Introduction: Uterine sarcomas are rare neoplasms with poor prognosis comprising around 2–6% of uterine malignancies. They include leiomyosarcomas, endometrial stromal sarcomas, undifferentiated sarcomas, carcinosarcomas (previously existed, but it does not exist anymore) and few other rare variants. Leiomyosarcomas are the most common uterine sarcoma. The most common clinical presentation is postmenopausal vaginal bleeding while others include lower abdominal pain and white discharge per vaginum. This study analyzes the general patient characteristics and survival data of uterine sarcoma patients treated in our institute. Materials and methods: The patients treated for uterine sarcomas in our institute from 2004 to 2019 were identified and their case records analyzed. The patient's baseline characteristics, stage distribution, recurrence patterns, survival, outcomes of laparoscopic, and open approaches in treating uterine sarcomas are all analyzed. Results: Totally, 31 patients were treated during the time period out of which 6 patients were lost the follow-up. The mean age of patients at diagnosis was 46.5 years. The most common type in our center was endometrial stromal sarcoma. Eleven (35%) patients had recurrence. Those with recurrences were offered surgery when it was limited to pelvis. The adjuvant chemotherapy and radiation were given as indicated. Four patients had a history of tamoxifen intake. Eight patients (25%) had died during the follow-up which makes up to 72% of the recurred patients. The median disease-free survival was 45 months after a median follow-up of 90 months. Conclusion: Although uterine sarcomas have poor prognosis, our patients had better prognosis on comparison with literature. The stage of the disease and the pathological type are the important factors determining prognosis. Laparoscopy offers better postoperative outcomes and larger studies are needed to demonstrate their oncological safety.

Aim: To analyze the perinatal mortality rate in a tertiary care center. Background: To identify possibly responsible maternal risk factors in a tertiary care hospital in developing country. Methodology: Data of perinatal deaths from 1 January 2019 to 31 December 2019 was collected from monthly perinatal mortality records. All patients with fetal death after 28 weeks of pregnancy till the period of 7 days after neonatal birth were included in this study. Results: The study conducted at our hospital aimed at investigating the causes of perinatal mortality and related maternal risk factors resulting in perinatal mortality. The total confinement number was 6,688; among these, the number of fresh stillbirth was 155, macerated stillbirth was 137, and neonatal death was 24. Among the 316 perinatal deaths, 241 deaths (69.6%) were noted before 37 weeks of pregnancy and 75 deaths were noted after 37 weeks of pregnancy (15.18%). Out of 316 deaths, 100 deaths observed in patients induced for labor. Of these, 100 neonates, 88 delivered vaginally and 12 neonates delivered by cesarean section. The 69 neonates (21.83%) deaths observed in the patients who had undergone cesarean section. A total of 33 (10.44%) deaths resulted due to birth asphyxia, 72 (22.78%) deaths observed due to preterm delivery, 22 (6.96%) deaths were due to congenital anomalies. Preterm was one of the most important risk factors observed in 72 (22.78%) women with perinatal deaths. Conclusion: Prematurity, low birth weight (LBW), no proper wrapping of newborns, and no guidance and proper training to mothers were significantly associated with higher probability of neonatal mortality.

Introduction: Endometrial carcinomas constitute a variety of tumors with varied morphology and clinical outcome. Though type I carcinomas were found to have better prognosis, subsequent studies have shown that 5–10% of type-I carcinomas may recur or metastasize, thus shortening the overall survival. This has led to the search of additional factors which might predict adverse outcomes in these otherwise low-grade tumors. Several histological and immunohistochemical markers were studied and some of them were found to be significantly associated with lymph node metastasis, recurrence, and poor outcome. Methods: In total, 50 cases of type-I, grade-1/2 endometrioid carcinomas were studied for microcystic, elongated, and fragmented (MELF) type of myoinvasion. About 23 cases showed MELF myoinvasion. The morphological and immunohistochemistry (IHC) pattern associated with MELF were studied. Their association with lymph node metastasis and survival was also noted. IHC done were cytokeratin (CK), CD44, progesterone receptor (PR), E-cadherin, and smooth muscle actin. Results: Large tumor size, papillary pattern, and lymphovascular emboli (LVE) were associated with MELF. Among the IHC, expression of CD44 and loss of expression of PR and E-cadherin were found to be statistically significant. None of the cases showed lymph node metastasis on routine sections, however, ultrastaging was not done. Conclusion: Morphological and IHC features differ between MELF-positive and -negative cases. There was no significant difference in survival between the MELF-positive and -negative cases.

Aim: To understand varied approaches for surgical management of large ovarian cysts to minimize cosmetic, intraoperative, and postoperative complications. Background: In the current era of medical practice, giant ovarian tumors have become a rarity due to increased awareness eventuating in early diagnosis. They cause mechanical pressure symptoms on the gastrointestinal, respiratory, and urinary tract and also cosmetic and postoperative complications related to large unsightly incisions required for surgery. Case description: We describe our experience of five such cases and suggest diverse and successful surgical approaches in the management of voluminous ovarian masses, which include techniques such as laparoscopic excision using a specimen retrieval bag, mini-laparotomy, and laparotomy via a vertical midline or transverse incision with or without intraoperative decompression of the cyst. Clinical significance: Enumerating methods that decrease complications like intraoperative spillage of cyst contents, unsightly scars, and early postoperative recovery in the management of ovarian tumors. Conclusion: Choosing the best route for accessing the cyst and then choosing the best possible way for astute management of ovarian tumors.

