Indian Journal of Obstetrics and Gynecology Research

176-179

Authors: Ritesh Sondawale, Dhwani Desai, Ragini Verma

Introduction: Pregnancy is not a disease state but sometimes it leads to severe morbidity and carries risk for mortality. Maternal death not only affect family but it also has an impact on society as well as nation. Maternal mortality rate is reflection of the quality of health care services provided by the country to the women population. Materials and Methods: This is a retrospective study of maternal deaths using facility based maternal death review forms supplied by Ministry of Health and Family Welfare Government of India filled by doctor on duty at that time as a baseline document. Results: This study shows that major cause of maternal mortality in tertiary care centre was hypertensive disorders of pregnancy however hypertensive disorder of pregnancy alone was not the only cause of maternal death, it was complicated with different other causes like ARDS, APH, HELLP syndrome, PPH, Sickle cell disease, ARF, DIC, severe Anaemia and many others. Hypertensive disorders of pregnancy contributed 33% of all deaths whereas Sepsis (12%), Hepatitis (10%), Haemorrhage (8%), Heart Disease (7%), Anaemia (5%), ARDS (5%), Sickle Cell Crisis (4%), Amniotic Fluid Embolism (2%), Diabetes Mellitus (2%) and others (12%). Conclusion: Most maternal deaths are preventable by optimum antenatal, intranatal and postnatal care. Early referral of high risk pregnancies to tertiary care centre will definitely change the outcome

186-189

Authors: Jalpa K. Bhatt

Introduction: Infertility affects 8-12% couples during their reproductive life. The number of infertile couple is on rise in India. The common reason for infertility may be female factor, male factor, unexplained or combined. IUI is a frequently indicated therapeutic modality for couples with male factor infertility, unexplained infertility and women with cervical mucus problems and mild endometriosis. Materials and Methods: This is a retrospective study performed at fertility clinic. The patients attending the outdoor department for infertility treatment, those who underwent ovarian stimulation along with IUI cycles were enrolled in the study. Results: Maximum 55 (52.88%) patients were of 26-30 years age group. 85(81.73%) Participants were having complain of primary infertility whereas 19 (18.26%) were having secondary infertility. Out of 30 conceptions achieved, 18 (60%) were stimulated by gonadotrophins along with IUI. Conclusion: IUI along with controlled ovarian stimulation gives higher pregnancy rate.

195-198

Authors: Nisha Bhatia, Krishna Kumari Meka, Manick Dass .S., DVLK Swetha

Introduction: Vaginal discharge is the most common complaint with which women of reproductive age group present to the gynecological outpatient. WHO syndromic approach algorithm helps in identifying the etiology based on the gross appearance of discharge but it often fails to detect the etiology correctly. Addition of simple microbiological tests helps to diagnose the etiology accurately. Objective: To compare the diagnosis of symptomatic vaginal discharge based on WHO syndromic algorithm and microbiological tests. Materials and Methods: 100 Women in the age group of 18 to 45 years with symptomatic vaginal discharge attending the gynecological OPD of Apollo Institute of Medical Science and Research, Hyderabad were examined in the outpatient and a clinical diagnosis made using WHO syndromic algorithm for vaginal discharge. Under aseptic precautions, vaginal discharge was collected and subjected to simple lab tests such as Gram’s stain and direct microscopy (wet mount). The lab results were compared with the clinical diagnosis. Results: Among 100 women, bacterial vaginoses was the most common diagnosis. In 55% of patients etiological agent could be identified by lab investigations. By WHO syndromic approach, bacterial vaginosis was over diagnosed (70 vs. 44 cases confirmed by lab) and candidiasis was slightly under diagnosed (8 vs. 10 cases by lab). The sensitivity of WHO syndromic approach in diagnosing bacterial vaginosis is 100% while specificity is only 53%. The difference in diagnosis rate of candidiasis clinical versus microbiological diagnosis was marginal (10% vs. 11%). Trichomoniasis was accurately diagnosed by WHO syndromic approach. Conclusions: WHO syndromic algorithm for vaginal discharge over diagnoses bacterial vaginosis but has a high sensitivity and specificity in diagnosing candidiasis and trichomoniasis. Simple microbiological test such as Gram stain and wetmount will increase the accuracy in diagnosis thereby preventing overtreatment.

