Indian Journal of Obstetrics and Gynecology

Background: Interstitial pregnancy is one of the most dangerous ectopic pregnancies and the diagnosis is challenging even in expert hands. Rupture of interstitial pregnancy can occur from 8- 16weeks of gestation and is associated with life threatening hemorrhage.

Case Presentation: In this case report, a 36years old G6P4L4A1 presented to North Easter Indira Gandhi Regional Instituteof Health and Medical Science Shillong with pain abdomen, bleeding per-vaginum following 1 month of amenorrhea. Ultrasonography detected hemoperitoneum and lesion in the pelvic cavity. On laparotomy, left interstitial pregnancy was detected and cornual wedge resection was done. Postoperatively patient was transfused with blood products.

Conclusion: High index of suspicion for this entity should be kept while performing sonography in a suspected case of ectopic pregnancy. Medical therapy and Minimal Invasive Surgeries should be offered as first line treatment in selected patients to improve future pregnancy outcomes but conventional management still requires in haemodynamically unstable cases.

Keywords: Interstitial Pregnancy; Cornual Pregnancy; Angular Pregnancy.

Failure of fusion of one of the mullerian ducts with partial fusion with the opposite side results in the formation of a rudimentary horn with unicornuate uterus. If a pregnancy occurs in a rudimentary horn, result is usually a rupture either in first or second trimester and it is usually a life threatening condition. The phenomenon is quite a rare entity and there are very few reported cases. This specific instance is an example of a case in which a pregnancy of 16 weeks occurred in the rudimentary horn of a unicornuate uterus, resulting in a rupture. 

Keywords: Ruptured Ectopic Pregnancy; Rudimentary Horn; Unicornuate Uterus.

Ovarian cancer has always been a perplexing problem to the clinicians. Most cases are detected at an advanced stage with poor and unpredictable response to therapy. Screening of ovarian cancer in general population has not proved to the useful due to low sensitivities of the available tests. There is need for newer tests which can overcome these problems clinicians are facing. Remarkable advances in the field of genetics and molecular techniques have given clinicians a hope for not only early diagnosis but also to monitor response to therapy and detect early recurrences and resistance to drugs. Circulating cell free DNA and circulating tumour cells have given a new hope, though it still hasprove its effectiveness in routine clinical use. This article throws light on these newer developments in ovarian cancer.

Keywords: Circulating Tumour Cells; Circulating Cell Free Tumour DNA; Ovarian Cancer.

PCOS is heterogenous condition with complex pathophysiology. It is one of the commonest endocrine metabolic disorder affecting 6- 10% of women in their reproductive age. PCOS in adolescent girl is a complex condition with psychological, reproductive and metabolic manifestations. Early detection of PCOS in adolescence can prevent many early and late complications. No “Magic bullet”  exists, combination of therapies may be required. The basic treatment of PCOS consist of calorie restriction, exercise, insulin sensitizing agents combined oral contraceptive pill, antiandrogens according to clinical presentation. Management of PCOS in adolescent girls pose challenge to clinician.

Keywords: Polycystic Ovarian Syndrome; Hyperandrogenism; Menstrual Irregularities; Metformin; Metabolic Syndrome.

Ovarian reserve tests are used for determination of the functional potential of ovary. They reûect the number and quality of oocytes in it. These tests are frequently used by the Gynecologist dealing with Infertility & IVFspecialists to predict the chances of success for ovarian stimulation and retrieval of follicles by knowing the reserves of ovary. Ovarian reserve is affected by many factors like biological age, chemotherapeutic drugs, radiation exposure, certain surgeries etc. It is well known that as the age of women increases fertility declines. So it becomes important for the IVF consultants to know the chances of success and the optimum dosages of ovarian stimulation protocols to be used; also the side effects can be predicted in some. These tests are useful in fertility assessment, as it provides a guide to ovarian reserve and identifies women that may need to consider either egg freezing or trying for a pregnancy sooner rather than later if their long-term future fertility is poor. Ovarian reserve can be measured by dynamic and static tests. Commonly used ovarian reserve tests are serum FSH, serum AMH and the Antral Follicle Count (AFC); these are static tests. Dynamic ovarian reserve tests are not commonly performed in clinical setting. Of these static tests AMH has certain advantages, due to its less inter and intra cycle variability. Many more uses of these tests have come up in recent years. These tests have some limitations so should be used with the knowledge of their limitations in clinical settings. 

