Objective: The aim of our study was to evaluate the efficacy and safety of low dose intravenous magnesium sulfate against the conventional Pritchard\'s regimen in cases of eclampsia.
Materials and methods: A total of 60 eclamptic cases attending the labor room were randomly allocated to receive low dose intravenous magnesium sulfate, i.e., 4 g intravenous bolus dose followed by a 0.8 g per hour maintenance dose to be continued up to 24 hours after delivery or the last fit, whichever is later, or conventional Pritchard\'s regimen. The two groups were compared for efficacy and safety.
Results: Low-dose regimen was found to have a statistically significant lower incidence of side-effects and complications. Failure of therapy was seen in more number of cases with low dose because of the lower serum magnesium levels.
Conclusion: Low-dose regimen is a good option for lean Indian women especially at the peripheral centers where intensive serum magnesium level monitoring is not practically feasible because of reduced risk of toxicity.
Aim: Acute kidney injury (AKI) is a rapid loss of kidney function. The proposed diagnostic criterion for AKI is an abrupt (within 48 hours) reduction in kidney function defined as an absolute increase in serum creatinine (level of >0.3 mg/dL) or a percentage increase in serum creatinine level of more than 50% (1.5 fold from baseline) or reduction in urine output (documented oliguria of less than 0.5 mL/kg per hour for more than 6 hours). The aim of this study is to determine the clinical spectrum of pregnancy-related AKI and the maternal outcome.
Materials and methods: This is a descriptive study conducted in the Department of Obstetrics and Gynaecology from January to December 2015. Patients admitted with pregnancy-related AKI kidney injury were enrolled. The exclusion criteria were evidence of renal disease, hypertension, or diabetes prior to pregnancy, renal stone disease, renal scarring, or small size kidneys on ultrasonography (USG). Acute kidney injury was diagnosed according to the standard definition. The maternal outcome was noted in terms of complete recovery, partial recovery, or irreversible renal failure.
Results: Twenty-eight patients were admitted with AKI. The mean age was 26.11 ± 6.2 years. One patient had antenatal checkup done at BP Koirala Institute of Health Sciences (BPKIHS). Acute kidney injury was diagnosed in the postpartum period in 24 (85.71%) patients. Fifteen (62.5%) patients had cesarean section and 9 (37.5%) had vaginal delivery. Out of 24 patients, 14 (58.3%) had delivered at BPKIHS and 10 (41.66%) at other health facilities. The most common diagnosis was hypertension complicating pregnancy (42.9%). Ten (35.7%) patients required dialysis. Blood transfusion was required in 18 (64.3%) patients. Ten (35.7%) patients required admission in the maternal intensive care unit (ICU). Complete recovery was seen in 25 (89.3%) patients and 3 (10.7%) patients expired.
Conclusion: Pregnancy-related AKI can be prevented by improving the existing healthcare facilities as well as increasing public health awareness.
Background: The maternal mortality ratio over seven years was studied and the causes leading to maternal deaths and preventable factors were analysed.
Materials and methods: The records of maternal deaths from January 2011 to December 2017 (7 years) were collected. Various factors such as maternal age, antenatal registration, parity, causes of deaths, and admission to death interval were reviewed.
Results: The mean mortality rate was 185. The direct causes of maternal mortality were haemorrhage (18.1%) and preeclampsia/eclampsia (18.1%). The indirect obstetric causes were hepatitis (9.09%), anaemia (9.09), heart disease (4.54), and miscellaneous (36.36%). Most of the cases (86.36%) were referred. The majority of the deaths (81.8%) occurred in the age group of 20–30 years.
Conclusion: Early antenatal registration, identification, and management of high risk patients and their early referral to higher centres can help in reducing complications and maternal mortality.
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Agrawal M, Acharya N, Joshi K, Shrivastava D. Effectiveness of Isosorbide Mononitrate in Cervical Ripening before Induction of Labor in Full-term Antenatal Patients. J South Asian Feder Obs Gynae 2019; 11 (2):96-99.
Aim: The aim of the present study is to prove the efficacy of isosorbide mononitrate (IMN) as a cervical ripening agent before induction of labor in term pregnancies.
Materials and methods: The present study was prospective and comparative, experimental randomized placebo-controlled, double-blind study conducted in the Department of Obstetrics and Gynaecology at Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha, over a period of two years extending from September 2014 to August 2016.
