Indian Journal of Obstetrics and Gynecology

 India is developing country, yet the development is less in the medical sector. Though the awareness of tubal ligation is vividly present in the rural set up, pressure on females are increasing due to preference of male child in the society. Some unfortunate circumstances, may it be pressure from the family members or unfortunate death of the existing children or poor economic status of the family to afford the In vitro fertilization for the next pregnancy, leading to compulsion on women to undergo tubal reversal. Hence, this case was brought to notice,while emphasis was laid on the surgical management of a case that we managed.

Keywords: Post Sterlisation, Tuboplasty; Microsurgery.

 Stroke or cerebrovascular thrombosis is a rare event in young and the risk in pregnancy is only slightly higher than the non pregnant population Here we present a case report of a 35 years old female who presented to us with 9 months pregnancy with history of cerebrovascular accident at 7 months of gestation. With conservative approach and close monitoring, we saw a positive outcome for both the mother and the baby.

Keywords: Stroke; Cerebrovascular Thrombosis; Pregnancy.

 Objectives: To assess success of vaginal birth after caesarean section and maternal-fetal outcome in such cases. Methods: Prospective Observational study in a University teaching hospital at Varanasi. The study period was June 2015- December 2015, a total of 68 patients were included. Those women who had Caesarean sections in past and were found suitable for VBAC were included in the study admitted to the labour ward. Results: 42 (61.76%) of women had VBAC (Vaginal Birth After Caesarean section) and 26 (38.23%) had ERCS (Emergency Repeat Caesarean Section). Maximum number of women who had VBAC has LSCS (Lower Segment Caesarean Section) in the past for fetal distress (73.33%). ERCS (failed VBAC) was done maximally for fetal distress (53.84%), then for failure to progress (38.46%) and 7.6% for scar tenderness.Maternal complications were lower in the VBAC group: fever (9.5%), blood transfusion (7.1%); while ERCS group had wound infection (30.76%), blood transfusion (34.61%). Conclusion: The study shows encouraging result for VBAC in a good set up to be followed to reduce Caesarean rate.

Keywords: Vaginal Birth after Caesarean Section; Lower Segment Caesarean Section; Uterine Rupture; Maternal Morbidities.

 Introduction: Globally, an estimated 287 000 maternal deaths occurred in 2010, a decline of 47% fromlevels in 1990. Sub-Saharan Africa (56%) and Southern Asia (29%) accounted for 85% of theglobal burden (245 000 maternal deaths) in 2010. Methodology: The Proforma prepared contained- name, age of the patient, IP No, Date of admission, date of death, booked or unbooked, presenting complaints and details antenatal care(if any). Obstetric history including marital status, age at marriage, age at first pregnancy primi or multi, history of previous pregnancy and labour, complication during present pregnancy, past and present medical problems. Results: According to present study, 40(93.024%) deaths occurred in third trimester followed by labour complication i.e. Out of 43 cases 40 (93.024%) died inlast trimester and 3 cases (6.976%)died in 2ndtrimester. This emphasizes the need of compulsory screening for high risk pregnancy. Conclusion: According to present study, during the study period from December 2011 to May 2013,15(28.31%)deaths occurred in 24-72 hrs interval

Keywords: Maternal Deaths; MMR; Taertiary Care Hospital.

 Every married couple is desirous to have full term newborn without any congenital anomalies and medical or surgical disorder. Recurrent miscarriage is the most distressing problem in many couples. Intrauterine infection remains one of the major challenges for the obstetrician during pregnancy. TORCH infection correlates with bad obstetric history (BOH). It may produce spontaneous abortion, intrauterine fetal death, congenital anomalies, IUGR and still birth. 83 patients with BOH were evaluated. These patients were investigated for presence of TORCH, IgG and IgM antibody by ELISA Test. In this study, 29.39% of cases were IgG TORCH positive whereas 3.01% IgM positive. 26.51% were Rubella IgG positive and 4.62% were Rubella IgM positive. 21.69% were CMV IgG positive and 15.61% Herpes simplex IgG positive. It was observed that incidence of preterm deliveries and congenital anomalies was more in toxo-positive titers while incidence of spontaneous abortion was more in Rubella, CMV and HSV positive titers. Outoff 83 patients 28 had still birth with congenital anomalies. It was concluded that TORCH screening is must and consulling for adverse effects may be of help to reduce ill effects of the infection.

