A follow up study of postpartum intrauterine device insertion in a tertiary health care centre

Background: In view of high rate of unintended pregnancy in our country, particularly in post-partum women, there is a need for reliable, effective and long-term contraception such as intrauterine device (IUCD) in post-partum women. This study was done to determine the efficacy and safety of Post-Partum Intrauterine Device (PPIUCD) and to compare the outcomes of PPIUCD insertion after vaginal delivery and caesarean section.Methods: This follow up study was carried out in the department of Obstetrics and Gynecology, Dr. R.M.L Hospital, PGIMER, New Delhi over a period of 7 month from January 2016 to July 2016. PPIUCD (cu T- 380 A) insertions were done in 136 women who fulfilled the inclusion criteria. Women having haemoglobin less than 8 gm%, rupture of membranes more than 18 hours, obstructed labour, Uterine anomalies, distorted uterine cavity by fibroid, significant postpartum haemorrhage, coagulation disorders, fever or clinical symptoms of infection during labour were excluded from the study. Post insertion counselling was done, and these women were advised to follow up at 6 weeks and then after 6 months postpartum in the family planning O.P.D. At the follow-up visit, the women were asked for any symptoms of unusual vaginal discharge, irregular or heavy bleeding per vagina, and any expulsions if noticed.Results: Total number of cases that reported for follow up in family planning OPD was 118. Therefore, 18 patients were lost in the follow up. In 58.47% women, there was no complaint. Heavy menstrual bleeding was found in 17.79% women and pelvic pain in 16.10% women. The expulsion rate was 5.08% and IUCD removal was done in 12.71% women. Though, the incidence of expulsion and removal rate was more in vaginal insertions than in caesarean insertions but this difference was not statistically significant, while the incidence of missing threads were found more in intra caesarean insertion (28% vs. 11.76% with p value <0.05). Continuation rate at 6 month was 82.20%.Conclusions: PPIUCD insertion is a safe, convenient and effective method of contraception. Although the expulsion rate and removal rate was more in vaginal PPIUCD insertions, the benefits of providing highly effective contraception immediately after delivery outweigh this disadvantage, particularly in our country where most of the women do not come for contraceptive advice after delivery

Saline infusion sonography in evaluation of uterine cavity abnormalities in infertility: a comparative study

Background: Infertility is defined as one year of unprotected intercourse without pregnancy. Female factor is responsible for 40-50% of cases of infertility. Uterine pathologies are the cause of infertility in as many as 15% of couples seeking treatment. The objective of this study was to evaluate the accuracy of trans-vaginal sonography (TVS) and saline infusion sonography (SIS) for detection of uterine cavity abnormalities in patients of infertility taking hysteroscopy as gold standard.Methods: A prospective comparative study was done in 60 patients of infertility. Patients were selected from gynaecology OPD of a tertiary care hospital. Patient selected underwent TVS and SIS followed by hysteroscopy for presence of uterine cavity abnormalities. The presence of uterine cavity abnormality and its type (endometrial polyp, submucous myoma, intrauterine synechiae or any other) was noted. The results of TVS and SIS were compared with hysteroscopy.Results: In 60 infertile patients, hysteroscopy revealed intrauterine pathology in 22 patients (36.7%). Among them eight had endometrial polyp and another eight patients had intrauterine synechiae. Submucous myoma was detected in five patients and one patient had thin endometrium. SIS detected eight out of 22 uterine cavity abnormalities indicating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 36.4%, 100%, 100% and 73.1% respectively. In comparison TVS showed abnormalities in six patients only and thus had sensitivity, specificity, PPV and NPV of 27.35%, 100%, 100% and 70.4 % respectively. Sensitivity of SIS for specific lesion was least for intrauterine synechiae (12.5%) and maximum for submucous myoma (60%).Conclusions: The sensitivity of both TVS and SIS for detection of uterine cavity abnormalities in patients of infertility was low in the present study and they cannot be recommended as replacement for hysteroscopy

Comparative study of the effectiveness of two different dosage of sublingual misoprostal for cervical ripening before hysteroscopy

Background: Hysteroscopy a minimally invasive approach for evaluating uterine cavity, and has become an indispensable diagnostic and therapeutic procedure. The main limiting factor while performing office hysteroscopy is the level of pain or discomfort encountered during the procedure. The pain is attributed mainly to the difficulty in entering the internal cervical os with the hysteroscope and while distending uterine cavity. It could be reduced if cervix is ripened before the procedure. The purpose of this prospective observational study was to compare the effectiveness, adverse effects and surgery-related complications associated with two different doses of sublingual Misoprostol (100 and 200 µg) given 2-4 hours before hysteroscopy.Methods: A randomised comparative study was conducted in the department of Obstetrics and Gynaecology of ABVIMS and Dr. RML hospital New Delhi, from 1st November, 2018 to 31st March, 2020. One hundred and twenty women, fulfilling inclusion criteria were subjected to hysteroscopy. Women received either 100 µg (Group I) or 200 µg (Group II) of sublingual Misoprostol 2-4 hours prior to hysteroscopy. The primary outcome of the study was cervical dilatation as measured by the largest number of Hegar dilator that could be inserted without resistance at the beginning of procedure. The largest dilator that negotiated cervical canal without resistance at the beginning of procedure was recorded as the baseline cervical width. The secondary outcomes were subjective assessment of the surgeon of the ease of dilatation of cervix and adverse effects of drug (i.e. vaginal bleeding, shivering, fever and pain as measured on visual analog scale).Results: The mean baseline cervical width as measured by first Hegar dilator that could be passed through the cervical canal without resistance was 6.6±0.62 mm in group I and 6.94±1.21 mm in group II respectively                    (p value=0.016). Adverse effects like vaginal bleeding, shivering was more in group II compared to group I. No statistically significant difference was found between group I and II with regards to visual analog scale.Conclusions: 100 µg Misoprostol can be used for cervical ripening prior to hysteroscopy with minimal adverse effects

