Indian Journal of Obstetrics and Gynecology

Introduction: Peripartum cardiomyopathy is an idiopathic and reversible form of dilated cardiomyopathy. It is defined as systolic heart failure in the last month of pregnancy or within 5 months of delivery. With an unknown etiology it can be fatal in young women but with prompt diagnosis and intensive supportive measures, it can be treated well with good prognosis. Although the prognosis of PPCM is favorable, misdiagnosis or delay in diagnosis leads to deadly consequences to the patient and thus high maternal morbidity and mortality. We present 5 cases of peripartum cardiomyopathy which presented to our hospital in a span of 6 months who were promptly diagnosed, bettter managed with good prognosis in all the patients.Hence high index of suspicion and vigilance required by the treating physician to facilitate timely recognition, intervention, and management of peripartum complications.

Keywords: Peripartum Cardiomyopathy (PPCM); Cardiac Disease in Pregnancy; Dilated Cardiomyopathy; Maternal Mortality. 

Objectives: to study indication of LSCS in our setting using modified Robson’s criteria. Materials and Methods: The study was carried out at Dept of Obstetrics and Gynecology, in our institute, for 1000 consecutive caesarean deliveries. Data was compiled from departmental records. Conclusion: History of previous LSCS is most common indication for LSCS. Refusal for VBAC has lead to higher LSCS rate. Counseling for VBAC during antenatal period and during labour may help to reduce LSCS rate in these patients. Induction of labour is the major associating factor for high LSCS rate. Allowing spontaneous labour and judicial selection of patients for induction may help to reduce LSCS rate. Result: The largest contribution to total CS rate was by group 5(34%) (All single cephalic pregnancy, >37 wks gestation, previous scar) followed by group 2 (20.4%) (Nullipara, single cephalic, >37 weeks, induced or CS before labour).

Keywords: LSCS, Robson’s Criteria. 

Background: Preterm births are the major cause of perinatal and neonatal morbidity and it represents one of the principal targets for obstetric health care. Aim of this study is to identify etiological factors and to assess the outcome with preterm labor and delivery. Methods: This study is conducted in the department of obstretics and gynaecology of a tertiary care center during the period of 3 years between 1st January 2015 to 31st December 2017. Patients presenting between 28 and 37 completed weeks with preterm labour were included in this study. Patients were subjected to detailed history with respect to age, parity, previous pregnancy outcome and to identify the presence of any risk factor in this pregnancy. A through obstetrics and systemic examination was done. Results: Incidence of preterm labour is found to be 23.06%. Highest incidence was found between the age group of 20 to 29 year (69%). The study shows that 31% patients had history of previous one abortion, 5% had previous two abortions, 2% had previous three abortion and 14% had previous one PTVD. This shows that total 38% patients were having history of previous abortions. Highest number of preterm labour were late preterm that is after 34weeks but before 37 completed weeks constituting about 64.34%. Most common risk factor was found to be PPROM constituting 29%. 2^nd most common being Preeclampsia/ Eclampsia accounting for 26%, UTI in 10% followed by APH in 8%. Study shows that 73% of wo men had vaginal delivery, 27% of wo men underwent ceserean section. Our study shows that 6.55% babies have birth weight <1000gm, 25.23% were having weight between 10001500gm, 37.38% had weight between 15002000gm and 30.84% had birth weight more than 2000gms. Our study shows that 78 (72.89%) neonates required neonatal intensive care unit (NICU) admission and the most common neonatal complications noted were jaundice in 34 (31.77%) neonates, followed by asphyxia 21 (19.62%) and RDS seen in 12 (11.21%) neonates. Conclusion: Various risk factors that lead to preterm labor are identifiable. The recognition of risk factors for preterm labour constitutes a part of basic prenatal care. Most etiological factors are modifiable and preconception counselling should emphasize and address these issues.

Keywords: Preterm Labour; Etiology; Risk Factor. 

