Indian Journal of Obstetrics and Gynecology

  Here in, we are reporting a case of 24 year old female with vesicouterine fistula (VUF) following repeat cesarean section who had presented with complaint of passing urine without any sensation of bladder fullness & menuria (menses in urine) along with urinary tract infection ; her whole diagnostic workup & repair of fistula by laparoscopy with outcome of management is mentioned.

Keywords: VUF; Menuria; LSCS; Laparoscopy.

Combined oral contraceptives (COCs) offer a convenient, safe, effective, and reversible method of  contraception. While being highly effective, the early COC formulations were associated with significant adverse effects and cardiovascular risk. Reduction in the dose of estrogen is a commonly accepted approach to reduce the side effects of COC. Improvements in tolerability and safety have been achieved with similar effectiveness, mainly via hormone dosage reductions and the development of new progestins. Use of newer generation of progestins, such as gestodene, reduces the androgenic side effects generally  associated with progestogens. A COC with gestodene 60 g and ethinylestradiol (EE) 15 g showed overall good contraceptive efficacy and cycle control. Patients experienced significant improvement in well-being with respect to pre-menstrual complaints and symptoms. This COC regimen was safe, well-accepted and welltolerated, reduced both the intensity and duration of bleeding. With the progress of treatment cycles, the incidence of breakthrough bleeding reduces. Gestodene/EE low dose was associated with lower incidence of estrogen-related adverse events, such as headache, vomiting, pain, and nausea. Furthermore, COCs containing low dose of estrogen have not been associated with any adverse effect on haemostasis in healthy women. Ultra-low-dose COCs can be  considered in women who are at risk of developing estrogen-related side effects. Patients with obesity, heavy smokers and who are at a risk of developing stroke or myocardial infarction should be given these Oral Contraceptive Pills (OCPs). These formulations maintained efficacy, safety, showed good cycle control with shorter periods and lesser withdrawal bleed and enhanced the quality of life of patients.

  Introduction: Amniotic fluid provides a protective cushion effect for growing fetus. It maintains the temperature and provides a thermally stable environment for fetus. It acts as shock absorber, protecting fetus from possible external injury. Amount of amniotic fluid is good indicator of baby’s wellbeing in advanced gestational age. It constitutes the important part of fetal wellbeing test called as biophysical profile. This biophysical profile is ultrasound test along with NST. Method and Materials: It is a retrospective study conducted in Srinivas institute of Medical Sciences and Research Centre, and other centers. In which records were studied by follow up from February 2017 to January 2018. Amniotic fluid volume was noted within 7 days of
delivery or at the time of admission to hospital. The patients were divided into2 groups with reduced amniotic fluid volume (AFI <5) and normal amniotic fluid volume (AFI >5cm). Results: Out of 1928 records studied. In that 612 patients were recruited for the study. Out of them 25 (28.41%) women in reduced amniotic fluid volume and 104 (19.85%) women in normal amniotic fluid volume, had meconium passage. Labor pain was induced in 61 (69.32%) in reduced amniotic fluid volume and 132 (25.19%) in normal amniotic fluid volume, Total 67 (76.14%) patients in reduced amniotic fluid volume and 126 (24.05%) in normal amniotic   fluid volume, had LSCS in that 36 (40.90%) women in reduced amniotic fluid volume and 41 (7.82%) women in normal amniotic fluid volume has non reassuring fetal heart rate pattern as indication of LSCS. Conclusion: Present study showed that reduced amniotic fluid volume good indicator of poor pregnancy outcome. 

Keywords: Induction of Labor; AFI; Ante Partum Surveillance; Non Reassuring Fetal Heart Rate Pattern; LSCS.  

