Neelam Aggarwal

This first paper of the Lancet Series on ending preventable stillbirths reviews progress in essential areas, identified in the 2011 call to action for stillbirth prevention, to inform the integrated post-2015 agenda for maternal and newborn health. Worldwide attention to babies who die in stillbirth is rapidly increasing, from integration within the new Global Strategy for Women's, Children's and Adolescents' Health, to country policies inspired by the Every Newborn Action Plan. Supportive new guidance and metrics including stillbirth as a core health indicator and measure of quality of care are emerging. Prenatal health is a crucial biological foundation to life-long health. A key priority is to integrate action for prenatal health within the continuum of care for maternal and newborn health. Still, specific actions for stillbirths are needed for advocacy, policy formulation, monitoring, and research, including improvement in the dearth of data for effective coverage of proven interventions for prenatal survival. Strong leadership is needed worldwide and in countries. Institutions with a mandate to lead global efforts for mothers and their babies must assert their leadership to reduce stillbirths by promoting healthy and safe pregnancies.

We welcome the global stillbirth estimates published by UNICEF and WHO in October, 2020.1 These data indicate that there are at least 1·9 million stillbirths globally each year. The heavy public health burden of stillbirth has long remained invisible, despite more than a decade of sustained effort to raise it on the global health agenda. Ironically, even the recent BMJ collection,2 highlighting the UN guiding principle "Leave no one behind", omitted any mention of the 26 million women and families who will experience a stillbirth by 2030.

Women with recent gestational diabetes (GDM) have increased risk of developing type 2 diabetes.To investigate whether a resource-appropriate and context-appropriate lifestyle intervention could prevent glycemic deterioration among women with recent GDM in South Asia.This randomized, participant-unblinded controlled trial investigated a 12-month lifestyle intervention vs usual care at 19 urban hospitals in India, Sri Lanka, and Bangladesh. Participants included women with recent diagnosis of GDM who did not have type 2 diabetes at an oral glucose tolerance test (OGTT) 3 to 18 months postpartum. They were enrolled from November 2017 to January 2020, and follow-up ended in January 2021. Data were analyzed from April to July 2021.A 12-month lifestyle intervention focused on diet and physical activity involving group and individual sessions, as well as remote engagement, adapted to local context and resources. This was compared with usual care.The primary outcome was worsening category of glycemia based on OGTT using American Diabetes Association criteria: (1) normal glucose tolerance to prediabetes (ie, impaired fasting glucose or impaired glucose tolerance) or type 2 diabetes or (2) prediabetes to type 2 diabetes. The primary analysis consisted of a survival analysis of time to change in glycemic status at or prior to the final patient visit, which occurred at varying times after 12 months for each patient. Secondary outcomes included new-onset type 2 diabetes and change in body weight.A total of 1823 women (baseline mean [SD] age, 30.9 [4.9] years and mean [SD] body mass index, 26.6 [4.6]) underwent OGTT at a median (IQR) 6.5 (4.8-8.2) months postpartum. After excluding 160 women (8.8%) with type 2 diabetes, 2 women (0.1%) who met other exclusion criteria, and 49 women (2.7%) who did not consent or were uncontactable, 1612 women were randomized. Subsequently, 11 randomized participants were identified as ineligible and excluded from the primary analysis, leaving 1601 women randomized (800 women randomized to the intervention group and 801 women randomized to usual care). These included 600 women (37.5%) with prediabetes and 1001 women (62.5%) with normoglycemia. Among participants randomized to the intervention, 644 women (80.5%) received all program content, although COVID-19 lockdowns impacted the delivery model (ie, among 644 participants who engaged in all group sessions, 476 women [73.9%] received some or all content through individual engagement, and 315 women [48.9%] received some or all content remotely). After a median (IQR) 14.1 (11.4-20.1) months of follow-up, 1308 participants (81.2%) had primary outcome data. The intervention, compared with usual care, did not reduce worsening glycemic status (204 women [25.5%] vs 217 women [27.1%]; hazard ratio, 0.92; [95% CI, 0.76-1.12]; P = .42) or improve any secondary outcome.This study found that a large proportion of women in South Asian urban settings developed dysglycemia soon after a GDM-affected pregnancy and that a lifestyle intervention, modified owing to the COVID-19 pandemic, did not prevent subsequent glycemic deterioration. These findings suggest that alternate or additional approaches are needed, especially among high-risk individuals.Clinical Trials Registry of India Identifier: CTRI/2017/06/008744; Sri Lanka Clinical Trials Registry Identifier: SLCTR/2017/001; and ClinicalTrials.gov Identifier: NCT03305939.

The osteopetrotic, microphthalmic (mi/mi) mouse lacks functional osteoclasts and has also been reported to be deficient in mast cells and natural-killer (NK) cells. The later deficiencies could be secondary to the osteopetrotic marrow, or a direct result of the mi allele. Therefore, heterozygotes were examined for these cell types, since these mice do not exhibit osteopetrosis. Adult +/mi animals have approximately 50%, and mi/mi animals examined by histologic techniques or tissue histamine levels have 0-10%, of the peritoneal, dermal, and intestinal mast cells compared with that of +/+ animals. Leukocyte histamine, indicative of the number of basophils, demonstrates the same pattern. Histamine content per mast cell in +/+ and +/mi animals is identical. The number of large granular lymphocytes (LGL) in splenic leukocyte preparations from +/mi animals is 50% that of +/+ animals, and these cells are undetectable in preparations from mi/mi mice. NK activity against YAC-1 cells paralleled the number of LGL present. The resorptive response of neonatal calvaria to parathyroid hormone was delayed in the case of cultured +/mi bone compared with that of +/+ bone, but the final rate of calcium release was identical. These data indicate that 1) the presence of one mi allele can affect the development of four distinct cell types, and 2) osteopetrosis alone does not account for the lack of mast cells, basophils, and NK cells in mi/mi mice.

Objective: To study maternal and perinatal outcome in congenital heart disease (CHD) and to compare outcome between cyanotic and acyanotic CHD. Method: A retrospective analysis of 196 cases of CHD was undertaken, and maternal and perinatal outcome of pregnancy was compared in cyanotic and acyanotic cases and between surgically corrected and uncorrected cases. Results: Maternal and perinatal outcome was better in the acyanotic group. Maternal complications included higher incidence of cardiac complications in cyanotic group, (33.3% vs 3.4% in acyanotic group, P = 0.001), abruption (12.5% vs nil) and pregnancy‐induced hypertension (16.6% vs 5.2%). Rate of prematurity (25% vs 11.6%), intrauterine growth retardation (50% vs 15.1%, P = 0.003) and abortion (4.1% vs 2.1%) was higher in cyanotic group. Mean gestational age at delivery was better in corrected group, 37.13 vs 34.93 weeks in uncorrected group. There was no case of infective endocarditis. There were four cases of maternal mortality in cyanotic group, two of which were in women with Eisenmenger syndrome. In acyanotic heart disease one case died undelivered and one died on first postoperative day. Conclusion: Maternal and perinatal outcome is better in acyanotic CHD compared to cyanotic CHD. Surgical correction of cardiac lesions prior to conception improves outcome.

Even though pregnancy is rare with cirrhosis and advanced liver disease, but it may co-exist in the setting of non-cirrhotic portal hypertension as liver function is preserved but whenever encountered together is a complex clinical dilemma. Pregnancy in a patient with portal hypertension presents a special challenge to the obstetrician as so-called physiological hemodynamic changes associated with pregnancy, needed for meeting demands of the growing fetus, worsen the portal hypertension thereby putting mother at risk of potentially life-threatening complications like variceal hemorrhage. Risks of variceal bleed and hepatic decompensation increase many fold during pregnancy. Optimal management revolves round managing the portal hypertension and its complications. Thus management of such cases requires multi-speciality approach involving obstetricians experienced in dealing with high risk cases, hepatologists, anesthetists and neonatologists. With advancement in medical field, pregnancy is not contra-indicated in these women, as was previously believed. This article focuses on the different aspects of pregnancy with portal hypertension with special emphasis on specific cause wise treatment options to decrease the variceal bleed and hepatic decompensation. Based on extensive review of literature, management from pre-conceptional period to postpartum is outlined in order to have optimal maternal and perinatal outcomes.

Hot flashes (HFs), defined as transient sensations of heat, sweating, flushing, anxiety, and chills lasting for 1–5 min, constitute one of the most common symptoms of menopause among women though only a few seek treatment for these. The basis of HFs lies in abnormal hypothalamic thermoregulatory control resulting in abnormal vasodilatory response to minor elevations of core body temperature. Recent data suggest an important role for calcitonin gene-related peptide, hypothalamic kisspeptin, neurokinin B and dynorphin signal system, serotonin, norepinephrine in causation of HFs in addition to estrogen deficiency which plays a cardinal role. The mainstay of treatment includes hormonal replacement therapy, selective serotonin, and norepinephrine reuptake inhibitors in addition to lifestyle modification. In this review, we address common issues related to menopause HFs and suggest a stepwise approach to their management.

Abstract Objectives: To study the maternal and perinatal outcome of pregnancies complicated by rheumatic heart disease. Methods: A retrospective study was carried out in the cardio‐obstetric clinic of the Postgraduate Institute of Medical Education and Research, Chandigarh (India) over a period of 13 years (1987–1999) involving 486 pregnant patients with rheumatic heart disease. Maternal and perinatal outcome was reviewed. Results: Three hundred and four patients (63.3%) had single valve involvement and mitral stenosis was the most predominant lesion (89.2%). One hundred and seventy one (38.6%) patients had undergone surgical correction prior to the onset of pregnancy. One hundred and thirteen patients (22.6%) were identified as NYHA class III–IV. Mitral valvotomy was performed during pregnancy in 48 patients. The incidence of preterm birth and small for gestational age newborns was 12% and 18.2%, respectively. There were 10 maternal deaths, of which eight patients were NYHA III and IV. Conclusions: Rheumatic heart disease in pregnancy is associated with significant maternal and perinatal morbidity in NYHA class III–IV patients.

Aim: We undertook this study involving 200 peri- and postmenopausal women to determine the prevalence of osteoporosis, and in turn increase the awareness, education, prevention, and treatment of osteoporosis. Setting and Design: Postgraduate Institute of Medical Education and Research, UT Chandigarh, India, and a clinical study. Materials and Methods: A detailed medical, obstetrical, menstrual, and drug history was recorded in a proforma designated for the study. Height and weight was measured, weight-bearing exercise was assessed, and sunlight exposure per day for each woman was recorded. Food intake was estimated by using the 24-hour dietary recall method, and calcium and vitamin D consumption pattern was assessed. Bone mineral density (BMD) at postero-anterior lumbar spine and dual femurs was assessed by densitometer. Women were classified according to the WHO criteria. Statistical Analysis Used: Student's t-test, multiple logistic regression analysis. Results: The prevalence of low BMD was found in more than half of this population (53%). The mean age in group I (normal BMD) was found to be 50.56 ± 5.74 years as compared to 52.50 ± 5.94 in group II with low BMD (P=0.02). The two groups were similar with respect to parity, education, socioeconomic status, family history of osteoporosis, hormone replacement therapy, and thyroid disorders. 46.8% of the women in group I and 33% of the women in group II had low physical activity and there was no statistically significant difference in sunlight exposure between the groups. Parity or the number of children and type of menopause was not seen to have much association with low BMD in our study. Lack of exercise and low calcium diet were significantly associated with low BMD. Multiple logistic regression analysis showed that age, exercise, menopause, and low calcium diet acted as significant predictors of low bone density. Conclusion: The findings from the study suggest the need for large community-based studies so that high-risk population can be picked up and early interventions and other life style changes can be instituted if there is delay in implementing national or international health strategies to tackle this increasing global health problem. Strategies to identify and manage low BMD in the primary care setting need to be established and implemented.

To study the outcome of pregnancy in women with non-cirrhotic portal hypertension (NCPH).A retrospective analysis of 50 pregnancies in 27 women with NCPH was carried out. Pregnancy outcome was compared in extra hepatic portal vein obstruction (EHPVO) and non-cirrhotic portal fibrosis (NCPF).The mean maternal age was 24.60+/-2.857 years, and the disease was diagnosed during pregnancy in 15 (55.6%) patients. Variceal bleeding occurred in 17/50 (34%) pregnancies and the majority (88.2%) of them responded to endoscopic sclerotherapy. Incidence of variceal bleeding during pregnancy was lower in pregnancies where the disease was diagnosed prior to pregnancy (8.6%), and it was 43.5% in EHPVO and 25.9% in NCPF. The mean birth weight of the neonates was 2668.4+/-427.42 g, and the incidence of abortion, prematurity, small for gestational age babies and perinatal death was 20, 17.5, 12.5 and 20%, respectively. Variceal bleeding during pregnancy was associated with a higher incidence of abortion (29.4%) and perinatal death (33.3%).Variceal bleeding is the most common complication in pregnancies with NCPH. Pregnancies can be allowed and managed successfully in patients with NCPH.