Background: Antiphospholipid syndrome (APS) is one of the important treatable causes of bad obstetric history (BOH). The literature on the association between the presence of antiphospholipid antibodies (APLA) in patients with BOH and clinical parameters is limited. Aims and objectives: (1) To estimate the prevalence of APLA in patients with BOH and (2) To determine the association of APLA with various clinical parameters in patients with BOH. Materials and methods: A total of 80 patients with BOH of unknown etiology and 40 age-matched controls with at least 1 successful pregnancy outcome were clinically assessed and screened for the presence of APLA {anti-β2 glycoprotein-1-IgG (ABGP1-IgG); anticardiolipin IgG and IgM [anticardiolipin antibodies (ACLA), ACLA-IgG and -IgM)]; and lupus anticoagulant (LAC)}. The clinical parameters of APLA-positive and APLA-negative cases were compared. Results: Antiphospholipid antibodies were detected in 12 of 80 cases (15%) compared with none among controls [odds ratio (OR) = 29.38; 95% confidence interval (CI) = 1.71–505.4; p = 0.0199]. The antibody ABGP1-IgG was the commonest one (n = 7, 58.33%) followed by LAC (n = 4, 33.33%) and ACLA-IgG and -IgM (1 each). Patients with APLA-positive BOH had significantly increased incidence of thrombotic episodes (p = 0.01), hypertension (p = 0.05), thrombocytopenia p <0.01), and anemia (9.67 ± 1.75 vs 11.04 ± 1.37 gm/dL; p <0.01). Second-trimester abortion was significantly higher (p = 0.03), and first-trimester abortions were significantly lesser (p = 0.02) compared with patients with APLA-negative BOH. Third-trimester adverse obstetric events were comparable between the two groups. Conclusion: Antiphospholipid antibodies are present in 15% of patients with BOH of unknown etiology. History of thrombosis, hypertension, thrombocytopenia, anemia, and second-trimester abortions were significantly associated with the presence of APLA in BOH. Clinical significance: The findings from this study will help in determining the subset of patients with BOH who have higher likelihood of presence of APLA and therefore increase the chances of treatment and a successful pregnancy outcome.

Introduction: The global incidence of low birth is 15%, and in India, it is 18%. Together with gestational maternal age and size, placental factors contribute to 32% of low-birth weight. Various factors influence the fetal growth such as the factors originating from fetus itself, maternal factors, placental factors, and the factors due to interaction of all these factors. Materials and methods: The placenta was collected from 30 mothers of low-birth-weight babies and 60 placentas from mothers of normal-birth-weight babies in the Department of Obstetrics and Gynecology from October 2020 to December 2020. Information regarding maternal characteristics, placental morphometry, and newborn parameters were recorded. Results: Mean of placental weight is significantly less in case group (420 + 7 gm) compared with control (560 + 100) group. Mean of placental length, breadth, surface area, diameter, and thickness is significantly less in the case group compared with the control group (p <0.05). The presence of hard areas, focal avascular villi, syncytial knotting, focal hyaline degeneration, and fibromuscular sclerosis was seen more in low-birth-weight babies when compared with normal-birth-weight babies (p <0.05). Conclusion: Placental factors such as placental weight, placental length, breadth, diameter, surface area, thickness, and volume were less in low-birth-weight babies. All the microscopic and gross findings like the presence of hard areas, focal avascular villi, syncytial knotting, focal hyaline degeneration, and fibromuscular sclerosis were seen more in low-birth-weight babies.

Aim: This study was done to compare the efficacy of plain cervical dilatation and curettage (D&C) and hysteroscopic-guided biopsy in evaluating endometrial pathology and to compare the histopathology findings of hysterectomy specimen. Materials and methods: This study was done at the Obstetrics and Gynecology outpatient department (OPD) in Dr Chandramma Dayanand Sagar Institute of Medical Education and Research, Harohalli, Ramanagara, Karnataka, India over a period of 1 year from January 2021 to January 2022. A total of 100 perimenopausal and postmenopausal women complaining of abnormal uterine bleeding in gynecology OPD were included. Those women who are eligible for diagnostic D&C, cervical dilatation and endometrial curettage were done under i.v. sedation in the operation theater (OT) and the curetting was sent for histopathological examination (HPE). Those women who needs hysteroscopy, it was done under short general anesthesia and the sample was sent for histopathologic examination. Patients for whom hysterectomy was indicated following D&C or hysteroscopy would be followed for the histopathological findings. Results: Our cases range in the age-group of 40–55 years who presented with abnormal uterine bleeding (AUB) without local gynecological cause and with failure of medical treatment for at least 3 months. The mean duration between the endometrial curettage and the hysterectomy being 2.5 weeks. The highest correlation was seen in the endometrial phase, followed by complex and then by simple hyperplasia. Clinical significance: The main reason for choosing this study is to find the diagnostic modality with higher accuracy so as to avoid unnecessary hysterectomy in patients with AUB.

Introduction: India is currently the world's second most populated country, accounting for over 20% of all births. Despite the fact that India was the first country to establish a National Family Planning Program in 1952, 13% of married women still have unmet family planning needs. The study also calculated the rate of unwanted pregnancy in India, finding that approximately half of the 48.1 million pregnancies in 2015 were unintended. Family planning is widely regarded as a woman's issue in many regions of the world, including India. So this study has been carried out to understand the awareness of males about family planning methods. Material and methods: This is a cross-sectional study conducted over a span of 3 months, including married men for at least 5 years. The data collection was done using a pretested semistructured validated questionnaire that consists of sections on knowledge, attitude, and practices of family planning of the men. Results: In this study, we studied awareness of family planning methods among 200 men. It was observed that 56% of men were of the opinion that primarily females are responsible for use of contraceptive methods. In this study, we observed that 84% of men were of the opinion that vasectomy causes loss of sexual desire and impotence. When asked about the future choice of permanent sterilization, out of 180 men, 97.2% of men chose female sterilization. Conclusion: So, it was observed that the rate of male participation in family planning was low among the studied sample. There was a significant lack of knowledge, attitude, and practice about family planning methods among the studied population. Clinical significance: There is a need to strengthen the awareness and practices of males about their role in family planning. This study serves as a benchmark to identify the areas needed for further improvements.

