How to cite this article: Shah N, Malhotra N, Malhotra J, Garg R, Tank J, Malhotra N.. Cesarean Section: A Storm in a Cup??? J South Asian Feder Obst Gynae 2017;9(4):291-296.

Malhotra N, Garg R, Malhotra N, Malhotra J. Oral Allylestrenol: A Pregnancy-supporting Progestogen. J South Asian Feder Obst Gynae 2017;9(4):297-303.

Polycystic ovary syndrome (PCOS) is a complex disease having genetic, immunologic, and environmental components, and candidate genes on innate immunity have been hypothesized to be involved in its etiology. We examined the possible association of CD14 and toll-like receptor 4 (TLR4) polymorphisms with PCOS.

A total of 219 women with PCOS and 272 healthy women were recruited in the study. Their samples were genotyped for the polymorphism of CD14 and TLR4 genes.

The distributions of genotypes of both polymorphisms were found to be significant in women with PCOS compared with controls. The distributions of alleles were also found to be predominant in PCOS compared with controls.

Polymorphisms in CD14-159C>T and TLR4-299A>G significantly increased susceptibility to PCOS. Further studies with larger sample sizes are warranted to confirm these findings.

Allauddin N, Rozati R. Single Nucleotide Polymorphisms in CD14 and Toll-like Receptor 4 Genes in Patients with Polycystic Ovarian Syndrome. J South Asian Feder Obst Gynae 2017;9(4):304-307.

DSouza RJ, Narayani BH, Rao SB. Outcome of Pregnancy with History of Previous Cesarean Section. J South Asian Feder Obst Gynae 2017;9(4):308-311.

(1) To investigate the association between term elective cesarean sections and neonatal respiratory morbidity and the importance of timing of the cesarean. (2) To assess the maternal morbidity when emergency lower segment cesarean section (LSCS) was required.

All women with singleton term (37—41 + 6 weeks) pregnancies and planned for elective cesarean section in Christian Medical College, Vellore, India.

The primary outcome measures were neonatal morbidities such as transient tachypnea of newborn (TTN) and respiratory distress syndrome (RDS). The secondary outcome measures were emergency cesarean section and maternal morbidities such as scar dehiscence, urinary tract infection (UTI), endometritis, peritonitis, and hemoperitoneum in the mother.

The percentage of TTN in the infants in group I was 1.3% while there were none in group II. No infants were diagnosed to have RDS. Out of the 150 women who were planned for elective cesarean section, 55 women underwent emergency cesarean section. Among this, 19 (25.3%) of women were from group I as compared with 36 (48.0%) in group II. The difference in proportion between the two groups was –22.7 [95% confidence interval (CI): –37.7, –7.7], which was statistically significant (p < 0.01). The incidence of scar dehiscence, UTI, endometritis, and hemoperitoneum in the mothers of group II was marginally higher than that in the mothers of group I. There was one woman with peritonitis in group I while none was reported in the other group. All the maternal morbidities occurred to women who underwent emergency cesarean section. Out of the 19 women in group I and 36 women in group II who underwent emergency cesarean section, 1 (5.3%) and 6 (16.7%) women had morbidities.

Women requiring elective cesarean section can safely be done between 37 and 39 weeks with no further significant increase in the rates of neonatal morbidity such as TTN and RDS.

Roy P, Jeyaseelan L, Ruby J, Garg R. Respiratory Morbidity in Term Infants delivered by Elective Cesarean Section at a Tertiary Care Hospital in India: A Randomized Controlled Trial. J South Asian Feder Obst Gynae 2017;9(4):312-317.

Wilson disease is a very rare inherited autosomal recessive disorder, with an incidence of 1 in 30,000 live births, associated with impaired copper metabolism leading to decreased biliary excretion and accumulation of copper in the liver and brain. Patients may be asymptomatic or might present with fulminant liver disease or neuropsychiatric illness. Untreated Wilson disease is related to infertility/subfertility/recurrent pregnancy loss.

To study the maternal and perinatal outcomes of Wilson disease in pregnancy.

It is a retrospective observational study carried out in the Department of Obstetrics and Gynecology, St. John's Medical College Hospital, Bengaluru, India, between November 2010 and November 2015. Five patients with Wilson disease were identified during the study period. Pregnancy outcome was good in all these five women who were on regular treatment.

Patients with Wilson disease who receive regular treatment and who remain asymptomatic and conceive normally have favorable pregnancy outcomes. They merit regular surveillance and active management in higher centers with multidisciplinary approach involving gastroenterologists, obstetricians, neurologists, and intensivists.

