Abstract

COVID-19 is a Public Health Emergency of International Concern. Its impact on pregnant women is not yet clear owing to limited data and the knowledge is evolving in several aspects. Based on the available evidences, various clinical guidelines for management of COVID-19 have been formulated. This article intends to compile and summarise guidelines from esteemed organisations, along with their implication in the Indian scenario, and offers an easy tool for clinicians managing pregnant women in times of COVID-19.

Keywords COVID-19 • SARS-CoV • Pregnant women • Postpartum care

Abstract

Endometrial polyps are frequently seen in subfertile women, and there is some evidence suggesting a detrimental effect on fertility. How polyps contribute to subfertility and pregnancy loss is uncertain and possible mechanisms are poorly understood. It may be related to mechanical interference with sperm transport, embryo implantation or through intrauterine inflammation or altered production of endometrial receptivity factors. Different diagnostic modalities such as two- or three-dimensional transvaginal ultrasound, saline infusion sonography or hysteroscopy are commonly used to evaluate endometrial polyps with good detection rates. The approach of clinicians towards polyps detected during infertility investigations is not clearly known, and it is quite likely that there is wide variation amongst different groups. Most clinicians suggest hysteroscopy and polyp removal if a polyp is suspected before stimulation for in vitro fertilisation or a frozen embryo transfer cycle. However, the clinical evidence and benefit of different management options during assisted reproduction technology cycles are conflicting. Currently, there is insufficient evidence to recommend one particular option over others when a polyp is suspected during stimulation for in vitro fertilisation. A properly designed randomized controlled trial is needed to determine the best treatment option. In this article, we present the available evidence and our practice related to different diagnostic modalities and management options. We also discuss the available literature relevant to the management of endometrial polyps in relation to natural conception, intrauterine insemination and in vitro fertilisation.

Keywords Endometrial polyps, Infertility, Ultrasound, Hysteroscopy, In vitro fertilisation

Abstract

Hypothalamic–pituitary–gonadal axis regulates the reproductive system. The overall health and wellbeing of a woman is subject to fluctuations in the sex hormones throughout her lifespan. Menopause, either natural or surgically induced, is often associated with cognitive complaints, especially memory disturbances. Sex hormones, besides affecting the reproductive function, affect the central nervous system in many ways. Here, we aim to review the role of sex hormones in cognition and the current evidence on use of or against menopausal hormonal therapy as a cognition enhancer in women with cognitive disturbances, including those with Alzheimer’s disease.

Abstract

Ovum donation (OD) pregnancies are becoming increasingly common. Obstetric complications with IVF pregnancies are well documented. However, until recently OD had not previously been investigated as a separate subtype of this. It could be postulated that there may be more complications with OD pregnancies as the embryo is immunologically different to the mother. The subsequent allograft reactions can cause problems with placental development and function leading to pathology. Initial studies investigating OD pregnancies were inadequate due to small sample size and inappropriate control groups. Studies specifically comparing to spontaneous pregnancies alone are not suitable when we already know that IVF in itself increases the risk to both mother and baby. Recent research has optimised the control group by using women undergoing IVF with autologous ovum. Ovum donation has now been shown to be an independent risk factor for hypertensive disease in pregnancy, post-partum haemorrhage and increased risk of caesarean section. Neonatal outcomes are less clear-cut, although there is some evidence to suggest there is increased risk of small for gestational age babies and preterm delivery. It is now clear that OD pregnancies are higher risk than IVF pregnancies with autologous ovum and they should be treated as such. Women with ovum donation pregnancies should have obstetric-led care, in a unit which has ready access to both blood transfusion and cell salvage. Future research should investigate how to reduce the risk of ovum donation to these women.

Abstract

Maternal mortality is disastrous news for the society, family, newborn, and the obstetrician. Yet, we all who are care providers to these apparently healthy women carrying another life within them are dumbfounded by the clinical conditions arising due to the pregnancy or the effects of the pregnancy, that it becomes difficult to provide an ideal care to them. The rapid uprising of a condition and the worsening of commonly occurring benign conditions— preeclampsia, hemorrhage, etc., necessitates that all obstetricians are well versed with the physiological changes and should be able to not only provide the best of obstetric care to the mother and the newborn but also perform or assist in performance of life-saving procedures.

Abstract

Doubling of C-section rates from year 2000 to 2015 globally was declared an eye-opener on October 13, 2018, in FIGO World Congress. Rapid increase in rates without clear evidence of concomitant decrease in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. This review addresses issues related to exponentially rising rates, reasons for it, and strategies to reduce. Previous cesarean delivery has main contribution to rising rates as per evidence from the literature search in last 5 years. Focus on optimizing indications of primary C-section resulted in making us rethink modifiable indications like labor dystocia, indeterminate fetal heart rate tracing, suspected fetal macrosomia, malposition, risk-adapted obstetrics, litigation fears, on demand cesarean in literate women and overuse of labor induction. Use of uniform classification system (Robson/WHO classification) with recommendations of WHO, FIGO and annual audits with cloud-based anonymous registry will streamline decisions for cesarean in nullipara and help to control the situation.