Introduction: COVID-19 infection is a pandemic health emergency with significant mortality in human population. The course of infection in pregnancy is not well-known. The understanding is fogged by the changes in the pulmonary and immunological systems during pregnancy. Initially, the COVID-19 infections among pregnant mothers were assumed to be having benign course. Recent investigations from Sweden have indicated that pregnant and postpartum women are at increased risk of severe complications associated with COVID-19 infections. Methodology: This prospective study was conducted at Department of Obstetrics and Gynecology BMCRI and Bowring Lady Curzon Medical College. All pregnant women diagnosed to have COVID-19 infection who died during treatment were included in the study. The details of clinical evaluation are entered in structured format. Cases were studied in detail to fulfill the study objectives. Aims and objective: To analyze the maternal mortality cases due to COVID-19 infection. To estimate the prevalence of maternal mortality due to COVID-19 infection. Results: Among 1070 COVID-19 cases diagnosed during pregnancy, 37 (3.45%) patients had maternal mortality due to COVID infection. The prevalence of maternal mortality was 0.6 (3.45%). Maternal mortality were mostly in 3rd trimester (51.4%). Saturation was below 90% in all cases, 90.8% of patients are antepartum, maximum gestational age 37 weeks, and minimum gestational age 12 weeks. Conclusions: COVID-19 pneumonia is an additional toll for maternal mortality. Obstetric patients in the 2nd and 3rd trimester having COVID-19 infection with late presentation to hospital, moderate-to-severe disease (RR >30 minutes), with raised inflammatory markers, and having bilateral lung affection are indicative of poor maternal outcome.

Objective: To assess pregnancy outcomes of patients with ultrasound-indicated and history-indicated McDonald cervical cerclage. Materials and methods: This was a cross-sectional study of pregnant women who had cervical cerclage performed at Aga Khan University Hospital, Karimabad campus. We obtained Institutional Review Board approval and reviewed the medical records of patients. A purposive continuous sampling technique was used. A total of 88 patients were included. There were no exclusion criteria. Outcome data were collected from the medical record of patients from January 2010 to December 2016. Results: Analysis reported a statistically significant lower gravidity and parity in the scan-indicated group as compared with other groups (p = 0.000 and p = 0.001, respectively). Previous history of cervical cerclage, history of mid-trimester miscarriage, and preterm labor were significantly associated with indication for cerclage (p = 0.001, 0.046, and 0.001, respectively). Cervical length was also significantly associated with the indication for cerclage (p <0.001). Lower gestational age at previous abortion in the history-indicated group as compared with other groups (p = 0.003 and <0.001, respectively). Pregnancy prolongation was significantly lower in the scan-indicated group as compared with other groups (p = 0.04 and 0.004, respectively). Conclusion: Our study showed that patients with a history suggestive of cervical incompetence or short cervix on ultrasound should be offered cerclage to prevent preterm birth and to improve neonatal outcomes. Ultrasound-indicated cerclage after the first trimester indicates that universal cervical-length screening by transvaginal ultrasound in the mid-trimester can pick silent cases, and inserting cerclage can prolong pregnancy to term. Clinical significance: Screening cervical length will help clinicians to reduce preterm birth rate, especially in resource-limited underdeveloped countries.

Introduction: India shares the huge burden of cervical cancer cases, contributing to nearly one-fourth of cervical cancer deaths worldwide. In wake of World Health Organization (WHO) global strategy to eliminate cervical cancer by 2030, there is a need to shift from opportunistic to population-based screening. Still, with limited resources, it is not feasible in current times. With this in mind, we performed wider hospital-based screening of females presenting to the outpatient department (OPD) of Department of Obstetrics and Gynaecology, King George's Medical University, Lucknow, Uttar Pradesh, India and present its findings. We also studied the spectrum and prevalence of epithelial cell abnormality and its association with clinical parameters such as age, parity, socioeconomic status, and clinical findings. Methods: Sexually active women in the age range of 21–65 years attending OPD for various complaints were screened from January 2015 to December 2019. Cervical cytology reports were retrieved from the hospital records. Demographic details of the patient along with presenting complaints were noted. Data was statistically analyzed using a statistical package for social sciences (SPSS software, version 20.0). The Student's t-test was used for comparison of continuous variables and the Chi-squared test for proportions. Results: A total of 14,510 women were screened; the majority were multiparous, aged 30–50 years. A total of 38.4% of patients presented with a chief complaint of discharge per vaginum, 14.6% with menstrual disturbances, 19% with pain in the abdomen, and 22% with no complaints. There were 0.13% inadequate smears and 8.8% had an inflammatory smear, 4.6% cases showed reactive cellular changes, 5.5% low-grade squamous intraepithelial lesion (LSIL), 1.2% high-grade intraepithelial lesion (HSIL), 1.2% atypical squamous cell of unknown significance (ASCUS), 3.14% atypical squamous cells–cannot exclude HSIL (ASC-H) were of 0.19% and 0.01% (two cases), which were reported as squamous cell carcinoma (SCC). There was a significant correlation between the age of presentation, parity, socioeconomic status, and the presence of epithelial cell abnormality. Conclusions: Cervical cytology is an effective method to screen for precancerous lesions of the cervix, with a wider hospital-based screening of a considerable number of females with cervical abnormalities that may be picked up for early intervention.

