Abstract

This article sets out to discuss the role if any of arginine in pregnancy, especially its use in the management/prevention of intrauterine growth restriction and pre- eclampsia. Nitric oxide is a free radical that plays a role in human physiology in various ways. Its role in obstetrics supposedly to induce smooth muscle relaxation and play a mitigatory role in the above mentioned conditions needs to be reviewed. The main site of production of nitric oxide is nitric oxide synthase in endothelial cells, which uses circulating L-arginine as a substrate. Hence, the local availability of this amino acid may be critical to the endothelial adaptive regulatory mechanisms opposing the vasoconstrictors in pre-eclampsia. L-arginine is considered to be a semi-essential amino acid because under increased demands, endogenous synthesis is not sufficient to fulfill requirements [1]. Defective synthesis of a key vasodilator, nitric oxide, has been demonstrated in patients with pre-eclampsia. Circulating L-arginine is a substrate for nitric oxide synthesis during pregnancy; preliminary data suggest that supplemental L-arginine in the diet may lower the risk of pre-eclampsia during pregnancy by promoting vasodilatation through increased production of nitric oxide.

Arginine may be insufficient in pregnancy [2]. Concentrations of asymmetric dimethyl arginine, a competitive inhibitor of nitric oxide synthase, are raised in women with pre-eclampsia [3]. As also endoglin which impairs the activation of nitric oxide synthase mediated by transforming growth factor b [4]. Supplemental L-arginine in the diet could provide a source of substrate for nitric oxide synthesis during pregnancy, which could promote vasodilatation. There are however limited studies in the use of L-arginine and other nitric oxide donators for preventing pre-eclampsia, as stated in the Cochrane review by Meher and Duley [5]. Existing literature suggests that L-arginine has direct effects on blood pressure in experimental animal models, normal humans, hypertensive patients, women with pre-eclampsia, and healthy pregnant women [6, 7]. In pre-eclampsia the role of arginine may be limited after the establishment of the condition, as is mentioned by Staff et al. [8] in a study where no effect of L-arginine was manifest when used in women with pre-eclampsia beyond 28 weeks of gestation. Germain et al. [9] disclosed some initial findings in women at high risk of pre-eclampsia who received L-arginine from week 10 of gestation. In a study in 2005 it was seen that in pre-eclamptic patients prolonged dietary treatment with low dose of L-arginine significantly decreased maternal blood pressure and increased bioavailability of endothelial nitric oxide [10].

Intrauterine growth restriction results due to placental insufficiency which in turn may be due to multiple factors including vascular insufficiency. L-arginine (3 g po daily) administered in intrauterine growth restriction seemed to improve estimated fetal weight in a study by Pace et al. [11]. In the past high doses of intravenous L-arginine was used to stimulate growth hormone secretion (Merimee et al.) [12].

Abstract

Respected Professor S. Arulkumaran, President Elect FIGO and chief guest, Dr. T.M. Mahapatra, Director IMS, BHU, Varanasi and guest of honor, Dr. P.C. Mahapatra, immediate Past President of FOGSI, Dr. Mandakini Parihar, Dr. Laxmi Shrikhande, Dr. Prashant Acharya, Dr. Mandakini Megh, Vice Presidents of FOGSI, Dr. Nozer Sheriar, Secretary General FOGSI, Dr. H.D. Pai, Deputy Secretary General, Dr. Parikshit Tank, Jt. Secretary, Dr. Jaydeep Tank, Treasurer FOGSI, Dr. Madhuri Patel, Jt. Treasurer, all outgoing Vice Presidents of FOGSI, Dr. Amod Prakash, Dr. P. Tiwari, Dr. Vibha Mishra, Chairpersons of Organising Committee of AICOG 2012, Dr. Anuradha Khanna, Dr. G.K. Tripathi, Dr. Majari Matah, Dr. Nisha Rani Agarwal, Organizing Secretaries of AICOG, all the other dignitaries on the dais, all the Chairpersons and Members of the Organizing Committee, Past Presidents of FOGSI,my teachers, International and National Faculty, Mr. Arun Khanna, CEO Emcure Pharma, Pharmaceutical company colleagues, my dear wife, my dear FOGSIans, ladies and gentlemen.