Keywords: Antral Follicle Count (AFC); Follicle Stimulating Hormone (FSH); Inhibin; Anti Mullerian Hormone (AMH).

Objectives: To study Fetomaternal complications arising in pregnancies with Infective Hepatitis.

Materials and Methods: This observational study was carried out in department of Obstetrics and Gynaecology, in our institute, enrolling 50 subjects from January 2017 to June 2017 who attended the emergency labour room and Antenatal OPD with history suggestive of Infective Hepatitis and admitted in Antenatal ward, and some were later transferred to Medical ward. All pregnant women with Infective Hepatitis were selected, all their details entered in preformed, effective interventions were recorded.

Results: Out of 50 subjects of infective hepatitis coagulopathy is the most common complication and managed by blood products transfusion.

Conclusion: Coagulopathy is the most common complication arising in subjects with Infective Hepatitis.

Keywrods: Complication; Infective Hepatitis; Feto-Maternal.

Introduction: The intrapartum assessment of fetal well being has become an integral part of the management of labour. Now a day’s cardiotocography (CTG) become a popular method to monitor fetal wellbeing. Objective of the study is the correlation of abnormal cardiotocography and perinatal outcome.

Material and Methods: In this prospective observational study 200 pregnant women with gestational age  37 weeks gestation with cephalic presentation in first stage of labour were taken. Results were assessed in the form of mode of delivery, color of the liquor , apgar score, NICU admission and perinatal mortality.

Statistical analysis was done by using Chi square test using software SPSS version 16 and p<0.05 is considered as statistically significant.

Results: Out of total 200 patients the CTG tracing was normal in 152 patients (76%), abnormal in 18 patients (9%) and suspicious in 30 patients (15%).
Caesarean section rate was statistically higher (72.2%) in abnormal CTG trace group as compared to those with suspicious (46.6%) and Normal (32.2%) group.
Incidence of Meconium stained liquor was statistically higher (27.7%) in abnormal CTG trace group as compared to those with suspicious (13.3%) and Normal (4.6%) group. Incidence of babies with low apgar scores was statistically higher (27.7%) in abnormal CTG trace group as compared to suspicious (13.3%) and Normal (5.26%) group. Incidence of NICU admission was statistically higher (33.3%) in abnormal CTG trace group as compared to suspicious (10%). and Normal CTG trace group (1.31%). The abnormal CTG patterns of the present study had 11.11% perinatal mortality.

Conclusion: Cardiotocography is the best non invasive screening test to evaluate the fetal health and to predict the perinatal outcome. Incidence of high caesarean rate, Meconium stained liquor, low apgar score, NICU admission and
perinatal moratlity was more frequent in those cases that have abnormal CTG traces.

Keywords: CTG; Abnormal Cardiotocography; Apgar score and Perinatal Outcome.

Aims and Objectives: The aim of this study was to evaluate the incidence, indications, maternal and foetal outcome in parous women who underwent caesarean section for the first time and who had delivered vaginally previously.

Material and Methods: This is a prospective study of 129 cases of primary caesarean section done between October 2015 to September 2016 in multiparous
women at ESICMC & PGIMSR hospital, Bangalore. Both elective and emergency caesarean sections in multipara were included in the study. Incidence according to age, gestational age, spacing between births, parity, antenatal complications, indication for LSCS, whether labour was spontaneous or induced, intraoperative and post operative complications were recorded. Foetal outcome was also evaluated.

Results: The primary caesarean section rate in multipara was 8.48%. Most were in the 26 – 30 age group and majority were primipara. Foetal distress (34.88%) was the commonest indication for caesarean section followed by abnormal presentations (22.48%) and prolonged labour (9.3%). In our study severe oligoamnios with fetoplacental insufficiency contributed to 8.53% of caesarean sections in multipara. 6.20% of women had caesreans for antepartum haemorrhage.

