Indian Journal of Obstetrics and Gynecology

Introduction: Ovarian carcinosarcoma is one of the lethal malignant tumours of the female genital system. It is extremely rare and represents 1% of all malignant ovarian tumours. It occurs most commonly in postmenopausal women with the incidence peak in sixth decade, with only 10% incidence in younger women. They are associated with an aggressive clinical course and overall poor prognosis. Case report: Our reported case was a 60 year old postmenopausal lady who presented to us with pain and mass in lower abdomen since 15 days. Physical examination revealed a huge non tender suprapubic mass of uterine size 24 weeks suspected to be of ovarian origin. Shewas investigated and radiological studies confirmed a lesion of approx. 13.6 x 14.3 x 15.3 cms arising probably arising from the ovary, with heterogenous enhancement. Staging laparotomy was done with maximum debulking of large ovarian mass followed by Total Abdominal Hysterectomy with bilateral salpingo-oophorectomy with infra colic omentectomy. Left ovary was totally replaced by growth. Right ovary was small atrophic. Histopathology revealed Malignant Mixed Mullerian Tumour (MMMT) of the ovary with positive peritoneal cytology. Conclusion: The poor prognosis associated with this rare disease emphasizes the need for collaborative prospective studies targeted to better understand the molecular changes of MMMT and the need to design new therapeutic regimens to improve patients’ survival.

Keywords: Malignant mixed Mullerian tumour; ovary; carcinosarcoma; staging laparotomy

 Sheehan Syndrome is a rare entity with an incidence of around 3% described from the Indian Subcontinent. It has a variable presentation from an acute catastrophic event like an adrenal crisis to more subtle symptoms like fatiguability. It is invariably associated with deficits in gonadotropic hormones leading to secondary infertility and assisted reproduction. Such pregnancies are considered high risk and require high medical vigilance. The present article discusses similar patient who developed the syndrome following events of her first pregnancy and later conceived with gonadotropin induced ovulation induction.

Keyword: Sheehan's Syndrome; gonadotropin induced ovulation induction.

 The aim of the study is to assess any existing association between ovarian reserve and vitamin D levels. This study was designed to assess serum vitamin D levels and association with ovarian reserve in infertile patients. The mean age of cases was 34.3 whereas that of the controls was 33.3 years. There is association between age and ovarian reserve markers. As age advances AMH & AFC is decreased whereas FSH increases. In our study we found significant relation between age and ovarian markers. Present studies did not find any association with BMI. There was no correlation found between vitamin D and AMH. FSH, AFC levels in both the infertile and fertile women groups. In our study both groups showed vitamin D insufficiency and deficiency. The rate of vitamin D deficiency among women with impaired fertility is alarming. Taken altogether, our findings suggest that there is no association between 25 (0H) D and ovarian reserve markers.

Keywords: Vitamin D; Infertility; Anti Mullerian Hormone.

Introduction: Eclampsiacontinue to be a major problem in developing countries like India contributing to significant maternal and perinatal morbidity and mortality. Aim and Objective: identify risk factors that lead to eclampsia and decrease the complication related to eclampsia in future. Material and methodology: A cross sectional study is conducted to identify the risk factors of all women presenting with eclampsia at new civil hospital Surat, Gujarat during 6 months period. Results: 25 cases (83.33%) are primigravida among total 30 cases in study. Majority of the patients were unbooked (73.33%), low socioeconomic class (80%) and presented at late term beyond 36 weeks (50%). Antepartum eclampsia (73.33%) accounted most of the cases and 90% with pre monitor sign and symptoms in which headache (60%) is the most common pre monitor symptom. Mostly present with Blood pressure more than 160 mmHg (56.66%) and proteinuria more than +4 (60%). Conclusion: The high incidence of eclampsia and its complication during this study indicate the need for early identification of risk factors and timely intervention to improve maternal and perinatal outcome.