I am humbled and honoured to stand before you today, as I accept the responsibilities and authority associated with becoming the President of FOGSI.

It is a privilege to be here as the President of the largest organization of specialists not only in India, but perhaps in the world.

I will do my level best to uphold all that FOGSI stands for, and I hope, with your help and support, fellow members, to take our organization to ever greater heights. I am sure this year can be made a memorable one through the infusion of hope and enthusiasm of our young colleagues, as well as with the guidance of our seniors. My profound heartfelt gratitude to almighty God and to each and every one of you for the great honour which has been bestowed upon me.

Abstract

Objectives With the objective of improving outcomes in oncological surgery, a new concept of surgical anatomy deduced from embryonic development, called ontogenetic anatomy and compartment theory of local tumor spread, is proposed by Michael Ho¨ckel from Germany. Hypothesis Compartment resection enables the preservation of functionally important tissues of different embryonic origin despite its close proximity to the tumor and incomplete resection of the compartment results in increase in local recurrences. This approach should maximize local tumor control and minimize treatment-related morbidity. Total Mesometrial Resection (TMMR) This new surgical technique has been developed and standardized over past 12 years for cervical cancer with a high local control rate without need for adjuvant radiotherapy.

Conclusion This Embryological based surgery holds a great promise for management of cervical cancer. However this novel surgery needs confirmation in multi institutional settings to translate research into practice for an excellent therapeutic index.

Abstract

Background Fetal umbilical cord blood sampling is now being performed worldwide, using an ultrasound guided technique, for prenatal diagnosis in pregnancies at high risk for several congenital and genetic defects in the fetus. Awareness of feasibility of the procedure and indications for the same should be known to every obstetrician.

Aims and Objectives To study the indications for Fetal Cord Blood Sampling in high risk pregnancy patients in the last 20 years at a tertiary referral center in India.

Materials and Methods Women referred to the Fetal Medicine Clinic for fetal blood sampling from January 1990 to November 2009, were assessed. An informed consent was taken. Under continuous ultrasound guidance, a 22 gauge long spinal needle was inserted through the maternal abdomen and uterine wall into the umbilical cord, and about 2–4 ml of blood, depending on the indication was aspirated by syringe. The various indications for fetal blood sampling in 1342 women were analyzed. Results Cord blood sampling was performed for the following indications: Hb in Rh Isoimmunized pregnancies— 553 cases, Chromosomal analysis—427 cases, non-immune hydrops/pleural effusion/ascites—cases 88, Congenital Infections—131 cases, Intrauterine Growth Restriction—51 cases, Thalassemia—53 cases, Hemophilia—36 cases, and for Thyroid function test for fetal goiter in 3 cases, in total 1,342 women.

Conclusion There were several absolute indications for fetal cord blood sampling in high risk pregnant women, to provide state-of-the-art information on the health of the fetus. Awareness of the procedure and indications for the same should be known to every obstetrician as it is technically feasible, expertise is available in India; so that women who require the procedure may be referred in time.

Abstract

Objective To determine the prevalence and impact of placental malaria on maternal and fetal outcome. Design Cross sectional observational. Setting The Department of Obstetrics of Government NSCB Medical CollegeHospital, Jabalpur (Madhya Pradesh). Population Five hundred parturient women with fever or history of fever during the present pregnancy.

Method(s) Subjects were tested for peripheral and placental malaria by thick and thin smear examination. Maternal and perinatal outcome correlated with malaria results.

Results(s) The mean age of the studied subjects was 24.5 ± 2.6 years, 60.6 % were primigravida, 87.2 % had unsatisfactory antenatal care. 89.2 % were not using effective malaria prevention measures. Peripheral smear positivity for malaria was detected in 1.8 % subjects and placental malaria positivity in 2.2 % subjects. The mean Hb was lower in malaric subjects (v2 = 14.47, p\0.05). Maternal mortality and prematurity was significantly higher in malaria ?ve subjects (p\0.001). The mean birth weight in malaria ?ve subjects was significantly less (p\0.001). Poor 5 min APGAR (p\0.0001) and perinatal mortality (p\0.05) was significantly more common in malaria ?ve subjects.