Results: There was a marked improvement in Bishop\'s score in study group as compared to control group. The mean baseline Bishop\'s score in case group was 2.65 + 1.29 and 2.64 + 1.26 in control group. Bishop\'s score after the 1st dose (i.e., 24 hours after admission) in study group was 5.95 + 1.56 and 3.43 + 1.35 in control group; p value is 0.001 which was statistically significant while Bishop\'s score after the 2nd dose (i.e., 24 hours after the second dose and 48 hours after admission) in study group was 7.73 + 2.26 and 4.47 + 1.73 in control group.
Conclusion: Isosorbide mononitrate is effective and safe when used for cervical ripening before induction of labor at term without causing any side effect on maternal hemodynamic and hyperstimulation of uterus.
Aim: The aim of this study is to study the levels of cancer antigen 125 (CA-125) in normal, preeclampsia, and gestational hypertension study groups and correlate with other parameters which mark the severity of the disease.
Materials and methods: A cross-sectional study was conducted at a Tertiary Care Hospital, Mangaluru, India. A total of 165 subjects were divided into three study groups: preeclampsia, gestational hypertension, and normal pregnancy, and each group consisted of 55 subjects. CA-125 levels were measured in these study groups.
Results: The mean value of CA-125 in the preeclampsia group was 56.7 IU/mL which was significantly higher compared with other two study groups. CA-125 was found to have a positive correlation with systolic blood pressure (BP) (r value = 0.4, p value = 0.001), diastolic BP (r value = 0.3, p value = 0.001), and uric acid (r value = 0.2, p value = 0.001) and also an association was observed between increasing CA-125 and proteinuria (p value = 0.001) oligohydramnios (p value = 0.001) fetal growth restriction (p value = 0.03) and onset of the disease (p value = 0.001). However, a negative correlation with platelets (r value = −0.14, p value = 0.06) and birth weight (r value = −0.113, p value = 0.15) was observed.
Conclusion: CA-125 is a marker indicating increasing severity of the disease. It is a biochemical marker which can be used in the screening of preeclampsia. Further studies are needed for the evaluation of raising serial CA-125 levels as a marker of progression of the disease.
Clinical significance: Hypertensive disorders of pregnancy are one of the most common causes of death due to pregnancy. CA-125 was proposed to be elevated in patients with hypertension due to chronic inflammation. Hence, CA-125 levels if used as a screening tool can estimate the severity of the disease and help clinicians in identifying women who are at risk for further complications and act accordingly.
Vishnupriya KM Naga,
Manjula S Kalappa
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Naga VK, Joseph B, Kalappa MS. Obstetric Outcome in Women with Intrahepatic Cholestasis: A 3-year Study in a Tertiary Care Hospital in Bengaluru. J South Asian Feder Obs Gynae 2019; 11 (2):103-106.
Objective: To study the incidence and obstetric outcome of pregnancies complicated by intrahepatic cholestasis.
Materials and methods: A retrospective case control study of 60 women with obstetric cholestasis was carried out in the Department of Obstetrics and Gynecology, St. John\'s Medical College Hospital, Bengaluru from January 2015 to March 2018. Statistical analysis was performed using the Z/T test when appropriate. A p value less than or equal to 0.05 was considered statistically significant.
Results: The frequency of intrahepatic cholestasis of pregnancy (ICP) was 60 among 8319 deliveries (7.21%). The most common symptom was generalized pruritus, which appeared in 36.6% during the 2nd trimester and 83.3% in the 3rd trimester of cases. Preeclampsia was seen in 31.6% (3.3% in controls); preterm deliveries were seen in (23% vs 5%). A higher incidence of meconium-stained amniotic fluid (25% vs 6.7%) was noted at delivery. The cesarean section rate was 41.7% vs 23.3%. There was no significant difference in the CTG changes, APGAR score less than 7, intrauterine growth restriction, NICU admission or perinatal mortality between cases and controls.
Conclusion: Multidisciplinary approach involving obstetricians, gastroenterologists and neonatologists improved the obstetric outcome. Early diagnosis was done with liver function tests (aminotransferases) and urinary bile salts and bile pigments. In most of the cases, antihistaminics and emollients relieved the symptoms. Ursodeoxycholic acid (UDCA) treatment is found to be effective in reducing the persistent pruritus.
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Texeira L, Pai BS, Dsouza N. Role of Percutaneous Nephrostomy in Improving Quality of Life in Advanced Carcinoma Cervix Presenting with Obstructive Uropathy. J South Asian Feder Obs Gynae 2019; 11 (2):107-109.
