Obesity in pregnancy is associated with several complications which today’s obstetricians have to face often. Overcoming these obstacles is truly challenging. There is a steady rise in incidence of overweight or obese women at reproductive age group in India and as well as other countries. Recent advances in bariatric medicine as well bariatric surgery have led to increasing number of pregnancies in obese women. Since obesity is associated with adverse maternal and fetal outcome, it is considered as a high-risk pregnancy and such pregnancies need to be managed in maternity units which are well equipped with necessary infrastructure and availability of expert multidisciplinary faculty. This editorial will look into various challenges and diffi culties faced by obstetricians and provide practical tips for managing obese pregnant women. We are introducing a new type of article “Invited Debate,” with this issue. It deals with pros and cons of bariatric surgery. I sincerely hope that readers are benefi tted from views and reviews presented in the invited debate as well as the editorial.
Background: Some women experience unforeseen complications during pregnancy and childbirth, which may be life threatening; their survival depends on intensive support and timely interventions. The aim of this study was to assess the long-term prevalence of adverse health conditions and their impact on quality of life in women who had severe acute maternal morbidity (SAMM).
Methods: This is a prospective cohort study comprising 43 women with SAMM during 2015 (exposure group) and 43 women who had an uneventful pregnancy and delivery (non-exposure group) during the same study period. Those who consented were given an additional follow-up date for free medical health check at 1 year.
Results: The incidence of SAMM during study period was 8.6/1000 births. There were five deaths in the exposure group. Adverse health events were seen in 30 (78.94%) out of 38 survivors. Abnormal lipid profile, thrombocytopenia, cardiac diastolic dysfunction, amenorrhoea, Sheehan and Asherman syndrome were major findings in the exposed group. Four (10.52%) women required re-admission, and eight (20.05%) required additional procedures to confirm screening abnormalities. The exposure group had higher mean scores on the EPDS scale, incidence of suicidal thoughts and poorer performance in the WHOQOL BREF psychological domain.
Conclusion: Health programmes need to focus on maternal health, provide medical treatment and psychological support for a longer duration than the traditional 6 weeks postpartum in women who experience SAMM.
Background: Some women experience unforeseen complications during pregnancy and childbirth, which may be life threatening; their survival depends on intensive support and timely interventions. The aim of this study was to assess the long-term prevalence of adverse health conditions and their impact on quality of life in women who had severe acute maternal morbidity (SAMM).
Methods: This is a prospective cohort study comprising 43 women with SAMM during 2015 (exposure group) and 43 women who had an uneventful pregnancy and delivery (non-exposure group) during the same study period. Those who consented were given an additional follow-up date for free medical health check at 1 year.
Results: The incidence of SAMM during study period was 8.6/1000 births. There were five deaths in the exposure group. Adverse health events were seen in 30 (78.94%) out of 38 survivors. Abnormal lipid profile, thrombocytopenia, cardiac diastolic dysfunction, amenorrhoea, Sheehan and Asherman syndrome were major findings in the exposed group. Four (10.52%) women required re-admission, and eight (20.05%) required additional procedures to confirm screening abnormalities. The exposure group had higher mean scores on the EPDS scale, incidence of suicidal thoughts and poorer performance in the WHOQOL BREF psychological domain.
Conclusion: Health programmes need to focus on maternal health, provide medical treatment and psychological support for a longer duration than the traditional 6 weeks postpartum in women who experience SAMM.
Background: High numbers of maternal mortality rate and child mortality rate continue to be the pressing issues in Indonesia. To tackle this problem, multiple approaches have been undertaken, particularly through distributing a Maternal and Child Health (MCH) handbook to every pregnant woman. However, despite the widespread usage of such handbook, its true efficacy in supporting safe motherhood by improving maternal knowledge on various stages of pregnancy and the associated obstetric danger signs is relatively unknown and remains to be established.
Methods: This is a primary cross-sectional study conducted at Majalengka General District Hospital on recently delivering postpartum women between August and September 2017. A total of 127 women were recruited and later divided into two separate groups according to their self-admission on the degree they had read the MCH handbook (C 50% and\50%) and administered a prevalidated questionnaire to assess their knowledge around pregnancy and its danger signs.
Results: We discovered that our population had high knowledge around pregnancy and its danger signs, and the MCH handbook did not hold a significant role in effecting this finding (p value 0.295). Furthermore, various sociodemographic factors (age, educational backgrounds, welfare status, distance from healthcare center, parity and number of ANC visits) also did not exert a statistically significant influence on the level of knowledge in our population (p values 0.579, 0.521, 0.617, 0.908, 0.342, 0.618 and 0.939 respectively).