Conclusion(s) Malaria, particularly placental infestation with malarial parasites significantly increases maternal and perinatal morbidity and mortality.

Abstract

Objective To test the hypothesis that women with high serum beta-HCG levels in early pregnancy are at higher risk of developing PIH.

Methods Serum beta-HCG estimation was done by CLIA method in 200 women between 13 and 20 weeks of gestation, selected randomly for this study from July 2008 to Aug 2009. Multiple of median (MOM) was calculated from charts of norms available for that week of pregnancy. They were followed till delivery for development of PIH and pregnancy outcome and results analysed statistically with Chi-square test and Z test.

Results Out of 200 cases, 178 (89 %) were finally evaluated. Of whom 22 (12.36 %) cases developed PIH. Beta HCG levels were considered raised if the levels were [2MOM.20 (83.33 %) out of 24 cases with beta HCG levels[2MOM developed PIH against 2 (1.2 %) cases out of 154 having beta HCG levels B2 MOM(P value\0.001). Also, higher levels of beta HCG are associated with increased severity of PIH (P value\0.01). The sensitivity was 90.91 %, specificity was 97.44 % and positive predictive value was 83.33 %.

Conclusion The study concluded that the serum beta HCG estimation at mid trimester (13–20 weeks) is a good predictor of PIH and higher levels of beta HCG are associated with increased severity of PIH.

Abstract

Objectives To compare the efficacy of intravenous single dose, less costly cefotaxime and more expensive amoxycillin– clavulanic acid combination for prophylaxis at cesarean section.

Method A double blind randomized controlled trial was undertaken on 760 subjects with two parallel treatment groups. Data were analyzed using Graphpad Instat 3 McIntosh software by Student’s t test, Mann–Whitney U test, the Chi-squared test or fisher’s exact test.

Results Comparatively narrow spectrum low cost cefotaxime is as effective as more expensive commonly used amoxicillin–clavulanic acid with no significant difference of infectious morbidity and hospital stay (p = 0.27 and 0.11 in elective and emergency cases respectively).

Conclusion Less costly cefotaxime should be preferred compared to more costly amoxicillin–clavulanic acid combination for prophylaxis at cesarean section.

Abstract

Objective To study oxidative stress in placental tissue as well as in serum in pre-eclamptic women.

Methods Fifty pre-eclamptic cases and fifty normal pregnant women were selected in the study. Thio barbituric acid reacting substances (TBARS) was measured as oxidative stress marker and superoxide dismutase (SOD) and GSH (reduced glutathione) were measured for assessment of antioxidant status in placental tissue extract and serum.

Results TBARS and SOD activity were increased significantly (P\0.001) in both placental homogenate and serum in pre-eclamptic women. Level of GSH was not altered much.

Conclusion Placental oxidative stress can be assessed by measuring serum oxidative stress markers and this may help in prevention of further progress of this condition.

Abstract

Objectives To correlate the perinatal outcome by noting the umbilical coiling index.

Methods The umbilical cords of the babies born to 100 women, who delivered either vaginally or by lower segment cesarean section, were examined and umbilical coiling index was calculated.

Results There was significant correlation (p value 0.003) between the hypercoiled cords (UCI[90th percentile) and intrauterine growth restriction of the babies. Apgar score at 1 min\4 and 5 min\7 was highly significant (p\0.001) with hypocoiled cords. Meconium staining was significantly (p value 0.001) associated with the hypocoiled cords (UCI\10th percentile) in the present study.

Conclusion The hypocoiled cords or UCI\10th percentile is associated with the meconium staining, Apgar score at 1 min\4 and Apgar score at 5 min\7. The hypercoiled cord or UCI [10th percentile is associated with intra uterine growth restriction.

Abstract

Objective To compare the safety and effectiveness of vaginal misoprostol with combined vaginal misoprostol and estradiol for induction of labor in unfavorable cervix. Method A prospective study was carried out from Jan 2008 to Jul 2008 on total of 90 women with unfavorable cervix (Bishop’s score was\5) and gestation[36 weeks with clinical indication for induction of labor. They were randomly assigned to receive either vaginal misoprostol 25 lg alone or vaginal misoprostol 25 lg with vaginal estradiol 50 lg. Misoprostol alone was repeated every 3 h in both groups till ripening of cervix (Bishop’s score was = 8) and establishment of active labor.

