Introduction: Involuntary loss of urine caused by raised intraabdominal pressure during exercise, coughing, or sneezing is known as stress urinary incontinence (SUI). Urinary incontinence affects over a quarter of women between the ages of 30 and 60, with SUI accounting for roughly half of the cases. Aging, smoking, straining, obesity, and COPD are all risk factors that may result in incontinence. Conservative therapy such as lifestyle changes, pelvic floor muscle training, bladder training, and medications are used as the first line of treatment for SUI. Surgery is recommended for patients who have not improved with conservative measures. Many surgical procedures are described to correct SUI. The essential premise in the therapy of SUI is to create functional kinking of the mid-urethra during episodes of raised intra-abdominal pressure to ensure adequate suspension. Two important sling methods are developed in the last two decades. Transobturator vaginal tape (TOT) technique is anatomically accurate and has the potential to reduce obstruction and postoperative voiding dysfunction. For the surgical treatment of SUI, these mid-urethral sling techniques became the gold standard. Aims: To study the postoperative complications, outcomes, and quality of life of patients undergoing TOT. Subjects and methods: This study is conducted prospectively from October 2018 to August 2021 on 24 genuine SUI patients, who underwent transobturator sling surgery in the Urology Department, Yenepoya Medical College, Mangaluru. The patients underwent all baselines and special examinations, such as an urodynamic study and a cystopanendoscopy. For the first 6 months, patients were treated with conservative therapy such as lifestyle changes, bladder training, pelvic floor exercise, and medications (duloxetine, imipramine, estrogens). All the patients who had failed or were dissatisfied with conservative treatment underwent the TOT treatment. Results: In total, 24 patients were assessed in this study. The patients ranged in age from 36 to 50 years old, with a mean age of 42.3 years. A total of 23 (95.8%) of the 24 patients were multiparous. All of the patients experienced involuntary urine leakage during straining, with 20 (83.3%) having grade II symptoms and 22 (91.6%) having symptoms for more than 3 years. Preoperatively, six (25%) of the patients had a minor cystocele, which was cleared after surgery. Diabetes mellitus/hypertension were present in four (16.6%) of the patients. ALPP ranged from 94 to 110 cm of water. All patients had maximal flow rate of more than 20 mL/second and a PVRU of less than 50 mL. The quality of life improved after surgery from a mean of 12.4 to 2.1. Urine flow rate was more than 20 mL/second in 19 patients (79.1%) after surgery, and 15–20 mL/second in 5 patients (20.8%) which improved after 3 months to more than 20 mL/second. In 20 (83.3%) patients, PVR urine was less than 50 mL, and in 4 (16.6%), it was between 50 and 100 mL. At 6-month follow-up, 22 (91.6%) patients were completely satisfied with the surgical outcome, while 2 (8.3%) patients were only moderately satisfied. Conclusions: TOT sling is a successful surgical treatment option for SUI, with a good success rate, patient satisfaction, minimal morbidity, and a shorter hospital stay. Patients endure and accept TOT surgery well, and it provides a long-term cure for SUI patients. We advocate TOT as the therapy of choice for SUI because of its safety, ease of use, short surgical time, speedier recovery, minimum problems, and high success rates.

Aim: To analyze the management approach of difficult and unusual leiomyoma conditions. Materials and methods: A retrospective analysis of all unusual cases of leiomyoma with special consideration to the challenges encountered during their management has been done in a tertiary care center in northern India over a 1-year duration. All cases were analyzed in detail and learning points extracted. Results: A total of 11 cases were retrieved. All of them were unique in their course of surgical management. Five cases presented with abdominopelvic mass (APM). Two cases presented with abnormal uterine bleeding (AUB). Pressure symptoms were presenting complaints in two cases. Three cases presented with complaints of something coming out of the vagina. One case was antenatal and presented with a huge lower uterine segment (LUS) leiomyoma and uterine torsion in term pregnancy. Conclusion: The unusual site, size, and location of leiomyomas may pose surgical challenges to their management. Proper preoperative planning, thorough knowledge of female pelvic anatomy, and good clinical acumen make management of such testing cases possible in the hands of an expert gynecologist. Clinical significance: This paper will provide insights to the treating gynecologist in the management of challenging leiomyoma cases posing a clinical and surgical dilemma to their management.

Objective: This study compared and evaluated the outcomes of using Interceed and skin graft in vaginoplasty for women with Mayer–Rokitansky–Kuster–Hauser (MRKH) syndrome on the basis of vaginal length (neovagina), procedure safety, patient satisfaction (sexual) after marriage, ease of procedure, procedure time, and morbidity. Materials and Method: Over the course of 18 months, this hospital-based randomized controlled trial was conducted at a tertiary care center. There were 17 women with primary amenorrhea and MRKH syndrome who had undergone vaginoplasty and met the inclusion and exclusion criteria. Nine women received vaginoplasty with Interceed and eight women got vaginoplasty with skin graft, and they were monitored for 6 months postmarriage using a computerized block randomization system. Anatomical and functional outcomes were assessed in these women. The percentage, mean, and standard deviation (SD) were calculated using Epi Info program. For the analysis, the Mann–Whitney and Fischer tests were used. Observations: Women in group A (Interceed) were 22.322 ± 1.59 years old, whereas those in group B (split-thickness skin transplant) were 23.85 ± 1.83 years old. On day 8, the length of the vagina in women who had vaginoplasty with Interceed (Group A) was 8.8330.4153 cm, which was longer than 8.413 ± 0.4190 cm in women who had split-thickness skin transplant (Group B). The vaginal width was determined to be two-finger breadth in both groups. The duration of surgery in women undergoing vaginoplasty with Interceed (Group A) was 32 ± 4.243 minutes as compared to split-thickness skin graft (Group B) where it was 61.38 ± 8.634 minutes. This difference is statistically significant. The functional outcome in relation to sexual satisfaction (lubrication, orgasm, satisfaction, and pain) in women undergoing vaginoplasty with Interceed was 77.8% as compared to 37.5% with Split-thickness skin graft. Conclusion: By using Interceed for vaginoplasty, gynecologist is independent and no separate procedure is required for graft. It is safe, easy, effective, less time-consuming and patient satisfaction with anatomical and functional outcome is good due to squamous epithelization. Hence, is a potential alternative for vaginal agenesis.