Keyword: Eclampsia, risk factor, maternal complication, parity

 Current study designed to assess the status of zinc and copper in women with preterm labour compared to women with term labour. 100 pregnant (50 in preterm labor and 50 in term labour) included in this study. Both study & control group age and parity are matched. Micronutrients Cu & Zn levels (both in maternal serum & fetal umbilical cord) are studied in both groups along with other measures. Normal serum copper level range in pregnancy is taken as 85-170 µg/dl. And umbilical cord copper range as 60-90 µg/dl. Maternal serum copper levels are high in study group (preterm group-114.9) compared to control group (term mothers-108.5) the with an insignificant p value of 0.540. Whereas, umbilical cord copper levels are less in study group (57.7) compared to control group (73.6) (p=0.0001). This implies that placental transport system changes during the latter stages of the development resulting in the transport of higher copper values towards the end of gestation than that of earlier pregnancy. Another finding observed was, umbilical cord copper is less than the maternal copper irrespective of period of gestation. Serum zinc values in term pregnancy is taken as 78- 132 µg/dl. Maternal serum zinc levels are high in control group (103.7) than in study group (91.8) (p=0.0001). In the same way umbilical cord zinc levels are more in control group (121.6) than in study group (101.2) (p=0.0001. Another finding was umbilical cord zinc levels are less than the maternal zinc levels irrespective of period of gestation. In present study, relationship of birth weight with maternal and umbilical cord copper was observed. Umbilical cord copper levels had a positive correlation with birth weight (p=0.001). In the same way, relationship of birth weight with maternal and umbilical cord zinc was observed. The study showed that maternal serum zinc levels had positive correlation with birth weight (p=0.0001). Umbilical cord zinc levels also had a positive correlation with birth weight, with a significant (p=0.0001). In the present study maternal/neonatal complications vs. Preterm and term was studied, which showed that higher neonatal complications occurred in preterm neonates (26%) compared to term neonates (10%) with a significant (p=0.03). In the same way, higher maternal complications occurred in preterm mothers (18%) compared to term mothers (6%) with a significant (p=0.03). No studies were available in literature regarding copper, zinc deficiency in relation to development of neonatal complications. Neonatal complications in relation to maternal serum and umbilical cord blood levels of copper and zinc were studied. The mean values of maternal serum and umbilical cord blood levels of both copper and zinc were found to be less in cases with fetal complications (p=0.0001).

Keywords: Micronutrients; fetal growth; maternal outcome.

Background: To evaluate the efficacy of low dose MgSO4 Regime in management of eclampsia and comparing it with Pritchard Regime regarding control of convulsions, Serum Magnesium levels, Maternal and perinatal outcome. Method: In this study total 120 Cases of eclampsia were included. Sixty Cases were treated by Pritchard regime and 60 cases by low dose Regime. Control of convulsions was studied in both groups. Serum Magnesium levels were done after loading dose and maintenance dose in both groups. Result: In 56 Cases (93.33%) in low dose regime and 57 (95%) in Pritchard regime, convulsions were controlled with loading dose itself. Recurrence rate was 4 (6.66%) in low dose regime and 3 (5%) in Pritchard regime. This difference in recurrence rate is statistically insignificant. The average serum Magnesium levels in low dose regime was 4.23 + 1.51 mg/ dl while in Pritchard regime it was 5.47+1.98 mg/dl. Conclusion: Low dose MgSO4 Regime is as effective as Pritchard regime in controlling and preventing the recurrence of Convulsions in eclampsia. Though there is statistical difference in Serum Magnesium levels in both regimes but there is no statistical difference as far as the Control of Convulsions.

Keywords:Low dose Magnesium Sulphate regime; Pritchard regime; Eclampsia; Convulsion.