Keywords: Screening in Pregnancy; ANC Checkup; TORCH Infection; Congenital Malformation; Still Birth.

 Introduction: Adolescence is the time during which endocrinal changes of puberty, sexual development and growth occurs. WHO definition, adolescents are the individuals in the 10-19 years age group. Menstrual disturbances in adolescents may present diagnostic and management challenges for the gynaecologist, and may add future disruption to this difficult phase for adolescents and their families. Aims & Objectives: This Study was conducted to find out the etiological factors of menorrhagia in adolescent girls, in age group 11yrs to 19yrs and to find out prevalence of these etiological factors. Material & Methods: This is retrospective study from March-2015 to Sept-2016.Adolescent girls in age group 11yrs to 19yrs attending gynaecology OPD in tertiary care Centre were selected. Results: In This Study 62 Patients presented with menorrhagia in Adolescent age group. In our Study 15 (24.19 %) girls had menorrhagia within 3 to 6 months duration, 24 (38.7%) girls had menorrhagia within 6 months to 1 year & 14 (22.58 %) girls suffered from menorrhagia for more than 1 year. Incidence of menorrhagia due to anovulation as etiological factor was 66.12%, and 13 patients (20.96%) had PCOD. Conclusion: Anovulatory dysfunctional uterine bleeding was the commonest cause of menorrhagia in adolescent girls. Analysis of data showed PCOD as second etiological factor. This emphasizes the need to evaluate menorrhagia in adolescent girls, so that pathology is detected early and treatment is given accordingly. This will prevent reproductive morbidity in future.

Keywords: Adolescence; Menorrhagia; Anovulation; Coagulopathy; Hypothyroidism

 Aim: To establish the efficacy of B-lynch suture as an alternative conventional surgical procedures in the treatment of postpartum haemorrhage. Study Design: Prospective. Study Place & Duration of Study: One year clinical study was carried out in depart ment of obstetrics and gynaecology, MVJ Medical College from 2013 January to 2015 January. The stitch was applied in those , To establish the efficacy of B-lynch suture as an alternative conventional surgical procedure in the treatment of postpartum haemorrhage. Methods: This prospective one year clinical study was carried out in MVJ medical college. A total of 40 patients for trial of B-lynch stitch technique on patients with massive postpartum haemorrhage were included in the study. Results: Out of 40 patients, 22(55%) patients were primiparae and 18(45%) were multipara. In 38 (95%) patients the cause of PPH was atony of uterus and 2(5%) patient had cervical tear. Different procedures were applied in the patients. Haemorrhage was arrested in all of them. Conclusion: B-Lynch brace suturing is very valuable alternative to hysterectomy in the control of massive postpartum haemorrhage.

Keywords: B-Lynch Suture; Primiparae; Atony

 Aim: To determine the efficacy and safety of Depot 17-α hydroxyprogesterone caproate and Human chorionic gonadotropin (hCG) in the management of threatened abortion. Setting and Design: This is a prospective comparative study in cases of threatened abortion in the first trimester. Material and Method: Use of Inj.hCG and Inj. depot 17-α Hydroxyprogesterone caproate studied in a randomized group of 80 pregnant women, diagnosed cases of threatened abortion in the first trimester. Result: In the present study Inj.hCG found comparatively better in cases of threatened abortion in a first trimester.

Keywords: Threatened Abortion; 17-α Hydroxyprogesterone Caproate; hCG.

 Aim: This study was conducted to analyze the congenital malformations- their incidence, types, maternal socio-demographic profile and probable risk- factors. Results: our study showed that unwanted pregnancies, lack of antenatal checkups, no periconceptional folic acid intake, maternal diabetes mellitus, hypertensive disorders including Pre Eclampsia & Eclampsia, fever, maternal infections and drug intake were important factors associated with congenital malformations in the baby. Conclusion: Regular and proper antennal checkups and care, periconceptional folic acid supplementation can significantly reduce and prevent the incidence of congenital malformations and there by decrease the mortality and morbidity associated with birth defects.

