Takayasu arteritis in pregnancy: case report of two cases and review of literature

Takayasu arteritis is a rare medical disorder of unknown etiology. The primary vasculitis mainly affects women of reproductive age group. Even though the usual course is slow, sometimes it may be unpredictable. It usually involves the branches of the aortic arch. With advancement of medicine most of the patients enter pregnancy with the disease already being diagnosed and on medications. Even though pregnancy is a favourable state complications are bound to happen especially when the disease is diagnosed for the first time during pregnancy. We are presenting two cases of Takayasu arteritis during pregnancy with different clinical presentations

Comparison of oral and vaginal misoprostol after oral mifepristone in early medical abortion

Background: Abortions are still a major problem in developing countries contributing to significant maternal morbidity and mortality. WHO has reported that 53 million unplanned pregnancies result in termination each year. One third of these are performed under unsafe conditions. Deaths related to these accounts for up to about 20% of the maternal deaths that occur each year throughout the world. the main objective of the present study is to compare the efficacy, side effects and acceptability of oral and vaginal misoprostol after single oral dose of mifepristone in induction of abortion in pregnancy up to 63 days.Methods: It was a prospective randomized trial of 100 healthy women opting for termination of pregnancy with ultrasound confirmed intrauterine gestation of less than or equal to 9 weeks who were randomized in to two groups. Mifepristone 200mg was administered on day one followed by 800µg of misoprostol orally or vaginally 48 hours later. They were reviewed on day 7 and day 14 by ultrasound for completeness of abortion. If abortion was incomplete or bleeding was excessive, surgical evacuation was performed.Results: The two groups were comparable with respect to age, parity and gestational age. The mean induction abortion interval was 51.2 hours.98% of the women in both the groups had complete abortion.  Nausea (68%) and vomiting (58%) were more common in oral group. Diarrhoea (60%) was common in vaginal group. None of them had fever. Mean duration of bleeding was 9 days. 92% of the women found the procedure to be highly acceptable and would recommend it to others.Conclusions: Medical abortion with 200mg mifepristone in combination with 800µg of misoprostol either orally or vaginally 48 hours later was found to be safe, simple, effective, inexpensive, noninvasive and acceptable method

A prospective randomized trial to compare side effects of early versus late removal of Foley’s catheter and vaginal pack following vaginal hysterectomy

Background: There is a controversy about the ideal time for removal of catheter and vaginal pack following vaginal hysterectomy. The present study was undertaken to compare post-operative morbidity in early and late removal of Foley’s catheter and vaginal pack.  The aim of this study is to compare post-operative morbidity in early and late removal of Foley’s catheter and vaginal pack following vaginal hysterectomy.Methods: This was a prospective randomized study with n=100 of those women who were undergoing vaginal hysterectomy with or without pelvic floor repair and fulfilled the inclusion criteria. After informed written consent, they were assigned to Foley’s catheter and vaginal pack removal group in 6 hours (group I, n=50) or 24 hours removal group (group II, n=50). Primary parameters used to assess were urine routine and microscopy, urine culture and sensitivity on post-operative day 2, need for re-catheterization and repacking, febrile morbidity, ambulation, vault infection and post-operative hospital stay duration were analyzed in both groups.Results: Febrile morbidity was found in 6% and 8%, Positive urine culture was found in 10% and 20%, Rate of re-catheterization was 10% in group I and group II respectively. Vaginal bleeding after pack removal and repacking was in 6% in group I whilst none had in group II.Conclusions: Early removal was associated with less incidence of urinary tract infection, and increased rate of re-catheterization and repacking. Needs larger comparative studies to support the practice of early removal

Association of placental position with the development of hypertension in pregnancy