Objective: India reported its first case of coronavirus in Kerala on 30th January, 2020. On March 24, 2020, the Government of India announced the first complete lockdown of the entire nation for 21 days for the containment of the virus. The immediate effect of the lockdown was that the cases and COVID-19-related deaths were significantly controlled. Besides the direct effects, the indirect impact of the pandemic and pandemic-control policies on healthcare services, communities, and the global economy may also affect vulnerable groups like pregnant women. The objective is to explore trends in maternal or neonatal outcomes during this pandemic by comparing the same in pre-pandemic, pandemic, and post-pandemic phases. Materials and Methods: This was a retrospective analysis of maternal and neonatal outcomes over the period from January 2020 to August 2021. The monthly statistics from the pre-pandemic period (2018 and 2019) were combined and then analyzed against the statistics from 2020 and 2021 using the Fisher's exact test or Chi-squared analysis as appropriate. Results: There was positive correlation between the monthly number of COVID-19-related deaths with the monthly number of stillbirths (p = 0.153). The diagnosis of antenatal complications such as hypertension in pregnancy occurred at the same rate pre-pandemic as in the months during the pandemic. There was a strong positive correlation between maternal mortality and the number of COVID-19-related deaths (p = 0.016). Conclusion: Women's healthcare is often adversely affected in humanitarian disasters, and our study highlights the importance of planning for powerfully built maternal services in any emergency services.

Aim: To study childbirth experience of women with coronavirus disease-2019 (COVID-19) at our institute and to assess clinical characteristics, maternal, and perinatal outcomes of SARS-CoV-2-positive pregnancies. Materials and methods: We conducted a prospective cohort study of all SARS-CoV-2-positive women who delivered at our institute from 1 September 2020 to 31 March 2021. The data was collected from labor room birth register, electronic medical record (EMR), and feedback questionnaire, Kerala Institute of Medical Sciences–Childbirth Experience Questionnaire (KIMS–CEQ), filled by women to express their childbirth experience. Results: Of the 50 women we studied, 84% were asymptomatic. In contrast to the majority of the studies published till now, preterm labor in our study was noted only in 12% cases. In our study, 62% delivered vaginally and cesarean section (CS) rate was 38%. All cesarean deliveries were done only for obstetric or fetal indications. A total of 6% women had minor peripartum complications. Majority of the neonates had normal appearance, pulse, grimace, activity, and respiration (APGAR) scores, and all were COVID-19 screen negative; 12% required neonatal intensive care unit (NICU) admission; 84% women opted to breastfeed their babies (direct breastfeeding or expressed breast milk) maintaining all precautions and hygiene they were taught; 88% women experienced positive childbirth experience based on KIMS–CEQ score. Conclusion: In our study, the pregnancy complications including the pre-term labor and severity of COVID-19 are not found to be above those in screen negative pregnant women nor any case of vertical transmission of SARS-CoV-19 reported. Our study is unique as it also assesses the birthing experience in women with COVID-19 which shows that most of them had a positive birth experience at our institute. The COVID-19 status should not deprive any women of her childbirth rights, although more precautions are warranted. Clinical significance: A positive or negative childbirth experience can have far-reaching consequences in life of a woman and the newborn. It is the need of the hour to address the important issue of positive birth experience, especially during the era of ongoing COVID-19 pandemic. The KIMS–CEQ provides an efficient tool to assess birthing experience of women with COVID-19.

Background: Pieces of clinical evidence suggest that coronavirus disease-2019 (COVID-19) viral infection results in hormonal imbalance leading to changes in menstrual cycles of women. This study has been conducted with the aim to determine the effect of COVID-19 infection and its vaccine on menstrual cycle patterns. Materials and methods: This was a cross-sectional study to observe any changes in menstrual cycle after COVID-19 infection or after its vaccination. A Web Link collector generated the survey‘s universal resource locator (URL) and was sent via social media messages to females in the general population as well as healthcare workers. Results: Menstrual cycles remained unaltered in 154/228 (67.5%) of women post-COVID-19 infection irrespective of its severity. Out of 228, one-third of women, i.e., 74/228 (33%), reported changes in their menstrual patterns, with respect to either cycle length, duration of flow, number of pads used, pain during menses, or premenstrual symptoms (PMSs). Menstrual blood loss was decreased by 14% (32/228) and 18%; 42 women complained of increased flow during menses. Twenty percent of women who had severe infections had menorrhagia. Out of the 590 women who completed the questionnaire, 436 (73.8%) were vaccinated against COVID-19 and 154 (26%) were unvaccinated. After vaccination, 290/436 around one-third of women (66.5%) had normal menstrual cycle, 21 women (4.8%) had decreased menstrual blood flow, and 18 women (4.1%) reported increased menstrual flow. Conclusion: COVID-19 infection affected the menstrual cycle of only one-third of women and this effect was temporary. This effect might be due to stress and anxiety affecting the hypothalamic-pituitary axis (HPA). More studies are needed to support this effect.