Abstract

Preterm birth is a global concern resulting in prematurity which is the leading cause of newborn death and long-term squeal in the survivors. In this review, we will summarize the data available to this date in regard to the causes, available interventions, and contemporary research for future applications.

Abstract

Objectives: Evidence based medicine (EBM) has transformed the way healthcare is delivered all over the world. It combines individual clinical expertise with best available research evidence so that the patients get a high standard of care. The growth of information technology has provided us with tools which enable us to scrutinise vast amounts of data within a very short amount of time. EBM is a lifelong learning process and is an effort to make the most effective use of medical knowledge for best outcomes in terms of patient benefit and safety. It is important to understand the basic concepts of EBM and practice as well as propagate evidence based healthcare in Obstetrics and Gynaecology.

Conclusion: Obstetricians and Gynaecologists need to be able to access and critically appraise the latest evidence in their area of expertise and apply it in clinical practice to provide best outcomes to women under their care.

Abstract

There are significant problems to consider when we reflect on ‘‘Standards for Gynecologic Surgery.’’ Surely most professional standards are already in place, or are they? Are standards already available, locally, nationally, or internationally? Where those standards are not already available will it be possible set new standards for the multiplicity of operative interventions, performed by an array of trainees, specialists, and colleagues many of whom are outside of our remit and spread over the continents? If we do set standards how do we audit outcomes to gynecologic surgery and insure that the standards are being complied with? How do we tutor our trainees effectively and also insure that established specialists retain their skill base, are up-to-date, and compliant with continuing medical education? It is important to realize that the success or failure of a modern surgical investigation or procedure will now be judged not on the pure surgical outcome alone, but will also need to reflect patient focus through excellence in the areas of communication, patient information, informed consent and confidentiality. The accessibility to services, appropriate environment, and processes being offered by trained and competent staff members—who are supervised when required—should all be included in audits of outcomes set against agreed auditable standards.

Abstract

Introduction: Skin changes occur in about 90 % pregnant women in one form or the other. The various skin changes maybe either physiological (hormonal), changes in preexisting skin diseases or development of new pregnancyspecific dermatoses. All of these dermatoses can be attributed to the profound hormonal, vascular, metabolic, and immunological changes occurring during pregnancy.

Classification: Pregnancy-specific dermatoses have now been classified into dermatoses which are definitively associated and dermatoses with uncertain association with pregnancy. Though most of these skin dermatoses are benign and resolve in postpartum period, a few can risk fetal life and require antenatal surveillance. Most of the dermatoses of pregnancy can be treated conservatively but a few require intervention in the form of termination of pregnancy.

Conclusion: Careful history taking and examination will help us to identify each condition clinically and appropriate management can be instituted for the well-being of the mother and the fetus.

Abstract

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.

Abstract

Diabetic pregnancies have attendant risks. Adverse fetal, neonatal, and maternal outcomes in a diabetic pregnancy can be avoided by optimum glycemic control. Most pregnancies with GDM can be managed with noninsulinic management, which includes medical nutrition therapy. However, many necessitate concomitant insulinic management. The new insulin analogs present undoubted advantages in reducing the risk of hypoglycemia, mainly during the night, and in promoting a more physiologic glycemic profile in pregnant women with diabetes. Rapidacting insulin analogs seem to be safe and efficient in reducing postprandial glucose levels more proficiently than regular human insulin, with less hypoglycemia. The longacting insulin analogs do not have a pronounced peak effect as NPH insulin, and cause less hypoglycemia, mainly during the night. The review focuses on glycemic goals in pregnancy, insulinic management of GDM, and posology of insulin and its analogs. Clear understanding of the insulinic management of GDM is essential for women’s health care providers to provide comprehensive care to women whose pregnancies are complicated with diabetes and rechristen the ‘‘diabetic capital of the world’’ to the ‘‘diabetic care capital of the world.’’

Abstract

This is a review on the transition from our empirical approach to treat ovarian cancer to a specific treatment based on molecular signature. We have reviewed not only the evidence-based medicine focused on the origin and tumor morphology of ovarian cancer but also the molecular signature era based on molecular phenotyping of the tumor and its microenvironment, which influences the direct targeted therapy. Evidence-based medicine has shown that the targeted therapy studies are mainly biomarker driven, more focused, and hence treat only those patients who have the underlying molecular abnormality. This molecular abnormality is the target of the drug, leading to higher rates of response. These findings will carry important implications for screening, detection, and treatment of ovarian cancer in the future.

