Primary amenorrhea: a clinical review

Primary amenorrhoea is a symptom with an extensive list of underlying causes, the majority of which are rare. According to the definition it should present in adolescence, although some conditions are diagnosed in childhood may present with failure of menstruation. Many causes of secondary amenorrhoea can also present with primary amenorrhoea if they arise very early in life. A systematic, compartment based approach will cover the commoner causes of primary amenorrhoea and recommend a pragmatic but cost-effective approach to achieve correct diagnosis. Treatment must be directed at the specific cause but has often wider implications for life long wellbeing like weight management, hormone replacement, sexual health and fertility

Comparison of oral, vaginal and sublingual misoprostol for induction of labour in premature rupture of membranes after 34 weeks of gestation: a randomized controlled trial

Background: Purpose of this study was to evaluate the efficacy and safety of different routes of administration of misoprostol - 50µg oral, 25µg vaginal and 50µg sublingual for induction of labour in women with premature rupture of membranes after 34 weeks of gestation.Methods: Women admitted to labour ward with premature rupture of membranes (PROM) after 34 weeks of gestation and requiring induction of labour were randomized into three groups. A total of 246 women participated in the study and were assigned to three groups to receive either 50µg oral misoprostol (n=80) or 25µg vaginal misoprostol(n=83) or 50µg sublingual misoprostol (n=83). The doses were repeated 4 hourly till active labour was established or up to a maximum of 4 doses. Patient factors, induction to delivery intervals, maternal side effects and fetal outcomes were noted.Results: The mean induction to active labour interval was not significantly different in the three groups (oral vs vaginal vs sublingual-7.52±4.8 vs 7.75±4.1 h vs 7.68±5.3 h; p=0.93). There was no significant difference in the induction to delivery time interval among the three misoprostol groups (oral vs vaginal vs sublingual - 10.9± 5.9 h vs 11.2±5.0 h vs 11.4±6.6 h; p= 0.88). Spontaneous vaginal delivery rate, instrumental delivery rate and lower segment ceasarean section rates were comparable among the three groups. The number of neonates with APGAR score <7 (low APGAR) at 1 minute of birth was highest in sublingual group and lowest in vaginal group which was statistically significant (oral vs vaginal vs sublingual, 16% vs 7.2% vs 20.5%; p= 0. 04). APGAR score <7 at 5 minutes was not significantly different among the three groups (oral vs vaginal vs sublingual, 4.8% vs 2.4% vs 7.2%; p=0.2). This implies that the need for immediate resuscitation was more in the sublingual group. Neonatal intensive care admission was least in the vaginal group although the difference was not statistically significant. Sublingual group had a higher rate of hyperstimulation and fetal heart rate abnormalities compared to oral and vaginal groups although these parameters did not reach statistical significance.Conclusions: Oral, vaginal and sublingual routes of administration of misoprostol are equally effective for labour induction in women with premature rupture of membranes after 34 weeks with sublingual route having slightly higher incidence of low APGAR scores at one minute for the neonate

An audit of caesarean section rate based on Robson’s ten group classification system

Background: Caesarean section (CS) rates are rising worldwide and is a major public health concern. There is lack of evidence supporting the maternal and neonatal benefits with the increasing CS rates. Robson’s ten group classification system serves as an initial structure with which caesarean section rates can be analysed. RTGCS helps us to analyse and allow us to bring changes in our practice.Methods: This was a hospital based cross sectional study conducted over a period of 10 months during the year 2018, which involved 1478 pregnant women, out of which 693 underwent CS, those who underwent CS were grouped according to Robson’s Ten group classification system and the data was collected and analyzed.Results: 693 women underwent CS and the overall section rate was 46.88%. Group 5 (previous LSCS) and Group 2 (nulliparous, >37 weeks, induced) contributed the maximum to the overall CS rates (33.9% and 26.3% respectively). The most common indication for caesarean section was previous LSCS (38%), fetal distress (19.2%) and meconium stained liquor (13.7%).Conclusions: Robson’s ten group classification system helps us in auditing the caesarean section rates. Group 5 and 2 contributes the maximum for caesarean section rates. Encouraging and adequate counselling for VBAC, proper training of obstetricians in CTG interpretation would reduce the caesarean section rates

