Indian Journal of Obstetrics and Gynecology

Introduction: Ovarian-cancer is the 3rd mostcommon cancer in Indian-women, accounting for 3% of all malignancies and 6% of deaths from cancer. It is 5th most-common cause of death from malignancy in women.1 Case-presentation: This is a cases-series of 4 cases Case 1 62 year, postmenopausal-woman with abdominalpain and ultrasound report of 109x82x87mm rightovarian-simple-cyst of (410cc), Ca-125 -> 8.50, posted for Laparotomy. A 15x 10cm right- ovarian-cyst removed. Frozen-section -> benign. Histopathology-> serous-cystadenoma Case 2 43-year, nulligravida. With pain-abdomen, posted for laparoscopic-cholecystectomy for gall-bladderpolyp with intraoperative findings of bulky-ovaries with ascitic-fluid showing malignant-cells , Ca-125 -> 66 , ultrasound s/o enlarged (7.6x6.4 cm) right-ovary, .Posted for exploratory-Laparotomy .Bulky irregularovaries removed. Frozen-section ->granulosa-cell tumour, Histopathology-metastatic adenocarcinoma / malignant sex-cord-stromal tumour. Case 3 70-year-old, COVID-19-positive patient referred for ovarian-torsion, with Ca125 - 8.7. Ultrasound -> 66x55 mm left adnexal-cyst with torsion; Posted for leftovariotomy + right-salpingoophorectomy. A 7x7cm left-sided-haemorrhagic-ovarian-Cyst removed. Histopathology -> serous-cystadenofibroma.Case 4 67-year-old postmenopausal-woman with painabdomen, Ca-125-154, ultrasound showing 14 x 7.5cm right-ovarian-complex-cyst, posted for Exploratorylaparotomy, a 15x15 cm twisted-right-ovarianhaemorrhagic cyst removed. Frozen-section->benign Histopathology ->Rt ovary- serous-cystadenoma + torsion Discussion: Ovarian cancer has nonspecificsymptoms resembling those of less serious conditions. Eg. Pain-abdomen. Staging-laparotomy with frozen-section remains the preferred approach for ovarian-tumors. Conclusion: In my case-series 3/4 women were postmenopausal, all presented with vague symptoms of pain-abdomen. Frozen-section may not be conclusive in every case, hence staging-laparotomy is ideal modality of management.

Introduction: Acute fatty liver of pregnancy (AFLP) is a rare, but potentially fatal condition, characterized by hepatic failure typically in the third trimester of pregnancy that is associated with multiorgan involvement resulting in several clinical and laboratory abnormalities. Aim and Objectives: To study the course of acute fatty liver of pregnancy which will help later to early diagnose, prompt delivery, and providing supportive care to improved maternal morbidity and mortality rates. Materials and Methods: The authors report an observational case series of patients who developed acute fatty liver of pregnancy and managed in critical care in a year that illustrated the compound challenges in recognition, monitoring, and management. One of the cases has been imprinted with maternal mortality because of deterioration of the condition leading to sepsis along with multiorgan dysfunction syndrome. Results: A total of three cases of acute fatty liver of pregnancy were found in a year. Nausea, vomiting, and anorexia were the most common symptoms among all. Jaundice and ascites were the most common findings. Deterioration of the condition can lead to complications like sepsis, Disseminated Intravascular Coagulation, multiorgan failure, and death. Conclusions: Early detection, delivery, and supportive care are sufficient to reduce fatality but in cases of deterioration of patients’ condition despite proper management can lead to multiple complications and ultimately mortality. Regular antenatal health check-ups can help in early detection.
 

Ovarian carcinoma is the fifth most common cause of cancer death. It is the second most common gynecologic malignancy in developed countries and the third most common gynecological cancer. There are several intrinsic problems that render ovarian cancer screening difficult. An optimal screening test has high sensitivity, specificity, patient acceptance. The three screening techniques available for ovarian malignancy are: Pelvic examination, Tumor Marker, TVS. Tumor markers are used to screen for or diagnose malignancies, determine prognosis or monitor therapy. Alpha Fetoprotein is tumour marker for Embryonal Carcinoma, Yolk Sac tumour, Immature Teratoma, Sertoli-Leydigs cell tumour. The concept of preventive oncology has been developed to approach cancer problem at various points in evolution with goal of reducing cancer suffering and death.