Background: Preterm labor is a major determinant of neonatal mortality and morbidity worldwide, especially in developing countries. Aims: The study aimed at finding out the incidence and the etiological risk factors responsible for preterm labor that could be targeted to reduce its risk. Materials and methods: In this prospective cohort study of 1 year, a total of 440 antenatal patients diagnosed with preterm labor were included and were followed up. In addition to the known risk factors for preterm labor, investigation data, gestational ages, neonatal outcome, and response to tocolysis if given were noted. The collected data were analyzed using descriptive statistics. Results: The incidence of preterm birth for the current study was 6.7%. The majority of patients were multigravida (59%) and mainly were of the age lesser than 30 years (89.3%). A total of 477 babies including 37 twins were delivered by 440 preterm deliveries of which 377 (79.03%) were live births. About 40.90% of babies had a birth weight in the range of 1.6–2 kg. Neonatal morbidity in preterm babies was 49.33% and was high with patients who had not received steroid coverage (90%) and when the gestational age was less than 34 weeks (72.57%). Similarly, neonatal mortality was found to be 26.52% in preterm babies and was higher in patients who did not receive steroid coverage (63.4%) and also when gestational age was less than 34 weeks (44.18%). Conclusions: Early recognition, appropriate management, and early administration of steroid in high-risk pregnancies along with advice on modifiable etiologies and preconception counseling can bring down preterm birth and thereby reduce neonatal morbidity and mortality.

Aims and objectives: The aim of the study were: (1) to study the correlation between clinical, sonological, and histopathological features of ovarian tumors; (2) to assess accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of color Doppler in differentiating benign and malignant ovarian pathologies; and (3) to study the epidemiology of ovarian tumors. Materials and methods: This is a prospective study conducted between March 2018 and September 2019. Inclusion criteria: All women who presented with adnexal masses (premenopausal: >5 cm, postmenopausal: any size) were included in this study. Exclusion criteria: Known case of ovarian tumors who came for second-look surgery. Anechoic unilocular cyst <5 cm in ovary that resolves on follow-up. Clinical presentation data such as age, parity, menstrual history, and per abdominal and per vaginal examination findings are collected. Ultrasound Doppler findings such as resistivity index (RI) and pulsatility index (PI) are calculated and correlated with histopathology postsurgery. Statistical analysis was done by Pearson's “R” correlation coefficient, sensitivity, specificity, accuracy, PPV, and NPV. Results: With RI (0.4) and PI (1), Doppler was able to differentiate 94.4% of the histopathological examination (HPE) benign cases and 97.1% of the HPE malignant cases. (Pearson's “R” for RI and HPE: 0.6925, Pearson's “R” for PI and HPE: 0.4215), the sensitivity and specificity of color Doppler 78.5 and 94.4%, respectively. The PPV was 84.6% and NPV was 91.8%. Diagnostic accuracy of color Doppler was 90.0%. Conclusion: Doppler with the prescribed RI and PI values has to be incorporated into screening of ovarian tumors as they have a high degree of sensitivity and specificity for malignant masses. Clinical significance: Doppler study is a cost-effective, noninvasive, diagnostic method and can be a useful tool for differentiating benign from malignant ovarian tumors.

Introduction: The gold standard treatment for managing patients with pelvic organ prolapse (POP) is sacrocolpopexy. Initially, open sacrocolpopexy was adopted; however, over the years classic laparoscopic approach and its modifications in the form of single port laparoscopy, NOTES (vaginal-assisted laparoscopy) and robotic-assisted laparoscopic sacrocolpopexy (LSC) have emerged. Usage of minimally invasive approaches has gained momentum in the recent past as they reduce the morbidity associated with open sacrocolpopexy, allowing faster recovery of the patient. Classic LSC has similar outcomes to abdominal sacrocolpopexy but is technically challenging especially due to the pelvic organ surgery offering limited area available for operating. Overcoming these limitations, by the characteristic features of the robotic system such as a “simulated wrist” of the mechanical arm with its enhanced freedom of movement along with a three-dimensional field of view, has attracted significant interest in recent years for robotic sacrocolpopexy (RSC). Aims: To evaluate outcomes and complications following minimally invasive sacrocolpopexy in patients with POP. Materials and methods: We evaluated a total of 20 patients with POP, 15 of those underwent LSC and five patients underwent RSC. We assessed outcomes in both these groups in terms of operating times, blood loss, blood transfusion, surgery-related complications, total hospital stay, and recurrence rates at 1-year follow-up. Results: Patients having RSC had a significantly lower rate of blood loss of ≤300 mL. Maximum postoperative complications were recorded as Clavien-Dindo grade I (seen in 75% of the patients). Most common among these were dysuria and urinary infection (seen in 40%). No Clavien-Dindo grade IVa, IVb, and V complications were recorded in either laparoscopic or robotic techniques conducted at our hospital. At 1 year of follow-up, no significant recurrence was seen in RSC (0%), while a low recurrence rate was seen in LSC (two patients, 13%). Conclusion: Robotic technology provides some advantages as compared to classic laparoscopic surgery. However, both approaches appear to provide equivalent clinical outcomes. But the cost of utilizing and maintaining the robotic system appears to be significant. Hence LSC is the suitable method of treating POP, especially in a country like India. However large randomized trials comparing both techniques are warranted.

