Introduction: In pre-COVID era, telemedicine was not widely accepted for patient care and management. In COVID-19 pandemic, due to strict social distancing and various government guidelines laid down for patient management and care, it has been widely accepted. Methods: We did an online survey from June 20 to July 20, 2020, to find out acceptance and knowledge of telemedicine among clinicians of India for patient care. Results: Earlier only 11% of clinicians were using telemedicine, due to strict social distancing there has been a surge; now 57% of clinicians have accepted it. Analytical data also showed that after this pandemic 69% of clinicians will still continue to use telemedicine. Discussion: With telemedicine we can easily solve complaints of patients in outdoor department and quarantine center, as well as provide psychological counseling of COVID-19 and non-COVID-19 patients.

Introduction: Implantation is one of the rate-limiting steps of success rates in patients undergoing in vitro fertilization. Repeated implantation failure is defined as failure of good-quality embryos to successfully implant in uterine cavity in repeated IVF treatment cycle. The cause of such implantation failures may be maternal or embryonal. Endometrial scratching and lateral metroplasty are found to increase successful implantation rates in various studies. There is hardly any study in the literature comparing the success rates of endometrial scratching and hysteroscopic lateral metroplasty. Keeping in mind this fact, we conducted this comparative study to compare the successful pregnancy rates and clinical pregnancy rates in patients who had undergone endometrial scratching and hysteroscopic lateral metroplasty for repeated implantation failures. Materials and methods: A total of 60 patients having primary or secondary infertility and had history of repeated implantation failure were included in this study on the basis of a predefined inclusion and exclusion criteria. The patients were divided into two groups on the basis of treatment they received. In group A, 30 patients underwent endometrial scratching, and in group B, 30 patients underwent hysteroscopic lateral metroplasty. The successful pregnancy rates and clinical pregnancy rates in both the groups were compared. SPSS 22.0 was used for statistical analysis, and P value less than 0.05 was taken as statistically significant. Results: Out of 60 patients, 50 (87.5%) patients belonged to primary infertility, whereas 10 (12.5%) patients were found to have secondary infertility. The mean age of patients in group A was 34.12 ± 3.12, whereas the mean age in group B was 35.42 ± 4.46 years. The mean duration of infertility in patients of group A and group B was found to be 7.43 ± 2.50 and 6.93 ± 2.54 years, respectively. The mean number of antral follicle count in group A was 9.52 ± 1.82, whereas in group B, it was 10.42 ± 1.52. In group A, 12 (40%) patients were confirmed to be having successful pregnancy on the basis of β-hCG levels on D14, whereas 17 (56.67%) patients in group B were found to have successful pregnancy on the basis of β-hCG. Fetal cardiac activity was present in 13 (43.33%) patients and 18 (60%) patients in group A and group B, respectively (p = 0.301). The difference was not found to be statistically significant (p = 0.30). Conclusion: Endometrial scratching and hysteroscopic lateral metroplasty both are effective management strategies in patients having history of repeated implantation failure. Though lateral metroplasty appears to be a better choice, the difference was statistically insignificant (p > 0.05).

