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OFFICIAL JOURNAL OF THE FEDERATION OF OBSTETRIC AND GYNAECOLOGICAL SOCIETIES OF INDIA - www.jogi.co.in

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(Emerging Sources Citation Index (ESCI), PubMedCentral, SCOPUS, EMBASE, Chemical Abstracts Service (CAS), Google Scholar, Indian Science Abstracts, MedInd, OCLC, PubMed (12 months embargo), SCImago, Summon by Serial Solutions.

ABSTRACTSVOLUME 68NUMBER 1JANUARY - FEBRUARY 2018

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OBITUARY

The Man, The Legend!
Dr. Chandrasekhar Vishweshwar Hegde (EDITOR IN CHIEF, JOGI – 2017)

Asha R. Dalal

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EDITORIAL

Change of Guard

Dr. Suvarna Khadilkar

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INVITED REVIEW ARTICLE

The Partograph in Childbirth: An Absolute Essentiality or a Mere Exercise?

Asha R. Dalal • Ameya C. Purandare

Abstract

WHO has recommended use of the partograph, a low-tech paper form that has been hailed as an effective tool for the early detection of maternal and fetal complications during childbirth. Yet despite decades of training and investment, implementation rates and capacity to correctly use the partograph remain low in resource-limited settings. Nevertheless, competent use of the partograph, especially using newer technologies, can save maternal and fetal lives by ensuring that labor is closely monitored and that life-threatening complications such as obstructed labor are identified and treated. To address the challenges for using partograph among health workers, health-care systems must establish an environment that supports its correct use. Health-care staff should be updated by providing training and asking them about the difficulties faced at their health center. Then only the real potential of this wonderful tool will be maximally utilized.

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INVITED MINI REVIEW ARTICLE

Amniotic Fluid Stem Cells: A New Era in Regenerative Medicine

Mala Srivastava • Neha Ahlawat • Ankita Srivastava

Abstract

Regenerative medicine has become an emerging field which focuses on repair, replacement or regeneration of cells, tissues and the entire organs. The regeneration may occur in patient’s own body by using their system as a bioreactor, e.g., cell therapy that involves transplantation of stem cells capable of proliferating, differentiating and replacing damaged host cells. As the field of regenerative medicine advances, and sources of stem cells has been intensified. Though embryonic and adult tissues can be used for isolation of pluripotent stem cells, the amniotic fluid (AF) has been proposed as an alternative source of stem cells for tissue regeneration. AF cells could be banked and used for either allogeneic or autologous transplantation.

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OBSTETRIC


ORIGINAL ARTICLES

Decision Delivery Interval in Emergency and Urgent Caesarean Sections: Need to Reconsider the Recommendations?

Nalini Mishra • Ruchi Gupta • Nomita Singh

Abstract

Introduction: The timeline between a decision made and delivery of the baby is termed decision delivery interval (DDI). According to current recommendations, an emergency caesarean section must be performed within 30 min of the decision. The present study was conducted with an objective to assess DDI in a busy obstetric unit in India and its impact on obstetric outcome.

Material and Method: A total of 480 women with indications of category I (emergency): Immediate threat to life of woman or foetus (n = 66), and category II (urgent): Maternal or foetal compromise but not immediately life-threatening (n = 414), were studied in the context of DDI and composite adverse perinatal outcomes including fresh stillbirth, 5-min Apgar score <7 and NICU admission.

Result: Recommended DDI of <30 min could be achieved in 30% cases of emergency CS only. Sixty-three per cent with prolapsed cord could be delivered within 30 min. The composite neonatal outcomes were not significantly increased up to DDI of 60 min for category I (emergency) (except in prolapsed cord) and up to 90 min in category II (urgent) caesarean sections.

Conclusion: Authors propose reconsideration of the present recommendations of DDI in categories I and II, while Crash CS (cord prolapse or catastrophic antepartum haemorrhage) should be a separate group with recommended DDI of 30 min. For the remaining cases in the present emergency CS group, the suggested DDI of 60 and, for urgent group, 90 min may be made following further studies to prevent this DDI yardstick from becoming a rod at our back.

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First-Trimester Inflammatory Markers for Risk Evaluation of Pregnancy Hypertension

Karuna Sharma • Ritu Singh • Manisha Kumar • Usha Gupta • Vishwajeet Rohil Jayashree Bhattacharjee

Abstract

Introduction: Hypertension in pregnancy is one of the potential causes of maternal and fetal morbidity and mortality. It complicates 7–10% of pregnancies. As of today, prediction of pregnancy hypertension is not possible.