Background: Gestational diabetes mellitus (GDM) is associated with various complications. Macrosomia is one such complication. Aim: To predict fetal macrosomia by sonographic measurements of umbilical cord thickness (CT) and cross-sectional area (CSA) in GDM in third-trimester. Method: This prospective-cohort-observational study on 40 antenatal women with GDM (group I) over a period of 12 months at a tertiary teaching institute against 40 antenatal women without GDM or any medical co-morbidity (group II). Cord parameters [CT (cm) and CSA (cm²)] were assessed sonographically after 36 weeks. Pregnancy outcomes were noted. CT/CSA value more than 90th centile taken as cut-off value was considered as large cord. The predictive accuracy of the cut-off of cord parameters to predict macrosomia was calculated. Results: The mean age and BMI of women under study were 27.9 ± 2.84 years and 26.05 ± 1.32 kg/m². The cut-off of large cords was 2.8 cm and 3.56 cm² for CT and CSA, respectively. Large cords were found in 70% of the study group. Sonographically detected umbilical-cord parameters were significantly larger in macrosomic fetuses as compared to nonmacrosomic fetuses macrosomia was found in 17.5% cases of study group. The sensitivity, specificity, positive predictive value, and negative predictive value of cord parameters to predict macrosomia were 57.1, 96.9, 80, and 91.4% for CT and 65.7, 63.6, 46.2, and 87.5% for CSA, respectively. Conclusion: Sonographically detected umbilical CT and CSA are good predictors of fetal macrosomia with high negative predictive value. Clinical significance: Cord is an easily accessible and assessable organ requiring minimal expertise for sonographic assessment compared to other available parameters. Thus, it can be used as an easy option to predict macrosomia along with other predictors.

Aim: To know the frequency of meconium-stained amniotic fluid (MSAF) among COVID-positive term pregnant mothers and to know perinatal outcomes in these neonates. Materials and methods: A retrospective study was conducted of COVID-positive term pregnancies admitted to Vanivilas hospital, Bangalore Medical College, during the study period of 1 year. The study period was from 1st of July 2020 to 31st of June 2021. High-risk pregnancies that confound the occurrence of MSAF were excluded (obstetric risk factors and medical risk factors complicating pregnancy). Data were collected from medical records of patients and parturition register, which are cross-verified with operation theater records and neonatal intensive care unit (NICU) registers. Results: In total, 200 pregnant women were included in the study. About 65% were delivered by cesarean, 34.5% by the vaginal route, and one vacuum-assisted delivery. In total, 199 live births and one fresh stillbirth are reported. About, 26% had MSAF and 6.5% of newborns had meconium aspiration syndrome. Grade I, II, and III cases were 4.5%, 12.5%, and 9% respectively. Low appearance, pulse, grimace, activity, and respiration (APGAR) scores were correlating with the grade of MSAF, which is statistically significant. There were two neonatal deaths in grade III MSAF cases. Conclusion: The frequency of MSAF is increased among COVID-positive mothers, which translates to low APGAR scores and poor perinatal outcomes. Vigilant intrapartum care is recommended for these pregnancies to reduce the risk of poor neonatal outcomes. Clinical significance: The current study is undertaken to know if coronavirus disease-2019 (COVID-19) is associated with an increased frequency of MSAF among COVID-positive pregnant women. Finding MSAF has implications on operative delivery, cesarean rates, and perinatal outcome. There is a lack of studies about MSAF and perinatal outcomes in COVID-positive mothers. Evidence generated by this study helps to counsel the COVID-positive mothers and guides in the management of COVID-positive laboring women.

Background: Adnexal mass means any swelling arising from the adnexa which comprises the ovary, fallopian tube, structures in broad ligaments, and other connective tissues in parametrium. Adnexal mass can be an incidental diagnosis, or it may be associated with other symptoms like pain in the abdomen. It is very commonly encountered in our clinical practice. Materials and methods: A single-center prospective observational study involving 60 adolescent girls who came to the OPD or emergency in Lokmanya Tilak Municipal Medical College and Hospital with clinical or radiological findings s/o adnexal mass from the year 2017 to 2019 over a period of 20 months. Results: The maximum number of adnexal masses belonged to the age-group of 14–16 years (56.7%). About 60% of patients had pain in the abdomen. While only 36.7% of patients had regular menses, and 3.3% had not attained menarche. The most common associated complaint was dysmenorrhea (20%) followed by menorrhagia (13.3%). In 86.7% of patients, no mass was palpable per abdomen, while 6.7% had a mass of 12 weeks palpable per abdomen and 6.6% had a mass of more than 12 weeks palpable per abdomen. Almost 35% of patients when followed up, showed a decrease in the size of the mass, while in 6.8% the size of the mass increased. Bilaterality was found in 10% of cases while left-sided masses (48.3%) were seen more commonly than those on the right side (41.7%). In total, 53 masses (88.3%) were non-neoplastic and 7 (11.7%) masses were neoplastic, of which 10% were dermoid and 1.7% were dysgerminoma. In our study, 8.5% of patients had ovarian torsion. Cancer Antigen 125 (CA-125) was raised in around 18.3% of patients. Out of 60 patients, 68.3% were managed conservatively out of which 3.3% underwent medical management, 28.3% underwent laparoscopy, and 3.3% patients underwent laparotomy. Conclusion: Adnexal masses are common among adolescents, they are usually benign and often can be managed expectantly. The evaluation of adolescents with an adnexal mass should include menstrual history and a confidential inquiry regarding sexual activity. Among benign lesions, a simple cyst is the most common pathology of adnexal mass. Germ-cell tumors are the most common ovarian malignancies in children and adolescents. Management of adnexal masses in adolescents should prioritize ovarian conservation to preserve fertility.