Takayasu's syndrome is a chronic inflammatory arteriopathy of unknown origin which primarily affects women of reproductive age. We report the course and outcome of 37 pregnancies in 15 women with Takayasu arteritis during the period 1999-2008.A retrospective analysis of 9 years was carried out in a tertiary hospital in Northern India. The effect of disease on the course of pregnancy, complications during pregnancy and perinatal outcome were analyzed.Hypertension was the most common presenting feature (27%). In the majority of the patients, vessels involved were the subclavian artery and arch of the aorta. Superimposed preeclampsia complicated 62% of pregnancies while 16% of pregnancies had intrauterine growth retardation. Six patients had preterm delivery and one had preeclampsia and placental abruption. The mean gestational age at delivery was 36 +/- 3 weeks. The majority of the patients had a vaginal delivery. There was one maternal death due to accelerated hypertension and its complications.Adequate control of blood pressure during pregnancy, planning the timing and mode of the delivery and vigilant monitoring during intrapartum period with special reference to management of blood pressure and its complications is essential for an optimum outcome.

Abstract Aim: Maternal complete heart block (CHB), which manifests for the first time during pregnancy and peurperium, poses a challenge to treating physicians. We present here four cases that were diagnosed during pregnancy and peurperium, and we discuss their management issues. Methods: A retrospective analysis of a 3‐year period was carried out in a referral hospital in northern India. The course of pregnancy, disease and perinatal outcome in women with CHB diagnosed during pregnancy was studied. Results: Of the four patients who presented with CHB, only one had a structural cardiac lesion (corrected transposition of great arteries). All of the women had an uneventful delivery. Two women were given prophylactic temporary pacing before labor and three women required subsequent permanent pacing. Intrauterine growth restriction (IUGR) was present in two babies and preterm labor occurred in one patient. None of the neonates had any rhythm disturbances. Conclusion: When a multidisciplinary approach is used, both maternal and neonatal outcomes are good. The incidence of IUGR and preterm birth may be on the increase; hence, clinical vigilance for these conditions is warranted.

Evaluate pregnancy outcome in women with extra hepatic portal vein obstruction (EHPVO).A total of 26 pregnancies in 14 women with EHPVO were evaluated for maternal and perinatal outcomes in a tertiary centre of Northern India. Fourteen pregnancies were evaluated prospectively while the details of 12 previous pregnancies in the same women were studied retrospectively.Mean age of pregnant women with EHPVO was 24.5 years and approximately one-third were primigravidae. Only one patient was diagnosed as EHPVO in the index pregnancy. The presenting event was hematemesis in 71% of the patients; others presented with thrombosis, pain abdomen and jaundice or incidental splenomegaly. The incidence of abortion, preterm deliveries and still births was 20%, 15.4% and 7.7%, respectively. Underlying hypercoagulable and prothrombotic state was diagnosed in around one-fifth of the patients. Half of these women required platelet transfusion in the intrapartum period due to hypersplenism resulting in thrombocytopenia. Anemia was seen in 40% of the patients; however, no other major complications were seen as a result of EHPVO. The vaginal delivery rate and obstetrical outcome were similar as in general population.Pregnancy outcome is expected to be successful in women with EHPVO if disease is adequately controlled prior to pregnancy.

Pregnancy in patients with cirrhosis of the liver is uncommon. We reviewed 9 pregnancies in 7 patients with cirrhosis. One patient conceived within 1 month of diagnosis and in another the disease was diagnosed during the index pregnancy. Four patients has associated portal hypertension and 1 of them conceived after lienorenal shunt. Complications associated with these pregnancies were jaundice (1) jaundice plus ascites (2) and gastrointestinal bleeding (1). In 2 patients endoscopic sclerotherapy was done during the index pregnancy. The incidence of preterm delivery was 50% (4 of 8) and the majority (75%) occurred in pregnancies where associated complications were present. There was 1 maternal death in the postpartum period due to fulminant hepatic failure.

To compare the efficacy of ultrasonographic cervical assessment with Bishop score before induction of labour in predicting the success of labour induction in nulliparous women.This is a prospective study conducted in 138 women who underwent cervical assessment with transvaginal sonography followed by digital cervical assessment using Bishop score before induction of labour. Ultrasonographic parameters evaluated were cervical length, posterior cervical angle and funnelling were blinded to the managing physicians. Statistical analysis was carried out using Mann-Whitney test, chi2 test, receiver operating characteristics curves and logistic regression analysis.Induction of labour was successful in 106 (76.8%) of the women. Multiple logistic regression analysis demonstrated cervical length and posterior cervical angle assessed by transvaginal sonography as independent predictors of successful outcome after induction of labour. Neither Bishop score nor its individual parameters were found to be significant in the regression analysis. The area under the receiver operating characteristic curve for cervical length and posterior cervical angle was greater than that of the Bishop score in predicting a successful labour induction. The best cut-off point for the parameters in receiver operating characteristics curve was 3.0 cm for cervical length and 100 degrees for posterior cervical angle. Cervical length of 3.0 cm had a sensitivity of 84.9%, and a specificity of 90.6% and a posterior cervical angle of 100 degrees with 65% and 72%, respectively.Transvaginal sonographic assessment of cervical length and posterior cervical angle is better than conventional Bishop score in predicting successful labour induction in nulliparous women.

Objective This study was undertaken to analyze the maternal and perinatal outcome in women with prosthetic heart valves on different anticoagulant regimens. Study design A retrospective chart review of pregnancies in 40 women with mechanical valve prostheses at a tertiary referral centre from 1997 to 2010. The main outcome measures were major maternal complications and perinatal outcome. Results The valves replaced were mitral (67.5%), aortic (15.0%), or both (17.5%). Forty-nine pregnancies (72.1%) resulted in live births, 3(4.4%) had stillbirths, and 13(19.1%) had spontaneous abortions and 1(1.4%) underwent therapeutic abortions. The live birth rate was higher in women on heparin (78.3%) compared with those on warfarin (66.9%). There were 2 maternal deaths due to acute mitral valvular thrombosis while on acenocoumarol in the second trimester. Hemorrhagic complications occurred in 3 patients on heparin in the postpartum period, 2 of whom required transfusion. In addition one patient who was on acenocoumarol developed secondary hemorrhage. Conclusion No anticoagulant regimen can be said to be entirely safe for use during pregnancy as there is a degree of risk with each regimen. Further larger studies are needed to come up with sufficient evidence-based recommendations for the best possible management of such patients to reduce the maternal risks after mechanical heart valve replacement without compromising fetal outcome.

The metabolic syndrome (MS) (syndrome X, insulin resistance syndrome) is a constellation of metabolic abnormalities and a complex predisease state that predicts future development of type 2 diabetes mellitus and cardiovascular disease. Menopausal transition and postmenopausal state are considered as a vulnerable period for developing MS, and this increased risk has been attributed to decreasing estrogen levels with an increasing risk of insulin resistance following menopause.This study aimed to determine the prevalence of MS and its components in pre- and post-menopausal women from North India.This is a cross-sectional study of 350 women in the age group of 45-55 years attending gynecology clinic in a tertiary center of North India. Details of sociodemographic data, menopausal history, reproductive, and medical profile were obtained. Then, waist circumference, body mass index (BMI), and blood pressure were recorded. A venous blood sample was collected for fasting blood glucose, triglycerides, total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol. MS was defined according to the modified National Cholesterol Education Program Adult Treatment Panel III criteria.The mean age was 49.09 ± 2.2 years in premenopausal and 49.54 ± 2.8 years in postmenopausal women. The prevalence of MS in the study group was 62.6%. Occurrence of MS was higher in older and obese women. Abnormal waist circumference was the most prevalent component (87%) of MS and in terms of odd ratio, correlation was highest for BMI followed by total cholesterol and waist-hip ratio.We should target obesity and deranged lipid profile by bringing out changes in lifestyle and dietary habits to decrease the higher prevalence of MS and the risk of cardiovascular diseases.

Our study sought to determine the characteristics of antenatal patients with tuberculosis (TB) and their pregnancy outcomes. Case records of 50 antenatal women with extra-pulmonary and pulmonary TB at a tertiary centre in India were compared to 150 antenatal women not suffering from TB, for adverse medical, obstetric and neonatal outcomes. The prevalence of TB was 1.16 per 1000 deliveries. Of these, 62% had extra-pulmonary TB. There were two maternal deaths. TB in pregnancy was associated with a five times higher risk of prematurity and three times higher risk of intrauterine growth restriction than the norm. Maternal prognosis depends on the complications of tuberculosis and treatment compliance.

We reviewed the obstetrical performance and outcome of 15 pregnancies in patients with systemic lupus erythematosus (SLE) (study group) and compared them with 45 age and parity-matched normal pregnancies (control group). Eleven women (73.8%) were in remission phase and 4 (26.7%) had active disease at the time of conception. The time interval between disease diagnosis and the index pregnancy was 4.2 +/- 2.5 years. Two patients with renal involvement had lupus flare-up during the antenatal period. There was no case of lupus flare-up in the postpartum period. Gestational age at delivery was significantly lower in SLE patients (35.9 +/- 2.5 weeks) compared to the control group (37.4 +/- 2.2 weeks). The incidence of intrauterine growth retardation was significantly higher in the SLE patients (40%). There was no case of neonatal lupus or congenital heart block.

Thyroid autoimmunity can have an adverse impact on the outcome of the pregnancy. Although the adverse effects of antithyroid antibodies have been well studied in hypothyroid women, their effects in euthyroid women are not well evaluated.The study was conducted to assess the overall prevalence of anti-Thyroid Peroxidase (anti-TPO) antibodies in pregnant women and the effect of anti-TPO positivity on the outcome of pregnancy in euthyroid women.One thousand Indian women, in their first trimester were screened for anti-TPO antibodies to know the prevalence. Of this, euthyroid women who were positive for the presence of anti-TPO antibody were selected and their obstetric history was recorded. These women were followed up and the incidences of maternal and foetal complications were recorded. The complications were compared with the past obstetric history and outcomes in parity and gestation matched controls (anti-TPO negative).The prevalence of anti-TPO positivity was 11% (n=110). Out of the positives, those with elevated Thyroid Stimulating Hormone (TSH) were 6.5%. The prevalence of euthyroid women who were anti-TPO positive was 4% (n=40). Anti-TPO positive, euthyroid females had a higher prevalence of infertility, anaemia and preterm delivery as compared to the controls (p<0.0001). No differences were observed between the two groups in terms of history of abruption recurrent abortions, intrauterine growth restriction, postpartum haemorrhage, symptomatic hypothyroidism, hypertensive disorders of pregnancy and foetal complications.Anti-TPO positivity is common in pregnant women. Anti-TPO positive euthyroid females had a higher prevalence of infertility, anaemia as well as preterm delivery. Our results indicate that anti-TPO screening in pregnancy, may aid in early identification of the women at risk.

Pregnancy is relatively uncommon in women with portal hypertension. 1 Britton RC. Pregnancy and esophageal varices. Am J Surg. 1982; 143: 421-425 Abstract Full Text PDF PubMed Scopus (89) Google Scholar Reports of pregnancy and successful delivery in patients with portal hypertension are few. 2 Schreyer P Caspi E Mohamad El-Hindi J Cirrhosis, pregnancy and delivery: a review. Obstet Gynecol Surg. 1982; 37: 304-312 Crossref PubMed Scopus (51) Google Scholar , 3 Hassim AM. Pregnancy after venous shunt operation for portal hypertension. Br Med J. 1965; 2: 280 Crossref PubMed Scopus (7) Google Scholar There are a few reports of successful endoscopic sclerotherapy (EST) for variceal bleeding in pregnant women. 4 Salena BJ Sivak MV. Pregnancy and esophageal varices. Gastrointest Endosc. 1988; 34 ([letter]): 422-423 Abstract Full Text PDF PubMed Scopus (15) Google Scholar , 5 Kochhar R Goenka MK Mehta SK. Endoscopic sclerotherapy during pregnancy. Am J Gastroenterol. 1990; 85: 1132-1135 PubMed Google Scholar Endoscopic variceal ligation (EVL), first reported by Steigmann et al., 6 Steigmann GV Goff JS Sum JH Davis D Bozach J. Endoscopic variceal ligation: an alternative to sclerotherapy. Gastrointest Endosc. 1989; 35: 431-434 Abstract Full Text PDF PubMed Scopus (74) Google Scholar has rapidly emerged as the treatment of choice for prevention of recurrent variceal esophageal bleeding. 7 Laine L Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding: a meta-analysis. Ann Intern Med. 1995; 123: 280-287 Crossref PubMed Scopus (632) Google Scholar Gastric (fundal) varices pose a risk of bleeding, 8 Sarin SK Lahoti D Saxena SP Murthy NS Nagawana UK. Prevalence, classification and natural history of gastric varices: a long term follow up study in portal hypertension patients. Hepatology. 1992; 16: 1343-1349 Crossref PubMed Scopus (932) Google Scholar which can be successfully controlled with injection of n-butyl- 2-cyanoacrylate. 9 Soehendra N Nam VC Grimm H Kempeneers I. Endoscopic obliteration of large esophagogastric varices with bucrylate. Endoscopy. 1986; 18: 25-26 Crossref PubMed Scopus (236) Google Scholar , 10 Soehendra N Grimm H Nam VC Berger B. N-butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy. Endoscopy. 1987; 19: 221-224 Crossref PubMed Scopus (187) Google Scholar

Abstract Background. Idiopathic thrombocytopenic purpura commonly affects women of childbearing age and is associated with maternal and fetal complications. Management of a pregnant patient is difficult and requires combined care of obstetrician and a neonatologist. We report our experience of idiopathic thrombocytopenic purpura during pregnancy during the last 7 years. Method. A retrospective study over the 7‐year period 1997–2003 was carried out in the Department of Obstetrics and Gynaecology in the Postgraduate Institute of Medical Education and Research, Chandigarh, India. The course of pregnancy, disease and perinatal outcome of 19 pregnancies in 16 patients with idiopathic thrombocytopenic purpura was studied. Results. Out of 16 patients with idiopathic thrombocytopenic purpura, eight were already diagnosed while the other eight were diagnosed during pregnancy. Five patients diagnosed during pregnancy had severe thrombocytopenia, and four of them showed hemorrhagic manifestation. Nine patients required steroids during pregnancy. Two patients received immunoglobulin therapy. During the antenatal period one patient developed pre‐eclampsia and one patient had gestational diabetes mellitus. Both of these patients were on steroids. There was no postpartum hemorrhage or maternal death. None of the neonates had bleeding complication, irrespective of mode of delivery. Conclusion. Pregnant patients with idiopathic thrombocytopenic purpura have generally good maternal and perinatal outcomes.