Conclusion: Though previous vaginal delivery is a factor in favour of vaginal delivery in the next pregnancy in a parous woman, caesarean section is not uncommon and is showing an increasing trend. The causes are complications like foetal distress, malpresentations and the increasing incidence of hypertension, diabetes and oligoamnios. Physician factors like increased intra partum surveillance and use of electronic foetal monitoring due to medicolegal concerns could be a factor for foetal distress being the commonest indication for Caesarean section in multipara.

Keywords: Caesarean Section; Multipara; Primary; Foetal Distress

Context: The complications of prolonged labour are well recognized and the caesarean section has been used in liberally. Although prolonged labour  continues to be a constant problem due to weak uterine contractions or poor cervical dilatation. The problem can be overcome with the ensure the efficacy, adverse effects, safety, and feto-maternal outcome of the Artificial Rupture of Membrane (ARM) and oral misoprostol with ARM and oxytocin infusion for augmentation.

Settings and Design: This prospective study was conducted in the labour room of
NRS Medical College and Hospital Kolkata and included 100 primigravidae women carrying singleton pregnancy at term with spontaneous onset of labour.

Methods and Material: Patients aged between 18 to 28 years, Primigravidae between 37 to 42 weeks of gestational age, Live singleton pregnancy, Cephalic presentation, Spontaneous onset of, Cervical dilatation of 4 cm or more, Inadequate uterine contractions less than three per ten minutes, reassuring foetal heart rate and giving informed consent were included in the study. Each of the agents was applied to every alternate case. Augmentation was done by oral misoprostol 25 mcg at 4-hour interval to maximum of 3 doses (misoprostol group, n=50) Oxytocin infusion was started at the minimum dose of 2mIU/min in Ringer lactate solution, adjusting the dose every 15 minutes till the desired uterine contractions are achieved, with a maximum dose of 5mIU/min at the rate of 15 to 20 drops per minute (oxytocin group, n=50).

Statistical analysis used: Data were expressed as a percentage and mean ± SD. Student’s t-test was used to check the significance of the difference between two
parameters in parametric data. Chi-square test was used to analyse the significance of the difference between the frequency distribution of the data.

Results: The study showed that in both the groups (misoprostol and oxytocin), the majority of the participants belong to the age group of 20-30years. The mean duration of delivery was 5.2 hour and 5.5 hours in misoprostol and oxytocin groups respectively. Prolonged was the major indication for LSCS in both the groups.

Conclusion: Both the agents i.e. oral misoprostol and intravenous oxytocin shortens the duration of effectively and are effective for augmentation of and the need for LSCS was almost similar in both the groups.

Keywords: Oxytocin; Misoprostol; ARM.

Introduction: Infertility is the failure to conceive (regardless of cause) after 1 year of unprotected intercourse. Its overall prevalence has been stable during the past 50 years; however, a shift in etiology and patient age has occurred. Though both male and female factors cause infertility women are held responsible and attend infertility clinic.

Aims and objectives: To know the prevalence of primary infertility and study the clinical, biochemical and radiological features associated with primary infertility.

Materials and Methods: This is a cross sectional observational study of 100 primary inferility patients at the gynecology outpatient department and infertility clinic at MVJ medical college and research hospital between august 2014 to july 2015.study participants underwent standard infertility evaluation including history,  physical examination, ultrasonography, endocrinological assay involving TSH, FSH, LH and serum prolactin and semen
analysis. The descriptive analysis of the data is done using Statistical software namely SPSS and Graphs and tables were generated using Microsoft word and excel.

Results: the prevalence of infertility was 10.6%. majority of patients were between 20-30 yrs. Mean duration of infertility was 6.7 yrs. 20% patients had symptoms like chronic pelvic pain, white discharge per vagina and dysparenuia. Abnormal semen analysis was found in 24% of male partners. 10% patients had hypothyroidism. 46% of patients had polycystic ovaries on ultrasound. Tubal block was found in 17% of patients.

Conclusions: The study is dominated by younger age at presentation and varied duration of infertility. Polycystic ovarian syndrome was first cause of infertility followed by pelvic inflammatory disease and male factor infertility.

Keywords: Prevalence; Primary Infertility.

Background: Hypertension is the most common medical problem encountered in pregnancy resulting into alteration of hematological profile, most common of which is thrombocytopenia. The present study is conducted to assess whether platelet count can predict severe forms of HDP and fetomaternal outcome.