Background: Liver disorders during pregnancy pose unique challenges to the managing obstetrician in terms of consequences to the mother and the fetus. The aim of the study is to evaluate the various etiologies, clinical presentation, and to find out the maternal and fetal outcomes in mothers presenting with liver disorders during pregnancy. Methods: The study prospectively analyzed 120 consecutive patients who presented to our tertiary care center and were diagnosed to have some liver disease based on a combination of clinical, serological, or radiological evidence. Patients with liver disorder secondary to sepsis and multiorgan failure were excluded from the study. Results: A maximum number of patients were in the age group of 21–30 (73.3%). In terms of frequency, most common liver disorder was hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome (21.7%) cases followed by pre-eclampsia (19.2%) and Hepatitis E (14.2%). There was high presence of preterm deliveries comprising 64.25% of all deliveries. There were 107 live births and still birth was noted in 13 patients. Among the still birth group, the most common associated liver disease was Hepatitis E in 10 (76.9%) patients. The maternal mortality was 13.3% (16 patients). Hepatitis E was the single most important cause of mortality in all 16 patients. Conclusion: Pregnancy-specific liver disorders were far more common in the study and HELLP syndrome accounted for maximum number of cases. The presence of hepatitis E was the single most important cause of both fetal and maternal mortality.

Background: Postpartum hemorrhage (PPH) remains the most common form of major obstetric hemorrhage and is also the leading cause of maternal morbidity as well as mortality. With the use of effective modalities and interventions to prevent and treat PPH, we can definitely reduce the burden of this life-threatening condition. In cases of PPH not responding to the medical line of management, second-line interventions like balloon tamponade, devascularization, compression sutures, and hysterectomy as the final resort can be thought of. Aims and objectives: The aim of this study is to determine the effectiveness of ESM-uterine balloon tamponade (UBT) in cases of PPH not responding to the medical line of management. Materials and methods: In this prospective case–control study, 26 cases with PPH refractory to the medical line of management in whom UBT was placed were studied. Data were collected over a period of 1 year and analyzed. Result: The total number of deliveries including vaginal as well as the cesarean section was 1,359 out of which 26 patients had PPH not responding to the medical line of management, thus contributing 1.9% incidence of refractory PPH in this study. The mean age of the study population was 28.4 ± 2.3 years, and the blood loss ranged from 800 to 3000 mL. The success rate of ESM-UBT alone was 85%, and if combined with additional interventions like stepwise devascularization and compression sutures, it increased to 96.15%. One patient required a peripartum hysterectomy in spite of all measures, so the failure rate was 3.85%. No maternal death was recorded in this study. Conclusion: ESM-UBT is an innovative approach in the management of the PPH not responding to medical management. Our study recommends using ESM-UBT in cases of PPH with failed medical management before directly proceeding with surgical interventions. Clinical significance: ESM-UBT is an inexpensive, cost-effective, easy-to-use, easily available, affordable, and effective tool to manage PPH not responding to medical management, and thus will definitely help to reduce related maternal mortality and morbidity.

Background: Anemia is a serious global public health problem that particularly affects young children and pregnant women. India ranks 170 out of 180 countries for anemia among women, according to global nutrition survey, 2016. Despite so many government measures and active participation of various NGOs, anemia is still looming large at India's horizon and the target of eradicating anemia from our country looks more unachievable. Aim and objective: The objective of the present survey was to assess knowledge, attitude, and practice (KAP) of Indian Obstetricians toward anemia and its management in their routine clinical practice, which refers to situation at real-life scenario or daily clinical practice in India. Materials and methods: This was a prospective, cross-sectional, observational, questionnaire-based survey conducted among Indian obstetricians and gynecologists. Total 20 multiple-choice questions (MCQs), on various practical aspects of anemia management, were developed by Safe Motherhood Committee, Federation of Obstetric and Gynecological Societies of India (FOGSI). The data were collected, analyzed, and summarized in frequency and percentage. Results: The knowledge gaps could easily be understood by the practices followed by the participants in the screening and diagnosis of anemia during pregnancy. The frequency of hemoglobin (Hb) estimation done by the participants in the second trimester was about 10% only. Out of the total of 1,974 obstetricians, majority of them (71.9%) did not perform thalassemia screening routinely, whereas only about 28% screen their patients for thalassemia either by Hb electrophoresis or by Mentzer index. Nearly 50% of caregivers are still not routinely performing deworming before initiating the oral iron therapy thus optimal iron response is not achieved in their patients. Conclusion: The present KAP survey highlights that anemia continues to be an important public concern to pregnant women. Majority of obstetricians and gynecologists are adequately working in diagnosis and management of anemia with the need of knowledge and practice upgradation for effective management of anemia. A way forward: Organizing of workshops at all levels of the society, and in all the corners of the country, will thus help in bridging the existing knowledge gaps and correct the faulty practices; thus, improving the health status of pregnant females and ultimately make the World Health Organization (WHO) goal of “Health for All by 2030” achievable.

Purpose: Pregnant women with coronavirus disease-2019 (COVID-19) are at an increased risk for preterm delivery, stillbirth, and severe acute respiratory illness which is mainly attributed to the physiological and immunological changes of pregnancy. The aim of this study was to assess the knowledge, attitude, and practice (KAP) regarding the health effects of the COVID-19 pandemic and preventive measures among pregnant women from South India. Materials and methods: A descriptive cross-sectional study was carried out among 505 antenatal women at the Department of Obstetrics and Gynecology, Government Medical College, Kozhikode, Kerala, India from July 2021 to September 2021. After taking informed written consent, the study participants were enrolled using a standardized and validated questionnaire. The data were analyzed in Statistical Package for Social Sciences (SPSS), version 15.0, for Windows (SPSSTM Inc., Chicago, IL, USA). Results: The mean age of the enrolled antenatal women was 26.53 years (SD ± 5.14). History of past or present COVID-19 was given by 97 (19.2%) study participants. The first and second doses of the COVID-19 vaccine were taken by 123 (24.3%) and 55 women (10.9%), respectively. About 491 women (97.2%) were perceived to have a piece of good knowledge, and 14 (34.7%) had a moderate knowledge. The attitudes of 468 (92.7%), 35 (6.9%), and two (0.4%) women were good, moderate, and poor, respectively. The preventive practice by all the participants was good. Conclusion: This study concludes that the KAP of pregnant women from South India regarding COVID-19 health effects and preventive measures are good. Antenatal clinics must ensure regular informative sessions stressing the importance of COVID-19 preventive behaviors.

