Abstract

Non-medical egg freezing has only been available for about the last 5 years, as new vitrification techniques have made the success rates for actual conception more reliable than the earlier method of slow freezing. The improved outcomes of new technologies of vitrification and intra-cytoplasmic sperm injection (ICSI) have led to the marketing of egg freezing for non-medical reasons, whereby women are offered the possibility of preserving their eggs until such time as they wish to have a child. For many women today, it is not cancer but the simple passage of time that robs them of their chance of motherhood. Social, educational, emotional and financial pressures often lead them to delay trying to start a family until their late thirties, by which time the chance of success is very low. Women at age 40 face a 40 % chance of miscarriage if they can get pregnant at all, and by the age of 45, the risk of miscarriage is 75 %. Donor eggs are not an option for many because of supply constraints and ethical and cultural concerns. Freezing a woman’s eggs at age 30 literally ‘‘freezes in time’’ her fertility potential and gives her the chance of a healthy pregnancy at a time of her choosing. Despite the initial reactions of disapproval, more and more fertility clinics are now offering oocyte cryopreservation to healthy women in order to extend their reproductive options. This procedure is now becoming popular even in developing economies, and egg freezing in major Indian Metros is now routine.

Abstract

Background: Bone turnover is high during lactation. However, studies on bone status of Indian urban mothers are scarce. Hence, the objective was to conduct a crosssectional study on the lactation-related changes in bone health status of Indian mothers postpartum using Dual X-ray Absorptiometry (DXA) at 3 time points: within a week of delivery, at 1- and 3-years postpartum. We also explored the association of dietary calcium intake, physical activity, serum vitamin D status, and dietary traditional food supplements (Dietary Food supplements) with bone health.

Methods: A cross-sectional study was conducted; 300 full-term, healthy primiparous women (28.6 ± 3.4 year) were randomly selected and categorized into 3 groups: 128 mothers within 7 days of delivery (Group A), 88 with 1-year-old children (B), and 84 with 3-year-old children (C). Anthropometry, lactation history, physical activity, diet, biochemical tests (vitamin D, parathyroid hormone), body composition, areal bone mineral density (a-BMD) at total body (TB), AP spine (APS), and dual neck femur (DF) were assessed by DXA (GE-Lunar DPX).

Results: Significantly higher APS-BMD (mean ± SD) was observed in Group C (1.107 ± 0.098 g/cm²) than that in A (1.045 ± 0.131 g/cm²) (p < 0.05). When adjusted for breastfeeding practices, mean (±standard error) APS-BMD was lowest in women in Group A (1.024 ± 0.013 g/cm²), but was higher at 1-year (1.079 ± 0.02 g/cm²) and at 3-years postpartum (1.111 ± 0.019 g/cm²), though differences were significant only between groups A and C (p < 0.05). Most mothers from all 3 groups consumed inadequate amount of nutrients except dietary fat and showed low physical activity. Multiple regression analysis indicated that dietary calcium, moderate physical activity, serum vitamin D, and consumption of dietary food supplements were not significant predictors of APS-BMD (p > 0.1).

Conclusion: Prevalence of nutrient and vitamin D deficiencies, low physical activity, and poor sunlight exposure were major concerns in Indian lactating mothers; improvement in bone mass at APS was observed at 3-years which was most likely due to physiologic changes.

Abstract

Aim: The study was done to determine the maternal and fetal outcome of pregnancies complicated by maternal diabetes either Gestational Diabetes Mellitus (GDM) or preexisting (type 1 or type 2) diabetes over a period from March 2011 to Feb 2013 in a tertiary care hospital, Varanasi.

Methods: This is a retrospective audit of the maternal and fetal outcome of women who presented to the Sir Sundar Lal Hospital, Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India from March 2011 to Feb 2013, with GDM or pre-existing type 1 or type 2 Diabetes with pregnancy. The audit group comprised 65 pregnancies (67 babies), of whom 27 had preexisting diabetes and 38 cases developed gestational diabetes. Pregnant women who were found to be diabetic preconceptionally or in the first trimester were classified as ‘pre-existing diabetes’.

