Ovarian function after hysterectomy is a subject of much controversy since many years. There is increasing awareness among gynecologists that the ovaries need to be spared at hysterectomy for benign conditions. However the awareness is limited, and many practitioners believe in removal of ovaries at hysterectomy. Removal of ovaries will save lives of patients at risk of developing ovarian cancer. But it will be unnecessary for low-risk women and will in fact endanger their lives by increasing cardiac risks. Recent data suggest that ovarian epithelial cancer arises from tubal epithelium, which adds new option of performing only salpingectomy and sparing ovaries, which will serve dual purpose of preventing ovarian cancer and continuing productive function of ovaries. Reproductive function is lost with hysterectomy. But it may be worth looking at impact of hysterectomy on productive function of ovaries. This editorial will focus on this issue and look at evidence on effects of other gynecological procedures on ovarian function.
Fetal growth restriction (FGR) is a failure of fetus to reach its expected biological growth, based on its genetically predetermined potential. Whenever effective fetal weight is less than, 10th percentile or 2 standard deviation of population-specific growth curve, it is considered small for gestational age (SGA). The FGR is associated with poor somatic growth with concomitant changes in placental and cerebral blood flow and/or biochemical markers along with EBW < 3rd percentile. It is an important cause of perinatal mortalities and morbidities. Ultrasound plays a definitive role in diagnosis and its management. This article is aimed to mini review the published guidelines on FGR and SGA and summarize the areas of consensus.
Keywords : FGR · SGA · IUGR · Growth potential
Background : World Health Organization proposed use of Robson Classification as a global standard for assessing, maintaining and comparing Cesarean section (CS) rates. This paper aimed to examine CS trend at a tertiary center according to Robson Ten-Group Classification System (TGCS) over three-year period (2015–2017) and to predict future Cesarean trends.
Methods : This prospective observational study was conducted at a tertiary teaching institute and included 81,784 females who delivered at this hospital over three-year duration (2015–2017). The data compilation was done according to Robson TGCS. The main outcome measures were overall annual CS rates, Robson group-wise CS rates, future overall and Robson group-wise CS trend. These parameters were calculated, trend analysis was done and trend over future 3 years was predicted.
Results : There were 81,784 deliveries (62,336 vaginal and 19,448 Cesarean deliveries) over the study period. The year-wise CS rate was 22.4%, 23.5% and 25.5%, respectively. The largest contribution was by group 5 followed by group 2 and group 1. Based on 3-year data, it was predicted that CS rate will increase by 0.905% annually over coming 3 years. In groups 3, 4, 6, 7 and 8, predicted trend value showed an annual increase by 0.65%, 0.05%, 0.05%, 0.05% and 0.10%, respectively; in groups 1, 2, 5, 9 and 10, it showed an annual decrease of 0.45%, 0.05%, 1.50%, 0.50% and 0.05%, respectively.
Conclusions: Increasing CS rate trend was seen over last 3 years with a predicted rise of 0.905% per year. Robson groups 5, 2 and 1 were at present major contributors; however, the trend analysis predicted a decreasing trend. Trend analysis predicted annual increment in groups 3, 4, 6, 7 and 8 over next 3 years, thereby suggesting need to focus on these groups as well.
Keywords Cesarean section audit · Cesarean trend analysis · Future Cesarean trends · Maternal health policy formulation
Introduction :Gestational diabetes mellitus is one of the most common conditions complicating pregnancy. Vitamin D deficiency is closely associated with gestational diabetes mellitus.
Objectives :To study the effect of vitamin D supplementation on diabetic pregnant women with vitamin D deficiency.
MethodsThis randomized controlled study was conducted with 100 diabetic pregnant women. They were randomized into group A and group B. Group A were screened for vitamin D deficiency once diagnosed with GDM of which 40 were found to be deficient and allotted to group D (n = 40) and were supplemented with 60,000 units of vitamin D3 per month. Group B were given routine antenatal care and were screened for vitamin D deficiency when they were admitted for delivery, and 39 of them were found to have vitamin D deficiency and were studied as control group C (n = 39). Ten women in both the groups had normal levels of vitamin D, and one of them was excluded from the study as she had molar pregnancy. The vitamin D supplemented group D and the control group C were matched for age and parity at the baseline.
Results:There was a significant increase in the mean insulin and metformin requirements in both the supplemented and control groups. Vitamin D supplementation did not improve the glycaemic control in diabetic pregnant women.
Conclusions:Vitamin D supplementation did not decrease insulin resistance or improve the glycaemic control in diabetic pregnant women with vitamin D deficiency.
