Application of laparoscopy in current fertility practice

Background: The present study is carried out with the objective of establishing the role of diagnostic and operative laparoscopy as a simple, safe and accurate tool in the evaluation of infertility. The aims of current study were to study the application of laparoscopy in current fertility practice, to evaluate indications for diagnostic laparoscopy for infertility, to study findings of diagnostic laparoscopy and to study various operative procedures performed for correction of infertility.Methods: This is a prospective study of 50 women undergoing infertility workup in a private hospital from January 2011 to January 2012. All infertile women having primary or secondary infertility were included in the study. Couples having male factor infertility were excluded from the study. Data were collected and analyzed.Results: Our study is conducted in 50 cases of infertility patients out of which 74% were primary infertility and 26% were secondary infertility. Uterine factors were found in 16% of cases, tubal factors were found in 44% of cases, ovarian factors were implicated in 30% of cases out of which majority (12%) had PCOD. Among the peritoneal factors (18%) endometriosis and pelvic adhesions were found in 6% each. Inspite of thorough laparoscopic evaluation no cause (unexplained infertility) was found in 14% of cases and hence overall, the pelvic pathology was found in 86% of cases.Conclusions: Laparoscopy is the gold standard for diagnosing tubal and peritoneal disease, endometriosis, adhesions and other pelvic pathology, because no other imaging technique provides the same degree of sensitivity and specificity

Study of 50 cases of modern management of ectopic pregnancy

Background: In recent years, an increased incidence of ectopic gestation has been noted, which can be attributed to different reasons. Cases with ectopic gestation were studied and objectives were to study the incidence in various age groups, to study predisposing factors, to study different modes of clinical presentation, to study different sites of ectopic pregnancy and to study changing trends of modern management from radical surgical method to laparoscopic and medical management.Methods: A study of 50 cases of tubal ectopic pregnancy was carried out from May 2009 to June 2011 in tertiary health centre. Patients managed with following treatment modalities were selected for study. (1) Medical management (MTX), (2) Laparoscopic management: salpingostomy, salpingectomy, (3) Laparotomy management: salpingostomy, segmental resection, fimbrial expression, salpingectomy.Results: Lower abdominal pain was most common presenting symptom of ectopic pregnancy in 96% cases. The classical triad of symptoms (amenorrhea, abdominal pain and vaginal bleeding) was present in only 28% cases. PID contributed 24% cases and previous abortion contributed 28% cases indicating these two as the common risk factors. Ampulla was the commonest site for ectopic pregnancy, in 52% cases. Salpingostomy performed mainly at this site. In 6% cases ectopic pregnancy in infundibulum were treated with fimbrial expression and fimbriectomy. 22% patients were managed medically (methotraxte). These were the cases having unruptured ectopic pregnancy and ectopic mass <4 cm. Laparoscopy was done in 34% cases, in 2 cases it was converted to laparotomy. While open laparotomy was done in 40% cases.Conclusions: Ectopic pregnancy is a treatable problem. Ultrasonography plays central role in the diagnosis and management. Mode of therapy is determined by a combination of clinical symptoms, sonography findings and serum b-HCG values. Surgical management is still a cornerstone of management of ectopic pregnancy. But now scope of medical and laparoscopic management is also there. In recent years laparotomy has been replaced by laparoscopic surgery which is more conservative, minimally invasive and less time consuming which leads to quick recovery

Role of hysterolaparoscopy in the diagnosis and management of infertility

Background: Infertility is defined by WHO and ICMART as a disease of the reproductive system by the failure to achieve a clinical pregnancy after 12 months or more regular unprotected sexual intercourse. Objective of this study were to assess the role of hysteroscopy and laparoscopy in the evaluation of female infertility. To assess the therapeutic role of these endoscopic modalities in cases of infertility.Methods: A prospective study of 112 women coming with the complain of infertility to a tertiary care centre hospital in Ahmedabad over a period of 30 months from January 2017 to June 2019.Results: Of the 112 cases, 69.7% had primary infertility and 30.3% had secondary infertility. Septum was the most common hysteroscopic finding (7.1%) followed by polyps (5.4%) and synechiae (3.6%). Adhesions was the most common laparoscopic finding (23.2%) followed by tubal blocks (19.7%) and fibroid (17.9%). Polycystic ovaries were seen in 12.5% patients followed by endometriosis in 10.7% women. Myomectomy was most common therapeutic procedure (17.9%) followed by adhesiolysis in 14.3% women and PCO drilling in 8.9% women.Conclusions: Hysterolaparoscopy is useful as a diagnostic and therapeutic measure for women having infertility

Partographic analysis of labour by modified WHO partograph in tertiary care centre