Results: There were total of 65 diabetic women in this retrospective study, 39 women were GDM (60 %) while 26 women (40 %) were having pre-existing diabetes (24 type 1 diabetes and 2 women were in type 2 diabetes group). There were 35 multigravid women (53.85 %) and 30 primigravid women (46.15 %). There were 39 (60 %) women on Insulin. There were 42 Lower Segment Caesarean Section (64.62 %) and 23 Spontaneous Vaginal Delivery (35.38 %). In fetal and neonatal complications, there were three still births, one case of intrapartum death, and one case of shoulder dystocia. Fetal anomalies were less frequent, one case of Gastroschisis with Hydrocephalus associated with Menigomyelocoele, there was one case of isolated Hydrocephalus, and there was also one case of Truncus arteriosus.

Conclusions: The study analyses maternal and fetal complication in the GDM group and also preexisting diabetes group. In our centre, the 60 % women were GDM while 40 % were having pre-existing diabetes. Total rate of fetal/neonatal complication rate was 7.69 % and of congenital anomaly rate it was 9.23 %. Proportion of still birth, Intrauterine death, and congenital malformations was higher in the pre-existing diabetes group although the data are not large enough to draw a statistically significant conclusion. LSCS rate was little higher in the GDM group (69.23 %) in comparison to the preexisting diabetes group where it was 57.69 %. SVD (Spontaneous Vaginal Delivery) rate was 30.77 % in GDM and 42.31 % in the preexisting diabetes group. HbA1c was within normal range 84.62 % of GDM group while in 15.38 % it was raised > 6 %. In the pre-existing diabetes group, only 19.23 % of women had HbA1c within acceptable range and 80.77 % had it > 6. The aim of St Vincent Declaration is to ‘achieve pregnancy outcome in the diabetic woman that is similar to that of the non-diabetic woman.’ But, so far we have not been able to achieve this. Our HbA1c level is remarkably high in the pre-existing diabetes group. Only 3 out of 65 patients’ women took Folic Acid periconceptionally. We need to work to achieve it our best. It is well known that insulin treatment during pregnancy results in reduction in the rate of macrosomia, fetal/neonatal, and maternal complications. Therefore, we need to use insulin judiciously and advocate its usage in the situations where it is needed.

Abstract

Background: Ectopic pregnancy (EP) is the commonest cause of maternal mortality-related death in the first trimester. Methotrexate (MTX) remains the first-line treatment in optimally selected patients.

Objective: To evaluate the success rate and predictors of success of a single-dose MTX treatment in EP.

Subjects and Method: We studied retrospectively 109 patients with unruptured EP who were treated with Intramuscular MTX administered in a dose of 50 mg/m2 on days 0 and in additional doses on day 7 if b-hCG levels did not decrease by 15 % during the follow-up period. The study was conducted at the Maternity and Children Hospital Buraidah, Saudi Arabia from June 2013 to December 2013. Pretreatment b-b-hCG, EP mass diameter, peritoneal fluid, and fetal cardiac activity were evaluated. The main outcome measures were success rate, the predictors of success without surgical treatment.

Result: Under this regime, the overall success rate was 60.6 % of patients. Of the failure group, only 4.7 % of patients experienced rupture of EP. No side effects were reported. The main predictors of failure were initial b-hCG value C 3.500 mIU/mL OR 4.11 (1.646–12.248, 0.043) and EP diameter 3.73 (1.646–12.10, p = 0.003).

Conclusion: The success rate of MTX in this study was 60.6 %, and the initial b-hCG concentration and EP diameter were the best predictors of successful treatment with MTX. Furthermore, MTX should be offered only to those patients with b-hCG < 2,000 mIU/mL and EP mass size < 3.5 cm.

Abstract

Background: Medical method of abortion (MMA) is a safe, efficient, and affordable method of abortion. However, incomplete abortion is a known side effect.

Objective: To study incomplete abortion due to medication abortion and compare to spontaneous incomplete abortion and to study referral practices and prescriptions in cases of incomplete abortion following MMA.

Method: Prospective observational study of 100 women with first trimester incomplete abortion, divided into two groups (spontaneous or followingMMA), was administered a questionnaire which included information regarding onset of bleeding, treatment received, use of medications for abortion, its prescription, and administration. Comparison of two groups was done using Fisher exact test (SPSS 21.0 software).

Results: Thirty percent of incomplete abortions were seen following MMA; possible reasons being self-administration or prescription by unregistered practitioners, lack of examination, incorrect dosage and drugs, and lack of follow- up. Complications such as collapse, blood requirement, and fever were significantly higher in these patients compared to spontaneous abortion group.