203-208

Authors: Hemanta Kumar Pradhan, Pratibha Singh, Garima Yadav, Meenakshi Gothwal

Introduction: The aim of this study is to accesses the use of the syndromic approach towards managing sexually transmitted infections (STIs) in north western part of India and to make recommendations about the strengths and weakness of syndromic management algorithms and to determine if evidence supports its continued use. Materials and Methods: Total of 412 patients diagnosed as STI based on clinical and physical examination were treated based on syndromic approach and finally 240 patients were recruited in the study. Diagnosis was made based on signs, symptoms and examination. Every symptomatic patient suggestive of STI was managed on the basis of algorithms of the syndrome approach and patients were again followed up after completion of treatment for assessment of clinical improvement/deterioration of signs and symptoms. Results: Vaginal discharge (48.5%, 194 out of 400) followed by lower abdominal pain (46.75%, 187 out of 400) were the most common complaints. On cervico-vaginal smear cytology, 31.70%, 12.19% and 4.87% tested positive for bacterial vaginosis, leptothrix and candidiasis respectively. Syndromic approach for patients of STIs with symptoms of pain abdomen, white discharge P/V and itching P/V are statistically highly significant (Chi-Square Value~86.44 and its p value <0.0001) but for genital ulcer and urinary tract infection is statistically not significant. (Chi-Square Value~0.55 and its p value is>0.05). Conclusion: Syndromic management may be an effective method for clinical management of symptomatic STIs in low resource setting as illustrated in our finding. But further research is needed to determine the cost-benefit ratio of introducing laboratory-based screening into a comprehensive public health program for the control of commonly seen STIs in populations at risk for STIs.

215-218

Authors: Uma Pandey

Objective: Prospective observational study of indications of hysterectomy and postoperative complications was done among benign gynaecology cases attending the outpatient department of Obstetrics and Gynaecology, Sir Sunder Lal Hospital, Banaras Hindu University, Varanasi, UP, India. Materials and Methods: Those women attending the outpatient department of Obstetrics and Gynaecology, Sir Sunder Lal Hospital, Banaras Hindu University, Varanasi, UP, India who had hysterectomy done were given questionnaire to fill or member of health care team filled questionnaires on their behalf if they were illiterate. The study duration was from July 2011 to June 2016. We included only those patients in whom hysterectomy was done at less than 30 years of age and total abdominal hysterectomy was done. Patients were asked regarding indication of hysterectomy, their understanding of their illness, postoperative recovery and current problem. Results: Total of 45 women gave information about their hysterectomy and their current health and they were all married. The 25-30 years age women were 93% in this observational study, 84% were from low socioeconomic status. In our questionnaire survey 71% of cases of Total Abdominal Hysterectomy (TAH) was done for the complaint of vaginal discharge. These women disliked the wetness of their undergarments (even if mild); they thought it as a harbinger of some severe illness. Fibroid was second most common cause (15%) in our group followed by heavy menstrual bleeding, then abdominal pain and prolapse. The most important observation of this study is presenting complain of the patients in this study. It is remarkable that 71% of women were operated for persistent vaginal discharge, while in 51% it was persisting at the time of presentation. When they were examined they had physiological discharge from the vaginal wall. 8% patients had persistent granuloma, which was causing post coital bleeding and discharge, and was treated. 15 % patients complained dyspareunia although no pathological cause could be elicited. Last and the most important questions which was asked, whether women understood her illness? Why did she need operation? Was she told of the complications? Only 11% patients knew it (e.g. had fibroid). This is not surprising. Vaginal discharge and indication of hysterectomy was not discussed with them. They were probably not offered medical treatment. Whether it was due to ignorance or some other factor, we could not elicit. Conclusion: This study shows higher rate of hysterectomy among patients with vaginal discharge. Majority of these women did not have medical treatment for their complain of vaginal discharge. Most important feature is that, in spite of hysterectomy these women continued to have vaginal discharge, which could perhaps indicates that their hysterectomies were unnecessary and their discharges were physiological. Education to health care workers and gynaecological patients is of utmost importance.