Primary squamous cell carcinoma of the fallopian tube masquerading inflammatory mass

Primary squamous cell carcinoma (SCC) of fallopian tube is exceedingly rare. Till date less than 10 cases have been reported to the best of our knowledge [2-10]. Serous adenocarcinoma is the most common primary malignancy arising from the fallopian tube. Primary SCC of fallopian tube is diagnosed after excluding invasion from the rest of the genital tract and metastasis. We are reporting this rare carcinoma in a 62- year -old female who was taken for laparotomy with pre-operative diagnosis of tubo-ovarian abscess

Effects of letrozole on patients with symptomatic leiomyoma in the reproductive age women

Background: Uterine leiomyoma is a common indication for hysterectomy in India. An effective medical treatment option may reduce hysterectomy associated morbidity. This study was undertaken to evaluate the effect of the Letrozole on patients with symptomatic leiomyoma in the reproductive age women.Methods: Prospective interventional study was conducted on 50 women between 30-45 years of age with menstrual or pressure symptoms on the bowel or urinary system, and having no. Of myoma ≤4 and size of single myoma ≥2 cms in diameter. They received tablet letrozole 5mg/day for 3 month, and effect of the drug on myoma volume and symptomatology were studied. Beside these, effects on uterine volume, ovarian volume, endometrial thickness and side effects of letrozole of any were also studied.Results: Average reduction of myoma volume by 47.68% and uterine volume by 19.58% was seen. Haemoglobin concentration was significantly higher at the end of study. It increased from 9.56g/dl to 10.76g/dl and overall improvement in symptomatology score was observed. Ovarian volume increased significantly from baseline mean volume of 8.18±0.51cm³ to 19.3±0.84cm³ and no significant change in endometrial thickness was observed at the end of 3 month. Sweating, hot flushes, nausea and vomiting were the main adverse effects observed and were self limiting.Conclusions: Letrozole, the aromatase inhibitor resulted in significant volume reduction of the uterus-leiomyoma structure and was effective in controlling the more frequent symptoms of this disorder with fewer side effects

Comparative evaluation of composite and simplified who partograms in a tertiary care centre in North India

Background: Early detection of abnormal progress and prevention of prolonged labour can significantly improve the outcome of labour. Partograph is an inexpensive tool which can provide a continuous pictorial overview of labour and is essential to monitor and manage labour. The objectives were to study the course of normal and abnormal labour and to evaluate the maternal and perinatal outcome using simple and composite WHO partogram.Methods: This was a randomized study conducted at Department of Obstetrics and Gynaecology, Government Medical College, Amritsar, a tertiary care centre in North India. 200 women with term, singleton, vertex gestation, in spontaneous labor were included in the study. In 100 cases composite partograph was plotted and in rest 100 cases simple partograph was plotted. The following outcomes were compared: labor crossing the alert and action line, augmentation of labor, rate of cesarean section, perinatal and maternal outcome.Results: The partogram crossed the alert line (p 0.008) and action lines (p 0.017), causing increased need for augmentation (p 0.034) in the composite partogram which was statistically significant. The numbers of vaginal deliveries were high (p<0.001) and decrease number of cesarean sections (p 0.007) and instrumental deliveries (p 0.009) in the simplified group. NICU admissions were also higher in the composite group (p<0.05), though most of the NICU admissions were due to hyperbilirubinemia and low birth weight and was not directly related to monitoring of labour.Conclusions: It was observed in the present study that labour can be managed without the latent phase being plotted on the partograph. The interventions were higher when the latent phase was included, with increased number of labours crossing the alert and action lines, increased no. of augmentations and larger number of caesarean sections. Our study favours the use of the WHO modified partograph, which should become routine practice in monitoring labour for better maternal and perinatal outcome

Maternal mortality in a tertiary care centre in North India: a retrospective study

