Ideal antenatal care-does it exist?

Antenatal care is systematic supervision of a pregnant mother and its objective is to ensure a normal pregnancy with delivery of a healthy baby from a healthy mother. It is quite effective in reduction of maternal and perinatal mortality and morbidity. Varied antenatal care protocols exist in the literature and all aim towards the same goal. This review endeavours to find out a protocol that is ideal and that suits every pregnant woman, every institute and every country in the world. The review was carried out in the period of 1900-2015 by searching in pub med, embase, scopus, google scholar, web of sciences using relevant key words. Reports, articles, fact sheets and official publications of World health Organization (WHO), Ministry of health and family welfare-government of India and various other countries were also reviewed. The review suggests that no such ideal protocol appears to exist that suits the requirement of every pregnant woman / country. However, it is possible to make and implement a near ideal protocol which is evidence based and is logistically and economically viable, for an optimal pregnancy outcome

Comparative study of oral mifepristone and endocervical prostaglandin-E2 gel as pre-induction cervical ripening agents in parturition

Background: Intracervical instillation of prostaglandin E2 is a well-known and widely practiced method of pre-induction cervical ripening. Mifepristone, due to its anti-progesterone action has been found to be a potential cervical ripening agent. This study was conducted to compare the safety, efficacy and outcome of these two drugs in pre-induction cervical ripening.Methods: One hundred antenatal women were recruited for the study; 50 in mifepristone arm and 50 in PG-E2 gel arm. Any singleton term pregnancy in vertex presentation with intact membranes and bishop’s score of <4 was included in the study. Any contraindication for vaginal delivery and any contraindication for mifepristone or PG-E2 were considered as exclusion criteria. Participants in the mifepristone arm were given tablet mifepristone 200 mg orally and those in PG-E2 gel group received endocervical instillation of PGE2 gel 0.5 mg, two doses 6 hours apart (if necessary). Induction of labour was considered successful if the parturient delivered within 48 hours of administration of mifepristone or first dose of PG-E2 gel, with or without labour augmentation with oxytocin. Delivery after 48 hours and caesarean delivery were considered unsuccessful induction.Results: There was a significant improvement in bishop’s score in mifepristone group 5.0±1.55 as compared to PG-E2 gel group 3.64±2.14; p value 0.001.Conclusions: Oral administration of 200 mg mifepristone is a safe, effective and convenient alternative to intracervical instillation of prostaglandin-E2 gel for pre-induction cervical ripening

Hyperhomocysteinemia in recurrent pregnancy loss and the effect of folic acid and vitamin B12 on homocysteine levels: a prospective analysis

Background: Recurrent pregnancy loss (RPL) affects about 5% of women. High levels of homocysteine, termed hyperhomocysteinemia, have been implicated in a number of pathologic processes in the venous and arterial vascular systems. Hyperhomocysteinemia in pregnant women has been associated with deep venous thrombosis, recurrent miscarriage, abruption placentae, preeclampsia, neural tube defects, and fetal growth restriction. This study aims at determining association between hyperhomocysteinemia and recurrent pregnancy loss and also association of folic acid (vitamin B 9) and vitamin B 12 with hyperhomocysteinemia (HHCY), in reducing its levels in the body and thus preventing obstetric complications.Methods: A prospective study of pregnant mothers booked at our hospital over a period of two years with history of unexplained RPL were included in the study and their serum homocysteine levels were assessed. Hyperhomocysteinemia (>12 micromol/l) patients were treated with folic acid and vitamin B12 supplements and homocysteine levels were assessed again, post treatment.Results: Out of the 100 patients who were assessed, 32% of RPL patients had hyperhomocysteinemia. Folic acid and VitB12 supplementation reduced homocysteine levels and this was found to be statistically significant.Conclusions: Hyperhomocysteinemia is associated with RPL. Vitamin supplementation to those with hyperhomocysteinemia, decreases homocysteine levels