Introduction: Menopause is defined as permanent cessation of menstruation, caused by ovarian failure. Average age of menopause is 52 years, with a range of 40–58 years. Women in developed world will live approximately 30 years, or greater than a third of her life, beyond menopause. Therefore, it is important to ensure these years are as healthy and productive as possible. Any amount of postmenopausal bleeding (PMB) is of great concern and it has to be evaluated thoroughly. Aim: To evaluate hysteroscopic findings in women with PMB in order to ascertain various causes of PMB and to determine their prevalence in our population and its correlation with histopathologic examination. Materials and methods: This was a prospective observation study, comprising a total number of 50 postmenopausal women attending Gyne OPD at Department of Obstetrics and Gynaecology, Command Hospital (CH), Lucknow, Uttar Pradesh, carried out over 1 year. Postmenopausal women with UV prolapse, bleeding diathesis, surgical menopause, and cardiac diseases were excluded from the study. After taking detailed history, thorough clinical examination, and informed consent, patients are subjected to transvaginal sonography followed by hysteroscopy with office hysteroscope and wherever necessary, endometrial biopsy was taken. Final diagnosis was established with the help of clinicohistopathologic workup. Results: The present study was carried out to evaluate hysteroscopically the causes of PMB. For this purpose, a total of 50 women with complaints of PMB were enrolled in the study. Age of patients ranged from 41–80 years. On hysteroscopy, half the cases (n = 25; 50%) were diagnosed as polyps followed by atrophic endometrium (n = 8; 16%). There were 7 (14%) cases in whom the cervix was classified as unhealthy without any particular diagnosis. A total of 5 (10%) cases were diagnosed as fibroid, 1 (2%) each as hyperplasia and degenerative changes, and 3 (6%) as endometrial carcinoma. These findings are well correlate with clinicohistopathologic diagnosis. Conclusion: Hysteroscopy is an office procedure that can be performed as a daycare procedure, provides a better view of various structural pathologies, and in case of a doubtful pathology, helps in obtaining endometrial sample to confirm the diagnosis.

Aim: Various congenital and acquired causes can lead to abnormal conduction of electrical impulses from atria to ventricles, resulting in complete atrioventricular dissociation. Such complete heart blocks (CHBs) are uncommon in pregnant women. However, when diagnosed in pregnancy, the management remains challenging. Here, we share our experience of managing patients with CHB diagnosed in pregnancy and their outcome. Materials and methods: A retrospective review of women diagnosed with CHB during pregnancy and managed in the Department of Obstetrics and Gynecology, Tribhuvan University Teaching Hospital, and in Manmohan Cardiothoracic and Vascular Center, from April 2016 to March 2020, was done. Data studied from case records included history, clinical examination, 12-lead electrocardiogram, echocardiogram, 24-hour Holter study, exercise tolerance, response to chronotropic drugs, and antenatal follow-up. Mode of delivery, need for pacing, and maternal and fetal outcomes were evaluated. Results: Six women had CHB diagnosed between 22 and 40 weeks’ gestation of index pregnancy. The mean age of the patients was 25.8 ± 5.1 years. The heart rate at diagnosis was between 40 and 48 bpm. None of the patients had any symptoms or abnormal echocardiography. Fifty percent had vaginal delivery. All of the patients had an uneventful peripartum period and none had any emergency indication for pacing. The mean birth weight of the babies was 2485.7 ± 389 g and two of them had intrauterine growth retardation. None of the babies had any conduction or cardiac structural abnormalities. Conclusion: Close monitoring, periodic follow-up, and vigilant management by a multidisciplinary team of obstetricians, cardiologists, anesthetists, and pediatricians in a center with the facility of insertion of a cardiac pacemaker can ensure a good maternal and fetal outcome in pregnant women with CHB. Clinical significance: Asymptomatic CHB in pregnancy can be managed conservatively without pacing.

Introduction: Partogram is an important tool to monitor the progress of labor. Existing WHO partogram is too cumbersome for the busy healthcare providers working in labor rooms in developing nations. There is a need to develop a more user-friendly way to measure the progress of labor and thus prevent the unfortunate events during labor. Methods: The descriptive study was conducted in the Department of Obstetrics and Gynaecology of a teaching medical institution of India. The participants were patients in labor. Patients were enrolled once they fulfilled eligibility criteria and gave informed consent. Expected time of delivery (ETD) was calculated by application of Friedman's formula of cervical dilatation in “active phase” of labor of 1 cm/hour, which is applicable from 4 cm dilatation onwards. It was written in bold letters on the case sheet. Women were managed as usual, and the progress of labor was monitored. Proportion of women delivered within reasonable time of the ETD was calculated. Results: Out of the 110 women included in the study, 73 (66.4%) were nulliparous. The mean (SD) gestational age of them was 38.47 (1.4) weeks. More than half of the women presented at 4 cm cervical dilatation. 11.7% of the women required either 2.5 or 5 U of Syntocinon injection. 75 (68.2%) women delivered on or before time of the calculated ETD. 33 (30%) women delivered within ±60 minutes of the calculated ETD. There was no significant association between the parity status of the woman and the induction of the labor. Similarly, parity status had no association with the time difference between the actual and expected time of delivery. Conclusion: Paperless partogram is an important alternative to the conventional partogram. It can be used in resource-constraint settings to save resources and future mothers.