Vishnupriya KMN, Sheela CNR, Thayumanasundaram M. Maternal and Perinatal Outcome of Wilson Disease in Pregnancy: A 5-year Experience at a Tertiary Care Center. J South Asian Feder Obst Gynae 2017;9(4):318-322.

To assess associated risk factors, maternal and neonatal outcome of pregnancies complicated by umbilical cord prolapse in South Indian population.

It was a descriptive study. Risk factors, maternal and neonatal outcome were noted down retrospectively from case records of mothers affected by umbilical cord prolapse from April 2014 to March 2016.

There were 39 cases of umbilical cord prolapse in 2 years. The incidence of umbilical cord prolapse in our hospital was 0.1%. Most of the women were ≤ 25 years of age (72%). Primis were 56%. Most common presentation in umbilical cord prolapse was cephalic presentation (64%). Among the affected individuals, 82% had term gestation, 79% had higher presenting part, and 87% had spontaneous rupture of membranes. Babies were delivered by lower segment cesarean section (LSCS) in 95% and birth weight was ≥2.5 kg in 67% of cases with umbilical cord prolapse. Decision to delivery interval (DDI) was ≤30 minutes in 84% of cases. APGAR score was ≥7 at 1 minute in 65% and ≥7 at 5 minutes in 83% of cases. There were 15 neonatal intensive care unit (NICU) admissions and 2 stillbirths. Most common gender was male (75%).

In our study, maternal risk factors were different from traditional risk factors in relation to age, parity, period of gestation, presentation, and birth weight. But, station of presenting part, early dilatation of cervix at diagnosis, and male gender predominance were similar to traditional risk factors. Neonatal outcome was good in our study with no birth injuries. All cases should be monitored properly to reduce the occurrence of umbilical cord prolapse even in low-risk population. Early detection and intervention is required for good neonatal outcome. Umbilical cord prolapse should be managed by an expert obstetrician.

Hembram M, Sagili H. Risk Factors, Maternal and Neonatal Outcome in Umbilical Cord Prolapse in South Indian Population. J South Asian Feder Obst Gynae 2017;9(4):323-326.

Contraception is an important intervention to reduce unwanted pregnancy and promote healthy and better living among women. As the population continues to rise, there will be overcrowding, a limiting of resources, and the quality of life will decline. India, as the first country in the world, initiated the National Family Planning program in the year 1951 with the objective of “reducing the birth rate to the extent necessary to stabilize the population at a level consistent with requirement of national economy.”

(1) To study awareness, acceptance, and preferred method of contraception among postpartum women. (2) To identify the reasons for rejection of contraceptive methods. (3) To contribute to the development of knowledge in the area of family planning.

The study is a community-based cross-sectional observational study. The study was conducted among postpartum women in reproductive age group who delivered in our hospital in the Department of Obstetrics and Gynecology of Netaji Subhash Chandra Bose Medical College & Hospital, Jabalpur, Madhya Pradesh, India. A total of 480 married women were interviewed in the local language using a pretested questionnaire. Their level of awareness, acceptance, and reason for acceptance/refusal was assessed.

A total of 65.2% of women were aware of at least one method of contraception; 73.9% women were using a contraceptive at the time of study; 34.8% women were unaware of any health care facility providing contraceptives in the vicinity. Maximum number of women preferred intrauterine contraceptive device (IUCD; 38.8%) as their first choice. Knowledge and practice of emergency contraceptive was very low. Main reason for nonacceptance of contraceptive was lack of knowledge and fear of side effects. Health professionals were the main source of knowledge.

There is till date lack of awareness of contraception in some postpartum women. Regular counseling is a must to all pregnant women from every health care center in a village to superspeciality centers in cities. Information should be provided about various methods of contraception and patient should be able to choose a method of her choice.

Sahu B, Tiwari P, Uikey V, Badkur P. Awareness and Acceptance of Contraception in Postpartum Women in Our Tertiary Hospital in Central India. J South Asian Feder Obst Gynae 2017;9(4):327-330.

To study the diagnostic accuracy of folliculometry and endometrial echo complex as an evidence of ovulation in infertility.

This clinical study was conducted on 100 infertile women. The women were subjected to follicular monitoring by transvaginal sonography (TVS) from cycle day 8 or 10 of menstruation with 7.5 MHz vaginal probe of Siemens ultrasound machine. Evidence of follicular growth, ovulation, and morphology of endometrial echo complex with its thickness was noted. Endometrial biopsy was performed premenstrually as a day care procedure after excluding pregnancy.

