To study the efficacy of digital and transvaginal ultrasonographic measurement of cervical length in asymptomatic high risk women at POG 16-24 weeks as a predictor of preterm delivery and progesterone and cerclage vs. progesterone alone for short cervical length in prevention of preterm labour

Background: Objectives of current study were (i) To correlate the Cervical Length (CL) measured digitally and by transvaginal sonography (TVS) at 16 to 24 weeks with outcome of pregnancy (ii) Estimate risk of spontaneous preterm labour (PTL) based on CL measurements and (iii) study intervention in short CL and their effect on maternal and neonatal outcome.Methods: Women with singleton pregnancy at POG 16-24 weeks with history of previous preterm birth or mid trimester abortions were included in the study and subjected to digital assessment of CL followed by TVS measurement. In patients with TVS CL ≤25 mm, intervention in the form of progesterone or cerclage with progesterone was done. The outcome of the pregnancy in the form of delivery before completed 37 weeks or at and after 37 weeks was noted.Results: Twenty two subjects out of total 153 subjects (14.4%) had preterm delivery. The incidence of preterm delivery in study was 14.4%. Using Receiver Operating Characteristics (ROC) Curve, cut off value of digital CL was found to be 1.5 cm. The sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV) and accuracy of digital CL ≤1.5 cm in prediction of PTL were 72.7 %, 37.4%, 16.3%, 89.1% and 42.5% respectively. Cut off value of TVS CL by ROC curve was found to be 2.85 cm. The sensitivity, specificity, PPV, NPV and accuracy of CL (TVS) of ≤2.85 cm in prediction of PTL is 81.8%, 68.7%, 30.5%, 95.7%, 70.6% respectively. The outcome in form of PTL in 30 subjects, who had TVS CL ≤2.5 cm in both the intervention groups (McDonald stitch with progesterone and progesterone alone) was comparable (P value 0.60 not significant).Conclusions: The CL, both digitally and by TVS, was inversely correlated with the probability of preterm delivery so that the shorter the cervix, the greater the likelihood of preterm delivery. TVS CL is more predictive of preterm delivery than digital CL when performed between 16-24 weeks in asymptomatic high risk women. Intervention in short CL in form of McDonald’s stitch application with progesterone and progesterone alone have similar efficacy for prevention of PTL

A prospective study of predictors of metabolic syndrome in women with polycystic ovary syndrome

Background: Polycystic ovary syndrome (PCOS) is a well-known gynecological hormonal imbalance. The consequences of PCOS pose a substantial risk for the development of metabolic and cardiovascular abnormalities similar to those that make up metabolic syndrome (MBS). Therefore, there was a need to identify predictors for MBS in PCOS subjects and study their strength of association.Methods: A prospective observational study was carried on 100 PCOS subjects for having features of MBS. MBS was diagnosed by National cholesterol education program’s adult treatment panel III 2001 criteria. Student’s independent t test, Chi square test and Fisher’s exact test were used for statistical analysis.Results: The present study estimated the prevalence of MBS in women with PCOS to be 31%. MBS in PCOS was more prevalent in non-vegetarians (51.6%). The individual components of MBS criterion had a statistically significant p value (p=0.001 to 0.008) for development of PCOS. Raised levels of triglycerides, fasting blood sugars and fasting insulin tests were related directly to MBS development, with statistically significant p values (<0.001, <0.001 and 0.005), respectively.Conclusions: Women with PCOS have a high prevalence of MBS and its individual components, particularly raised laboratory values of triglycerides, fasting blood sugars and fasting insulin. MBS in PCOS women is associated with advancing age and obesity

Causes of stillbirth according to different gestational ages

Background: Stillbirth is one of the most common yet the most poorly studied adverse outcome of pregnancy. Objective of present study was to determine the risk factors and prevalence of stillbirth at Department of Obstetrics and Gynecology, Kamla Nehru State Hospital, for Mother and Child, Indira Gandhi Medical College, Shimla, Himachal Pradesh.Methods: A prospective non-interventional study was conducted with effect from 1st August 2015 to 31st July 2016, during which all the intrapartum and antepartum stillbirths were enrolled.Results: During the study period total number of stillbirth were 94 and the total number of live births were 6412, giving a stillbirth rate of 14.66/1000 live births. The perinatal mortality was 22.1/1000 births. The most common cause of stillbirth as revealed in the study was hypertensive disorder.Conclusions: The stillbirth rate in the study was higher than the stillbirth rate of developed countries. Improvement of socioeconomic conditions, literacy and health education among women will definitely be important to curb the staggeringly high stillbirth rate, but the need of the hour is to deploy adequate number of dedicated skilled providers

