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ABSTRACTSVOLUME 68NUMBER 3MAY - JUNE 2018

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EDITORIAL

The Art and Craft of Making a Draft: Writing a Good Quality Scientific Paper!

Suvarna Satish Khadilkar

Abstract

Medical scientific writing is an art! The key to master this art is doing good research work and writing consistently good quality articles. While writing a scientific research paper you must first ensure that the research you performed has originality and a potential to be of help. Your work should have relevance to women’s health and should be significant enough to create an impact on health care. Will, skill, and drill are the three components of the art of quality scientific writing. These are built on the sound foundations of science and integrity of the researcher. This editorial will give useful tips towards writing a good quality scientific paper.

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INVITED REVIEW ARTICLE

Critical Care in Obstetrics: Where are We

Sushil Chawla • T. Jose • Manish Paul

Abstract

Maternal mortality is disastrous news for the society, family, newborn, and the obstetrician. Yet, we all who are care providers to these apparently healthy women carrying another life within them are dumbfounded by the clinical conditions arising due to the pregnancy or the effects of the pregnancy, that it becomes difficult to provide an ideal care to them. The rapid uprising of a condition and the worsening of commonly occurring benign conditions—preeclampsia, hemorrhage, etc., necessitates that all obstetricians are well versed with the physiological changes and should be able to not only provide the best of obstetric care to the mother and the newborn but also perform or assist in performance of life-saving procedures.

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INVITED MINI REVIEW ARTICLE

Pitfalls in Ultrasound Diagnosis of Cesarean Scar Pregnancy

Lakshmy Ravi Selvaraj • Nity Rose • Meenakshi Ramachandran

Abstract

Cesarean scar pregnancy (CSP) is a rare kind of ectopic pregnancy implanted in the previous cesarean scar and has an increasing incidence over the past 30 years. As the suspicion is low, the diagnosis may be delayed or misinterpreted in ultrasound, leading to treatment strategies that might end up in uterine rupture or hysterectomy. The objective here is to review the ultrasound findings in CSP with varied presentations. Transabdominal and transvaginal sonography combined with color Doppler is a reliable tool for the diagnosis of CSP. When the gestational sac is seen in lower part of the uterine cavity, differentiation between threatened miscarriage, cervical pregnancy and CSP could be difficult. Not all cases of CSP present with typical ultrasound findings and a high index of suspicion is needed for diagnosis in these cases. An attempted curettage or MTP pill taken in an undiagnosed CSP often alters the typical findings. The possibility of CSP should also be considered in cases presenting with abnormal uterine bleeding and have a prior history of cesarean section. With lack of awareness about this condition, the diagnosis can often be missed either with MRI or in ultrasound. Correct interpretation and timely diagnosis save the mother from life-threatening complications and also preserves future fertility.

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ORIGINAL ARTICLES


OBSTETRICS

Importance of Adopting BMI Classifications Using Public Health Action Points to Delineate Obstetric Risk Factors Resulting in Worsening Obstetric Outcomes Among Asian Population

Muniswaran Ganeshan • Mohamad Adam Bujang • Shahrul Aiman Soelar • Shamala Devi Karalasingam • Harris Suharjono • Ravichandran Jeganathan

Abstract

Aims :The aim of this study is to compare obstetric outcomes between overweight and class 1 obesity among pregnant women in their first pregnancy based on WHO’s BMI cut-offs and the potential public health action points identified by WHO expert consultations specific for high-risk population such as Asians.

Methods:This is a retrospective cohort review of data obtained from the Malaysian National Obstetrics and Gynaecology Registry between the year 2010 and year 2012. All women in their first pregnancy with a booking BMI in their first trimester were included in this study. The association between BMI classifications as defined by the WHO cut-offs and the potential public health action points identified by WHO expert consultations towards adverse obstetric outcomes was compared.

