Introduction: Traditionally, insulin has been the gold standard in the management of Type 2 diabetes in pregnancy and gestational diabetes. However, insulin therapy can be inconvenient because of the needs for multiple injections, its associated cost, pain at the injection site, need for refrigeration, and skillful handling of the syringes. This has led to the exploration of oral hypoglycemic agents as an alternative to insulin therapy.
Objectives: This review examines and evaluates the evidences on the efficacy, safety, and current recommendations of oral hypoglycemic agents.
Conclusion: The evidence of this study supports the use of glyburide and metformin in the management of Type 2 diabetes and gestational diabetes with no increased risk of neonatal hypoglycemia or congenital anomalies. The safety of these oral hypoglycemic agents are limited to the prenatal period and more randomized controlled trials are required to provide information on the long-term follow up on neonatal and cognitive development.
Oral hypoglycemic agents ● Gestational diabetes mellitus ● Type 2 diabetesObjective: The aim of this study of maternal deaths through FOGSI members is to see its current STATUS. Method A three-year retrospective observational study from January 2005 to December 2007 formed the basis for collection of the data for analysis.
Results: A wide variation of maternal mortality ratio (MMR) in the five zones (West—342; South—229; East— 709; North East—709 and North—814) was observed. Leading causes of maternal deaths also varied among the zones [hemorrhage in West (31 %), South (26 %), and North East (21.5 %); hypertension in East (34 %) and North (22 %)]. When the data were analyzed as a whole, the leading causes of deaths were determined as hypertension (29.4 %), hemorrhage (21.56 %), sepsis (15.05 %), and medical disorders (12 %). Analysis of data in India (including Kerala State) for the year 2005 revealed significant drop in MMR to 147.
Conclusion: MMR in India varied widely in zones. There is significant difference in MMR for the whole country as well as for the south zone with or without inclusion of Kerala. Areas of discrepancy in data had been observed in different sources. Prioritization of causes of death and appropriate allocation of resources are needed. A prospective study for evaluation of exact MMR in India is an immediate necessity.
Background: Thrombocytopenia is defined as a platelet count of less than 150 9 103 ll. It is commonly diagnosed and has attracted more interest from the researchers in pregnant women during the last 20 years, especially in hypertensive pregnant women.
Aim: To assess the incidence of thrombocytopenia in hypertensive pregnant women during the third trimester of pregnancy.
Methods: Five hundred forty-four pregnant women were included in this study from a total of 10,272 admitted at the Obstetrics and Gynecology Department at Tripoli Medical Center during January–August 2007. Frequent blood pressure monitorings and full blood counts were performed in several medical follow ups. They were not known to be HBV, HCV, or HIV positive women before pregnancy, and none was reported to have evidence of HBV, HCV, or HIV upon performing HBs-Ag, anti-HCV antibody, or HIV-antigen positive tests. Data were arranged in Excel Microsoft program version 2010, and statistically analyzed by SPSS windows program version 17.
Results: Five hundred and forty-four women were hypertensive according to WHO hypertension definition criteria. Sixty-seven women had only one reading of high blood pressure, while 39 women fulfilled HELP syndrome criteria (hemolysis elevated liver enzymes low platelet). These 39 women were excluded from the study. Therefore, only 438 pregnant women remained eligible for the study. The mean age was (32.56 ± 1.5), with their ages ranging between 18 and 49 years. Most of the included women were primigravida 179 (39 %), gravid 2, para one were 72 (16.4 %), and the rest were gravid 3 or more (42.6 %). The blood pressure was 140-160/90-110 mmHg in 365 women (83.4 %), and 73 women (16.7 %) had blood pressure readings more than 160/110 mmHg. Mean platelets count was (206.49 9 103/ll ± 3.35), and ranged between (41.0 - 449.0 9 103/ll). Thrombocytopenia (less than 150 9 103/ll) was recorded in 103 women (23.5 %). All pregnancy cases were delivered safely with no fetal complications.
Conclusion: Gestational thrombocytopenia (GT) is recognized as a major cause of thrombocytopenia particularly in hypertensive pregnant women during the third trimester. Careful follow up during and after pregnancy for those women is recommended.
Pregnancy, Thrombocytopenia, Gestational hypertension, ThrombocytopeniaPurpose: Profile of maternal deaths in selected districts of four Indian states was studied to examine the regional differences in non-biological causal factors (socioeconomic and sociocultural) in maternal mortality and to examine the method and completeness of implementation of Maternal and Perinatal Death Inquiry and Response (MAPEDIR) process.
Methods: An integrated qualitative and quantitative method was used to study the MAPEDIR process in selected districts of four states in India, through the use of standard- ized questionnaire for key informant interviews, participant observation checklist, analysis of verbal autopsy questionnaire, and maternal death reports.
Results: A comparison of Profile’s maternal deaths investigated showed that women died between 25 and 27 years of age. Half of the women died at home because of inability to afford transport (Delay II) and treatment costs. One third of the deaths had occurred in a health facility (Delay III) because of lack of specialists, equipments or blood. Two thirds of the delays (Delay I) were in seeking medical care. Review of the implementation process of MAPEDIR highlighted that the social audit review model is a unique field based collaborative initiative comprising of stakeholders from various sector in order to improve maternal health programming by reducing maternal mortality.