Introduction: The increased rate of cesarean delivery has been related to increased incidence of the adhesive placenta in the last three decades. Improved management of adhesive placenta will increase the survival rate. Internal iliac artery or hypogastric artery (HA) ligation was one of the prophylactic techniques to prevent massive bleeding and expected to increase the survival rate. Aims: To determine whether HA or internal iliac artery ligation can improve the outcome of cesarean hysterectomy in cases with the adhesive placenta. Methods: This is a retrospective descriptive study involving 50 patients with confirmed adhesive placenta who underwent cesarean hysterectomy from March 2017 to January 2021 in Sanglah General Hospital. Data were presented in percentage and analyzed using the Chi-square test or Fisher's exact test. Results: The patients had a mean age of 32.5 years, with a median number of children being two and a median history of cesarean section of two times. None of the patients had a previous history of curettage. Based on the comparison of the results of patients who underwent iliac artery ligation, it was found that patients who were not treated had more complications of bladder rupture, repeated laparotomy, and had more internal bleeding (p-value 0.643, 0.630, and 0.645, consecutively). Conclusion: Patients who were not treated had more complications of bladder rupture, repeated laparotomy, and had more internal bleeding.

Background: Risk of ovarian malignancy algorithm (ROMA) and risk of malignancy index (RMI) are two scoring systems that are commonly used to predict ovarian tumor malignancy. Literature shows different cutoff points for a different population. Objective: This study aims to validate and compare the performance of ROMA and RMI and also validate the cutoff points for Indonesian population. Methods: This is a retrospective study conducted at Dr Cipto Mangunkusumo Hospital (CMH). Medical records of patients with epithelial ovarian cancer who underwent surgery in our institution during 2010–2014 were collected. The diagnostic values of ROMA and RMI were calculated. Results: From the analysis of 213 subjects included in this study, ROMA was statistically better than RMI [AUC (area under the curve) in all groups: 87.00% > 81.30%, p ≤0.001; postmenopausal group: AUC 91.47% > 88.97%, p ≤0.001]. RMI had values of sensitivity: 85.3%, specificity: 66.3%, positive predictive value (PPV): 79.7%, negative predictive value (NPV): 74.3%, positive likelihood ratio (LR): 2.53, negative LR: 0.22, and accuracy: 0.77. ROMA had values of sensitivity: 95.4%, specificity: 32.5%, PPV: 68.9%, NPV: 81.8%, positive LR: 1.41, negative LR: 0.14, and accuracy: 0.71. At the ideal cutoff point (RMI 330, premenopausal ROMA 30.4, and postmenopausal ROMA 53.1), ROMA showed better sensitivity and specificity than RMI (sensitivity of 82.31 vs 74.62%; specificity of 78.31 vs 75.9%). Conclusion: ROMA is better than RMI in predicting epithelial ovarian cancer in Indonesian population. Using the modified cutoff, the specificities of both ROMA and RMI were better than the standard cutoff points.

Aim: The study aimed to compare the safety and efficacy of levetiracetam to magnesium sulfate for the prevention of convulsions in preeclampsia. Materials and methods: A total of 60 women with preeclampsia with severe features were randomized to receive either levetiracetam or magnesium sulfate. In the levetiracetam group, a loading dose of 1000 mg/day (500 mg 12th hourly for 24 hours) was administered slowly over 5 minutes intravenously followed by an oral tablet of levetiracetam 500 mg 12th hourly for 5 days. In the magnesium sulfate group, 4 gm of magnesium sulfate was given IV over 3–5 minutes followed by a maintenance dose of 1 gm/hour for 24 hours. Magnesium sulfate solution was given in dilution via infusion pump. Results: This study shows that levetiracetam is non-inferior to magnesium sulfate as none of the patients in both arms had any convulsions. Conclusion: Levetiracetam is non-inferior to magnesium sulfate in the prevention of convulsions in preeclampsia. It can be used as an alternative to magnesium sulfate, especially when magnesium sulfate is contraindicated.

Iron therapy is a cornerstone for treating iron-deficiency anemia (IDA) in pregnancy and in the postpartum period. Oral iron is the first choice of iron preparation around the globe. However, intolerating gastrointestinal side effects with oral iron seriously affect the compliance. Intravenous (IV) iron, such as ferric carboxymaltose (FCM) is a useful alternative to oral iron for treatment of IDA. Use of FCM in the second and third trimesters of pregnancy and in postpartum anemia (PPA) is associated with a significant rise in hemoglobin (Hb) and replenishment of iron stores. With increasing use of FCM in IDA of pregnancy and PPA, there is a need for a unified approach. With this context, nearly 250 experts from the field of obstetrics and gynecology (ObGy) discussed the current evidence and their experiences with FCM use. After a series of expert meetings on an online platform, key opinions were formulated for the use of FCM in management of IDA in these subgroups. This paper brings out current evidence along with expert opinions for the use of FCM in the management of IDA in pregnancy and postpartum periods.

