As frontline clinicians in the management of adolescence and puberty related menstrual issues, pregnancy management and menopause management, obstetrician-gynaecologists play a very important role in sensitising, preventing, identifying obesity. We need to develop an understanding of a progressive, long term relationship with the patient for this purpose. This will facilitate regular follow up in the short term and obesity interventions in the long term. For overweight and obese patients, interventions that facilitate weight loss include lifestyle counselling and modification, a calorie-restricted diet, exercise, metformin, and surgery like sleeve gastrectomy if required.

Background : The purpose of antenatal care (ANC) is to identify ‘at-risk’ pregnant women, to provide quality care for all, and maximize the allocation of resources for those who need them the most. To address the synergistic effect of risk factors, clinicians across the globe developed antenatal scoring systems. Objective This review aims to investigate various antenatal risk scoring systems developed and used in India to predict adverse neonatal outcome.

Methods : We reviewed articles published between January 2000 and April 2020, which have either developed a scoring system or used a scoring system, among the Indian population. This systematic review is reported based on Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Prediction model study Risk Of Bias Assessment Tool (PROBAST) was employed for the assessment of the quality of included studies. Data sources such as Embase, MEDLINE/Pubmed, APA PsycExtra, PsycINFO, CINHAL Plus, Cochrane Library, IndMED, LILACS, Scopus, WHO Reproductive Health Library and Web of science were searched.

Results : An initial search retrieved a total of 6246 articles. This systematic review identified six studies, of which one study developed an antenatal scoring system and the other five studies used two antenatal systems for predicting adverse neonatal outcome. The study which developed a risk scoring system had a high risk of bias (ROB) and concern for applicability. The overall sensitivity of the antenatal scoring system was high (77.4%), but the specificity was low (45%). Similarly, the positive predictive value is low (15.3%), and the negative predictive value is high (94.2%). A meta-analysis was not conducted due to the heterogeneity of the studies and insufficient data.

Conclusions : There is a need for a systematically developed antenatal scoring system for India. Such scoring systems can be promising in public health, proposing a paradigm shift in the implementation of effective mother and child health programmes locally as well as nationally.

Antenatal risk scoring · Risk score development · High-risk pregnancy · Systematic review · India

The prevalence of cardiac arrest in pregnant women varies from 1/20,000 to 1/50,000 pregnancies and is associated with high fetomaternal mortality. The pregnant mother is more susceptible to cardiac arrest as hypoxia is poorly tolerated. Hemorrhage, eclampsia, sepsis, and embolism are common causes of arrest. Cardiac arrest is preventable if a predisposing clinical problem is detected in time by an early warning score and treated immediately. Resuscitation in obstetric patient is challenging and special as it involves the lives of two patients, the mother and the fetus. Physiological and anatomical changes during pregnancy need special considerations during cardiopulmonary resuscitation. Chest compressions, defibrillation, and drug administration guidelines are similar to those in non-pregnant women. Early endotracheal intubation by an expert is desirable but bag-mask ventilation with oxygen supplementation should be initiated immediately by the first responder to prevent hypoxia. Hyperventilation should be avoided. An intravenous line should be established above the level of the diaphragm. Manual left lateral uterine displacement is necessary to relieve aortocaval compression when uterine height is more than 20 weeks. Perimortem cesarean delivery at the site is a part of resuscitation if spontaneous circulation is not established within 4 min, after detection of the arrest. Echocardiography and ultrasonography can help to find out the etiology of the arrest. Targeted temperature management and extracorporeal cardiopulmonary resuscitation should be considered as needed. The newborn will be taken care of by a neonatologist. Following emergency protocols, early warning scores, training and updating resuscitation guidelines, simulations, collecting a national database of pregnant mothers along with the teamwork of obstetrician, anesthesiologist, neonatologist, and emergency physician can reduce fetomaternal mortality. Cardiopulmonary Resuscitation · Pregnancy · Perimortem cesarean section delivery · Early warning score

Renal disease has always been a challenge for the treating obstetrician. With new advances in the management of renal disease, an increasing number of patients can continue the pregnancy and with individualization have a better outcome.

Material and Methods : To analyze the pregnancy outcomes in renal disease, a retrospective cohort observational study over 5 years at a tertiary care institute in northern India was done. All the pregnant women with pre-existing renal disease of any etiology presenting at any period of gestation who consented were included and those not consenting were excluded from the study.

Results : Of 62 patients enrolled, 82.26% (n = 51) were followed,17.74%(n = 11) were lost to follow up. 58.82% (n = 30) had to undergo termination of pregnancy and 41.18%(n = 21) had delivery after 28 weeks of gestation. The antenatal complications seen were hypertension in 15.69%, diabetes mellitus in 9.80%, anemia in 5.88%. Fetal complications included preterm delivery (42.85%) and small for gestational age babies(61.90%). Cesarean delivery was 85.71% and normal delivery in 14.29% of patients.