Aim: To apply the Robson Ten Group Classification System (TGCS) in major South Asian hospitals to begin making recommendations to optimize cesarean section (CS) rates. Materials and methods: This cross-sectional study was conducted from September 2018 to February 2019 at public sector hospitals in five South Asian countries. We analyzed the pooled data for all five hospitals. The data were then stratified by the study hospitals. We utilized a Pearson χ² test to assess differences in CS by group. And p values <0.05 were considered statistically significant. Statistical analysis was performed using STATA 16. Results: A total of 37,251 women delivered in the five participating hospitals during the 6-month study period. Of these, 13,592 women were delivered by CS with a composite CS rate of 36% (range, 22–53%). Women in groups 1, 2, and 5 were the largest contributors to the overall CS rate in the participating hospitals. Statistically significant differences in CS rates between the hospitals were found in all groups except group 9. Conclusion: TGCS is useful as a starting point with which to identify patient groups warranting interventions to optimize CS. However, data collection alone is not sufficient. Analysis and interpretation should also include assessing maternal and neonatal outcomes. Clinical significance: Preliminary findings indicate that strategies to optimize the use of CS should include avoidance of medically unnecessary primary CS and increasing vaginal birth after cesarean.

Aim: Labor dystocia is one of the commonest indications of lower segment cesarean section (LSCS). Recent studies have shown a dramatic change in the rate of cervical dilatation and labor progress. There are no large studies to assess labor in this ethnic group and hence this study has been done to find out labor behavior in women with spontaneous labor in South India. Materials and methods: A retrospective study was done in our teaching hospital. Labor was managed as per protocol and a partogram was maintained. Data were extracted from case-records and analyzed. Results: Labor progress was much slower than what was thought of. There was wide variability in the duration of labor. Conclusion: Many women took time up to the 95th percentile and some even crossed three times the median time to deliver. Clinical significance: Though many women will deliver in the expected time, it is important to know the maximum time or the 95th percentile for each dilatation so that sufficient time can be allowed before labeling a case as prolonged labor.

Introduction: Toxoplasmosis, other agents, rubella, cytomegalovirus, and herpes simplex virus (TORCH) infections are important groups of organisms which are initially inapparent, asymptomatic, and difficult to diagnose on the clinical ground during pregnancy but have the potential to cause bad obstetrical outcomes. The aim was to study the association of TORCH infection with the perinatal outcome in cases of high-risk pregnancies. Materials and methods: A total of 200 high-risk pregnant patients of age group <35 years attending Antenatal Care Outpatient Department or admitted in Inpatient Department of Obstetrics and Gynaecology Department at Acharya Vinoba Bhave Rural Hospital, Sawangi, were included in the present study. The study group includes high-risk pregnant women with fetal congenital anomalies, recurrent pregnancy loss, oligohydramnios, intrauterine fetal death, fetal growth restriction, hypertensive disorders, bad obstetric history, preterm labor, polyhydramnios, and other medical disorders. Patient's serum was analyzed for IgG (immunoglobulin G) and IgM (immunoglobulin M) antibodies against TORCH agents using ELISA kit and followed till delivery for the perinatal outcome. Perinatal outcome in high-risk pregnant women with seropositivity and seronegativity was compared. Results: In 200 cases of high-risk pregnancy, the majority of women with seropositivity for TORCH infection were of younger age group with low parity, residing over rural areas and of low socioeconomic status. One hundred sixty-two cases (81%) were seropositive and 38 cases (19%) were seronegative for TORCH antibodies. The seropositivity in high-risk pregnant women for toxoplasma, rubella, cytomegalovirus, and herpes was 5.5, 75.5, 56, and 14.5%, respectively for IgG, while it was 0, 6, 4, and 0% for IgM, respectively. Our study showed that pregnant patients with high-risk factors for TORCH infection with seropositivity showed a significant association with adverse perinatal outcomes. Conclusion: Association of seropositivity with high-risk factors for TORCH infection was found to be associated with adverse perinatal outcome as compared to seronegativity in same high-risk groups.