An analysis of endometrial bleeding patterns in perimenopausal women

Background: Perimenopause is the period surrounding menopause characterized by ovulatory dysfunction and menstrual irregularities. Taking into consideration the importance of perimenopause and its consequences, we decided to study this topic in order to know the different menstrual irregularities in relation to age, the spectrum of endometrial histopathology, in relation to various gynaecological conditions as per the PALMCOEIN classification of AUB.Methods: The study population comprised of 100 women in the age group of 40- 59 years who reported to our tertiary care centre of Armed Forces for evaluation of abnormal uterine bleeding. The study was a community based cross - sectional descriptive study. Patients were examined, using one of the three techniques – Dilatation and curettage, suction aspiration and hysteroscopy and endometrial biopsy.Results: Out of the 100 women evaluated for perimenopausal bleeding, heavy menstrual bleeding was the commonest in 53% cases. The maximum no. of cases was in 40-44-year age group (57.44 %). The clinical diagnosis of fibroid uterus was found in 45% cases, AUB (O) in 36% cases, AUB (Polyp) in 8% cases, AUB (Adenomyosis) in 9% cases and AUB (Malignancy) in 2% cases. On endometrial curettage, proliferative type of endometrium was found in 43% cases, secretory type in 18% cases and hyperplasia was found in 37% cases. Out of 2 cases of atypical hyperplasia 1 case each (50%) was found in the age group of 50-54 years and 55-59 years, respectively.Conclusions: In the present study, there was good correlation between abnormal uterine bleeding, clinical diagnosis and histopathological findings

A rare case of Takayasu’s arteritis in pregnancy

Takayasu’s arteritis (TA) is an uncommon, chronic inflammatory vascular disease of unknown etiology that primarily involves aorta and its branches and pulmonary arteries. Though it is present worldwide, it is more prevalent in Asian countries. It usually presents during reproductive age group with non-specific symptoms. The symptoms of the disease are varied and patients can present asymptomatically with impalpable pulses. There are no specific laboratory tests to diagnose TA. Angiographic imaging is considered to be the gold standard investigation in diagnosing TA. Steroids with subsequent tapering doses are the mainstay of medical treatment. Reconstructive vascular surgery is limited to the severe and irreversible stenotic lesions. Though the disease process theoretically is not aggravated by the pregnancy, development of preeclampsia and fetal growth restriction may occur during pregnancy. Preconception counseling and careful monitoring of pregnant mother by a multidisciplinary team, improves the pregnancy outcome. Here we present a bad obstetric case with TA who subsequently developed severe preeclampsia and fetal growth restriction. The pregnancy outcome could be made favourable by strict monitoring and multidisciplinary team approach

A rare case of thyroid storm following caesarean section

Thyroid storm in pregnancy is a rare life threatening emergency, with very high maternal and perinatal mortality and morbidity. Here we present an unusual case of a 30 year-old G2P1L1 woman, a known case of post caesarean pregnancy with hyperthyroidism who presented with severe preeclampsia and on second post op day developed thyroid storm. Early recognition and timely institution of appropriate management resulted in good outcome in this case

Evaluation of the incidence and outcome of gestational diabetes mellitus using the current international consensus guidelines for diagnosing hyperglycaemia in pregnancy

Background: Diabetes Mellitus in pregnancy has long been recognized as a serious problem for both mother and fetus. Gestational Diabetes Mellitus (GDM) is defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy. Even though there are many diagnostic criteria and guidelines for management of GDM, there still exists lack of consensus regarding diagnosis and management of patients with GDM. After Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, International Association of Diabetes in Pregnancy Study Group (IADPSG) has formulated a new consensus guideline for diagnosing hyperglycaemia in pregnancy which has formed the back bone for this particular study. The aim of this study was to assess the incidence of GDM using current international consensus guidelines with 75g Oral Glucose Tolerance Test (OGTT) and evaluation of maternal and fetal outcome.Methods: All antenatal patients were screened for GDM with 75g OGTT and their glycaemic control was evaluated throughout pregnancy. Either Medical Nutritional Therapy or Oral Hypoglycaemic Agents or Insulin Therapy was advised for glycaemic control. Maternal and neonatal outcomes were evaluated.Results: A total of 856 Antenatal patients were screened and 111 were diagnosed as GDM, showing an incidence of 13%. Medical Nutritional Therapy was found to be an effective method for glycaemic control in GDM.Conclusions: The incidence of GDM in the studied population was found to be 13%. Previous history of GDM was found to be the most significant high risk factor associated with GDM followed by family history of Diabetes. Medical Nutritional Therapy was found to be highly effective in the management of GDM. Only 9% of GDM patients required insulin therapy. With adequate glycaemic control, all late pregnancy complications and neonatal complications can be alleviated