Introdution: Our aim was to determine the potential value of a routine ultrasound examination in low-risk pregnancies at 37 to 41 weeks for the prediction of likely outcome of labour, including the risk of prolonged pregnancy and the need for Caesarean section for failed induction or lack of progress in labour. Aims and Objectives of the Study: To assess cervical length in the subjects attending antenatal OPD with a singleton gestation with vertex presentation between 37 to 41 weeks and to study the likely outcome of labour. Material and Methodology: Women having gestational age of 37 to 41 weeks with cephalic presentation, intact membranes, live fetus and not labouring were included in the study. Conclusion: This study has demonstrated that measurement of CL at term can be used to determine the likelihood of prolonged pregnancy and the risk of emergency CS for failure to progress or failed induction of labour.

Keywords: CL- cervical length; FTND- Full term normal delivery; LSCS- Lower segment caesarean section; TVS- transvaginal sonography.

Introduction: Cephalopelvic disproportion/deflexed head increases the hazard of vaginal delivery both for the mother and for the child. Protracted labour is more common in primigravid women than in multipara. Initially it was X-ray pelvimetry which was used but now a days due to advanced technology it is ultrasound which has replaced X-ray pelvimetry and it is more informative and more accurate. Aims and Objectives: (1) To quantify the degree of fetal head deflection (2) To determine whether a parameter derived from ultrasound examination has a relationship with the course and outcome of labor. Subjects and Methods: The primigravidas with 1. Low risk pregnant women at or beyond 37 weeks of gestation in the 1st stage of labour with vertex presentation with 2. Cervical Dilatation 3-6 cms and 3. The station above the ischial spine with regular contractions. Methods: From the Eligible patients, informed consent was taken. Measurement of occipitospinal angle using abdominal probe of the USG machine and readings were noted. Summary: Age of the patient, Gestational age and weight of the baby are not found to have any significant association with the outcome of the labour. patients with lower occipitospinal angle (<120°) had undergone caesarean section majority of the time (11 patients) and those with occipitospinal angle >120° had spontaneous vaginal delivery (86 patients). Conclusion: The degree of fetal head deflexion in the first stage of labour may be quantified accurately by means of transabdominal ultrasound. The occiput-spine angle width seems significantly related to the fetal head station and to the risk of obstetric intervention.

Keywords: Primigravida with Vertex Presentation; OcciputSpinal Angle and Outcome of the Labour (Lscs or Normal Vaginal Delivery).

 Background: The metabolic syndrome (MS) is a constellation of interrelated abnormalities. Polycystic ovarian syndrome (PCOS) is the most common cause of anovulatory infertility. PCOS is associated with insulin resistance and significantly higher ratio for the development of various cardiovascular risk factors and a significantly greater risk of MS. Aim: (1.)To find out the prevalence of metabolic syndrome (MS) in females with polycystic ovary syndrome (PCOS). (2.) Assess the metabolic risk factors in PCOS as per the definition of IDF criteria of metabolic syndrome. Study design: Descriptive and cross sectional hospital based study. Materials and methods: This study was conducted in the department of obstetric and gynecology at tertiary care center. Study duration 1 year. Statistical analysis: It was done using SPSS version 22.0 using Karl Pearson Chi Square Test, Paired T test. Results: MS was diagnosed in 35.45% of cases (39/110) with 33.33% in adolescents (14/42) and 36.77% in adults (25/68). Conclusion: we should change the attitude towards the polycystic ovarian syndrome -PCOS patients should be screened for Metabolic Syndrome and also should be offered prevention and further treatment.

Keywords: polycystic ovary syndrome; metabolic syndrome.