Objectives: To determine the diagnostic value of ProEx C in the detection of cervical squamous epithelial lesions. Materials and methods: A cross-sectional study was conducted on 60 cataloged cervical biopsy specimens. The specimens were received from incident cases for routine histopathological evaluation in MS Ramaiah Hospital. Immunohistochemical examination was performed on paraffin biopsy blocks of the specimen for nuclear and cytosolic staining with ProEx C. From the data, the proportion of positive staining cells and the average intensity of staining were assessed. Results: As per this study, the sensitivity and specificity of ProEx C were found to be 95 and 83%, respectively. Conclusion: ProEx C is an ascertained highly sensitive and specific marker. This will help to overcome the drawbacks of basic screening methods in terms of inter- and intra-observer variations and false-positive and false-negative values, and either replace or complement the less economical human papillomavirus (HPV) DNA testing in the triage for developing nations. Clinical significance: The use of ProEx C as an immunohistochemical marker is a highly reliable indicator of not only the presence of cervical squamous epithelial lesions but also the grade of the lesion. With high positive and negative predictive values for dysplasia and invasive carcinomas as well, ProEx C serves as an excellent diagnostic tool for cervical intraepithelial lesions.

Background: Presently care to all women is given under the single umbrella of obstetrics and gynecology. Obstetrics is a very demanding field with unpredictable working hours and less social life. That is why over the career line many doctors leave obstetrics and go for gynecology practice. This trend has increased over the years which can affect the future workforce. Laborist model of care has been proposed to overcome this. But segregating obstetrics and gynecology can give a permanent solution to the future workforce. To evaluate this hypothesis, a survey was done to gather the opinion of obstetrics–gynecology specialists on the perceived need, benefits, and harms of separating obstetrics and gynecology. Material and methods: This was a questionnaire-based cross-sectional study conducted from September 2016 to May 2018. Enrolled subjects were the obstetrician and gynecologists who have completed their postgraduation. A questionnaire was prepared using Google forms, keeping in view all the aspects of study. Obstetricians and gynecologists were contacted by mail, Facebook and WhatsApp groups, or in person to fill the pro forma. Stata was used to analyze the data. Mean was calculated for continuous variables and proportions for discrete variables. Analysis was performed to evaluate any relation of age, years of experience, or type of workplace from the viewpoint of segregating the branch. Results: One hundred sixty-seven responses were received. Mean age was 39.4 ± 10.3 years. Thirty-seven percent had 15 years of experience in obstetrics and gynecology. Eighty-eight percent of the respondents were practicing both fields. Doctors for and against the segregation of obstetrics and gynecology were 55% and 39%, respectively. Main reasons for the segregation were delivering better medical care, increased scope of subspecialization, and improved knowledge and skills of doctors. Others cited that obstetrics and gynecology are very much interrelated branches so cannot be separated. If already separated fields, 65% (48/137) would have opted gynecology and 35% (48/137) obstetrics. However, no difference was found in the preference for or against the segregation of medical field by age, years of experience, or the type of workplace (government/private). Conclusion: Medical fraternity feels the need for segregating obstetrics and gynecology.