Conclusion: To conclude, the MCH handbook did not exert a significant influence in improving maternal knowledge levels around pregnancy and the associated obstetric danger signs.
Background: The rate of institutional deliveries in India is 78.5%. Kerala and Tamil Nadu (99.8%) had the highest numbers of institutional deliveries in 2010–13, but still it is less than 60% in about 170 districts in the country. Balrampur (Uttar Pradesh) has recorded the least institutional deliveries in the country.
Objectives: To assess the factors associated with low utilization of healthcare institutions for delivery in rural Balrampur district, Uttar Pradesh.
Methods: A community-based cross-sectional survey was conducted among mothers between the ages of 15–49 who gave birth 12 months before the study in Balrampur district, Uttar Pradesh. Both qualitative and quantitative methods were used for the study. Multistage random sampling was used to select the participants for the quantitative study. Qualitative data collection was done using in-depth interview among 10 women.
Results: Mothers who were not desirous of having more children had a 2.7 times greater chance of delivering at home compared to mothers who were desirous of having more children (OR 2.705, CI 95% 1.189–6.155). Women who married before 18 years of age had a greater chance of home delivery than women who married later (OR 2.381, CI 95% 1.034–5.482). Respondents living far away from home (more than 30 min–1 h travel) were more likely to deliver at home compared to those living close by (OR 2.385, CI 95% 2.357–8.028). Women who were unaware of complications of pregnancy were more like to deliver at home compared to their counterparts who were well aware (OR 2.355, CI 95% 1.677–3.309). Qualitative data showed that cultural beliefs, financial problems, lack of decision making power by the pregnant women were significant determinants of non-utilization of institutional deliveries. Conclusion Despite the cash incentive program, strong cultural and social factors prevent women from accessing institutional deliveries in Balrampur district of UP.
Background: When a mother loses a baby after the period of viability, there is no way to fathom her grief, neither any words, nor an explanation. It is an unexpected event. Stillbirth presents a situation where the early activation of the grief process primarily in mother is exacerbated by the circumstances surrounding the loss. It thus becomes imperative for the healthcare providers to evaluate the significance of parent’s perception on the loss and the factors contributing to it before the initiation of therapy. Objective To evaluate the psychosocial impact of stillbirth among mothers and its contributing factors.
Materials and Methods: A WHO-funded prospective study was conducted in VMMC and Safdarjung Hospital from September 2015 to August 2016 on all women who gave birth to a stillborn baby, using a questionnaire based on EPDS, after taking their written informed consent. Data were entered on the predesigned proforma and analyzed after applying Chi-square test, keeping a null hypothesis value of 15% for all the variables.
Results: Out of the 709 women who delivered stillborn babies, 645 respondents, who willingly consented to participate, were included in the study. There was a significant relationship between psychosocial impact after perinatal loss and support from caregiver and family.
Conclusion: Mothers with stillborn fetuses should be screened for psychosocial impact and offered support when needed. Appropriate counseling by healthcare providers and continued psychosocial and emotional support by family members must be provided.
Purpose: To evaluate the effects of intravenous tranexamic acid (TA) and sublingual misoprostol on reducing bleeding after cesarean section.
Materials: One hundred and fifty-eight participants with term pregnancies scheduled for cesarean section were randomly divided into two groups. In M group, two sublingual misoprostol pills (400 mg) were administrated, immediately after the delivery. In TA group, ten minutes before skin incision, TA ampoule (1 g) was injected. In both groups, immediately after the delivery, 20 units of oxytocin in 1 L ringer lactate with speed of 1000 CC/h was injected. At the end of the operation, the amount of bleeding was measured based on the number of small and large gauzes, the blood in the suction container and the difference of patient’s hemoglobin before and 24 h after surgery.
Results: Hemoglobin level reduction in the TA group was higher than the M group (- 2.45 ± 0.84 vs - 2.14 ± 1.38 g/dL) (P\0.001). Furthermore, number of used gauze and blood suction in the TA group was significantly higher compared to sublingual misoprostol (4.67 ± 1.34 vs 3.25 ± 1.31 and 260.25 ± 79.06 vs 193.94 ± 104.79 cc, respectively) (P\0.001). Mean blood pressure during the entire duration of surgery in the TA group decreased significantly as compared to the M group (P\0.001).
Conclusion: Total bleeding was significantly lower in sublingual misoprostol as compared to the tranexamic acid group. Furthermore, in misoprostol group hemodynamic variables were stabilized greater than tranexamic acid group.