Mid-Pregnancy Ultrasonographic Cervical Length Measurement (A Predictor of Mode and Timing of Delivery): An Observational Study

Objective: Even though cervical length is considered as predictor of timing and mode of delivery, it is not used as a screening tool in low risk asymptomatic population. This study was carried out with the intention to know the timing and mode of delivery in asymptomatic low risk women using second trimester ultrasonographic cervical length measurement and predict the risk of pretermlabor, prolonged pregnancy and need for caesarean section. 1) To determine the association between cervical length at mid-pregnancy and timing of delivery. 2) To determine the usefulness of mid-pregnancy ultrasonographic cervical length measurement in predicting mode of delivery. Materials and methods: Transvaginal sonography was performed to measure the cervical length between 20-24 weeks of gestation. These patients were followed till delivery to assess the gestational age at delivery and mode of delivery. Results: Totally 237 patients were recruited of which 173 satisfied the inclusion criteria. Out of 15 patients with cervical length less than 3cm, 14(93.33%) had preterm delivery. Postdated pregnancy was observed in 45(90%) out of 50 patients with cervical length more than 4cm. In the group with cervical length less than 3cm, 12 (80%) delivered vaginally. Among cervical length more than 4cm group 24 (48%) required cesarean section. Conclusion: Cervical length of less than 3cm measured between 20-24 weeks of gestation is associated with preterm births and favours vaginal birth whereas, cervical length of more than 4cm is associated with postdated pregnancy and increased incidence of cesarean section

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Comparison of oral, vaginal and sublingual misoprostol for induction of labour in premature rupture of membranes after 34 weeks of gestation: a randomized controlled trial

Background: Purpose of this study was to evaluate the efficacy and safety of different routes of administration of misoprostol - 50µg oral, 25µg vaginal and 50µg sublingual for induction of labour in women with premature rupture of membranes after 34 weeks of gestation.Methods: Women admitted to labour ward with premature rupture of membranes (PROM) after 34 weeks of gestation and requiring induction of labour were randomized into three groups. A total of 246 women participated in the study and were assigned to three groups to receive either 50µg oral misoprostol (n=80) or 25µg vaginal misoprostol(n=83) or 50µg sublingual misoprostol (n=83). The doses were repeated 4 hourly till active labour was established or up to a maximum of 4 doses. Patient factors, induction to delivery intervals, maternal side effects and fetal outcomes were noted.Results: The mean induction to active labour interval was not significantly different in the three groups (oral vs vaginal vs sublingual-7.52±4.8 vs 7.75±4.1 h vs 7.68±5.3 h; p=0.93). There was no significant difference in the induction to delivery time interval among the three misoprostol groups (oral vs vaginal vs sublingual - 10.9± 5.9 h vs 11.2±5.0 h vs 11.4±6.6 h; p= 0.88). Spontaneous vaginal delivery rate, instrumental delivery rate and lower segment ceasarean section rates were comparable among the three groups. The number of neonates with APGAR score &lt;7 (low APGAR) at 1 minute of birth was highest in sublingual group and lowest in vaginal group which was statistically significant (oral vs vaginal vs sublingual, 16% vs 7.2% vs 20.5%; p= 0. 04). APGAR score &lt;7 at 5 minutes was not significantly different among the three groups (oral vs vaginal vs sublingual, 4.8% vs 2.4% vs 7.2%; p=0.2). This implies that the need for immediate resuscitation was more in the sublingual group. Neonatal intensive care admission was least in the vaginal group although the difference was not statistically significant. Sublingual group had a higher rate of hyperstimulation and fetal heart rate abnormalities compared to oral and vaginal groups although these parameters did not reach statistical significance.Conclusions: Oral, vaginal and sublingual routes of administration of misoprostol are equally effective for labour induction in women with premature rupture of membranes after 34 weeks with sublingual route having slightly higher incidence of low APGAR scores at one minute for the neonate

