Association of early neonatal-maternal outcomes with timing of elective caesarean section at term gestation

Background: The decision for optimal time for elective caesarean section (ECS) should be taken considering the minimum risk to the newborn as well as to the mother. This prospective observational study aimed to investigate the effect of gestation of ECS, on neonatal and maternal outcomes.Methods: All the pregnant term mothers admitted to our hospital for ECS and fulfilling the inclusion criteria were enrolled and divided into 2 groups, early term and full term. Patients having high-risk factors like intrauterine growth restriction, amniotic fluid disorders, multiple pregnancies, placenta previa, abruption placenta and medical co-morbidities were excluded. Early neonatal and maternal outcomes were compared between the 2 groups.Results: 244 mothers were eligible for ECS, 183 (75%) women underwent ECS in the early term and 61 (25%) at full term as per the decision of obstetricians of various units. The incidence of neonatal respiratory morbidity (NRM) was 2 percent in our study. Out of 244 newborns, 4 developed NRM in the form of delayed adaption in 3 and respiratory distress in 1. The incidence of respiratory distress was comparable in both groups. The incidence of NNJ, MSL and sepsis was higher in the early term but it was not significant statistically. Maternal outcomes like postpartum haemorrhage, the need for blood transfusion, bladder injury, thin scar, adhesions poorly formed LUS were observed in the early term but the difference was not significant.Conclusions: More research needs to be done for optimization of timing of ECS

Perinatal lethal skeletal dysplasia: a case report

The word dysplasia originates from ancient Greek words dys (anomalous) and plasia (formation). Skeltal dysplasia (SD) is a heterogeneous group of congenital anomalies characterized by abnormalities in the development of the bone and cartilage tissue. This results in mark disproportion of the long bones, the spine and fetal head relation to the trunk. Perinatal lethal skeletal dysplasia leads to still birth or early neonatal death due to pulmonary hypoplasia. 30 yrs old G3P3L2 at 32 weeks presented with leaking per vaginum. Her serial scan was done as she had previous stillborn male child with short limbs. Her antenatal scan revealed short limbs from 24 weeks. From18 weeks to 24 weeks she did not underwent any sonography. She went into spontaneous labor and delivered still born male baby with clinical and radiological features suggestive of skeletal dysplasia. Skeletal dysplasia can be diagnosed on antenatal 2 D ultrasound from 14 - 16 weeks onwards. Prenatal genetic testing should be done to diagnose the genetic anomaly and patient should be referred to higher institute for this test. Even if genetic test not done even then termination of pregnancy should be considered based on ultrasound diagnosis especially with family history because of poor fetal prognosis and long term morbidity if survived

Histogenesis of developing human fetal stomach

Background: Human stomach is a highly specialised organ with distinct types of glands and microscopic features for its physiological activity. This study aimed to assess the chronological order in the development of different layers and the cyto-differentiation of various glandular cells in 50 fetuses from 12 weeks of gestation till term.Methods: Tissue was taken from cardiac, body and pylorus to investigate with light and confocal microscopy.Results: The gastric gland formation began as an indentation of the surface epithelium, gastric pit and simultaneous development of glandular buds in the mucosa. The pyloric glands preceded the development of cardiac and gastric glands showing retro cranial sequence of development. In contrast, the muscularis externa showed the classical craniocaudal model of development with oblique layer in the cardiac region by 14 weeks and body region by 16 weeks of gestation. The parietal cells were well developed by 12 weeks and the chief cells by 16 weeks with prominent secretory granules. In addition, the pyloric sphincter was a clearly defined anatomical sphincter developed by whorling of the inner circular layer at the pyloric end of the stomach evident from 12 weeks of gestation.Conclusions: The results showed that the significant cellular morphogenesis occurred between 12-20 weeks of gestation. This aggregated data will serve as a catalyst in the understanding intricacy of embryogenesis, pathogenesis tracing of congenital anomalies and invention of new drugs

Two years follow up study of post placental insertion of IUCD during caesarean sections: safety, efficacy and complications