Background: The partograph is a simple, inexpensive tool to provide a continuous pictorial overview of labor. The goal of this study is to use partograph to monitor labor, initiate uterine activity that is sufficient to produce cervical changes, fetal descent while avoiding uterine hyperstimulation, hypostimulation and fetal distress and provide timely surgical intervention where required. Methods: A hospital-based observational study involving prospective review of partographs for births that occurred in 2020 was conducted in 2 hospitals including SVP Hospital and V.S hospital Ahmedabad. A partographic analysis of labour was done in randomly selected 200 patients using modified WHO partogram. The study population was divided into Primigravida (96) and Multigravida (104) term patients. partograph recording were commenced at 4 cm dilatation. close maternal and fetal monitoring was done throughout the labour and partogram was plotted to detect any deviation from normal course.Results: Patients were grouped into primigravida and multigravida and based on partogram finding divided into mode of delivery. 22 of total 96 primigravida underwent caesarean section and 74 delivered vaginally. 8 of total 104 multigravida underwent caesarean section and 96 delivered vaginally. Out of 200 newborn only 11 had Apgar score <7 at 5 minutes.Conclusion: The WHO modified partograph is highly effective in reducing both maternal and neonatal morbidity. It aids in assessing the progress of labour and to identify when intervention is necessary. It is effective in preventing prolonged labour, obstructed labour, reducing operative intervention and improving neonatal outcome

Role of dinoprostone gel in induction of labour

Background: Labour induction is one of the most common intervention in obstetric practice. A simple application of PGE2 intracervical gel can ripen the cervix effectively and improve Bishop’s score there by helping in successful vaginal delivery. Considering its good performance, the dinoprostone slow-release vaginal insert is the first choice for elective induction of labour in postdate pregnancy and in patients with term pregnancy of premature rupture of membranes.Methods: This was a single year retrospective study conducted in a tertiary care center of western India from May 2019 to May 2020.Results: In group I women who delivered within 24 hours were included, in group II women who required re-instillation were included. The most common indication for induction in both the groups was past dates (accounting for 36.1% in group I and 47.3% in group II). The success rate in group I was 68.1% while in group II was 36.8%.  The rate of cesarean delivery in group I was 25.9%, while in Group II, it was 60.1%. Negligible maternal and neonatal complications were seen in both the groups.  Conclusions: The study showed that intracervical application of prostaglandin E2 is an effective, safe and acceptable method for induction of labor in women with unfavorable cervix and indications for induction. All these effects were achieved without increasing maternal and neonatal morbidity

Maternal and perinatal outcome in severe pre-eclampsia and eclampsia: a study of 120 cases at a tertiary health care center in Western India

Background: Hypertensive disorders of pregnancy are a leading cause of maternal and perinatal mortality and morbidity worldwide. Pre-eclampsia accounts for the majority of referrals in a tertiary care center as it stands one of the major causes of maternal and perinatal morbidity and mortality. It complicates 6-10% of all pregnancies. In India, they account for the third most important cause of maternal mortality. Patients with PIH are at a greater risk of abruptio placenta, cerebrovascular events, organ failure and DIC. Fetuses are at a greater risk of IUGR, preterm birth, small for gestational age and IUD. This study aimed to determine the maternal and perinatal outcomes of hospitalized pregnant cases with severe preeclampsia and eclampsia.Methods: This was a single year retrospective study conducted in a tertiary care center of Western India from May 2019 to May 2020. Maternal and perinatal outcomes were analyzed among the severe preeclampsia and eclampsia groups.Results: A total 52 (43.33%) of the cases were in the age group of 21-25 years, 64 (53.33%) were primigravidae and the majority were referred from peripheral hospitals. Liver function tests were deranged in 26.68% of the patients and 32.5% had abnormal renal function. Labetalol was the most commonly used antihypertensive and magnesium sulphate was the anticonvulsant used in all the cases. Lower segment caesarean section was the mode of delivery in 62 (51.67%) of the cases. Commonest maternal complication was atonic PPH (12.5%). There was one maternal mortality due to aspiration pneumonia. 85 (70.83%) of the babies needed NICU admission. There were 5 (4.16%) perinatal deaths.Conclusions: Accessible health care and health education and awareness regarding antenatal check-ups for all women will lead to early detection of severe preeclampsia. Prompt treatment and management of its complications will certainly improve the maternal and fetal outcome