 Introduction: Amongst the gynaecological malignancies, epithelial ovarian carcinoma is the most lethal. Early stage neoplasms in the fimbriated end of the fallopian tube could be the cause of development of ovarian carcinoma. We aim to correlate opportunistic tubal ligation / salpingectomy as an effective preventive strategy in the occurrence of epithelial ovarian carcinoma. Material & Methods: This is a prospective case-control study. Cases were patients who underwent total hysterectomy with bilateral salpingo-oophorectomy with a histologically verified epithelial ovarian cancer and controls were patients who underwent the same surgical procedure for benign gynaecological conditions specifically myoma uteri and adenomyosis with normal ovaries a final histology report. Using appropriate statistical methods the correlation between the occurrence of epithelial ovarian carcinoma and previous tubal ligation / salpingectomy was determined. Results: A total of 158 cases were included in the study amongst which 28 cases were post-surgical patients with histologically verified epithelial ovarian cancer and 130 post-surgical patients for benign gynaecologic conditions with normal ovaries a final histology report were controls. The study showed that without previous tubal ligation / salpingectomy procedure the odds of developing epithelial ovarian carcinoma increased by 1.54 times in the subjects after adjusted for age, parity and obesity. Conclusion: Tubal ligation / salpingectomy reduces the risk of developing epithelial ovarian carcinoma. At the time of surgery and planning a hysterectomy for benign indications patients should be counselled regarding risk-reducing salpingectomy to conserve ovarian function and prevent ovarian epithelial carcinoma.

Keywords: Epithelial ovarian carcinoma, Tubal ligation, Salpingectomy.

Introduction: In the last few years ultrasonography has become an integral part of antenatal care, playing a central role in accurate pregnancy dating and screening for fetal abnormalities, placenta previa and multiple pregnancy. In the third trimester, ultrasound is used selectively in the diagnosis and management of problems suspected from clinical examination, such as fetal growth restriction, macrosomia, malpresentation and antepartum haemorrhage. In the present study we report the ndings of cervical length at 37 to 41 weeks and the interval of delivery. Aims of the Study: The aims of this study undertaken were as follows: To assess cervical length in the subjects attending antenatal OPD with a singleton gestation with vertex presentation between 37 to 41 weeks, To study the association of time interval of cervical length measurement and onset of labour. Materials and Methodology: The following inclusion criteria were used while selecting the subjects for the study: 1. Singleton pregnancy from 37 to 41 weeks of gestation, 2. Cephalic presentation, 3. Intact membranes, 4. Live fetus 5, Non labouring. Conclusion: CL by transvaginal ultrasound at term in singletons gestations, which is easily performed, could be used for prediction of spontaneous labour. It can be used to estimate the chance that a woman has a spontaneous delivery within 1 week.

Keywords: CL-cervical length; TVS-transvaginal ultrasonography.

 Introduction: The practice of hysterectomy in intellectually disabled individuals has raised a lot of controversy in both the medical fraternity and the general public. The request comes from the primary caregivers mostly parents in view of not being able to maintain menstrual hygiene and the fear of unwanted pregnancy. Materials & Methods: Twelve Indian mothers of daughters with intellectual disability were interviewed to study their perception regarding the hysterectomy for menstrual suppression. Results: Six mothers had considered hysterectomy due to difficulties related to menstrual cycle whereas another six had not thought about it and were either undecided or did not think it was appropriate. Conclusions: Half of the study population perceived hysterectomy as an option for menstrual cessation. This highlights that service providers should offer appropriate reproductive health education to primary caregivers about various options available for menstrual manipulation. Treatment policies should be clearly defined with the scope for tailoring individual needs.

Keywords: Hysterectomy; intellectually disabled; Indian mothers; perspective.

 Objective: To compare the diagnostic accuracy of Risk of malignancy Index (RMI) with final histopathological diagnosis and to find out the role of RMI in preoperative evaluation of ovarian mass. Materials and Methods: Prospective study with 50 subjects who underwent surgical removal of ovarian tumour and performed histopathological examination in GRH, Madurai for a period of six months from January to June 2018. Results: The best cut off value of RMI was 100 with a sensitivity 96%, specificity 92% and accuracy 94%. Conclusion: The RMI is a simple scoring system and has a high sensitivity and specificity for the detection of malignant adnexal masses. Application of the RMI in clinical practice may provide a rational basis for speciduals to treat patients with adnexal masses before diagnostic surgery.

Keywords: Aadnexal masses; RMI scoring system; Tumour.