Case series on uterine rupture depicting the atypical presentations in the labour room

Uterine rupture is the complete division of all the three layers of uterus. Most uterine ruptures occur during labor in pregnant women, most commonly seen in previously scarred myometrium. Consequences of uterine rupture depend on the time between diagnosis of uterine rupture and intervention, and can be as grave as fetal and maternal death. Vigilance and avid action by the obstetrician can lead to better outcomes. Case 1 represented a 28-year-old moderately anemic G4P2L2A1 having previous 2 LSCS at POG 39 weeks 1 day presented in COVID emergency in active labour and was found to have a uterine scar rupture (5 cm rent) extending towards bladder wall with shoulder presenting on rent. A live female baby with thick meconium staining was delivered and uterine repair along with bilateral tubectomy was performed. Case 2 represented a 21-year-old primigravida with breech presentation at a gestation of 34 weeks 6 days with preterm labour pains who had been referred to our centre. Decision for LSCS was taken and on entering the abdomen rupture uterus with an inverted T-shaped rent in the upper segment extending up to the fundus was seen. A stillborn male fetus was delivered through the rent, followed by successful uterine repair. In spite of massive blood loss, the mother had survived. Case 3 represented a 30-year-old grand multipara at a gestation of 38 weeks 3 days with ultrasound documented fetal demise with fetal hydrocephalus and holoprosencephaly with labour pains was taken up for laparotomy due to suspicion of uterine rupture based on examination findings. Intra-operatively, baby was found lying in the peritoneal cavity with an unsalvageable uterus with a rupture in lower uterine segment and left lateral wall extending upto round ligament above and cervix below. A stillborn male fetus was delivered and peripartum subtotal hysterectomy with left salpingoophorectomy and right salpingectomy was done with a good maternal outcome. The above series suggest that the signs and symptoms of uterine rupture are usually variable and nonspecific, hence posing a challenge for the diagnosis. Early diagnosis and timely intervention by the obstetrician, can help us to improve the fetal and maternal outcome drastically

Partial HELLP syndrome: case report

HELLP syndrome is a complication in pregnancy clustered by haemolysis, elevated liver enzymes, and a low platelet count. It is seen as a serious complication of preeclampsia and eclampsia. Serious manifestations like haemorrhage, infarction, rupture and other hepatic manifestations are usually associated with it. In this case study, 29 years old primigravida is a booked case admitted in ward at 39 weeks 1 day with decreased fetal movement for 2 days. No history of pain abdomen, bleeding per vaginum, discharge per vaginum. Her blood pressure records at the time of admission was 110/72 mmHg and she was normotensive throughout pregnancy. Urine routine examination was negative for urinary protein. However, blood tests showed platelet count of 66,1000/cumm, with ALT of 174 U/L and AST of 123 U/L on peripheral blood film. RBC were predominantly normocytic, normochromic with few macrocytes. WBC has normal morphology. Platelets were reduced on smear. Giant platelets were seen. Ursodeoxycholic acid 300 mg 12 hourly were given to the patient and 3 doses of vitamin K I/M 24 hourly. She was delivered by cesarean section which was performed due to failure of progression of labor with a deflexed head. There was presence of retroplacental clot of 4×3 cm indicating placental abruption, a complication of HELLP syndrome. From this we conclude that we should be careful in suspecting complications of full blown diseases even when the patients are asymptomatic but have atypical laboratory findings