Abstract

The modern era of infertility treatment was heralded over half a century ago with the introduction of new hormonal drugs that could effectively induce ovarian ovulation. However, it was quickly recognized that the birth of these new ‘‘miracle drugs’’ was associated with a remarkable increase in the incidence of high-order multiple births. Despite the fantastic improvement in our ability to monitor ovarian response during ovulation induction, and our power to control the number of embryos introduced into the womb through IVF, multiple births remain a leading cause of long-term child morbidity among infertility patients. Efforts to prevent what was coined in the 1960s as the ‘‘multiple birth epidemic’’ remain an urgent concern. A new body of research clearly points at our capacity to reduce the risk of multiple births and their associated long term morbidity without diminishing current high success rates of infertility treatment.

Abstract

Preeclampsia and eclampsia are grave complications of pregnancy responsible for morbidity and mortality. National Eclampsia Registry of the FOGSI has helped in
quantifying the magnanimity and also the clinical relevant pointers which can help in improving the health care delivery. Many complex pathogenic mechanisms are now
implicated to be responsible for this disease rightfully called the GESTOSIS which means pregnancy going abnormal. Many preventive strategies have been suggested but only a few are scientifically proved to be useful. Early antenatal care, clinical risk assessment, biomarkers, close vigilance, calcium and nutritional supplementation are useful.

Abstract

The obstetric forceps was designed to assist extraction of the foetal head and thereby accomplish delivery of the foetus in the second stage of labour. More than 700 types of obstetric forceps have been described. An understanding of the anatomy of the birth canal and the foetal head is a prerequisite to becoming a skilled and safe user of forceps. Operative vaginal delivery rates have remained stable at between 10 and 13 %. The last few decades has seen a rise in caesarean section, along with the introduction and safe use of the vacuum extractor. This has resulted in a decline both in the use of the obstetric forceps as well as in the training for the same. The forceps is less likely to fail when used as the primary instrument thereby reducing the need for the sequential use of two instruments which increase the morbidity of the neonate. Perineal trauma is more likely to occur with the use of the forceps but the evidence is that the maternal concern is less when compared to the ventouse. Simulation training is an important part of obstetric training. Application of forceps blades in the simulation setting can improve the skill level of obstetricians. The use of the forceps should not be decreasing and more senior involvement in training is necessary so that juniors develop the proper skills to perform forceps delivery in a competent and safe manner. It is vital that the art of the forceps is not lost to future generations of obstetricians and the women they care for.

Abstract

In the management of women with fibroid disease, GnRH agonists (GnRHa) are frequently used to reduce volume and vascularity before myomectomy, apparently to render the operation easier and reduce operative blood loss, and to enable a transverse supra-pubic incision instead of a midline vertical one. They induce amenorrhoea and thus aid in the correction of pre-operative anaemia. Other gynaecologists use GnRHa to shrink sub mucous fibroids greater than 5 cm in diameter to facilitate access and reduce blood loss and operating time at transcervical resection. GnRHa are also occasionally used as a temporizing measure in women with symptomatic fibroids within the climacteric. We argue against the use of GnRHa in the management of fibroid disease because they are not cost effective, render myomectomy more difficult to apply because they destroy tissue planes, the more difficult enucleation in fact increasing rather than reducing perioperative blood loss and operating time. When used before myomectomy, they increase the risk of ‘recurrence’ because they obscure smaller fibroids that ‘recur’ when the effects of the GnRHa wear off, and are associated with side effects in situations where they confer no benefits, or where alternative cheaper drugs with fewer side effects are available.

Abstract

Fetal head progression during labor is difficult to assess. Digital examination has been shown to be an inaccurate method. Utilizing the ultrasound technology in the delivery room can standardize the way we assess head progression. Intrapartum ultrasound is applicable, for the assessment of the progression of labor and assists the obstetrician, in decision making regarding the need for an assisted delivery. This article summarizes the latest studies regarding the usage of ultrasound in the delivery room and the measurements that are used during delivery.

Abstract

Objectives: Background-Contraception is the intentionalprevention of conception through the use of various devi-ces, sexual practices, chemicals, drugs or surgical proce-dures. An effective contraception allows a physicalrelationship without fear of an unwanted pregnancy andensures freedom to have children when desired. The aim isto achieve contraception in maximum comfort and privacy,with minimum cost and side effects. Some methods, likemale and female condoms, also provide twin advantage ofprotection from sexually transmitted diseases. The burdenof unsafe abortion lies primarily in developing countries.Here, contraceptive prevalence is measured among cur-rently married women of reproductive age, and levels havenot yet reached those that exist in developed countries.

Conclusion: In countries like India, there is a dire need forcontraceptive methods to be more women friendly, acces-sible and provide adequate privacy. Providers also need to be sensitive to special needs of adolescents as they are at acritically vulnerable segment.