Aim: Acute abdomen constitutes 5–10% of all emergency department visits and is the leading cause of hospital admissions. The clinical scenario of two patients with the same underlying pathology may look different or similar with the disease entities very distinct. Background: Diagnosis of acute abdomen requires meticulous history taking, a thorough evaluation of symptoms, evaluation, and prudent use of investigations to specify the disease and management which many times could be surgery. Accurate knowledge is essential for appropriate and timely decisions. The clinical presentation included pain in the abdomen (16.6%), pain in the abdomen and vomiting (44.4%), pain in the abdomen in shock (39%), and abdominal tenderness (33.3%). Discussion: Retrospective study conducted in a tertiary care center after ethical committee approval. The term acute abdomen refers to any serious acute intra-abdominal condition accompanied by pain, tenderness, and muscular rigidity, for which emergency surgery should be contemplated. It is often indicative of a clinical course of abdominal symptoms that can range from minutes to hours to weeks and is commonly used synonymously for a condition that requires immediate surgical intervention. Conclusion: Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and non-specific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, and ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, and ovarian torsion) must be considered. Clinical significance: A good clinical acumen along with diagnostic intervention aids in diagnosing acute abdomen aptly.

Background: There are multiple inducing agents available—pharmacological and non-pharmacological. The search for an ideal inducing agent continues worldwide. An ideal inducing agent should have less induction interval to delivery time, less side effects such as fetal distress and hyperstimulation, patient safety, economical, and have ease of administration. The two preparations of Dinoprostone (PGE2) gel and pessary were compared for efficacy in vaginal delivery, induction delivery interval (IDI), and cost effectiveness. Materials and methods: A prospective observational study was done in 100 patients in a tertiary level teaching hospital from 1 November 2019 to 31 March 2021. A total of 50 patients in group A received 0.5-mg PGE2 gel and 50 patients in group B had insertion of sustained release 10-mg PGE2 pessary for induction of delivery at term. The two groups were compared for the rate of vaginal delivery and IDI. Other variables, such as need of augmentation, fetal distress, postpartum haemorrhage (PPH), and neonatal intensive care unit (NICU) admission, were also compared. Results: The rate of vaginal delivery in both groups were similar. Mean induction to vaginal delivery interval was significantly lesser in the Dinoprostone pessary group (17.72 ± 6.81 hours for PGE2 pessary group vs 19.57 ± 5.46 hours for PGE2 gel group); duration of augmentation with Oxytocin was significantly lesser in the pessary group (5.68 ± 4.05 hours in pessary group vs 7.41 ± 3.44 hours in gel group). There was no significant difference in failed induction, uterine hyperstimulation, fetal distress, PPH, and NICU admission in the two groups. Conclusion: Dinoprostone gel and pessary are similar in rate of vaginal delivery. The IDI and need of oxytocin are less with PGE2 pessary. Failure rate is same for both PGE2 pessary and gel. In comparison, no marked superiority of pessary was seen over economical gel preparation.

Aims and objectives: To study associated risk factors, a clinical pattern of presentation, course of the disease, and outcome in Peripartum cardiomyopathy (PPCM) cases. Materials and methods: A retrospective observational study of cases diagnosed with peripartum cardiomyopathy was conducted at the Department of Obstetrics and Gynecology, LTMMC, Mumbai, for a duration of 2 years (from January 2020 to December 2021). Results: Out of a total of 12,880 delivered patients in 2 years, 9 (0.07%) cases were diagnosed and managed as PPCM. Our study revealed that PPCM was common in young patients in the age group 21–30 years. About 5 (55.6%) were primigravidas and 4 were (44.4%) multigravidas. In our study, 56% of cases presented antenatally and 44% postnatally. The majority of study participants had NYHA grade III breathlessness. Cardiogenic shock in the form of the postpartum collapse was noted in a single case. Preeclampsia was the most common obstetric comorbidity noted in 66% of cases. Medical comorbidity in the form of type-1 diabetes mellitus (DM) was present in 11% of cases and chronic hypertension in 22% of cases. Mean ejection fraction was 34% on 2D echo. No thromboembolic event was noted in any case. Maternal mortality was seen in 2/9 (22%) cases. Conclusion: The majority of the study participants were young primigravidas with preeclampsia being a strongly associated risk factor. Early signs and symptoms of heart failure can be obscured by physiological hemodynamic changes in pregnancy. A high index of suspicion is thus essential for early diagnosis and timely intervention, which is the key measure for a favorable outcome.

