The COVID-19 pandemic is thought of as the most crucial global health calamity of this Century and is the greatest challenge that the human-kind faced since the 2nd World War. Doctors have never handled this much suffering and death in a lifetime. This will further burden the already burdened health care system. In medical colleges too, resident doctors were at the fore front of fighting this pandemic. The pyramid of the unit structure had to be reversed to give optimum care to the infected patients within the frame work of the burdened health care system. Telemedicine can be used in training the health care like lectures, conferences and also help in remote decision‐making, where specialists are not available. Let us be flexible in our timings, flexible in our approach to patients, flexible in self-care to reduce co morbidities, flexible in treatment, flexible in our surgeries.
Pelvic organ prolapse (POP) is a very common condition which can greatly impact a woman’s quality of life. Treatment options are individualized and typically involve a combination of physiotherapy, pessary insertion and surgical treatments. It is well known that nulliparous prolapse in India constitutes 1.5–2% of genital prolapse, while the incidence is even higher (5–8%) for young women who have delivered one or two children, thus making it one of the highest rates in the world. This has necessitated the development of numerous conservative surgical treatment options for POP, which allows women to retain their sexual and reproductive function and therefore allows for subsequent pregnancies. With the controversy surrounding the use of mesh, a variety of surgical treatment options should be considered. Such alternative treatments include the use of surgical sling procedures, which have been used widely in Indian practice for the treatment of POP for over 60 years. This review outlines some of the well-established conservative treatment options for POP. It also highlights the unique contribution of Indian Obstetricians in the development of these conservative surgical treatment options, from prominent Indian Gynecologists including Dr VN Shirodkar, Dr BN Purandare, VN Purandare, RP Soonawala, Brigadier SD Khanna and Dr RM Nadkarni.
Pelvic organ prolapse , Conservative management of pelvic organ prolapse , Conservative surgical procedures for pelvic organ prolapseMullerian malformations are not uncommon. Overall incidence ranges widely between 1 in 200 women and 4 in 100 women
(Chan et al. in Hum Reprod Update 17:761–771, 2011; Grimbizis et al. in Hum Reprod 28:2032–2044, 2013). Other way,
these observations suggest presently an increased number of Mullerian abnormalities are diagnosed with more details, following the use of newer diagnostic modalities. Most classifications that are available have limitations. Diagnosis was based
on imaging studies that had low diagnostic accuracy. It was focused mainly on the anomalies of the uterus. Less is known
about the anomalies of the cervix or the vagina in isolation or in combination with the utero-cervical and vaginal malformations. Improved diagnostic modalities and incorporation of assisted reproductive technology have improved the outcome
further. Therefore, a more expanded classification needs to be introduced with wider criteria for the clinicians. This will
make clinicians’ approach for the management more simple.
Background Childbirth experience is unique to every woman. Negative experience is detrimental to both mother and child. This study was undertaken to understand the positive and negative experience and felt need of women undergoing labor and the factors affecting them.
Methodology This cross-sectional descriptive quantitative study was conducted among women who delivered in JIPMER and consented to participate through a questionnaire that captured four areas of childbirth experience. The study was carried out before the LaQshya guidelines were implemented.
Results Three hundred and seventy women completed the study. The mean age of women in this study was 24.5 years and 60% were primipara. Five women (1.3%) experienced physical abuse. Another 47 (12.7%) experienced disrespect in the form of scolding/insult/discrimination or nonconsented care. Three-fourths of the women wanted a relative (majority preferred their mother) with them, and 54% wanted a prayer hall in the labor room. On univariate analysis, no significant determinant was found for negative experience constituting disrespect and abuse. Complete pain relief as a need was found to be significantly higher (X2 = 11.0783, p < 0.004) in women of lower parity. The women educated beyond scholastic level felt that informa-tion given about delivery is inadequate when compared to participants who were illiterate or had primary education only.
Conclusions In our hospital 12.7% women undergoing labor experienced disrespectful behavior and 1.3% experienced physi-cal abuse. Need for prayer hall, complete pain relief and presence of relative was felt by more than half of the participants. We did not find any specific factor influencing the negative experience.