  Introduction: Maternal mortality is a sensitive index to know the type of obstetrics care the women receive during pregnancy, labor and puerperium. It indirectly reflects the socio-economic status of society and state. Aims & objective: The present study was undertaken to study the causes of maternal mortality and to plan strategies to further improve the health services to reduce the incidence of maternal mortality in western Rajasthan. Materials and methods: This was a retrospective study conducted in Department of Obstetrics & Gynaecology, at Umaid hospital attached to Dr S N Medical college, Jodhpur during the period of five years with effect from January 2005 to December 2009. Data were collected from record room of this hospital and scrutinized. Results: Most maternal deaths i.e 70%(181) occurred within 24 hours of admission. Maximum numbers of deaths were in age group of 21-30 years (68.48%), incidence in primigravidae was 37.74%, maximum i.e. 93.4% deaths were in  unbooked patients, 72% patients were from rural areas and 28% patients were from urban area. Conclusion: Haemorrhage, eclampsia and anaemia are the major causes of maternal deaths contributed by illiteracy in a developing country like India. PPH is a preventable cause of maternal mortality. Hospital delivery, prevention and treatment of anaemia, training of health personal at peripheral level for   timely identification and referral of high risk cases, timely availability of blood products and active management of third stage of labor are key factors to reduce maternal mortality due to haemorrhage in our areas. 

Keywords: Postpartum Haemorrhage (PPH); Maternal Mortality Rate (MMR); Subtotal Abdominal Hysterectomy (STAH); Puerperium; Eclampsia; Toxaemia.  

  Background: Education of pregnant women leads her to utilize the information available to manage her pregnancy. Aim: To study the pregnancy outcome in relation to her educational status. Materials and Methods: It is a retrospective study in which records were studied by follow up from January 2017 to June 2017. Their demographic features, associated maternal conditions, adverse maternal and perinatal outcome were noted. Results: Out of 917 records studied total 754 pregnant women were recruited for the study after excluding cases of missing information. In them 56.36 % were in age group of 20-29 years. In them women who had primary school and secondary school education were 66. 31%. Whereas 21.62% women dint had formal education. Anemia and hypertension was seen in majority of women who dint had formal education and had only primary education (70.06% and 60.60% respectively). PPH was seen more in women who dint had formal education (42.85%) and was similar in women who had only primary school education (42.85%). Preterm delivery and chance of cesarean section more in women who had primary school education followed by women who dint had formal education. NICU admissions and perinatal problems were more in women who had primary school education and   women who dint had formal education. Conclusion: Education plays important role in pregnancy outcome. One of the methods to reduce perinatal and maternal morbidity and mortality is giving good education to the people of the country. 

Keywords: Educational Status; Anemia; Hypertension; Preterm Delivery; Cesarean Section.  

  Introduction: Cervical cancer is the second most common cancer in Indian women. India bears about one-fifth of the world’s burden of cervical cancer. HPV infection has proven to be the culprit in causing 70% of the cases. Through robust screening programs, developed countries have proven that cervical cancer is preventable with the help of various primary and secondary preventive strategies available today. Aim: Assessment of awareness regarding cervical cancer, its prevention and early detection methods among general female population. Methodology: This prospective observational study was conducted through convenience sampling in 506 women (Age: 15- 65years) who attended ObstetricsGynaecology OPD at Bharati Vidyapeeth Hospital, a tertiary care center in Pune, India. The duration of the study was from September 2016-february 2017. A pre-validated  closed–ended self-administered questionnaire was used in English and Marathi for data collection. Result: Out of 506 women, 52.6% were aware of cervical cancer. Majority of the women did not know the cause of cervical cancer and had not heard of HPV. 61.7% were not aware of the risk factors. 76.1% did not know about the symptoms of cervical cancer. Only 30.2% women were aware of various screening tests available. Only 5% had opted for one of the screening tests in their lifetime and 2.4% had taken the HPV vaccine. Conclusion: Despite being   the second most common cancer, a killing disease in Indian women, majority are not aware of the risk factors and preventive measures of cervical cancer. Hence, nationwide public awareness campaigns are still the need of the hour. Clinical significance: Our study is an eye opener about apathy and lack of awareness about this disease still prevalent around. It highlights the need of continuous efforts still needed to make the women aware and come forward for vaccination and screening tests to reduce the burden. 

Keywords: Cervical Cancer; Cervarix; Pap Smear; HPV.  

