Pregnancy presents a unique window of opportunity in the life of the women to improve her long-term health by allowing her to visit a doctor for antenatal care many times during the pregnancy. This rapport with the doctor can continue throughout life, if the doctor also extends a helping hand. Post pregnancy interventions for appropriate weight of the mother, breastfeeding and lactational tips and tricks, and optimal nutrition prevent the development of chronic non communicable diseases. Screening for postpartum anaemia, hypothyroidism and blood sugars at the end of six weeks along with contraception counselling if not already undertaken will help the woman to be confident about her future health.
Many healthcare providers feel ill-equipped to accurately counsel women about health nutrition or shortage of time to speak in detail to the woman in a busy clinic. The FIGO Nutrition Checklist has been developed as an easy tool to facilitate these discussions. This checklist has been validated against a robust dietary assessment tool—the Food Frequency Questionnaire—and has been found easy to use in many settings in Europe, India, Hong Kong, and South Africa. The FIGO Nutrition Checklist is now available online via the FIGO website and can be adapted for local dietary practices. M-health accessible from women's smart phones can also be a useful resource for nutrition advice.
FIGO is committed to improve women's health across the life course and the FIGO Committee on Impact of Pregnancy on Long-term Health will continue to advocate for improved women's health. FOGSI in its turn has labelled 2023 as the year of “Badlav” which means change in Hindi. It denotes the change required in doctors thinking about Obstetrics as a separate entity from the general health of the women. The work of an Obstetrician is not over when the patient has delivered. In fact, it has just began. Contraception, immunisation, screening for non-communicable diseases, screening for infectious diseases, screening for malignancies, the list is very very long.
“Mothers are not dying because of diseases we cannot prevent or treat. They are still dying because societies have yet to make the decision that their lives are worth saving.” This observation made by Mohammed Fathallah in 1997, and sadly even today it remains a glaring, inconvenient truth.
Background and Objective
Oxidative stress is one of the pathophysiological factors of pPROM and Vit. E being antioxidant may have preventive role. Study was conducted to estimate maternal serum vitamin E levels and cord blood oxidative stress markers in pPROM cases.
Methods
This was a case–control study including 40 pPROM cases and 40 controls. Maternal serum vitamin E levels were measured at recruitment. Cord blood was collected at delivery for estimation of telomere length and mtDNA copy number as oxidative stress markers. Levels were compared using student’s t test or Mann Whitney test. For correlation Pearson coefficient was used.
Results
Maternal serum vitamin E levels were normal in pPROM cases. Cord blood telomere length was more in pPROM than controls (428.99 ± 290.65 vs 322.35 ± 180.33) (p value 0.05). Cord blood mtDNA copy number was more in pPROM than controls (516.46 ± 443.55 vs 384.77 ± 328.27) (p value 0.13) though it was not significant. mtDNA copy number had negative correlation with Vit. E levels but it was statistically not significant (p value 0.49). There was no association of vitamin E levels with telomere length (p value 0.95).
Interpretation and Conclusion
pPROM was not associated with vitamin E deficiency. There was insignificant oxidative stress in cord blood as measured by mtDNA copy number but cord blood telomere length measurement did not detect any oxidative stress in pPPROM cases.
Purpose
No consensus exists whether to administer prophylactic antibiotics in conjunction with manual placenta removal. This study aimed to investigate the postpartum risk of a new prescription of antibiotic treatment, a possible indirect variable for infection, after manual placenta removal.
Methods
Obstetric data were merged with data from the Anti-Infection Tool (Swedish antibiotic registry). All vaginal deliveries (n = 13 877) at Helsingborg Hospital, Helsingborg, Sweden, from January 1st, 2014 until June 13th, 2019 were included. Diagnosis codes for infection can be lacking, while the Anti-Infection Tool is complete as it is unavoidable in the computerized prescription system. Logistic regression analyses were performed. The risk of a prescription of antibiotics 24 h to 7 days postpartum was analyzed in the entire study population, and in a subgroup of women not having received any antibiotics 48 h prior to delivery until 24 h after delivery, referred to as “antibiotic-naïve.”
Results
Manual placenta removal was associated with an increased risk of an antibiotic prescription, adjusted (a) OR = 2.9 (95%CI 1.9–4.3). In the antibiotic-naïve subgroup, manual placenta removal was associated with an increased risk of antibiotic prescription, in general, aOR = 2.2 (95%CI 1.2–4.0), endometritis-specific antibiotics, aOR = 2.7 (95%CI 1.5–4.9), and intravenous antibiotics, aOR = 4.0 (95%CI 2.0–7.9).