Conclusions: MAPEDIR has been able to identify socio-cultural, economic and health care systems related determinants of maternal deaths. Standardization the mechanism for information data sharing at district, sub-district and village level can maximize the use of available evidence for advocacy and policy shifts by developing policies and interventions suited to local needs.
Maternal death, India, Social audit, MAPEDIRObjectives: The aim of this study was to analyze the incidence, possible etiological factors, pathology, clinical manifestations, brain CT scan features, treatment, and prognosis of cerebrovascular complications occurring in pregnancy and puerperium.
Methodology: This is a prospective analytical study con- ducted at the Govt. Hospital for women and children, Chennai, from January 2006 to February 2008. During the above period, 26 women were diagnosed with various cerebrovascular complications. In these patients, the clin- ical data, risk factors, neurological features, investigations, results, and neuroimaging reports were analyzed.
Results : The incidence of cerebrovascular complications in this study was 66 per 100,000 deliveries. None had prior history of diabetes, hypertension, renal disease, or seizure disorder. Two women were suffering from cardiac disease. PET and eclampsia were seen in 19/26 (73 %) cases. Seven women were suffering from anemia and one with severe sepsis. The neurological complications manifested pre- dominantly in the postpartum period. Cases presented with hemiplegia/facial palsy and aphasia. CT scan imaging showed intracerebral hemorrhage in four cases, cerebral infarcts in five cases, and cortical vein thrombosis in 16 cases. There were five maternal deaths in this study.
Conclusion : Stroke occurring in pregnancy, though rare, is a serious complication which can lead to maternal death. In this study, hypertension has emerged as an important risk factor; therefore, attention should be focussed on maintaining normotension in the peripartum period.
Cerebrovascular complications, Stroke, Risk factors, Pregnancy and puerperiumObjectives: Hypertension disorders are associated with higher rates of maternal, fetal, and infant mortality, and severe morbidity, especially in cases of severe preeclampsia, eclampsia, and HELLP syndrome. The aim of the study was to determine maternal outcomes in pregnant women with severe preeclampsia.
Data Source: The data source consisted of 349 cases with severe preeclampsia.
Design: A cross-sectional study was undertaken on 349 cases of severe preeclampsia in pregnancy.
Setting/Period: The patients selected for this study were from those who presented at Kermanshah University of Medical Sciences, Department of Obstetrics and Gynecology during 2007–2009.
Materials and Methods: Statistical analysis was performed using SPSS 16 software and conducting Chi square and independent sample t tests. Demographic data involving age, parity, gestational age, clinical, and laboratory findings were recorded from the medical files. In addition, delivery route, indications of cesarean delivery, and maternal complications were determined.
Results: Of the 349 severely preeclampsia cases, among the 22 cases (6.3 %) who had suffered fromeclamptic seizers, 17 cases (77.3 %) were in the age group of 18–35 years (P = 0.351) and 13 cases (59.1 %) in the gestational age group of 28–37 weeks (P = 0.112). One case (0.3 %) was demonstrated to have HELLP syndrome. Placental abruption was obstetric complication in 7.7 %(27 cases). Delivery route was vaginal in 120 cases (34.4 %), while 229 cases (65.6 %) underwent cesarean delivery. The most frequent maternal complication (37 cases) reported was coagulopathy (10.6 %).
Conclusions: We concluded that severe preeclampsia and eclampsia are associated with higher rates of maternal severe morbidity and that these two factors still remain the major contributors to maternal morbidity in Iran.
Objectives: To compare maternal and neonatal effects of assisted vaginal delivery by forceps and vacuum extraction.
Methods: A prospective randomized study. One hundred eligible women requiring assisted vaginal delivery in the second stage of labor were randomized to deliver by forceps or vacuum extraction.
Results: All of those allocated to forceps delivery actually delivered with the allocated instrument (100 % delivery rate in forceps vs. 90 % in VE); however, maternal trauma (40 % in forceps vs. 10 % in VE, p\0.001), use of analgesia (p\0.001), and blood loss at delivery (234 ml in VE vs. 337 ml in forceps group, p\0.05) were significantly less in the group allocated to deliver by vacuum extraction. Vacuum extraction, however, appears to predispose to an increase in neonatal jaundice and incidence of cephalhematoma. More serious neonatal morbidity was rare in both groups.
Conclusion: Extrapolation of the data from the study reveals that there is a significant reduction in maternal injuries. However, vacuum extraction has the potential to injure babies more.
Vacuum extractor, Obstetric forceps, Comparative morbidity, OutcomeObjectives: The aim of this was to evaluate the accuracy of two-dimensional (2D) ultrasonography in the diagnosis of nuchal cord to enable us determine if it can be recommended for its antenatal diagnosis.