Background: Almost 1015% of marriages prove to be childless. Infertility is inability of a couple to achieve conception after one year of unprotected coitus. Aims & Objectives: To evaluate the role of diagnostic hysteroscopy and laparoscopy in the assessment of primary and secondary infertility and to help in planning appropriate treatment and to study the frequency of various pathological conditions in female reproductive tract leading to infertility. Materials & Methods: A prospective study on 205 infertile women of age group 18 to 44 years visiting GMCH, Udaipur from October 2015 to October 2017. Hysterolaparoscopy was performed under general anesthesia in the preovulatory period between days 610 of the cycle for infertility evaluation. Routine investigations were performed. Results were tabulated in Microsoft Excel 2013 software and analyzed using SPSS16. Results: More primary (61.95%) than secondary infertility (38.05%). Maximum patients in 2630 years of age in primary and 3135 years of age in secondary infertility. Uterine septum and fibrosedostea (6.29% each) were main findings in primary whereas uterine polyp/fibroid was the main hysteroscopic finding in the secondary infertility. Endometrium was polypoidal in 4.72%, hyperplastic in 3.93% in the primary, 8.97% and 21.79% in secondary infertility respectively. Uterine perforation (1.57%) was the complication in the primary and gaseous distension of abdomen (3.84%) in the secondary infertility. Most common pathology was PID (16.08%) followed by fibroid 8.29%, endometriosis 7.8%, PCOD 7.31%, uterine septum, polyp/myoma and hydrosalphinx 6.34%, fibrosed ostea and TO mass 5.36%. Conclusion: Female infertility cases especially in whom all tests are normal, endometrial study helps to reduce the unexplained etiological factors in infertility and to know the ovulatory factor. Both laparoscopy and hysteroscopy combined together is a valuable technique for complete assessment of female factors of infertility especially in a symptomatic patient and should be used early in the diagnostic workup.

Keywords: Hysteroscopy; Laparoscopy; Infertility; Hysterolaparoscopy. 

Intra uterine growth retardation (IUGR) due to fetoplacental vascular insufficiency is rampant in developing countries like India. Owing to the lack of awareness, antenatal patients often present in their third trimester for their first ultrasound examination. Alterations in the wave forms and Doppler indices of fetal middle cerebral artery (MCA), umbilical artery and been extensively described in various studies in the literature. However, the role of each doppler parameter in actually predicting reduced birth weight (for gestational age) in the third trimester is often debatable and frustrating. Method: A prospective study was done on 500 patients of clinically suspected IUGR highrisk pregnancies of 28weeks onwards pregnancy. The cases were followed till delivery; the doppler and grey scale findings. Result: All cases were followed up for perinatal outcome. Adverse perinatal outcome included low birth weight (<2.5 kg), preterm delivery, APGAR score <7 at 5min, admission to the NICU and perinatal mortality. Raised umbilical artery indices had 74% Sensitivity and 94% Specificity in predicting adverse perinatal outcome. Raised MCA indices had 80% Sensitivity and 95% Specificity in predicting adverse perinatal outcome Reversed cerebroumbilical ratio had 85% Sensitivity and 98.7% Specificity in predicting adverse perinatal outcome Absent end diastolic flow or reversed end diastolic flow had 88.8Sensitivity and 100% Specificity in predicting adverse perinatal outcome With the presence of abnormal Doppler indices, chances of operative intervention in form of caesarean section increases. Conclusion: Doppler ultrasound is a safe and noninvasive hemodynamic tool for assessing foetal well being and prediction of adverse perinatal outcome in clinically IUGR pregnancies. A combination of umbilical artery and middle cerebral artery Doppler study helps to identify foetus at risk for morbidity and mortality so that appropriate obstetric intervention required can be done timely so as to reduce perinatal morbidity and mortality.

Keywords: Uterine; Intrauterine growth restriction (IUGR). 

Background: Ectopic pregnancy is a major health risk factor for women of child bearing age and if not diagnosed and treated properly can lead to life threatening complications. Aims: To determine the incidence, clinical presentations, risk factors, treatment, morbidity and mortality associated with ectopic pregnancy. Materials and Methods: It is a prospective study conducted at Vijayanagara Institute of Medical Sciences (VIMS), Ballari from January 2016 to June 2017. A total of 54 patients with ectopic pregnancy were admitted. These cases were analysed on clinical presentation, clinical findings, investigations, operative findings and outcome. Results: The incidence of ectopic pregnancy in the present study was 0.49% (54/10,836 deliveries). A majority of women (46.29%) were in the age group of 2530 years and 89% were multigravida. The commonest risk factor identified was tubal surgery (25.92%). Pain abdomen (94.44%) and amenorrhea (79.62%) were the most common presenting symptoms. Salpingectomy was done in 83.33% of patients, where as 16.66% underwent salpingoophorectomy. All women received blood transfusion. No maternal mortality was noted. Conclusion: Ectopic pregnancy continues to be one of the important obstetrics emergencies. A high index of suspicion is needed for an early diagnosis, to prevent complications and to preserve the future reproductive function of the patient.