Conclusion
Manual placenta removal is associated with an increased risk of antibiotic treatment postpartum. An antibiotic-naïve population might benefit from prophylactic antibiotics to reduce the risk of infection, and prospective studies are needed.
Objectives
To evaluate the mRNA expression of epidermal growth factor-like domain 7 (EGFL7) in maternal blood and its protein level in sera of pregnant women complicated with preeclampsia (PE).
Method
Case–control study involving 25 pregnant women diagnosed with PE (cases) and 25 gestational age-matched normal pregnant women (controls). EGFL7 mRNA expression in normal and PE patients was quantified by (qRT-PCR), and EGFL7 protein level was estimated using ELISA.
Results
The RQ values of EGFL7 in the PE group were significantly higher than in the NC group (P < 0.001). Pregnancies affected with PE showed higher serum EGFL7 protein compared with matched controls (P < 0.001). EGFL7 serum level cutoff value ≥ 38.25 µg/ml could be used in the diagnosis of PE with sensitivity = 92%, and specificity = 88%.
Conclusion
EGFL7 mRNA is overexpressed in maternal blood of pregnancies complicated with preeclampsia. Serum EGFL7 protein is elevated in PE cases and can be used as a diagnostic marker for preeclampsia.
Background
Intrapartum fetal hypoxia which is one of the leading causes of neonatal morbidity and mortality is a preventable cause. Over the past years, many methods have been employed to diagnose fetal distress, a sign of fetal hypoxia, among these, cardiotocography (CTG) is the most widely used method. Diagnosis of fetal distress based on CTG can have high inter and intraobserver variation leading to either delayed or inessential intervention henceforth increasing maternal morbidity and mortality. Fetal cord arterial blood pH is an objective method to diagnose intrapartum fetal hypoxia, hence by observing the incidence of acidemia in cord blood pH among those newborns born through cesarean section (CS) in view of non-reassuring CTG can help make a judicious decision.
Methods
In this single institutional observational study, patients admitted for safe confinement were subjected to CTG in the latent and active phases of labor. Non-Reassuring traces were further classified based on NICE guideline CG190. The cord blood of these neonates born through CS in view of non-reassuring CTG was drawn and sent for ABG analysis.
Results
Among the 87 neonates delivered through CS in view of fetal distress, 19.5% had acidosis. Among those with pathological traces, 16(28.6%) had acidosis and one (100%) which was categorized as the need for urgent intervention showed acidosis. This result showed a statistically significant association (p value-0.003). No statistically significant association was obtained when variation in baseline characters of CTG when taken independently.
Conclusions
In our study, neonatal acidemia which is the objective evidence of fetal distress was seen in 19.5% of our study population who underwent cesarean in view of non-reassuring CTG. Among these, acidemia was significantly associated with pathological CTG trace compared to suspicious trace. We also observed that abnormal FHR features when taken independently showed no significant association with acidosis. Acidosis among newborns certainly increased the requirement for active resuscitation and additional hospital stay. Hence, we conclude that by recognizing specific fetal heart rate patterns associated with acidosis in a fetus, a more judicious decision can be made, thereby preventing both delayed as well as inessential intervention.
Background
This is a quality improvement study in North India undertaken to observe the efficacy and safety of a proposed set of interventions along Quality Improvement guidelines to reduce cesarean rates.
Materials and Methods
It was a retrospective cross-sectional study conducted in New Delhi. Measures were iteratively introduced from 2017 and improved using multiple PDSA (Plan, Do, Study, Act) cycles to note the overall reduction in cesarean rates. Chi square tests were done with subanalysis based on the Robsons classification.
Results
There was a significant reduction of annual cesarean rates from 36.35 to 22.87% over four years (p < 0.01) and in neonatal nursery admissions (p < 0.01). Covid outbreak saw a comparatively increased cesarean rate in 2020, for which it was excluded from the detailed study. The relative risk of cesarean delivery in the postintervention period was 0.62. Maximum reductions were seen in Robsons II, VI &VII.
Conclusion
Devising multipronged interventions and their implementation through PDSA cycles are essential. Such measures in moderate resources are replicable elsewhere as well.
Background
Whether vertical transmission or placental pathology occurs after maternal infection during pregnancy remains unknown. There is a clear need for studies on the impact of COVID-19 on pregnancy outcome. A systemic inflammatory or hypercoagulable state may be the contributing factor for placental pathology.
Methods
The pregnant women with COVID-19 who delivered between May 2020 and May 2021 were followed and data were collected about pregnancy course and placentas were examined for macro- and microscopical changes and were compared to controls with non-infected women.