Materials and Methods: Between 01 January and 30 April 2012, 93 singletons pregnancies in cephalic presentation with 2D ultrasound scan done at term but within 24 h before onset of labor for exploration of the presence or absence of nuchal cord were reviewed. The procedure was carried out using the same equipment (Voluson 730 Expert) and by the same radiologist who had good training in the ultrasonographic diagnosis of nuchal cord.
Results: Among the 38 cases of nuchal cord present at delivery, the diagnosis by means of 2D ultrasonography was done in 32 cases (sensitivity: 84.2 %). The diagnosis was also correct among 47 of the 55 absent nuchal cords at delivery (specificity: 85.4 %). In eight cases, nuchal cord diagnosed by 2D ultrasonography was not observed at delivery (positive predictive value: 80 %). Furthermore, six cases of nuchal cord were undiagnosed by 2D ultrasonography (negative predictive value: 88.7 %).
Conclusion: Two-dimensional ultrasonography for the antenatal diagnosis of nuchal cord by a skilled radiologist can reach sensitivity and specificity of more than 84 %. Therefore, in settings where only 2D ultrasonography is available, efforts should be made by operators for antenatal diagnosis of nuchal cord.
Nuchal cord entanglement, Two-dimensional ultrasonographic diagnosis, Sensitivity SpecificityPurpose: Our aim was to identify couples at risk of having a homozygous or compound heterozygous child with a severe hemoglobinopathy by antenatal screening and prenatal diagnosis in Surat, South Gujarat.
Method: Pregnant women were screened for hemoglobinopathies by means of red cell indices, the solubility test, cellulose acetate electrophoresis tests, and confirmation by HPLC. Husbands of the pregnant women having hemoglobinopathies were counseled and screened for hemoglobinopathies. The couples at risk were again counseled and referred to the National Institute of Immunohematology, where mutations in parents and fetuses were identified by molecular analysis. After prenatal diagnosis, the continuing pregnancies were followed up and infants were tested at birth.
Results: Out of 3,009 women, 37.04, 52.6, and 10.3 % were in the first, second, and third trimester of pregnancy, respectively. Among those having hemoglobinopathies, 102 (3.38 %) had the b-thalassemia trait, 46 (1.5 %) the Sickle cell trait, and 26 (0.86) had hemoglobin variants like Hb DPunjab, Hb E, Hb DIran, Hb QIndia, Hb JParis-I, and Hb OIndonesia. Out of the 14 couples at risk of having an affected child, 11 (78.5 %) couples opted for prenatal diagnosis. Three fetuses had homozygous b-thalassemia and hence the pregnancies were terminated. Follow up of normal or heterozygous fetuses confirmed the diagnosis.
Conclusion: During antenatal screening, we found many Hb variants of β and α globin chains. Late antenatal registration, non-cooperation of the husband for investigation, and refusal for prenatal diagnosis are the main hurdles in the hemoglobinopathy prevention program and awareness is necessary.
β-Thalassemia trait, Sickle cell trait, Hb variants, Antenatal screening, Prenatal diagnosisBackground: Cervical and endometrial carcinoma incidentally found in the surgical specimen with high risk pathological finding or with gross residual disease.
Material and Methods: Between 2004 and 2010, 320 cervical and endometrial cancer patients were treated with EBRT and brachytherapy after having undergone total/ subtotal hysterectomy. Sixty patients were lost to followup.
Results: Median follow-up was 21 months. Endometrial and cervical cancer with a high risk for local recurrence achieved CR 93.8 and 89 %, respectively. 56 % patients experienced CR with residual disease with cervical cancer. Median OS for endometrial and cervical cancer with residual disease was 8.5 and 24 months, respectively. Grade 3 adverse events were 5 and 3.5 % for rectum and bladder, respectively.
Conclusion: The incorporation of chemotherapy during pelvic radiotherapy followed by HDR interstitial brachytherapy for residual disease is inadequate and improves survival. We are still in learning phase of brachytherapy in post-operative gynaecological malignancy cases; expertise will be developed by practice.
Gynaecological malignancy, Hysterectomy, Brachytherapy, SurvivalObjective: Vulvovaginal candidiasis (VVC) is a common gynecological finding among the women worldwide. Candida species are often less susceptible to antifungal agents. Owing to this fact, in this study, we aimed at assessing the prevalence rate and antimicrobial susceptibility pattern of various azoles against Candida species causing VVC in symptomatic women.
Methods: The prospective study included 217 female patients with symptoms of vaginal discharges. Specimens were characterized microscopically and were subjected to antimicrobial susceptibility testing against various azoles according to NCCLSM44 disk-diffusion method.
Results: VVC was detected in 18.4 % of the cases. Based on age distribution, the highest rate of Candida infection was observed in the age group of 20–29 years (42.5 %). Antifungal susceptibility revealed that fluconazole was highly effective against Candida Species (97.2 %); on the contrary, the highest resistance was observed in the case of miconazole (63 %).
Conclusion: In the current study, prevalence rate of VVC was found to be 18.4 %, and among the various azoles tested, fluconazole has the highest antimicrobial activity.
Vulvovaginal candidiasis, Fluconazole, Miconazole