A rare case of low transverse vaginal septum

Transverse vaginal septum is a rare cause of genital outflow tract obstruction. It results from incomplete fusion/recanalization between the vaginal components of the mullerian ducts and the urogenital sinus. The septum varies in thickness and may be present anywhere along the vagina, although most are found in the upper and mid-vagina. A complete septum results in primary amenorrhoea and several short term and long term sequelae including endometriosis and infertility. We present a case of 12-year old girl who presented with intermittent, colicky abdominal pain. She had undergone low anorectoplasty at 18 months of age. She had not yet attained menarche. Secondary sexual characters were appropriately developed. The clinical examination revealed a small, blind ending lower vagina and a tender, bimanually palpable mobile mass in the suprapubic region. The ultrasound examination revealed fluid collection with internal echoes within the endometrial cavity extending into the upper vagina. The magnetic resonance imaging of pelvis confirmed the thickness (four cm) and location of the transverse vaginal septum (lower one third) along with presence of hematocolpos in upper 2/3rd of the vagina, hematometra and hematosalpinx. She underwent successful excision of the septum. Amnion was used for the epithelialisation of the denuded vaginal mucosa

Evaluation of the incidence and outcome of gestational diabetes mellitus using the current international consensus guidelines for diagnosing hyperglycaemia in pregnancy

Background: GDM is defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy. It may be appropriate to screen pregnant women belonging to high-risk populations during the first trimester of pregnancy in order to detect previously undiagnosed Diabetes Mellitus. Formal systematic testing for Gestational Diabetes is usually done between 24 to 28 weeks of gestation. Even though there are many diagnostic criteria and guidelines for management of GDM, there still exists lack of consensus regarding diagnosis and management of patients with GDM. After HAPO study, IADPSG has formulated a new consensus guideline for diagnosing hyperglycaemia in pregnancy which has formed the back bone for this particular study.Methods: This prospective observational study was carried out for a period of one year from July 2014 to Jun 2015 at AFMC, Pune in Dept. of Obstetrics & Gynaecology. To determine if gestational diabetes is present in pregnant women, a standard OGTT was performed with 75 g glucose. The incidence of GDM in antenatal population visiting AFMC, Pune was calculated. Maternal and neonatal outcome was observed and was compared with those of euglycaemic antenatal population.Results: The incidence of GDM in the antenatal population visiting AFMC, Pune was found to be 12.4%. Family history of Diabetes among first degree relatives is the commonest risk factor associated with GDM. It was found that, with adequate glycaemic control, most of the maternal as well as neonatal complications associated with GDM can be reduced to a level comparable with euglycaemic antenatal population.Conclusions: The new international consensus guideline in diagnosing GDM has shown an incidence of GDM comparable with other criteria for diagnosing GDM. Ensuring an adequate glycaemic control throughout the antenatal period alleviates most of the maternal and neonatal complications associated with GDM

Ideal antenatal care-does it exist?

Antenatal care is systematic supervision of a pregnant mother and its objective is to ensure a normal pregnancy with delivery of a healthy baby from a healthy mother. It is quite effective in reduction of maternal and perinatal mortality and morbidity. Varied antenatal care protocols exist in the literature and all aim towards the same goal. This review endeavours to find out a protocol that is ideal and that suits every pregnant woman, every institute and every country in the world. The review was carried out in the period of 1900-2015 by searching in pub med, embase, scopus, google scholar, web of sciences using relevant key words. Reports, articles, fact sheets and official publications of World health Organization (WHO), Ministry of health and family welfare-government of India and various other countries were also reviewed. The review suggests that no such ideal protocol appears to exist that suits the requirement of every pregnant woman / country. However, it is possible to make and implement a near ideal protocol which is evidence based and is logistically and economically viable, for an optimal pregnancy outcome