Registration Number IRCT201708308611N6
Objective: The aim of this study was to compare the efficacy and safety of sublingual and vaginal misoprostol in second-trimester termination of pregnancy in 24 and 48 h. Study Design This is a retrospective study of 240 pregnant women seeking termination in second trimester (13–18.5 weeks), in which the patients are subdivided into two groups—first group received 400 mcg of misoprostol sublingually (n = 120), and second group received 400 mcg of misoprostol vaginally (n = 120) every 4 h for a maximum of five doses. The course of misoprostol was repeated if the patient did not abort within 24 h.
Results: The mean induction-to-abortion interval was shorter in sublingual group (10.28 ± 3.1 h) versus 14.68 ± 4.2 h in vaginal group in 24 h (p = 0.0001), and 36.9 ± 4.4 h in sublingual versus 29.7 ± 14 in vaginal group in 48 h (p = 0.0933). Mean dose requirement for misoprostol by sublingual route was low as compared to vaginal misoprostol (1048 ± 301 mg versus 1250 ± 375 mg; p = 0.0001 in 24 h and 1110 ± 833 mg versus 1325 ± 536 mg; p = 0.0231 in 48 h). No significant difference was found in the success rate (both at 24 and 48 h) and in side effects among the two comparison groups.
Conclusion: Misoprostol as such by any route has been proven as an effective abortifacient in second trimester. Both sublingual and vaginal routes are effective for medical abortion. But shorter induction-to-abortion interval in sublingual route, less dose requirement and higher acceptability makes sublingual route as a better choice.
Introduction: There is a definite need to find a highly sensitive and specific, noninvasive, and cost-effective marker for prediction of preterm labor. We hypothesize that a measurement of adrenal gland volume can predict a preterm as well as a term labor.
Materials and Methods: Two hundred and sixty-eight pregnant women were enrolled in the study at 28–34 weeks’ antenatal visit. Final analysis was done in 204. All of them were subjected to 2D ultrasonographic measurement of the corrected fetal adrenal gland volume (cFAGV) and fetal adrenal zone parameters including the width ratio and depth ratio. The cohort was followed up to term, and a reassessment of cFAGV and fetal adrenal zone parameters was repeated between 37 and 39 weeks. Women who presented with features of preterm labor had a scan at the time of presentation to record cFAGV and fetal adrenal zone parameters.
Results: Women, who developed features of preterm labor eventually, had a significantly high cFAGV (404.70 mm3/ kg body weight) during the first scan compared to those who reached term asymptomatically (241.35 mm3/kg body weight). A cutoff value of 271.16 mm3/kg body weight showed 90% sensitivity and 81.9% specificity. Fetal adrenal gland width ratio had the best efficacy (sensitivity 96.67%, specificity 86.2%) followed by cFAGV (sensitivity 96.67%, specificity 83%) for predicting preterm delivery.
Conclusion: 2D ultrasound measurement of fetal adrenal gland parameters can be used as a marker for prediction of preterm delivery. cFAGV at term can also be used to predict the possibility of spontaneous onset of labor.
Background: The efficacy of a single bolus dose of epidural dexamethasone added to levobupivacaine–fentanyl combination for labor analgesia has not been studied. In this randomized double-blind controlled trial, we assessed the effect of epidural dexamethasone in reducing the hourly average consumption of epidural levobupivacaine–fentanyl combination in laboring parturients and to study its effect on pain score, maternal satisfaction, maternal and neonatal outcome.
Methods: Sixty adult ASA I-II single-gestation full-term primigravid laboring parturients with cervical dilation B 5 cm were randomly assigned to two equal-sized groups. Combined spinal–epidural block was performed in all the parturients. After placing the epidural catheter in epidural space, 8 mg of preservative-free dexamethasone was administered to the dexamethasone group, and 0.9% saline to the placebo group. All parturients received continuous background infusion of 5 ml of 0.1% levobupivacaine with 2 lg/ml of fentanyl with the provision of patient-controlled bolus of 5 ml of 0.1% levobupivacaine with 2 lg/ml of fentanyl (lockout interval 15 min). The primary outcome measure was the hourly total consumption of levobupivacaine–fentanyl mixture. The secondary outcome measures were maternal satisfaction, pain score, maternal hemodynamic parameters, fetal heart rate, duration of second stage of labor, mode of delivery, Apgar scores and adverse effects.
Results: Hourly drug consumption and hourly bolus requirement were significantly lower in the dexamethasone group than placebo group (6.97 ml ± 1.22 vs. 8.40 ml ± 2.59 and 0.41 ± 0.26 vs. 0.72 ± 0.55, respectively, P = 0.008 for both). There were no significant differences in other outcome measures.
Conclusion: Epidural dexamethasone significantly decreased average hourly drug consumption and the number of boluses in laboring parturients, thus providing epidural drug dose-sparing effect.