KeywordsVitamin D deficiency · Gestational diabetes mellitus · Glycaemic control · Vitamin D supplementation · Neonatal outcomes
Introduction : Non-progress of labour forms the largest indication caesarean section. The diagnosis of failure of descent using serial digital examination is objective, poor reproducibility, carries the risk of infection and is painful to the labouring patient. There is a need if not an alternative, adjunctive to digital vaginal examination. Measuring angle of descent (AOD) to predict vaginal birth in late labour by transperineal ultrasound provides an alternative without any of the above-mentioned drawbacks.
Materials and Methods : A prospective observational study in 64 patients in the late first stage and second stage of labour with cephalic presentation was carried out, from September 2017 to December 2018, in PGIMER and DR. RML Hospital. Angle of descent was measured by transperineal ultrasound. Angle of descent is the angle between the longitudinal axis of pubic bone and a line joining the lowest edge of the pubis to the lowest convexity of the foetal skull. Time of assessment of AOD1 was noted, and if patient did not deliver within 2 h, another AOD2 was recorded. Eighty-five readings were obtained, and AOD predicting successful vaginal delivery was calculated.
Results and Discussion : AOD of 116° and more resulted in vaginal delivery, spontaneous or instrumental. As the angle of descent increased, there was a decrease in time interval to vaginal delivery with correlation coefficient of − 0.939.
Conclusions : The use of intrapartum transperineal ultrasound and measurement of angle of descent can prove to be a valuable adjunct in management of labour, especially in cases of prolonged first and second stages of labour in predicting successful vaginal delivery. AOD of 116° or more can predict successful vaginal delivery within 2 h. AOD can be used in centres having facilities of intrapartum ultrasound. The authors recommend the use of ultrasound in labour room as it is non-invasive and can provide a lot of information. This method is currently useful for tertiary centres or medical colleges.
Keywords : Transperineal ultrasound · Angle of descent · Progress of labour
Objective : To assess the intra- and postoperative results of cesarean myomectomy.
Methods : A retrospective study was conducted to collect the results of cesarean myomectomy procedures performed in our tertiary center between June 2013 and December 2018. The subjects were 2219 pregnant women undergoing cesarean section at these units.
Results A total of 2219 scheduled patients undergoing CS were included in the present study. Sixty-five patients have undergone intramural myomectomy during CS; 82 patients have had subserosal myomectomy during CS. No statistically significant differences were found between the three groups in changes of preoperative Hb, postoperative Hb, mean Hb and length of hospital stay. Operation times were significantly longer in both intramural and subserosal myomectomy groups (45.23 ± 8.498 vs. 39.02 ± 6.824 vs. 32.14 ± 5.423 min, p 0.01). Only in the intramural myomectomy group, two patients were subjected to blood transfusion (3%). Assessment of intramural myomectomy patients was carried out by taking 5 cm as the cutoff value. No statistical differences were found between the two groups in terms of mean Hb change, operation time, length of hospital stay. In the group with intramural myomectomy larger than 5 cm, two (15.38%) patients needed a blood transfusion.
Conclusions : Cesarean myomectomy operation performed by experienced surgeons has no adverse effects other than lengthening the duration of operation and can be safely implemented.
Keywords Myoma uteri · Cesarean section · Myomectomy
Background :Prevalence of obesity among women of reproductive age is increasing worldwide. As the prevalence increases among the women of reproductive age group, so it does among pregnant females. This study was conducted with the aim to assess obesity-related adverse maternal, neonatal and perinatal outcomes using new Asian Indian guidelines.
Methodology :Pregnant women up to 16-week gestation on first visit were enrolled. There were two exposure groups: one with BMI < 25 kg/m2 and second with BMI ≥ 25 kg/m2 matched for maternal age and parity, 100 in each group. The study focused on development of various adverse maternal and foetal/perinatal complications. Comparative analysis of data was done to estimate the odds of each outcome taking non-obese group as reference.
ResultsThere was a significant increase in risk among obese mothers compared to non-obese mothers for maternal complications like hypertensive disorders of pregnancy{OR 3.83}, preeclampsia{OR 9.2}, gestational diabetes mellitus{OR 4.85} and insulin requirement{OR 12.46}, induction of labour{OR 2.71}, caesarean section post induction{OR 8.50}, prolonged labour{OR 4.69}, caesarean sections{OR 5.18} and postpartum haemorrhage{OR 2.21}. Also, there was a significant increase in risk among obese mothers compared to non-obese mothers for foetal and perinatal complications like miscarriages{OR 4.85}, preterm newborns{OR 4.63}, medically indicated preterm{OR 6.59}, shoulder dystocia{OR could not be calculated}, large for gestational age{OR 5.91}, hyperbilirubinaemia {OR 4.26} and neonatal intensive care unit admissions{OR 3.26}.