223-227

Authors: Bhagyalakshmi Manthri, Nina. V. Kate

Introduction: Post-term pregnancy is one that extends to or beyond 42 weeks of gestation, Patients at 40 weeks can either undergo induction or can be managed expectantly. At 41weeks of gestation the perinatal mortality rate is 9 per 1000 live births, and it continues to rise thereafter. Labour induction at 41 weeks gestation for otherwise uncomplicated singleton pregnancies reduces caesarean delivery rates without compromising perinatal outcomes. Study Design: 200 Low risk primigravida at 40 weeks of gestation were included and randomized into two groups. Group I=Induction group (n=100) Patients were admitted at 40 weeks and were induced at 40+0 to 40+6 Weeks. Patients in Group II the Expectant group which was further subdivided into 2 groups. Group IIa=Those who went into labour or had PROM or any omnious event during the Expectant period till 41weeks. Group IIb=Patients who reached 41weeks and then were induced. Results: Expectant management till 41weeks and then inducing labour at 41weeks resulted in a significantly higher number of patients having vaginal delivery when compared with patients who were induced at 40weeks. The incidence of meconium stained liquor, caesarean section, non-reassuring CTG, maternal complications and neonatal morbidity was high in Group I when compared to Group II. Conclusion: Labour induction in uncomplicated pregnancies at 41 weeks is not associated with increased rates of operative delivery, maternal and neonatal morbidity.

233-238

Authors: Puneeta Mahajan, Vinita Gupta, Aarushi Chaudhary, Shinky Mehta

Introduction: Hypertensive disorders during pregnancy may cause damage to liver which may manifest biochemically as a deranged liver function test and subsequent maternal morbidity and mortality any elevation in liver enzymes in a pre-eclamptic patient is significant and influences fetomaternal outcome this study evaluates the liver enzymes as a diagnostic and therapeutic tool in the management of preeclampsia and establishes a correlation between severity of liver function test derangement and severity of fetomaternal complications and use it as a predictive tool of severity of preeclampsia and for termination of pregnancy. Aim was to evaluate maternal and neonatal outcome in pre-eclamptic mothers with and without transaminitis. Primary objective of the study was to compare the maternal and neonatal outcome in pregnant women with preeclampsia in singleton pregnancies with gestational age >24 weeks with and without transaminitis. Secondary objective was to correlate the severity of liver enzyme derangement in preeclamptic mothers with adverse maternal and / or fetal outcome and use it as a predictive tool of severity of preeclampsia and for termination of pregnancy Materials and Methods: This prospective cohort study was conducted on 281 patients after approval by the institute ethics committee informed consents were taken from patients inclusion and exclusion criteria were met all enrolled patients were classified into mild, moderate and severe hypertension and managed as per standard guidelines. Specific investigations were performed if during any visit ast >25 iu/l and/or alt >32iu/l and/or alp > 418 iu/l, patients were called again after a week and blood pressure and fetomaternal well-being was assessed termination of pregnancy was done as per standard guideline statistical analysis done and hypothesis established. Results: From the present study it can be derived that at ast >66 iu/l and alt > 64 iu/l poor maternal outcome is expected with ast >60 iu/l and alt>64 iu/l adverse fetal complications are likely to occur. Conclusion: From the present study it can be concluded that severity of liver function test derangement is directly related to severity of preeclampsia which in turn is related to severity of fetomaternal complications.