Out of 100 women, 81 cases were with evidence of ovulation on TVS and 68 were confirmed on histopathology. All the studied patients were also evaluated for endometrial thickness on the day of ovulation, echo complex of endometrium suggestive of ovulation was seen in 64 cases, out of these 59 cases were confirmed on histopathology. On histopathological study of 100 cases, we found 69 cases with secretory endometrium, 18 with proliferative endometrium, 10 patients with endometritis, one each with luteal phase defect, irregular shedding of endometrium, and hormonal imbalance.

We found folliculometry predicted ovulation 86% accurately with a specificity of 58.60% and sensitivity of 98.55%. Similarly, appearance of endometrium predicted ovulation 85% accurately with a specificity of 83.80% and sensitivity of 85.50%. Thus, TVS has undeniable advantages in terms of cost, time, acceptability, risk, convenience, and could easily diagnose signs of ovulation in cases of infertility. The TVS has quintessential role as the first diagnostic modality in patients presenting with infertility.

Katiyar S, Arya SB, Goel JK, Sinha M. Sonographic Folliculometry and Endometrial Echocomplex as an Evidence of Ovulation in Infertility Cases. J South Asian Feder Obst Gynae 2017;9(4):331-335.

The polycystic ovary syndrome (PCOS) is the most common condition associated with chronic anovulation affecting 4 to 6% of reproductive age women.

To compare the effectiveness of laparoscopic ovarian drilling (LOD) for ovulation induction with gonadotropins in clomiphene-resistant PCOS in terms of ovulation, pregnancy, live birth, abortion, multiple pregnancies, and complication like ovarian hyperstimulation syndrome (OHSS).

A prospective hospital-based randomized trial.

It was a prospective study, which was carried out from January 2012 to May 2015. Totally, 89 women were evaluated in the study, out of which 44 women were in gonadotropin group and 45 were in LOD group.

Standard statistical analysis was done and significance of difference in results was tested by chi-square test.

Ovulation rate in gonadotropin group was 75.0% at 6 months, whereas in LOD group, it was 20% at 3 months and was increased up to 66.66% after addition of clomiphene citrate and gonadotropin. The primary outcome in terms of pregnancy in gonadotropin group was 45.45% after 6 cycles and in LOD group was 11.11% after 3 cycles and 40.00% after 6 cycles with supplementation of clomiphene citrate and gonadotropin.

The ongoing pregnancy rate from ovulation induction with LOD alone was significantly less but if supplemented by clomiphene citrate and gonadotropin, it seems equivalent to ovulation induction with gonadotropin, but the former procedure carries a lower risk of multiple pregnancies.

Yadav P, Singh S, Singh R, Jain M, Awasthi S, Raj P. To Study the Effect on Fertility Outcome by Gonadotropins vs Laparoscopic Ovarian Drilling in Clomiphene-resistant Cases of Polycystic Ovarian Syndrome. J South Asian Feder Obst Gynae 2017;9(4):336-340.

Polycystic ovarian syndrome (PCOS) is an endocrine disorder affecting all age groups and presenting with myriad problems like menstrual irregularities, hirsutism, anovulatory infertility, and long-term complications like diabetes, cardiovascular problems, etc.

Study was aimed at finding the prevalence, characteristics, and various risk factors of metabolic syndrome (MS) in reproductive age group in our hospital.

Using statistical table, a sample size of 131 was calculated and patients were recruited as per inclusion criteria. Polycystic ovarian syndrome was diagnosed by the American Society for Reproductive Medicine (ASRM)/European Society of Human Reproduction and Embryology (ESHRE) criteria. After informed consent, a detailed history was obtained and physical examination was carried out to assess, body weight, height, body mass index (BMI), waist—hip ratio (WHR), and blood pressure (BP). Fasting blood glucose, triglycerides, and high-density lipoprotein (HDL) were measured for each woman

Prevalence of MS in our study was 45.8%; 26.7% of patients had a combination of increased waist circumference, raised triglycerides, and low HDL; 55.2% of patients had a fasting blood sugar (FBS) levels more than 100 mg%. Age of the patient was a statistically significant risk factor of MS with 100% of patients in the age group of 35 to 39 presenting with MC. Body mass index was also a statistically significant risk factor with 82.6% with BMI > 30 having MC. Other important risk factors include a WHR more than 0.95, presence of diabetes in mother or sister, and presence of acanthosis; 71% of patients with WHR more than 0.95 had MC. Age of menarche, duration of menstrual cycles, and hirsutism showed no significant relationship.