Prevalence and associated risk factors of abnormal pap smear in pregnant women

Background: The Papanicolaou test is a method of cervical screening used to detect pre-cancerous and cancerous processes. The incidence of cervical cancer in India is alarmingly high and is the leading cause of cancer in women in India accounting for 147 deaths per lakh women. Cervical cytological abnormalities are found in up to 5% of all pregnancies. In Indian settings, published data on abnormal Pap smear in pregnancy is lacking. The present study was designed to know the prevalence of abnormal Pap smear in pregnant women and its associated risk factors.Methods: This prospective study included 450 pregnant and 450 non-pregnant women who fulfilled the inclusion criteria. After a detailed history, clinical examination and investigations, Pap smear was collected as per conventional method and reported using 2014 Bethesda system.Results: 53.6% pregnant and 44.6% non-pregnant subjects had abnormal Pap smear. Out of the abnormal smears in pregnant women, 31.18% had inflammatory cytology, 15.37% had bacterial vaginosis, 4.01% had Trichomonal and 3.34% Monilial pathology. No epithelial cell abnormality was seen. Rural residence, lower class, age at first intercourse less than 21 years and having more than one sexual partner were important risk factors observed in our study and were statistically significant.Conclusions: Bacterial vaginosis, the most common infection detected on Pap smear is strongly associated with previos preterm labour and delivery. This opportunity for screening of cervical cancer and counselling should not be missed in the antenatal period

Assessment of Indian Medical Graduate (IMG)’s knowledge about emergency contraception (EC) in a medical college of Himachal Pradesh

Background: Undergraduate curriculum of the medicine is created to ensure achievement of goal of “health for all” in India. In addition, it aspires graduates to meet or exceed global benchmark in knowledge, attitude, skills and communication (1). Objectives: 1) To assess undergraduates’ knowledge regarding the types and correct usage of available Emergency Contraceptives. 2) To utilize the data base for capacity building by focusing on the Core Competency of Emergency Contraceptives. Methods: This cross-sectional study was done among 442 undergraduates of all the Profs in our college in September 2017 after approval from Institutional Ethical Committee (17/66) and informed verbal consent from the participants. This pretested, pre-designed and self-administered 11-questionnaire proforma in English was used as a tool of investigation. Results: Maximum participation was from 3rd and 4th year. 7.2 % had a very poor knowledge, attempted 3 or less questions correctly.  Only 14.5% attempted 8 or more questions correctly. Conclusion:  Young population of our country forms the broad base of the pyramid, they should be provided with correct knowledge about EC for improving their reproductive health.  Since these graduates are going to serve the community, their knowledge and skill in this core competency is going to help the community

To study the association of Doppler derived indices of uterine artery resistance with composite of PIH/PET

Background: Hypertensive disorders of pregnancy (HDP) are among the main public health issues worldwide. They account for an estimated 10-15% of maternal deaths globally. Among the hypertensive disorders of pregnancy, pre-eclampsia is most dangerous, occurring in 10% of first pregnancies, and in 20-25% of women with past history of hypertension. The objective of present study is to investigate the association of Doppler derived Indices of uterine artery resistance with composite of PIH/PET.Methods: A prospective follow up observational study, including pregnant women at 11-13+6 weeks of gestation in whom Uterine Artery Resistance measured using Doppler ultrasound.Results: A total of 100 subjects were enrolled, out of which 11 developed pre-eclampsia/ gestational hypertension. All Doppler indices (Resistance Index, Pulsatility Index and Systolic/Diastolic Index) had high specificities and negative predictive values.Conclusions: The potential advantages of early screening of hypertensive disorders and their associated complications may allow investigations or prophylactic interventions before 20 weeks of gestation

Causes of stillbirth according to different gestational ages

Background: Stillbirth is one of the most common yet the most poorly studied adverse outcome of pregnancy. Objective of present study was to determine the risk factors and prevalence of stillbirth at Department of Obstetrics and Gynecology, Kamla Nehru State Hospital, for Mother and Child, Indira Gandhi Medical College, Shimla, Himachal Pradesh.Methods: A prospective non-interventional study was conducted with effect from 1st August 2015 to 31st July 2016, during which all the intrapartum and antepartum stillbirths were enrolled.Results: During the study period total number of stillbirth were 94 and the total number of live births were 6412, giving a stillbirth rate of 14.66/1000 live births. The perinatal mortality was 22.1/1000 births. The most common cause of stillbirth as revealed in the study was hypertensive disorder.Conclusions: The stillbirth rate in the study was higher than the stillbirth rate of developed countries. Improvement of socioeconomic conditions, literacy and health education among women will definitely be important to curb the staggeringly high stillbirth rate, but the need of the hour is to deploy adequate number of dedicated skilled providers