This article reviews the WHO and CDC guidelines related to obstetrics keeping in view the current Covid-19 pandemic. We are currently facing an unprecedented healthcare crisis caused by the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The infection is spread by human-to-human transmission through droplet and direct contact, causing mild symptoms in the majority of cases, but critical illness, bilateral viral pneumonia, and acute respiratory distress syndrome (ARDS) in a minority. We suggest how personal protective equipment’s (PPE’s) and specific infection control policies related to the risk of viral transmission to the anaesthetists, intensivists and other healthcare workers can be minimised particularly in obstetric patients. Although pregnancy doesn’t appear to exhibit higher susceptibility to COVID-19 than the general population but implementing strict infection control in the maternity department presents unique challenges. Particularly it necessitates decreasing the risk of postnatal transmission from mother to neonate and methods to accommodate emergency patients to labour ward and emergency care with a high patient turnover. Performing routine and emergency procedures for obstetric patients, such as neuraxial anaesthesia, is made more technically difficult and time consuming by wearing a PPE. These new challenges have anaesthetic implications and mandate a change in approach for team working, protocols for perioperative anaesthesia care and infection prevention policies. With limited evidence as of now but antenatal vertical transmission appears to be rare.Placental samples, amniotic fluid, cord blood, neonatal throat swabs and breast milk samples from COVID-19 infected mothers have all tested negative in various case series. There is currently no evidence concerning transmission through genital fluids. Pregnant patients presenting to the emergency room and labour ward should be risk stratified and then screened for covid-19 irrespective of being symptomatic or not before admission and subsequent care provided taking all the precautions. Aerosol generation during labour, particularly when coupled with symptoms secondary to COVID-19 lung sequelae, may increase airborne transmission. For these reasons, surgical facemasks should be worn by the parturient Proper donning and doffing of PPE is paramount for decreasing the risk of transmission of infection for labour epidural, OT’s and obstetric ICU’s and needs creation of space within the older system and newer guidelines and protocols to be implemented in letter and spirit.

The umbilical cord is the fetal lifeline and is the vital link between the fetus and placenta. Various abnormalities are observed in morphology and pathology of placenta. Variations in umbilical morphometry leads to neonatal morbidity and mortality. Vasa previa is one of the insertion anomaly of umbilical cord. Antenatal diagnosis is possible using ultrasonography. Diagnosis of vasa previa should be confirmed with colour or power doppler demonstrating pulsatile flow with fetal vascular waveform pattern. Vasa previa is one of the rare cause of antepartum haemorrhage. What differentiates vasa previa from other etiological factors of antepartum haemorrhage is that bleeding is of fetal origin. Although a rare anomaly, Vasa previa has significant mortality rates and therefore should always be looked for with great precision in antenatal ultrasonography.

Aim: Present study was undertaken with an aim to evaluate the incidence, maternal profile, indications, type, no. of transfusions, matenal outcome and how they are behaving over past 2 years (2018 – 2020) in our Government headquarters hospital virudhunagar. emergency obstetrics hysterectomy remaining an essential weapon in any obstetrics armoury. Methods: Case sheets of emergency hysterectomy for there major indications (resistant atomic PPH, Rupture uterus, adherent placenta) were taken and analyzed. Conclusion: Initially atomic PPH being the commonest indication for peripartum hysterectomy. According to present study rupture uterus being the commonest indication for peripartum hysterectomy,increasing no. of cs nowadays should be the reason for this change.

Background: According to the recent survey done by National Mental Health Survey (NMHS)-2016,it has found, in India every 10th person is suffering from some sort of depression or anxiety and in that 20% were either pregnant or lactating mothers. Research studies done earlier had clearly showed a significant association between maternal stress disorder and altered placental function and epigenetic changes. Aim: To assess the prevalence of psychological disorders among antenatal mothers and the factors influencing it. Methodology: A cross-sectional study was conducted for a period of 6 months in the department of obstetrics and gynaecology in a tertiary care hospital in Salem district. All antenatal mothers in the age group between 18 and 40 years reporting for regular antenatal check-up during the study period were included as our study subjects. A total of 240 study subjects had participated in the study. A semistructured and pretested questionnaire was made to collect the demographic details and the clinical history from the study subjects and along with it depression, anxiety and stress scale assessment tool which consist of 21 questions (DASS-21) with 7 items for each disorder was administered on all the study subjects to assess the presence of psychological disorders in antenatal mothers. Results: The prevalence of stress, anxiety and depression were 52.5%, 47.1% and 27.5% respectively. Most of them had mild stress disorder whereas mothers having anxiety type of psychological disorder majority of them were having moderate to severe type of anxiety disorder. All patients with depressionhad either stress or anxiety as a psychological comorbid condition. Primigravida mothers, mothers with previous history of abortion/still birth, people with history of infertility, history of psychological disorders in the previous pregnancy, history of medical and psychological disorders in the present pregnancy, family history of psychological disorders, history of domestic violence, history related to lack of family and social support and previous history of LSCS were found to be influencing factors for psychological disorders among antenatal mothers. Conclusion: Effective screening measures should be adopted to screen the antenatal mothers for all psychological disorders which would help to identify and manage it earlier and thereby preventing further complications both in mother and the new born.