Aim and Objectives: Evaluation of pregnancy associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin, tumor necrosis factor-α (TNF-α) and interferon gamma (INF-γ) in establishing a biomarker or combination of biomarkers for the early identification of pregnancy hypertension.

Methodology: This prospective study was carried out in two phases. Phase I was a cohort study in which 2000 pregnant women were enrolled in their first trimester (11 + 0 to 13 + 6 weeks of gestation) and followed till delivery. Women who developed hypertension were compared with normotensive cohort (women who remained normotensive till term). Phase II was a case–control study. The women who were diagnosed with hypertension in phase I were cases and their controls were matched for gestational age and sample storage time from normotensive cohort population. Two additional proinflammatory markers TNF-α and INF-γ were evaluated in this case–control population.

Results: Out of 2000 women, 199 women developed hypertension and 1454 women remained normotensive throughout their pregnancy. Among 199 hypertensive women, 151 (9.13%) cases had gestational hypertension, 45 (2.72%) had preeclampsia (PE) and 3 (0.18%) had eclampsia (E). First trimester mean arterial pressure (MAP) (p < 0.001) and body mass index (BMI) (p < 0.001) were found significantly higher in hypertensive women when compared with normotensive women. Maternal serum levels of PAPP-A (p < 0.001) were significantly low in hypertensive women as compared to normotensive women, while free β-hCG (p = 0.59) was high, but the difference was not statistically significant. TNF-α (p < 0.001) and INF-γ (p = 0.014) both were high in hypertensive women. When all biomarkers were combined we found the positive predictive value (PPV) of 51.6% an negative predictive value (NPV) of 71.4%.

Conclusion: Increased levels of proinflammatory cytokines suggest the role of underlying inflammation in pathogenesis of pregnancy hypertension, and low PAPP-A may be attributed to impaired implantation. Combining biomarkers may improve the prediction of pregnancy hypertension in the early stages of gestation. NPV of 71.4% depicts that if woman has all biomarkers in normal ranges during first trimester, she will have 71.4% chances of remaining normotensive during pregnancy.

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Salivary and Serum Antioxidants in Women with Preeclampsia  with or Without Periodontal Disease

Mamatha S. Shetty • Amitha Ramesh • Prasanna Kumar Shetty • Priyanka Agumbe

Abstract

Background and Objectives: Preeclampsia is a challenging disease of human pregnancy that affects the mother and her foetus. It is a common obstetric syndrome of undefined aetiology affecting 7–10% of pregnant women. This study aimed to investigate the total antioxidant capacity (TAC), superoxide dismutase (SOD) and glutathione peroxidase (GPx) activities, malondialdehyde levels, uric acid, vitamin C, and vitamin E levels in serum and saliva of preeclamptic and normotensive pregnant women with and without periodontitis.

Methods: Sixty pregnant women, divided into four groups, preeclamptic women with and without periodontitis, and normotensive pregnant women with and without periodontitis, were recruited between 26 and 36 weeks of gestation from the Outpatient Department of Obstetrics and Gynaecology, KS Hedge Hospital, Mangalore. Pocket depth, clinical attachment loss, and gingival index were measured in all subjects. Saliva and serum levels of TAC, SOD, and GPx activities, malondialdehyde levels, vitamin C, vitamin E, uric acid were determined using spectrophotometer.

Results: Comparison of sociodemographic variables among the study groups showed no significant differences. Salivary malondialdehyde levels were highest (p = 0.025), levels of antioxidants vitamin C (p = 0.027) and uric acid (p = 0.013) being significantly lower in preeclamptic women with periodontitis. This group also had significantly lower serum levels of vitamin C (p = 0.041) and SOD (p = 0.004).

Conclusions: The results of our study show that periodontal disease may be potential risk factor for severity, progression, and even initiation of preeclampsia because of reduced antioxidant capacity or increased oxidative stress

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Comparison of Mifepristone Followed by Misoprostol with Misoprostol Alone for Treatment of Early Pregnancy Failure: A Randomized Double-Blind Placebo-Controlled Trial

Priya Sinha • Amita Suneja • Kiran Guleria • Richa Aggarwal • Neelam B. Vaid

Abstract

Objective: To compare the efficacy and safety of mifepristone followed by misoprostol with misoprostol alone in the management of early pregnancy failure (EPF). Study Design A randomized double-blind placebo-controlled clinical trial.