Methods: An observational study was conducted in the Department of Obstetrics and Gynaecology at Pt. J.N.M Medical College Dr. BRAMH, Raipur from May 2016 to July 2017. A total of 100 women in their third trimester of pregnancy were investigated. They were divided in two groups on the basis of platelet count and followed till delivery. The mode of delivery, gestational age at the time of delivery and fetomaternal complications were noted. The data collected was tabulated and analyzed.

Results: A significant association was found between severity of HDP and thrombocytopenia p=(.003). Women of HDP with thrombocytopenia had significantly higher number of pretermbirth (p<0.001). Similarly higher number of complications were noted like HELLP(16%), abruption (16%), pulmonary edema (16%), renal failure (11.1%) and PPH (27%) in women with thrombocytopenia. The mean duration of pregnancy was reduced in women with thrombocytopenia (34.57 weeks) as compared to women with normal platelet count (36.36 weeks). The women with thrombocytopenia had more number of fetal complications. 44% had IUGR, 11.1% had IUD and 88% of neonates required NICU admission.

Conclusion: A simple test of platelet count which is cost effective, rapid and accurate can be used in in assessing severity of HDP and timely management.

Keywords: HDP; Platelet Count and Fetomaternal Outcome.

Introduction: Adolescent girls live in a grey zone between childhood and adult female. Health issues of these girls have often been overlooked and gynecological problems are ignored as being part of growing up or as trivial symptoms.

Aims: this study was undertaken to analyze and create awareness about the physiological and pathological conditions related to gynecology of adolescent girls.

Methodology: A total of five hundred urban adolescent girls of age range (12-19 years) were included in this study.

Result: Among the 500 urban girls although 98% were educated but only 40% knew about pubertal changes before they actually occurred. Mean menarche age noted was 13.45 years; ranged from 9-18 years; 93.4% attained menarche till the age of 15 years; and varied with socioeconomic status 12.1, 13.4, 14.2 years in high, middle and low socioeconomic groups. Most common gynecological problem was menstrual disorder seen in 60% of cases and among these 70% had menorrhagia, 19.3% oligohypomenorrhea and 9% had amenorrhea; 25 cases of menorrhagia required hospitalization due to severe anemia. Dysmenorrhea was prevalent in 56% of cases and 50% of these required analgesics for relief. Leucorrhoea and urinary problems were seen in 12.2% of cases. PCOD was diagnosed in 10 (2%) cases. There were 11 cases (2.2%) of  anomalies of genital tracts comprising of imperforate hymen (0.8%), transverse vaginal septum (0.8%), hypoplastic uterus (0.4%) and vaginal atresia (0.2%). Use of sanitary pads was seen in only 27.2% and taboos related to menstruation were seen in 80.4% of all cases.

Conclusion: Magnitude of health problems in adolescent girls is large and this study reveals lack of knowledge about puberty and menstruation as well as various misconceptions among Indian adolescent girls. Clinicians and gynecologist should be aware of these problems and be able to prevent and treat them. Ensuring good adolescent reproductive health will ensure ‘Safe Motherhood’. 

Keywords: Adolescent; Menstruation; Menarche; Menorrhagia; Dysmenorrhea.

 

Aim: To study the effect of low dose mifepristone on the leiomyoma volume reduction, leiomyoma-related symptoms and endocrinal profile in patients with
symptomatic leiomyoma.

Setting: Tertiary care hospital

Material and Methods: Sixty-two patients with symptomatic uterine leiomyoma were recruited and distributed to receive 10 mg mifepristone (Group 1) and placebo capsule containing 10 mg lactose (Group 2) OD for 3 months. Baseline leiomyomarelated symptoms and leiomyoma volume was recorded, followed by monthly assessment for three months. Baseline hormonal profile was done and repeated at the end of therapy.

Main outcome measure (s): The reduction in the uterine leiomyoma volume, effect of mifepristone on the leiomyomarelated symptoms and the hormonal levels.

Result (s): There was a significant percentual decrease (p = 0.000) in the total leiomyoma volume in the mifepristone-treated group, -58.36±8.92% (mean ±S.D), compared with the control group, 0%. Mifepristone treatment significantly reduced the bleeding days (p = 0.000) by causing amenorrhea in all the patients (100%). There was a significant improvement in the leiomyoma-related symptoms and the hormonal levels remained unchanged.