Aim: A nested case–control study was conducted to establish an association of placental tissue estrogen receptor alpha gene expression with postpartum depression. Materials and methods: Antenatal women were enrolled in their third trimester, and after delivery, their placentas of 1 × 1 cm were stored in freezer at −80°C. Women were evaluated at 2 weeks and 6 weeks after delivery by Edinburgh Postnatal Depression Scale (EPDS) Hindi version, to identify postpartum depression (PPD) cases and controls. Results: Out of 209 eligible women recruited, 30 PPD cases and 30 controls were identified on follow-up visits, and then, their stored placental tissues were analyzed for ESRα gene expression and the quantitative levels of ESRα RNA expression were evaluated. It was observed that ESRα gene was significantly downregulated by 1.33 times among cases as compared to controls, and the placental ESRα delta Ct value among cases was significantly higher with respect to controls. Conclusion: Women developing PPD after delivery have significantly lower expression of ESRα gene in their placenta at the time of delivery, which is 1.33 times less as compared to women who remain healthy. The mean ESRα delta Ct value in PPD cases (3.33 ± 0.697 SD) was significantly higher than the controls (2.91 ± 0.759 SD), with p value 0.032. Thus, the downregulation of placental ESRα gene expression at delivery plays a crucial role in PPD.

Premature rupture of membrane (PROM) has significant adverse events in the prenatal, peripartum, and neonatal period. Understanding the maternal and neonatal outcomes of PROM is very important to reduce maternal and child mortality by prevention of complications and better management of the condition. The present study is undertaken to determine the maternal and fetal outcomes in patients with PROM and factors influencing the maternal and neonatal outcomes following PROM. We retrospectively evaluated the maternal and neonatal outcomes and the associated risk factors for 200 consecutive singleton pregnancy outcomes by PROM. Our results suggest that the mean age of the study participants was 22.90 ± 3.45 years ranging from 18–40 years. The estimated occurrences of unfavorable maternal and neonatal outcomes were 24.5 and 28.0%, respectively. Fever (67.3%) followed by puerperal sepsis (12.3%), wound infection (6.1%), and postpartum hemorrhage (6.1%) were common maternal outcomes and birth asphyxia (55.4%) followed by neonatal septicemia (25.0%) and convulsion (5.4%) were common neonatal outcomes. C-reactive protein (CRP) was positive among 44.0% of the mothers, and Escherichia coli was the commonest organism isolated in the cervical swab. The positive serum maternal CRP levels with an adjusted odds ratio (AOR) of 3.3 and 4.8 and latency in conducting delivery with an AOR of 1.1 each were the significant independent predictors of the maternal and neonatal morbidities (p <0.05).

Objective: Our study evaluates the clinical efficacy of intravenous (i/v) amino acids in the prevention of lactation insufficiency and improvement of neonatal weight gain. Design: A prospective, randomized, open-label, placebo-controlled clinical trial is reported. Population or sample: This study recruited 305 lactating mothers of age-group, 22–35 years. Methods: Test group, n = 152, received i/v amino acid infusion, 500 mL, as study drug once daily for 4 days, and control group, n = 153, received normal saline as placebo, 500 mL od for 4 days. Main outcome measures: We studied the efficacy and safety of i/v amino acids in the prevention of lactation insufficiency. We further evaluated the role of maternal amino acid supplementation in ameliorating physiological weight loss and overall neonatal weight gain. Results: Lactation onset was reported in 86.3% of mothers in the amino acid group at day 0 as compared to 32.23% in the control group (p value < 0.001). Lactation was achieved by all the mothers in the study group by day 1 itself with two doses of i/v amino acids (p value < 0.001). An increase in neonatal weight was observed in the amino acid group, (2.900 ± 0.488, p value = 0.001) compared with the control group at 2 weeks (2.716 ± 0.484, p value = 0.001). Conclusion: Maternal amino acid supplementation is proven to be both efficacious and safe in augmenting breast milk production, thereby preventing lactation insufficiency. It effectively prevented neonatal physiological weight loss at 2 weeks and promoted substantial weight gain over a period of a month after birth.