Conclusion : Both maternal and fetal outcomes are influenced by the cause and degree of renal dysfunction. A better outcome is seen when the renal disease is under control, good antenatal follow-up, multidisciplinary approach, and timely delivery.

Pregnancy with renal diseases · Outcome of pregnancy · Creatinine levels

Introduction After initial studies suggested that pregnant women were not at a higher risk of complications due to COVID‐19 infection. Recent investigations from Sweden and the US have indicated that pregnant and postpartum women are at increased risk of severe complications associated with COVID‐19. This study aims to find out the prevalence of maternal mortality and the clinical course of maternal mortality cases due to COVID-19 pneumonia.

Methodology : A cross-sectional study was conducted from May 1st, 2020, to April 30th, 2021, at Postgraduate Institute and YCM Hospital Pimpri Pune (Maharashtra), a dedicated COVID hospital during COVID pandemic. During study period, all pregnant women who were diagnosed to have COVID-19 infection by RT PCR/Rapid Antigen Test were admitted and were enrolled for the study.

Aim : To audit the maternal mortality due to COVID-19 infection.

Primary : To estimate the prevalence of maternal mortality due to COVID-19 infection in obstetric patients.

Secondary : To systematically study and analyze the clinical course of infection in mothers who had mortality due to COVID-19 pneumonia. Data collected in standard format regarding Demography, clinical presentation, need for ICU/HDU, CXR findings, laboratory parameters and cases with maternal mortality were studied in detail to fulfill the study objectives.

Results : Among 871 COVID-19 cases diagnosed during pregnancy, nine patients had maternal mortality due to covid pneumonia. There was no obvious obstetric cause for mortality in these cases. The prevalence of maternal mortality was 0.01 (1.03%). Cases with maternal mortality were mostly in 3rd Trimester (5 of 9 cases) and presented with moderate to severe illness with breathlessness and myalgia in all 9 cases, cough and fever in 7 out of 9 cases, Tachypneoa was noted in all patients. Saturation below 90 in 6 cases and below 94 in 3 cases. Chest X-ray showed bilateral lung affection in all 9 cases. Leukocytosis with raised N:L ratio was predominantly seen, thrombocytopenia noted in 5 cases and elevated levels of acute phase reactants and inflammatory markers such as CRP, S. ferritin, ESR, LDH, D-dimer and S. fibrinogen was observed. None of the study participants received vaccine for COVID-19. Conclusions COVID-19 pneumonia is an additional toll for maternal mortality. Obstetric patients in 2nd and 3rd trimester having COVID-19 infection with late presentation to hospital, moderate to severe disease (RR > 30 min), with raised inflammatory markers (N:L ratio, CRP, Ferritin, d-Dimer, etc.) at presentation, having bilateral lung affection are at risk of poor maternal outcome.

Maternal mortality · COVID-19 · Viral pneumonia

Objectives : This prospective clinical trial was conducted to assess serum bile acids (BA) levels in women with intrahepatic cholestasis of pregnancy (ICP) compared to both pregnant and non-pregnant controls; and evaluate perinatal outcome in relation to bile acid levels. A scoring is proposed based on biochemical markers to optimize management in ICP cases.

Materials and Methods : Serum bile-acids(BA) were assessed in 71 intrahepatic-cholestasis of pregnancy(ICP) cases (group-I), versus 50 pregnant (group-II) and 35 non-pregnant (group-III) controls. Ursodeoxycholic acid (UDCA) was administered in ICP group. Baseline bilirubin (SB), aminotransferases (AT), alkaline-phosphatase were sent in groups I & II. Investigations were repeated in group-I after 4 weeks. Perinatal complications were noted.

Results : Mean BA in group-I was 75.92 ± 39.9 µmol/L which reduced to 41.3 ± 15.4 µmol/L(45.6%, p < 0.001) with UDCA. Mean BA was 29.2 ± 5.7 and 5.9 ± 1.8 µmol/L in group-II and group-III. UDCA significantly reduced itching-score. Rate of fetal distress linearly increased with the increasing baseline levels of serum BA, AT and SB: from 2.5 to 100% at BA < 40 and ≥ 200 µmol/L, (p = 0.008); from 16.1 to 100% at AT < 100 and ≥ 500 IU/mL(p = 0.016); and from 6.8 to 100% at SB < 0.8 and > 5 mg/dL (p = 0.001); respectively. Their baseline levels were divided into 5 groups in correlation to fetal distress. Serum BA < 40, 40–80, 80–120, 120–200, ≥ 200 µmol/L; AT < 100,100–200,200–500, ≥ 500 IU/mL; and SB < 0.8, 0.8–1.0, 1.1–2, 2.1–5 and > 5 mg/dL. Nutan ICP scoring was proposed with a score 0 to 4 given to each parameter and score-based management protocol was suggested for fetal surveillance and delivery.

