Aim: Aim of our study is to demonstrate that modified O'Connor's technique is possible and feasible for all types of postobstetric and gynecological procedures vesicovaginal fistula (VVF). Materials and methods: The study of 38 patients includes 34 primary and four recurrent (operated primarily elsewhere) type of VVF treated by modified O'Connor technique with omental flap interposition between January 2009 to June 2016 by a single surgeon. Patients were followed postoperatively at 3 weeks, 3 monthly for 6 months and later depending on symptoms. Results: Common age group in our study between 30 years and 40 years (50%). Twenty-eight patients had simple fistula while 10 had a complex fistula. Fistula size ranges from 5 mm to 4 cm with the most common size ranges between 1 cm and 3 cm (28 patients). Thirty-three patients had a single fistula and 5 had two fistulae includes one patient of asymptomatic vesicoperitoneal fistula. The most common cause of fistula was posthysterectomy, for benign diseases (25 cases). the most common site was supratrigonal (28 cases) and in 10 cases involving either trigone or infratrigonal area. All patients were dry following catheter removal. The success rate of the technique was 100%. There was no perioperative complication except one patient had mild stress urinary incontinence (SUI), one had recurrent urinary tract infection and three had storage lower urinary tract symptoms (LUTS). Conclusion: Modified O'Connor repair is safe and gives excellent functional results in postobstetrics and gynecological procedures related to VVF. Selection of technique should depend on experience and preference of surgeon which gives maximum success rate. Summary: Is one approach sufficient for all types of VVF following postobstetric and gynecological cause?

Background: Maternal health is an indicator of the development status of a country. Reducing the maternal mortality ratio needs better maternal health services delivery and management of the factors at the community level. Aims: To explore the factors that contribute to maternal health in Hamirpur district of Himachal Pradesh in North India Materials and methods: A qualitative study using focus group discussion was conducted among women. Interviews were semi-structured, thematic and included open-ended questions. Interview topics included support and care of the family, the importance of male child, problems faced in the hospital during an antenatal checkup, knowledge of danger signs during pregnancy and preference of place of delivery. Results: One core category emerged, ‘factors that affect maternal mortality, which connected the categories ‘community-level factors” and ‘hospital-level factors’. Barriers to access antenatal care services are: “inadequate family support” and “inadequate knowledge of danger signs in pregnancy”. “Negative attitude of healthcare staff” and “fixed day ANC care” are the factors which pose as a barrier from delivering baby in the hospital and seeking care. Conclusion: The study concluded that there are community-level issues and health system level issues which predict maternal health. The need of the hour is to launch community-based programs to educate people about the importance of family support in ANC care. There is a need to dispel the notion regarding preference for a male child. Government initiatives like Beti Bachao Beti Padhao should be promoted urging people to change their patriarchal attitudes toward girls. Good behavior from hospital staff and avoiding fixed day ANC care will go a long way in promoting institutional delivery.

The success of induction of labor depends on the degree of ripening of the cervix. This study compares the use of mechanical and a pharmacological method simultaneously to improve Bishop's Score.

Introduction: It is well established that the graduating medical practitioner must have knowledge and expertise in women's health. List of competencies have been developed for specialist training; however, expected competencies have not been defined for undergraduate medical students in India. Aims and objectives: To assess the competencies of the students in conducting normal delivery and common clinical tasks using various tools. Methods: Forty-four final year medical students and 26 teachers participated in the study that was conducted over a 4-month period. Planned curriculum, teaching methods, and assessment plans were displayed prominently. Faculties and students were sensitized regarding assessment using multiple choice question (MCQ), short answer question (SAQ), objective structured clinical examination (OSCE), and direct observation of procedural skills (DOPS). Self-assessment by the students was also done in each competency. Results: All the faculties liked the teaching-learning-assessment method >3 on the Likert scale. Each student assisted in conducting 20–40 deliveries. Mean score in MCQ and SAQ was 63.6%, 71.7% in OSCE, and 70.7% in DOPS. Mean score in assisting normal delivery by all methods was 77%. Lower than expected score was observed in partogram interpretation (61.3%), and postpartum care (55%). Student self-assessment is lower than faculty expectations in postpartum care (34.3%), family planning services (50.3%), and newborn resuscitation and care (58.7%) Conclusion: Students are confident in assisting normal delivery. They are less confident in partogram interpretation, neonatal resuscitation and care, postpartum care, and family planning service. Assessment using various tools and student self-assessment is important in the identification of thrust areas in curriculum planning.