Aim: To investigate the accuracy of fetal kidney length (FKL) in determining gestational age (GA) in the third trimester by ultrasound and comparing it with existing parameters. Materials and methods: This is an observational and comparative study conducted over a period of 1 year in the Department of Obstetrics and Gynecology of a tertiary care teaching hospital located in Puducherry, India. The study included pregnant women between 28 weeks and 34 weeks. All had a dating scan (DS) in the first trimester. The total study population was 100. All patients underwent a growth scan, and FKL was determined during the same. This value was compared with a normogram, and gestational age was determined. This was compared with the gold-standard gestational age derived from crown-rump length (CRL). The software used was MedCalc software. Results: The average FKL was positively correlated with CRL which was statistically significant (p <0.001). The Kappa analysis showed agreement of average FKL with CRL. Both sides of the kidney had comparable values, but the average length showed the best correlation to determine gestational age in the third trimester. Conclusion: The study showed that FKL is an accurate parameter to date pregnancy. It correlated well in combination with the other routinely used parameters for the estimation of gestational age in the third trimester. Clinical significance: The present study is one of the few studies conducted in the third trimester to date the pregnancy. It is applicable in low-resource settings where DS might not be available to accurately date the pregnancy.

Introduction: With the rise in COVID-19 cases round the world, we have the problem of COVID-19 positive pregnancies at hand. Various case series and reports around the world have shown a high incidence of cesarian deliveries in these patients. We have attempted to study the factors predicting an increase in cesarean section (CS) rates in COVID-19 positive pregnancies admitted to our institution. Methods: Retrospective analysis of all deliveries of COVID-19 affected pregnancies in a tertiary care center in north Kerala from 15 April 2020 to 31 October 2020. There were 253 deliveries during this period with 183 cases of cesarean and 70 vaginal deliveries. The data were entered in Microsoft Excel and analyzed with appropriate statistical software. Results: There was 71.42% cesarean section rate in women below 35 years of age compared to 100% in those above 35 years. The rate was higher among nullipara (77.77%) compared to 67.32% among multipara. There was also a positive correlation between cesarean with obesity [prepregnancy body mass index (BMI) more than 30]. There were 70.22% term cesareans compared to 89.28% in preterm. Induction of labor also seemed to increase rate of cesarean. Fetal growth restriction (88.88%) contributed more to cesarean rates unlike those without (71.06%) preterm rupture of membranes (PROM) and meconium staining of amniotic fluid (MSAF) was also seen to increase the possibility of cesarean. Cardiotocogram abnormalities (13.83%) were another important contributing factor. A total of 100% of patients with abnormal cardiotocogram (CTG) underwent cesarean section when compared to only 67.88% in those with normal CTG. In patients delivered while still positive, the incidence of cesarean section was 77.63%, while this reduced to 63.04% in those whom delivery was delayed till seronegativity achieved. A total of 75.95% cases were done in the morning. There were 19.67% cases of fetal distress which added to the cesarean numbers. Conclusions: We found increased maternal age, obesity, nulliparity, fetal growth restriction, PROM, MSAF as factors which contributed to increased cesarean section rates in COVID-19 positive pregnancies. Hence these pregnancies need careful monitoring.

Introduction: Cesarean delivery commonly induces moderate to severe pain lasting for 48 hours. Any form of intervention that leads to improvement in pain relief can positively impact ability to breast feed early. Infiltration of local anesthetics (LAs) into the surgical wound is a simple, safe, and low-cost technique for postoperative analgesia. Systemic side effects seen with central neural blockades are avoided. Analgesic requirements are also reduced. Risks of LA toxicity are very low or negligible. Aims and objectives: To compare the effect on postoperative analgesia of bupivacaine (BP) infiltration into the incision line vs normal saline (NS) infiltration after cesarean section (CS) by analyzing pain-free interval, pain score, and overall analgesic consumption in first 24 postoperative hours. Materials and methods: A prospective, double-blinded, randomized controlled study was conducted in the Department of Obstetrics and Gynecology, RG Kar Medical College and Hospital over 1 year including 130 patients undergoing cesarean delivery under spinal anesthesia. Before skin closure, 30 mL 0.25% BP or NS infiltration was infiltrated over incision line (10 mL in rectus sheath; 10 mL for each upper and lower subcutaneous flap). Postoperatively, the patients were evaluated at 2, 4, 6, 12, and 24 hours. Analgesic drugs were considered on pain score above 4 on visual analog scale (VAS). Diclofenac intramuscularly 75 mg was given on the first request and tramadol on second, if VAS was above 4 within 12 hours. Results: Mean time of first analgesic demand was 274.30 minutes in BP group whereas 149.15 minutes in NS group (p <0.0001). Pain scores (on VAS) were significantly reduced for up to 6 hours postoperatively in BP group as compared to NS group (at 2 hours, p = 0.000 and at 6 hours, p = 0.007). There was no statistical difference in pain scores in two groups beyond 6 hours. In BP group, 58.46% patients required only 75 mg of intramuscular diclofenac and 41.54% patients required 150 mg of diclofenac in two divided doses whereas in NS group; only 23.08% patients had pain control by 75 mg of intramuscular diclofenac and 76.92% required 150 mg (p = 0.0001). In addition to diclofenac, 26.15% patients in NS group required 100 mg of tramadol vs only 7.7% in BP group (p = 0.0101). Conclusion: Direct infiltration of 0.25% BP along incision line following cesarean delivery under spinal anesthesia prolongs pain-free interval, provides adequate analgesia for 1st few postoperative hours, reducing requirement of systemic analgesic in first 24 postoperative hours with negligible side effects.

Objective: To analyze the risk factors associated with mortality in COVID-positive pregnant women. Material and methods: The study was designed as a case–control study and was conducted at COVID-designated tertiary care hospital. It included 42 deceased and 96 RT-PCR-positive surviving pregnant women who developed severe forms of disease. All the affected patients were admitted and managed according to Indian national guidelines. Risk factors – age, residence, socioeconomic status, gestation age, parity, and comorbidities were evaluated for their association with mortality. Results: Advanced maternal age (>28 years), rural residence, diabetes, and comorbidities were found to be associated with increased risk of mortality among the COVID-affected pregnant women, the respective adjusted odds ratio was 15.45, 12.61, 2.65, and 4.77, respectively. Conclusion: Pregnant women are vulnerable to COVID infection. They were at higher risk of mortality with comorbidities, advanced age, and low access to healthcare in the rural areas.