Aim: To compare the efficacy and side effects of 800 micrograms rectal Misoprostol with intravenous oxytocin in managing the third stage of labour. Materials and methods: This study was done in 300 women undergoing full term vaginal delivery with or without episiotomy were enrolled to compare to efficacy and side effects of rectally administered Misoprostol with inj.oxytocin for management of III stage of labour. Study was done over a period 2 years, women enrolled and randomly distributed to two groups. 150 women in Group A received rectal Misoprostol and 150 women's in Group B received 10 IU IV oxytocin in drip. Results: Majority of subjects were between 21-26 years in both the groups. Majority of the subjects were primigravida 53% and 52% in Misoprostol group and oxytocin group respectively. Mean haemoglobin in two group was 8.86±1.05 gm/dI and 8.08±0.83 gm/dl in Misoprostol and oxytocin group 1-day postpartum. Mean PCV was 30.71±2.30 (Mean change=1.93±1.97) and 27.58±3.61 (Mean change = 3.77±4.4) respectively in misoprostol and oxytocin group. Duration of III stage in misoprostol group was 11.07±2.49 minutes compared to oxytocin group 11±3.93 minutes.5.33%, 2%, 4% and 2% had shivering, pain abdomen, temperature and diarrhea respectively in group A and 2% & 4.6% had shivering and fever respectively in Group B. All these were minor ailments subsided on their own without any intervention. No case of PPH was reported. Conclusions: Present study justify the use of per rectal misoprostol as an alternative to prophylactic injection oxytocin because of several advantages.

Keywords: Misoprostol, Postpartum haemorrhage, Oxytocin.

 The commonest endocrinological problem in pregnancy is hypothyroidism and affects both maternal and fetal outcome. The aim of the study was to determine the prevalence of hypothyroidism in asymptomatic females presenting for antenatal care and delivery at PMCH situated in Udaipur, Rajasthan, India. This study was conducted from January 2017 to April 2018. A total of 765 patients were included in the study. 651 patients (85.10%) had normal TSH values and 114 (14.90%) had increased TSH values.

Keywords: Pregnancy; Delivery; Hypothyroidism

 Background: This is an era of increasing trend in placenta accreta in modern obstetrics. The aim of this study is to identify the risk factors of such cases, early antenatal diagnosis, peripartum management protocol, and to evaluate maternal and neonatal outcome in tertiary care centre. Method: It is a prospective study conducted for a span of one year from 2017-2018. Result: A total of 15 cases of placenta accreta were identified and studied in Madurai medical college from March 2017 to April 2018. It was found that 40% cases were above 30 years of age, 93% have previous ceaserean section history and 26% have previous dilatation and curettage history. 73% cases underwent hysterectomy, and almost all cases required ICU admission and blood transfusion. One case of bladder injury was reported (6%). Neonatal outcomes include preterm birth (53%), 60% cases required NICU admission. one perinatal death was observed. Conclusion: placenta accreta cases are highly associated with increasing caesarean section rate, high maternal age and repeated curettage. It causes adverse maternal and neonatal morbidity and mortality. Hence prompt antenatal diagnosis with ultrasound and planned management in multidisciplinary setup helps in reducing morbidity and mortality.

Keywords: Placenta accreta; Caesarean section; Hysterectomy; ICU, NICU.

