Objective: HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) is a component of hypertensive disorders of pregnancy that is associated with significant maternal and perinatal morbidity and mortality. HELLP syndrome is regarded as a high risk for the mother and neonate compared to preeclampsia. Aims: This study evaluates the maternal and perinatal outcome in HELLP syndrome so that the management is improved resulting in reduced mortality and morbidity. Materials and methods: It is an observational study where a total number of 56 cases of HELLP syndrome above 24 weeks of gestational age were admitted in Vanivilas Hospital, Bengaluru, during the study period of 24 months from October 2010 to October 2012. Results: In the present study, majority (71.43%) of the patients were unbooked. There was no difference in parity among cases. Maternal mortality was 7.14% and perinatal mortality was 46.43%. Conclusion: We have to intensify our efforts to reduce preeclampsia with HELLP syndrome from the grassroot level with regular antenatal care, early detection of preeclampsia, and its prompt management and early detection of complications with timely intervention.

Introduction: Placental sonography is the study of placental location, placental attachment, size, shape, and structure of placenta. Generally, placental sonography is carried out in second trimester and onward and is generally missed in the first trimester. However, looking at the placenta and finding any abnormality in the attachment is highly important in the firsttrimester itself. Abnormalities like morbidly adherent placenta, cesarean scar pregnancy, etc., can be picked up on first trimester placental sonogram which can help us decide the patient management better. Aims and objectives: The purpose of this article is to establish the importance of diagnosis of abnormal placental attachment in the first trimester ultrasound so that: • Termination of pregnancy can be discussed with the patient. • To prepare for major complications like postpartum hemorrhage and peripartum hysterectomy if need arises. • Patient counseling regarding a high-risk pregnancy can be started at an early gestation. Materials and methods: In this retrospective study, we have discussed a few cases that visited IPD and OPD in GGS Medical College, where abnormal placental attachment and location was missed and which could have been diagnosed at an early scan to prevent such morbidity to the patient. Conclusion: With first trimester ultrasound, we can view into the early intrauterine environment. Examination of the placental morphology in the first trimester ultrasound to rule out placenta accreta, especially in high-risk patients, should be encouraged to improve patient education and choice and limit morbidity of this rising iatrogenic placental disorder.

Background: COVID-19 pandemic is stressing the already burdened healthcare systems all over the world. To prevent infrastructure from getting overwhelmed, it is required that infection prevention practices are followed by everyone. Objectives: To assess whether a knowledge gap exists in the correct use of face masks, attitude, and practices of participants in wearing a face mask to limit the spread of COVID-19. Materials and methods: Faculty, medical officers, and postgraduate trainees working in SN Medical College, Agra, were invited to participate in this survey. All participants were asked to complete a self-administered closed-ended questionnaire about their knowledge, attitudes, and practices regarding the use of face masks. Data were analyzed using descriptive statistics. Quality improvement intervention was done. Results: Among the 136 respondents, 73.5% knew the correct steps in wearing a face mask, and their attitudes toward face masks were strongly positive. Further analyses showed that respondents were equally likely to wear a face mask at hospital or at non-hospital places. Moreover, two-thirds respondents reported to have some problems while wearing a mask. Conclusion: Studied subjects had a positive attitude but poor level of knowledge and good practices regarding the use of surgical face mask. Awareness campaigns regarding the proper use of face mask by utilizing all forms of available media and resources would be helpful during this pandemic.

Introduction: Misoprostol is a therapeutic method for uterine ripening in postmenopausal women under hysteroscopy, and determination of best dosage and time of administration is important to attain the best outcomes. Objectives: This study was performed to determine and compare efficacy of sublingual misoprostol for uterine ripening 2, 6, and 12 hours before hysteroscopy in postmenopausal women. Materials and methods: In this randomized clinical trial, 103 postmenopausal women attending to Akbarabadi and Rasool Hospitals in 2017 and 2018 for hysteroscopy were enrolled and randomly assigned to receive sublingual misoprostol for uterine ripening either 2 or 6 hours or and 12 hours before hysteroscopy. The outcomes and adverse effects were determined and compared. Results: In this study, the frequency rate of complications and also the external and internal os diameters were alike across the three study groups (p value > 0.05). Conclusion: It may be concluded that efficacy of sublingual misoprostol for uterine ripening 2, 6, and 12 hours before hysteroscopy in postmenopausal women is same, and for this matter, use at 2 hours before hysteroscopy is recommended for further supervision and more convenience.