Results
Placenta of COVID-19-infected females had increased prevalence of decidual arteriopathy and placental injury reflecting hypoxia and uteroplacental insufficiency within the intervillous space. Features of maternal vascular malperfusion such as increased syncytial knots were present in 100% cases. Fibrinoid necrosis was seen in 100% cases and increased focal perivillous fibrin depositions were presented in 37.7% cases. About one fourth infected placentas had evidence of villitis. Even after matching for comorbidities like preeclampsia, these changes were present.
Conclusion
The most common pathological findings of the placenta of COVID-19 infections are signs of maternal and fetal malperfusion. Future studies should target infections in different stage of gestation, including first and second trimesters.
Background
Hypertensive disorders of pregnancy are first identified during pregnancy (gestational hypertension, pre-eclampsia, eclampsia, and HELLP syndrome) or may present as a complication of previously existing disease (chronic hypertension, renal disease, and systemic disease). These hypertensive disorders complicate the pregnancy, leading to significant maternal and perinatal morbidity and mortality, especially in low- and middle-income countries (Chappell in Lancet 398(10297):341–354, 2021). These hypertensive disorders are about 5–10% of all pregnancies.
Methods
This is a single institutional study, which was conducted among 100 normotensive asymptomatic antenatal women at, 20–28 weeks of gestation attending our OPD. Voluntary participants were selected based on inclusion and exclusion criteria. Spot urine sample was taken for estimation of UCCR by an enzymatic colorimetric method. These patients were followed up throughout the pregnancy and monitored for the development of pre-eclampsia. UCCR is compared in both groups. Pre-eclampsia women were further followed up to observe the perinatal outcomes.
Results
Among 100 antenatal women, 25 of them developed pre-eclampsia. UCCR of < 0.04 was considered as cutoff and compared between pre-eclampsia and normotensive women. This ratio yielded a sensitivity of 61.54%, specificity 87.84%, positive predictive value 64%, and negative predictive value of 86.67%. It was also observed that primigravida had more sensitivity (83.3%) and specificity (91.7%) in predicting pre-eclampsia compared to multigravida. The mean and median UCCR among pre-eclamptic women was significantly low (0.062 ± 0.076, 0.03) compared to normotensive women (0.15 ± 0.115, 0.12) with a p value of < 0.001.
Conclusions
Spot UCCR is a good predictor of pre-eclampsia in primigravida women and can be considered as a routine screening test at 20–28 weeks of gestation during regular antenatal visits.
Aim
To evaluate the oocyte retrieval rate and blastocyst formation rate with DuoStim protocol in patients belonging to POSEIDON groups 3 and 4.
Methods
This observational, retrospective, single-center study including 90 patients belonging to POSEIDON groups 3 and 4 was conducted at a tertiary care hospital from October 2017 to March 2020. Patients were allocated into two groups based on POSEIDON classification criteria: group A (POSEIDON group 3) and group B (POSEIDON group 4). DuoStim protocol was performed with human menopausal gonadotropin (hMG) at 225 IU and 300 IU in groups A and B, respectively. Study groups were again subdivided by considering the phase in which stimulation had been done [follicular phase stimulation (FPS) and luteal phase stimulation (LPS)], and then, inference was made accordingly in terms of oocytes retrieval rate and blastocysts formation rate. Data were compiled and analyzed using statistical software SPSS version 20.
Results
The baseline characteristics of two groups were compatible with POSEIDON groups 3 and 4. A significant difference was found between study groups with respect to age and anti-mullerian hormone levels (p < 0.05). Significantly, a greater number of oocytes and blastocysts were obtained in LPS stage, substantially more in group A (3.69 ± 3.4 vs. 4.52 ± 4.3 and 1.36 ± 0.65 vs. 3.17 ± 1.84) than group B (2.2 ± 1.36 vs. 3.6 ± 4.5 and 0.41 ± 0.8 vs. 1.29 ± 2.04). A greater blastulation rate (50 vs. 66.7% and 33.3 vs. 50%) and 100% oocyte maturity rate were observed in LPS stage of both the study groups.
Conclusion
In patients belonging to POSEIDON groups 3 and 4, the number of oocytes retrieved and blastocyst formation rate were greater in LPS stage when compared to FPS with DuoStim protocol.
Background
There are conflicting reports on status of ovarian function after hysterectomy and opportunistic salpingectomy in premenopausal women. The present study was undertaken to understand the effect of salpingectomy done at the time of hysterectomy on ovarian reserve and function as measured by serum AMH and FSH levels before and after the surgery.
Methods
This was a prospective study conducted on 60 women who underwent hysterectomy at our tertiary care centre, Shri Guru Ram Rai Institute of medical and health sciences, Dehradun, from January 2020 to September 2021. Serum AMH and FSH levels were monitored preoperatively and 3 months postoperatively in patients undergoing hysterectomy with bilateral salpingectomy and hysterectomy without salpingectomy.