Conclusions : SBA are higher in Asian Indian pregnant women. Levels > 30 µmol/L can be taken as a cut off for diagnosing ICP in Asian-Indian women. Adopting higher cut-offs for this geographic part will avoid over-diagnosing ICP and iatrogenic early termination of pregnancy. Suggested scoring will help clinicians in optimizing the time of delivery on an individualized basis.

Intrahepatic cholestasis of pregnancy · Serum bile acid · Ursodeoxycholic acid · Scoring for ICP

Introduction : Stillbirth is a global health problem having many emotional, social and economic consequences. India has the largest number of stillbirths per year in the world. Objective The objective of this study is to review the causes of stillbirth and classify the causes into maternal, foetal and placental causes and further classify causes by relevant condition at death (ReCoDe) classification. We intend to observe the causes of and demographic factors contributing to the burden of stillbirths. Using this data, the areas of action can be identified and measures can be formulated to reduce a significant number of perinatal mortalities.

Methodology : This is an observational study of data collected over one year (January 2019–December 2019) from a tertiary care centre in Mumbai, India. The maternal demographic characteristics and causes of stillbirth were studied. The causes of stillbirths were classified into maternal, foetal and placental causes and relevant condition at death (ReCoDe) classification [1].

Results : A total of 9074 babies were delivered during this period. There were 275 stillbirths in this year (SBR 30.3 per 1000 total births). Majority of the mothers were in the age group of 26–30 years (32.7%). Almost all the mothers (98.5%) were from urban areas. As per the modified Kuppuswamy classification for urban India, 195 (71.79%) belonged to the upper lower class. 31.2% were primigravidae, and 54.8% had 3 or more antenatal visits. Maternal conditions (pre-eclampsia, diabetes, pre-existing medical disorders) as a group were the cause of maximum number (42%) of stillbirths either directly or as a contributory risk factor. 78% of the stillbirths occurred in the antepartum period. Ours being a referral centre, 65% subjects in the study were referred to us from other peripheral hospitals. 53.8% of the stillborn babies were male. 58.9% were macerated stillbirths. According to the ReCoDe classification, hypertensive disease in pregnancy was the most common cause of stillbirths (76) followed by foetal growth restriction (30).

Conclusion : Most of the stillbirths in this study were due to maternal medical conditions. Out of these conditions, hypertensive disorders of pregnancy and its consequences were the most common (66.08%). Better regulation of the private healthcare sector, provision of healthcare providers and better equipments in peripheral health centres and a well-chalked out referral system will contribute to reduction in the number of preventable stillbirths. Regular facility-based stillbirth review meetings and healthcare provider accountability would also help to reduce the burden of this silent epidemic as well as reach the goal of a “single-digit” stillbirth rate by the year 2030.

Stillbirth · Classification of stillbirth · ReCoDe classification

Objective : To evaluate the impact of adenomyosis on pregnancy outcome in ICSI/FET cycles and the beneficial effect of GnRH agonist pretreatment, conservative surgery or combination therapy on pregnancy outcome.

Materials and Methods : This is a retrospective cohort study where 613 ICSI cycles done in the period from Jan 2018 to Dec 2020 in Sudha infertility centre, Erode were analyzed. Study populations include 235 women with adenomyosis undergoing ICSI/FET cycle.

Result : Overall, the outcome in terms of clinical pregnancy rate, miscarriage rate, live birth date and ongoing pregnancy rate was lower in women with adenomyosis following ICSI/FET cycles. We found significant improvement in clinical pregnancy rate who had pretreatment with GnRH agonist, conservative surgery or combination therapy.

Conclusion : Adenomyosis as such has detrimental effect on ICSI clinical outcome. Pretreatment with GnRH agonist and conservative surgery and GnRH agonist long protocol could be beneficial. Further large scale prospective comparative studies are needed to confirm this result.

Adenomyosis · Pregnancy outcome · Systematic analysis · ICSI-FET cycles

Objectives : Enhanced recovery after surgery (ERAS) is a set of multidisciplinary, evidence proven guidelines which enhance perioperative recovery in various surgical branches. This study was planned as a pilot effort with the aim of evaluating the surgical team’s compliance to ERAS, in the absence of a structured programme, in the department of gynaecologic oncology of a tertiary care hospital in India.

Methods : This is a retrospective audit of patients who underwent elective surgery, in the department of gynaecologic oncology, in a tertiary care centre in India, between 15th August 2019 to 15th October 2019. Emergency operations and those surgeries with palliative intent were excluded from the study. Electronic outpatient and inpatient records of patients chosen by convenient sampling were examined. Adherence to 18 components (pre-operative, intra-operative and post-operative) from the ERAS guidelines pertaining to surgical care were analysed.