Introduction: Management of intrauterine fetal death (IUFD) poses dilemma for obstetrician.1 Options for health care are either to await for spontaneous labour or to induce labour.2 Medical consequences of postponing delivery can be significant in view of complications like disseminated intravascular coagulopathy or haemorrhage and even maternal death. Aims and Objectives: To evaluate effectiveness and side effects of repeated vaginal administration of small doses of misoprostol in termination of second and third trimester pregnancies.1 Methods: This study carried out on 100 women with IUFD in second and third trimester pregnancies collected from NMC Medical college, RAICHUR, from October 2017 to October 2019. Patients history taken, physical examination, Bishop scoring assessed. 25µg of misoprostol in the posterior fornix of vagina was placed every 4th hourly over 24 hours. The progress, and outcomes were assessed. Results: The success rate was 92.76% and 64.52% in women with third and second trimesters respectively. The mean induction-delivery interval was 15.67+9.64 and 24.94+8.23. The induction delivery interval correlated negatively with the duration of gestation age. The mean value x of total required dose of misoprostol was 192.42 +128.99 and 361.29 + 139.92 for 2nd trimester and 3rd trimester women. Conclusion: Low dose Misoprostol appears safe, effective, practical and inexpensive method for termination of third trimester pregnancies compared to second trimester pregnancies complicated with Original Research Article Indian Journal of Obstetrics and Gynecology Volume 8 Number 4, October–December 2020 DOI: http://dx.doi.org/10.21088/ijog.2321.1636.8420.7 intrauterine fetal death and its effects increases with duration of gestation.

Background: Abruptio placenta is separation of a normally situated placenta after 20 weeks of gestation and prior to the birth of the foetus. It is an important cause of antepartum haemorrhage and presents as an acute abdomen in the third trimester of pregnancy. The study was aimed to find out the incidence, obstetric risk factors, and various complications of abruptio placenta and to analyze the maternal and perinatal outcome of the same. Materials and Methods: The retrospective observational study was carried out in the obstetric department in CG hospital attached to JJM medical college, Davangere between October 2017 and September 2018. Results: Out of 9800 deliveries there were 64 cases of abruptio placentae. The incidence of Abruptio placentae was found to be 0.65%. Associated risk factors were preeclampsia (45%), previous caesarean section (18.6%). PPH occurred in 13(20%) of patients.22 (34%) of patients required blood transfusion. Eighty five percent (85%) babies required NICU and 54% had early neonatal death. Conclusion: Abruptio placenta is associated with poor maternal and fetal outcome. Hence early diagnosis and prompt resuscitative measures would prevent both perinatal and maternal mortality and morbidity.

Background: Preterm labour defined as less than 37 weeks of gestation is responsible for most of the neonatal morbidity and mortality worldwide. This study was conducted to estimate the relation between C reactive protein (CRP) with preterm labour. Method: This prospective observational cohort study was conducted from February 2018 to January 2019 at Obstetrics and Gynecology department of Srimati Heera Kunwar Ba hospital, Jhalawar Medical College, Jhalawar, Rajasthan with 150 outpatient singleton pregnant women of <20 weeks of gestation enrolled at the prenatal visit. Baseline data and serum CRP values were taken in all participants. Conventional statistical methods were used for analysis. Result: We discovered measurably critical contrasts in the CRP levels estimated in early pregnancy between the women delivering preterm and those delivering at term. The baseline cut off value for maternal CRP was 5.5 mg/l with sensitivity of 100%, and specificity of 95.7%, positive and negative predictive value for serum CRP to predict preterm labour were 95.8 % and 99.2% respectfully. Conclusion: Maternal serum concentration of CRP can be utilized as fitting biomarker for foreseeing preterm delivery.