Keywords: Congenital Malformations; Birth Defects; Live Births; Morbidity; Mortality.

 Context:Estimation of birth weight is an important factor in antenatal and labour management. Estimation of birth weight determines the time, mode and place of delivery. Aims: This study aims at comparing the accuracy of Johnson’s method and Dare’s method for estimating foetal birth weight at term. Settings and Design: This was a prospective observational study done at a tertiary care teaching hospital over a period of one year. Methods and Material: 300 women with singleton uncomplicated term pregnancy satisfying inclusion and exclusion criteria were included in the study. Foetal weight estimation was done by Johnson’s method and Dare’s method within 72 hours before delivery and was compared with actual birth weight. Statistical analysis used: Statistical analysis for comparison was done using SPSS software (version 20). Mean absolute error, percentage error, overestimation and underestimation of both methods was compared. Results: The mean actual birth weight (ABW) was 2861.8±460 grams. The mean estimated birth weight (EBW) by Johnson’s method and Dare’s method was 2979.1±382 grams and 2925.01±420 grams respectively. About 23.6% were low birth weight (LBW) and 1% was macrosomic babies. Dare’s method had least maximum and minimum error than Johnson’s method. The mean absolute error by Dare’s method was lower than Johnson’s method. The birth weight of 73% and 73.7% cases could be predicted within 10 % error of ABW by Dare’s method and Johnson’s method respectively. Both methods overestimated birth weight in LBW babies. Conclusions: Dare’s method is more accurate than Johnson’s method in estimating foetal birth weight and predicting LBW and macrosomic babies.

Keywords: Dare’s Method; Estimated Foetal Weight; Johnson’s Method.

 Introduction: Mifepristone is a 19- nor steroid that binds to the progesterone receptor and inhibits the activity of progesterone at cellular level. It ripens cervix with minimal effect on uterine contractility, favouring pre-induction cervical ripening to enhance the rate of spontaneous labour without apparent maternal and neonatal side effects. Aims and Objectives: • To determine the efficacy and safety of Mifepristone to prime the cervix and induce labour at term. • To compare the effect of Mifepristone with placebo on cervical ripening before labour induction in term pregnancy. Material and Methods: 100 patients with singleton pregnancy of 37-42 weeks with Modified Bishop’s score ï‚£ 5 were included in the study after their informed consent. Exclusion Criteria: Cephalopelvic disproportion • Previous LSCS • Hypersensitivity to Prostaglandins and Mifepristone Patients were given either oral Tablet Mifepristone 200mg (n=50) or Placebo (n=50) after assessing Modified Bishop’s score. Change in Modified Bishop’s score is assessed after 24 hrs and 48 hrs. Even after 48 hrs if labour had not begun or Modified Bishop’s score ï‚£ 5 induction with Prostaglandin E2 0.5mg gel or Prostaglandin E1 tablet 25 µg done. Results: Out of 100 patients, 29 patients entered spontaneous labour within 48 hrs, of which 19 were treated with Mifepristone (38%) & 10 with placebo-(20%). 9 of Mifepristone treated (18%) & 3 of placebo treated (6%) patients required only oxytocin for labour augmentation. 59 patients required Prostaglandins for induction, of which 22 were Mifepristone treated (44%) & 37 Placebo treated (74%). Mifepristone treated patients had 72% vaginal delivery rate with reduced induction-delivery interval while it was 46% with placebo. Cesarean rate was 14% in those treated with Mifepristone while 42% with placebo. There was no statistical difference in instrumental delivery. There was no significant difference in intrapartum uterine contractile abnormality and fetal heart rate pattern. There was no significant difference in neonatal outcome measured by APGAR score and NICU admission. Conclusion: Mifepristone is safe & efficient in cervical ripening and initiation of labour at term with increased chance of vaginal delivery in 48hrs.In this era of high primary cesarean rates, Mifepristone provides a new milestone to enhance vaginal delivery rates with safe maternal and neonatal outcome. Theme: “Let Mifepristone unveil the curtains to a new era with drastically decreased primary cesarean rates”

Keywords: Mifepristone; Term Pregnancy; Cervical Ripening; Vaginal Delivery; Cesarean Rate.