Background: Hypertensive disorders remain the most common medical complication during pregnancy and contribute greatly to maternal and perinatal morbidity and mortality. Several tests have been proposed to identify the women at risk of developing hypertension. Among the various predictors, the placental location by USG at 18-24 weeks is cost effective, non- invasive and has a good positive predictive value. The present study was undertaken to predict the association of placental location with the development of hypertension in pregnancy.Methods: This was a longitudinal cohort study conducted on 380 uncomplicated primigravid women who attended the obstetric OPD of MGMC&RI over a period of 18 months (March 2017-august 2018). A detailed history was taken, and examination done and B.P. was measured. The placental location was determined by ultrasound at 18-24 weeks and the patients were divided into two groups : group A were women with lateral placenta and group B were women with other placental locations. All women were followed up for signs and symptoms of hypertensive disorders of pregnancy and mode of delivery and neonatal outcome were noted.Results: Out of 380 women, 56(14.7%) had lateral placenta and 324(85.3%) had other placental locations. Out of the 57 women who developed hypertensive disorders in pregnancy, 16(28.6%) had lateral placenta and 41(12.7%) had other placental locations. The risk of developing hypertension in pregnancy with lateral placenta was 3.5(odds ratio) with a 95% confidence interval (1.4-8.6). The sensitivity, specificity, positive predictive value and negative predictive value when placental laterality is used as a predictive test was 28.1%, 87.6%, 28.6% and 87.4% respectively.Conclusions: The placental laterality as determined by ultrasound at 18-24 weeks is a simple, non-invasive, cost-effective predictive test to predict women at high risk of developing hypertensive disorders of pregnancy and this test has a high specificity and negative predictive value

Comparative study of DIPSI and IADPSG criteria for diagnosis of GDM

GDM is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. The prevalence of GDM varies, widely based on the diagnostic criteria used and the ethnic group studied. It is associated with adverse maternal and perinatal outcome. Incidence of GDM in India is 1-14%. There are several screening and diagnostic tests for GDM. It is important to diagnose early and treat to prevent these complications. The present study was done to compare Diabetes in Pregnancy Study Group India (DIPSI) with International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria for diagnosis of GDM and to assess the validity of these methods.Methods: It was a cross sectional study done in 144 pregnant women who fulfilled the inclusion criteria. They underwent non - fasting OGTT with 75 grams glucose which was given irrespective of the last meal. A venous blood sample was drawn two hours after glucose administration. They were advised to come two to three days later and repeated with 75 grams OGTT after an overnight fast of atleast 8 hours. Venous blood sample was drawn at fasting, one hour and two hours after load with 75 grams of glucose. Plasma glucose was measured by using an autoanalyzer by glucose - oxidase peroxidase (GOD - POD) technique.Results: The epidemiological parameters like Age, BMI, Parity and Gestational age did not have any difference between two groups. 17.4% was diagnosed by DIPSI criteria and 15.3% was diagnosed by IADPSG criteria and 6.9% was diagnosed by both. Sensitivity and specificity of DIPSI was 45% and87% and sensitivity and specificity of IADPSG was 40% and89% respectively. According to kappa statistics, the p-value is 0.000.Conclusions: In present study it was concluded that screening is very essential in all pregnant women due to high prevalence of GDM in India. By comparing these two criteria, sensitivity of DIPSI was found better than IADPSG criteria in diagnosing GDM. Though IADPSG is universally accepted for diagnosis, DIPSI has still got a place in low resource countries as it is easy, cost effective and non fasting test

Successful management of pregnancy in a non-communicating rudimentary horn of a unicornuate uterus

Pregnancy in a rudimentary horn pregnancy is a rare clinical condition. The usual consequence is rupture culminating in hypovolemic shock. We had a different scenario of unruptured rudimentary horn pregnancy which was detected following failed attempt of MTP. She underwent laparotomy and excision of rudimentary horn. Post-operative period was uneventful. We present this case not only because of rarity but also high index of suspicion is required to diagnose at an early stage before a devastating course

Isolated oligohydramnios: effects on obstetric and perinatal outcome

Background: Outcome of oligohydramnios has been studied at a large. Varying results have been projected in each study. This study has been done to establish the obstetric and perinatal outcome in pregnancy associated with oligohydramnios as compared to women with normal liquor.Methods: This was a prospective case controlled study done which included 100 women with oligohydramnios who were compared with 100 women with normal liquor. Maternal and perinatal outcome was compared between the two groups.Results: There was a significant difference in the obstetric and perinatal outcomes among the study and control groups. Significant variation was seen in the obstetric outcome with regards to the incidence of induction of labor and mode of delivery (by caesarean section). Both were increased among the study group as compared to the control group. CTG changes, meconium stained liquor, neonatal admissions and observations were more among the study group as compared to control group.Conclusions: Athough there is an increased rate of caesarean section, NICU admission and observation, thick meconium stained liquor and NST changes there is no significant increase in the perinatal morbidity and mortality

Early detection of IUGR: can it prevent stillbirth?