Women with cardiac disease have need for effective long-lasting reversible contraception. Women with cardiac disease are at increased risk for bacterial endocarditis. There is limited research regarding the use of intrauterine contraceptive devices (IUD) in women with cardiac disease.In a prospective study, the IUD copper (Cu T200B) was inserted in 40 women with cardiac disease. Infective endocarditis prophylaxis was given 1 h before IUD insertion. The IUD was inserted under aseptic conditions. Ten milliliters of venous blood was obtained for culture of aerobic and anerobic bacteria within 1 h of insertion of the copper T IUD. Women were contacted for follow-up at frequent intervals.There was no incidence of uterine perforation, hemorrhage or spontaneous expulsion of the IUD. All blood cultures were sterile. There were no cases of infective endocarditis. Four women (10%) had menorrhagia at the 6-month follow-up which responded to medical management. One woman had PID for which antibiotics were given. Five women had mild cramps and five had spotting after insertion of the IUD. Patient adherence was excellent as none returned for removal for reasons other than desire for another pregnancy.The Cu T200B IUD is a reasonably safe and effective method of temporary contraception in women with cardiac disease who are not receiving anticoagulant therapy.

Stillbirth is associated with significant physical, psychosocial and economic consequences for parents, families, wider society and the healthcare system. There is emerging momentum to design and evaluate interventions for care after stillbirth and in subsequent pregnancies. However, there is insufficient evidence to inform clinical practice compounded by inconsistent outcome reporting in research studies. To address this paucity of evidence, we plan to develop a core outcome set for stillbirth care research, through an international consensus process with key stakeholders including parents, healthcare professionals and researchers.The development of this core outcome set will be divided into five distinct phases: (1) Identifying potential outcomes from a mixed-methods systematic review and analysis of interviews with parents who have experienced stillbirth; (2) Creating a comprehensive outcome long-list and piloting of a Delphi questionnaire using think-aloud interviews; (3) Choosing the most important outcomes by conducting an international two-round Delphi survey including high-income, middle-income and low-income countries; (4) Deciding the core outcome set by consensus meetings with key stakeholders and (5) Dissemination and promotion of the core outcome set. A parent and public involvement panel and international steering committee has been convened to coproduce every stage of the development of this core outcome set.Ethical approval for the qualitative interviews has been approved by Berkshire Ethics Committee REC Reference 12/SC/0495. Ethical approval for the think-aloud interviews, Delphi survey and consensus meetings has been awarded from the University of Bristol Faculty of Health Sciences Research Ethics Committee (Reference number: 116535). The dissemination strategy is being developed with the parent and public involvement panel and steering committee. Results will be published in peer-reviewed specialty journals, shared at national and international conferences and promoted through parent organisations and charities.CRD42018087748.

The need for respectful bereavement care following a stillbirth has been poorly recognised within global public health initiatives. To date, there has been no comprehensive cataloguing of providers that support parents after stillbirth, nor any review of the challenges they face. We aimed to identify providers (organisations and point persons) that support bereaved parents worldwide and to investigate the challenges they face.&#x0D; A systematic global online search was conducted to identify providers of support after stillbirth. Subsets of providers were surveyed and interviewed. These were purposively sampled to achieve diversity in geography, organisation size and point person role. Challenges in providing support in six key areas – stigma, funding, reach, policy, workforce, and advocacy – were analysed thematically.&#x0D; Overall, 621 providers from 75 countries were identified. No support providers were identified in 123 countries, and in the 6 countries that carry almost half of the global burden of stillbirths, only 8 support providers were found. Support providers faced challenges in accessing funding, reaching key populations, and training and retaining staff, while complex policies hampered bereavement care. Support providers were challenged by silence and stigma around stillbirth. Overcoming these challenges requires collaboration, effort, and political will at local and international scales.

Abstract Objective: To analyse factors associated with maternal mortality in eclampsia and preeclampsia. Method: Retrospective analysis of 69 maternal deaths due to (eclampsia‐61; severe preeclampsia‐8) was carried out during a period of 17 years (1982–1998). Maternal condition on admission, associated complications and principal cause of death was analysed in each case. Results: Mean time interval between hospitalization and maternal death was 49.56 + 62.01 hrs (1–240 hrs). Twenty (28.9%) women died undelivered. Twenty‐three (37.7%) women were in grade IV coma and 52.4% of eclampsia patients had recurrent convulsions (&gt; 10) prior to admission. Associated complications in form of hemorrhage, cerebrovascular accidents, acute renal failure, jaundice, aspiration pneumonia and pulmonary oedema were 30.4, 31.8, 34.8, 18.8, 17.8, and 5.8%, respectively. Maternal mortality in eclampsia was significantly low in time period B (4.1%) when magnesium sulphate was used as an anticonvulsant. Conclusions: Maternal condition on admission and associated complications are the major determinant of maternal outcome. Use of magnesium sulphate is associated with significant reduction of maternal mortality.

Abstract A strong synergism between overbased sulphonate (OBS) and zinc dialkyldithiophosphate (ZDDP) in a proven diesel engine oil formulation has been reported in an earlier communication. 1 In continuation of these studies, the effect of different types of dispersant, of varying nitrogen content, and an antioxidant, on a synergistic combination of OBS‐ZDDP has been investigated. Both detergency and dispersancy of the optimised formulation were improved with high nitrogen‐content dispersants, which also increased strongly the wear tendencies. The antioxidant, though it improved detergency, did not show any positive effect on antiwear performance. Detailed IR and 31 p‐NMR spectroscopic analyses on interactive additive pairs, namely, ZDDP‐PIBS and ZDDP‐antioxidant, indicated the formation of association complexes and hydrogen bonding respectively.

Abstract Aim: Ebstein's anomaly is a rare congenital cardiac abnormality, associated with cyanosis and arrhythmia. Patients often reach childbearing age and pregnant women pose a challenge to the treating physician. We describe the course and outcome of pregnancy in women with Ebstein's anomaly and discuss the related management issues. Methods: Analysis of pregnancies in four women with Ebstein's anomaly was carried out in a referral institute in northern India. Data of two women were analyzed retrospectively and the other two women were prospectively followed in their pregnancies during the study period. The course of the pregnancy, disease and perinatal outcome in each woman were analyzed. Results: Four women had eight pregnancies all resulting in vaginal deliveries. There were two premature deliveries. The mean birth weight was 2.54 ± 0.88 kg. Of the eight babies, six did not have any cardiac anomalies; one was an unexplained neonatal death and for another, no data was available. Pregnancy was well tolerated in two patients, while one had right heart failure during early pregnancy, and one had arrhythmia during labor, which was managed medically; one patient had arrhythmia in the postpartum period, which was managed medically. Conclusion: When a woman with Ebstein's anomaly reaches childbearing age, fertility is not affected, even in cyanotic women. Under close supervision by the woman's obstetrician and cardiologist, the pregnancy outcome is usually favorable.

A prospective study was done in 311 women undergoing induction of labour for the formulation of a new score, which will be more objective than the conventional Bishop's score. Pre-induction cervical assessment was done by the transvaginal sonographic parameters followed by the digital examination. Labour induction was successful in 79.09%. A new score was formulated using the parameters having independent association and weighting of individual components was given according to its regression coefficients. A new score with a maximum value of 13 was proposed. The best cut-off point for the new score in receiver operating characteristics curve was six with a sensitivity of 95.5% and specificity of 84.6%. The new score was found to have a better area under the curve than the conventional score.

To study the blood transfusion practices in women undergoing cesarean delivery at a tertiary care centre in northern India.This was a prospective study conducted in 1769 women who underwent cesarean section at a tertiary centre hospital from May 2008 to November 2009. A comprehensive predesigned proforma was filled in for each woman. Data related to antenatal, intrapartum and postnatal events was recorded and compared between women receiving blood transfusion during cesarean section and women not receiving blood transfusion.The cesarean section rate was 26% and the blood transfusion rate was 12.21%. The overall crossmatch transfusion ratio in our study was 5.46:1. After multiple regression logistic analysis factors, like placenta previa (OR 15.19, 95% CI 9.28-24.82), anemia (OR 9.93, 95% CI 5.17-19.06), blood loss >1000 mL (OR 5.97, 95% CI 4.32-8.24), abruptio (OR 4.18, 95% CI 2.02-8.62), intraoperative complications, like uterine incision extension, uterine atony, hysterectomy (OR 2.69, 95% CI 1.70-4.24), general anesthesia (2.48, 95% CI 1.70-3.61) and inadequate antenatal supervision (OR 1.59, 95% CI 1.05-2.42) were found to be significantly associated with a higher risk for blood transfusion during cesarean section.Routine crossmatching of blood for all women prior to cesarean section needs to be reviewed. Cesarean sections performed on women with high risk factors for blood transfusion can have sudden and significant blood loss and thus adequate blood arrangement prior to cesarean section is justified only in this group of women and not in all women.

Objective To analyse the aetiology of stillbirth and its changing trends in a single tertiary care referral institute of northern India over a 10‐year period (2007–2016). Design Retrospective study. Setting Tertiary care hospital in the north of India. Sample Medical records of all mothers who delivered a stillborn at the institute. Methods Data was collected from monthly and annual perinatal audits and causes of stillbirths were classified using Simplified CODAC classification. Annual reduction rate was calculated by linear regression analysis and Cusick test for the changing trends over 9 years. Main outcome measures Of 54 160 births, 3678 babies were stillborn. Over 9 years, the annual stillbirth rate has reduced significantly from 73.6 to 62.0 per 1000 total births with an average annual reduction rate of 1%. The most common causes of stillbirths were hypertensive disorders of pregnancy (27.6%), antepartum haemorrhage (19.5%), and congenital anomalies (9.3%). Conclusion The annual reduction rate (1%) of stillbirth remains low. The aetiology of stillbirths remains unchanged over a 10‐year period and hypertensive disorder of pregnancy remains the single most preventable cause of stillbirth. Tweetable abstract Analysis of stillbirths over a 10‐year period in an Indian institute showed a high but declining trend with annual reduction rate of 1%.

Background and Aims: Parenteral analgesics and epidural analgesia are two standard options to treat postoperative pain after total abdominal hysterectomy (TAH). Fascial plane blocks such as transversus abdominis plane (TAP) block have gained popularity recently. However, effect of these analgesic regimens on quality of postoperative recovery (QoR) has not been studied. Hence we aimed to assess and compare the QoR with three different postoperative analgesic regimens---parenteral analgesia, epidural analgesia, and TAP block in patients undergoing TAH under general anesthesia. Material and Methods: Sixty female patients undergoing TAH were randomized into three groups of 20 each for postoperative analgesia. Epidural group received boluses of 0.125% bupivacaine for 24 h, parenteral group received injection diclofenac and injection tramadol alternately every 6 h for 24 h, and TAP group received bilateral TAP block with 0.25% bupivacaine at end of operation. QoR was assessed postoperatively by 40-item questionnaire-QOR-40 and pain was assessed by numerical rating scale (NRS). Results: QOR-40 score was comparable across the three groups at 24, 48, and 72 h postoperatively. TAP block prolonged the time to first rescue analgesic (P = 0.02) and reduced the total 24-h postoperative morphine consumption by 2.4 (95% CI: 1.0, 3.8) mg (P = 0.002) and 7.8 (95% CI: 6.4, 9.1) mg (P < 0.001) when compared with epidural and parenteral groups, respectively. Conclusion: The QoR after abdominal hysterectomy is similar with either intravenous analgesics or epidural analgesia or TAP block when used with rescue analgesia to manage postoperative pain. TAP block provides superior analgesia and reduces 24-h morphine consumption when compared with parenteral and epidural analgesia.