Aims and objectives: Percutaneous nephrostomy (PCN) is an interventional procedure which is mainly used in the decompression of the renal collecting system. Urinary diversion by this procedure can improve renal function. We examined the role of PCN in the management of advanced cervical cancer patients presenting with obstructive uropathy with a detailed analysis of improvement in the quality of life, morbidity, and survival rates.
Materials and methods: We prospectively evaluated 50 gynecology patients having cervical cancer with obstructive uropathy and deranged renal functions. A PCN was performed under local anesthesia using the Seldinger technique. Positions of catheters were confirmed with the nephrostogram at the end of the procedures. Health survey was conducted before the PCN procedure, 1st week, and 4th week and at the 3rd month after the PCN procedure.
Results: PCN was successfully established in all patients with the recovery of renal function. The median serum creatinine before and 1 month after the procedure was 6.6 and 2.0, respectively. Complications relating to the procedure (60%) were fever/sepsis 7 (14%), bleeding in 5 (10%), pericatheter leak in 10 (20%), and slippage of catheter requiring replacement in 7 (14%). Overall, 45 (90%) patients died of the primary disease and 5 are alive. The 3, 6, 9, and 12 months’ death rates were 8 (16%), 15 (30%), 21 (42%), and 2 (1%), respectively. Fifty percent of death occurred within 6 months and 90% of death occurred by 9 months.
Conclusion: PCN provides a significant improvement in renal function parameters in majority of the patients. The quality of life is improved significantly at 1 week and 1 month which is not sustained at 3 months. As the benefits of PCN urinary diversion after 3 months are not established, counseling is essential and the wishes of the patient and her family have to be considered.
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Shrikhande BA, Shrikhande LA. Association between Weight Loss in Obese Indian Adolescent Girls with Polycystic Ovarian Syndrome and Decline in Anti-Müllerian Hormone Concentrations. J South Asian Feder Obs Gynae 2019; 11 (2):110-112.
Objective: Several studies have reported anti-Müllerian hormone (AMH) concentrations in girls with polycystic ovarian syndrome (PCOS), but longitudinal studies of changes in AMH concentrations in relation to change in weight status are lacking in Indian adolescent girls with PCOS. Our objective was to study the longitudinal changes in AMH concentrations in obese Indian adolescent girls with PCOS with respect to weight loss.
Materials and methods: This longitudinal study was conducted at the adolescent clinic of Shrikhande Hospital and Research Centre Pvt Limited, Nagpur, India, from January 2017 to December 2017. 120 obese girls aged 13–19 years (50% with PCOS) were included in the study after obtaining informed consent. Girls with and without PCOS were matched to age, BMI, and weight status. Serum AMH, gonadotropins, testosterone, and oestradiol levels were determined. The intervention consisted of promoting physical activity, delivering nutrition education, and behavior therapy. Normal distribution was tested by the Kolmogorov–Smirnov test for all variables. The primary outcome was the change in AMH concentrations over time.
Results: Obese girls with PCOS demonstrated significantly (p < 0.001) higher AMH concentrations (5.7 ± 3.1 ng/mL) as compared to obese girls without PCOS (2.4 ± 1.3 ng/mL). Participants who had experienced weight loss were found to have significantly lower baseline AMH levels (−1.3 ± 1.8 ng/mL, p = 0.04). An association was also found between degree of weight loss and a decline in AMH levels, with subjects experiencing more weight loss demonstrating a higher decline in AMH level (−10.5 ± 1.1 kg vs −4.0 ± 1.0 kg; p = 0.001).
Conclusion: Anti-Müllerian hormone was increased in Indian obese adolescent girls with PCOS and decreased with weight loss.
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Lestari P, Wibowo N, Alexander E. Hemodynamic Profile and Cardiac Morphometry in Normotensive and Severe Preeclamptic Pregnant Women. J South Asian Feder Obs Gynae 2019; 11 (2):113-119.
Objective: To identify the differences in hemodynamic profile and morphometric changes of maternal heart in normotensive pregnant women and severe preeclampsia.
Materials and methods: Cross-sectional study was conducted on 34 pregnant women divided into three groups: normotensive (n = 12), early-onset (n = 11), and the late-onset (n = 11). Subjects were patient from ER and inpatient unit of the Department of Obstetrics and Gynecology, Faculty of Medicine, Sriwijaya University/Dr Mohammad Hoesin Hospital, Palembang, during April–June 2015.