Conclusion: Mifepristone may offer an effective conservative treatment option for women with symptomatic uterine leiomyoma and the associated pronounced uterovaginal bleeding. It is efficacious in reducing leiomyoma volume and leiomyoma-related symptoms of menorrhagia and dysmenorrhoea.

Keywords: Mifepristone; Leiomyoma; Leiomyoma Volume; Leiomyoma Related
Symptoms.

Introduction: The rapidly accumulating advances in the field of Pathology lead to the evolution of newer models of Ovarian carcinogenesis, that classify Surface Epithelial tumors into Type-I and Type-II. Type-I are those ovarian tumors, where precursor lesions in the ovary have clearly been described. Type II tumors are those, where such lesions have not been described clearly and tumors  may develop de novo from the tubal and/or ovarian surface epithelium, comprising of high grade carcinomas, causing significant mortality. Hence, we undertook the study to identify the precursor lesions of these malignant neoplasms and provide a road-map for early diagnosis.

Aim: To study the morphological spectrum of ovarian surface epithelial neoplasms with emphasis on tumorogenesis of malignant tumors.

Materials and Methods: This is a prospective study conducted from July 2015 to July 2017. Cases diagnosed as Ovarian tumors were included in the present study, with special emphasis on extensive examination of fallopian tubes using SEE-FIM protocol.

Results: Out of 133 cases of Surface Epithelial tumors, malignant tumors accounted for 25 cases and  were associated with Serous Tubal Intraepithelial Carcinoma (STIC) in three cases and ‘Atypical changes’ in two cases.

Conclusion: The Serous Tumors of the Ovary, may have an identifiable precursor lesion in the form of STIC arising from the fallopian tube, more commonly from the TuboPeritoneal Junction at the fimbrial end.

Keywords: Surface Epithelial; Ovary; STIC; Atypical Changes; Malignant; Serous Carcinoma; Tubo-Peritoneal Junction; Fimbrial; Precursor Lesion.

Introduction: Preterm labor is a significant cause of neonatalmorbidity and mortality. Urinary tract infections and Genital infections are related with increased incidence of preterm labor. This prospective case–control study was performedto see the association between preterm labor andurinary tract infections.

Patients and Methods: A case control study was undertaken in a tertiary care centre. The study compriseof 162 subjects, which were further divided into cases and control with a ratio of 1:2. Cases n=54 and control group was n=108. All subjects were evaluated by detailed history , examination and following laboratory tests were done. Complete blood count (CBC), Urine Routine – Albumin, Sugar, Microscopy, Urine culture and sensitivity. Statistical analysis were done using SPSS version 20.0 Armonk, NY, USA.

Results: In our study mean age of Patientsin cases was 23.29±2.96years and control was 23.98±3.59years. Urine culture was positive in 24.07% (n=13) in case group and 7.4% (n=8) in control group.The difference was statistically significant (pvalue- 0.0031). E.coli was the most common organism in urine culture among both the groups. Most of organisms were sensitive for Gentamycin, Cotrimazole, Imipenem and Piperacilin in both groups.

Conclusion: The present study shows significant association between Urinary tract infections and preterm labor. Urinary tract infections was 3.2 times more in preterm labor compared to term labor patients. Identification and treatment of Urinary tract infections at the earliest can prevent preterm labor and maternal morbidity.

Keywords: Preterm Labour; Urinary Tract Infections.

Background: To investigate the etiology, obstetrical risk factors, complications and outcomes of pregnancies affected by thrombocytopenia.

Methods: Study was conducted on 100 pregnant women who had thrombocytopenia from may 2017 to September 2017, in Government Rajaji Hospital, Madurai, India. Clinical data including basic history, physical examination and investigations of those women were evaluated.

Results: 36% of these women had viral infections as the commonest cause of thrombocytopenia. Gestational thrombocytopenia accounted 33%. Pregnancy specific hypertension and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) accounted for 27% cases whereas in 4% of pregnant women, idiopathic thrombocytopenic purpura (ITP) was the causative factor. A higher rate of IUGR (Intrauterine growth restriction), placental abruption and labor induction was noted among those gravidas who had moderate to severe thrombocytopenia.