Introduction: Hypertensive disorders in pregnancy are a major cause of maternal and perinatal morbidity and mortality worldwide. Modified biophysical profile (MBPP) combines Non stress test as a short term marker of fetal status and the amniotic fluid index as a marker of long term placental function which is easier to perform and less time consuming. Aim: To study the antepartum fetal surveillance with modified biophysical profile and perinatal outcome in pre-eclamptic women. Materials and Methods: Prospective descriptive study of perinatal outcome included 150 ANC patients gestational age between 34 to 40 weeks both primi gravida and multigravida with pre-eclampsia admitted in SMIMER hospital during January 2017 to June 2018. Patients were treated in line with standard protocol and perinatal outcome were then studied. Results: Of the 150 NST’s in MBPP, 77% were reactive and 23% were non-reactive. When the MBPP was abnormal with respect to both parameters 60% of the cases had LSCS and 40% of them had vaginal delivery. When both parameters were normal there were only 3.63% cases were MSL. When NST was abnormal and AFI normal 45.45% cases were MSL and when NST was normal and AFI abnormal 42.8% cases were MSL. When both the parameters were abnormal 63.6% of the cases had APGAR <7 `whereas when NST was normal and AFI was abnormal 2(28.5%) the cases had APGAR <7. When AFI was normal and NST was abnormal 36.3% of the cases had APGAR <7. Conclusions: Modified biophysical profile (MBPP) is easier, less time consuming, cost effective and patient compliant test.
 

Introduction: Placenta previa unpredictable obstetric emergency substantially contributing to maternal morbidity and mortality. Aim: To Determine the Maternal and Neonatal outcome associated with Placenta Previa. Materials and Methods: A Retrospective observational Hospital based study, conducted in the Department of Obstetrics and Gynecology of Bharati Hospital, Pune from March 2019 to September 2020. Results: Out of 20 cases studied 3 were Morbidly Adherent Placenta, out of these two underwent Hysterectomy. Placenta Previa risk increase with scarred uterus and increase linearly with number of prior caesarean sections and curettage. In present study 38.8 % of all cases present with massive PPH, 33.3% of these require massive blood transfusion. Newborns are most likely to be lowbirth weight due to increase in incidence of preterm delivery with placenta previa. Out of these 20 cases, 2 patients were missed on ultrasonography and were diagnosed on table. Conclusion: Placenta previa is a medical emergency, with timely diagnosis and proper management associated complications can be prevented. There is significant relationship between placenta previa and scarred uterus, this risk becomes very high with escalation in a number of cesarean sections. Clinical significance: In present era with increasing number cesarean sections number of placenta previa cases and associated complications require obstetricians on toes to manage these deadly complications. Timely diagnosis along with judicious expectant management with blood transfusion is required, and timely delivery can lead to the most favorable outcome.

Objectives: To assess the efficacy of oral micronized progesterone SR 300 in preventing preterm labour after arresting it, with changes in dosage timing. The main purpose of this study is to find out whether there is a clinico pharmacological correlation if same drug is given at different timings Materials and Methods: Prospective randomized study was done at our institution. Total sample size of 130 women who came in preterm labour and process of preterm labour was arrested with Tocolytics were included in the study group. Sample was divided into 2 groups of 65 womens in each group in view of prevention of preterm labour. One group was given MNP SR 300 at 9am and 2nd group was given MNP SR 300 at 9pm by oral route. They were studied for the difference in maternal outcomes like prolongation of gestational age at delivery and neonatal outcome like birth weight, maturity, morbidity and mortality. Results: Both the group were comparable with respect to age and parity. Our study showed that there was no statistically significant difference with respect to maternal and fetal outcome with changes in timings to two groups who were given MNP SR 300 orally at 9am and 9pm. Conclusion: More studies on big samples are recommended to further analyse our results, since this the only study till date.

Background: For Endometrial biopsy Pipelle sampling can be done as an office procedure. In this study Pipelle is being studied in terms of specificity and sensitivity for diagnosis and for replacing other methods of sampling. Methods: 60 patients underwent pipelle endometrial sampling on OPD basis followed by hysteroscopic evaluation and endometrial sampling in the same menstrual cycle . Histopathology report of both the pipelle and hysteroscopic endometrial samples were compared and statistical analysis done. Results: In subjects with proliferative Endometrium in Hysteroscopy 93.9% were diagnosed by pipelle sample, In Secretory Endometrium in Hysteroscopy, 83.3% were diagnosed by pipelle sample, Out of 33 subjects with Disordered Endometrium in Hysteroscopy, 100% were diagnosed by pipelle sample. In the sample Hyperplasia in hysteroscopy, 100% were diagnosed by pipelle sample. In samples without simple Hyperplasia in Hysteroscopy, 98.3% were negative in pipelle sample and 1.7% were positive in pipelle sample (False Positive). In Adenomatous Polyp in Hysteroscopy 20% were diagnosed by pipelle sample and 80% were negative (False Negative). In Cystoglandular Hyperplasia in Hysteroscopy, 100% diagnosed by pipelle sample. Conclusion: Pipelle is 100% sensitive in diagnosing premalignant changes in the endometrium. Hence pipelle, a cost effective non-invasive procedure, can be used as a first line method to diagnose endometrial pathology in abnormal uterine bleeding.