  Introduction: In India, unhealthy cervix is a common finding on per speculum examination and it is recommended to do the cervical cytology to detect any epithelial cell abnormality. Aim: To correlate the finding in 100 women with unhealthy cervix by cytology, colposcopy and colposcopically directed biopsies. Materials and Methods: A total of 100 patients with unhealthy cervices on speculum examination were evaluated bycytology, colposcopy and colposcopicdirected biopsies. Results: The colposcopy was more sensitive (96%) than the cytology (44%) where as its specificity was only 76% compared to 90% on cytology. 60% of the patients with abnormal colposcopy had dysplasia and malignancy on HPE. 63% of the patients with positive cytology had dysplasia on HPE. So, the predictive value of both the tests were comparable. The false negative resultof colposcopy was only 1% compared to 18% for cytology, whereas false positive rates were almost the same for both the tests. Conclusions: Colposcopy in an excellent extended gynecological examination tool for the evaluation.

Keywords: Cytology; Cervix Colposcopy

  Background: Polycystic ovary syndrome (PCOS) is thought to be one of the most common endocrinopathies in women. It is possible to hypothesize that metformin therapy would augment the induction of ovulation in CC – resistant women because of its favourable change in adrogens, gonadotrpins, and insulin through mechanisms distinct from those of CC. Hence, the present study was undertaken to study effects of Metformin on clinical and endocrine profile in PCOS patients. Method: A total of 35 patients coming to out patient department diagnosed as a case of PCOS on the basis of common complaint of irregular menstrual cycles in whom ultrasound finding of polycystic ovaries was confirmed. All patients will receive metromin per oral 1 gm per day after breakfast for 6 mths, baseline and at six month follow up clinical examinations and endocrine profile recorded and studied. Result: Hirsutism was a compliant only in the subjects of the study with 31.4% of subjects having demonstrable levels with varied gradation. The prevalence of acne in this subject group was 20.6%. There is significant improvement in menstrual cycles regularity, p =0.00016. There is no change in acne & hirsutism complaints. Metformin is not the drug of choice for hirsutism & acne treatment. Conclusion:  Metformin was effective in restoring regular menses, metformin should be considered the first choice drug for treating oligomenorrhea in PCOS   patients in whom OCs are contraindicated. LH levels improved after metformin treatment with beneficial effect on LH: FSH
ratio and testosterone shows improved levels without change in DHEAS levels. 

Keywords: Meformin; PCOS; Hirsutism; Menstrual Cycles.  

  Background: Polycystic Ovarian Syndrome (PCOS) is a heterogeneous, multifactorial, polygenic endocrine condition seen in women of reproductive age group. The diagnosis of PCOS is made based on Rotterdam’s criteria 2003 (Any two out of the following three-Oligoovulation and/or Anovulation, Hyperandrogenism, Polycystic ovaries). Hyperinsulinemia and Insulin resistance contribute to the basic pathogenesis of PCOS.

Aims: The present study aims to study the prevalence of metabolic syndrome in PCOS in reproductive aged women. Settings and Design: Observational study. Materials and Methods: All the women aged 15 to 40 years attending the gynaecology OPD diagnosed with PCOS based on Rotterdam’s criteria during the study period of one year with a sample size of 146 were included in this observational study. After getting informed written consent from these patients,detailed history of age, parity, socioeconomic status, menstrual, marital, obstetric, past,personal and family history were obtained. They were screened for metabolic syndrome according to the modified American Heart Association / National Heart Lung Blood Institute modified ATP 111 definition 2001 which defines metabolic syndrome as the cooccurrence of three or more of the following risk factors (i) central   obesity with waist circumference  88 cm in women, (ii) elevated systolic and/or diastolic blood pressure of 130/85 mmHg, (iii) impaired fasting serum glucose 110 mg/dL, (iv) elevated fasting serum triglycerides 150 mg/dL, and (v) fasting high-density lipoprotein (HDL) cholesterol <50 mg/dL. Statistical Analysis used: Statistical analysis was done using SPSS version 25. Continuous variables were summarized as mean with standard deviation and analyzed using sample t-test. Categorical variables were expressed as proportions and analyzed by Chi-square test. Results: The prevalence of metabolic syndrome in PCOS was 38.4%.The occurrence of metabolic syndrome was more in the age group 26 to 35 years (62.33%). Central obesity with waist circumference  88 cm in women, elevated systolic and/or diastolic blood pressure of ï‚³130/85 mmHg,impaired fasting serum glucose 110 mg/dl, elevated fasting serum triglycerides 150 mg/dL, and fasting high-density lipoprotein (HDL) cholesterol <50 mg/dl and the ultrasound features of PCOS were observed to be statistically significant.No significant association was observed with hyperandrogenic clinical features and PCOS in USG in our study. Conclusion: The prevalence of metabolic syndrome in our study was 38.4%, which obviates the necessity of routine screening for metabolic syndrome in women with PCOS attending the gynaecology outpatient department. The study outcome can be utilised to prepare a screening protocol for metabolic syndrome, especially in low resource centres.