Aim: Utero vaginal prolapse is a very common complaint of patients in the OPD. It’s an entity that existed since a very long time and hence many classifications were proposed; however, only one system was found to be a validated system for determining the degree of prolapse— POP-Q system. Objective To determine the relationship of decubitus ulcer with POP-Q staging.
Materials and Methods: A prospective study of 100 patients with complaints of prolapse (something coming out of vagina) was considered. The patients were staged in accordance with POP-Q system. The number of patients with decubitus ulcer were noted. The area of each decubitus ulcer was also noted, by measuring the radius. Statistical tests were applied to find out if the relationship of the presence of and the area of decubitus ulcer with stage of prolapse was significant.
Results: It was found that as the stage of prolapse increased, the number of patients with decubitus ulcer also increased. Also, as the Point C measurement increased, the area (small/medium/large size) of the decubitus ulcer also increased.
Conclusion: There is a definite correlation between the presence of decubitus ulcer along with its area and the POP-Q component. The study also indicated that POP-Q staging is the only method of classification available that allows accurate and standardized measurements, foregoing pitfalls of all previous classifications.
Purpose of the Study Intrauterine contraceptive devices (IUCDs) are highly effective form of long-acting reversible contraception having least number of complications. We aimed to find the incidence, risk factors and the management done for incarcerated and transmigrated intrauterine contraceptive devices at a Tertiary Care Teaching Hospital during past 5 years.
Methods: A cross-sectional retrospective analysis of 5 years (January 2013–December 2017) was done, and the case records from Medical Record Department and Family Planning Unit of our institution were analysed.
Results: Total number of IUCD insertions done in last 5 years (from January 2013 to December 2017) in our institution was 4557. Misplaced IUCDs requiring surgical interventions were 71 (1.6%) out of which 63 (88.7%) were incomplete perforations or embedded and 8 (11.3%) were complete perforations or transmigrated IUCDs. Transmigration sites were omentum, uterovesical fold, mesentery and bladder. Laparotomy was needed in 4 (5.6%), and 2 (2.8%) needed each laparoscopy and cystoscopy. Main risk factors identified were postpartum previous on or two caesarean sections, low parity, grade of operator and IUCD and uterocervical length discrepancy.
Conclusion: The risk of perforation should not be a reason to defer IUCD insertion and every effort should be made to bring down its failure and complication rates.
Objective: To compare the rates of intraoperative and postoperative complications of open and robotic-assisted surgery in the treatment of endometrial cancer.
Methods: This retrospective study was performed at a single academic institution from January 2014 to February 2017 in the Department of Gynecology Oncology at Amrita Institute of Medical Science, Kerala, India. The study included patients with clinically early stage uterine malignancy undergoing open or robotic-assisted surgery.
Data collected included clinicopathological factors, intraoperative data, length of hospital stay and intraoperative and postoperative (early and late and severity according to Clavien–Dindo classification). Morbidity was compared between two groups.
Results: The study included 128 patients, of whom 61 underwent open surgery and 67 underwent robotic-assisted surgery. Mean operative time (P = 0.112), mean estimated blood loss (P\0.001), number of patients requiring blood transfusion (P\0.001) and mean length of hospital stay (P\0.001) were significantly lower in robotic group. None of the patients in robotic group experienced intraoperative hemorrhage (P = 0.010). The early postoperative complications, SSI (P\0.001), infection (P = 0.002), and urinary complications (P = 0.030) and late postoperative complications lymphoedema (P = 0.002), vault-related complications (1.5% robotic vs. 6.6% open) and incisional hernia (none in robotic vs. 4.9% in open) were significantly lower in robotic group. Grade-II complications (Clavien– Dindo classification) were significantly lower in robotic group (P\0.001).
Conclusion: Robotic-assisted surgical staging for uterine cancer is feasible and safe in terms of short-term outcomes and results in fewer complications and shorter hospital stay.
Background: One-third of each woman’s life is naturally during her menopause. This study was conducted to determine the factors related to the quality of life in postmenopausal women.
Materials and Methods: This cross-sectional study was carried out using cluster sampling method on 218 postmenopausal women aged 40–60 years old in Kermanshah 2014. The data were collected through interview and with the standard questionnaire of Menopausal Quality (MENQOL) of Life and analyzed using SPSS software version 19.
Results: The mean age of menopause was 50.03±4.48 years. Mean scores of quality of life and four domains, vasomotor, psychosocial, physical and sexual were 3.15±0.970, 3.71 ± 1.81, 3.32±0.959, 2.91 ± 1.06, 3.74 ±1.59, respectively.
Conclusion: Chronic conditions such as hypertension in postmenopausal women can lead to lower quality of life. Therefore, provision of coherent support programs for controlling chronic diseases requires serious intervention from health care providers.