Conclusion: The side effects of incomplete abortions following MMA can be avoided by the following standard guidelines. Self medication, over- the-counter use, and prescription by unregistered doctors should be discouraged and reported, and need of follow-up should be emphasized.

Abstract

Objective: To assess the predictive value of cerebroplacental ratio (i.e., S/D ratio of middle cerebral artery to S/D ratio of Umbilical artery) in detection of perinatal outcome in high-risk pregnancies.

Material and Method: This retrospective study was conducted on 150 patients between 28 and 40 weeks of gestation (25 low risk and 125 high risk) who attended OPD and indoor wards of Teerthanker Mahaveer medical college and research center, Moradabad. All patients had serial color Doppler ultrasounds done after taking informed consent which was repeated at 2 weeks interval, and data were collected with regard to perinatal outcome.

Result and Conclusion: Cerebroplacental ratio is having higher sensitivity and negative predictive value in detection of IUGR, Meconium aspiration syndrome, operative interference for fetal distress, and NICU admissions in comparison to its components. So, better prediction of neonatal outcome can be done by C/U ratio.

Abstract

Objective: To study the incidence of elective cesarean deliveries at term and to correlate their neonatal outcomes at different gestational ages (37^0/7–40^6/7).

Methods: Outcomes including the rate of NICU admissions, usage of ventilator/CPAP, and other morbidities were analysed and compared with the gestational age during the study period from January 2012 to April 2013.

Results: The incidences of elective deliveries at 37, 38, 39, and 40 weeks of gestation were 10.6, 29.7, 28, and 31.5 %, respectively. NICU admissions-RR 3.94 (95 % CI 1.92–8.09), respiratory distress-RR 5.255 (95 % CI 1.9–14.4), ventilatory usage, and hospitalization stay (P value < 0.05) were higher in neonates born at 37^0/7-6/7 versus 39^0/7–6/7 weeks (least morbidity group).

Conclusion: Despite recommendations, more than onethird of term babies are delivered electively at < 39 weeks. The fivefold augmented respiratory morbidity and fourfold increased NICU admissions in early term neonates, and the least morbidity in neonates delivered at 39 weeks emphasize the importance of restricting the non-emergent/elective deliveries to 39 weeks of gestation.

Abstract

Background: The purpose of this study was to assess the efficacy and outcomes of preoperative prophylactic metoclopramide and dimenhydrinate use in elective cesarean births.

Methods: Participants (n = 84) scheduled for elective cesarean births were randomized equally into placebo (10 cc 0.9 % NaCl), 10-mg metoclopramide or 50-mg dimenhydrinate groups. Oral alimentation was prohibited 8 h before the surgery; however, patients continued drinking water until 4 h before surgery. Placebo and antiemetics were administered 1 h before the anticipated procedure in a 5-ml syringe. In metoclopramide and dimenhydrinate group, an ampoule of the agents was completed to 5 ml by adding 0.9 % NaCl. In the control group 5 ml of 0.9 % NaCl was used. All prophylactic agents were administered intramuscularly. All patients received a general anesthesia. The placebo group (control group) was compared with the metoclopramide and dimenhydrinate groups.

Results: Demographic data including maternal age, height, weight, body mass index, gravidity, parity, miscarriage, induced abortion, the number of offspring, and the medical history did not show significant differences among the three groups. Postoperative nausea, vomiting, and the use of rescue medication ratios were significantly lower in metoclopramide and dimenhydrinate groups compared with the placebo group (p\0.05); however, the difference between the metoclopramide and dimenhydrinate groups was not significant (p > 0.05).

Conclusion: Dimenhydrinate and metoclopramide significantly decrease postoperative nausea, vomiting, and the need for rescue antiemetic medication. Both agents have similar efficacy and may be used as an alternative to each other.

Abstract

Objective: The objective of this study was to evaluate severe maternal outcomes (including maternal deaths and maternal near-miss cases).

Materials & Methods: A prospective study of severe maternal outcomes (including maternal deaths and maternal near-miss cases) from May 2012 to April 2013 was performed. For each woman, data were collected on the occurrence of selected severe pregnancy-related complications, the use of critical interventions, and admissions to intensive care unit

Results: The total number of deliveries were 2340. The number of maternal deaths was three. The natures of the near-miss cases during the study period were recorded. Prevalence of SAMM (severe acute maternal morbidity) was 2.025 %.