Aim: To compare the clinical and biochemical characteristics of obese and lean women with polycystic ovary syndrome (PCOS). To confirm the significance of body mass index (BMI) in classifying PCOS. Materials and methods: This was a comparative cross-sectional study done at Assam Medical College Hospital, Dibrugarh, Assam, in 1 year. Women who attended the hospital diagnosed to have PCOS based on Rotterdam's criteria were divided into lean and obese with BMI cut-off of 23. Clinical, anthropometric, and biochemical characteristics of both were compared. Body fat percentage was calculated using Harpenden skinfold calipers, and based on it, the lean group was found to have a normal weight, and obese subgroup with body fat percentage more than the cut-off. Result: There was a significant difference in age, hirsutism score, and family history of diabetes and PCOS between the groups. The systolic blood pressure, serum cholesterol, and serum low-density lipoprotein (S.LDL) were statistically higher in the obese group. The normal weight obese group had features of the lean group, except for hyperandrogenism. Conclusion: The lean and obese PCOS are two discrete groups. Obese patients have a more androgenic and atherogenic lipid profile, but both groups should be screened. Body mass index is the easily available method, but it has a chance of missing out on the normal weight obese PCOS. Clinical significance: Follow-up is needed in both the groups, and the normal weight obese group behaves as the lean PCOS group; hence, BMI can be continued to be used as the differentiating factor.

Objective: To study the role of the cerebroplacental ratio (CPR) in the prediction of adverse neonatal outcomes and mode of delivery in low-risk women at 37–41 weeks’ gestation. Materials and methods: Three hundred and seventy low-risk women with singleton pregnancy at 37–41 weeks of gestation, with known last menstrual period (LMP), were prospectively evaluated over a period of 1 year in a medical college setting. Doppler examination was performed and the indices recorded. Defined maternal and neonatal outcomes were studied. Nonparametric tests such as test for comparison of population means, test for comparison of proportions, and tests of diagnostic accuracy were performed. Receiver operating characteristic (ROC) curves were used to determine the area under the curve. Results: Total 78 subjects had CPR below 5th centile. The mean CPR value at the 5th centile was 1.2. The mean (SD) of CPR for the total population was 1.48 (+0.39); the mean (SD) value for CPR was lowest for the infants requiring neonatal intensive care unit (NICU) admission (1.12 ± 0.22). The CPR below the 5th centile had an independent association with APGAR < 7 at 5 minutes, induced labor, and NICU admission. Birth weight centile did not affect this association. Conclusion: The CPR below the 5th centile was associated with a higher risk of obstetric intervention for intrapartum fetal compromise and adverse perinatal outcomes in subjects with low-risk pregnancy at term.

Background: To evaluate intraoperative and postoperative complications and to evaluate recurrence of vault prolapse in women who have undergone unilateral (left) sacrospinous ligament fixation. Aim: To evaluate safety, effectiveness, and ease of sacrospinous ligament fixation for prevention and treatment of vaginal vault prolapse. Materials and methods: This study was conducted between January 2016 and October 2017 at Smt. Kashibai Navale Medical College and General Hospital, Pune. This study included 106 patients (out of which18 had vault prolapse and 88 patients had III or IV degree uterine prolapse). Concomitant hysterectomy and sacrospinous ligament fixation were done in 88 patients with uterine prolapse, and patients with vault prolapse underwent sacrospinous ligament fixation. Sacropinous ligament fixation was combined with any other additional procedure if required for that patient. Results: All complications including intraoperative and postoperative were noted in all patients. One patient had rectal injury (n = 1; 0.94%), 1 patient had abscess (n = 1; 0.94%), 1 patient had hemorrhage requiring blood transfusion (n = 1;0.94%), 1 patient had cystocele (n = 1; 0.94%), 3 patients had urinary tract infection (n = 3; 2.8%), 16 patients had postoperative fever (n = 16; 15%), 21 patients had postoperative pain (n = 21; 20%), and 2 patients had sciatic neuralgia (n = 2; 2.8%). No recurrence of vault prolapse was noted. Conclusion: Sacrospinous ligament fixation is a safe, effective, and simple procedure for prevention and treatment of vaginal vault prolapse.