Background The etiology and pathophysiology of hypertensive disorders of pregnancy remains enigmatic, and till date, no test can accurately predict it. Early screening may allow vigilant antenatal surveillance, timely delivery and thus substantially reduce maternal and perinatal morbidity and mortality. Our study aims to evaluate the predictive value of uterine artery mean pulsatility index (PI) at 11–14 weeks and find a reference value for hypertensive disorders of pregnancy.
Methods A prospective study of 240 antenatal women using non-probability simple random sampling was carried out in a tertiary care center. Mean uterine artery PI was obtained at 11–14 weeks of gestation. Pregnancies were followed till delivery and 7 days postpartum. The major end point was development of hypertensive disorders of pregnancy. Maternal and neonatal outcomes were also assessed.
Results The predictability of uterine artery mean pulsatility index (PI) at 11–14 weeks for hypertensive disorders of pregnancy was significantly high with an odds ratio of 174.45 (95% CI 65.31–549.13; p < 0.0001), sensitivity (89.3%), specificity (95.8%), positive predictive value(90.5%) and negative predictive value (95.1%).
Conclusion Uterine artery mean PI at 11–14 weeks of gestation is a cost-effective predictive test for hypertensive disorders of pregnancy, and the recommended reference value for Indian population of is 2.28.
Introduction Medical students are known to have high levels of depression, anxiety and stress from the high-pressure envi-ronments that they study and train in. The coronavirus pandemic presents source of stress and anxiety to large populations in general, and to healthcare professionals in particular. This study was undertaken to assess the psychological effects of this pandemic on the mental health of medical students and trainees.
Materials and Methods An online questionnaire was designed to capture information on the participant’s anxieties related to the pandemic and included a validated tool for the assessment of anxiety and depression symptoms (GAD-7 and PHQ-9, respectively). The questionnaire was prepared on Google Forms, and the link to the questionnaire was disseminated to 113 medical students and junior doctors on 19 April 2020, and the survey closed on 22 April 2020 midnight.
Results The survey was sent to 113 students, and 83 students participated. Of the participants, 47 (56.6%) were female and 36 (43.4%) were male, and 80 (96.4%) were aged less than 30 years old. Formal anxiety and depression scores using the GAD-7 and PHQ-9 tools indicated 15/82 (18.3%) had anxiety scores of 0 (lowest possible) and 21/82 (25.6%) had the lowest possible depression score of 0. However, 6/82 (7.3%) had scores that were classified as severe depression. Females had significantly higher median anxiety (5 v 2, p < 0.002) and depression scores (5 v 3, p = 0.025) than male participants. Direct patient care and care of patients with Covid-19 did not result in significant deterioration in anxiety and depression.
Conclusion Female students/junior doctors showed higher anxiety and depression scores than males. Direct patient care and care of patients with Covid-19 did not result in a measurable deterioration in anxiety and depression in this study. In this stressful pandemic situation, it is imperative to look after the mental health of healthcare workers as well as patients.
Purpose of the Study To estimate and to compare the levels of cervical phIGFBP-1 among primigravida with prolonged pregnancy, with and without successful induction of labor (IOL).
Methods A diagnostic study (cross-sectional study design) was conducted in our institution from November 2016 to April 2018 on 84 primigravida at ≥ 41 weeks with uncomplicated singleton pregnancy. The results were analyzed using SPSS software and receiver operating characteristics curves to determine the best cutoff using Youden Index. Sensitivity, specific-ity, positive predictive value (PPV), negative predictive value (NPV), positive (+ LR) and negative likelihood ratio (− LR) were calculated. P value < 0.05 was considered significant. Logistic regression analysis was used to determine the predictive ability of the three markers for successful IOL.
Results The cutoff level of phIGFBP-1, Bishop score (BS) and transvaginal cervical length (TVL) were 7.8 μg/l, 3 and 3.5 cm, respectively. The sensitivity, specificity, PPV, NPV, + LR and − LR of phIGFBP-1 (> 7.8 μg/l) were 0.87, 0.87, 0.89, 0.85, 6.76 and 0.15, respectively. Using logistic regression analysis, phIGFBP-1 was found to be the best predictor of successful IOL (OR 44.200; 95% CI 12.378–157.831, p < 0.001).
Conclusion phIGFBP-1 is a strong independent predictor successful IOL as compared to TVL and BS in primigravida with prolonged pregnancy.