Aim: To evaluate the association of altered lipid levels and development of adverse maternal and fetal outcomes. Materials and methods: Women attending outpatient department (OPD), antenatal care (ANC) and in patient department (IPD) of the Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Hospital, Aligarh Muslim University, Aligarh, were included in this study after obtaining informed consent and ethical approval from the institute. Results: Mean age of pregnant women in the study group was 24.89 ± 3.12 years, whereas in the control group, it was 24.72 ± 3.76 years. Mean prepregnancy weight was 51–55 kg in both study and control groups. Mean BMI of the pregnant women in the study group was 21.89 ± 1.89 kg/m², whereas in the control group, it was 21.52 ± 1.47 kg/m². The levels of total cholesterol, triglycerides (TG), low density lipoprotein (LDL) and VLDL were significantly high in women who developed gestational diabetes mellitus (GDM) when compared to those who did not develop GDM and the difference was found to be statistically significant (p <0.001). The levels of total cholesterol, TG, and VLDL were significantly high in women who developed preeclampsia as compared to the women who did not develop preeclampsia (p <0.05). The levels of total cholesterol, TG, LDL and VLDL in women who developed preterm labor were found to be significantly high in women who developed preterm labor (p <0.01) as compared to women who did not have PTL. The levels of total cholesterol, TG, LDL, and VLDL in women who developed intrahepatic cholestasis of pregnancy (IHCP) were statistically significant when the two groups were compared (p <0.001). The levels of total cholesterol, TG, LDL, VLDL, in women who developed macrosomia were not statistically significant when the two groups were compared (p >0.05). Women who developed small for gestational age (SGA) had statistically significant high levels of total cholesterol, TG, LDL, and VLDL (p <0.05). Conclusions: The present cohort study was undertaken in the north Indian population to explore the association between dyslipidemia in pregnancy and its adverse maternal and fetal outcomes. It was seen that third trimester maternal dyslipidemia is associated with various maternal and fetal complications such as gestational diabetes mellitus, preeclampsia, IHCP, preterm labor, and SGA babies.

Objective: The rationale for using vitamin D in polycystic ovary syndrome (PCOS) with insulin resistance women is based on the fact that it reduces insulin resistance. Materials and methods: This was a prospective, open-label, randomized controlled trial involving supplementation of Vitamin D in two different doses in insulin-resistant PCOS women to assess the effects on clinical, metabolic, and hormonal profiles. We recruited 72 women of PCOS aged 20–35 years with HOMA-IR >2.5, Vitamin D levels <20 ng/mL, and BMI <30 kg/m². Selected patients were randomized in two groups: Patients in group I received tablet Metformin 500 mg twice a day orally along with tablet vitamin D3 1000 IU orally per day for 3 months. Patients in group II received Metformin 500 mg twice a day orally along with tablet vitamin D3 4000 IU orally per day for 3 months. Results: This study showed that vitamin D supplementation in dose of 4000 IU for 12 weeks to insulin-resistant women with PCOS had more beneficial effect on HOMA-IR, mFG score, global acne score, menstrual cycle regularity, BMI, LH levels, LH:FSH ratio, triglyceride levels, DHEAS levels, FBS, PPBS, fasting insulin, and postprandial insulin as compared to vitamin D supplementation in dose of 1000 IU daily for 3 months. Conclusion: As it was a single-center study, results cannot be extrapolated to population as a whole. Major strength was that it was a randomized controlled trial comparing efficacy of both upper and lower limits of vitamin D supplementation in two groups having similar baseline characteristics. However, absence of consensus pertaining to optimal dose of vitamin D warrants need of further intervention trials with larger sample size.

Objective: To assess the real-world safety and effectiveness of norethisterone 10 mg-controlled release (CR) formulation in the management of abnormal uterine bleeding (AUB). Methods: This was a retrospective analysis of real-world data collected between January 2021 and March 2021 across 40 centers in India. A total of 308 women in the reproductive age-group (18–45 years) with ovulatory AUB were treated with norethisterone CR 10 mg once a day for 10 days. The data from women with a confirmed diagnosis of AUB were included in the study. The clinical records that were analyzed for the primary objectives included the time required for arresting heavy menstrual bleeding after initiating medication, the incidence of breakthrough bleeding, safety and tolerability, and the secondary objectives included the timing of withdrawal bleeding after the last tablet was taken, assessment of heaviness of bleeding, and treatment compliance. Results: The mean age [± standard deviation (SD)] was 33.8 ± 8.3 years. Out of the 308 women with AUB, the majority of women (n = 193, 63%) experienced styptic action of norethisterone 10 mg CR within 4 hours of administration of the medication, 61% of the women (n = 187) did not report any incidence of breakthrough bleeding, and 70% of the women (n = 216) reported withdrawal bleeding within 24–72 hours of administration of the last medication dose. No adverse events were reported. Heavy bleeding was noted in only 7% of the women. More than 80% of compliance with therapy was observed in 94% of women (n = 290). Conclusion: Our analyses of the retrospective data suggested that norethisterone 10 mg CR was safe and effective for the treatment of AUB in Indian women. Clinical significance: To the best of our knowledge, this is the first real-world study to show that norethisterone 10 mg CR effectively treats AUB, is safe, and is associated with a high compliance rate in Indian women of reproductive age-group (18–45 years).