242-246

Authors: Fareha Khatoon, Garima Maurya, Nagma, Parul Sinha

Introduction: India, with 1.34 billion people is the second most populated country in the world, while china is on the top with over 1.41 billion people. Total fertility rate of India is 2.2 and the current total fertility rate of U.P is 3.72 which is still lagging behind other states like Kerela, Tamilnadu. Since the inception of program, several knowledge, attitude and practices studies have been conducted. Materials and Methods: A cross sectional descriptive study was done in department of obstetrics and gynaecology, Era’s Lucknow medical college, Lucknow, Uttar Pradesh. The study group include 523 married women of reproductive age group attending Gynaecology OPD. The results are presented in frequencies and percentages. Chi-square test is used for comparisons. The p-value<0.05 was considered significant. All the analysis was carried out on SPSS 16.0 version (Chicago, Inc., USA). Results: Among the 523 women of reproductive age group maximum respondents belong to age group 21-30 years (78.77%). Most of the contraceptive non-users belongs to age below 20 years (64.7%) which is statically significant (p value=0.008). among respondents majority were Hindus (64.2%). Majority of respondents belongs to lower class (49%). Among lower class 67% respondents were non-contraceptive users. Among the temporary methods, condom is the well – known method, 78.8% and second most is oral contraceptives 76.1% followed by intrauterine devices (75.5%). Only 9.9% women knew about injectables. 77.8% women had positive attitude towards contraceptive usage and they would like to encourage others also for contraceptive usage. 64.9% women not practicing any family planning methods because of lack of knowledge while 18.7% women not using any contraceptive methods because of fear of side effects. Conclusion: In our study we observed that with increasing educational status and socioeconomic status contraceptive practices is increasing. We need more services to improve women’s education and proper family planning counseling to allay the anxiety and fear about contraceptive usage. Also, women should be educated regarding available modern contraceptive methods.

253-258

Authors: Prinka Bajaj, Sandhya Jain, Seema Pundir, Ritu Khatuja

Objective: To study the role of intravaginal micronized progesterone in preterm labour in prolonging the pregnancy up to term and thus improving neonatal outcome Materials and Methods: A prospective randomized study wherein 100 pregnant women between 26-34 weeks of pregnancy admitted to labour ward with s/s of preterm labour were included in the study. After initial management with tocolytics and antenatal steroids, when the labour got arrested these women were randomly divided into two groups 1and 2. Group 1 received 200 ug of intravaginal micronized progesterone from inclusion in the study to 36 weeks or till delivery whichever was earlier. Group 2 received only supportive therapy. None of women received oral tocolytics after initial arrest of labour. All women were followed up till delivery and obstetric outcome noted Primary variables were prolongation of pregnancy from inclusion in study to delivery interval, gestation age at delivery. Neonatal outcome variables were birth weight, need for NICU transfer, length of stay in NICU and neonatal complications The results observed were subjected to statistical analysis by SPSS-13 unpaired student t-test, Mann-Whitney for quantitative variables and Chi-square/fisher exact for qualitative variables Results: The two groups were comparable in term of age, parity and rural/urban status. Baseline presentation characteristics of the two groups such as period of gestation, number of uterine contractions per 10 minutes, cervical dilatation and, cervical effacement were also comparable (p value <0.05). Mean gestational age at delivery in group 1 was significantly more than group 2 (36.808 weeks vs. 34.078 weeks). Patient delivering beyond 37 weeks of gestation were significantly more in group 1 (60%vs 14%). Prolongation of pregnancy was significantly more in group 1, mean no. of days being 34±15.25 and 24.22±12.73 in group 1 & 2 respectively. Neonatal outcome in terms of birth weight was significantly better in group 1.mean birth weight being 2675.2±382.20 and 2393.2±378.05 in group1 and 2 respectively. Neonatal complications in terms of need for NICU admission, RDS, sepsis and mechanical ventilation were more in group 2. Conclusion: In preterm labour once the labour is arrested with tocolytics, intravaginal micronized progesterone therapy is effective in prolonging the pregnancy and thus increasing the gestational age at delivery. Neonatal outcome is improved because of increased birth weight and lesser complications.