Background: The World Health Organization (WHO) estimates that, of 536,000 maternal deaths occurring globally each year, 136,000 take places in India. Maternal death has serious implications to the family, the society and the nation. It deprives the surviving infant of mother's care. This study was done to assess maternal mortality in a tertiary care centre in north India where large numbers of patients are referred from the peripheral centers and the rural parts. This study was done to assess the causes of maternal mortality and suggest remedial measures to reduce the same. Objective of present study was to assess the causes of maternal death over a period of one year at G.M.C Amritsar, India.Methods: A retrospective hospital based study of 22 maternal deaths over a period of 1 year from June 2012 to June 2013. The information regarding demographic profile and reproductive parameters were collected and results were analyzed.Results: Over the study period, there were 22 deaths and 7272 live births (Majority were referral from other districts all over Punjab). Most common direct cause of maternal mortality was haemorrhage and anemia was the most common indirect cause. Most maternal deaths were seen in patients from rural areas, unbooked, illiterate patients and patients from low socioeconomic status.Conclusions: Proper health education should be given to the women; early registration of antenatal cases should be done which allows for rapid diagnosis and treatment of high risk cases. Also constructing a well equipped health care facility with trained staff and prompt transport facilities for early referral can bring down the maternal mortality rate in our country

Analysis of fetomaternal outcome of COVID-19 antenatal mothers-initial experience

COVID-19 is an infectious disease caused by newly discovered single stranded RNA virus of Coronaviridae family. A retrospective study conducted in ABVIMS and RML hospital, Delhi in antenatal patients with COVID-19 infection detected by RT-PCR in nasopharyngeal and oral swab. It was found that patients with mean age of 27.2 years and mean gestational age of 39 weeks, mostly asymptomatic. Three patients undergone c section for obstetrical indications, while rest delivered vaginally. COVID-19 in pregnancy in small group of cases had good feto-maternal outcome but warrants further study

Clinical study on presentation and management of ectopic pregnancies in a tertiary care centre

Background: Ectopic pregnancy means pregnancy outside the normal uterine cavity. It is the leading cause of maternal morbidity and mortality in first trimester. Early diagnosis and timely intervention can significantly improve the outcomes.Methods: Retrospective observational study done in the department of obstetrics and gynecology ABVIMS and Dr. RML hospital, New Delhi from January 2016 to March 2019. Case records of 76 patients of confirmed ectopic pregnancy were retrieved and studied from the medical record section. The main aims were to see the clinical presentation, mode of diagnosis, predisposing risk factors; treatments offered and associated morbidity and mortality.Results: The incidence of ectopic pregnancy in present study was 1.7%, highest in 21 to 30 years age multiparous patients. 85.1% presented as acute emergencies, 75% patients had classic triad of amenorrhea, pain and bleeding. Pain was the commonest symptom in 96.1%. The commonest clinical sign was adnexal mass and tenderness. Ultrasound findings had adnexal mass in 98.7% and free fluid in 84.7% cases with empty uterus in 100%. 90.7 % case were tubal ectopic and 69.73 % were ruptured. Surgery was the main treatment modality in 96.0% cases. Salpingectomy was the commonest surgery in 80.25%. There was 0% mortality and 78.9% cases required blood transfusions, 44.7% patients had no known risk factors whereas some of the common identifiable risk factors were history of previous abortion, previous pelvic surgeries and pelvic inflammatory disease.Conclusions: ABVIMS and Dr. RML hospital is a tertiary care center so majority of patients with ectopic pregnancies presented late, as such surgery was the main treatment modality but there was 0% mortality in our study. Conservative treatments such as laparoscopy and medical management can also be offered to hemodynamically stable patients

Chronic kidney disease in pregnancy and fetomaternal outcome

Background: Chronic kidney disease is a heterogeneous group of renal dysfunctions with complex and varied presentations in pregnancy. With a long asymptomatic course, timely diagnosis and management is crucial for fetomaternal wellbeing.Methods: A retrospective cohort study over a period of 3 years and 4 months included all obstetric in patients with known or newly diagnosed renal disorders. Maternal outcome was measured with regard to biochemical parameters presence /absence of proteinuria, hypertension, mode of pregnancy termination and complications. Fetal outcome was noted with respect to antenatal complications, weight, Apgar, NICU stay. Computation of results was done using percentages, mean and proportions.Results: Out of 13 women studied, 53.8% were pre-diagnosed cases of renal dysfunction and 46.2% were diagnosed during pregnancy. 38% had proteinuria at first visit and 50% remained so even after delivery. 60% had history of pregnancy induced hypertension in their previous pregnancies. Secondary hypertension and superimposed preeclampsia were seen in 30% and 38% cases respectively, with only one patient requiring magnesium sulphate prophylaxis in post-partum. Cardiac dysfunction was found to be coexisting in 15.3% cases with pre-existing renal leision. Intrauterine growth restriction was seen in 61.5% cases Average fetal weight was 2. 26kg with 30% having NICU stay. 30.6% had preterm delivery. Mode of delivery was caesarean section in 46% cases.Conclusions: Pregnancy with CKD is a high-risk pregnancy with adverse fetomaternal outcomes. For optimal pregnancy outcomes, an expert multidisciplinary team is required. With limited studies in south Asian population, there needs to be an upgradation in registry system