To assess the diagnostic accuracy of random urine protein-creatinine ratio for the prediction of significant proteinuria in patients with preeclampsia.155 pregnant patients diagnosed to have hypertension in late pregnancy were instructed to collect urine during a 24-hour period. Protein-creatinine ratio was evaluated in a random urinary specimen. Out of these, 120 patients fulfilled the inclusion criteria. The predictive value of the random urinary protein-creatinine ratio for the diagnosis of significant proteinuria was estimated by using a 300-mg protein level within the collected 24-hour urine as the gold standard.104 patients (86.67%) had significant proteinuria. There was significant association between 24-hour protein excretion and the random urine protein-creatinine ratio (r(s)=0.596, P < .01). With a cut-off protein-creatinine ratio greater than 1.14 as a predictor of significant proteinuria, sensitivity and specificity were 72% and 75%, respectively. The positive predictive value was 94.9% and negative predictive value was 29.2%.The random urine protein-creatinine ratio was not a good predictor of significant proteinuria in patients with preeclampsia.

Mullerian adenosarcoma is a rare biphasic malignant neoplasm of the cervix characterized by an admixture of benign epithelial elements and a malignant sarcomatous stromal component, which may be either homologous or heterologous. An aggressive variant of adenosarcoma, mullerian adenosarcoma with sarcomatous overgrowth (MASO) is extremely rare, with only two such cases being reported in the English literature to date. In this report we present a case of MASO of uterine cervix with heterologous elements in a 15-year-old unmarried girl presenting with foul smelling menstrual bleeding and passage of fleshy masses. Because MASO with heterologous elements seems to appear at the earliest stages of reproductive lifespan in women, and have an uncertain malignant potential, gynecologists and pathologists should be aware and think about the possibility of this tumor.

Liver diseases occurring during pregnancy can be serious and can progress rapidly, affecting outcomes for both the mother and fetus. They are a common cause of concern to an obstetrician and an important reason for referral to a hepatologist, gastroenterologist, or physician. Liver diseases during pregnancy can be divided into disorders unique to pregnancy, those coincidental with pregnancy, and preexisting liver diseases exacerbated by pregnancy. A rapid differential diagnosis between liver diseases related or unrelated to pregnancy is required so that specialist and urgent management of these conditions can be carried out. Specific Indian guidelines for the management of these patients are lacking. The Indian National Association for the Study of the Liver (INASL) in association with the Federation of Obstetric and Gynaecological Societies of India (FOGSI) had set up a taskforce for development of consensus guidelines for management of patients with liver diseases during pregnancy, relevant to India. For development of these guidelines, a two-day roundtable meeting was held on 26-27 May 2018 in New Delhi, to discuss, debate, and finalize the consensus statements. Only those statements that were unanimously approved by most members of the taskforce were accepted. The primary objective of this review is to present the consensus statements approved jointly by the INASL and FOGSI for diagnosing and managing pregnant women with liver diseases. This article provides an overview of liver diseases occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and the recommended treatment options.

To investigate any correlation between plasma levels of lipid peroxides, antioxidant nutrient (alpha-tocopherol) and oxidized high-density lipoprotein (HDL) in patients with gestational diabetes and those with a normal pregnancy and the incidence of pre-eclampsia.Sixty pregnant women attending an antenatal clinic were recruited for the study and were divided into two groups. Thirty women with gestational diabetes mellitus were recruited in the study group. The glucose-tolerance-test criteria, using 100 g of glucose taken orally, as laid down by the American College of Obstetricians and Gynecologists (1994) for diagnosis of gestational diabetes mellitus was used. Thirty gestation-matched pregnant women with normal glucose tolerance test results were recruited as controls. A 10 mL venous blood sample was collected from each subject at the time of recruitment and thereafter at 4 week intervals until the time of delivery. Samples were analyzed for malondialdehyde thiobarbituric acid reactive, oxidized HDL-cholesterol and alpha-tocopherol. The incidence of pre-eclampsia and its correlation with antioxidant and lipid peroxide levels were compared in both the groups.Ten subjects out of 30 in the study group and three subjects out of 30 in the control group developed pre-eclampsia. The incidence of preterm labor in both the groups was same (16.66%). The mean lipid peroxide level was lower in the study group at recruitment and later the levels kept falling, whereas levels of alpha-tocopherol and oxidized-HDL were higher in the study group and kept on rising at follow up.Gestational diabetes is not associated with increased levels of lipid peroxides and decreased levels of alpha-tocopherol.

The objective was to evaluate pregnancy outcome in women with tetralogy of Fallot, including impact of corrective cardiac surgery on pregnancy outcome in a tertiary care referral hospital. The study was a retrospective analysis of maternal and perinatal outcome in all women with tetralogy of Fallot treated in a cardio-obstetric unit during 1996–2008. Ten women had 21 pregnancies. Of the 10 women, 7 with uncorrected tetralogy of Fallot had 16 pregnancies. Obstetric and cardiac complications were more frequent in the uncorrected group (70% vs 40% and 40% vs nil, respectively). The frequency of spontaneous abortion and preterm birth was greater in the uncorrected group (37.5% vs nil and 25% vs nil, respectively). The percentage of babies who were small for gestational age was 40% in the uncorrected group and 20% in the corrected group. Tetralogy of Fallot carries substantial risk to mother and fetus. Surgical correction is associated with improved maternal and perinatal outcome. These patients need detailed prepregnancy evaluation and should be under joint supervision of an obstetrician, a cardiologist, a congenital cardiac surgeon, and an anesthetist.

The potential of soy isoflavones to interfere with thyroid function has been reported. However, there are limited data regarding their effect on thyroid function and autoimmunity in surgical menopausal women. The present study aimed to evaluate the effect of isoflavones on thyroid function and autoimmunity, menopausal symptoms, serum follicle stimulating hormone (FSH) and estradiol levels in oophorectomised women.A randomized, double blind, placebo-controlled trial was conducted in 43 oophorectomised women to evaluate the effect of soy isoflavones (75 mg/day for 12 wk) on serum thyroid profile (free T3, free T4, TSH, TBG and anti-TPO antibody titres) assessed at baseline, 6 and 12 wk after randomization. Assessment was also done for menopause symptom score (MSS) three weekly, and FSH and estradiol levels at baseline and at study completion.There was a significant alteration in free T3 levels in the group receiving isoflavones (4.05 ± 0.36, 4.12 ± 0.69 and 3.76 ± 0.55 pmol/l at baseline, 6 and 12 wk, respectively; P=0.02). However, the mean change in various thyroid parameters at 12 wk from baseline was not significantly different between the two groups. MSS was also significantly decreased at 9 and 12 wk from baseline with isoflavones (12.47 ± 8.15, 9.35 ± 5.23 and 9 ± 5.14 at baseline, 9 and 12 wk respectively; P=0.004) with significant improvement in urogenital symptoms compared to placebo. Isoflavones did not significantly affect other parameters during study period. There were no serious adverse events reported and the proportion of patients experiencing adverse events was similar between the two groups.Modest reduction in serum free T3 levels in the isoflavone group in the absence of any effect on other thyroid parameters might be considered clinically unimportant.

A number of classification system are available to classify stillbirths, but there remains a lack of a uniform global system of classification. This study evaluated the feasibility of the ICD-PM classification system and COD-AC to classify the stillbirths and to discuss the interpretation of “the newer” classification system (ICD-PM) over the COD-AC system. Over a period of one year, out of 5776 total births 314 were stillborns with a stillbirth rate of 54 per 1000 total births. As per ICD PM Classification System, 69.1% of stillbirths were ante partum and rest intrapartum. The associated maternal conditions at the time of foetal death were also classified into five groups and maximum mothers (44.3%) were grouped under M4-medical/surgical disorders. According to COD-AC system of classification 90% of cases were assigned the cause of death, rest 10% remained unexplained. The ICD-PM and CODAC classification both seem to be feasible but ICD-PM clearly defines the time of foetal death and correlates feto-maternal dyad together.IMPACT STATEMENTWhat is already known on this subject? Classifying stillbirths is crucial to recognise the actual cause of foetal death and to gather the relevant information for planning the preventive strategies especially in low middle-income countries (LMICs) which contribute to 98% of total global burden of 2.6 million stillbirths annually. In literature CODAC system was found most suitable for low middle-income countries. In 2016, WHO proposed a newer system, i.e., ICD-PM: WHO application of ICD-10 to deaths during the perinatal period.What do the results of this study add? With ICD-PM classification stillbirths were categorised more clearly in different groups and feto-maternal condition were linked together along with both intrapartum and ante partum stillbirth which can help to set the priorities and future planning for prevention. The proportion of unexplained stillbirth has also reduced significantly compared to CODAC system.What are the implications of these findings for clinical practice and/or further research? CD-PM system of classification seems feasible and would facilitate the uniform and consistent stillbirth data even from LMICs for global comparison although more number of studies are needed for conclusion. The system has been changed to ICD-PM in our institute.

Abstract Acute intermittent porphyria (AIP) is an inherited disorder characterized by partial defects in the heme biosynthetic pathway. Although its association with pregnancy is rare, it presents the obstetrician with challenging problems especially in labor management, as one of the obstetrical life line drugs (methergin) is contraindicated for use in these patients. We hereby present a case of AIP who had an uneventful pregnancy with a good neonatal outcome.

A unicornuate uterus with a rudimentary horn is a rare mullerian abnormality which may cause many gynecological and obstetrical complications. Rupture of pregnant rudimentary horn in the second trimester is the usual presentation, resulting in maternal morbidity and even mortality.

International Journal of Gynecology & ObstetricsVolume 94, Issue S2 p. S139-S140 Rectal misoprostol versus oxytocin in the prevention of postpartum hemorrhage — A pilot study Babita Gupta, Babita Gupta Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, IndiaSearch for more papers by this authorVanita Jain, Corresponding Author Vanita Jain [email protected] Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, IndiaCorresponding author. Tel.: +91 172 275-6352; Fax: +91 172 274-4401.Search for more papers by this authorNeelam Aggarwal, Neelam Aggarwal Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, IndiaSearch for more papers by this author Babita Gupta, Babita Gupta Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, IndiaSearch for more papers by this authorVanita Jain, Corresponding Author Vanita Jain [email protected] Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, IndiaCorresponding author. Tel.: +91 172 275-6352; Fax: +91 172 274-4401.Search for more papers by this authorNeelam Aggarwal, Neelam Aggarwal Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, IndiaSearch for more papers by this author First published: 08 December 2006 https://doi.org/10.1016/S0020-7292(06)60014-3Citations: 10AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References [1]Prendiville WJ, Elbourne D, McDonald S Active versus expectant management in the third stage of labor Cochrane Database Syst Rev 3 2000 CD000007 PubMedGoogle Scholar [2]Khan RU, El-Refaey H Pharmacokinetics and adverse effect profile of rectally administered misoprostol in the third stage of labour Obstet Gynecol 101 2003 968 974 10.1097/00006250-200305000-00025 CASPubMedWeb of Science®Google Scholar [3]Gerstenfeld TS, Wing DA Rectal misoprostol versus intravenous oxytocin for the prevention of postpartum haemorrhage after vaginal delivery Am J Obstet Gynecol 185 2001 878 882 10.1067/mob.2001.117360 CASPubMedWeb of Science®Google Scholar [4]Patel A, Goudar SS, Geller SE, Kodkany BS, Edlawitch SA, Wagh K et al Drape estimation vs. visual assessment for estimating postpartum hemorrhage Int J Gynaecol Obstet 93 2006 220 224 10.1016/j.ijgo.2006.02.014 CASPubMedWeb of Science®Google Scholar Citing Literature Volume94, IssueS2Postpartum Hemorrhage — The Leading Global Cause of Maternal Mortality Proceedings of the International Congress on Evidence Based Interventions to Prevent Postpartum Hemorrhage: Translating Research into PracticeNovember 2006Pages S139-S140 ReferencesRelatedInformation

To assess pregnancy outcome in patients with severe chronic hypertension.A retrospective analysis of a 10-year period (1995-2004) in a referral hospital in northern India. The outcome was compared with those women with mild chronic hypertension who registered in the hypertensive disorders with pregnancy clinic immediately before and after each woman with severe chronic hypertension.Hospital data identified 25 such women. Superimposed preeclampsia (36.4% versus 8%), preterm delivery (86.4% versus 42%), and perinatal mortality (27.2% versus none) were increased in patients with severe chronic hypertension as compared to those with mild hypertension.The small number of cases reflects the lack of antenatal supervision in developing countries. A much larger number of women are referred in the third trimester with eclampsia or severe preeclampsia, at which time it is not possible to identify whether or not they had underlying hypertension. Adverse events were found to occur more often in patients with severe chronic hypertension compared with those with mild hypertension.