Methods: Ninety-two women with EPF ≤12 weeks were recruited and randomly allocated to receive either mifepristone 200 mg (n = 46) or placebo (n = 46). Forty-eight hours later, patients in both the groups were given 800 µg misoprostol per-vaginum. If no expulsion occurred within 4 h, repeat doses of 400 µg misoprostol were given orally at 3-hourly interval to a maximum of 2 doses in women ≤9 weeks by scan and 4 doses in women >9 weeks by scan.

Results: Pre-treatment of misoprostol with mifepristone significantly increased the complete abortion rate (86.7 vs. 57.8%, p = 0.009) and, hence, reduced the need for surgical evacuation (13.3 vs. 42.2%, p = 0.002), induction to expulsion interval (4.74 ± 2.24 vs. 8.03 ± 2.77 h, p = 0.000), mean number of additional doses of misoprostol required (0.68 vs. 1.91, p = 0.000), and side effects.

Conclusion: Use of mifepristone prior to misoprostol in EPF significantly improves the efficacy and reduces the side effects of misoprostol alone.

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GYNECOLOGY


ORIGINAL ARTICLES

Use of Hysteroscopy in Abnormal Uterine Bleeding: An Edge Over Histopathological Examination

Parul Sinha • Nidhi Yadav • Uma Gupta

Abstract

Purpose of the Study: To assess the efficacy of hysteroscopy in diagnosis of AUB.

Method: A total of 56 women in reproductive and peri-menopausal age group (20–50 years) with complaints of abnormal uterine bleeding were enrolled in the study. All the patients underwent hysteroscopic examination followed by biopsy/histopathological evaluation. Hysteroscopic findings were compared against histopathological findings. Sensitivity, specificity, PPV, NPV and accuracy of hysteroscopy were calculated.

Results: Mean age of patients was 36.4 ± 7.6. Majority (60.7%) presented within 6 months of complaints. Clinically, 66.1% were diagnosed as menorrhagia, 30.4% polymenorrhoea and 3.6% intermenstrual bleeding. Hysteroscopically 53.6% presented with abnormal pathology, it diagnosed polyps in 16.1%, calcification in 12.5%, submucous fibroma in 10.7%, necrotic mass in 7.1%, adhesion and forgotten IUCD in 5.4% cases each. However, on histopathology, 33 (58.9%) cases had normal/proliferative/atrophic endometrium, 12 (21.4%) had hyperplasia, 7 (12.5%) had calcified endometrium, and 12 (21.4%) had polyp. No significant difference between two modalities was observed with respect to number of normal/proliferative/atrophic endometrium (p = 0.185). Histopathology diagnosed hyperplasia in significantly higher proportion of patients as compared to hysteroscopy (p = 0.042). Hysteroscopy diagnosed significantly higher proportion of patients with submucous myoma (p = 0.012) and necrotic mass (p = 0.042). Statistically, no significant difference between two modalities was observed with respect to other pathologies (p > 0.05). Overall agreement between two modalities was 62.5%. For pathological abnormalities in general, hysteroscopy had sensitivity, specificity, PPV, NPV and accuracy values of 78.3, 63.6, 60, 80.8 and 69.6%, respectively.

Conclusion: Hysteroscopy provided additional information for some of the pathologies, otherwise remaining undiagnosed by HPE.

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Comparison of Cervical Length Measured by Trans-vaginal Ultrasonography and Bishop Score in Predicting Response to labor Induction

Ronak Khandelwal • Purvi Patel • Dipa Pitre • Tosha Sheth • Nandita Maitra

Abstract

Background: This study aims to compare the value of the Bishop score and cervical length measurement by transvaginal ultrasonography in predicting active labor within 6 h, induction-to-delivery interval, and the duration of active labor and to estimate the most useful cutoff points for the two methods.

Methods: This is a prospective comparative study of Bishop score and cervical length measured by transvaginal sonography on 62 nulliparous subjects who underwent induction of labor. Results The Bishop score of the subjects ranged from two to seven (2–7). The mean Bishop in this study population was 4.37 + 1.23. The mean cervical length in this study was 25.59 + 6.07. Bishop score was highly significant (P value < 0.0001) in predicting active phase of labor as compared to cervical length (P = 0.004). The best cutoff value for Bishop score to predict induction of labor within 6 h was more than 4 with sensitivity of 69% and specificity of 79%. Similarly, best cutoff value for cervical length to predict induction of labor within 6 h was less than or equal to 25 mm with sensitivity of 51% and specificity of 70%. Bishop score was more significant (P = 0.001) in predicting induction-to-delivery interval within 12 h as compared to cervical length (P = 0.01).

Conclusion: The Bishop score was superior in predicting the response to induction as compared to the cervical length measured by transvaginal ultrasonography.