Introduction: Hydatid cyst is a zoonotic infection caused by dog tapeworm Echinococcus species. The liver and lungs are the most commonly affected organs with this disease. Rarely, pelvic organs are also involved. Case: A 36-year-old female presented with pain in the abdomen for a 1-week duration with a normal menstrual cycle. Ultrasound revealed a bilateral ovarian mass. Laparotomy revealed left broad ligament hydatid cyst and right-sided pelvic peritoneal hydatid cyst, which were confirmed by histopathological examination. After surgical excision, the patient was given albendazole for 6 months. Conclusion: Female pelvic hydatid cyst is a rare entity. In endemic settings, the possibility of a pelvic hydatid cyst should be kept as a differential diagnosis in an ovarian cyst in the presence of coexisting hepatic hydatid cyst and negative tumor markers.

Aim: To describe two cases of late presentation of acardiac twin in monochorionic gestation, which was earlier diagnosed as a vanishing twin in first trimester scans and later on found to be an acardiac twin (TRAP sequelae) on follow-up scans. Background: Monozygotic twinning is complicated by anomalous vascular connections in the placenta resulting in clinical syndromes such as twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence (TAPS), and twin reversed arterial perfusion sequence (TRAPS; acardiac twinning). Twin reversed arterial perfusion sequence is a condition arising due to paradoxical retrograde transfusion by a structurally normal “pump” twin, there is a disruption of organ development in the perfused twin. Case description: Twenty-one-year-old G2A1 who was initially diagnosed with vanishing twin in the 14-week scan, which was later on found to be acardiac twinning at 29 weeks and presented with PPROM. She went into spontaneous labor and there was a dilemma regarding delivering her vaginally or by cesarean section. The second case of primigravida, initially diagnosed as single fetal demise at 12 weeks and found to have TRAP sequelae later on at 31 weeks, was admitted and underwent elective LSCS at 32 weeks on maternal request. Conclusion: This lays down the importance of early diagnosis with dedicated ultrasound and management at tertiary care centers for better perinatal outcomes. Clinical significance: The phenomenon of the “vanishing twin” refers to the occurrence of a single fetal loss in a twin gestation during the first trimester. Such cases seen in the first trimester may be a case of acardiac twins, which might become evident later in a growth scan. Hence, it is important to be alert to the possibility of missing an acardiac twin since it is associated with 50% mortality of the pump twin.

Aim: To emphasize that medication errors can jeopardize a patient's life, leading to increased morbidity and mortality. Background: Safe and vigilant medical practice is key to patient safety, but still, in our country, nearly 5.2 million medical errors are happening annually. Medication errors in the operation room (OR), such as wrong labels, look like appearance and location of ampules, unlabeled syringes, lack of complete knowledge, poor communication, and careless, relaxed attitude, have contributed to patients’ fatal outcomes. Major morbidities and mortalities have been reported following inadvertent intrathecal injection of tranexamic acid (TXA). Case description: We report a case of accidental injection of TXA instead of bupivacaine during spinal anesthesia, leading to neurotoxicity and myoclonus complicated by cardiac arrhythmia. However, the timely, multidisciplinary intervention helped to save the mother and fetus. Conclusion: Properly standardized drugs in the operating room, sensitization of working staff, proper training, and reading the drug label before use can minimize fatal therapeutic errors related to drugs. Early detection and timely resuscitation can reduce morbidity and mortality. Clinical significance: A proper standardization of protocols with a strict emphasis on the right drug with proper administration is a must to avoid fatal mistakes endangering patients’ life.

Background: Body stalk anomaly was a rare, sporadic defect in the abdominal wall with the expulsion of the contents of the thoracoabdominal organs. Body stalk anomaly was reported in about one in 7,500 births within 10–14 weeks of gestation. Body stalk anomaly was a rare malformation with a prevalence of about 0.12 cases per 10,000 births (both live and stillbirth). Aim: To compare the antenatal and postnatal findings of body stalk anomaly. Case description: A 29-year-old multigravid patient was referred to our hospital due to a congenital anomaly. There were several findings on ultrasonography and magnetic resonance imaging (MRI), namely low-set ears, banana sign, neural tube defects, severe scoliosis, short umbilical cord, fetus attached to the placenta, abdominoschisis, thoracoschisis with some organs out, and defects in both legs. Hysterotomy was performed at 24 weeks of gestation. A male baby weighing 650 gm with a body length of 33 cm and head circumference of 24 cm was born. His Apgar score was 1/1/1 and survived for 30 minutes after birth. The postnatal examination of the baby, performed postmortem, confirmed the antenatal diagnosis. Synopsis: A case about a comparison between ultrasound and MRI prenatal screening with postoperative findings in the diagnosis of body stalk anomaly. Conclusion: Antenatal ultrasonography provided an accurate diagnosis of body stalk anomaly, and the results could be a consideration for detection of the defect earlier. Furthermore, it could help in patient counseling about poor outcomes in neonates and termination planning earlier to avoid other additional risks or even complications of delivery.

Aim: Gynecologists, or for that matter any surgeon, are often looking forward to challenges. While challenges come in various forms, the ones encountered intraoperatively are the most challenging and satisfying as well once successfully countered. Background: Uterine leiomyomas are a routine presentation at a gynecologist's table. Depending upon the location, size, and desirability of fertility in the future, multiple therapeutic options can be offered to the patient ranging from expectant and medical management to a conservative surgical myomectomy or a more radical method, hysterectomy. Preoperative optimization of the surgical field can be done in several ways, as we did with ureteric stenting in this case. Case discussion: We report a case at our tertiary care center in a patient with multiple intrauterine fibroids, a huge broad ligament fibroid, a large endometrioma, a hematosalpinx with a history of imperforate anus and horseshoe kidney, and an intraoperative finding of the umbilical urachal sinus. Conclusion: A diagnostic challenge with a therapeutic riddle, with a multidisciplinary team approach, the patient was successfully operated on and freed of her ignominy. Clinical significance: Ureteric stenting, in this case, helped avoid inadvertent ureteric injury as was anticipated due to the broad ligament fibroid and deep endometriosis.