Background: There is a significant increase in the total cesarean rate with primary cesarean accounting for most of the increase. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. Aim: The aim was to asses CS rate and indications in primigravida at El Shatby maternity university hospital. Patients and methods: the study included 952 primigravidas attending to El Shatby Hospital for delivery, assessment of the type of delivery vaginal or cesearean. Women were divided into two groups as regards mode of delivery and indications of CS. Results: CS rate is increasing now especially in primigravida, CS accounting 46.01% of all primigravida, fetal distress is the most common indication, abnormal presentations comes second and sever PET. Conclusion: There is a significant increase in the total cesarean rate with primary cesarean accounting for most of the increase.

Polycystic ovary syndrome (PCOS) affects 20–33% of women of reproductive age and the leading cause of infertility. Treatment includes lifestyle modification, metformin, ovulation induction, surgery, in vitro fertilization. Clomiphene citrate is most commonly used for ovulation induction but is antiestrogenic. Clomiphene resistance occurs in 15–20% of patients. Letrozole, an aromatase inhibitor, inhibits aromatization thus conversion of androstenedione and testosterone to estrogen in the ovary. This releases the hypothalamic/pituitary axis from estrogenic negative feedback, follicle stimulating hormone secretion increases, stimulating ovarian follicular development. We compared clomiphene citrate vs letrozole for ovulation induction in the treatment of anovulatory infertility in women with the polycystic ovarian syndrome. Two hundred consecutive women were observed for a number of cycles required to achieve ovulation, follicular growth, endometrial thickness, dominant follicle size, pregnancy, multiple, and abortion rates. The groups were matched for age, parity, duration of married life, menstrual regularity and prior history of treatment for infertility. Clomiphene showed a significantly increased number of follicles. Monofollicular development and endometrial thickness were higher in the letrozole group. The difference in dominant follicle size, number of cycles to achieve pregnancy or difference in ovulation rate per cycle, number of pregnancies and pregnancy losses per cycle lacked statistical significance. Greater number of follicles in the clomiphene group did not result in increased pregnancy rate. A number of pregnancies were marginally higher but not statistically significant in the letrozole group. There were one quadruplet and one twin gestation in the clomiphene group with none in the letrozole group. This data was not sufficient for statistical analysis. There were no instances of ovarian hyperstimulation syndrome or congenital anomalies in either group.

Background: Preeclampsia is a disorder of pregnancy having an impact on multiple organ systems. Cardiac manifestations in preeclampsia are varied which can be easily studied by echocardiography. With the advancement in the field of strain imaging, we can also analyze and predict the subclinical left ventricular dysfunction in these patients which may help us to assess high-risk groups. Objective: To compare maternal cardiovascular hemodynamics and function with emphasis on diastolic parameters and strain imaging using echocardiography in normal pregnant women with those having preeclampsia in the third trimester of pregnancy. Methods: Thirty preeclamptic women and 30 women with a normal singleton pregnancy of 34 weeks gestation were compared for systolic and diastolic parameters on echocardiography. Strain imaging was done to find the global and circumferential strain. Results: Blood pressure and total vascular resistance were significantly more in preeclamptic subjects than control. Women with preeclampsia had more diastolic dysfunction than those having a normal pregnancy. The global longitudinal strain was less in the preeclamptic group (–15.63 ± 1.69) than control (–20.86 ± 1.52). Similarly, the circumferential strain was lower in the preeclamptic group (–16.93 ± 1.11) than control (–21.76 ± 1.25). Conclusion: Preeclamptic women have a significant difference in systolic and diastolic dysfunction as compared to pregnant females having normal blood pressure. Early assessment of these parame- ters may help to identify the high-risk groups. Knowledge of these changes may help us to understand better the pathophysiological basis of disease which may further help in managing these patients.

Introduction: In India, 10–15% of all babies are born prematurely, and it accounts for 70–80% of all perinatal deaths. Beta-agonist like Isoxsuprine is widely used to prevent preterm labor, but can sometimes have life-threatening side effects; hence alternative glyceryl trinitrate (GTN) patch is compared with Isoxsuprine for efficacy and safety. Methods: Fifty women of gestation age 28–36 weeks, with two or more uterine contractions every 10 minutes for more than 1 hour but not in active labor with cervical dilations less than 2 cm. were included in the study. Twenty-five women were administered tablet isoxsuprine (duvadilan) 10 mg thrice daily and the rest 25 women received transdermal GTN patch releasing 10 mg per 24 hours. If after 2 hours there was no effect, an additional patch of 10 mg was applied. Time taken for the arrest of contractions, dose required for cessation of contractions, duration of delay in delivery, foetal outcome, APGAR score at birth, and birth weight were recorded for both the groups. Results: Eighty-eight percent achieved successful tocolysis in GTN group as compared to76% in Isoxsuprine group (p = 0.467), while the mean time taken to stop uterine contractions was less in GTN group (4.84 hours) as compared to Isoxsuprine group (7.8 hours) (p = 0.020). Mean gestational age at delivery was 34.97 weeks in the GTN group versus 33.24 weeks in isoxsuprine group (p = 0.004). Fetal outcome and maternal adverse effects was more favorable in the GTN group as compared to Isoxsuprine. Conclusion: Nitroglycerine is well tolerated, noninvasive and convenient therapy for tocolysis, requiring minimal monitoring of mother and fetus as compared to Isoxsuprine.