 Introduction: Almost one-fourth of the global cervical cancer burden is in India. There is an enormous opportunity for screening with the prospect of detection of cancer at the preclinical stage and hence, cervical cancer control programs become important. Aims and Objectives: To correlate abnormal Pap smears with colposcopic findings, HPV testing, FHACT and cervical biopsy findings. Materials and Methods: The present study was a prospective observational study carried out at Kamineni Hospital, LB Nagar, Hyderabad, over a period of two years. The study group consisted of 150 women with abnormal cytology report (ASCUS and above) in whom colposcopy guided biopsy, HPV test and FHACT test were done and results were correlated. Observations and Results: The prevalence of abnormal Pap smears was 2.91%. In the 150 patients with abnormal pap smears, 63.3% cases, showed normal per speculum findings. Pap smear test had a very low sensitivity of 34.29% and high specificity of 95.65%, PPV of 92.31% and NPV of 48.89%. Colposcopy had a sensitivity of 60% and specificity of 73.91 %, PPV of 77.78%, NPV of 54.84%. HPV test was positive in 40% cases. Conclusions: It is recommended that colposcopy when available, should be used as the next step in evaluation of women with ASCUS/ASCH/LSIL instead of following them up with repeat smears. The FISH-based HPV-associated cancer test can be used as a secondary screening assay, along with HPV subtyping to assist in patient management decisions.

Keywords: Pap Smears; Colposcopic Guided Biopsy; FISH; HPV Subtyping; FHACT

 Objective: To evaluate the effectiveness of extended clomiphene citrate therapy in the women who failed to ovulate despite of traditional regimen of clomiphene citrate. Study Design : It is a prospective study done on 25 women who failed to ovulate despite of standard dose of clomiphene citrate. The stair step protocol is performed as follows – 50mg of clomiphene citrate is given for 5 days. USG done on day 11 to day 14 . If result is unresponsive, immediate begins 100mg of clomiphene citrate for 5 days . Repeat USG in 1 week. If result is unresponsive start 150mg of clomiphene citrate for 5 days and repeat USG after 1 week. Result : Total time required to ovulate in extended clomiphene citrate is less as compared to traditional regimen in women with ovulatory disorders.

Keywords: Extended Clomiphene Citrate; Stair Step Protocol; Ovulation.

 Fetal NST is a simple noninvasive test performed over 28 weeks of gestation during pregnancy. Antepartum evaluation of fetus at risk for damage or death in uterus remains major challenge in modern obstetrics. NST is a noninvasive easily performed, interpreted and readily accepted by the patient. It contains – baseline heart rate, beat to beat variability of FHR, presence or absence of accelerations, early accelerations, late accelerations and variable accelerations. FHR device, Doppler ultrasound transducer, Tocodynameter, Event marker were used in fetal assessment. 50 pregnant patients were included having single fetus pregnancy with gestational age more than 30 weeks, hypertensive disorders of pregnancy, intrauterine growth retardation, post dates, liquor abnormalities and BOH. The patients having gestational age less than 30 weeks, ante partum haemorrhage, eclampsia, multiple pregnancy, ruptured membranes, congenital anomalies, and intrauterine death were excluded from study. NST was performed in all cases with CTG and recording of fetal heart rate, fetal movement and uterine contractions were noted. The fetus was stimulated for 20 minutes externally and activity was noted. It was observed that PIH (28%) and post dates (32%) are the risk factors. Majority of patients were primigravida (60%). The last NST results were with fetal outcome. Amongst NST reactive cases (33) meconium stained, Apgar score less than 7. Among non-reactive cases (74%) meconium stained. Apgar score less than 7 (75%) required ICU admissions.

Keywords: Pregnancy; NST Test; Reactive and Reactive Test; Fetal Outcome.