Results Main indications were post dated pregnancies (period of gestation [41 weeks) and pregnancy induced hypertension. Age, parity and mode of delivery were not significantly different. No significant difference was found in pre induction Bishop’s score, fetal outcome and maternal complications. However, doses of misoprostol required for cervical ripening (p = 0.017), time required for cervical ripening (p = 0.042), time required for starting of active labor (p = 0.017) and time required for delivery in vaginal delivery cases (p = 0.047) were found significantly less in combined estradiol and misoprostol group.

Conclusion Estradiol acts synergistically with misoprostol vaginally and significantly hastens the process of cervical ripening, initiation of active labor and vaginal delivery.

Abstract

Introduction The most common reason for demand for abortion in India is unintended pregnancy. Aim To obtain information from low income urban married women regarding incidence and cause of unintended pregnancy.

Methods All pregnant married women belonging to low income group were selected for study. The incidence and cause of unintended pregnancy among low income group was noted. Comparison was done between education of the women and parity at which they came with unintended pregnancy also the reasons women gave for nonuse of contraception were compared with their education. Statistical analysis was done using EPI Info ver-5.0. Chi square test was used to test the significance of data.

Results The total 7,146 women comprised the study group. The incidence of unintended pregnancy was 15.5 %. Educated women came with unintended pregnancy at lesser parity than illiterate women. The most common reason given by women for not using contraception was that they did not think they could become pregnant (42.6 %). Conclusion The incidence of unintended pregnancy in low income urban population is low because there are fewer pregnancies which were wanted. There is need to create awareness regarding use of contraception. Education plays a major role in improving the acceptance of contraception.

Abstract

Objective To evaluate the demographic profile, high risk factors, fetomaternal outcome and management options in morbidly adherent placenta (MAP).

Study Design Retrospective analysis. Methodology Review of 20 case records of women with MAP during year 2001–2006.

Results The mean age and parity of the women was 27.7 ± 4.2 years and 2.5 respectively. 70 % women had previous uterine scar, and similar number had placenta previa. 60 % women presented with antepartum hemorrhage and 20 % with retained placenta. 85 % women underwent hysterectomy with 5 % requiring internal iliac artery ligation, another 5 % partial cystectomy and 15 % bladder repair. Blood loss was between one and nine litres requiring an average of six units whole blood and 4 units FFP. There were six (30 %) maternal deaths. 55 % of the newborns were preterm and the perinatal mortality was 33.3 %.

Conclusion Cesarean section and placenta previa are significant risk factors. MAP is associated with high fetomaternal morbidity and mortality.

Abstract

Objectives The present study was undertaken to check the relevance of reversal of sterilization in women in the present era of test tube babies, to evaluate the Standard guidelines for sterilization, (The site of the occlusion of the fallopian tube must be always be within 2–3 cmfromthe uterine cornu in the isthmal portion, excision of 1 cm of the tube should be done. Use of cautery and crushing of the tube should be avoided.) are being followed universally in the institution and outside, to study the demographic patterns of women coming for reversal of sterilization and to evaluate the causes for either the inability to perform reversal of sterilization or the adversaries like ectopic pregnancy that occur after the procedure.

Methods The present study is a retrospective study carried out in the Department of Microsurgery, Obstetrics and Gynecology, Government Kilpauk Medical College and Hospital Chennai based on the case records maintained in the institution. Three groups of women have been chosen at various periods and the various factors related have been compared. This includes the women who have come to the institution for reversal of sterilization during the years 1991–1995, 2000–2004 and 2006–2008 respectively.

Result The demand for reversal has increased almost 81 % after 2005 whereas the standards of sterilization are actually being followed in\17 % of women. The incidence of Ectopic pregnancies has increased and the incidence of take home pregnancies has come down.

Conclusion There is a need to stick to the standards of sterilization. Proper selection of candidates for sterilization and reversal of sterilization is important.