Background and Objective: Due to increased risk of uterine rupture with prostaglandins in previous cesarean patients, its use has been discouraged as ripening agent in previous cesarean patients. This study was conducted to compare the efficacy and safety of Foley catheter with low dose oxytocin as cervical ripening agent in women with previous cesarean section (CS). Materials and Methods: This was prospective randomized study, including 60 women (30 in each group) with previous CS with unfavorable cervix who needs induction of labor after 28 weeks. Outcomes were analyzed in terms of change in Bishop score (BS), route of delivery and complications. Results: The BS before and after ripening between the two groups was similar (P > 0.05). However, the change in BS within each group was 3.07 and 3.30 in Foley and oxytocin group respectively and this was statistically significant (P < 0.001). Twenty (66.7%) patients in Foley group had a vaginal delivery and 18 (60%) in oxytocin group did so. There were two cases of scar dehiscence in oxytocin group and non in Foley group. Conclusion: Both Foley and low dose oxytocin are good cervical ripening agents in previous cesarean patients. However, the two cases of scar dehiscence in low dose oxytocin group is a concern of safety.

Objective: Indwelling transurethral catheter is frequently used after gynecological surgeries in order to prevent urinary retention. There is controversy about the ideal time to remove the catheter after surgery. This randomized controlled study was undertaken to determine whether the immediate removal of urinary catheter after abdominal hysterectomy affects the rate of symptomatic urinary tract infection (UTI), recatheterization, subjective pain perception and febrile morbidity. Study Design: This prospective randomized controlled trial included 70 women undergoing abdominal hysterectomy with or without salpingoophrectomy for benign diseases. Patients were divided into two equal groups on the basis of timing of removal of urinary catheter (Group I - Immediate removal after surgery, Group II - Removal after 24 h and evaluated for benefits versus risks of immediate catheter removal. The results were compared by the Chi-square test. Results: Recatheterization was required in three patients of immediate removal group and none in late removal group (P = 0.07). Higher incidence of positive urine cultures (25.9%) and febrile morbidity (10%) was found in Group II when compared to immediate removal group (8%). Pain perception was not statistically different in both groups (P = 0.567). Conclusions: The early removal of an indwelling catheter after surgery was not associated with an increased rate of febrile events, UTI. Pain perception was also lower in early removal group. Although need of recatheterization was higher in early removal group, but not statistically significant.

<br><b>INTRODUCTION:</b> Data on efficacy and safety of levetiracetam (LEV) during pregnancy is still limited. We analyzed efficacy and safety of LEV during pregnancy in North Indian women with epilepsy (WWE) which is being presented here.<br><b>PATIENTS AND METHODS:</b> This retrospective study included 99 WWE (on treatment with a single antiepileptic drug [AED]) who were evaluated in medical-surgical disorder antenatal clinic of the department of obstetrics and gynecology at a tertiary care teaching hospital and referral center in North India. All the obstetric and fetal data as well as data pertaining to epilepsy were noted meticulously.<br><b>RESULTS:</b> In this study (<i>n</i> = 99), 35 women received carbamazepine, 28 received LEV, 15 received valproate (VPA), 13 received phenytoin (PHT), three each received oxcarbazepine and lamotrigine, respectively, and two received clobazam. Although the use of VPA was associated with significantly better control of seizures compared to LEV, its use was associated with higher risk of major congenital malformations (13.3%). The incidence of gestational hypertension was lower while incidence of fetal distress was significantly higher in WWE receiving PHT during pregnancy. None of the child born to pregnant women receiving LEV had any congenital malformation.<br><b>CONCLUSION:</b> LEV is a first-line AED during pregnancy. Future prospective studies using therapeutic drug monitoring during pregnancy may further help in establishing its role during pregnancy.<br>

Studies on pregnancy with rheumatic heart disease (RHD), still common in the developing world, are relatively old and small. This retrospective study was conducted to study the outcome of pregnancy in women with RHD and factors associated with poor outcome. We studied 353 pregnancies in 273 women. In 35% of the patients, the diagnosis was first made during index pregnancy. Women with severe MS had lesser gestational age at delivery and birth weight than those with mild-to-moderate MS. Women with NYHA III-IV status delivered at lesser gestational age had lesser birth weight and had higher perinatal and maternal mortality than NYHA I-II status. Pregnancy outcome was better among women who underwent Balloon mitral valvotomy (BMV) when indicated than those who did not. Cardiac complications were higher in women with severe MS and poor NYHA status. Early booking is important for the optimal outcome. BMV is safe during pregnancy and should be done when necessary.Impact statementWhat is already known on this subject? Rheumatic heart disease continues to be the major cause of maternal morbidity and mortality in developing countries. Most of the recent studies discuss pregnancy with heart disease as a whole with RHD being a part.What do the results of this study add? A large number of women in developing countries conceive with unknown underlying heart disease. Late access to antenatal care is associated with poor outcome. Cardiac and obstetric complications are significantly higher in women with severe mitral stenosis and poor NYHA functional status. Balloon mitral valvotomy (BMV) during pregnancy is safe and technically feasible. BMV averts major complications that may occur due to severe disease. Patients with RHD can undergo labour and vaginal delivery under vigilant monitoring.What are the implications for clinical practice? Thorough clinical examination by the clinician at initial visit is important to detect unknown heart disease. Symptoms pointing towards underlying heart disease should prompt evaluation. This study provides evidence for population-based screening for heart disease in women. Optimal management of compensated mitral stenosis requires weighing the risks and benefits of pharmacological therapy versus BMV in the context of maternal condition. BMV should be performed when necessary.

Abstract Objective To study the feasibility and benefits of closed mitral valvotomy (CMV) during pregnancy. Design Prospective study from 2000 through 2003 to study the effect on maternal condition and perinatal outcome of closed mitral valvotomy during pregnancy were evaluated. Methods Eight pregnant women with severe mitral stenosis refractory to medical therapy had closed mitral valvotomy at different stages of pregnancy (one during labor). Results All patients improved clinically (according to the New York Heart Association classification), and the mitral valve area increased. There was no mortality or major morbidity. Conclusion Closed mitral valvotomy offers excellent results and is cost effective during pregnancy. It is still the procedure of choice in poor countries when balloon mitral valvotomy (BMV) is not affordable.

To assess the usefulness of angiographic embolization in hemorrhage due to gestational trophoblastic neoplasia (GTN).We conducted a retrospective analysis of data of patients with gestational trophoblastic disease within the time period 2002-2008.Eight women with GTN presented with massive hemorrhage during this time period. According to the International Federation of Gynecology and Obstetrics Scoring system 2000, 4 of those patients had high-risk GTN. Vaginal metastasis was present in 50% of the women. All women underwent angiography, and embolization was performed in 7 of the 8 patients. One patient could not undergo embolization due to technical reasons. Two patients underwent embolization of bilateral internal iliac arteries, 4 had bilateral uterine artery embolization and 1 had bilateral uterine and hepatic artery embolization. Embolization was successful in 85.7% of the patients. All patients received chemotherapy: high-risk patients received combined regimen chemotherapy (EMA-CO), while low-risk cases received methotrexate/folinic acid regimen. Out of the 8 patients, 5 are in remission and 3 succumbed to the disease. In 2 women who tried to conceive, 1 delivered a term infant and the other had a miscarriage. The most common side effect of embolization was pain requiring parenteral analgesia.Transcatheter embolization is a safe and quick procedure and should be considered in GTN patients with acute hemorrhagic life-threatening complications.

Controversies persist regarding risks associated with pregnancy and delivery in women with hypertrophic cardiomyopathy (HCM). To date, pregnancy outcome data for these patients is scarce. We report the experience of pregnancies with HCM in a tertiary care hospital.Data regarding cardiac illness and obstetric profile of all women attending the cardio-obstetrics clinic from January 1990 to December 2012 were studied. The records of cardiac illness of all women were checked and all patients with HCM were included in the study.Out of total 2016 patients booked in the cardio-obstetrics clinic between 1990 and 2012, only 4 women were found to have a diagnosis of HCM (0.2%). Of these, 2 women with left ventricular outflow tract obstruction and one with non-obstructive HCM had only mild symptoms and tolerated pregnancy and labour well. One patient had HCM with restrictive physiology developed heart failure and intra-uterine fetal death.HCM is underdiagnosed and rarely identified in pregnancy. Most patients with HCM tolerated pregnancy well, howeverone patient with restrictive physiology developed heart failure during her first pregnancy.

Retained surgical sponges in the peritoneal cavities are an infrequent operative/surgical complication and an error which is avoidable. The unfortunate situation of forgotten or missed foreign bodies after any surgical procedure may lead to medico legal problems. Though gossypiboma can be found at any operative site but intraperitoneal cavity is the most frequent site reported in literature. Over a period of three years, June 2009-2012, we conducted retrospective analysis of case summaries of eight patients who underwent re-laparotomy for retained surgical sponge at our institute. Pre operative diagnosis was made in 7out of 8 patients, 5 of whom underwent re-laparotomy and one had sponge removed through the caesarean incision, while in another it was removed per-vaginum through the open vault (post hysterectomy). In one patient, gossypiboma was an incidental finding on laparotomy done for adnexal mass. There was no mortality in any of the cases.

Congenital uterine arteriovenous malformation (AVM) is an extremely rare condition with &lt;100 cases documented in literature. We report multiparous women presenting to us with a history of postcoital bleed. Initial Doppler ultrasonography was consistent with features suggestive of AVM. Subsequently, computed tomography (CT) angiography confirmed the diagnosis. Embolization was chosen as the treatment because of the large extension of AVM and the risk of hemorrhage during hysterectomy. The patient was discharged in a stable condition with a plan of repeat embolization in the next setting. At 6 and 12 weeks of follow-up, she did not experience any further episodes of bleed. The purpose of this case report is to highlight the salient clinical features, diagnosis, and the management options available for this rare clinical condition.

Stillbirth or neonatal death is one of the most traumatic and distressing life experiences with negative psychosocial effects. Perinatal grief is natural and understandable, and, if not recognized and well supported, may lead to long-term harmful effects. Harm may also be caused to the other surviving siblings, families, and next generation. This can be helped by effective bereavement care. Bereavement care is an area of enormous needs, relatively untraveled road. Though the loss cannot be undone, but a negative impact can be minimized by compassionate supportive care. This chapter will focus on the need of a trained team for effective bereavement care. Principles of evidence-based best practices from the literature will be reviewed and translated into key practice implications. An emphasis is laid on a structured training involving the whole team. We hope this will help in day-to-day situation handling so as to prevent the harm associated with unaddressed grief. Areas of gap with the further need of research are highlighted.

India has the highest number of stillbirths in the world in 2019, with an estimated stillbirth rate of 13.9 per 1,000 births. Towards better identification and documentation, a stillbirth surveillance pilot was initiated with the World Health Organization Southeast Asia collaboration in Northern India in 2014. This study aimed to assess whether stillbirth surveillance is feasible and whether this approach provides sufficient information to develop strategies for prevention.This study followed the framework provided in "WHO Making Every Baby Count" in which mortality audit is conducted in six steps; (1) identifying cases; (2) collecting information; (3) analysis; (4) recommending solutions; (5) implementing solutions; and (6) evaluation.A total of 5,284 births were examined between December 2018 and November 2019; 266 stillbirths were identified, giving a stillbirth rate of 50.6 per 1,000 births in a tertiary care referral hospital of northern India. Out of 266 stillbirths, 223 cases were reviewed and recommendations were formulated to strengthen obstetric triage, implementing fetal growth charts, strengthen the existing referral system and improve the communication skills of health care providers for better compliance with clinical practice guidelines.Conducting stillbirth surveillance review and the response of cases in low-middle income countries setting is feasible. As countries progress towards ending preventable mortality, this has the potential to serve as a key process in improving evidence-based and context-specific planning and preventive strategies towards improving the quality of care.

Peri- and post-menopausal women are vulnerable to suffer from mental health problems including depression, anxiety, and stress, which might have increased during the COVID-19 pandemic.To estimate the prevalence of depression and associated factors among peri- and post-menopausal women during the COVID-19 pandemic in Chandigarh.A community-based cross-sectional study was conducted among 200 urban peri- and post-menopausal women of age 40-60 years in Chandigarh, from May to June 2021. Patient Health Questionnaire-9, Generalized Anxiety Disorder 7, and EuroQol-5D validated tools were used to screen depression, anxiety, and quality of life (QOL). Fear of COVID-19 scale was developed as part of this study was used to assess the fear related to COVID-19 infection. Data analysis was done using the Statistical Package for the Social Sciences (SPSS) software version 26.0. Binary multivariate logistic regression model was used to identify the predictors.The prevalence of depression was 39% and anxiety 29.5% among peri-and post-menopausal women. The fear of COVID-19 infection (adjusted odds ratio [aOR] 8.43, confidence interval [CI]: 1.99-35.64; aOR 10.54, CI: 2.76-40.24) and sleeplessness (aOR 13.29, CI: 3.22-54.82) were the significant (P < 0.005) predictors of depression and anxiety, respectively. Fearful peri- and post-menopausal women (aOR 5.94, CI: 2.68-13.13) and widow status (aOR 7.08, CI: 1.10-45.28) were the significant (P < 0.005) predictors of poor QOL.The prevalence of depression was high among peri- and post-menopausal women during the COVID-19 pandemic. Fear of getting COVID-19 infection was significantly associated with depression, anxiety, and poor QOL.