Result: A total of 88,837 pregnant women were included in this study. We noted that the risk of adverse obstetric outcomes was significantly higher using the public health action points identified by WHO expert consultations even among the overweight group as the risk of stillbirths was (OR 1.2; 95% CI 1.0,1.4), shoulder dystocia (OR 1.9; 95% CI 1.2,2.9), foetal macrosomia (OR 1.8; 95% CI 1.6,2.0), caesarean section (OR 1.9; 95% CI 1.8,2.0) and assisted conception (OR 1.9; 95% CI 1.6,2.1).

Conclusion :A specifically lower BMI references based on the potential public health action points for BMI classifications were a more sensitive predictor of adverse obstetric outcomes, and we recommend the use of these references in pregnancy especially among Asian population.

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Maternal and Early Perinatal Outcomes of Triplet Pregnancy: Study of 82 Triplets from a Single Perinatal Centre in South India

Priya Rajan • Srinivas Murki • Suseela Vavilala • Nirupama Surubhotla

Abstract

Objective : To study the recent trends in maternal and perinatal outcomes of triplet pregnancy from a perinatal centre in South India.

Methods : All triplet pregnancies booked at Fernandez hospital, Hyderabad (a tertiary care perinatal centre in South India), or those referred between 2000 and 2014 were included in the study. The maternal, fetal and neonatal outcome and any interventions like cerclage, steroid administration were studied.

Results: There were 82 triplet deliveries over the study period of 15 years (82 per 69,584 live births). Most of them (78%) conceived with assistance and 83% of the triplets were trichorionic triamniotic. Anaemia and pregnancy induced hypertension were the commonest medical disorders (40.2 and 22%, respectively). Mean gestational age at delivery was 32 ± 2.8 weeks and 91% were delivered by caesarean section. Preterm labour and preterm pre-labour rupture of membranes were present in 29 and 15%, respectively. Antenatal steroids were administered in 87.8 and 53.7% had a cerclage. There were 20.7% growth restricted fetuses and 5.6% still births among the triplets. The mean birthweight among the live born neonates was 1.5 kg, and birthweight discordancy of >25% was seen in 14%. Among the live born neonates, 80% required admission to the neonatal intensive care unit, 11% had culture positive sepsis, 3% had bronchopulmonary dysplasia, and 4% died during the hospital stay. None of them had periventricular leukomalacia or retinopathy requiring LASER. Mothers in the spontaneous conception group were younger and had more monochorionic triamniotic pregnancies than in the assisted conception groups (11.8 vs. 2.9%, p = 0.001). The incidence of PPROM was significantly more in the spontaneous conception group than in the ovulation induction, intrauterine insemination groups (29.4 vs. 2.9%, p = 0.03), we do not have an explanation for this. There was no difference in the other maternal, fetal or neonatal parameters based on the mode of conception.

Conclusion:Though triplet pregnancies are encountered infrequently, obstetricians should be familiar with their management. Appropriate antenatal, perinatal care with neonatal support can result in optimal outcome.

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

Mahmoud Thabet • Mohamed Sayed Abdelhafez • Emad Ahmed Fyala

Abstract

Objective: To describe the use of intrauterine inflated Foley’s catheter balloon for control of postpartum hemorrhage (PPH) during cesarean section (CS) in cases of abnormally invasive placenta previa aiming to preserve the uterus.

Method : Retrospective case–control study of the data of women who underwent elective CS on abnormally adherent placenta previa was carried out. Women in whom inflated Foley’s catheter balloon was used for control of PPH during CS (n = 40) were compared with a control group of women who underwent elective CS by the same technique but without use of intrauterine catheter balloon (n = 38).

Results:Use of intrauterine inflated Foley’s catheter balloon significantly reduced the estimated amount of blood loss (P = 0.008), amounts of crystalloids, colloids and packed red blood cells transfusion (P = 0.025, 0.017 and 0.022, respectively), and the need for bilateral internal iliac artery (IIA) ligation (P = 0.016). No significant difference was observed between both groups regarding the use of massive transfusion protocol, performing cesarean hysterectomy, relaparotomy, and admission to the intensive care unit.