Introduction and objectives: The healthcare system of India, being publicly funded relies on the numerous health programs run by the government. Maternal health is benefitted from many such programs. One such innovation by the National Health Mission, Tamil Nadu is the “mentoring” program, where obstetricians from the first referral units (FRU) mentor the service providers at the primary health care level. Our study aims to examine the efficacy of the program. Materials and methods: We conducted a prospective, mixed-methods, longitudinal study at Government Kamaraj Hospital, Chidambaram, Tamil Nadu. Two blocks of the taluk and their nine primary health centers (PHC) were included in the study. The two-mentor obstetricians gave virtual mentoring over WhatsApp groups and real-time mentoring by organizing camps twice a month and collecting the data. Results and discussion: A total of 1,054 antenatal women-kilometers per week were saved due to the reduction of travel from PHC to FRU. Reduction in the waiting time at the outpatient department (OPD) of FRU from 74 ± 31 minutes to 52 ± 19 minutes. Increase in the proportion of elective surgeries by 53%. Reduction in the rate of re-referrals by 5.8 times. The questionnaire-based satisfaction score showed 82% of the PHC team were extremely satisfied with the mentoring program. Conclusion: Mentoring of the primary health care providers by the obstetricians of the FRU is a novel and innovative concept by the National Health Mission, Tamil Nadu, and has helped bridge the gap between pregnant mothers and obstetricians in the resource-limited setting of the rural public sector.

Aim: This case report is aimed to study an ovum donor, hospitalized with severe ovarian hyperstimulation syndrome (OHSS) and anuria. Background: Ovarian hyperstimulation syndrome is an iatrogenic complication now on the rise with the increasing use of assisted reproductive technologies and ovulation induction. The syndrome can range from mild symptoms to life-threatening conditions. Case description: A 30-year-old patient with abdominal distention, anuria, and ultrasonography suggestive of grossly enlarged ovaries. The patient was managed with hemodialysis and multidisciplinary approach until she had an ovarian follicular rupture with hemoperitoneum and had to undergo surgical management. Conclusion: Patients with high risk for OHSS should be hospitalized and monitored closely when undergoing assisted reproductive methods like intrauterine insemination or ovulation induction. The condition is managed by medical therapy and surgical intervention is required only if the ovarian cysts rupture, undergoes torsion or patient starts debilitating vitally. Clinical significance: Careful selection of candidates for assisted reproductive technology (ART), close monitoring and prompt management can control the progression of OHSS from mild to critical and can be lifesaving.

Background: Ovarian cysts are the most common indication for surgery. Some cysts are due to endocrine dysfunction and mostly do not require surgery. Case description: We report a case of a 32-year-old female who presented with large ovarian masses and pituitary enlargement seen in association with hypothyroid. Initially, her radiological imaging and risk of malignancy index (RMI) were in favor of malignancy. On further workup of the patient, high thyroid stimulating hormone (TSH) and prolactin levels were found and she was planned for surgery after optimization. There was a dramatic symptomatic relief as well as a decrease in the size of the ovarian mass after four months of thyroxin supplementation. Conclusion: In young patients presenting with bilateral multicystic ovarian masses, a thyroid function test is mandatory and if thyroid dysfunction is detected, it should be addressed before any surgical intervention. Clinical significance: Hypothyroidism should be considered in differential diagnosis of female with multicystic ovarian mass.

Background: Achondroplasia is a rare genetic disease of bone growth with an incidence of 1:20,000 live births which is characterized by short stature disproportionate body, shortening of long bones, macrocephaly, and kyphoscoliosis. While pseudoachondroplasia is caused by an autosomal dominant mutation in the cartilage oligomeric matrix protein (COMP). Due to the rarity of this condition and its adverse impact on the obstetrical outcome, we find it interesting to report two cases of achondroplasia and pseudoachondroplasia with pregnancy. Case description: The first case was a 24-year-old woman with achondroplasia (patient's height was 116 cm) primigravida, who was referred at her 36–37 weeks of gestation. Ultrasound examination of the fetus revealed micromelia skeletal dysplasia. At 37–38 weeks of gestation, the patient underwent a cesarean section under the subarachnoid block (SAB) regional anesthesia because of the complication of cephalopelvic disproportion (CPD). The baby had a relatively large head circumference, frontal bossing, disproportionate short limbs, and trident hand appearance which is pathognomonic of achondroplasia. The second case was a 26-year-old woman with pseudoachondroplasia (patient's height was 127 cm) multigravida with a history of one abortion, who was referred at her 35–36 weeks of gestation. The patient underwent elective cesarean section with SAB regional anesthesia and the baby looked physically not inheriting maternal abnormalities. Conclusion: Achondroplasia increases maternal and fetal obstetric complications; thus, requiring prenatal counseling, comprehensive risk evaluation, and multidisciplinary team management of anesthesia, obstetrics, and neonatology.