Despite advances in medical care, we still come across pregnancy in Eisenmenger syndrome. Eisenmenger syndrome represents the severe end of the spectrum for disease in pulmonary artery hypertension associated with CHD. Due to very high maternal and perinatal morbidity and mortality, pregnancy is contraindicated among these women. Current guidelines also recommend that the women who become pregnant should opt for early termination of pregnancy. Here, we present a case series of 11 women of Eisenmenger syndrome and their pregnancy outcome.It was a retrospective analysis of 12 pregnancies among 11 women with Eisenmenger syndrome who were managed in a tertiary care referral centre of Northern India.The mean age of these women was 28 ± 4 years (range 22 to 36 years). Almost 80% of them (9/11) were diagnosed with Eisenmenger syndrome during pregnancy. The commonest cardiac lesion was Ventricular Septal defect (54.5%) followed by Atrial Septal defect (27.3%) and Patent Ductus arteriosus (9.1%). Only three women opted for medical termination of pregnancy, rest eight continued the pregnancy or presented late. Pregnancy complications found include pre-eclampsia (50%), abruption (22%), and fetal growth retardation (62.5%). There were three maternal deaths (mortality rate 27%) in postpartum period.This case series highlights the delay in diagnosis and treatment of CHD despite improvement in medical care. Women with Eisenmenger syndrome require effective contraception, preconceptional counselling, early termination of pregnancy, and multidisciplinary care.

The acardius syndrome occurs with an incidence of approximately 1% of monozygotic twins and one in 34 600 births (1). This condition belongs to the broad spectrum of twin-to-twin transfusion syndrome and is presumed to result from the fused placentation of monochorionic twins, in which vascular anastomoses arise between the arterial circulation of the hemodynamically larger ‘pump’ twin and that of the recipient ‘perfused’ twin. The severity of this syndrome depends upon the type of anastomoses and the timing of their establishment. Circulation is accomplished by the heart of the pump twin who is at risk of heart failure. The perfused twin may display severe and sometimes lethal anomalies, such as acardia and acephalus. The mortality risk of the pump twin has been reported to be 50–75%. Early diagnosis is essential to formulate a plan of management focused on the normal twin. Fetal surgery has been reported to be the best available treatment for acardiac twinning. We hereby report a case of monozygotic twins where one of the twins was acardiac acephalus weighing 67% more than the pump twin and in spite of this, the pump twin did not have congestive failure or hydramnios. Also a review of literature is presented. A 24-year-old woman gravida 2, para 1, was referred to us at 35 completed weeks gestation as a case of twin pregnancy with one malformed fetus. Pregnancy was apparently uncomplicated and a sonogram was advised at 34 weeks due to disparity in fundal height and gestational age. The fundal height was greater than expected. She was then referred with the presumed diagnosis of twin pregnancy with probably one acardiac acephalus fetus. On examination the uterus was found to be distended first presenting as vertex and only one fetal heart was audible. An ultrasound examination at our center revealed a normal fetus with no congenital malformation. The placenta was anterior and fundal. In the upper part of the uterus there was a large amorphous mass that appeared to be adherent to the placenta containing echogenic areas. In the center of this amorphous mass, fetal long bones were noted. There was no evidence of a fetal head or cardiac structure. There was no separating membrane between the twins. A diagnosis of monozygotic twin pregnancy with one fetus with acephalus acardia was made. The patient was admitted and the pregnancy was monitored by biweekly biophysical examination. The pregnancy was terminated at 36 weeks 5-day period of gestation due to poor biophysical profile. After 6 hr of labor, she had a vaginal delivery. The first fetus, a live born girl, weighed 1800 g with Apgar scores of 7 and 9, respectively, at 1 and 5 min. There was no clinical evidence of edema or cardiac failure at birth. Except for right-sided equinovalgus, the neonate did not have any other congenital malformation. The other twin was acardiac acephalus, macerated still born, weighing 3000 g. Normal external female genitalia were present. The upper portion of the torso consisted of a soft globular mass. The spinal column and rudimentary ribs were present. The heart, lungs, head and upper limbs were absent. There were only two toes on each foot (Fig. 1). The placenta was single and weighed 650 g. Both mother and the normal twin were discharged in good condition. Acardiac acephalus fetus The acardius fetal malformation, occurring once in every 35 000 births, was first described in 1533. This rare, lethal malformation of one of twin fetuses has four main types: acardious acephalus, in which there is an absence of the fetal head and thoracic organs; acardius acormus, in which there is development of the fetal head only; acardius amorphus, in which there is only a shapeless mass of tissue without a recognizable human part; and acardius myelacephalus, in which there is a suggestion of one or more extremities and a partially developed head. Acardiac acephalus is the most commonly encountered anomaly. The anomaly is thought to result from an umbilical artery-to-artery anastomosis between twin fetuses in the presence of a fused placenta and referred to as the twin-reversed arterial perfusion sequence (TRAP) (2). Diagnosis of acardia continues to be problematic. Frequently, the acardiac fetus is mistaken for a twin who has died or an anencephalic fetus. The ultrasonographic features of absent head and trunk regions and increased soft tissue in the body aid in correct diagnosis. Recently, pulsed Doppler examination has been used to show reversed flow through the umbilical artery of the acardiac twin (3). The acardiac malformations are uniformly fatal in the affected twin and mortality in the co-twin has been reported to be as high as 55%. The principal problems are congestive heart failure of the pump twin, polyhydramnios and preterm labor. The congestive cardiac failure develops because of the cardiovascular demands placed on the normal twin. In the largest reported series of acardiac twinning, Moore et al. (4) reported that half of the acardiac pregnancies resulted in fetal or neonatal death. Their data suggests that relative weights in acardiac twins provide prognostic information regarding outcome. If the twin-weight ratio was above 70%, the incidence of preterm delivery, hydramnios and pump twin congestive heart failure was significantly greater as compared with when the ratio was less. Congestive heart failure developed in 100% of pump twins when the weight of the acardiac twin exceeded 70% of that of the pump twin. However, in our case no such problem was seen in spite of the acardiac twin's weight being 67% of the pump twin. None of the acardiac pregnancies reported in their series underwent invasive therapies other than therapeutic amniocentesis in four cases. Thus, the finding of 50% mortality provides a standard against which newer management schemes can be compared. The recognition of this abnormality in the antenatal period becomes important from the stand point of management. The early ultrasound recognition of these should afford time to plan a rational management scheme. The management of acardiac twinning involves either a conservative approach with intermittent therapeutic amniocentesis, termination of the pregnancy despite one normal twin or selective early delivery of the abnormal fetus or intrauterine fetal therapy. Review of the literature reveals 22 cases of acardiac twinning treated with invasive procedures, seven of them using endoscopic laser coagulation (5). The goal is interruption of vascular communication between the pump and recipient twins. Mortality of the pump twin with fetal surgery occurred in three (13.6%) in comparison with 50% mortality with expectant management. They concluded that fetal surgery is the best available treatment for acardiac twinning; endoscopic laser coagulation at or before 24 weeks and endoscopic- or sonographic-guided umbilical cord ligation after this gestational age. Because our patient reported at 35 completed weeks and there was no evidence of congestive cardiac failure in the normal twin none of these were considered.

International Journal of Gynecology & ObstetricsVolume 94, Issue S2 p. S137-S138 Full Access A double-blind randomized controlled trial to compare sublingual misoprostol with methylergometrine for prevention of postpartum hemorrhage Preeti Verma, Preeti Verma Department of Obstetrics & Gynecology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, IndiaSearch for more papers by this authorNeelam Aggarwal, Corresponding Author Neelam Aggarwal [email protected] Department of Obstetrics & Gynecology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, IndiaCorresponding author. Tel.: +91 172 277-1121; Fax: +91 172 744-401.Search for more papers by this authorVanita Jain, Vanita Jain Department of Obstetrics & Gynecology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, IndiaSearch for more papers by this authorVanita Suri, Vanita Suri Department of Obstetrics & Gynecology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, IndiaSearch for more papers by this author Preeti Verma, Preeti Verma Department of Obstetrics & Gynecology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, IndiaSearch for more papers by this authorNeelam Aggarwal, Corresponding Author Neelam Aggarwal [email protected] Department of Obstetrics & Gynecology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, IndiaCorresponding author. Tel.: +91 172 277-1121; Fax: +91 172 744-401.Search for more papers by this authorVanita Jain, Vanita Jain Department of Obstetrics & Gynecology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, IndiaSearch for more papers by this authorVanita Suri, Vanita Suri Department of Obstetrics & Gynecology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, IndiaSearch for more papers by this author First published: 08 December 2006 https://doi.org/10.1016/S0020-7292(06)60013-1Citations: 8AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References [1]Kodkany BS, Deeman RJ, Goudar SS, Geller SE, Edlavitch SA, Naik VA et al Initiating a novel therapy in preventing post partum hemorrhage in rural India: a joint collaboration between the United States and India Int J Fertil Women's Med 49 2004 91 96 [2]Lam H, Tang OS, Lee CP, Ho PC A pilot randomized comparison of sublingual misoprostol with syntometrine on the blood loss in the third stage of labor Acta Obstet Gynecol Scand 83 2004 647 650 [3]Vimala N, Mittal S, Kumar S, Dadhwal V Sublingual misoprostol versus methylergometrine for active management of the third stage of labor Int J Obstet Gynecol 84 2004 1 5 [4]Patel A, Goudar SS, Geller SE, Kodkany BS, Edlavitch SA, Wagh K et al Drape estimation vs. visual assessment for estimating postpartum hemorrhage Int J Obstet Gynecol 93 2006 220 224 Citing Literature Volume94, IssueS2Postpartum Hemorrhage — The Leading Global Cause of Maternal Mortality Proceedings of the International Congress on Evidence Based Interventions to Prevent Postpartum Hemorrhage: Translating Research into PracticeNovember 2006Pages S137-S138 ReferencesRelatedInformation

Intrahepatic cholestasis of pregnancy (ICP) is associated with safe maternal outcomes but perinatal outcomes have been variable. We assessed clinical factors and impact of bile acid levels on maternal and neonatal outcomes in ICP.Patients with ICP (defined as pruritus with serum bile acids ≥ 10 mmol/l) were included prospectively with an assessment of risk factors, modes of delivery as well as maternal and neonatal outcomes. Mild and severe ICP were diagnosed when serum bile acid was always <40 mmol/l and ≥40 mmol/l, respectively. Patients with gestational pruritus served as controls.Out of 643 patients, 375 patients (mean age 29 ± 7.6 years, 45.8% primigravida) met inclusion criteria. Pregnancy-induced hypertension [PIH: 10.5%; odds ratio (OR): 4.8; 95% confidence interval (CI): 2.4-8.5; P = 0.0014], gestational diabetes (GDM: 12.5%; OR: 2.6; 95% CI: 2.3-4.1; P = 0.045) and spontaneous preterm labor (15.1%; OR: 2.5; 95% CI: 1.2-3.5; P = 0.040) were higher in patients with ICP. Ursodeoxycholic acid (UDCA) (median dose 900 mg; 600-1800 mg) ameliorated symptoms of cholestasis, bile acid levels and liver aminotransferases in 79% cases. When compared with patients with mild ICP, patients with severe ICP presented at a lower gestational period (26 vs. 32 weeks, P = 0.036), required frequent induction (12.5%; OR: 3.2; 95% CI: 2.1-5.6; P = 0.045) and had increased fetal distress (15%; OR: 1.9; 95% CI: 1.3-4.9; P = 0.048).Overall eight stillbirths were recorded.Severe ICP is associated with a higher incidence of GDM and PIH, risk of pre-term labor, elective induction and stillbirths. UDCA remains a first-line agent in treating ICP.