Conclusions:Application of an intrauterine inflated Foley’s catheter balloon during CS in cases of morbidly adherent placenta previa helps to control PPH with preservation of the uterus and decreases the need for the invasive IIA ligation.

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First-Trimester Uterine Artery Pulsatility Index and Maternal Serum PAPP-A and PlGF in Prediction of Preeclampsia in Primigravida

Islam Mohamed • Magdi Ammar

Abstract

Background:Preeclampsia is a heterogeneous disorder affecting different body systems and frequently associated with morbidity and mortality. Early preeclampsia prediction will reduce this associated morbidity and mortality as it will give the chance for frequent maternal and fetal surveillance and application of prophylactic procedures

Objective:The aim of this work is to evaluate the role of mean pulsatility index (PI) of the uterine arteries and maternal serum concentrations of pregnancy-associated plasma protein A (PAPP-A) and placental growth factor (PlGF) in early preeclampsia prediction in primigravida.

Patients and Methods: Three hundred primigravida attending the antenatal care clinic in Zagazig University Hospitals were included in the study. The mean PI of the uterine arteries was calculated. Maternal serum levels of PAPP-A and PIGF were analyzed by specific immunoassay.

Results:Three hundred women were included in the final analysis, of them 30 patients (10%) suffered from preeclampsia. There was a significant difference between preeclamptic and normal women as regards the mean PI of the uterine arteries and levels of PAPP-A and PIGF at 11–13 weeks. When combining the cutoff levels of the three methods, mean PI of the uterine arteries ≥1.69, PAPP-A assay <0.96 multiple of median (MoM) and PlGF assay <0.91 MoM, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy were 56.7, 99.3, 89.5, 95.4 and 67%, respectively.

Conclusion: The combined measurement of maternal serum PAPP-A and PlGF concentrations and mean PI of the uterine arteries at 11–13 weeks of pregnancy may help to predict preeclampsia in primigravida when other parameters of preeclampsia prediction are normal. However, we need more studies on larger and variable populations to evaluate the use of those combined methods in preeclampsia prediction.

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Nonimmune Hydrops Fetalis: Factors Which Predict Outcome

Manisha Kumar • Vandana Jha • Anuradha Singh

Abstract

Aims and Objective:To evaluate the cause of NIHF cases referred to a tertiary referral center and to analyze the outcome.

Materials and Methods:A total of 130 cases of fetal hydrops registered during eight-year study period were reviewed. Antenatal ultrasound, blood investigations and postnatal fetal examination were done, and outcome was noted.

Results:Out of 130 cases of NIHF, antenatal ultrasound showed the presence of structural malformations in 94/130 (72.3%), cardiac abnormality was the most common (34/130, 26.1%) and cystic hygroma was seen in 15/130 (11.5%). Chromosomal abnormality was observed in 15(11.5%) cases, and Doppler US showed anemia in 4/130 (3.1%) cases only. Live born were 25 (12.9%), and rest all were stillborn or abortion. Later mean gestational age of presentation (p = 0.0001), presence of gastrointestinal malformation (p = 0.0001) and absence of structural malformations (p = 0.0441) were factors significantly associated with live birth; the presence of cystic hygroma (p = 0.0431) or structural heart defect (p = 0.007) was significantly associated with poor outcome.

Conclusion: Fetal anemia was not a common cause of NIHF in the study population. The early onset of hydrops and presence of structural malformation carry a graver prognosis; type of structural defect also has bearing on outcome.

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Blood Transfusion Practices in Obstetrics: Our Experience

Sushil Chawla • Maj H. K. Bal • Brig Shakti Vardhan • Col T. Jose • Ipsita Sahoo

Abstract

Objectives:To ascertain and analyze the indications for transfusion of blood components in obstetric practice at our center.

Materials and Methods:A prospective observational study was conducted to analyze the various indications for transfusion of blood components in a tertiary care hospital.