Background The aim of this study to determine maternal adiponectin and leptin levels as biomarkers of pre-eclampsia and compare adiponectin and leptin ratio.
Materials and Methods This is a prospective study. The enrolled women were divided into two groups: first, study group (n = 60) comprised of women diagnosed with pre-eclampsia and second, control group (n = 60) comprised of age- and gestation-matched normotensive and nonproteinuric women.
Main Outcome Measures Maternal serum adiponectin and leptin levels and their ratio were compared in pre-eclamptic (study group) and normotensive (control group) women.
Results Adiponectin levels were insignificantly higher in study group than control group. Leptin levels in study group were significantly higher than control group (p < 0.001). Adiponectin/leptin ratio was significantly lower in study group than con-trols (p < 0.0001). Sensitivity, specificity, positive predictive value and negative predictive value of serum leptin and serum adiponectin/leptin ratio as a biomarker of pre-eclampsia were 90%, 88.3%, 88.5%, 89.8% and 68.3%, 90%, 87.2%, 74%, respectively. Serum leptin levels and serum adiponectin/leptin ratio had cut-off point as 23.3 ng/ml and < 0.153, respectively. Accuracy of both serum leptin and adiponectin/leptin ratio was significant (p < 0.0001).
Conclusion Maternal leptin-level estimation should be integrated into the investigations for pre-eclampsia, and a cut-off level of > 23.3 ng/ml should be used as a biomarker for diagnosis. Adiponectin–leptin ratio should be considered as a biomarker for PE and should be determined in all cases of pre-eclampsia, and a cut-off of < 0.153 should be used for diagnosis.
Leptin , Adiponectin , Adiponectin and leptin ratio , Pre-eclampsia , BiomarkersBackground Genetic and epigenetic factors play significant roles in the aetio-pathogenesis of pre-eclampsia (PE). The effects may vary across racial and geographical boundaries. The role of epigenetic modification in pre-eclampsia was studied among African populations in Lagos, Nigeria.
Aim and Objectives This study aimed to determine the pattern of Methylene tetrahydrofolate reductase gene (MTHFR) CpG island methylation in pre-eclampsia, and evaluate associated covariates.
Methodology This study was an observational, cross-sectional, study conducted at the Lagos University Teaching Hospital and the Lagos State Island Maternity Hospital. A total of 400 pregnant women consisting of 200 pregnant women diagnosed with pre-eclampsia (study group) and 200 pregnant normotensive and apparently healthy women (control group) were recruited for the study. Demographic and clinical histories were obtained through questionnaires. The DNA Methylation status of the CpG Island in promoter region of the MTHFR gene was assessed using bisulphite conversion and methylation specific PCR method. The biochemical parameters measured in the study were: red cell folate, vitamin B12, plasma homo-cysteine (Hcy) and methylene tetrahydrofolate reductase enzyme level.
Results Homozygous MTHFR CpG island hypomethylation pattern was significantly associated with pre-eclamp-sia (χ2 = 22.96; p = 0.000), Mean values of plasma homocysteine in PE women with homozygous hypomethylation (26.1 ± 9.1 umol/L) were significantly higher than (20.1 ± 4.2 umol/L) observed in PE subjects with homozygous hyper-methylation (p = 0.008). Homozygous CpG island hypomethylated pattern of the MTHFR promoter region, was associ-ated with the lowest median MTHFR enzyme level (72.8 ± 39.8 pmol/L) compared with heterozygous methylated pattern (91.3 ± 60.9 pmol/L; p = 0.047) and homozygous methylated pattern (82.3 ± 31.0 pmol/L; 0.047). Red cell folate and Vitamin B12 levels were not significantly associated with CpG island methylation status.
Conclusion Epigenetic modification plays significant role in the pathogenesis of pre-eclampsia.
Objective We aimed to determine performance of sequential organ failure assessment (SOFA) and Sepsis in Obstetrics Score (SOS), in women with pregnancy-associated sepsis (PAS) with respect to critical care admission and mortality.
Methods Obstetric patients with PAS fulfilling any 2 of the quick SOFA (qSOFA) criteria were enrolled as cases. The vari-ous parameters of SOFA and SOS were recorded at admission and compared for outcomes.