Background: Maternal mortality in India is decreasing with the advances in health care facilities, increase in the number of hospital deliveries, improvement in the transport facilities etc. Present study aimed at to evaluate the causes for antepartum stillbirths.Methods: It is a retrospective study from the case records of the stillbirths that occurred from June 2015 to March 2018. All stillbirths between 28-41 weeks were studies. Stillbirths occurring in twin pregnancies were excluded. The total number of stillbirths that were studied was 102. Results: Most of the IUDs occurred between 28-37 weeks 82 (80.39%). The mean period of gestation at which the stillbirth occurred was 33.84±3.8 weeks. There was more number of male stillborns as compared to female stillborns. When the weight distribution of all stillbirths was compared with weight for gestational age 48 (47.5%) were <10% (SGA) and 46 (45.09%) of stillbirths weighed between 10th and 50th percentile Most of the IUDs were caused due to cord accidents, abruption and as a complication of hypertensive disorders of pregnancy.Conclusions: Stillbirths were higher in IUGR fetusus as compared to AGA fetuses. Hence in order to prevent stillbirth it would be mandatory to detect IUGR at an earlier stage and delivery should be planned if the fetus shows any features of compromise. Doppler studies can help in deciding the timing of delivery

Cancer in pregnancy

Cancer in pregnancy though rare is a challenging problem both for patient and obstetrician. It is on rise though pregnancy does not predispose cancer. Persistent symptoms like vomiting, abdominal pain, discharge etc should be thoroughly evaluated by clinical USG and if necessary by MRI if there is a strong suspicion of malignancy to detect early and treat promptly. A multidisciplinary discussion is necessary. Management depends on type of malignancy, stage, risk factors, histopathology and gestational age. Carcinoma of breast and cervix are common malignancies that occur in pregnancy. It is preferable to postpone surgery and CT till first trimester is completed. A through counseling is essential regarding termination of pregnancy, type of treatment and its effects in mother and fetus and prognosis. Aim should be curative treatment to the mother with some modifications in the treatment keeping in mind maternal and fetal safety

Comparative study of uterine repair during caesarean section: exteriorization repair versus in-situ repair

Background: Cesarean section is one of the most common major obstetrical operation performed worldwide and the rates of cesarean section are increasing. It is associated with both intra-operative and post-operative complications. Many variations in surgical methods have been devised to decrease the adverse effects and morbidity. One such method is technique of uterine repair after delivery of the fetus and placenta by exteriorizing the uterus or in-situ repair.Methods: A prospective comparative study was conducted in the department of Obstetrics and Gynecology at MGMCRI Pondicherry over 18 months from March 2015 to August 2016. Two hundred women undergoing caesarean section were assigned to 2 groups. Group 1 (Exteriorization) 100 women and Group 2 (In-situ repair) 100 women. Intra-op and post-operative complications were assessed in both groups and compared.Results: There was no significant difference between the two groups with regard to age, parity, gestational age and type of cesarean section. There was no significant difference between two groups with regard to fall in Hb, operating time, mean drop in pulse rate and blood pressure, nausea, vomiting and intra-op pain. There was significant difference in blood loss during surgery in in-situ repair, P value was <0.001 highly significant and also statistically significant increase in transfusion rates in in-situ group with a p value of 0.038. Postoperative complications like febrile morbidity was significantly more in in-situ repair P=0.046. There was no significant difference in other variables like urinary tract infection, surgical site infection, endometritis and hospital stay.Conclusions: Both techniques are accepted methods of uterine repair. Technique of repair depends on surgeon’s choice and clinical situation. Exteriorization repair is a valid option with no significant increase in morbidity compared to In-situ repair especially in cases where exposure of lower uterine segment is difficult, there is extension of incision and difficulty in achieving hemostasis