An outstanding fact that emerged in this study was that 94% of women with PCOS had HDL values <50 mg/dL. And 58% had triglycerides more than 150 mg/dL. Hence, lifestyle modification and early intervention will hopefully spare long-term complication of PCOS.

Madusudhanan RR, Nambisan B, Brahmanandan M, Radha S. Study on the Prevalence and Characteristics of Metabolic Syndrome in Women of Reproductive Age Group with Polycystic Ovarian Syndrome. J South Asian Feder Obst Gynae 2017;9(4):341-347.

Nayak S, Shetty PK. A Study on Challenges faced by Mothers and the Coping Strategies adopted by them during the Postpartum Period. J South Asian Feder Obst Gynae 2017;9(4):348-355.

Cervical ectopic pregnancies account for less than 1% of all pregnancies. It may present with abnormal and occasionally heavy bleeding.

To understand the challenges associated with management of cervical ectopic pregnancies and learn to individualize the available treatment modalities for a successful outcome.

A 42-year-old woman, G6P2L2MTP3 with amenorrhea of 2 months, was diagnosed with cervical ectopic pregnancy of 9 weeks on ultrasonography. She was a known case of dilated cardiomyopathy with type II diastolic dysfunction and an ejection fraction of 25%. The patient was given systemic methotrexate followed by intra-amniotic methotrexate and fetal intracardiac potassium chloride. She was followed up with serial β-human chorionic gonadotropin (hCG) reports. However, she developed abdominal pain with bleeding per vaginum and ultrasonography suggestive of a hematoma. The patient was then taken up for a bilateral uterine artery embolization followed by an immediate suction evacuation. The products of conception sent for histopathology confirmed the microscopic diagnosis of cervical pregnancy.

It is a challenging clinical situation to diagnose and manage. It needs to be diagnosed early, and management needs to be individualized.

Even with advanced diagnostic modalities and reduction in current mortality rates, cervical pregnancy remains a life-threatening condition. It is of utmost importance to be thorough with the emerging trends in its management, as it comes with the promise of being unpredictably catastrophic.

Raza N, PaiDhungat NP. Successful Conservative Management of a Case of Cervical Ectopic Pregnancy complicated with Preexisting Cardiomyopathy. J South Asian Feder Obst Gynae 2017;9(4):356-359.

Arora G, Bagga GR, Nandu VV. A Rare Case of Twin Gestation with Sirenomelia and a coexisting Normal Fetus. J South Asian Feder Obst Gynae 2017;9(4):360-362.

HELLP syndrome, consisting of hemolysis, elevated liver enzymes, and low platelet count, is a rare complication of occurring in 10 to 20% of women with severe preeclampsia and in 0.2 to 0.6% of total pregnancies. Delivery is the only definitive treatment, with maternal condition usually improving in the postpartum period.

Hemoperitoneum in a woman with preeclampsia is very rare, usually secondary to hepatic hematoma with rupture. While the prevalence of intrahepatic hematoma in these women has been reported to be as high as 39%, capsular rupture is rare, occurring up to 12% in women with capsular hematoma, carrying with it high mortality for both the mother and fetus.

We report an unusual case of hemoperitoneum secondary to liver hematoma in severe preeclampsia in the postpartum period that was conservatively managed leading to good maternal outcome.

We report a case of postpartum onset of severe preeclampsia in a 25-year-old woman complicated by hepatic dysfunction with coagulopathy and hemoperitoneum. This was secondary to a contained subcapsular hematoma and was conservatively managed resulting in a good outcome.

Prompt recognition with careful clinical examination, laboratory investigations and imaging, supportive treatment, and early fetal delivery remain the cornerstone in the management. Although reaching the diagnosis was initially challenging in our case study, both mother and baby had a good outcome with an appropriate supportive treatment.

Most cases with liver hematomas may lead to hepatic rupture with hemodynamic instability, necessitating an aggressive operative approach. However, conservative management with close monitoring of hemodynamic status can be undertaken if the patient is hemodynamically stable with good outcome, as illustrated in this case.

Loh M, Kathirvel R. An Unusual Case of Severe Preeclampsia in the Postpartum Period with Hemoperitoneum. J South Asian Feder Obst Gynae 2017;9(4):363-366.