Keywords: Ectopic Pregnancy; Abdomen and Amenorrhea. 

Introduction: Maternal Mortality Rate is a reflection of health care provided by a society to a women.Though, pregnancy being considered asa physiological state, it carries a risk of serious maternal morbidity and mortality. ICDMaternal Mortality (ICDMM) is based on 10th revision of ICD (ICD10) and its coding rules. It is intended to facilitate the consistent collection, analysis and interpretation of information on maternal deaths. 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 infections not related to pregnancy (19%), obstetric haemorrhage (17%), respiratory condition (7%), pregnancy related infection (6%), pregnancy with abortive outcomes (6%), CNS condition (4%), cardiac disease (4%), other obstetric complication (2%), endocrine condition (1%) and genitourinary condition (1%). Conclusion: Causes of Maternal Death varies from country to country and a woman may die from a wide range of complications in pregnancy, childbirth or the postpartum period. Applying ICDMM will decrease errors in coding and improve cause of maternal death attribution. This will enhance usability and comparability of maternal mortality statistics generated from ICD data.

Keywords: ICDMM Group; Maternal Mortality; Hypertensive Disorders of Pregnancy. 

Objectives: To study the clinical course, morbidity and mortality in the pregnant patients affected by the disease, To study the effect of Infective hepatitis on outcome of pregnancy. Material & Method: The present study was undertaken at New Civil Hospital, Surat. The time period was of 6 months i.e. from January 2017 to June 2017. All pregnant females having infective hepatitis were included, Pregnant females having other diseases and condition which resembles the clinical presentation of viral hepatitis were excluded. Summary: (1) Incidence of viral hepatitis in pregnant women in the present series was 1.21, (2)Total maternal mortality is 2 cases in the analysis of 50 cases i.e. mortality 4%, (3) Mortality is higher during second trimester (16.6%) as compared to first and third trimester, (4) Higher mortality in delivered patients (4.54%), (5) Fetal wastage was more in patients having viral hepatitis (6% )abortion. 10% still birth, 48% premature birth. Conclusion: Infective hepatitis is a potentially devastating disease. In pregnancy maternal morbidity and mortality is severe and the infection exerts a significantly negative effect on perinatal outcome.The early diagnosis and prompt initiation of therapy are of utmost importance in reducing the risks of serious maternal and fetal complications. In present study multigravida constituted 64% and primigravida 36% maximum cases were admitted in III trimester (34 out of 50 cases). The high rate of abortion (4/50 cases), premature labour (6/50 cases) and still birth (10/50 cases) may be due to indirect effect of disease, hypoproteinemia and excess of estrogen in circulation which sensitizes the uterus to oxytocin and prostaglandins.

Keywords: Primigravida; Hepatitis.

Background: Preeclampsiaeclampsia remains the leading cause of maternal and perinatal morbidity and mortality. Present study was planned to study maternal and perinatal outcome in women with eclampsia. Materials and Methods: This prospective observational analytic study was conducted in the department of Obstetrics and Gynecology, Surat Municipal Institute of Medical Education and Research (SMIMER) from August 2016 to July 2017. Results: Total 60 cases of eclampsia were admitted having incidence of 0.72%. 78.4% cases were antepartum eclampsia. 40% cases had taken no ANC visits. Maternal death occurred in two cases. 18.3% cases had stillbirths, 26.7% babies required NICU admissions. Conclusion: Eclampsia is an important Obstetric emergency with high maternal and perinatal mortality and morbidity. Timely and appropriate interventions including primary management, early referral and proper management help in reducing complications.

Keywords: PreEclampsia; Eclampsia; Maternal Morbidity; Perinatal Morbidity. 