Immunohistochemical distinction between mesothelial and adenocarcinoma cells in serous effusions: A combination panel-based approach with a brief review of the literature

Background: The prognostic and therapeutic significance of differentiating adenocarcinoma (AC) from reactive mesothelium (RM) in effusions cannot be overemphasized. To avoid diagnostic errors, ancillary techniques like immunohistochemistry are employed. However, results vary and no universal standard has been accepted so far. Objective: To study the combined diagnostic efficacy of epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA), E-cadherin (EC), calretinin (CAL), desmin (DES) and vimentin (VIM) in distinguishing RM from AC cells in serous effusions. Study Design: Unequivocally diagnosed cases of 39 adenocarcinomatous and 38 RM populations were studied using sections from 49 formalin-fixed, paraffin-embedded cell blocks. Materials and Methods: The immunomarkers were applied on cell block sections using the avidin-biotin peroxidase technique. The distribution/intensity of immunostaining in mesothelial and AC cells were graded semiquantitatively. Statistical Analysis Used: Fischer&#x2032;s exact test was used to calculate the efficacy of individual markers and their combinations. Results: EMA was the best single marker for AC, with 100&#x0025; sensitivity and 97.37&#x0025; specificity. For the mesothelial cells, CAL exhibited 100&#x0025; sensitivity and 92.31&#x0025; specificity. DES was more specific than CAL but had a poor sensitivity of 55.26&#x0025;. EC, CEA and VIM had unsatisfactory predictive values precluding their use as individual diagnostic markers. Among the combinations, two panels - EMA&#x002B; AND (CAL- OR DES-) for ACs and CAL&#x002B; AND (EMA- OR CEA-) for RM had 100&#x0025; specificities and sensitivities. Conclusions: Most panel studies on fluid cytology are based on the arbitrary use of individual markers with the best statistical values, leading to a less than accurate diagnostic assessment. We believe that statistical parameters calculated in combination provide for a more practical and objective evaluation as well as allowing for meaningful comparative studies

Informal Insurance Arrangements in Ethiopia: A Literature Review

Various researches on informal financial sector presented its potential to achieve financial inclusion among low-income households. Apart from social networking, the informal financial sector will likely continue to be important in developing countries as well as among immigrants in developed countries in terms of financial access and support. Among the informal financial mechanisms, informal insurance arrangements are popular in developing countries whose beneficiaries include mainly low-income households. This article presents the general overview of informal insurance arrangements, mainly the Ethiopian iddir in Ethiopian communities and to explore whether these arrangements can complement with formal insurance services

Angiogenic factors and histomorphological alterations encountered in preeclamptic placentae

Background:Preeclampsia complicates 10% of pregnancies in the developed world. Alteration in angiogenic factors occurs in preeclampsia which leads to chronic hypoxic changes in placenta.Aim:To assess the histomorphological changes and expression of angiogenic factors in placenta of preeclamptic patients in comparison to normal placenta.Design: Cross sectional analytical study.Materials&amp; Methods: This study was conducted from October 2013 to August 2015 and included 53 placenta from preeclamptic patients and 53 placenta from healthy pregnant women. Histomorphological changes were studied in the placenta. Expression of vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor-1 (VEGFR-1) in the placental villi were evaluated using immunohistochemistry (IHC).Statistical analysis: Done using IBM-SPSS 21.0. ‘p’ value &lt; 0.05 was taken as significant.Results: In our study, 92.5% of preeclamptic group were in the age group of 21 to 34 years and 62.3% of them had placental weight of less than 500 grams.&nbsp