Results Critical care was required in 32 (50.7%) patients and associated mortality was high (31.7%). For our study population, a threshold of SOFA ≥ 6 had the best combination of sensitivity (84.4%) and specificity (61.3%) for critical care admission. For SOS, a cut-off value of ≥ 6 gave best sensitivity (64%) and specificity (40%) for the same.
Conclusions SOFA was far more predictive of patient’s critical condition as well as mortality compared to SOS. SOFA was superior to SOS in determining critical care admission and mortality for PAS.
SOFA , SOS , Obstetric sepsis , Pregnancy-associated sepsisObjective This study aimed to examine the associations of cone margin and human papillomavirus (HPV) status after coniza-tion with cytological abnormalities and disease recurrence in patients with cervical intraepithelial neoplasia grade 3 (CIN3).
Methods This is a retrospective study of 366 women with CIN3 who underwent conization at Kagoshima University Hospital between 2004 and 2017. Conization was performed using an ultrasonic scalpel. The polymerase chain reaction for detecting HPV genotypes was performed using fresh cervical cell samples. We examined the associations of margin status and HPV status after conization with cytological abnormalities and recurrence.
Results Among 224 women with CIN3, 193 (86.2%) underwent HPV genotype testing before conization. The HPV-positive rate was 84.9%. The most common HPV genotypes before conization were HPV 16, 31, 58, 52, 18, 35, and 33. In 191 patients, the uterus was preserved after conization. Sixteen patients had pathologically positive margins, 165 had negative margins, and 10 had unclear margins. There was no significant difference in abnormal cytology and recurrence rate after conization between the three groups. Five patients with positive margins and abnormal cytology during follow-ups were HPV16- or HPV58-positive in the preoperative HPV testing. Of the 191 women, 91 (47.6%) underwent pre- and postoperative HPV genotype testing, among whom 14 (15.4%) were HPV-positive after conization. No significant difference in abnormal cytology based on HPV status after conization was found. The recurrence rate tended to be higher in HPV-positive patients than in HPV-negative patients after conization (21.4% vs. 1.3%, p < 0.05). Three patients with HPV positivity after coniza-tion and recurrence during follow-up were HPV16- or HPV58-positive.
Conclusions HPV positivity after conization for CIN3 was associated with a high recurrence rate, especially in HPV16- and HPV58-positive patients. HPV58 has not received much attention thus far, but abnormalities in cytology and recurrence may be as likely as those associated with HPV16. Thus, a careful follow-up in such patients is recommended.
Introduction Cervical cancer is the most common cancer in India. Screening of cervical cancer helps in marked reduction in invasive cervical cancers. The low sensitivity of Papanicolaou cytology (Pap smear) and high-risk human papillomavirus (HR-HPV) in excluding high-grade intraepithelial lesion (ASC-H) leads to unnecessary referrals to colposcopy-guided biopsy. The combined cervical cytology screening and HR-HPV have its own limitations and still need further standardization. Using additional biomarkers like staining with p16 and Ki-67 might help in triaging abnormal pap smear.
Materials and Methods A prospective, cross-sectional study was performed in the Department of Obstetrics and Gynaecol-ogy, in collaboration with Department of Pathology over a period of 16 months to know the efficacy of immunostaining with p16/Ki-67 in predicting the presence of significant lesion in cases of mild cytological atypia. PAP smears conventional and LBC along with P16, Ki-67 and available biopsies were correlated.
Results Liquid-based cytology (LBC) was done in 2134 cases, out of which 46 cases showed abnormal cytological find-ings such as [22 atypical squamous cells of undetermined significance (ASCUS), 3 low-grade squamous intraepithelial lesion (LSIL), 8 atypical squamous cells cannot exclude high-grade lesion (ASC-H), 6 high-grade squamous intraepithelial lesion (HSIL), 5 squamous cell carcinoma (SCC), 2 adenocarcinoma, 1 atypical glandular cells of undetermined signifi-cance (AGUS)]. Immunostaining with p16 and Ki-67 was performed on 38 cases of abnormal cytological smears. Out of 38 abnormal cytology cases, 28 cases had shown co-staining for both p16 and Ki-67, suggestive of true HPV infection of the cells. Of the 38 cases, 07/14 ASCUS, 06/06 HSIL, 07/08 ASC-H, 05/05 squamous cell carcinoma and 02/02 adeno-carcinoma also showed dual positivity for p16 and Ki-67. One AGUS was diagnosed, but the smear was unsatisfactory for immunocytochemical evaluation and excluded from the study. Three cases of LSIL were also diagnosed on cytological evaluation, and 1 of them however showed positivity for p16 and Ki-67 on immunocytochemistry (ICC). In the ASC-US group, the sensitivity and specificity of the immunostaining in diagnosing CIN2 + lesions were 87.51%, and in LSIL group, the sensitivity and specificity of the immunostaining in diagnosing CIN2 + lesions were 100%. p16/Ki-67 positivity also increased with cytological severity which in turn corresponded with histological findings: it reached from 50% in ASC-US to 100% in both HSIL and SCC categories.
