure. Available Options for correcting an inversion are Hydrostatic, as well as manual and surgical reposition with or without pharmacological agents (Uterine relaxants). Here is a case report of complete chronic uterine inversion following spontaneous mid trimester Abortion.

Uterine inversion can be a life-threatening obstetric complication. Although uncommon, if unrecognized, severe hemorrhage and shock will lead to maternal death. It can also follow an abortion. It is imperative that every physician providing obstetric care be aware of the common signs of inversion so that the diagnosis can be determined and treatment initiated immediately.

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CASE REPORT


GYNECOLOGY

A Rare Case of Malignant Melanoma of Vagina

Rizwana Habib Kant • Shabir Iqbal • Mufti Mahmood Ahmad • Javed Shafi • Sabia Rashid • Preeti Sharma

Abstract

Malignant melanoma of vagina is a rare tumor with an indigent prognosis. There is also high risk of recurrence, distant metastasis and short survival time. Current therapeutic options for primary vaginal melanoma are local excision or radical surgery, radiotherapy, chemotherapy and immunotherapy which can be used individually or in combination. This is a case report of 40 year old female para 4 live 4 (previous 3 LSCS) diagnosed with malignant melanoma of vagina. Patient underwent Radical excision – hysterectomy with complete vaginectomy and lymph node dissection. This was followed by reconstruction of vagina. Patient received radiotherapy in post operative period. The patient is alive after 1 year and doing well.

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SHORT COMMENTARY

Artificial Intelligence: The Future of Obstetrics and Gynecology

Gaurav Shyam Desai

Abstract

Background :Artificial intelligence or ‘big data’ comprises of algorithms which aid in decision making. It has made an impact on a number of professions including obstetrics and gynecology.

Objective :To make readers aware of where artificial intelligence has a role in obstetrics and gynecology.

Material and methods :A comprehensive review of the literature was undertaken to compile a list of instances where artificial intelligence was applied to obstetrics and gynecology.

Conclusion :Artificial intelligence should be utilized to benefit patient care and assist the physician in providing data for decision making.

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LETTER TO EDITOR

Retinal Detachment in Women with Eclampsia and Pre-Eclampsia

Lorenzo Ferro Desideri • Fabio Barra • Simone Ferrero

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