263-266

Authors: Roopam Singh, Sonia Singhal, Shweta Saini

Introduction: One of the most common medical problems in pregnancy is iron deficiency anemia throughout the developing world1-5 with the burden of disease impacting in both mother and newborn. Anaemia affects nearly half of all the pregnant women in the world. Data shows that it affects approximately 52% patients in the developing and 23% patients in the developed world. Materials and Methods: A prospective study conducted on pregnant women in 26 to 34 weeks of gestation which comes under inclusion criteria. Duration of the study was 18 months.100 patients were taken 50 in each group, Blood indices such as Hb, MCV, serum ferritin, reticulocyte count and adverse drug reactions were compared. Results and Conclusion: Both intravenous and oral iron supplements were associated with increment of blood indices although rise was significantly higher intravenous group. Also intravenous iron is better tolerated compared to oral group. Thus, it can be concluded that IV iron therapy is much more effective in improving iron deficiency in pregnancy than oral.

272-277

Authors: Dolly Chawla, Rashmi Khatri, Shylaja T, Menka Verma

Introduction: Unintended pregnancy is still a major concern in India. It can be only prevented by effective contraceptive measures especially if it is used in postpartum period as it is highly vulnerable period to unintended pregnancy. The immediate postpartum period, after birth but before discharge from hospital is an important but underutilized time frame to initiate contraceptives specially long acting contraceptives like intrauterine contraceptive device. The study was conducted to evaluate the efficacy, side effects, continuation rates, and reasons for removal along with effects of expertise on complication rate between post partum IUCD, intra cesarean IUCD and interval IUCD insertion. Materials and Methods: study was prospective randomized conducted on 300 women for one year. IUCD insertion was done in three groups; group A (post-placental), group B (intra cesarean), group C (interval IUCD). All the groups were evaluated and compared with respect to the efficacy, side effects, continuation rates, and reasons for removal along with effects of expertise on complication rate Results: Most of women were of middle socioeconomic status and second gravida of age group 25-30 years of age. In all groups overall continuation rate after 6 weeks of insertion, 6 month and one year was 56.7%, 51.7% and 51.7% respectively. Complication rates are more after 6 weeks than 6 months and 1 year. Most common reason for removal was missing threads (16%).Complications needing removal were less when inserted by consultants than residents. Conclusions: We concluded that IUCD (Cu T 380 A) is an effective and safe reliable long term, reversible and convenient method of contraception which if properly implemented can help the unmet need of contraception to a greater extent even in postpartum period.

282-286

Authors: Rajendra P. Maurya, Tanmay Srivastav, Soni Chaudhary, Priyanshi Awasthi, Mamta Rajan

Aim: To determine the prevalence and pattern of retinal vascular disorders in pregnant women. Materials and Methods: This hospital based, prospective observational study was conducted over a period of two years. Patients were selected from outpatient department and antenatal ward of Department of Obstetrics and Gynecology and outpatient department of Ophthalmology, SS Hospital, IMS, BHU, Varanasi. In all cases detailed obstetric history including age, gravida, gestational age, general and antenatal examination and relevant pathological investigations like blood sugar, blood urea, serum creatinine and urinary protein were carried out. After taking ocular history, detailed ocular examination including visual acuity and fundus examination under mydriasis with 1% tropicamide eye drop was carried out. All the findings were recorded on a data sheet and were analyzed using SPSS programme. The Chi-Square test was used to evaluate the association between the various antenatal factors and retinal vascular changes. Results: Of 210 patients 38.09% patients were primigravida and 28.57% were second gravida. 28.57% had pregnancy induced hypertension (PIH), 13.33 % had gestational diabetes mellitus, 12.38% had preexisting diabetes mellitus. Fundus abnormalities were observed in 110 (52.38%) cases among them commonest retinal pathology was hypertensive retinopathy 38 (34.55%) followed by diabetic retinopathy (32.73%), retinal vein occlusion (16.36%) and central serous chorioretinopathy (7.27%). Out of 60 cases of PIH 38 (63.33%) had retinal abnormalities. Retinal vascular disorders were seen in > 80% cases of severe pre-eclampsia and about 90% cases of eclampsia. Majority (68.42%) of PIH patient had grade I hypertensive retinopathy. The commonest retinal change was arterial attenuation (28.57%) followed by dot and blot hemorrhage (21.90%), A-V crossing changes (20.48%), hard exudates (19.05%), flame shaped hemorrhage (42.56%) and macular edema (18.10%). However in 5.71% cases papilledema and in 5.24% cases ischemic optic neuropathy was observed. Conclusion: The most common vision threatening retinal vascular disorders in pregnancy was hypertensive retinopathy (34.55%) followed by non proliferative diabetic retinopathy (32.73%), pregnancy associated venous occlusive disorders of retina (16.36 %) and central serous chorioretinopathy (7.27%). Other retinal abnormalities seen in pregnancy included optic neuritis, papilledema and macular edema. Pregnancy may be one of the risk factors for retinal vasculopathy and temporary visual impairment. Thus, ocular fundus examination may be a valuable and necessary routine investigative procedure in pregnancy.