Background: The mortality rate is one of the most important indicators that represent the socioeconomic development of the country. To reduce maternal mortality rate, it is vital to recognize the trend and causes of maternal mortality. This study aimed to determine the mortality rate and causes of maternal mortality in Hamadan province from 2002 to 2016. Materials and methods: The study was performed as a retrospective descriptive study in Hamadan province. To investigate the causes of mothers’ death in Hamadan province, the data were extracted from the maternal care system for 2002 to 2016. Furthermore, locally weighted scatter smoothing (LOWESS) method was used to smooth the trend of the mortality rate. The data analysis was carried out using STATA software. Results: The maternal mortality rate has reduced from 35 per 100,000 live births in 2002 to 14 per 100,000 live births in 2016. The most important causes of maternal mortality in Hamadan province were bleeding and preeclampsia, Also the majority of deaths occurred in the hospital. Conclusion: The rate of maternal mortality in Hamadan has a decreasing trend and is met for the United Nations Sustainable Development Goals (SDGs) before 2030. Despite the decline, the cause of death by blood and bleeding remains as the main causes of maternal mortality. To reduce maternal mortality, all women need to be provided with the equal access to prenatal and post-pregnancy complications during pregnancy, sex education, and family planning.

Background: Intrauterine contraceptive devices (IUCDs) are a common method of contraception adopted for birth spacing in India. Copper T (CuT) 380A is marketed by the government free of cost, which makes it widely available to the patients in need. But a common problem of missing threads leads to an unwanted complication, which needs to be analyzed. Materials and methods: This is a retrospective analysis of patients with missing CuT threads attending the outpatient department (OPD) of gynecology of Mahatma Gandhi Medical College, Puducherry, over a 3-year period between 2017 and 2019. Data regarding patients complaints, timing and place of insertion, obstetric history, ultrasound report, and method of retrieval were analyzed. Results: Out of 75 users of IUCD attending OPD of gynecology over the last 3 years, 28 patients came with missing IUCD threads. Out of 28, 2 patients had spontaneous expulsion, 6 opted for continuation after confirming its normal placement within the uterine cavity, whereas 20 patients opted for retrieval. The most common reason for removal was the need for conception (60%). In 46.4% of cases, IUCD was found embedded in the myometrium and 50% required diagnostic hysteroscopy. Use of ultrasound during retrieval helped in around 50% of cases. Difficulty in retrieval was seen in two cases whereas perforation was seen in one case. Conclusion: Most of the missing IUCD threads were found in patients with history of previous cesarean and though ultrasound in most cases revealed IUCD within the uterine cavity, in few cases it was embedded in the myometrium making retrieval difficult requiring an OT setup.

Liver disease is a potentially serious complication seen in pregnancy occurring more in developing countries. The advances in understanding of the diseases with timely diagnosis and management have resulted in a significant reduction in the adverse outcome occurring both in the mother and the fetus. Aim and objective: To study the fetomaternal outcome due to the various causes of liver diseases in pregnancy. Materials and methods: • Study design: Observational prospective study. Study setting: The study was conducted in the Department of Obstetrics and Gynaecology, Government Medical College, Kozhikode from March 2016 to September 2017, a total of 18 months. • Study subjects: Pregnant patients with liver diseases who presented as jaundice and attended the Department of Obstetrics and Gynaecology during the study period were included in the study. Nonpregnant ladies with jaundice were excluded from the study. • Methodology: A detailed history, clinical examination, and necessary investigations were done for all cases. Results: The observations from this study were as follows: The total number of deliveries in this period was 24060. The number of cases with liver diseases complicating pregnancy was 52. Thus the incidence of liver diseases complicating pregnancy was 0.22%. In this study, out of the 52 cases of liver diseases complicating pregnancy, 18 (34.6%) were found to be due to hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Maximum number of cases were between 34 weeks and 37 weeks of gestation (40.4%). Of the total 52 cases, 23 underwent cesarean delivery and 29 had vaginal delivery. There was one case of maternal death which was due to fulminant hepatic failure in a case of hepatitis A. The perinatal mortality rate in this study was 122 per 1,000 cases of liver diseases. Conclusion: Early diagnosis and prompt management of cases may decrease the perinatal and maternal morbidity as well as mortality to a greater extent.