Objective: To find out whether amniotic fluid lamellar body concentrations (LBC) can predict neonatal respiratory distress syndrome (RDS) Materials and methods: Amniotic fluid was obtained at the time of cesarean section was sent to the laboratory for lamellar body concentrations in amniotic fluid. The lamellar body concentrations were analyzed and correlated with the incidence of RDS. Results: The incidence of RDS at different gestational age with an LBC cut off of 41,500 was studied. Among 220 patients studied, Respiratory distress was seen in 53 (24.09%) of patients. There is a significant correlation between decreasing lamellar body count in preterms and incidence of RDS. LBC count has a sensitivity of 92.7 %, the specificity of 90 %, a positive-predictive value of 73% and a negative-predictive value of 98% in predicting respiratory distress syndrome. Conclusion: LBC count in the current study is a cheap, easy and reliable method of assessing fetal lung maturity. Abbreviations: RDS: Respiratory distress syndrome; LBC: Lamellar body count; FLM: Fetal lung maturity. Ethics approval: Ethical committee clearance was obtained on 15/9/2011 before the start of the study from Manipal University ethical committee and Kasturba Hospital, Manipal under reference number IEC248/2011.

Introduction: The present study was conducted to evaluate the maternal and fetal outcomes in elective versus emergency cesarean section (CS), performed at a tertiary hospital in southern India. Materials and methods: The study was a prospective observational study conducted at a tertiary referral center in Bangaluru, India. 500 consecutive CS, over 29 months (January 2011 to June 2013), were studied. The questionnaire-based tool was used to collect data from the patient's case sheet, labor record, intra-operative records, and treating clinician. The main outcomes were maternal and early neonatal (< 7 days) severe morbidity. Results: Total of 3393 deliveries took place during the study period. The CS rate was 16%. The emergency CS was 58.4% of all sections. In the emergency CS group, 89 patients (30.4%) experienced at least one intra-operative difficulty/complication against 54 patients (25.9%) in the elective CS group (p = 0.31). The incidence of any postoperative complication was 30.3% and 24.3%, in the elective and emergency CS group, respectively (p = 0.20). The mean (SD) length of hospital stay was 4.57 (1.8) and 4.7 (1.2) days in the elective and emergency CS group, respectively (p = 0.30). There was no maternal mortality. In the emergency CS group, neonates tended to have significantly lower birth weight, APGAR scores at 1 and 5 minutes, had higher morbidity and required NICU more frequently. Conclusion: Although maternal morbidity was similar between the emergency and elective CS patients, the fetal outcomes were worse in the emergency CS patients. Whether this is due to fetal distress or complication as an indication for emergency CS or the result of emergency CS is not clear and could be evaluated in future studies.

Study objective: The aim of this study is to analyze the findings in females on whom laparoscopy was performed for the evaluation and management of infertility. Design: Retrospective study in a Multispecialty Hospital. Participants: Two hundred patients who underwent diagnostic and Operative Laparoscopy for evaluation and management of infertility in the age group 20–49 years were selected. Materials and methods: In this retrospective observational study we evaluated 200 patients on whom laparoscopy was performed for evaluation of primary or secondary infertility, and simultaneous management of the cause was done in a gynae-endoscopy unit in Delhi. The study included 120 females of primary Infertility and 80 women with secondary Infertility for 18 months. Laparoscopic findings, patient's age, nature of pathology and their distribution, the most common factor involved in infertility, chromopertubation, and results were analyzed from the data collected from these available case records. Results: Total 200 women on whom laparoscopy was performed for evaluation of infertility, it was observed that there were 120 cases were of primary infertility, Out of 120, 8 cases had no abnormal finding. A most common finding was endometriosis in 6/120 (57.5%) cases including endometrioma in 38 (31.7%) cases. Tubal factor 24 cases (20%), ovarian factor 14 cases (11.7%), bowel and Omental adhesions 28 cases (23.33%), PCOD 32 cases (26.7%), and myoma 34 cases (28.33%), similarly Out of 80 cases of secondary infertility in 11 cases no abnormal finding was there. Strangely, even in cases of secondary infertility, we found endometriosis to be the most common cause in about 53/80 (66.3%) cases which is a significant number. This may be the possible reason for adhesions (Bowel, mental and other) also which account to 42 cases (52.5%). Tubal factor 13 cases (16.25), ovarian factor 9 cases (11.25%), endometriosis 24 cases (30%), PCOD 4 cases (5%), Myoma 17 cases (21.25%).In both primary and secondary infertility, filmy dense adhesions were seen distorting the normal anatomy. These findings were not significant according to age groups 20–30 years and >30 years. Conclusion: In this study, endometriosis was found to be the most significant factor contributing to both primary and secondary infertility and also giving an explanation to increased finding Bowel/Omental and pelvic adhesions. Sometimes, more than one factor is present in overlapping fashion making management more difficult. Laparoscopy has a key role in delineating and managing such cases. It is the minimally invasive method, reaching new horizons with better technique. Simultaneous chromopertubation can be done for evaluation of tubal patency. Now in this era, it is impossible to consider workup for infertility without the aid of laparoscopy. Clinical significance: This study demonstrates the benefits of laparoscopy in the evaluation of infertility patients and the advantages of the minimally invasive technique. Statistical analysis: Fischer's exact test for calculation of p value. A p value <0.05 shows a statistically significant difference.