Hypertension in pregnancy is a high risk situation for both the mother and the fetus. A good antenatal care, control of hypertension and prevention of severe hypertension and eclampsia are essential for the well being of both the mother and the baby . All women with hypertension complicating pregnancy should be advised antenatal check and delivery at a tertiary care centre . This study was conducted on mothers with hypertension in Govt Rajaji Hospital, Madurai during a period of 6 months from February 2017 to July 2017. The study included women with known hypertensive disorder detected preconceptionally and antenatally. A total of 198 patients were included. The incidence, comorbidities, complications, maternal and perinatal outcome were studied. The mean age of the patients was 25 years. 105 patients were primigravida (53%) and 93 were multigravida (47%). Out of 198 patients, 110 patients had non severe PE (55.6%), 32 patients had chronic hypertension (16.2%), 9 patients had severe PE (4.5%), 24 patients had imminent eclampsia (12.1%), 13 patients had antepartum eclampsia (6.6. %), 8 patients had HELLP syndrome (4.1%) and 2 patients had recurrent NSP (1%). Preeclampsiaeclampsia and its variants remain the major cause of hypertension in pregnant women. Hypertension during pregnancy is responsible for high maternal and perinatal morbidity and mortality.

Keywords: Hypertension; Preeeclampsia; Eclampsia. 

Context: If it is possible to predict PIH, then its prevention can be undertaken. In this direction many attempts have been made to find out a suitable test which can predict the occurrence of PIH in pregnancy, but till date such type of test was not found. Aims: To study the role of maternal serum beta human chorionic gonadotropins as a predictor for pregnancy induced hypertension. Settings and Design: Hospital based follow up study carried out at Chalmeda Anand Rao Institute of Medical Sciences, Karimanagar. Methods and Material: Present study was carried out among women of 1320 weeks gestation. They were divided into two groups. Group I consisted of 90 normotensive women and group II consisted of 10 women with Pregnancy induced hypertension. Maternal serum beta hCG was measured and mean values were compared in both the groups. Statistical Analysis: Chi square test was applied to study significance of difference between proportions and t test was used to study significance of difference between mean values. Results: It is found that severity of PIH correlated with serum beta hCG levels in hypertensive patients. The mean serum beta hCG levels were significantly higher in PIH group compared to normotensive group. The sensitivity of beta hCG in predicting occurrence of PIH was 100%, specificity was 97.7%, positive predictive value was 83.3% and negative predictive value was 100%. Women with > 2 MOM of beta hCG had 6 times more risk of having PIH compared to women with beta hCG < 2 MOM. The mean Serum beta hCG for low birth weight, IUGR and preterm delivery was significantly higher in PIH group compared to normotensive group. Conclusion: Early detection by screening tests and appropriate treatment may prolong pregnancy long enough to ensure a satisfactory outcome for both mother and fetus. Serum beta hCG levels were found to be effective in early prediction of PIH.

Keywords: IUGR; Beta hCG Levels; Normotensive. 

Context: From19601970’s Indian populations became more aware of laparoscopic tubal ligation, It is female sterilization permanent surgical method of contraception. Aims: To evaluate the cases registered for tubal ligation by single puncture method with respect to their age, parity, intraoperative and postoperative complication of the single puncture laparoscopic tubal ligation in tertiary health care centre. Method: A retrospective study of the laparoscopic tubal ligation done at rural medical college during January 2013december 2017 interval. Total number of caseswere 4294. Laproscopic tubal ligation done under IV sedation and local anesthesia. Procedure carried out in interval laparoscopic tubal ligation, puerperal laparoscopic tubal ligation and after 1st trimester MTP. Results: Most of the patient were in age group of 2130 yrs (73.3%). Most of the patient were having two children, previous 2 LSCS were 1045 (55.3%), previous 3 LSCS were 356 (39.6%). 752 (17.51%) patients had tubal avulsions, 20 (0.46%) patients had uterine perforation, only 2 patients required laparotomy and one patient had superficial inferior vena ceva puncture. Conclusions: Single puncture laparoscopic tubal ligation was found to be easy to performwith no or minimal complication rate.

Keywords: Single Puncture Laparoscopic Tubal Ligation; Previous Caesarean Section; Retrospective Study. 