Conclusion: In areas where the maternal mortality is low, there is a need to shift focus to maternal near-miss cases or SAMM, which is a useful adjunct to maternal death enquiries

Abstract

Introduction: In carcinoma of cervix, if overall treatment time (OTT) is prolonged beyond 6 weeks, then the total dose required to achieve a given probability of tumor control is to be increased by 0.6 Gy for each day of prolongation, to control the accelerative repopulation of the cells, i.e., 1 % loss of tumor control, and to avoid increased treatment delays and drop outs due to the prolonged gap between EBRT and intracavitary brachytherapy (ICBT).

Objectives: To evaluate local disease control and early complications of concomitant HDR-ICBT with EBRT and thereby decrease the OTT in I B–III B stage carcinoma cervix.

Methods: Fifty patients of carcinoma cervix (FIGO-I B/III B) were randomly divided into two groups: the study group treated with concomitant EBRT and HDR-ICBT (EBRT = 50–50.4 Gy/25–28 Fr, HDR 7 Gy in 3 Fr during the 3rd, 4th, and 5th weeks), EBRT and weekly cisplatin were not given on the day of HDR-ICBT; and the control group treated with EBRT followed by HDR-ICBT and weekly cisplatin. Acute reactions and local disease response were compared after treatment and at 6-month follow-up.

Results: Medians of OTTs were 42 and 63 days in the study and the control groups, respectively. Dysuria and diarrhoea incidences were more in the study but manageable. At the completion of the treatment, there were 92 and 80 % complete responses; 4 and 4 % partial responses; and 4 and 16 % stable diseases in the study group and the control group, respectively. DFSs (disease free survivals) at 6-month follow-up were, respectively, 96 and 84 %, and most of the stable diseases were observed in stage III B.

Conclusions: Response was better in the study group but statistically insignificant, acute reactions were manageable, and there was decrease in drop outs due to completion of treatment at a stretch, but larger number of patients and longer follow-up are required to arrive at concrete conclusions.

Abstract

Study Objective: To evaluate the association between outcomes of laparoscopic hysterectomy with respect to clinical factors, intraoperative variants, and post-operative complications.

Design: The study conducted was retrospective (Canadian Task Force Classification II-1). Setting The set used in this study was a gynecological laparoscopic centre.

Patients: The present study included 858 women who underwent laparoscopic hysterectomies with or without bilateral/unilateral salpingo-oophorectomy, from December 2004 to May 2014.

Interventions: Eight hundred and sixteen patients underwent total laparoscopic hysterectomy, 14 patients underwent subtotal laparoscopic hysterectomy, 20 patients underwent laparoscopic-assisted vaginal hysterectomy, and 8 patients underwent laparoscopic radical hysterectomy with bilateral pelvic lymph node dissection.

Measurements and Main Results: All surgeries were performed by the same surgeon, using the same surgical technique. The medical records were reviewed, and data were collected with respect to age, indications, type of surgery performed, intraoperative variants, and post-operative complications. Patient average age was 44.9 ± 6.2 years. Most common indication for benign TLH was leiomyoma of 54.4 %. Indications for laparoscopic radical hysterectomy were early stage endometrial cancer (n = 5) and early stage cervical cancer (n = 3). The maximum uterine size operated on was from 20–26 weeks, 4.9 % (n = 42). 9.7 % had previous abdominopelvic surgery. Fifty three % underwent unilateral/bilateral salpingo-oophorectomy. Conversion rate was 0.93 % (n = 8). The minimum and maximum operating time during the total study period was 20 min–2 h. The major complication rates were 0.9 % (n = 8). The hospital stay was not more than 2 days.

Conclusion: In our experience of 858 laparoscopic hysterectomies, 850 were done for benign indications, and 8 done for malignancies. TLH can be performed more safely and under vision, with less blood loss, early post-operative recovery, less post-operative infection, and less complication rate.

Abstract

Background: Uterine AV malformation is a rare cause of torrential post-abortal hemorrhage, which can present with varying grades of severity. Diagnosis requires a high degree of suspicion and is done with ultrasound and Doppler.