Results:1.3% of all obstetric patients from our center had blood components transfusion during the study period. Postpartum hemorrhage, placental causes and anemia are the commonest causes for need of transfusion in obstetric practice.

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ORIGINAL ARTICLES


GYNECOLOGY

Postpartum Intrauterine Device Refusal in Delhi: Reasons Analyzed

Aruna Nigam • Ayesha Ahmad • Anshu Sharma • Poonam Saith • Swaraj Batra

Abstract

Aim: To assess knowledge and attitude of women toward postpartum intrauterine contraceptive device (PPIUCD) and analyze reasons of refusal.

Setting and Design: Hospital-based cross-sectional study for 1 year.

Materials and Methods: 550 women were enrolled in the study. Sociodemographic characteristics, knowledge, and attitude toward contraception especially PPIUCD were noted, and the reasons for refusal of PPIUCD were analyzed.

Statistical Analysis:SPSS version 17.0 is used. Continuous variables were reported using mean, and categorical variables were reported using percentages.

Observations:PPIUCD insertion rate was 9.1 %. 78.6 % of women in the study belonged to the age group of 20–30 years, with 79.2 % having education of Class X and above. The overall contraceptive knowledge was 94.4 %. Although 48.4 % women were aware of Cu T as a method of contraception, only 21.9 % of 48.4 %, however, were aware of PPIUCD. None of the women had ever used it before. The commonest prevalent myths regarding Cu T were fear of malignancy (38 %) and fear of menorrhagia (36.4 %). The husband and mother-in-law played important roles in decision regarding PPIUCD insertion and refused the same in 59 % of cases.

Conclusion: The study shows that awareness of PPIUCD is low in this region despite good education, leading to high refusal rates. The commonest reason is lack of appropriate counseling, and not only the woman but the husband and mother-in-law also must be provided the knowledge of it as they play important roles in our society.

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Audit of Female Genital Aesthetic Surgery: Changing Trends in India

Sejal Ajmera Desai • Varun V. Dixit

Abstract

Introduction: Female genital cosmetic surgery (FGCS) is undoubtedly a fast-growing speciality in the world with increasing demand for a variety of procedures to beautify the female genitals. In India, over the last few years, there has been a steady growth in the interest for these procedures.

Materials and Methods: A variety of FGCS procedures were performed on 76 patients from January 2012 to August 2016. The procedures performed were as follows: vaginal tightening, labia minoraplasty, labia majoraplasty, clitoral hood reduction, and hymenoplasty.

Discussion:Based on FSFI scores, labia minoraplasty was more valuable as a cosmetic procedure and vaginal tightening was associated with better sexual function after surgery.

Conclusion: FGCS is no doubt in its infancy in India. However, there is a steady rise in the awareness and demand for these procedures. A combination of procedures to improve individual components leads to improved aesthetic and functional aspects of female genitalia.

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Study on Quality of IUD Services Provided by Trained Professionals at Teaching Institutes

Noopur Prasad • M. L. Jain • B. S. Meena

Abstract

Objective:Access the completeness in IUD services provided by trained professionals and find out the weak links.

Materials and Methods:Study was conducted on 100 IUD trained professionals of tertiary care hospital and nursing teaching institute. All were given questionnaire that was duly filled by them. Data obtained were analysed. Protocols of case selection, pre-insertion counselling, insertion process and follow-up were assessed.

Results:All the four criteria were assessed on score of ten. Study group could not get ten points under any of the set criteria. Average of 53% case selection, 31.4% pre-insertion counselling, 42.5% insertion protocols and 46.1% follow-up counselling criteria were observed by study group. Highest compliance of protocols was seen among postgraduate students.

Conclusions: Although IUD training is given to all medical professionals and IUD facility is available up to subcentres but the study shows that completeness in services is still lacking. Ensuring ideal place for IUD insertion, proper case selection, use of specific instruments for insertion and observance of insertion protocols are very vital for the success of IUD.