Aim: The aim of the article is to illustrate that women with preeclamptic organ dysfunction can present with a clinical picture of acute pancreatitis. Background: Pancreatitis is a rare condition complicating pregnancy with a quoted incidence of 1–3 cases per 10,000 deliveries, with maternal mortality and fetal loss closer to 3%. Currently, there is increasing speculation that in the absence of any known risk factors, pancreatitis may be associated with a rare spectrum of preeclampsia. Case description: A 25-years-old primigravida at a period of gestation of 34 weeks presented with an acute onset of epigastric pain/tenderness and vomiting of one-day duration. Her BMI was 18 kg/m², and she did not have any risk factors for acute pancreatitis. Other known etiologies of acute pancreatitis were excluded, but an ultrasound scan revealed swollen pancreas with a thin rim of free fluid in the splenorenal pouch with normal gallbladders. Also, serum amylase was significantly elevated. On the 3rd day of her illness, blood pressure was persistently elevated along with albuminuria and with a falling trend of platelet count. Further, she developed acute renal failure with metabolic acidosis. A category 2 cesarean section was performed, and a healthy baby was delivered. On the 4th postoperative day, her biochemical parameters were back to normal. A contrast-enhanced computed tomography of the abdomen performed on the 4th postoperative day showed features suggestive of resolving interstitial pancreatitis. Conclusion: In conclusion, acute pancreatitis should be considered as a complication of preeclampsia, especially in patients deteriorating despite management of preeclampsia. Clinical significance: A woman with preeclampsia is at increased risk of developing systemic complications due to organ dysfunction, which may result in a unique and rare clinical picture at presentation. Thus, detecting the underlying organ dysfunction is necessary for a better pregnancy outcome.

Aim: We report an uncommon case of uterine inflammatory myofibroblastic tumor (IMT), a unique mesenchymal tumor often misdiagnosed as “fibroid uterus” on radiology. Background: Inflammatory myofibroblastic tumor is a mesenchymal tumor reported in the lungs, mesentery, omentum, and retroperitoneum. Its occurrence in the uterus is rare and is often misidentified as a smooth muscle or endometrial stromal tumor. Herein, we report a case of IMT of the uterus. Case description: A 33-year-old lady presented to the OP with menorrhagia. USG abdomen was reported as bulky uterus with an intra-mural (8.7 × 7 cm) fibroid arising from the anterior myometrium. No lymph nodes or free fluid noted. “Myomectomy” was done under spinal anesthesia, and the specimen was sent for HPE. Grossly, it was a circumscribed gray–white soft-tissue mass mimicking a leiomyoma. However, microscopy of the mass was rather unusual to call it a leiomyoma. It had a “tissue-culture-like” or “nodular fasciitis-like” appearance. There were spindle cells in fascicles and prominent myxoid change with lymphoplasmacytic infiltrate. No nuclear atypia, necrosis, or infiltrative margins were noted. So, a morphological diagnosis of IMT was made. Conclusion: The case is reported for its diagnostic challenge and rarity. Clinical significance: Inflammatory myofibroblastic tumors are uncommon mesenchymal tumors of low malignant potential with a tendency to recur and rare metastases. Surgical excision is the treatment of choice. Recurrent IMTs can be treated with ALK-based targeted therapy.

Background: Conservative surgeries such as sling procedures are gaining popularity for pelvic organ prolapse. The technique of this sling surgery has changed along with the materials used for it. So, this case series was planned to find out the usefulness of cotton (umbilical) tape in this surgery as a sling for pelvic organ prolapse. Methods: This study is a case series carried out in the Department of Obstetrics and Gynecology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India in the period between 2010 and 2019. Intervention: Use of cotton umbilical tape [Ethicon Umbilical Sterile Cotton Tape (W276)] as a sling for conservative surgery for prolapse. Outcome measured: Patient satisfaction, postoperative complication, and recurrence. Result: A total of 76 patients were analyzed; 75 women had 98.7% satisfaction. One patient had sinus formation and one patient had a recurrence. Conclusion: Cotton umbilical tape can be used as an alternative to commonly used mersilene tape for sling procedures in a resource-constrained setting.

Aim: To diagnose a rare congenital liver disorder, Dubin–Johnson Syndrome (DJS), compounded by pregnancy and its several differential diagnoses that impede the progress toward diagnosis. Background: Icterus, or jaundice, is defined as the yellow discoloration of the skin, more so of the sclera. While it classifies as one of the most common symptoms in medical literature, it gains added significance when it arrives in congruence to pregnancy. And with that added significance comes the increased risk of maternal and fetal morbidities and mortalities. Case description: Here, we discuss a 19-year-old antenatal patient with refractory hyperbilirubinemia whose etiology eluded our team, until a final shot at it through liver biopsy helped us fetch a surprising diagnosis of DJS. Conclusion: A nonfatal clinical syndrome with very few comorbidities, pregnancy at worst, worsens the icteric component without producing too many adverse fetomaternal outcomes. Clinical significance: The aid of a sound algorithm to rule out other more morbid causes of hepatic dysfunction in pregnancy.

Aim: To summarize the current status of respectful maternity care (RMC) in Sri Lanka and the way forward with the pandemic. Background: Respectful maternity care is a human right with the capacity to improve maternal and neonatal outcomes. Promoting respect at interpersonal and health system levels attracts more women to the health facilities, gives them a positive birth experience, attenuates preventable maternal deaths, improves perinatal outcomes, and minimizes gaps and inequities in women's health. Irrespective of the personal, resource availability, cultural, or any other issue, efforts need to be taken to implement all the domains of RMC in all birthing suites. Methodology: A comprehensive literature review was carried out on Google Scholar and MEDLINE databases to find out the relevant scientific literature on the RMC in the South Asian and the Sri Lankan context. The focus was given to identify the current concepts and the strategies to improve the RMC in the South Asian setting. Review results: We have summarized the various aspects of the RMC, its dimensions, measurement of RMC, the impact of RMC and its importance. The RMC in the South Asian setting needs to be developed in various aspects. Conclusion: The provision of RMC needs concern as a priority measure. The impact of COVID-19 pandemic has implications, especially in allowing a labor companion. However, promoting of RMC could be performed in micro, meso/intermediate, and macro/national levels. Clinical significance: The present challenges and the proposed strategies in achieving this best practice need to be considered in Sri Lanka and other South Asian settings.