Results: CO values of the early onset group was lower (3.4 + 0.27, p < 0.001) with higher SVR (3100.2 + 261.3, p < 0.001) than the other two groups. SVR in preeclamptic group was higher compared to the control, the early onset presenting higher SVR than the late-onset group (3100.2 + 261.3 vs 2217.1 + 407.8, p < 0.001). Cardiac index variables between groups were also different, except in the early onset group and controls (p = 0.045). In blood pressure and MAP variable, we only noticed difference between the early onset group and control (p < 0.001) as well as late-onset group and controls (p < 0.001). LVMi, LVID and LVPWT in control group was lower than the others (p < 0.001; p = 0.049; p = 0.009), but were similar for the early onset and late-onset groups [98.7 (86.5–203) vs 132 (77.7–17.6); 4.7 (0.4) vs 4.8 (0.5); 1.1 (0.7–1.3) vs 1.1 (0.8–1.6)]. RWT was relatively similar across the three arms of the study (p = 0.264).
Conclusion: In severe preeclampsia, there are changes in hemodynamic, ventricular morphometry, and left ventricular function, which is more evident in the group of early-onset preeclampsia than late-onset preeclampsia.
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Radhakrishnan G, Mehdiratta A, Gupta R. Awareness, Attitude, and Acceptability for Abortion Law among MTP Seekers at a Tertiary Care Center of East Delhi. J South Asian Feder Obs Gynae 2019; 11 (2):120-125.
Introduction: Termination of pregnancy has been prohibited by law in many countries, but in India induced abortion is legal, under the medical termination of pregnancy act (MTP) 1971. Despite the emergence of health services and availability of legal abortions, estimated 22 million abortions continue to be performed each year unsafely, resulting in the mortality of almost 47,000 women and morbidity for 5 million women due to ignorance amongst women. This study was done to evaluate the level of awareness, attitude and acceptability abortion law among MTP seekers at a tertiary care center.
Materials and methods: Structured questionnaire-based interview schedules were used to assess the awareness, attitude, and acceptability of the MTP seekers.
Results: About 95.4% and 31.6% have a vague idea about the gestational limit and indication for MTP. 87.8% had the preference for Government hospital only because of the “low cost of treatment”. 45.5% preferred only lady doctor and 83.6% felt that husband\'s consent is mandatory for MTP. 13.7% of women were aware that it is legal under certain circumstances.
Discussion: Women should be motivated to overcome socioeconomic and religious barriers and adopt effective contraception. Mass media should be made more informative and effective regarding safe abortion (gestational limit, person, place), usage of emergency contraception, mifepristone, and misoprostol for early abortion and discourage delay in decision making for MTP.
Smruti B Vaishnav,
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Vaishnav SB, Raithatha N, Kathawadia K, Phatak A, Modi N, Patel R. Making Magnesium Sulfate Therapy Safer in Eclampsia: A Comparative Study of Zuspan Regime vs Low-dose Intravenous MgSO4 Regime. J South Asian Feder Obs Gynae 2019; 11 (2):126-130.
Objective: Magnesium sulfate is a universally accepted drug for the control of convulsions in eclampsia. Regimes available have been well tried in western countries where the weight of women is much higher than Indian women. In the present study, we tried to compare the doses used in zuspan regime (used previously in our hospital) with the regime where we reduced the maintenance dose to half for average weight women of the rural area (≤50 kg).
Design: A PRE-POST comparative study of 2 regimes of magnesium sulfate therapy in cases of eclampsia.
Setting: Tertiary care center in the low-resource rural area of central Gujarat.
Population: Group I: All patients of eclampsia, March 2007 to April 2012. Group II: All patients with eclampsia who were weighing ≤50 kg (BMI ≤25) May 2012–Oct 2013.
Materials and methods: Group I: Zuspan regime: Loading dose 4 g intravenously 20% over 20 minutes and maintenance dose 1 g/hour intravenously. Group II: Low maintenance dose regime: Loading dose: 4 g intravenously 20% over 20 minutes and maintenance dose: 0.5 g/hour.
Main outcome measures: Rates of recurrence of convulsions, magnesium sulfate toxicity, and maternal mortality.
Results: Recurrent convulsion rate was 5% in group I and 9.6% in group II. Toxicity was seen in 15.3% of cases in group I while it was not seen in group II. Maternal mortality in group I was 1.5% and no mortality in group II.
Conclusion: A low maintenance dose of magnesium sulfate is safe and effective for controlling convulsions in patients with eclampsia weighing ≤50 kg.