Conclusion This immunostaining with p16 and Ki67 can be a useful method in the triaging of the ASC-US and the LSIL group as considering the high sensitivity and specificity values.
p16 , Ki67 , ASC-US , ICC , Liquid-based cytologyMultiple myeloma is a B-cell neoplastic disorder and represents 1% of all cancers and 13% of hematological malignancies. It is predominantly a disease of elderly, and less than 3% of all cases are below the age of 40 years. We present the case of a 29-year-old lady with multiple myeloma who had spontaneous conception during maintenance therapy and subsequently a successful pregnancy outcome. She gave birth to a healthy female infant through normal vaginal delivery and subsequently could remain off therapy for 5 years. Since the patient had a history of abortions and stillbirth, it was a precious pregnancy and we could successfully salvage both the mother and the baby. Young female patients of myeloma who are in remission can be encouraged to start a family during their reproductive years with the support of a comprehensive care team of hema-tologists/oncologists and obstetricians.
Cloacal anomalies are rare anorectal malformations usually affecting girl child. It needs surgical correction in childhood and may have significant bearing on the reproductive outcome in later life. We are presenting a case report of such a case posing obstetric challenge and complications.
Congenital diaphragmatic hernias are usually detected during fetal life or soon after birth, though there are several reports of this condition being diagnosed later in life. When it manifests first in pregnancy, the diagnosis can be extremely challenging and delayed, resulting in poor maternal and perinatal outcomes. We report one such case, who presented with acute symptoms late in pregnancy, and the cascade of misleading events before the correct diagnosis was made and treatment could be instituted.
Pseudoaneurysm of uterine artery is rare and can present as abnormal uterine bleeding or as postpartum hemorrhage. Uterine artery embolization (UAE) is used for management for pseudoaneurysm but not preferred in women wanting future fertility as it might cause ovarian failure and pregnancy complications. Here we present two cases where women with uterine artery pseudoaneurysm who presented with abnormal uterine bleeding and were managed with UAE and subsequently conceived and delivered without any complication. Successful pregnancies after UAE for fibroid have been reported but not after pseudoaneurysm treatment.
Abnormal uterine bleeding, CT angiogram, Pseudoaneurysm, PregnancyBackground Laparoscopic repair of female pelvic organ prolapse is a technically challenging surgery, especially for the beginners.
Methods We performed a follow-up study of women who underwent laparoscopic sacrocolpopexy or sacrohysteropexy (LSCP/LSHP) for pelvic organ prolapse between January 2015 and October 2019. We analysed anatomical and subjective success rates, perioperative complications and medium-term complications.
Results Twenty women underwent LSCP/LSHP with average follow-up of 16 months. Anatomical success rate was 95%, and subjective success rate was 90%. Blood loss averaged at 24 ml. Majority of women (90%) reported improvement in their symptoms and 10% reported no change in symptoms. There were no mesh complications.
Conclusion Laparoscopic sacrocolpopexy is an effective and safe surgery for female pelvic organ prolapse even by beginners.
William Hunter (1718–1783) was a Scottish anatomist and physician. He started his career as a man midwife and went on to become the leading obstetrician in London. He prepared anatomically dissected specimens depicting anatomy of gravid uterus and undelivered fetus with placenta in different stages of gestation. Hunter compiled illustrations prepared from these specimens with his clinical notes and published his treatise Anatomia uteri humani gravidi in 1774. This article is a tribute to William Hunter as we approach the 250th year of publication of his work which is a significant milestone in the history of obstetrics and its practice.