Background: An ectopic pregnancy occurs when a fertilized ovum implants at a site outside the uterine cavity. The most common location is within the fallopian tube and the condition can be life threatening due to risks of tubal rupture and hemorrhage. Unless more cases are diagnosed at an early stage, it is difficult to reduce mortality, and provide fertility preserving management. Aim and objective: To determine the local incidence of ectopic gestation, its risk factors, clinical presentations and management provided. Materials and methods: This was a prospective observational study where ectopic pregnancy cases admitted over one year in a tertiary care hospital in eastern India, were analyzed regarding age, parity, risk factors, signs and symptoms, management and morbidity. Results: There were total 280 cases, with incidence of 13.03/1000 deliveries. Most patients were primipara, between 21–30 years. The common risk factors were previous cesarean section (CS) in 26.07% and pelvic inflammatory disease (19.04%). Predominant symptom was abdominal pain (98.21%) and classic triad was present in 45% cases. Adnexal and cervical motion tenderness was elicited in most, while 10% presented in acute shock. Right sided ampullary tubal ectopic was the most common type encountered, with 70% cases in ruptured state. Salpingectomy was the mainstay treatment (85.36%). Successful non-surgical management was given to 7.14% cases. There was no mortality. Conclusion: The majority of cases in this study were received in ruptured condition, rendering conservative management impossible, a drawback in the era of modern diagnostics. With global increase in CS rate, a risk factor, the ectopic incidence may inadvertently rise, which is an alarming concern. Clinical significance: Awareness of the local trends of ectopic pregnancy, its risk factors, and diverse clinical presentation is of paramount importance for providing efficient management.

Aims and objectives: The main aims and objectives of this study were to study efficacy, safety, and quality of life with combination anticholinergics and desmopressin compared to anticholinergics alone. Materials and methods: A total of 92 patients were randomly assigned to two groups. Patients were randomly assigned to receive 5 mg of solifenacin (group I) or 5 mg of solifenacin and 0.2 mg of desmopressin (group II) for 1 month. The patients were followed for 2 weeks to look for undesired side effect and then at 1 month with 3-day voiding diary. IIQ-7 questionnaire score was used to assess changes in voiding symptoms and quality of life. Results: Out of 42 in group I and 50 in group II, one patient in group I and three patients in group II did not follow and were excluded from the study. Baseline parameters between the two groups were statistically similar. Posttreatment parameters such as mean number of voids in first 8 hours decrease from 5.53 to 3.48 in group I vs 5.7 to 2.13 in group II, p valve <0.01. The mean number of urgency episodes in first 8 hours in group I decreased from 4.23 to 3.11 vs 4.68 to 2.29 in group II, p valve <0.01. The mean number of nocturnal voids in group I decreased from 3.55 to 2.48 vs 3.35 to 1.34 in group II, p valve <0.01. The mean IIQ-7 score in group I decreased from 51.10 to 32.8 vs 54.63 to 18.82 in group II, p valve <0.01. Differences were statistically significant. There was statistically insignificant change in serum sodium level posttreatment between group I and group II. Conclusion: Combination of desmopressin and anticholinergics was more effective and safe than anticholinergics alone in the treatment of female patients with overactive bladder. Therefore, desmopressin combined with anticholinergics could be considered feasible and safe method for relief of symptoms in female patients with overactive bladder. However, larger and long-term studies for proper evaluation are warranted.