 Introduction: In ovarian tumours diverse histopathologies are common reflecting the different cell origins of the tumours. Ovarian cancer is the one of the common cancer among females of India and continues to present at an advanced stage. Aims and Objectives: To study USG versus Histopathological diagnosis of ovarian masses at tertiary care center. Methodology:After approval from Institutional ethical committee, this prospective study was conducted at Department of Obstetrics and Gynecology during the period of September 2013 to September 2015 on 100 women who were randomly selected among the women attending the hospital’s Obstetrics and Gynecology OPD with: Menstrual irregularities, Pelvic inflammatory disease, chronic pelvic pain, mass per abdomen. Patientsunderwent transvaginal / transabdominal ultrasound.Initially diagnosis of mass done by sonography later on by histopathology. Result: Ultrasonography suggested that there were 30% cases of PCOS, 21% cases of benign ovarian cyst, 17% cases of benign ovarian tumor and 11% cases were of dermoid cyst, 9% functional cyst, 7% haemorrhagic cyst, 3% chocolate cyst, 2% malignant ovarian tumor. HPE reports found that the most common mass was serous cyst adenoma 26%, Mucinous cyst adenoma 12%, Cystic teratoma 11%, Chocolate cyst 3%, serous cyst adenocarcinoma 2%. Conclusion: The ovarian tumors are detected effectively by Ultrasound but the nature of pathology i.e. Benign or Malignant is confirmed by histopathology so both these investigations be done in patients for accurate diagnosis of the ovarian masses.

Keywords: Ovarian Masses; PCOS; Benign Ovarian Tumor; Hemorrhagiccyst; Chocolate Cyst; Malignant Ovarian Tumor; Cystic Teratoma

 Introduction: Oligohydramnios has adverse effect on perinatal outcome and is associated with incidence of increased rate of labor induction, non-reassuring fetal heart pattern, stillbirth, meconium aspiration syndrome (MAS) and neonatal death. . Criteria for oligohydramnios are Amniotic fluid volume < 500 cc at 32-36 weeks of gestation,Single deepest vertical pocket of < 2 cm, Amniotic fluid index (AFI) < 8cms at 34 weeks of gestation. Material and Methods: The study was level II study i.e. prospective - observational study comprising of one hundred fifty pregnancies divided into two groups; one group had seventy-five pregnancies with oligohydramnios and the control group with seventyfive pregnancies without oligohydramnios confirmed by ultrasound examination. Maternal and perinatal outcome was evaluated at or beyond 34 weeks of gestation. Results: Majority of cases were between the age group of 20 to 30 years in both study and control group. Oligohydramnios was commonly found in primigravida – 65% in study group and 48% in control group (p=0.0476). Most common cause of oligohydramnios was idiopathic i.e. 51% followed by pregnancy induced hypertension (PIH) in 21% cases. It was observed that 45% of cases in study group required induction of labor by cervipime gel ( 0.5 mg given by intracervical route) as opposed to control group in which 29% of cases required induction (p=0.043). Non-reactive non stress test (NST) at the time of admission in labor room or at the time of labor was more in the study group (36%) than in control group (15%) [p=0.0427]. It was also observed that meconium stained liquor (thin +thick) was more common in study group than control group i.e. 43% v/s 23% respectively (p=0.0419).

Keywords: Oligohydramnios; Perinatal Morbidity; Amniotic Fluid Index(AFI)

Introduction: Fetal birth weightis an important predictor of neonatal problems and an useful indicator of intrauterine environment indirectly reflecting the health of mother. Accurate estimation of fetal weight is vital in the management of labor and delivery. Aims and Objectives: Tostudy the assessment of fetal weight in term pregnancy by Johnson’s formula and comparison with actual birth weight of baby. Methodology: This was a Prospective Study carried out at medical college and hospital from January 2009 to October 2010 in the department of obstetrics and gynecology. Two hundred women at term were studied. The fetal weight was estimated at the time of admission by using Johnson’s formula. Thestatistical analysis done by SPSS 17 version. Result: The mean of baby’s weight at birth was 2643 gms with 331.14 standard deviation on either side. Minimum value of Jonson’s formula was below that of minimum 2000 actual weight of babies. Determined weight by Johnson’s formula had mean error of 273 gms over that of actual weight. Johnson’s formula had 11.3% mean error of birth weight. The Johnson’s formula significantly differed from the actual birth weight (P<.000). In Johnson’s formula error of more than 200gms had it in 68.5% babies. Johnson’s formula can determine 55.5% accurately birth weight with 15% error. In 74% babies birth weight was overestimated by Johnson formula; of them 56.5% babies weight was estimated above 200 gms. Birth weight was underestimated in 26% babies and 12% babies had weight determined less than 200gms of actual weight. Johnson’s formula can predict accurately in 14% with 100gms difference. Conclusion: From our study it can be concluded that Johnson’s Formula is least accurate in predicting fetal birth weight, so other methods like USG and Symphysio fundal methods should be used to calculate the fetal birth weight.