 Postpartum hemorrhage from uterine atony, a major global and local health burden, remains to be a leading cause of maternal mortality. Intravenous oxytocin infusion has become the conventional first-line drug in the active management of third stage of labor in most countries. This, however, has been associated with refractory uterine atony and major hemodynamic side effects; hence the need to explore on the possibility of a better alternative such as intramyometrial oxytocin administration. Objectives: To compare the efficacy of 10IU of Intramyometrial Oxytocin and 10IU of Intravenous Oxytocin in prevention of Postpartum Haemorrhage during Cesarean Section. Settings and Design: A prospective randomised control study was conducted in the department of obstetrics and gynaecology at R.L Jalappa Hospital, Kolar. Methods and Material: Blood loss was considered as the primary measure variable and uterine tone at 1 min and 5 min of oxytocin administration and diasystolic blood pressure at 1 min and 5 mins post oxytocin administration were secondary outcomes measured. Statistical analysis used: Descriptive analysis was carried out by mean and standard deviation for quantitative variables, frequency and proportion for categorical variables. Data was also represented using appropriate diagrams like bar diagram. Results: A total of 186 subjects were included in the study. A total of 92 intravenous and 94 intramyometrial were included in the final analysis. The mean blood loss in ml patient was 624.78±132.85 in intravenous oxytocin group and it was 455.85 ±119.5 in intramyometrial, with a mean difference of 168.93 (p value < 0.001), which was statistically significant. Conclusions: Intramyometrial oxytocin at the same dose as i.v. administration both initiate contractions at similar intervals post administration. Intramyometrial infusion has a better safety profile when assessed using fall in diastolic blood pressure. It also resulted in lesser blood loss when compare to intravenous oxytocin.

Keywords: Oxytocin; Post partum haemorrhage; cesarean section; uterine atony.

Objectives: To reduce the primary caesarean section rate by rescheduling the cerviprime dosing intervals thereby achieving successful vaginal delivery. Methods: A prospective observational case control study was carried out on 70 women undergoing induction of labour between March 2016 to May 2016. In the study group of 50 subjects labour was induced by intracervical dinoprostone where the repeat doses were rescheduled at 0 hr - 24 hrs – 36 hrs, which compared with the control group, which was assigned the conventional induction schedule of 0 hr-6 hrs-12 hrs. In both the groups’ maximum of 3 doses as needed were used. The effectiveness was compared on the basis of rate of successful vaginal deliveries. Results: Successful vaginal delivery was 80% in study group and 40% in conventional control group. p value is 0.005. The difference was statistically significant. Conclusion: By prolonging the interval between the repeat dinoprostone gel inductions, improves the success of vaginal deliveries thereby bringing down the incidence of primary caesarean section.

Keywords: Induction of labour; vaginal delivery; Caesarean section. 

 Background: Caesarean myomectomy for decades has been averted due to the fear of increased chances of haemorrhage and post operative morbidity. However, a number of studies have recently shown that myomectomy during caesarean section doesn’t increased the risk of haemorrhage or post-operative morbidity. Method: 16 cases of Caesarean myomectomy are reviewed here. Myomectomy was done, after delivering the baby by lower segment transverse incision followed by suturing with adequate haemostasis. Results: The incidence of haemorrhage in the study group was 12.5%. There was no significant increase in the incidence of operating time (55 min,) of postpartum fever (18.75%), and length of postpartum stay (4.68 days). No hysterectomy was done for Post Partum Haemorrhage. Amount of blood loss was not associated with the size & number of myomas. Conclusions: This study shows that myomectomy in well selected patients during caesarean section is a safe procedure and is not associated with major intra operative and postoperative complications in experienced hands.

Keywords: Caesarean delivery; Fibroid; Myoma; Myomectomy.

Background: Maternal age plays important role in pregnancy outcome. Aim: To study various pregnancy outcomes in different age group. 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. Women below 19 years were 9.42% and women above 40 years were 3.85%. In them 71.83% women below 19 years had anemia where as 51.76% in the age group 20 – 29 years had anemia. Hypertension and gestational diabetes was more common in women more than 40 years (10.34% & 24.14% respectively). Bleeding problems in pregnancy like APH & PPH was also more common in women aged above 40 years (6.89% in both conditions). Normal vaginal delivery was more in age group 20 – 29 years (96.24%) where as cesarean was more in women aged above 40 years (82.76%). Baby NICU admission was seen more (38.03%) in women aged less than 19 years and there were 2 perinatal death in study group in them 1 was below 19 years and 1 was above 40 years. Conclusion: Maternal age plays important role in pregnancy outcome. One of the methods to reduce perinatal and maternal morbidity and mortality is by educating people about ideal age to have children.

Keywords: anemia; hypertension; preterm delivery; cesarean section.