Since historical times, the presence of meconium in the amniotic fluid has been worrisome for midwives and accoucheurs alike. Its association with a neonate who does not cry has often been a chill factor in delivery suites. Having said that, all cases of meconium-stained amniotic fluid (MSAF) do not necessarily result in low APGAR scores. In addition to in utero fetal hypoxia, meconium passage has also been associated with maternal drug abuse, use of vaginal misoprostol for induction of labor, chorioamnionitis, and maternal diabetes. The main pathology associated with MSAF is the aspiration of meconium during intrauterine gasping or during the first few breaths. This causes meconium aspiration syndrome (MAS) which has serious consequences on neonatal outcome. MAS is a common cause of severe respiratory distress in term neonates, with an associated highly variable morbidity and mortality. The pathophysiology of MAS is multifactorial and includes acute airway obstruction, surfactant dysfunction or inactivation, chemical pneumonitis, and persistent pulmonary hypertension of a newborn. Concepts regarding meconium and the management of MSAF to prevent MAS have changed in the last two decades or so. Guidelines published by the American Academy of Pediatrics/American Heart Association have changed the immediate neonatal management following delivery in the presence of MSAF. Initially, amnioinfusion was considered an important tool in the management of MSAF. However, evidence to support this view has not been forthcoming and current guidelines recommend amnioinfusion only in controlled and research settings. The future thrust should be aimed at early detection of MSAF and prevention of MAS. Needless to say, the obstetrician and the neonatologist need to work in consonance for achieving a better neonatal outcome in the presence of MSAF.
Introduction: Glanzmann\'s thrombasthenia is an inherited autosomal recessive bleeding disorder in which there is a deficiency of platelet glycoprotein GpIIb/IIIa. These receptors allow platelets to aggregate by sticking to each other, releasing granular contents to potentiate the process of clotting. Platelets are not able to clump together when stimulated, resulting in failure to form platelet aggregates. In such instances, bleeding time is prolonged and the clot retraction is defective, resulting in increased bleeding tendency. GT is diagnosed by tests that determine whether there is a deficiency of the α11bβ3 (GpIIb/IIIa) receptor. The diagnosis is confirmed mainly by flow cytometry and monoclonal antibodies. In the platelet function analyzer 100 (PFA-100), platelets fail to plug on the filter, as platelet aggregation response is defective. The condition may present in early childhood causing repeated nasal bleeds, or in adulthood as menorrhagia, antenatal, and postpartum hemorrhage. Patients may require many leukocyte-depleted blood products during bleeding episodes.
Objectives: Objectives of this review article is to understand the implications of Glanzmann\'s thrombasthenia, its pathogenesis, diagnostic modalities and treatment options as it is a rare platelet disorder. Surgeons have to be on the alert if the case is a Glanzmann\'s thrombasthenia, as uncontrolled hemorrhage not responding to usual treatment can have fatal consequences.
Materials and methods: An extensive search and review of current literature was undertaken via PubMed and EMBASE to know the historical background with its latest management options available.
Results and evidence: Studies have suggested that GT is a hereditary disorder occurring predominantly in consanguineous populations with female preponderance.
Remarks and conclusions: As consanguinity is very high in this part of the world awareness among clinicians of this medical disorder is necessary to avoid unanticipated hemorrhage and its untoward complications.
Kavitha D Yogini,
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Yogini KD, Balasubramaniam D, Karunanithi S, Parthasarathi R. Perianal Endometriosis: A Rare Presentation of Extrapelvic Endometriosis. J South Asian Feder Obs Gynae 2019; 11 (2):138-139.
Endometriosis is the ectopic location of functioning endometrial glands and stroma. Perianal endometriosis can present as a painful swelling and are usual mistaken as perianal abscess, thrombosed hemorrhoids, sebaceous cyst, or a resolving hematoma. The uncommon presentation delays the diagnosis and brings agony to the patient.
Case description: A 34-year-old para 2, live 2 (P2L2), both uneventful vaginal deliveries, presented to our outpatient department with complaints of perianal pain for 3 years. Initially, the pain was more during her menstruation. Gradually it worsened and the patient started having severe noncyclical pain. There was no history of any obvious swelling or discharge from the perianal region. She gave a history of episiotomy given during her second delivery, 7 years back. There was also a history of perianal abscess drainage 2 years back. On local examination, there were no scars noted on the perineum. Per speculum and per vaginal examination were unremarkable. On per rectal examination, there were tenderness and induration noted at the 4 o\'clock position. The patient was taken up for surgical exploration. The cyst wall was excised without any damage to the sphincter muscle and sent for histopathology. The histopathology report was suggestive of endometriosis.
Conclusion: Since perianal endometriosis has varying clinical presentations, this condition has to be kept in mind especially when the patient has cyclical perianal pain.