Uterine arteriovenous malformation (AVM) is a rare condition, with fewer than 100 cases reported in literature.[1] It is seen as heavy vaginal bleeding, which may be postpartum, postabortion, or menstrual and which is usually refractory to conventional therapies. The onset and cessation of bleeding are abrupt, something like the opening and closing of a faucet. Uterine AVMs may be congenital or acquired. Congenital AVMs have multiple vascular connections, may manifest at other sites, and involve surrounding structures, whereas acquired AVMs usually have a single connection between an artery and a vein.[2] Acquired AVMs may be preceded by uterine curettage, cesarean section, gestational trophoblastic neoplasia, or endometrial carcinoma. Pregnancy is thought to play a role in their pathogenesis. Chorionic villi necrosis followed by incorporation of venous sinuses in scarred myometrial areas may lead to formation of an AVM. AVMs are hormone-responsive and congenital AVM may manifest at puberty or after a pregnancy.[3] AVMs may be diagnosed by Doppler ultrasonography, computed tomography, magnetic resonance imaging, and angiography. On hysteroscopic examination, the subsurface of the endometrium appears to have a tangled pulsatile mass of irregular bluish-purple distended vessels that differ markedly from the normal vasculature, which has a fine-capillary net pattern.[2] Management depends on hemodynamic stability and the amount of bleeding as well as on the patient's age and her desire to preserve fertility. Some years ago, hysterectomy was performed for symptomatic AVMs, especially if fertility was not a concern. In the last decade, an increasing number of women have been treated conservatively with success and hysterectomy is no longer considered essential. Acute management includes measures to stabilize the patient, uterine tamponade with Foley's catheter or rolled gauze packing, and medical therapies like estrogens, progestins, methylergonovine, danazol, and 15-methyl-prostaglandin F2alpha.[2,4,5] In stable women, expectant management, surgical removal of an AVM, laparoscopic bipolar coagulation of the uterine blood vessels, and long-term medical therapy with combined oral contraceptive pills are reported.[6–10] Coagulation of the AVM may also be done under hysteroscopic guidance with a neodymium:yttrium-aluminum-garnet laser fiber held several millimeters above the AVM (without touching the AVM) using a power of 50 to 60 watts. Such treatment may be repeated 2 to 3 times (at monthly intervals) until the AVM disappears completely. There are, however, reports of hysteroscopy being abandoned because of heavy blood loss during the procedure and therefore its value is limited.[2] Another treatment modality is selective uterine artery embolization, which has been used successfully for treating AVMs in emergency settings and when other treatment modalities have failed. Although it may not always succeed and subsequent treatment may be required, selective uterine artery embolization is currently considered the treatment of choice in women of all age groups.[2,11,12]

Sustained fetal supraventricular tachycardia (SVT) with a heart rate of approximately 210 bpm may lead to increased atrial and venous pressures and congestive heart failure. There is no clear consensus regarding the best drug-treatment regimens for fetal SVT. However, considerable nonrandomized experience in the transmaternal treatment of fetal SVT is available with a number of antiarrhythmic agents. We report a case of fetal supraventricular tachyarrhythmia with hydrops detected at 32 weeks that was managed with combination of oral digoxin and sotalol and review management guidelines available in the literature.

One of the postulated mechanism for cardioprotective potential of isoflavones is their ability to exert antioxidant action. However, various reports give conflicting results in this area.The present study was conducted with an objective to probe into the cardioprotective mechanism of isoflavones by evaluating their antioxidant potential in oophorectomized women.This was a randomized, double-blind, parallel, placebo controlled study. A total of 43 women were randomized to receive 75 mg/day isoflavones tablet or placebo for 12 weeks. Red blood cell antioxidant parameters including lipid peroxidation, superoxide dismutase (SOD), catalase and glutathione peroxidase (GSH-Px) were determined at baseline and at the end of the study.After 12 weeks of administration of isoflavones, there was no statistically significant difference in lipid peroxidation (P value for isoflavones: 0.37; for placebo: 0.37), catalase (P value for isoflavones: 0.35; for placebo: 0.84), SOD (P value for isoflavones: 0.41; for placebo: 0.28) and GSH-Px (P value for isoflavones: 0.92; for placebo: 0.29). There was no statistically significant difference in the proportion of patients experiencing adverse events in the two groups (P -1.00).The study strengthens the concept that the cardioprotective mechanism of isoflavones might be due to some other reason apart from the antioxidant pathway.

Endometriosis is a common benign disease of reproductive age women, and can involve the intestinal tract. Inconsistent clinical presentation, similar features on radiological imaging and colonoscopy with other inflammatory and malignant lesions of the bowel makes the preoperative diagnosis of bowel endometriosis difficult. We present a case of a 42-year-old perimenopausal female clinically presented, investigated and managed in the lines of carcinoma of sigmoid colon. She underwent terminal ileac resection with end to end anastomoses, Hartmann's procedure and total hysterectomy with bilateral salpingoophorectomy. The histopathological report revealed endometriosis of small intestine, large intestine, mesentery, right ovary and adenomyoma of uterus. Thus, bowel endometriosis should also be considered as differential diagnosis in reproductive age women with gastrointestinal symptoms or intestinal mass of uncertain diagnosis.

To compare maternal and perinatal outcomes in pregnant women with underlying heart disease who underwent induction of labor with those who had spontaneous labor.A total of 50 pregnant women with heart disease who were registered in cardio-obstetric clinic were recruited consecutively between 38-41 weeks' gestation. Patients with favorable Bishop scores at 38 weeks were randomized into two groups. Induction of labor with oxytocin was performed in one group, and the second group underwent spontaneous onset of labor. Descriptive analysis in terms of mean, standard deviation, and percentage was performed. Unpaired t-test was applied for comparison of two groups using SPPS statistical software.No significant difference in the rate of maternal complications was observed between the two groups. No cardiac complications were reported in pregnant females who underwent induction of labor. Fifty-two percent of patients delivered during workday hours when labor was induced, whereas only 24% of pregnant women delivered during working hours who underwent spontaneous delivery. No maternal or neonatal deaths were reported.Induction of labor with oxytocin is a relatively safe procedure in women with heart disease, it does not result in any cardiac complications. More patients delivered during daytime when electively induced, which minimized the maternal and fetal risks because obstetric, anesthesiologist, cardiologist, and perinatologist specialists are readily available during the daytime.

Acardiac twinning, a rare congenital anomaly of monozygotic twin pregnancy, often results from abnormal placental vascular anastomoses. This leads to twin reversal arterial perfusion with complex pathophysiology. Current information on early recognition and treatment for salvation of the normal twin is based on individual case reports in the literature. We report 2 cases of acardiac-acephalus twins and briefly review the relevant literature.

Gangrenous cystitis is now a rare condition with the advent of antibiotics and better obstetric services. It has a multifactorial causation manifesting as urosepsis or peritonitis. We report a case of 24-year-old lady who presented at day 12 postpartum with abdominal distension and vomitings. History of prolonged labour was present. Peritoneal tap was suggestive of pyoperitoneum. Hence she was taken up for emergency laparotomy and incidentally found to have bladder necrosis. Partial cystectomy was done and patient was discharged in a satisfactory condition after 2 weeks.

Objective (s):The aim of the study was to find out the characteristics of emergency obstetric referrals, to evaluate the lapses in the existing referral system and to suggest the plausible solutions to improve the obstetric health care delivery system in India.Materials and methods: This prospective descriptive study was carried out in the Department of Obstertrics and Gynaecology PGIMER Chandigarh India from September 2012 to December 2012.All the obstetric emergency referrals to our institute, a tertiary care centre in North India were critically reviewed for reason for referral, adequacy of care provided before referral, lapses in management, factors behind suboptimal care and remedial measures are suggested.Results: There were 232 emergency referrals available for analysis. Of these 76% patients were referred directly to the institute, the highest level in referral chain in the region. Mean age was 26yrs, 28.6% of the patients were illiterate. In 75.5% of cases, the management of obstetric emergency before referral was suboptimal or poor. In 16% of cases patient failed to seek medical help timely despite emergency. In 40% of cases there was undue delay in referring or failure to provide even the basic care. Anticipated premature delivery and hypertensive disorders of pregnancy were the most common diagnosis at referral.Conclusion: Results from this pilot study shows that in spite of the most extensive health care infrastructure and so- called hierarchal referral system, there is gross inadequacy in referral system in India.Bangladesh J Obstet Gynaecol, 2015; Vol. 30(1) : 25-29

Abstract Background: To study autoantibody titres against oxidized low density lipoprotein in preeclamsia. Methods: Ten millimeters of heparinized blood samples were collected from 20 primigravidae with severe preeclamsia (study group) and 20 gestation‐matched normotensive primigravidae (control group). Concentration of malondialdehyde, metabolite of lipid peroxidation were measured in sera by HPLC and autoantibodies against oxidized low density lipoproteins (obtained after oxidation with 2 mm CuSO 4 ) were determined by ELISA. Statistical analysis was performed by Student's t ‐test and χ 2 test. Results: Mean triglyceride levels were significantly ( P &lt; 0.001) higher in the study group (193.20 ± 31.16 mg/dL) compared to the control group (170.60 ± 23.2 mg/dL). Mean plasma lipid per oxide levels were not significantly different between the study (4.45 ± 1.28 mmol/mL) and control (3.88 ± 0.99 mmol/mL) groups. The majority of women in both groups had low antibody titres (&lt;1.32) against low density lipoprotein. Six women (30%) of the study group and four (20%) of the control group had high autoantibody titres (≥1.32). In preeclamptic women, diastolic blood pressure, the amount of urinary protein excretion and the plasma level of urea were significantly higher ( P &lt; 0.05) in patients with higher auto antibody titre. Conclusion: Titres of autoantibodies to oxidized low density lipoprotein were similar in normotensive and preeclamptic women. In preeclamptic women, titres correlated positively with the severity of preeclampsia.

Swyer-James-MacLeod (SJM) syndrome is a chronic, progressive lung disease as a result of infection and bronchial obstruction that ultimately leads to emphysema. It is associated with chronic cough, sputum production and recurrent chest infections and is occasionally seen in women of reproductive age. The radiological finding of unilateral hyperlucent lung is considered synonymous with the disease entity.

SummaryA randomised prospective trial was carried out to compare the efficacy and safety of intravaginal Misoprostol with intracervical dinoprostone gel for induction of labour in cases of unfavourable cervix. One hundred women with an unfavourable cervix requiring induction of labour were randomised to receive either 25 µm vaginal Misoprostol 4-hourly or 0.5 mg of intracervical dinoprostone 12 hourly. The outcome measured was change in Bishop's score, percentage of women going into labour, induction to delivery interval, need for oxytocin, mode of delivery and complications. The parity, mean period of gestation and Bishop's score were similar in both the groups. The improvement in Bishop's score at 12 h was significantly better in the Misoprostol group. Induction to delivery interval was shorter in the Misoprostol group, 16.59 ± 5.13 h vs 27.77 ± 12.71 h. The rate of complications was comparable. Vaginal Misoprostol 25 µg 4-hourly is safe and effective for induction of labour with shorter induction to delivery interval.

However varicella-associated Guillain-Barre syndrome in the third trimester of pregnancy has not previously been reported. Guillain-Barre syndrome in the third trimester is associated with increased maternal risks of respiratory complications and premature delivery [2]. A 32-year-old primigravida presented with a 10-day history of acute onset, progressive weakness of all four limbs during the third trimester. At the time of presentation to the emergency services, she was unable to bear weight on her legs and had upper limb involvement in the form of difficulty raising her arms above the shoulder or combing her hair. She had developed a mild fever and a generalized vesicular rash all over the body, suggestive of varicella zoster virus (VZV) infection (Figure), 2 weeks prior to the onset of limb weakness. Abdominal examination showed a pregnancy of 32 weeks of gestation with normal fetal movements and cardiac activity. Sonographic examination revealed a single viable fetus corresponding to the predicted gestational age, with no congenital malformation. Nervous system examination of the patient confirmed reduced power of grade 3/5 in the upper limbs, and grade 2/5 in the lower limbs. There was generalized hypotonia and areflexia with bilateral flexor plantar response. The cranial nerves were spared and there was no sensory impairment or bladder or bowel involvement. During her hospital stay, the patient’s weakness progressed over the next 24 hours and she developed bilateral facial weakness; however, her respiratory effort remained good. Electrophysiological studies revealed evidence of demyelinating polyradiculoneuropathy in the form of prolonged distal latencies of compound muscle action potentials, reduced conduction velocities and absent “F” waves. A diagnosis of Guillain-Barre syndrome was therefore confirmed. Cerebrospinal fluid (CSF) contained 5 cells/μL; proteins, 72 mg/dL (normal, 15–45 mg/dL); and sugar, 64 mg/dL (normal). Serum VZV complement fixation antibody titer was 1:128; however, polymerase chain reaction of VZV in the CSF was not performed. The patient was treated with intravenous immunoglobulin (IVIg) therapy at dose of 2 g/kg (a total of 100 g) in divided doses, administered over 5 days. Her neurologic condition stabilized over the next few weeks, with improvement in muscle power. The patient was kept under observation in the hospital and repeated neurologic examinations were performed, with regular monitoring of respiratory functions. Her pregnancy was supervised, with regular clinical and ultrasound examinations to monitor fetal

Thrombotic thrombocytopenic purpura (TTP) occurs more commonly in women and so can be associated with pregnancy. The time during pregnancy with greatest risk for development of TTP is near term and during the post partum period. TTP occurring in early trimester is uncommon and is also associated with great maternal and fetal mortality. We report a successful outcome of pregnancy in a woman with TTP in early first trimester who was treated with therapeutic plasma exchange.

Myasthenia gravis is an acquired, autoimmune neuromuscular disorder characterized by voluntary muscle weakness. Pregnant patients may have disease exacerbation, respiratory failure, crisis, adverse drug reaction, surprisingly enough remission at any trimester or postnatal period. Concurrence of myasthenia gravis with severe preeclampsia is a dreadful condition raising diagnostic and management issues. We hereby discuss a case of myasthenic woman who developed severe preeclampsia during pregnancy and presented in last trimester with clinical features mimicking signs of impending eclampsia. Keeping in mind the history of myasthenia gravis, urgent neurology review taken and diagnosis of myasthenic exacerbation was entertained. She responded well to injection neostigmine and in this way inadvertent use of magnesium sulphate was avoided.