Background: The present study evaluates safety, efficacy, expulsion rate and complications of PPIUCD insertion in women undergoing caesarean section in a medical college for 2 years period.Methods: This is a prospective cohort study done over a 2 year period. Total 185 patients undergoing caesarean section and fulfilling medical eligibility criteria for PPIUCD were enrolled in the study. The followup of these patients was done at 6 weeks, 6 months and 1-2 years.Results: Thirteen patients (7%) lost to follow up so final outcome analysis was done in 172 patients. The problems encountered were spontaneous expulsion in 4 patients, removal due to heavy menstrual flow in 13 patients, non-visibility of threads in 4 patients, discharge per-vaginum in 1 patient and pain lower abdomen in 1 patient. Voluntary removal was done in 3 patients by 2 years who wished to conceive. The successful continuation rate came out to be 84.9% by 2 years. There was no failure reported in terms of intra-uterine or extra-uterine pregnancy and no increased risk of infection or perforation over the 2 years follow up.Conclusions: Immediate post-placental IUCD insertion is safe and effective method of contraception with no need to wait for 6 weeks which thereby reduces unwanted pregnancy rates. Mild discomfort and the minor post procedure complaints are taken care of well in puerperium. Higher rate of expulsion can be taken care of by early follow-up with regular visits and offering other safe and effective method of contraception

Evaluation of high risk screening protocol for detection of overt hypothyroidism in pregnancy

Background: Overt hypothyroidism is a known cause of feto-maternal morbidity. Many large-scale studies do not support the identification and treatment of sub-clinical hypothyroidism. Hence, we need a screening protocol that will identify all cases of overt hypothyroidism. The present study aimed to evaluate the high-risk screening protocol for detection of overt hypothyroidism during pregnancy.Methods: Authors performed a prospective observational study for detection of thyroid dysfunction in 604 pregnant women in a tertiary care hospital setting. Detailed demographic, medical and obstetric history was noted and baseline serum thyrotropin (TSH) level and urinary iodine levels were checked. Reflex testing for thyroid peroxidase antibody was done in women diagnosed to have hypothyroidism. The enrolled women were then grouped as high risk if any of the high-risk criteria provided by ATA was positive.Results: The study population was iodine sufficient with median urinary iodine (MUI) level of 255µg/l. Overall 32.2% women (n=201) were found to be hypothyroid (TSH >2.5mIU/L), 0.8% women (n=5) were hyperthyroid. Overt hypothyroidism was seen in 3.8% women (n=23), all of whom were in the high-risk group as per the ATA guidelines. This co-relation was highly significant (likelihood ratio 24.94; P 0.05.Conclusions: High risk screening protocol is highly sensitive for detection of overt hypothyroidism and provides the best therapeutic payoff

Correlation of HbA1c levels in late pregnancy with maternal and perinatal outcome in patients with gestational diabetes mellitus

Background: Estimation of HbA1c in gestational diabetes mellitus patients is not being recommended by any societies/guidelines as studies regarding the role of HbA1c for monitoring of euglycemic control and predicting the maternal and perinatal outcomes in GDM patients (unlike overt diabetes) are conflicting and sparse.Methods: This was a prospective study with an aim to evaluate the role of HbA1c estimation in late pregnancy (early and late third trimester) for prediction of pregnancy outcomes in GDM patients. 53 patients with GDM (diagnosed before third trimester) were recruited for the study. HbA1c levels were estimated in late pregnancy (at 28-32 weeks and again repeated at 37 - 39 weeks or at the time of delivery). Correlation of HbA1c levels in third trimester with maternal and perinatal outcome was studied in patients with gestational diabetes mellitus and cut off taken was 5.8%.Results: Of the total 53 patients 54.7% had HbA1c levels <5.8% and 45.3% had HbA1c ≥5.8% done at 28-32 weeks. Also when HbA1c levels done at 37-39 weeks POG/ at the time of delivery, 52.8% patients had <5.8% and 47.2% had HbA1c ≥5.8%. Approximately one-fourth of the patients had HbA1c ≥ 5.8% even with normal blood sugar levels (euglycemic) control. There was statistically significant increased incidence of polyhydramnios, LGA (large for gestational age babies) and increased mean birth weight in patients with HbA1c ≥ 5.8%, done in late pregnancy. However there was no statistically significant difference in the incidence of preterm labour, gestational hypertension or preeclampsia, urinary tract infections, vulvovaginal infections, caesarean deliveries and postpartum haemorrhage in patients with HbA1c ≥5.8% compared to patients with HbA1c <5.8%.Conclusions: The study revealed that in patients of GDM with HbA1c levels ≥5.8% done in third trimester was statistically significantly associated with increased incidence of polyhydramnios, large for gestational age babies and increased mean birth weight when compared to patients with HbA1c <5.8%

Randomised controlled trial to compare safety and efficacy of vaginal versus oral route of misoprostol for induction of labour in term pregnancy with unfavourable cervix