Aim: The aim of this review article was to analyze and summarize the current treatment options of endometriosis-associated pain to provide additional information about treatment personalization for clinicians. Background: Despite numerous studies being published, endometriosis is still one of the main challenges in gynecology. The etiology of endometriosis is unclear while its mechanism is believed to be connected to the peritoneal endometriotic lesions via retrograde menstruation, immunity abnormalities, and genetic, environmental, and lifestyle factors. Patients with endometriosis generally have to cope with chronic pelvic pain which definitely affects the quality of life. The disease is often characterized by a persistent recurrent course; therefore, when choosing a treatment, special attention should be paid not only to its efficacy, but also to long-term safety, tolerability, and compliance. Review results: Actual and relevant publications in PubMed and eLibrary databases were studied. The authors highlight the pathogenic mechanisms of endometriosis and the current state of pharmacological management options. The available evidence on the use of combined oral contraceptives (COCs) for pelvic pain is critically assessed and the authors propose their opinion on the alternative treatment options with progestogens which seem to be an effective alternative to COCs with a more favorable safety profile. Conclusion: Progestogens are an effective alternative to COCs in the treatment of endometriosis-associated pain; however, further well-conducted trials are needed in both types of therapy. Clinical significance: The results of this literature review provide additional information to enable clinicians to personalize the treatment of endometriosis-associated pain.

Obstructed hemivagina, ipsilateral renal agenesis (OHVIRA) syndrome, as well as didelphic uterus, is a rare, obstructed müllerian anomaly, affecting the physical, reproductive, sexual, and mental health of the patient. The diagnosis is often delayed because of unawareness of the fact that even common gynecological complaints like vaginal discharge can be associated with this rare entity. The most common symptoms at presentation, however, include pain in the abdomen and menstrual complaints. Therefore, while evaluating them, the possibility of this rare entity should be kept in mind; hence, emphasizing the importance of local examination. A 3D ultrasound and a magnetic resonance imaging are helpful in confirming the diagnosis. In this article, we report case series of OHVIRA syndrome with extreme clinical symptoms at presentation. We reviewed the literature and discussed various classifications used for this syndrome, including the newer classification based on the type of obstruction. The minimally invasive “vaginoscopic no-touch” technique of surgery is an alternative option available for adolescents where preservation of hymen seems to be important.

Background: The severe acute respiratory syndrome coronavirus-2 was initially believed to be an infection of only the respiratory system. It is now known to have many extrapulmonary affections including gastrointestinal symptoms associated with high mortality rates. An unusual presentation of bowel perforation in a patient who had recently undergone cesarean delivery prompted us to report this mini review of bowel perforations attributed to coronavirus. Case: Our patient, a 19-year-old primigravida, underwent an emergency cesarean section under spinal anesthesia. Intraoperative events and postoperative period were uneventful, and the patient was discharged on postoperative day 5. On the 10th postoperative day, the patient presented in septic shock to the emergency department with complaints of acute epigastric pain, vomiting, loose stools, and bilious discharge from the wound site. Oral contrast computed tomography was done, which revealed a proximal jejunal perforation. The patient was taken up for laparotomy followed by bowel repair with placement of intraperitoneal drains. Immediate postoperatively, the patient developed high-grade fever for which reverse transcription polymerase chain reaction (RT-PCR)_for COVID-19 was sent. The result for the same turned out to be positive. Twenty-four hours after the laparotomy, the intraperitoneal drains again started draining copious bilious discharge along with the deterioration of general condition of the patient. She expired on the third postoperative day. This was followed by a thorough research of the literature into possible etiologies for bowel perforation. In this mini review, we shall be discussing various case reports to determine the cause of such unusual presentation in our patient.