Conclusions:It was concluded that obesity defined by Asian Indian guidelines (BMI ≥ 25 kg/m2) is associated with adverse pregnancy outcomes at odds comparable to western studies with obesity taken as BMI ≥ 30 kg/m2.
KeywordsMaternal obesity · Asian guidelines · Pregnancy outcome · Perinatal outcome
Immediate post-placental IUD insertion is defined as IUD insertion within 10 min of the expulsion of the placenta. Although the expulsion rate in post-placental insertion is higher than interval insertion, the benefits of highly effective contraception immediately after delivery may outweigh the risks of expulsion.
Aims : To compare post-placental IUD (PPIUD) insertion with interval IUD insertion (IIUD) in terms of safety, effect on menstrual cycle, efficacy and satisfaction
Materials and Methods : After meeting all eligibility criteria, the patients were asked to choose between post-placental IUD insertion and interval/delayed IUD insertion. In PPIUD group, insertion was done within 10 min of expulsion of placenta by hand technique. Individuals in IIUD group were asked to return after 6 weeks for IUD insertion by withdrawal technique. Both the groups were followed at 6 weeks, 6 months, 12 months by history, physical examination, per speculum examination and ultrasonography.
Observations 238 patients were allocated to PPIUD group and 273 to IIUD group. In the PPIUD group, there was no bleeding/ spotting demonstrable as it was masked by the lochia. Mild pain at insertion was seen in only 11 patients in the PPIUD group. Slight bleeding/spotting was seen in 7.8% patients in the IIUD group, while mild to moderate pain was seen in 39.9% patients. At 6 weeks, 6 months and 1 year follow up with regard to patients complaining of pelvic pain/dysmenorrhea, the difference between the two groups was not statistically significant. Our study found that irregular bleeding or spotting was more in interval insertion than in the post-placental group. The difference in the two groups was statistically significant at 6 weeks and 6 months, but was not significant at 1 year. There was no case of perforation in either group. Our study found a statistically significant difference in expulsion after post-placental compared to delayed insertion. The difference between the two groups was statistically significant (p = 0.006) for cumulative expulsion. However, for interval expulsion rate, the difference was not statistically significant (p = 0.6). In our study, continuation rates appear to be higher in the PPIUD group, but the difference is not statistically significant.
Conclusions: PPIUD is a safe, easy and effective alternative to interval IUD insertion and qualifies to be popularized as a first-line contraceptive agent in eligible patients owing to its immediate and sustained contraceptive benefit, patient comfort, convenience and lower incidence of side effects.
Keywords Post-placental · Interval IUCD · Contraception · Intrauterine contraceptive device · Delayed IUCD · IUCD expulsion
Background/purpose of the study: Following mid-urethral tape insertion, for stress urinary incontinence (SUI), a proportion of women experience complications such as voiding dysfunction or tape erosion which fail to respond to conservative management approaches. These women thus require further surgical treatment. Our objective was to describe the outcomes of the surgical management of complications in these women.
Methods: This retrospective study describes the results obtained following the surgical management of mid-urethral tape complications. Twenty-nine consecutive women who required mid-urethral tape lysis, loosening or excision for tape-related complications in the period 2007–2017 were included. Primary outcomes were improvement in voiding dysfunction and resolution of pain, while secondary outcomes were evaluation of the recurrence of stress urinary incontinence and patient satisfaction. Patient outcomes were measured using the Patient Global Impression of Improvement questionnaire.
Results: There were 1459 mid-urethral tape procedures performed in the study period. Twenty-nine women (1.99%) who had revision surgery for tape complication were identified. Interventions included tape loosening or lysis in 19 women and tape excision in ten women. Twenty-three of the 29 patients reported a significant improvement in their symptoms postoperatively. Two women had a recurrence of SUI in the tape excision cohort; all patients following tape loosening or lysis remained continent.
Conclusion: Tape revision surgery is a safe and effective treatment for mid-urethral tape complications with the majority of women maintaining continence following revision. Early intervention and proactive management of complications, by the appropriate specialist, will improve outcomes.
Keywords: Voiding dysfunction · Mid-urethral tape procedure · Stress urinary incontinence · Tape exposure
Introduction and Hypothesis :Urethral mucosal prolapse is most frequently seen in children and postmenopausal women, and extremely rare in young adult patients. In this context, we aim to describe our experience with this condition and compare our findings with the literature.
Methods: We reviewed the medical records of our outpatient micturition disorders clinic (between August 2014 and April 2017) for patients with a diagnosis of urethral mucosal prolapse, seeking to evaluate their demographic characteristics, presenting complaints, treatment, and outcomes.