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CASE REPORT


OBSTETRIC

Partial Molar Pregnancy with a Normal Fetus with Complete Placenta Previa

Smitha Surendran • Teena Thomas • V. S. Vishnupriya

Abstract

Molar pregnancy is a neoplasm of the trophoplast resulting from fertilization of an ovum. In Complete Mole there is proliferation and pleomorphism of the epithelial cells of the cytotrophoblast and syncytio trophoplast. The stroma of each villus is at first edematous and soon the whole centre core including vessels are destroyed. The villus then swells to form a rounded cyst filled with watery fluid. Thus, chorion becomes a mass of grape like structure varying in size from pin head to a cherry.

Partial mole is characterized by the presence of fetal / embroyonic tissue, focal changes of hydatidiform, swelling of chorionic villi and trophoblastic hyperplasia, marked scalloping of chorionic villi and prominent trophoblastic stromal inclusions. Partial hydatidiform mole can occur without the death of the foetus very rarely. These are cases of twin pregnancies with only one foetus affected. Such fetuses usually do not survive. Those which survive have chromosomal abnormalities, IUGR, or congenitial anomalies.

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CASE REPORT


GYNECOLOGY

Recurrent Ruptured Hemorrhagic Corpus Luteal Cyst in a Known Case of Combined Deficiency of Factor V and VIII

Shruthi Kesireddy

Abstract

Background : Female patients with combined deficiency of factor V and VIII may present with recurrent ruptured hemorrhagic corpus luteal cyst which can be symptomatic and lead to recurrent surgery .This is a case report of a 18 years old patient with combined deficiency of factor V and VIII presenting with recurrent hemorrgahic corpus luteal cyst

Case :18 year old girl with her second episode of hemoperitoneum with severe pain secondary to ruptured corpus hemorrhagicum .She required second laparoscopy within 6 months after the first one.

Conclusion : Ovulation should be supressed with oral contraceptive pills in patients with combined deficiency of factor V and VIII as they may be at risk of recurrent ruptured hemorrhagic corpus luteal cyst . The patient and attendants have to be counseled regarding the need and safety of prolonged usage of contraceptive pills to suppress the ovulation and prevent recurrent life-threatening bleeds, preserve fertility and avoid the potential morbidity caused by repeated surgeries.

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SHORT COMMENTARY

George Papanicolaou (1883–1962): Discoverer of the Pap Smear

Vijayalakshmi Chandrasekhar • Chandrasekhar Krishnamurti

Abstract

Born in 1883 in Kyme, Greece, George Papanicolaou obtained his medical degree in 1904 from the University of Athens and doctorate in Zoology in 1910 from the University of Munich. He migrated to the USA in 1913 and worked as an assistant at the Department of Anatomy in the Cornell Medical College. There, Papanicolaou examined vaginal smears under his microscope, charted the cyclic ovarian and uterine changes every day and harvested the oocytes at the appropriate time. He published his research on the cytologic patterns in guinea pigs in the American Journal of Anatomy in 1917. Eventually, he began taking similar scrapings from women and noticing malignant cells in smears taken from women with cancer. In 1928, his presentation on the topic at the Race Betterment Conference in Battle Creek, Michigan, was greeted with skepticism as researchers felt that a biopsy and tissue examination was the only way to detect the disease. In 1939, he collaborated on a clinical study with Herbert F. Traut, MD, a gynecologic pathologist at Cornell, to validate the diagnostic potential of the vaginal smear and published their landmark paper in 1943 titled “Diagnosis of uterine cancer by the vaginal smear.” In 1954, Papanicolaou published the “Atlas of Exfoliative Cytology.”

George Nicholas Papanicolaou was a pioneer in cytopathology and creator of the Papanicolaou test or Pap smear. This revolutionized the early detection of cervical cancer and led to a 70% reduction in cervical cancer deaths.

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LETTER TO EDITOR

Combined Cabergoline and Metformin in Patients with Polycystic Ovarian Disease with Hyperprolactinemia: Methodological Concerns

Ahmed Mohamed Abbas

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