Analysis of ectopic pregnancy at a tertiary care hospital: one year study

Background: Ectopic gestation is the leading cause of maternal mortality and morbidity in first trimester and is a major cause of reduced child bearing potential. The aims of our study were to understand the clinical profile, risk factors, sites and management modalities of ectopic pregnancy at tertiary care hospital.Methods: This is a retrospective study carried out for one year at the department of Obstetrics and Gynaecology of our institute. Data of the women admitted for management of ectopic pregnancy during January to December, 2010 was collected and analysed.Results: The proportion of ectopic pregnancy was 0.7 % at our institute. Majority of women 45(83.2%) were between the age group of 21-30 years. Pelvic inflammatory disease (PID) contributed to ectopic pregnancy in 16(29.6%) women. The most common symptom was lower abdominal pain, in 50(92.6%) women. Marked pallor was present in 25(46.3%) women and 38(70.4%) women had cervical motion tenderness. Out of all women, 10(18.5%), 18(33.3%) and 26(48.1%) women were managed successfully with methotrexate, laparoscopy and laparotomy respectively. The success rate was 83.3%, 90% and 100% with methotrexate, laparoscopy and laparotomy respectively. Blood and blood products were given to 25(46.3%) women. Conclusion: Ectopic pregnancy is a growing problem of reproductive age group. Women should be encouraged regarding early reporting of missed periods and made aware of complications of ectopic pregnancy and necessity of seeking urgent medical help as early as possible so that early diagnosis and prompt conservative surgical or medical management of ectopic pregnancy can be done

A comparative study of vaginal misoprostol versus oral misoprostol for induction of labour

Background: Induction of labour defined as artificial initiation of uterine contractions before the onset of spontaneous labour, after the period of viability, by any methods. The successful outcome depends on the Bishop Score, maternal age and parity. Authors compared the most preferred two routes; vaginal and oral for induction and outcome, adverse events and side effects were noted.Methods: This was a prospective comparative study carried out at SVPIMSR, Ahmedabad, from January 2019 to June 2019, Gujarat, 100 patients who required induction were randomly divided in two groups- Group A received 25µg oral misoprostol, Group B - received 25µg vaginal misoprostol repeated 4 hourly up to maximum five doses in both groups. The induction to delivery interval, mode of delivery, maternal and neonatal outcome and complications were observed.Results: The mean induction to delivery interval was less in vaginal group than oral (18.7 hours in vaginal versus 22.4 hours in oral). Vaginal delivery and caesarean section rates were comparable in both groups. 60% patients in Group A required more than two doses as compared to 36% in Group B. No major complications or adverse events were observed.Conclusions: Both oral misoprostol in a dose of 25μg and vaginal misoprostol 25μg every four hours, to a maximum of five doses, have safety and efficacy for induction. With The vaginal route, delivery occurs in less time and few doses required as compared to oral

A study of gestational diabetes mellitus and fetal outcome in a tertiary care center

Background: Modern desk-bound lifestyle and unhealthy dietary changes have brought a rise in the prevalence of obesity and gestational diabetes mellitus (GDM). It is associated with severe hazards to the mother and the baby. It is mandatory that early diagnosis ensues and timely and congruous management is undertaken.Methods: In this observational study, 1250 women were included. A standardized questionnaire was formed and their details were noted. Tests for glucose levels, complete blood picture, urine examination were performed. An oral glucose tolerance test was performed on all the patients. Neonatal outcomes in terms of birth weight and the presence of complications were noted.Results: A total 201 (16.1%) of all women were having gestational diabetes mellitus (GDM). Most mothers were in the 25-30 age group. The majority of the women had a BMI between 26-30. 21.9% of babies were having weight >3.5 kgs. 11.4% of babies were <2.5 kgs. Out of 201 neonates, 90 babies were having complications. Major complications in neonates were macrosomia and respiratory distress. Therefore, early diagnosis, glycemic control, and timely and congruous management are advantageous to both mother and baby.Conclusions: GDM complicating the pregnancy results in a higher prevalence of complications in the mother and the neonate. Therefore, appropriate control of the sugar level in mothers is necessary and it decreases the morbidity and mortality rates in the babies as well as the mothers.

Acute kidney injury and its outcome in obstetrics

Background: Acute kidney injury occurring during pregnancy, labour, delivery, and/or postpartum period. Proper management of AKI (acute kidney injury) is challenging because (i) both maternal and fetal health must be considered and (ii) the cardiovascular and renal adaptations of pregnancy add to the complexity for management.Methods: The objective of this study was to study association and contributing factors in AKI, a retrospective study of 20 cases of AKI complicating pregnancies carried out in department of obstetrics and gynecology, SVPIMSR over a period of 12 months and results were studied and analysed. Etiological factors, associated liver pathology, coagulation abnormality, thrombocytopenia, sepsis, recovery status and fetomaternal outcome were studied and tabulated. AKI was analysed in terms of maximal stage of renal injury attained as per risk, injury, failure, loss of function, and end-stage renal disease (RIFLE) criteria.Results: The incidence of ARF (acute renal failure) in pregnancy was about 0.3%. Hypertensive disorders were the major causative factor. Amongst the 20 cases, 8 cases were referred from outside and two of them died. Total 5 of 20 cases required hemodialysis and two of them had partial recovery.Conclusions: AKI complicating pregnancies are not uncommon. If recognized and treated promptly, recovery is assured in majority of cases. Early identification and prompt management of pre-eclampsia and sepsis can prevent majority of cases. Ultrasonography revelation of placenta previa or abruption helps in early management eventually decreases the chances of bleeding which is one of the causes of AKI (pre-renal cause)