Keywords: Hyperandrogenism; Metabolicsyndrome; Polycystic Ovarian Syndrome; Central Obesity; hypertension.  

  Background: Glucose intolerance with its first onset or first recognition during pregnancy is called as GDM. Women with GDM are at an increased risk for both maternal and fetal adverse outcome. Aim: To study the pregnancy outcome in women diagnosed with GDM. Materials and Methods: It is a retrospective study in which records were studied by follow up from January 2017 to December 2017.Their demographic features, associated maternal conditions, adverse maternal and perinatal outcome were noted. Results: Out of 2118 records studied total of 56 of GDM patients were detected according to diagnostic criteria. In those patients 54 % belong to the age group 25-30 years. 11% belong to the rural and 89% belong to urban population. GDM patients had a higher incidence of PIH, Hypothyroidism, high incidence of UTI and candidiasis. There was higher incidence of cesarean delivery, higher admissions to NICU. 41.07% of patients had their blood glucose level controlled on diet therapy. Others required oral  hypoglycemic and/or insulin.  Majority of second gravida patients had history of GDM in previous pregnancy. Conclusion: Incidence of GDM is on rise, as it is associated with adverse maternal as well as adverse fetal outcome, early diagnosis and a good control of blood sugar levels should be done in order to achieve optimal maternal and perinatal outcome.  

Keywords: Gestational Diabetes (GDM); Gestational Hypertension; Cesarean Section; Birth Weight; NICU.  

  Background: Success of induction depends on the cervical favorability, which is quantified in points by Modified Bishop Score. Aim: This study compared the efficacy and safety of Extraamniotic Saline Instillation with Transcervical Foley Catheter and Vaginal PGE2 for improving Bishop score in term pregnant patients. Materials and  Methods: It is a prospective and comparative study on 200 patients with various indications for induction with unfavorable cervix (Bishop score <6), satisfying inclusion and exclusion criteria, are the subjects of the study. All patients undergone vaginal examination, the patients were divided randomly into two groups. Group A: 100 Cases, in whom, PGE2 gel was instilled intracervically for preinduction cervical ripening. Group B: 100 Cases, in whom, extramniotic saline infusion was done along with transcervical Foley catheter. Results: The mean Bishop Score at Zero hour of both the groups was comparable 3.92±1.49 in Group A and 3.5±1.48 in Group B. Success of cervical ripening defined as improvement in Bishop score > 4 points at the end of 24hours. Cervical ripening failure
was defined as a increase in Bishop’s score < 4 points following 24 hours. There were 78% with successful ripening in Group A and 94% in Group B. The difference in the success rates among the two groups is significant (p<0.05). 25% in Group A and 37% in Group B had an instillation delivery interval between 24 & 48 hours. There is no significant difference in instillation delivery interval among the two groups. 83% in Group B and 58% in Group A had vaginal delivery. 43% in Group A and 16% in Group B had EMLSCS. Uterine tachysystole was seen 4% patients in Group A and no patient in Group B had tachysystole. There was no significant
difference in the APGAR at 1min and 5mins in both the groups. 18% in Group A and 16% in Group B had NICU admissions. The indications for admissions were APGAR at 5min <7, Meconium stained liquor and respiratory distress.

Conclusions: Extraamniotic saline Instillation with Transcervical Foley Catheter is better alternative to PGE2 in term higher success rate in improvement in Bishop score, shorter ripening time, fewer complications like uterine tachysystole. 

Keywords: PGE2; Extraamniotic Saline Infusion; Transcervical Foleys Catheter; Cervical Ripening.