Background: The objective of the study was to compare safety and efficacy of vaginal versus oral route of misoprostol for induction of labour in term pregnancy.Methods: A total of 100 pregnant women with clinical indication for labour induction and poor bishops score were randomly assigned to receive vaginal or oral misoprostol. Group A received 25 μg of misoprostol vaginally (maximum up to 3 doses 4 hourly interval) and group B received 25 μg of misoprostol orally (up to 5 doses 2 hourly interval) in solution form. Maternal and fetal outcomes were compared in both groups to assess the safety and efficacy of vaginal versus oral route.Results: Fifty women received vaginal and 50 women received oral misoprostol. Average interval from induction to active stage was shorter in oral misoprostol (7.42±4.2 hours versus 10.30±5.1 hours) (p=0.006). There was no significant difference (p=0.272) in the average interval from induction to delivery between the vaginal group (14.42±5.01hrs) and oral group (13.14±5.5 hrs). No significant difference in caesarean section rates (p=0.42). Incidence of hyperstimulation was significantly higher (p=0.025) in vaginal group as compared to oral group (18 % vs 4 %). Incidence of nausea, vomiting, vaginal or cervical tears and postpartum hemorrhage were comparable in both the groups. There were no statistically significant differences in neonatal outcomes.Conclusions: Oral misoprostol has a better safety profile than vaginal route as the incidence of hyperstimulation and tachysystole was significantly more in vaginal group, although there were no significant differences in the maternal and neonatal outcomes

Pseudo-Meigs syndrome: a rare presentation of pedunculated fibroid

Serosal fibroid of uterus are usually asymptomatic but rarely; it may present with atypical symptoms to simulate malignancy and needs extensive evaluation. Authors are reporting a case of 26 years old P1L1 female with history of asymptomatic multiple intramural fibroids since 6 years came with complained of progressively increasing abdominal distension and mild pain abdomen from 2-3 months. On evaluation, she had ascites, pleural effusion and raised Ca-125. MR imaging of pelvis revealed moderate ascites and pedunculated serosal fibroid in addition to intramural fibroids with normal bilateral ovaries. She was evaluated to rule out uterine sarcoma and tuberculosis but diagnosis of them could not be established. Finally, conclusion of Pseudo-Meigs syndrome was made. Myomectomy of single pedunculated fibroid relieved her symptoms. Though, subserosal fibroids are benign in pathology, timely surgery is must to avoid morbidity and mortality owing to massive ascites and pleural effusion

Comparison of diagnostic accuracy of hysteroscopy and ultrasonography in relation to histopathology in cases of postmenopausal bleeding

Background: To evaluate the role of hysteroscopy and ultrasound in relation to histological findings in patients of postmenopausal bleeding and to find out the sensitivity, specificity, positive predictive, negative predictive values and accuracy of ultrasound and hysteroscopy.Methods: A retrospective analysis of the 30 women who underwent hysteroscopic evaluation out of total 103 patients of postmenopausal bleeding over the period of one year (August 2017 and July 2018) was done. Records were taken out to collect the relevant information. USG and hysteroscopic findings were correlated with histopathology for the comparative analysis.Results: Indications of hysteroscopy cases were suspected polyp (5), fractional curettage (F/C) technically not feasible (7), inconclusive USG reports (5), recurrent bleeding with normal fractional curettage report (4), no tissue on F/C (1), removal of intra-uterine contraceptive device (1). Causes of postmenopausal uterine bleeding were found to be atrophic endometrium including one case of senile cystic atrophy (33.3%), secretory endometrium and endometrial polyps (23.3% each) and endometrial malignancy (20.0%) cases. Overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy values of USG in various endometrial conditions was found to be 57.1%, 85.2%, 55.1%, 86.2% and 78.5% respectively and for hysteroscopy was 87.1%, 97.5%, 90.0%, 96.7% and 95.3% respectively.Conclusions: Hysteroscopy is a minimally invasive, safe and effective modality with least complications and morbidity rate and an ideal method for establishing the pathology as well as offering therapeutic intervention simultaneously

Spontaneous heterotopic pregnancy with tubal rupture: a case report and review of the literature

<p>Abstract</p> <p>Introduction</p> <p>Heterotopic pregnancy is diagnosed as the presence of two gestations simultaneously. This is a rare situation with a reported prevalence of 0.08% in normal conception.</p> <p>Case presentation</p> <p>We report a case of a 24-year-old primigravida of Indian origin who was seen in the emergency department with a diagnosis of a ruptured ectopic pregnancy. A careful ultrasound assessment led to the diagnosis of a heterotopic pregnancy. Immediate surgical intervention with supportive measures resulted in a successful outcome.</p> <p>Conclusion</p> <p>An obstetrician should keep in mind the occurrence of a heterotopic pregnancy while dealing with pregnant females. The ectopic gestation invariably ruptures over a period of time leaving the patient in an emergency situation. A quick assessment and careful handling of the normal gestation can lead the patient to term with gratifying results.</p