Background: To compare the safety &amp; efficacy of oral nifedipine with transdermal nitroglycerin in the inhibition of preterm labour.Methods: This study included 84 women in preterm labour, randomly divided into two groups, 43 receiving oral nifedipine and 41, transdermal nitroglycerin (NTG). Patients in preterm labour with a single gestation, between the 26th and the 34th week and no contraindication for tocolysis were selected. Women with fetal malformation and medical or obstetric diseases were excluded. The variables analyzed were: delay in delivery for 48 hours, 7 days or more than 7 days, period of gestation at delivery, side effect profile of drugs &amp; neonatal outcomes.Results: Mean prolongation of pregnancy with NTG (29.04 days) was similar to that of nifedipine (34.46 days). Nifedipine was significantly more successful in prolonging pregnancy beyond 48 hours, especially in women with advanced cervical dilatation (&gt;3 cm). Failure of acute tocolysis, defined as delivery within 48 hours, was significantly more common with NTG (31.7 %) as compared to nifedipine (11.6 %). Headache was significantly higher in the NTG group (41.5 %) compared to nifedipine group (4.7 %). The neonatal outcomes in terms of the mean birth weight, incidence of low birth weight and very low birth weight babies, need and duration of neonatal intensive care was similar in both groups.Conclusions: Oral nifedipine is a safe and effective tocolytic with a lower failure rate and better side effect profile as compared with transdermal nitroglycerin.

The objectives of the study were: (1) to determine if there is a change in pattern of antiepileptic drug (AED) prescription during pregnancy in women with epilepsy (WWE) attending a tertiary care institute in North India and (2) to determine if change in AED prescription pattern has resulted in improved fetal and maternal outcomes in WWE.The current study was a retrospective analysis of records of WWE attending a medical and surgical disorder clinic of obstetrics and gynecology department of a tertiary care teaching hospital in North India. We retrospectively collected data of all the patients during the 5-year period from 2011 to 2015 (Group A) (n = 177) and compared it with our previously published data during the years 1987-1994 (Group B) (n = 219).There was significantly higher use of (i) levetiracetam (LEV) in Group A compared to Group B when women on monotherapy were compared (P<0.0001) and (ii) LEV (P<0.0001), clobazam (P<0.0001) and lamotrigine (P=0.0004) in Group A compared to Group B when women on polytherapy were compared. A significantly higher (P=0.02) number of women were using more than two antiepileptic drugs simultaneously in Group A compared to Group B. There was a significantly higher incidence (P = 0.001) of small for gestational age babies in Group A.Although there is an increase in the use of newer AEDs in WWE during pregnancy in North Indian population, it has not resulted in improved maternal and fetal outcomes. (2) to determine if change in AED prescription pattern has resulted in improved fetal and maternal outcomes in WWE.

Abdominal pregnancy is defined as an implantation in peritoneal cavity, exclusive of tubal, ovarian, or intraligmentary pregnancy.These pregnancies are rarely encountered and can go undiagnosed until advanced period of gestation [1]. Frequency of abdominal pregnancy has been directly related to the frequency of ectopic gestation as constituting 2% of ectopics and nearly 0.01% of all pregnancies [2-4]. These pregnancies are seen more commonly in developing countries and poses special challenges to the clinician. Advanced abdominal pregnancy is life-threatening condition and carries high risk of hemorrhage, disseminated intravascular coagulation, bowel injury, and fistulae [5]. The perinatal outcome is mainly influenced by the availability of blood supply and site of implantation [6]. Most of the fetus die in utero because of compromised environment, and those who survive face problems due to congenital malformations [3,7]. Patients of abdominal pregnancy can have variable clinical presentation, and physical examination may be inconclusive for making diagnosis [7,8]. Clinical features like irregular bleeding per vaginum, abdominal pain, dyspepsia, altered bowel habits, malpresentation, and extremely anteriorly placed cervix should raise the suspicion [2,3,8,9]. Diagnostic challenge with oxytocin stimulation, abdominal x-ray, hysterosalpingography, and ultrasonography has been used as tools to assist in diagnosis [10,11]. Magnetic resonance imaging is found to complement sonography in making accurate diagnosis and can be useful to demonstrate the relationship between fetus, the cervix, and the myometrium [12]. We hereby report a successful operative delivery of a live baby after a term extrauterine abdominal pregnancy in a multigravida in whom the diagnosis was made after laparotomy.

Maternal genital infections, particularly bacterial vaginosis has been implicated as a cause for preterm labour and adverse pregnancy outcomes. This prospective study aimed to study the association of bacterial vaginosis with preterm labour. The prevalence of bacterial vaginosis was studied in 60 women in preterm labour who had no recognisable cause for prematurity and in 60 term labour controls. Demographic factors, pregnancy outcome and reproductive history were also studied. Vaginal specimens for Gram-stain and culture were collected from posterior vaginal fomix and bacterial vaginosis was defined by evaluation of Gram-stained smear by Spiegel criteria. Bacterial vaginosis was diagnosed in 31.6% of women in preterm labour and in 15% of term labour controls ( p<0.05). In preterm labour group, preterm delivery occurred in 48 women (80%) out of which 18 women had bacterial vaginosis and term delivery occurred in only one woman with the condition. Anaerobes were significantly associated with bacterial vaginosis ( p<0.01) and were more common in women with preterm labour ( b>0.05). The results indicates that bacterial vaginosis has a significant association with preterm labour and adverse pregnancy outcome.

Rheumatic mitral stenosis is the common valvular heart disease seen during pregnancy. Percutaneous transvenous mitral commissurotomy is an effective, safe, and recommended treatment for critical mitral stenosis during pregnancy. We hereby report the maternal and fetal outcomes of pregnant women subjected to percutaneous trans- venous mitral commissurotomy at our institute.Seventy consecutive pregnant women with critical mitral stenosis, who under- went PTMC during the last 10 years, were retrospectively analyzed. All patients had a detailed clinical and obstetric evaluation and were optimally managed with drugs, before the intervention. A comprehensive pre- and post-percutaneous transvenous mitral commissurotomy transthoracic echocardiographic evaluation was performed. Detailed obstetric and fetal outcomes were noted at the time of delivery. Six weeks of post-partum follow-up was noted in all patients.The mean gestational age at the time of percutaneous transvenous mitral com- missurotomy was 29.5 ± 6.68 weeks. Percutaneous transvenous mitral commissurotomy was successful in 97% of patients. Post-percutaneous transvenous mitral commissurot- omy New York Heart Association functional class, mitral valve area, trans-mitral pres-sure gradient, and left atrial pressure had a significant improvement (P < .001). The mean gestational age at the time of delivery was 36.92 ± 3.02 weeks. The mean birth weight of live newborn was 2.29 ± 0.55 kg. The fetal complications include growth restriction in 62.85%, preterm delivery in 34.37%, and low birth weight in 67.21%. A delayed percutane- ous transvenous mitral commissurotomy at about 30 weeks of gestation did not affect the maternal and fetal outcomes.Percutaneous transvenous mitral commissurotomy is safe and efficacious in managing pregnant women with critical mitral stenosis. There was a significant improve- ment in clinical symptoms and echocardiographic parameters following percutaneous transvenous mitral commissurotomy.

A 28-year-old multigravida was referred to us at 20 weeks' gestation with ultrasound diagnosis of twin pregnancy showing one hydatidiform mole and a co-existing viable fetus. She had hyperemesis and spotting per vaginum for the past 15 days. She had hemoptysis and had developed features of hyperthyroidism with the possibility of developing a thyroid crisis. On examination she was found to be anemic. There was tachycardia and the blood pressure was normal. Uterine height was 26 weeks. Investigations revealed hemoglobin (Hb) 8.3 g% with a microcytic normochromic picture. β-Human chorionic gonadotropin (β-hCG) was 150 000 mIU/mL. Free triiodothyronine (T3) and thyroxine (T4) were high, thyrotropin (TSH) was 0.12 IU/mL. A radiograph of the chest was found to be normal. Ultrasound showed one normal viable fetus corresponding to 20 weeks and a hydatidiform mole below the fetus. The medical treatment comprised carbimazole, dexamethasone and propranolol, and surgical evacuation was planned in view of continued bleeding per vaginum and medical complications. After arranging adequate blood, an oxytocin drip was started and at about 3–4 cm dilatation suction evacuation was performed and the molar tissue was evacuated followed by delivery of the fetus by pulling upon one leg. The other placenta was normal. Bleeding was controlled by injection of carboprost and 3 units of blood were transfused. Histopathologic examination confirmed a complete hydatidiform mole with a chromosome complement of 46 XX. Post evacuation the patient remained well and was discharged on the third day. She was followed up by serial weekly measurement of β-hCG levels, which came down to normal within 8 weeks. A 1-year follow-up has shown negative β-hCG and thyroid function status is normal (T3 1.4 ng/mL, T4 110 ng/mL). Twin pregnancy consisting of a complete hydatidiform mole and a normal co-existing fetus is rare (1). Such a pregnancy is distinguished from a partial molar pregnancy because there are two concepts; a normal placenta attached to the fetus and a molar gestation. The management guidelines for decision making are limited as there are only a few published reports in the literature and most are case reports. Ultrasound helps in the antenatal diagnosis of this peculiar condition (2). The condition has been described in association with fertility therapy (3,4), implying thereby that continuation of pregnancy is desired in such cases. The optimal management in such cases is not well established because of the paucity of literature. Vejerslev (1) described management of 113 pregnancies with mole and co-existent fetus in his review. He reported persistent trophoblastic disease in 19.2% of pregnancies interrupted at diagnosis and 9.1% in those who intended to continue. Clinical problems in such pregnancies included vaginal bleeding, toxemia and excessive vomiting. Fishman et al. (5) reported outcome of seven twin pregnancies consisting of a complete hydatidiform mole and a co-existing normal fetus. Only two of these women delivered viable infants at 26 and 34 weeks; interruption of pregnancy was required in the rest because of excessive bleeding. Four of these seven needed chemotherapy for treatment of nonmetastatic gestational tumors. In a study (2) at the New England Trophoblastic Disease Center (NETDC) comprising eight well-documented cases of twin pregnancy with a co-existent fetus, it was shown that these patients are at higher risk for developing a persistent gestational trophoblastic tumor compared to patients with a singleton complete hydatidiform mole. The presenting symptoms were similar in both of the groups. Thus if pregnancy is desired in such cases, the patient must be counseled regarding complications and risk of a persistent gestational trophoblastic tumor. Careful monitoring during pregnancy, delivery and postpartum follow-up is required. Regarding termination of midgestation molar pregnancies, various options should be considered including surgical evacuation following dilatation with an oxytocin drip or local prostaglandins and also hysterotomy. Adequate blood should be kept available and termination planned at a time when expertise is available to handle any complication if it arises. In our patient, we started with the oxcytocin drip and remained ready for an emergency hysterotomy.

Abstract We report a case of pentalogy of Cantrell with anencephaly diagnosed in utero on 2‐dimensional sonography at 17 weeks of gestation. Due to associated anencephaly, termination of pregnancy was carried out. Histopathological examination confirmed the sonographic findings. © 2010 Wiley Periodicals, Inc. J Clin Ultrasound, 2010

Cold haemagglutination is a primary or acquired autoimmune disease involving antibodies that lead to agglutination of red blood cells at low temperature followed by complement fixation and haemolysis on rewarming. This disease can lead to adverse consequences in patients undergoing cardiothoracic surgery, especially when hypothermic cardiopulmonary bypass is applied. The authors discuss the management of two patients who underwent mitral valve replacement surgery while cold agglutinins were detected in the perioperative period. In the first patient, the diagnosis was made preoperatively followed by administration of glucocorticoids to achieve acceptable level of antibody titers. The second patient experienced haemoglobinuria during her intensive care unit stay. The case report describes the pathophysiology of cold agglutination, relevant laboratory investigations such as antibody titers and thermal amplitude, identification of at-risk patients, and management strategies to avoid serious complications.

With the cessation of estrogen and progesterone at menopause, the hormone withdrawal affects various systems in the woman's body. In earlier days, menopausal hormone therapy (HT) was prescribed for primary prevention of coronary artery disease (CAD) and osteoporosis, which were thought to be because of estrogen deprivation and epidemiologic data supported a beneficial effect of estrogen on the heart and bone. Later on, robust data from the Women's Health Initiative study comparing two HT trials demonstrated adverse outcomes in terms of excess risk of CAD, stroke, venous thromboembolism, and breast cancer. Even with risk stratification based on family history, approximately only 15% of women diagnosed with breast cancer have such a risk factor. This implies that family history will not be elicited in more than 85% of women who develop breast cancer. Literature review suggests that the prior use of conjugated equine estrogen (CEE) alone has the potential to be effective as an intervention, leading to a reduction in mortality due to breast cancer. Therefore, it is time to reevaluate the risk reduction strategies for breast cancer that are currently in practice. In terms of absolute numbers, for every 10,000 person-years of prior use of CEE alone, there would be only two fewer deaths from breast cancer and two fewer deaths secondary to its sequelae. This translates into a significant number of women in our country with a population of 1.38 billion (of which 48%, nearly 650 million, are women).