Aim: To present a rare case of cauliflower-like pelvic tumor in a 29-year-old lady with an intraoperative diagnostic dilemma. Background: Ovarian adenofibromas are rare benign neoplasms accounting for 1.7% of all benign ovarian tumors. A cauliflower-like growth is usually suggestive of malignancy; however, benign tumors like leiomyoma, granulomas, and polypoidal endometriosis can have similar morphology, especially in young women. Case description: A 29-year-old nulligravida with abnormal uterine bleeding and abdominal pain for 2 months presented to our outpatient department. Ultrasonography demonstrated a well-defined left adnexal solid cystic lesion with the minimal color flow. Laparoscopy was done and intraoperatively there was solid, cauliflower-like growth of 3 cm in the pouch of Douglas (POD) between the left ovary and posterior uterine surface that mimicked a malignancy. The left ovary had a simple cyst of 4 cm. Complete excision of the cauliflower-like pelvic mass, left ovarian cystectomy and staging peritoneal biopsies were done. On histopathology, the cauliflower lesion was diagnosed as ovarian serous adenofibroma. Conclusion: Ovarian serous adenofibromas are benign lesions that look deceptively malignant but have a good prognosis. Intraoperative frozen section is ideal for the appropriate management in such situations of clinical dilemma. If a frozen section facility is unavailable, performing an excision biopsy to confirm or refute a malignancy before proceeding with radical surgery, particularly in young women, is advised. Clinical significance: Ovarian serous adenofibromas are uncommon benign neoplasms that morphologically mimic malignancy and can cause a diagnostic dilemma but have a good prognosis after excision.

Gynandroblastoma is the sex cord-stromal tumor composed of clearly identifiable granulosa–theca cell and Sertoli–Leydig cell elements in variable amounts which comprise less than 1% of the sex cord-stromal tumors. Very few cases of gynandroblastoma are present in the literature to our knowledge. We discuss a case of gynandroblastoma of the ovary in a 62-year-old menopausal female. The microscopic features of the tumor showed both Sertoli cell and granulosa cell component. These tumors are associated with hormonal imbalance as the cells involved participate in the ovarian hormonal function. Thus, extensive sectioning of the tumor must be done by the surgical pathologist to rule out the possibility of other tumors and provide with a correct diagnosis of the tumor which can help the clinicians to plan an adequate management protocol for this rare tumor which will further elucidate into a properly regulated hormonal status and a better quality of life for the patients.

Cesarean scar pregnancy (CSP) is a life-threatening ectopic pregnancy that is frequently misdiagnosed. Ectopic pregnancy affects 2% of all pregnancies, while cesarean scar ectopic pregnancy affects about 1 in 2,000 of all pregnancies. Cesarean scar pregnancy is likely to become more common as cesarean section rates rise, resulting in complications such as uterine rupture and hemorrhage. We discuss the case of a 26-year-old woman who had previously undergone one cesarean section and was diagnosed with a type I cesarean section scar ectopic pregnancy based on transvaginal ultrasonography. Patient was managed by aspiration under ultrasound guidance which resulted in avoiding major invasive procedures. The precise cause of pouch or niche formation is still unsolved, yet the risk factors for its growth are commonly known. They include hysterotomy scar site, history of multiple previous cesarean section, technique of suturing, and diabetes/smoking. Here, with this unique technique, we emphasize the need of early detection and treatment of CSP.

Aim: To understand a systematic and meticulous approach towards Wilson disease, a genetic disorder of copper metabolism, complicating pregnancy. Background: Wilson's disease results in increased body retention of copper and its eventual toxicity and related effects on several organ systems, especially neurological and hepatic. Case description: Here we study a case of a female with neuropsychiatric and hepatic manifestations of Wilson disease, conceiving spontaneously eventuating with a successful maternal and fetal outcome. Conclusion: With the accurate application of a multidisciplinary team approach with timely investigations, imaging studies, and counseling, successful maternal and fetal outcome in Wilson disease is well within our reach. Clinical significance: Women of reproductive age-groups with Wilson disease, face recurrent miscarriages and poor obstetric outcomes due to copper deposition in the body with the concomitant chronic liver disease and its sequelae making management challenging.

Aim: To discuss the role of prebiotics and probiotics in vulvovaginal infections. Background: Depletion of vaginal microflora in healthy women can lead to various vulvovaginal infections (VVIs). Probiotics such as Lactobacilli are used successfully in treatment and prevention of VVIs. Prebiotics are nutrient substrates for probiotics. Review results: Different strains of Lactobacilli possess different activities (pathogen displacement, bactericidal, and immunostimulatory) that are beneficial in women with VVIs. In nonpregnant women, probiotics administration either orally or vaginally improves clinical, mycological cure rate, and also reduces the recurrences in VVIs. In pregnant women also, probiotics are useful for bacterial vaginosis (BV). In pregnant women, it improves glucose metabolism and might be useful in cases with preterm premature rupture of membranes. Conclusion: In VVIs, intravaginal microbial environment is dysregulated. Upregulating this microflora environment with the use of pre- and probiotics, referred as synbiotics, increases treatment success rate and helps in prevention of recurrences. Clinical significance: Probiotic and prebiotic combination can be considered as one of the essential aspects in the management of VVIs.