Background: Aim is to study occurance of various adverse fetomaternal outcome in pregnant women having abnormal O’Sullivan results. Materials and Methods: 75 gm of oral glucose ingestion by pregnant women at the time of registration irrespective of fasting status (O’Sullivan test) and measuring blood sugar level after 2 hours. Subjects were follow up and observed for development of adverse fetal and maternal outcome in subsequent antenatal visits, intranatal period and during postnatal period. Results: Out of total 464 subjects 76 subjects had abnormal O’Sullivan test results. Amongst the subjects with abnormal O’Sullivan test results 2627% subjects develop complications during subsequent antenatal visits e.g. polyhydramnios, hypertension, Intra uterine fetal demise (IUFD), preterm labor, abruption palcenta, eclampsia., 6.79% mother having extreme premature, 13.75% had premature babies, 35.09% subjects delivered by LSCS, 10.26% subjects had baby weight more than 3.5 kgs at birth, 10.4% babies had adverse neonatal outcomes e.g. birth asphyxia, NICU admission, congenital anomaly, neonatal hypoglycaemia, early neonatal death (END), 26.9% subjects had intranatal and postnatal complications. Conclusion: Subjects with abnormal O’Sullivan result had higher chances of developing adversefetal and maternal outcome.

Keywords: O’Sullivan Test; IUFD; END. 

Epidemiological data pertaining to maternal mortality is valuable in each setup to design interventional programs to reduce the ratio favourably. This study was design to evaluate the mortality rate in our hospital, to assess the epidemiological aspects , types of delay, and to suggest recommendations for improvement. Objective of the study was to analyse type of delay, and to suggest measures to reduce it. Methods: A retrospective study done at a tertiary level care centre , data were collected from maternal death review forms and case records. Data studied and analysed. Results: (Majority women were from rural area (73.5.%), and majority (66.8%) were emergency cases .79.3% cases were belonging to lower socioeconomic class and 76.8%cases were uneducated. most cases Type 1 delay was most common (75.4%) comparatively to Type 2 and 3 delay. Conclusions: High risk cases should be identified. Early referral, easy transport, continued skill based training, monitoring of health services can reduce maternal mortality. Special training should be conducted for ASHA workers and ANM who generally works at grass root level in our country. Continued medical training is required for medical officers who are working at PHC and sub district hospital for early recognition of high risk women and their referral in time to higher centers to avoid maternal near miss or death. 

Laparoscopic surgeries are in vogue, with little importance paid to the comfort of the surgeon and the operating team. We conducted a questionnaire basedqualitative study with the following. Objectives: 1. Assess the ergonomic challenges faced by the laparoscopic surgeon 2. Assess the types and extent of ill health faced by these surgeons 3. Modifications to improve operative practice. Methodology: 25 gynaecologists practicing laparoscopic surgery were asked to answer a questionnaire to know the personal characteristics, their level of awareness of ergonomics and any ill health faced by them after performing a laparoscopic procedure, Statistical analysis was done using thematic analysis in the form of percentages. Results: Only 60% of surgeons adopted ergonomics, majority (80%) operated with poor OT setups, in odd postures, standard sized instruments were used. Patient related factors were trouble some to all surgeons. Neckpain, backache and finger joint pains were common physical constraints while mental fatigue and stress was common among surgeons in the post procedure period. Conclusion: Laparoscopic surgery is more demanding to the surgeons. Surgeons need to be aware and adopt optimal ergonomics during laparoscopic surgery.

Keywords: Laparoscopic Surgeon; Ergonomics in Laparoscopy; Surgeon Safety. 

Introduction: Admission test is a noninvasive, easily performed, interpreted and readily accepted by the patients. It can be used as screening procedure to detect preexisting fetal hypoxia and plan early intervention to prevent adverse perinatal outcome. The present study was thus conducted to evaluate the efficacy of admission test in predicting fetal outcomes at birth in term low risk pregnant women. Materials & Methods: A prospective observational study was conducted from August 2015 to July 2017. 100 low risk (normal) pregnant mothers fulfilling the inclusion criteria, attending the labour room were included.The admission test was conducted and interpreted for all patients. On the basis of admission test results, type of delivery and neonatal outcome at birth was assessed. Data was analyzed using SPSS ver 21.0. Results: NonReassuring Admission Test was observed in 12% subjects. Caesarean delivery was conducted in 41.7% of females with nonreassuring  NST as compared to 11.4% females with reassuring NST. Meconium stained liquor was observed in 50% of babies with nonreassuring NST as compared to 3.4% babies with reassuring NST (p<0.01). APGAR score at 1 and 5 minutes were significantly lower in babies with nonreassuring NST (p<0.01). Fetal distress and NICU admission rate was observed in 50% and 66.7% of babies with nonreassuring NST as compared to 2.3% and 2.3% babies with reassuring NST (p<0.01). The sensitivity and specificity of NST in predicting fetal distress was 50% and 97.7% respectively. Conclusion: The result of admission test can be used to identify patients likely to develop adverse fetal outcomes and help in optimal utilization of labour room with limited resources. Thus, admission test can be used as an important noninvasive method to diagnose fetal compromise present at the time of admission in low risk patients in early labour.