Results
The mean age of the patients was 41.83 yrs in group 1 and 43.73 yrs in group 2 [p value = 0.078]. Most common indication of hysterectomy was AUB-L in both the groups (86% and 80%, respectively). Mean operative time was 115.50 min in group 1 and 114.40 min in group 2 [p value = 0.823]. Mean intra-operative blood loss was 214 ml in group 1 and 199.33 ml in group 2 [p value = 0.087]. Serum AMH and FSH were insignificantly decreased in both the groups post-operatively after 3 months, and the difference between both groups was also not statistically significant.
Conclusion
Salpingectomy done at the time of hysterectomy for benign indications with preservation of ovaries did not have any short-term adverse effects on ovarian reserve and function.
Background
In absence of a dedicated teaching curriculum for non-PG residents in Obstetrics and Gynecology department, a concise teaching learning method, One-Minute Preceptor (OMP) with feedback being its core component may be introduced to translate their theoretical knowledge into clinical practice.
Methods
This descriptive cross-sectional study included four faculty members and 20 residents. Each resident was exposed to three OMP sessions pertaining to common gynecological case scenarios with a gap of at least two days in between the sessions with faculties acting as preceptor and as observer. After three OMP sessions, feedback from residents and faculty regarding their teaching and learning experience after implementing this tool was obtained through separate pre-validated questionnaires graded on Likert’s scale.
Results
The satisfaction index of the residents and faculties for OMP was found to be 96.3% and 95%, respectively. All residents and faculty members had consensus that OMP addressed the learning gaps (mean score 4.45 ± 0.51 and mean score 4.5 ± 0.57, respectively) and expressed being highly satisfied with OMP in busy clinical settings as compared to traditional method of teaching with mean score of 4.9 ± 0.30 and 4.75 ± 0.5, respectively. The faculties had consensuses that OMP can assess all domains of learning (mean score 4.75 ± 0.5). All residents and faculties opined that the time allotted to address all micro-skills was less and 60% residents advocated allotting at least 5 min time to the teaching encounter.
Conclusion
Our study indicates the beneficial role of OMP in time-constraint clinical environment and warrants further research to review the time frame keeping in view the learners’ needs and the discipline.
Methods
This is a prospective randomized study. The study population included were women with primary and secondary infertility registered at our center, fit into the inclusion and exclusion criteria of this study. The total 180 patients were included.
Results
Hysteroscopies were performed in 90 patients with at least one IVF cycle failure and another 90 patients taken as control with similar demographic parameters. The average duration of infertility between both the groups was not significant. Hysteroscopy was able to detect intrauterine pathologies in around 40% of the cases, which were treated in the same treatment phase. Early ultrasound findings with gestational sac and cardiac activity were found to be significant between two groups.
Conclusion
We noticed clinical improvement in IVF success rate after hysteroscopy. Hysteroscopy may be offered to the patients with previous one or more IVF failures, as clinically some of the previously undiagnosed pathologies could be detected and treated to achieve the positive outcomes.
A 59-year-old post-menopausal female presented with complaints of per vaginal spotting for 3 months. Histopathological examination of contents of dilation and curettage revealed endometrial carcinoma (FIGO stage I), along with benign endocervical polyps. MRI also showed presence of left-sided structure indicative of ectopic pelvic kidney. The patient underwent laparoscopic radical hysterectomy, bilateral salpingo-oophorectomy and bilateral ilio-obturator lymph node dissection. Dissection was started along the left pelvic plane. The left pelvic kidney was seen, and left ureter was located and confirmed below the uterus. The patient withstood the procedure well. Anomalies of pelvic anatomy, such as a malpresentation of the kidney and ureter, may prove as surgical challenges while performing open and laparoscopic surgery. However, in depth preoperative imaging, meticulous intraoperative dissection and proper identification of surrounding structures reduces the risk of such complications.
Bela Kedia1,2 · Nilesh Chordiya3,4,5 · Keya Ganatra6Tumor lysis syndrome is an oncologic emergency, usually occurs in hematologic malignancies and remains very rare in gynecological malignancies. We present a case of a young unmarried girl who presented with a large abdominopelvic mass with acute kidney injury and characteristic biochemical abnormalities of tumor lysis syndrome.
Medical devices and materials commonly used in management of common gynecological conditions or during surgical procedures may present with acute or chronic complications due to incorrect application, improper use and lack of follow up. We present two interesting cases highlighting this problem. A strong index of suspicion is very crucial in early diagnosis and successful management.
Vaginal pessary · Rectovaginal fistula · Gossypiboma · Medical devices