Case Series: In our institution, during the period 2008–2013, five cases of symptomatic uterine AVMs have been reported. All of them were in the reproductive age group (22–36 years), presenting with a history of miscarriage or termination of pregnancy for which curettage was done. The presentation was with recurrent bouts of torrential bleeding, some triggered by second curettage, and not controllable with regular measures. Diagnosis was by ultrasound- gray scale, color Doppler, and spectral Doppler. The time interval between the onset of symptoms and the primary curettage was 8–89 days; four patients underwent selective arterial embolization, and one patient opted for hysterectomy. On follow-up, all the four patients are presently free of symptoms; two of them conceived within 2 years of the procedure and carried the pregnancy to term—one resulting in a live-birth and the other intrauterine death.

Conclusion: Uterine AV malformation should be thought of as a differential diagnosis in all cases presenting with bleeding after miscarriage or curettage, since diagnosis is simple and treatment by selective arterial embolization saves morbidity of surgery and anesthesia, and more importantly reduces hospital stay and the absence from work.

Abstract

Objective: In this study, we evaluate the safety and feasibility of cesarean myomectomy and compare this procedure with abdominal myomectomy in single fibroid, in terms of blood loss and postoperative complications.

Methods: Thirty-three patients who underwent cesarean myomectomy from June 2006 to 2012 in Amrita Institute of Medical Sciences, were included in the study. Almost an equal number of patients who underwent abdominal myomectomy (32) in the same period were included. Women are divided into two groups: group 1—cesarean myomectomy, group 2—abdominal myomectomy.

Results: Mean age of the women was comparable; mean gestational age in group 1 was 37.97 ?/- 1.57 weeks; and 60 % were primiparous. Hemoglobin (Hb) drop postoperatively was compared between the groups, and there was no significant difference. Though there was statistically significant difference among the groups regarding the size of fibroids, the main outcome measure of the study, the Hb drop was comparable between group 1 and 2. There is statistically significant difference in the Hb difference with increasing mean diameter of the fibroids. As the size increases, Hb drop also increases indicating the increasing blood loss. The measures used to reduce blood loss such as vasopressin instillation and stepwise devascularization influence the blood loss, and P value shows borderline significance. There was no difference in Hb drop among the groups according to the type of fibroids.Butmore subserousfibroidswere removed in group 1, whereas more intramural fibroids were removed in group 2.

Conclusion: Cesarean myomectomy can be safely done in single fibroids and is comparable to abdominal myomectomy in terms of blood loss.

Abstract

Antagonist cycles have an inherent issue of lack of flexibility. As a result where batching of cycles is desired, it is not the preferred protocol in ART cycles. There is also the limitation of ovarian response in antagonist cycle due to the size heterogenesities of antral follicles at the start of stimulation. Among the different options available, use of estrogen in the luteal phase of the preceding cycle has definitely shown benefits with regard to better control of cycle as well as synchronization of follicles available for stimulation. The article gives a detailed analysis of the different options available for timing the egg collection in antagonist cycles, the advantages and drawbacks, and the method of use of estrogen. Whereas in the majority of the trials where estrogen pretreatment was used, the goal of scheduling of egg collection was definitely achieved, increased duration and dose of gonadotropin stimulation were required. There was definite advantage of higher oocyte yield in these cycles. The possibility of premature LH rise later during stimulation and subsequent poor implantation in these cycles has to be further evaluated. Nevertheless, batching of patient friendly antagonist cycles can be effectively possible by use of precycle estrogen treatment.

Abstract

Addressing vaginal laxity, atrophic vaginitis, stress urinary incontinence (SUI), and different manifestations of sexual dysfunction has always been problematic due to women’s traditional difficulty discussing these issues with doctors as well as the societal attitude of resignation toward these conditions. The recent rise of noninvasive feminine rejuvenation using energy-based modalities to vaginal tissue has its origins in aesthetic medicine. Transcutaneous temperature-controlled radiofrequency therapy at the vulvovaginal region has shown promising results in giving a more youthful appearing vulva, restoration of vaginal elasticity and ‘tightness’, considerable improvement in SUI, reduction in overactive bladder symptoms, and reduction in sexual dysfunction. It is also emerging as the non-invasive treatment modality for mild to moderate SUI. It seems that the time has come, when women shall ever be grateful to their gynecologist for management of SUI with ThermiVa without an incision.