Keywords: Fetal Birth Weight; Johnson’s Formula; Symphysiofundal Height.

 Context: Assessing the effect of Lamaze breathing on labor pain in primigravida mothers. Settings and Design: The study was conducted at Community Health center, kolar road, Bhopal (M.P.). The primigravida mothers who were in first stage of labor were selected from labor room. An experimental research was conducted to assess the effectiveness of Lamaze breathing techniques on labor pain and anxiety. Women taken in control group were assessed for their labor pain, and women in experimental group were instructed to perform Lamaze breathing exercises during pains and their level of pain & anxiety were assessed and then compared with women of control group. Methods and Material: The tools used were- Demographic variables, clinical variables, a visual analogue pain perception scale, and an observational rating scale for performing Lamaze breathing. Statistical Analysis Used: The findings were analyzed using ‘t’ test, chi square test, and Karl Pearson formula. Results: Comparison of level of pain perception between control and experimental group on the basis of paired ‘t’ test shows that the level of pain perception in control group is higher than the experimental group. The mean of control group is 7.55 and of experimental group are 4.55. Mean percent is 75.5% and 45.5% of control and experimental group respectively. And, SD of control group is 0.945 and of experimental group, it is 1.234. The ‘t’ value is 3.96 and P value is P<0.001 which is highly significant. Result shows, that after receiving the Lamaze breathing exercises, the labor outcome during first stage of labor was good. Conclusions: Continuous ongoing assessment helped to evaluate the performance of breathing exercises during pregnancy and labor. Practice of breathing exercises conditioned the mother to breathe and relax during contractions to control the experience of pain in gravid mothers. Practice of breathing exercises shortens the duration of labor, and prevents the complications during labor.

Keywords: Effectiveness; Lamaze Breathing; Primigravida; Labor.

 Objective: To compare efficacy of systemic methotrexate with concurrent intra-embryonic potassium chloride (KCl) instillation versus systemic methotrexate alone in cases of live unruptured ectopic pregnancies. Method: In this retrospective comparative study conducted in tertiary care centre; six patients with documented cardiac activity suitable for medical management were given ultrasound-guided intra-embryonic KCl along with systemic methotrexate (Mtx) (Group-1). Their response was compared with six historical cases managed with systemic Mtx alone (Group-2). Results: Medical management was successful in 100% patients in Group-1 treated with combined KCl and Mtx, all responded to only single dose of Mtx. In Group-2, success rate was 83% where 2/6(33.3%) cases were successfully treated with single dose; 3/6(50%) patients responded to 2nd dose of Mtx and 1/6(16.7%) case had rupture. Mean duration for hCG to become negative was 5 weeks (range 3-7 weeks) in Group-1 versus 7.2 weeks (range 4-10 weeks) in Group-2. Conclusion: Live unruptured tubal ectopic pregnancies can be effectively managed with intraembryonic KCl and concurrent systemic Mtx therapy. Addition of KCl alleviates the need for second Mtx dose, minimizes the risk of rupture and results in faster fall of hCG. Patients with high baseline hCG can also be effectively treated with this combined treatment.

Keywords: Live Ectopic Pregnancy; Medical Management; Methotrexate; KCl Injection. Synopsis: Ultrasound-guided intraembryonic KCl instillation with systemic methotrexate may alleviate need for second Mtx dose, minimize risk of rupture and reduce follow-up with serial âhCG.

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