Introduction: Cancer of the appendix is an uncommon disease and is typically identified incidentally during appendicectomy. Bilateral ovarian metastases may occasionally occur in mucinous adenocarcinomas of appendix mimicking primary ovarian malignancies and can present a diagnostic challenge. The prognosis is poor as it is usually diagnosed at an advanced stage, either due to a low threshold of suspicion and also due to difficulties in diagnosis before surgery. Here we are reporting such a case of occult appendiceal adenocarcinoma which presented clinically as primary ovarian malignancy. Staging laparotomy revealed large bilateral ovarian tumors of FIGO Stage III, with presumed appendiceal implants. Histological examination revealed transmurally infiltrating Mucinous Adenocarcinoma of the appendix with mesoappendiceal invasion and serosal involvement, with lymphovascular invasion with secondaries to bilateral ovaries and omentum. Immunohistochemical staining revealed positive for CK 20 and CDX2 and negative staining for CK 7. The diagnosis of a primary mucinous adenocarcinoma of Appendix with bilateral ovarian metastasis was confirmed with pT4aG2pNxpM1c; TNM stage IV. The patient is planned for right hemicolectomy, total peritonectomy and hyperthermic intraperitoneal chemotherapy (HIPEC). Conclusion: Although adenocarcinoma of the appendix is uncommon, they should be considered in the differential diagnosis of intraabdominal masses, as the treatment modalities vary.

Papillary squamotransitional cell carcinoma (PSTCC), a less commonly reported histopathological subtype of cervical cancer's most common “squamous cell carcinoma”. Papillary cervical carcinoma has similarity to urinary tract transitional cell cancers. PSTCC present more in postmenopausal women with late symptom presentation, are underdiagnosed and underreported because of rarity and also have recurrences many years after initial diagnosis. Here we report a case of 52-year-old postmenopausal woman with complaints of bleeding per vaginum for few months. Her cervical cytology reported atypical cells of undetermined significance (ASCUS) and cervical biopsy as a high-grade squamous intraepithelial lesion (HSILs). The patient underwent total laparoscopic hysterectomy with bilateral salphingoopherectomy and her hysterectomy specimen pathological evaluation diagnosed her to be papillary squamotransitional cell carcinoma mixed type. With 18 months follow-up, the patient did not show any local, regional or systemic recurrence. When cytology and histology findings do not match, clinical suspicion and awareness of papillary squamotransitional cell cervical cancer are prerequisites for an accurate diagnosis.

Youssef syndrome which is also known as vesicouterine fistula is a very rare condition with an incidence of 1–4%. It is an iatrogenic complication, the cesarean section being a common etiology while vaginal birth after cesarean section is uncommon. It may have delayed presentation ranging from weeks to years. It can be diagnosed with sonography, cystoscopy, magnetic resonance imaging, but hysteroscopy is more reliable. The definitive management is a surgical treatment only.

There has been an increase in the rate of cesarean section performed worldwide recently with a parallel increase in associated complications. Uterine wound dehiscence and pelvic hematoma with abscess collection is a very rare complication of cesarean section. Frequency of uterine dehiscence is between 0.06% and 3.8 %.¹ Postoperative pyrexia may result from various causes, pelvic abscess being a very rare one, occurring in <1% of patients with postcesarean endometritis.² If uterine dehiscence leads to severe infection, laparotomy should be performed.^3-5 During laparotomy, conservative resuturing after debridement can be chosen, but in the presence of marked wound infection, endometriosis and/or intra-abdominal abscess, hysterectomy should be considered. A high index of suspicion with appropriate investigations can highlight such problems for early treatment and cure with the least morbidity and mortality.