Conclusions: Commonest cause of thrombocytopenia in pregnancy is viral infections as there was a viral fever outbreak at the time of our study period, followed by gestational thrombocytopenia, preeclampsia and HELLP syndrome. ITP is a rare cause of this disorder in pregnancy. Early detection and treatment of expected complications is the key focus in management of such cases.

Keywords: Etiology; Obstetrical Risk Factors; Complications; Outcomes; Thrombocytopenia.

Background and Objectives: Asymptomatic bacteriuria is a major factor for the development of urinary tract infections. In addition to complications of urinary tract infections, a variety  of conditions have been reported to be associated with asymptomatic bacteriuria. Of these pre-term labor, low birth weight, prematurity, pre-eclampsia and chronic renal disease that have been cited as significant adverse obstetric outcomes. Thus, early detection and treatment can possibly decrease the occurrence of these effects. The relatively high prevalence of asymptomatic bacteriuria during pregnancy, the adverse effects on the pregnancy, the opportunity to avoid sequelae with treatment; justify screening pregnant women for bacteriuria. Objectives are to determine the prevalence of asymptomatic bacteriuria in pregnancy, the type of bacteria causing the asymptomatic bacteriuria and the antibiotic sensitivity and resistance of the organism.

Materials and Methods: This is a cross-sectional, observational study conducted at the Out Patient Department of Obstetrics and Gynaecology of Navodaya Institute of Medical Sciences, Raichur. All pregnant women with no genitourinary complaints, no histories of fever and without any intake of antibiotics for any indication during the current pregnancy were included in the study. The women were asked to submit urine specimens for culture and sensitivity tests.

Results: 200 pregnant women were studied of whom 7, (3.5 percent) were identified to have asymptomatic bacteriuria. The most common isolates were Escherichia coli (28.5 percent) Staphylococcus aureus (28.5 percent). The organisms were found to be sensitive to Amikacin, Cefoperazone, Ciprofloxacin and Cefaclor in decreasing order. The organisms were comparatively more resistant to amoxicillin.

Conclusion: Asymptomatic Bacteriuria during pregnancy may cause serious maternal and perinatal, morbidity. All pregnant women should be screened for bacteriuria by urine culture in their first visit and they should be treated if the results are found positive. So it is recommended to do urine culture as a routine screening during pregnancy.

Keywords: Asymptomatic Bacteriuria; Prevalence; Pregnancy.

Introduction: Prelabour rupture of membrane complicates pregnancy affecting delivery route and course of labour. This study aims at comparison of oral misoprostol and oxytocin infusion for labour induction in term PROM.

Objective: To compare efficacy and safety of oral misoprostol with oxytocin infusion for induction of labour in term PROM.

Methods: The study is retrospective study carried on 100 pregnant women admitted in department of OBGY, ACPM medical College, Dhule from June 2015-June 2017. The women were assigned randomly to anyone of 2 equal groups. Group A received 25 micrograms of misoprostol every 4 hrs for maximum of 4 doses. Group B received oxytocin infusion primigravida 2 IU diluted in IV fluid and multigravida with 2.5 IU diluted in IV fluid with maximum dose of 5 IU in primigravida and 2.5 IU in multigravida. The primary
outcome was induction delivery interval. The secondary outcomes were mode of delivery, maternal and neonatal outcomes.

Results: The study showed that mean induction delivery interval was significantly lower (5.6hrs) in misoprostol group as compared to oxytocin  group (7.2hrs). In misoprostol administered group 78% patients delivered by vaginal route while in oxytocin group it was 70% whereas
22% required Caesarean Section in misoprostol group while it was 30% in oxytocin group. Incidence of hypertonus was higher (22%) in misoprostol group as compared to oxytocin group (10%).

Conclusion: In our study, the time intervals from induction to delivery were significantly shorter in misoprostol group than oxytocin group. Meconium stained liquor was seen more in women induced with misoprostol group than oxytocin. Intravenous oxytocin is still an effective option.

Keywords: Induction of Labour; Misoprostol, Oxytocin; Premature Rupture of Membranes.