Aim: Our aim is to highlight the emerging trends of management of a moderate-to-severe degree of Asherman's syndrome/fibrotic uterine cavity in the form of either relook hysteroscopic surgery or postoperative hormonal therapy. Background: Asherman's syndrome also known as Fritsch syndrome or Fritsch–Asherman syndrome is a condition where iatrogenic intrauterine adhesions (IUA) develop and it occurs most commonly following dilatation and curettage or pelvic infections, e.g., endometrial tuberculosis. Diagnosis is based on the history and a high index of suspicion followed by confirmation by saline infusion sonography (SIS) or hysterosalpingography (HSG). Hysteroscopy is the gold standard for both diagnosis and treatment of Asherman's syndrome. This case highlights the importance of hysteroscopic management of a known case of Asherman's syndrome/IUA and also highlights how important are relook hysteroscopic surgeries and their interval from primary surgery and gradually decreasing the dose of postoperative hormonal therapy to cure the same and to improve the clinical outcome. Case description: We present a case where a patient underwent curettage after retained products leading to fibrosis of the uterine cavity. Multiple surgeries abroad were unsuccessful to correct the problem. Then patient came to our institute where hysteroscopic adhesiolysis and lateral wall metroplasty along with laparoscopic adhesiolysis and right-sided ovarian cystectomy followed by intrauterine contraceptive device (IUCD) insertion, i.e., multiload without copper was done followed by two more relook hysteroscopic procedures leading to reformation of a normal uterine cavity. The authors discuss the stepwise management of a known case of Asherman's syndrome through this successful and challenging case. Conclusion: IUA develop most commonly after vigorous curettage or endometrial tuberculosis. Diagnosis is based on the history and a high index of suspicion and confirmation by SIS and HSG. The hysteroscopic management of IUA is a safe and effective method. It is a surgical pearl for both diagnostic and therapeutic purposes. Sequential estrogen and progesterone therapy and a splint are found to be helpful, but further studies are needed to assess their efficacy. Relook hysteroscopy acts as an adjunctive method to improve the outcome. We emphasize on relook hysteroscopy and its interval from the primary surgery which is usually after next menses when the patient resumes menses as it helps to get a better and long-term clinical outcome. Clinical significance: Hysteroscopy acts as both a diagnostic and therapeutic tool for the management of fibrotic uterine cavity. Relook hysteroscopic surgery is useful to manage a moderate-to-severe degree of fibrotic uterine cavity along with insertion of IUCD without copper to prevent further adhesions. Gradually decreasing the dose of hormonal therapy (estrogen plus progesterone) helps to regenerate the endometrium and to resume normal menses.

Aim: To present a rare case of struma ovarii in a 46-year-old lady presenting with features pointing toward malignancy. Background: Struma ovarii is a specialized or monodermal teratoma, which is predominantly composed of mature thyroid tissue. It accounts for less than 5% of all ovarian teratomas. It is mostly benign, and malignant changes are extremely rare. Most patients are asymptomatic or may present with mild signs and symptoms. Although the vast majority are benign, they may rarely present mimicking malignancy. Case description: A 46-year-old lady presented with a large complex abdominopelvic mass with ascites and elevated CA-125 levels, thus arising suspicion of malignancy. Postoperatively, histopathology revealed a benign struma ovarii, which was further confirmed by immunohistochemistry. Conclusion: Struma ovarii can imitate ovarian malignancy clinically, especially if it is complex and found in combination with ascites and an elevated CA-125 level. There is paucity of literature about such cases, and hence, it makes an accurate and timely diagnosis difficult. Clinical significance: This case is one of the very few that provide a description of an atypical presentation of a rare tumor, struma ovarii. A high level of clinical suspicion may help with better preparedness before surgery and prevent extensive laparotomies in such patients.

Obstetric practice in recent times has witnessed a steady increase in the rate of primary cesarean sections and thus, the consequences of the same. Managing previous cesarean cases in obstetrics has now become a routine, and the complications which we encounter in these patients. In this case series, we present five different presentations of previous cesareans and their outcomes. Treating the complications in these leads to a lot of diagnostic and management dilemmas as there is no definite prescribed protocol and individualized management strategies need to be adopted. Atypical clinical and radiological signs should be identified in such cases and should be managed in a tertiary care hospital for the best outcome of the patient.