290-292

Authors: 290-292

Introduction: Huge borderline ovarian tumour are rare in modern medicine because of the awareness, earlier medical consultation and available ultrasound facility even in rural area. Here we report a case of huge ovarian mass proved to be borderline malignant. Case Report: A 38 years old female presented with abdominal distension of rapid onset within 3 months. On examination, there was a cystic mass of 30×20 cm arising from pelvis with variegated consistency. Ultrasound and CECT evaluation illustrated a well-defined cystic lesion with solid component arising from right ovary. With the working diagnosis of ovarian tumour, staging laparotomy was performed with total abdominal hysterectomy with bilateral salpingo oophorectomy. Histopathological examination revealed the tumour as borderline mucinous cystadenocarcinoma of ovary, without any local spread.

297-300

Authors: Shobha Lalit Lad, Vijayan Vela, Ruey Soon

Fryns et al described a syndrome in the year 1979.1 Fryns syndrome is characterized by diaphragmatic defects, facial dysmorphism including coarse face, hypertelorism, broad and flat nasal bridge, with thick nasal tip, long philtrum, tented upper lip, wide mouth, micrognathia, low set and poorly formed ears and distal digital hypoplasia, pulmonary hypoplasia and others.2 We report a case of fryns syndrome in twenty- nine years old, Chinese, primigravida diagnosed during antenatal ultrasound scan at 26 weeks of gestation. The diagnosis has been confirmed by clinical finding, ultrasound, X-ray chest, CT brain, and ECHO at the postnatal period.

303-305

Authors: Shashikala Karanth, A.P. Roshini, Sheela C N, Rajalakshmi T

‘Steroid cell tumors not otherwise specified (SCT-NOS)’ are rare sex cord-stromal tumors of the ovary with malignant potential, accounting for less than 0.1% of all ovarian tumors with the highest incidence in premenopausal women. These tumours represent a unique cause of female virilization. We present a case of a 48-year-old post-menopausal lady with bleeding per vagina and a 2-year history of truncal obesity and hirsutism. Past history was unremarkable. Examination revealed feature of obesity, virilization and clitoromegaly. Serum testosterone was 3.62 µg/L& CA-125 was 40.67. CECT gave the evidence of adnexal tumor, but histopathology confirmed SCT-NOS. Total abdominal hysterectomy(TAH) and bilateral salping-oophorectomy(BSO) was performed. Post-operative period was uneventful. This case is being reported for its rarity of occurrence and challenges faced in diagnosis of this case.

308-310

Authors: Jayesh R Shah, Jiten Senta, Shrina Shah, Dhruv Patel, Manish Pandya, Kalpana Khanderiya

Leiomyomas are the most common benign tumor of the uterus and affect 40 % to 50% of women older than 35yrs of age. Usually they are asymptomatic(70% to 80%).approximately 5% of leiomyoma are of submucosal type being least common but usually are more symptomatic. symptomatic leiomayomas are managed with either medical therapy or surgical management in the form of myomectomy or hysterectomy. multiple submucosal fibroid in pregnancy is a rare and often complicate with a fetal morbidity and mortality.1