Keywords: Admission Test; Low Risk Pregnancy; Neonatal Outcome; Cardiotocography. 

Objective: to study indication of LSCS in induced nullipara and its effect on subsequent LSCS rate. Materials and Method: This study was carried out at the department of obstetrics and gynecology, in our institute for 1000 consecutive caesarean section deliveries. Data was compiled from departmental records. Conclusion: In induced nullipara subjects, the indication for LSCS, with maximum number of subjects is MSL. And 2nd max is fetal distress. Hence, there should be prudent practice of induction of labour so as to reduce subsequent LSCS. Also reducing the rate of LSCS in nullipara will in turn reduce the overall LSCS rate. Result: Highest LSCS rate was observed in subjects with previous history of LSCS and 2nd highest was in induced Nulliparous subjects. Highest rate of LSCS was due to MSL in induced nullipara and 2nd highest was fetal distress.

Keywords: Nullipara; LSCS rate. 

Introduction: Term premature rupture of membrane is defined as the spontaneous rupture of foetal membrane after 37 completed weeks and before labour onset. One of the most important functions of the membrane is to remain intact until the onset of labour at term in order to maintain the protective intrauterine fluid environment, the amniotic fluid upon which foetus depends for its survival in utero. PROM complicates the pregnancies and leads to many complications. It increases the risk of prematurity and leads to other perinatal and neonatal complications with risk of foetal death. Aims and Objectives: 1. To study the outcome of labour in PROM. 2. To study maternal complications in PROM. 3. To evaluate perinatal outcome In PROM. Material and Methods: Total 100 patients of PROM in between 3740weeks gestation were selected. This is retrospective study for duration of 2 years in ACPM Medical College. Results: In this study 34 patients went into spontaneous labour and 40 patients needed induction or augmentation. Incidence of LSCS was 26% & vaginal delivery was 74%. Maternal morbidity was found in 7%. Perinatal morbidity & mortality were significantly increased mainly due to Jaundice, RDS, sepsis and birth asphyxia. Conclusions: PROM is a significant obstetrics problem which lead to increased maternal complications, operative procedures, neonatal morbidity and mortality. Careful antenatal monitoring, Strict aseptic precautions, appropriate therapy, identification of risk factors like cervicovaginal infection and their management and regular antenatal followup are important factors in the prevention and management of PROM.

Keywords: Premature Rupture of Membrane (PROM); Respiratory Distress Syndrome (RDS); Infection; Chorioamnionitis. 