Results: We found 12 cases of urethral mucosal prolapse, including a mother and daughter and a reproductive-aged patient. Presenting symptoms included bleeding, urinary retention, partially thrombosed mucosa, and pain. Misdiagnosis was common and caused treatment delay, even in some very symptomatic patients.
Conclusions: Urethral mucosal prolapse is a readily diagnosed condition and often associated with complications in our series. Proper diagnosis is key to successful, timely treatment. Descriptive studies such as this are important to raise awareness of this diagnosis and improve patient care.
Keywords: Prolapse treatment · Urethral caruncle · Urethral mass · Urethral prolapse · Urological surgery · Vaginal bleeding
Objective: To study aetiology and management of complicated genital fistulae and to evaluate the outcome of the treatment.
Methods: This observational study enrolled patients with complicated genital fistulae from September 2008 to August 2018 at Sant Parmanand Hospital, Delhi. Patients underwent a reparative surgery or ureteric stenting after a detailed preoperative workup. Patients were followed up for the assessment of outcomes.
Results: A total of 16 patients were recruited: Ten (62.5%) patients had fistulae secondary to gynaecological surgeries (seven laparoscopic and three abdominal hysterectomies) and six (37.5%) patients had obstetric fistulae. At a mean follow-up of 5.8 years among obstetric fistulae and 7.3 years among post-operative fistulae, 100% success rate was maintained with the first attempt of reparative surgery or ureteric stenting. There were no major complications. Two patients had recurrent urinary tract infections, and one patient had transient urinary incontinence for 4 weeks.
Conclusions: The study demonstrates that complicated genital fistulae occur more commonly secondary to gynaecological surgeries as compared to obstetric complications in a contemporary cohort from a metropolitan city. A 100% success rate of reparative surgery could be achieved with a transperitoneal approach. Good outcome in ureteric fistulae can be achieved with conservative approach, after proper case selection.
Keywords: Complicated genital fistula · Urogenital fistulae · Laparoscopic hysterectomy · Vaginal hysterectomy · Obstetric fistulae
BackgroundTo study the course of pancreatitis in pregnant women and demonstrate that early diagnosis and conservative management leads to good maternal and perinatal outcome.
Methods:This article is a retrospective case series study. Six patients with acute pancreatitis during pregnancy were seen in a tertiary referral based obstetric practice at our department in the last 5 years. One of them had gallstones, one hyperlipidemia, one Diabetes and one miliary tuberculosis on ATT . Conservative treatment was instituted for pancreatitis. All of them were followed at least six weeks post-partum.
Results:There was no maternal mortality and perinatal mortality. Acute pancreatitis occurred in both primipara and multipara patients. Preterm labor was a complication in most of our cases complicated by acute pancreatitis. Most patients experienced relief from the pancreatitis soon after delivery. One patient underwent cesarean section due to fetal distress all the other 5 patients had vaginal delivery. One patient had Pseudopancreatic cyst and had a morbid postpartum period.
Conclusion:Pancreatitis is a rare event in pregnancy, approximately 3 in 10,000 pregnancies. It is most often acute and related to gallstones but nonbiliary causes should be sought because they are associated with worse outcomes. Although acute pancreatitis is a rare complication of pregnancy with 50% maternal and 70 % perinatal mortality early and appropriate treatment is of utmost importance to improve the outcome.
Filariasis is parasitic disease with significant morbidity and socio-economic implications. Its uncommon presentation in female genital organs and rarer presentation in ovarian follicles pose a major diagnostic problem even in endemic regions.As in recent times, there is increase in travel and immigration ,physicians need to be familiar with cases not only endemic to their region but to non endemic diseases as well.Herein ,we report a case of a 26 year old female patient who presented with chronic pelvic pain and polymenorrhoea. Transvaginal ultrasonography revealed microfilariae in ovarian follicular fluid which led to correct diagnosis. This case report sheds light on uncommon presentation of filariasis which needs to be considered for correct diagnosis in endemic as well as non-endemic regions.
Baliyan et al. (in J Obstet Gynecol https ://doi.org/10.1007/s1322 4-019-01220 -8, 2019) in their study evaluated the sensitivity and specificity of MCV and MCH for the screening of the beta thalassemia trait in late pregnancy. However, they failed to rule out iron deficiency, which is a confounding factor for low MCV and MCH; as a result, they observed low specificity. Authors recommend ruling out iron deficiency prior to screening for beta thalassemia and preferably in the first trimester of pregnancy so that antenatal diagnosis can be performed in high-risk subjects if necessary.
Keywords Red cell indices · Beta thalassemia · Pregnancy