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Endocrine Abnormalities in Adolescents with Menstrual Disorders

Siddhesh R. Rajiwade • Haritha Sagili • R. Soundravally • L. Subitha

Abstract

Purpose: To look for endocrine abnormalities like thyroid disorders, hyperprolactinemia, hyperandrogenism and PCOS among adolescents with menstrual disorders and to compare the above endocrine status with those without menstrual disorders.

Methods: This was a case–control study carried out in adolescent girls aged 10–19 years in gynecology outpatient department of a tertiary care hospital. Sample of venous blood (5 ml) was taken for hormonal studies as clinically indicated—thyroid function test, serum prolactin, total testosterone, which were analyzed by chemiluminescence system.

Results: Oligomenorrhea was the most common menstrual abnormality in our study, the prevalence being 61.0% in cases followed by primary amenorrhea (16.4%). Thyroid dysfunction was found in 13.6% girls with menstrual disorders compared to 3.5% in those without menstrual disorders, and this was statistically significant (p = 0.006). Biochemical hyperandrogenism was seen in 9.04% cases compared to 0.7% controls (p = 0.001). The overall prevalence of hyperprolactinemia was 0.94%, and there was no statistically significant difference in girls with and without menstrual disorders. The prevalence of PCOS was 12.4% in the study population and 22.6% cases. Oligomenorrhea and PCOS were the most prevalent phenotypes in 52.5% of PCOS girls. No endocrine abnormality was detected in cases of polymenorrhea, hypomenorrhea and intermenstrual bleeding.

Conclusions: Although immaturity of hypothalamic pituitary ovarian axis is considered to be the most common cause of menstrual irregularities in adolescent girls, endocrine abnormalities, namely thyroid dysfunction and hyperandrogenism, may be responsible in some cases, thus warranting further evaluation.

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Comparison of Effectiveness of Different Protocols Used for Controlled Ovarian Hyperstimulation in Intrauterine Insemination Cycle

Manish Banker • Azadeh Patel • Ashwini Deshmukh • Sandeep Shah

Abstract

Introduction: Intrauterine insemination (IUI) is one of the most commonly performed procedure of assisted reproductive technology, for the treatment of infertility. Controlled ovarian hyperstimulation is an important first step while performing IUI. This study aims at establishing a relationship between stimulation protocol and pregnancy outcome following IUI.

Methods: This is a retrospective study of 1001 cycles of IUI in which the patients were divided into two groups: Group A Clomiphene citrate (CC only) and Group B Clomiphene citrate and Gonadotropin or Gonadotropin alone(CC+GN OR GN alone). The primary outcome assessed was clinical pregnancy rates (CPRs), and the secondary outcomes were miscarriage rate (MR), multiple pregnancy rates (MPRs), follicle numbers and endometrial thickness (ET).

Results: Significantly, higher CPR was observed in Group B in comparison with Group A (14.55 vs. 7.82%; p = 0.05). MR was much higher in Group A in comparison with Group B, (14.29 vs. 5.43%; p = 0.94), but it was non-significant. The follicle number and the ET of the Group A versus Group B are (1.54 ± 0.69 vs. 1.90 ± 1.04; p = 0.0003) and (8.56 ± 1.33 vs. 8.39 ± 1.29; p = 0.1784), respectively; and for subgroups, Group B1 and Group B2 are 1.92 ± 0.99 versus 1.65 ± 0.92; p = 0.0008 and 8.32 ± 1.27 vs. 8.69 ± 1.24; p = 0.0004, respectively.

Conclusion: GN, either alone or the combination with CC, gives a higher CPR and a lower abortion rate following IUI, thus increasing the multiple pregnancy rate.

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OBSTETRIC


CASE REPORT

Rare Presentation of Catastrophic Antiphospholipid Syndrome with Myocarditis in Post-partum Period: Case Report and Review of Literature

Bhavana Girish • Shalini Gainder • S. C. Saha

Abstract

Catastrophic antiphospholipid syndrome (CAPS) is a rare complication, occurring in less than 1% of pregnancies complicated by antiphospholipid syndrome. We report a patient with partial HELLP syndrome who developed CAPS with myocarditis in postpartum period following emergency Caesarean section done for severe pre-eclampsia. Women with APS who develop HELLP syndrome in pregnancy are at very high risk for CAPS, which may further be precipitated by stressors like surgery. Hence possibility of this rare diagnosis should be kept and anticoagulation should be restarted in post-partum period.

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INVITED BOOK REVIEW

Contraception

Neerja Goel • Himsweta Shrivastava • Bindiya Gupta

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