Results : A total of 50 patients were included. Mean age group was 50 years (22–76 years). Majority of patients (60%) had a Charlson Deyo score of 0. Excellent compliance was noted with respect to preoperative counselling (94%), intraoperative management (86%) and post-operative factors such as early ambulation, thromboprophylaxis and early discharge. Practices which required improvement included reduction of period of pre-operative fasting, prehabilitation, carbohydrate loading, gum chewing and coffee consumption and early initiation of feeding in post-operative period.

Conclusion : Dedicated and co-ordinated team effort will ensure that an ERAS protocol is enforced. Periodic auditing will reveal inconsistencies in compliance and guarantee benefit to patients.

ERAS · Gynaecology oncology · Audit · Compliance

Background : Pelvic organ prolapse (pop) is a chronic disorder, often asymptomatic. There are several factors involved in the aetio-pathogenesis of POP. Perimenopausal women bear most of the burden of pop. Vaginal delivery is an established risk factor and clinical presentation may take years when women are symptomatic in menopausal age.

Method : A cross-sectional study was done for one year in a rural teaching hospital, where 150 pop women were included. Variables associated with both asymptomatic & symptomatic pop were analyzed. The mean, proportion, & simple logistic regression were used to analyze the data and p value < 0.05 was considered significant.

Results : The prevalence of pop was 4.8%. Associated socio-economic & obstetrical variables were age group of 41–50 years (82.7%), housewives (84%), multiparty (93.33%), lower economic conditions (86.7%), home deliveries (74.71%), and early resumption of work after delivery (61.3%). Bulging in the vagina (p < 0.001), & difficulties in micturition (p = 0.001) were significant symptoms. Among asymptomatic & symptomatic pop, difference in BMI (p = 0.042), education level (p = 0.001), menstrual history (p = 0.001) & place of delivery (p = 0.037) were significant. Different stages of pop were significantly associated with differences in age groups (p < 0.001), menstrual history (p < 0.001) & place of delivery (p = 0.039). Differences in the proportion of constipation were significant with anterior compartment defects (p < 0.001), whereas the association of chronic lung diseases was found significant (p = 0.028) in the case of apical compartment prolapse. Simple logistic regression of co-variants shows age can predict the severity of pop stages (OR 7.25; 95% CI 1.95–26.99).

Conclusion : All stages of pop were present mostly in the age group of 41–50 years rather than in the over 50 years age group. Menopause is associated with the severity of prolapse and is mostly symptomatic. Age can predict the severity of pop.

Perimenopause · Menopause · Pelvic organ prolapse · Symptomatic and asymptomatic pop

Melioidosis is a disease caused by Burkholderia pseudomallei, which is a gramnegative bacterium. It is an emerging problem in India. It is usually transmitted by inhalation, ingestion and exposure through the abraded skin. The patients who are immunocompromised or having underlying diseases like diabetes mellitus, chronic liver disease, chronic alcoholism, chronic lung disease, occupational exposure are prone to develop melioidosis. But melioidosis can develop in persons without risk factors also. Transmission of infection can occur via inhalation, aspiration, and occasionally by percutaneous inoculation or ingestion. Cases of pneumonia following presumptive inoculating skin injuries are well documented, suggesting that the organism can reach the lungs via the haematogenous route. Laboratory-acquired infections and iatrogenic infections from contaminated hospital or surgical equipment occasionally occur. Melioidosis during postpartum period is very rare. Here we report a rare case of a young non immunocomprised female who developed acute disseminated melioidosis after LSCS surgery, She presented in a critical condition and was discharged in near normal condition after about a month of life saving parental antibiotic and other life supporting treatment.

Choriocarcinoma is a rare highly malignant neoplasm which may present with early metastases as it has a propensity of rapid haematogenous spread. However the neoplasm is chemosensitive and has a good prognosis even in advanced stages. We are presenting a case of a 26 years old female with early pregnancy presented with lung and vaginal metastases with obstructive jaundice. [International Federation of Gynaecology and Obstetrics (FIGO) stage III; World Health Organization score, 14]. Serum beta-hCG was 3,61,131 mIU/ml. Radiological evaluation suggested marked lung metastases with vaginal metastases. Patient was started on single agent chemotherapy doxorubicin in view of deranged liver function test. Patient was given 5 cycles of doxorubicin with liver function test and beta hcg monitoring. After liver function test normalized, patient was shifted to EMACO regimen for 6 cycles of treatment dose and 2 cycles of maintenance dose. Doxorubicin · EMACO · Beta hCG · Molar pregnancy · Chemotherapy

In this manuscript the authors describe the Ellavi balloon tamponade device and its use in the management of atonic postpartum hemorrhage. Additionally the manuscript discusses a case in which this device was used.

Balloon device · Tamponade · Postpartum hemorrhage