Introduction: Increased ovarian production of androgens due to the stimulation of luteinizing hormone (LH) on theca cells can cause hyperandrogenism that may present with signs of alopecia in postmenopausal women. Case description: A 65-year-old postmenopausal woman presented to the gynecology clinic with male-pattern baldness. Serum testosterone was high that was suppressed with gonadotropin-releasing hormone analog (GnRH agonist). This confirmed ovarian source of androgens. Laparoscopic salpingo-oophorectomy helped reduce androgen levels over a period of an year therefore reversing at least partially the hair loss. Conclusion: Gonadotropin-releasing hormone analogs can be useful to diagnose the source of increased androgen levels to be of ovarian origin. Once confirmed, laparoscopic bilateral salpingo-oophorectomy can reverse hair loss in these cases.

Fibroids are the most common tumors of the female reproductive system. It is impossible to determine their true incidence, although frequently quoted incidence of as high as 50% has been found in certain longitudinal studies. Typical leiomyoma is a firm nodular well-circumscribed structure arising from the myometrium. Some of these fibroids may be asymptomatic while the usual symptoms associated are heavy menstrual bleeding, dysmenorrhea, abdominal discomfort, and pressure symptoms. Fibroids can be easily diagnosed by ultrasonography and MRI. However, some cases of fibroids may present as a diagnostic dilemma due to their bizarre presentation and unusual ultrasounds and MRI reports. Here we report three cases of fibroids with atypical clinical features that resulted in difficulty in making diagnosis.

Background: Uterine arteriovenous malformation (AVM) is a very rare cause of secondary postpartum hemorrhage (PPH) which might present along with retained products of conception (RPOC). Despite being a rare entity, it is a life-threatening condition and hence high degree of suspicion is required for prompt diagnosis and appropriate treatment as certain procedures, such as instrumental evacuation, commonly performed for RPOC could be devastating. With the recent advancements, color Doppler ultrasonography has become a preferred noninvasive method for diagnosing AVM though angiography remains the gold standard for diagnosis. Case description: This case report describes a 36-year-old multiparous woman who presented 3 weeks after delivery by lower segment cesarean section (LSCS) with secondary PPH. Transabdominal ultrasound (TAS) revealed an involuting uterus with an ill-defined hypoechoic area within the myometrium adjacent to the endometrium with significant intrinsic vascularity raising the suspicion of placenta accreta. Magnetic resonance imaging (MRI) with contrast was performed for confirmation which showed an AVM with coexistent RPOC. Since the patient did not give consent for uterine artery embolization which was offered to her during counseling, hysterectomy was carried out. Histopathological diagnosis of uterine AVM was conclusive. Conclusion: Arteriovenous malformation, although a rare entity, should be ruled out in a patient presenting with hemorrhage after delivery/miscarriage even if the imaging shows the presence of RPOC by the diagnostic modalities available so that appropriate treatment can be instituted.

Cesarean scar ectopic pregnancy (CSEP) is on the rise with increasing rate of cesarean section and better diagnostic modalities. Therefore, prompt and correct diagnosis and decision about treatment modality are important to reduce mortality and morbidity. Expertise of both gynecologist and radiologist is needed. High index of suspicion should be kept in mind, and any delay in management can lead to detrimental consequences. Here is a case series of three cases with CSEP and their conservative line of management. Diagnosis was made through history, clinical examination, serum beta-human chorionic gonadotropin (β-hCG) levels, ultrasound and hysteroscopy, and confirmed with histopathology also. Methotrexate was the primary treating modality in all the three cases, and the future fertility was preserved. The follow-up was by serum β-hCG and ultrasound scans.

Labial adhesions are usually a pediatric condition and are asymptomatic. They are identified by parents or on routine examination. They can also occur in postmenopausal age group albeit uncommon due to hypoestrogenism causing senile vaginitis. Here, we have two cases of labial fusion in different age groups, 17-years-old and 65-year-old females presenting with urinary symptoms. The release of labial fusion was done under general anesthesia in both the patients. The labial adhesions are usually a pediatric condition and are asymptomatic. Although one needs to have high index of suspicion to diagnose this rare condition, as the patient often presents with common gynecological symptoms of difficult menstruation and urinary dribbling. It can also occur in postmenopausal women though uncommon, one needs to have high index of suspicion due to hypoestrogenism.