Background: Twin gestation are the major cause of perinatal and neonatal morbidity and it represents one of the principal targets for obstetric health care. Aim of this study is to identify etiological factors and to assess the outcome with twin gestation. Methods: The study conducted in WEST INDIA in a tertiary care center for a period of 5 year (January 2012 to December 2017). A total of approx 500 antenatal cases with twin gestation attending antenatal OPD in our hospital study.Antenatal USG scan done to document twin gestation and confirm type of twins gestation and gestational age. Maternal parameters (demographic and physiological) and fetal outcome (birth weight, NICU admission, etc) parameters documented and analysed using statistical methods. Results: Patients with twin gestation, more than 28 weeks of pregnancy, booked, emergency and referred cases are taken as inclusion criteria for patients. • Incidence of twin pregnancy in this study was 1.05%, Positive family history was found in 4% cases. Positive obstetric history of twins was found in 9.3% cases, In our study, 89% had conceived spontaneously, 9.7% after ovulation induction by clomiphene citrate and gonadotrophins, and 1.3% after IVF. Most of the patients were primiparous and second gravid (29%, 33.3%) and from low socio economic class (63%). 70.7% mothers developed preterm labour before 37 completed week. Antepartum, intrapartum and postpartum maternal and fetal complications were studied. Preterm labor was the commonest complication in our study. Incidence of preterm labor was 71%, preeclampsia 22% and anemia 27%. Antepartum haemorrhage was not seen in any patient. Post partum hemorrhage was seen in 2.7% cases. Pressure symptoms in form of breathlessness oedema feet was seen in 13% patients. Commonest presentation was vertexvertex 31% followed by breechbreech 27%. • In the present study a. Cephaliccephalic in 31% b. Cephalicbreech in 21% c. Breechbreech in 27% d. Breechcephalic in 20% • The majority of cases in this study had vaginal delivery (57%) and 39% had cesarean sections. 1.3% of first twin delivered by forceps. In vertex presentation incidence of LSCS was 13%. In breech presentation incidence of LSCS was 24%. The most common indication of cesarean section being non vertex presentation of the first baby followed by fetal distress. • Incidence of maternal morbidity >blood transfusion (26.6%) >breast engorgement (10.7%) >wound gap (6.7%) >decreased milk secretion (6.7%) >UTI (2.7%) >Puerperal infection (2.7%) • Neonatal morbidity was in form of RDS (30%), Jaundice (7%), Sepsis (2%), Hypoglycemic convulsion (3%), Asphyxia (3%). In the present study, 5.4% of first twin and 9.4% of second twin were less than 1500 grams; 81.3% of first twin and 77.3% of second twin were between 15002500 grams and 13.3% of first twin and 13.3% of second twin had a birth weight of >2500 grams. 1st twin with birth weight 11.5 kg neonatal mortality was 75% while for birth weight 1.52 kg it was 8%. 2nd twin with birth weight 11.5 kg neonatal mortality was 86% while for birth weight 1.52 kg it was 14%. In our study, 45.33% NICU admission was observed for prematurity, low birth weight, Respiratory Distress Syndrome, septicemia and hypoglycemia. Neonatal mortality was seen in 14.6% of cases, were prematurity, hyaline membrane disease, meconium stained liquor aspiration being the commonest cause of death.

Keywords: Twin Gestation; Etiology; Risk Factor. 

Introduction: A number of methods were tried since decades for Termination of mid trimester pregnancy yet there is no satisfactory, highly effective and safe method. Aim: evaluate the efficacy and safety of normal saline instillation in induction of mid trimester abortions and if it is effective to be considered in area with limited resources. Materials and Methods: Eighty cases who needed mid trimester termination of pregnancy ranging from 16 – 20wks were studied. Out of these 80cases, 40 cases were instilled normal saline and ethacridine Lactate was instilled in 40 cases extraamniotically. Results: The indications of termination of pregnancy were studied obstetric causes for termination of pregnancy were more. Interval between instillation of the agent and expulsion of the Foleys bulb has been observed that in 87.5% of cases in normal saline group and 72.5% of case in ethacridine group the bulb expelled with in 24 hrs of instillation. Interval between the expulsion of bulb to abortion was 70% of cases in ns group and 80% of cases in EL group aborted with in 6 hrs of expulsion of the Foleys bulb. 5% and 15% of cases in NS and EL group expelled in 6–12 hrs of expulsion of bulb respectively. Induction abortion interval is the interval from the instillation of normal saline or ethacridine lactate solution into the extra amniotic space to expulsion of the products of conception. (fetus, placenta and membranes). Mean induction abortion interval in this study in normal saline group is 23.03hrs and ethacridine group is 25.31hrs. Induction abortion interval increased for cases with gestational age 19 – 20 wks. Escalating doses of oxytocin upto 20U starting from 5U given through drip (30 drops/min) until there were moderate uterine contractions after 6 hrs of instillation of agent. It is observed that 12.5% cases in NS group and 5% cases in EL group required no oxytocin as they aborted with in 6 hrs of instillation. 82.5% of cases induced with EASI aborted completely and 90% of cases induced with ethacridine lactate aborted completely. Success rate at 36 hrs of instillation was 87.5% in NS instilled group and 85% in EL instilled group. Success rate time 48 hrs it is 92.5% and 87.5% in NS and EL groups respectively. There were 7 cases of incomplete abortion in NS group and 4 cases in EL group which required check curettage. 2 cases in NS group had fever. 3 cases required reinstillation of agent in NS group as there was no change in bishops score and the bulb didn’t expel at 36 hr of instillation Conclusions: Normal saline is a safe and cost effective drug in mid trimester terminations of pregnancy without any major complications.

Keywords: Abortions; Saline Instillation.