A two year retrospective study on outcome of forceps delivery – rejuvenating a dying art

Background: The obstetric forceps was designed to assist the extraction of the fetal head and 10% of all deliveries in the western world are accomplished by either vacuum or forceps. Forceps helps in avoiding Caesarean sections and can help in reducing the increase in the number of Caesarean sections. The aim of the study was to evaluate the maternal and neonatal outcome in a tertiary care hospital over a period of two years.Methods: This study was a retrospective observational study conducted over a period of two years from 1st July 2013 to 30th June 2015 in the labour ward of Christian Medical College and Hospital, Ludhiana. All operative vaginal deliveries conducted on singleton fetus in cephalic presentation were included in the study after applying the exclusion criteria. Maternal demographic data, various indicators for operative vaginal delivery and neonatal outcome were recorded.Results: A total of 2920 deliveries took place in the study period of which 156 cases (5.34%) were forceps delivery. The mean age of the patients was 26.2 years. The numbers of primigravida were 92 and multigravida was 64. Low mid cavity and outlet forceps was applied in 67 and 89 patients respectively. The most common indication for application of forceps was fetal distress (56.4%). Maternal morbidity was found in 36 women. Most of the babies were appropriate for gestational age (61.53%). Only 10.25% of the babies had low APGAR score <5 and required NICU care.Conclusions: The obstetric forceps is an effective instrument that may avoid unnecessary Caesarean sections and its complications

A randomized control study of titrated and oral misoprostol solution for induction of labor at term

Background: Quest for an induction method with safety, efficacy, feasibility, low cost, and patient preference is a constant pursuit for all obstetricians. Oral misoprostol is one such method which has been shown to be effective in achieving vaginal birth and has been recommended by WHO (2011) and FIGO (2012) for induction of labor. This study aimed to evaluate effectiveness and safety of hourly titrated oral misoprostol solution in comparison with two hourly static-dose oral misoprostol solution for induction of labor at term.Methods: Single centre interventional single-blinded randomized controlled trial conducted in a tertiary care centre in Ludhiana. 264 term pregnant women were randomly given titrated (group A) or static oral misoprostol solution (group B) till the onset of active labor. Induction to delivery time was the primary outcome measure while the secondary outcome measures pertained to efficacy and safety of the regimens.Results: 268 women were randomized, 4 patients were excluded from analysis because of drop out, leaving 264 women for intention to treat analysis. The mean interval between induction and delivery was 16.19±10.48 hours in group A and 15.28±8.34 hours in group B (p&gt;0.10, NS). 71 women (53.8%) in group A and 72 women (54.5%) in group B had vaginal delivery within 24 hours (p&gt;0.10, NS). 40.9% women in group B required more than 8 hours to receive the required number of doses as compared with 8.3% women in dose group A (p&lt;0.01, SS). Oxytocin requirement was significantly higher in group A (76.5%) as compared to group B (59.8%) (p&lt;0.05, SS). Incidence of fetal and maternal complications, rate of cesarean section and instrumental delivery was comparable between the two groups (p&gt;0.10, NS).Conclusions: Titrated oral misoprostol, considering its efficacy, safety and time saving is comparable to WHO recommended static oral misoprostol

Thrombocytopenia in pregnancy in a tertiary care hospital: a retrospective study

Background: To investigate the etiology, obstetrical risk factors, complications and outcomes of pregnancies affected by thrombocytopenia.Methods: A retrospective surveillance study was conducted on the basis of hospital records of 1532 women who delivered during a period of one year, in Christian Medical College and Hospital, Ludhiana, India. Clinical data including basic history, physical examination and investigations of those women who had thrombocytopenia, was evaluated and compiled into three groups depending upon the etiological factors.Results: Sixty four of 1532 women (4.2%) had thrombocytopenia of varying severity. 77.8% of these women had gestational thrombocytopenia (GT) as the commonest cause. Pregnancy specific hypertension and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) accounted for 20.6% cases whereas in 3.2% of pregnant women, idiopathic thrombocytopenic purpura (ITP) was the causative factor. A higher rate of IUGR (Intrauterine growth restriction), placental abruption and labor induction was noted among those gravidas who had moderate to severe thrombocytopenia. Maternal mortality, bleeding complications and adverse perinatal outcomes were not seen in this study.Conclusions: Commonest cause of thrombocytopenia in pregnancy is GT, followed by preeclampsia, eclampsia and HELLP syndrome. ITP is a rare cause of this disorder in pregnancy. Early detection and treatment of expected complications is the key focus in management of such cases

Pattern of utilization of blood and blood components in obstetrics at a tertiary care center: a cross-sectional study

Background: Blood transfusion is an essential lifesaving component in obstetrics. Extra blood loss in pregnancy can occur due to various gestational disorders and complications during labour and delivery. Reduction in maternal morbidity and mortality has been observed by increased use of comprehensive emergency obstetrics care in which blood transfusion has achieved recognition as one of the important components. In a developing country like India, the need for well maintained and readily available blood and transfusion services becomes paramount to decrease maternal morbidity and mortality. We wanted to determine the clinical characteristics and indication of blood transfusion in obstetrics and also determine any adverse blood transfusion reaction.Methods: This cross-sectional study was conducted in the department of obstetrics and gynaecology, Christian medical college, Ludhiana for a period of eighteen months from 15th October 2018. The study group included all the antenatal and postnatal patients up to 6 weeks postpartum who were admitted in the obstetric unit, requiring blood or component transfusions. Clinical characteristics, indication of blood transfusion and any adverse blood transfusion reaction were recorded.Results: In our study, about 7.84% of obstetric admission required blood and blood components. Most common indication for blood transfusion was anaemia either during antenatal or during postnatal period (33.91%). Majority of the patients were unbooked antenatally (63.91%) and were multiparous (93.91%). 4 or more blood transfusions were given in 28.26% of cases.Conclusions: Blood transfusion is live saving measure in many obstetric patients. Blood transfusion is an essential component of emergency obstetric care and appropriate blood transfusion significantly reduces maternal mortality. Severe anaemia is the most common condition requiring blood transfusion, which may be chronic due to nutritional deficiency or following acute blood loss, followed by postpartum haemorrhage, placental abruption and placenta previa. Availability of transfusion facility and blood products in obstetric care setting in peripheral health centres can reduce need for referral of patients and indirectly reduce the maternal morbidity and mortality

Abnormal umbilical artery Doppler in third trimester and perinatal outcome: a retrospective study

Background: Umbilical artery Doppler (UAD) has the greatest impact in modern obstetric assessment in high risk pregnancies. The objective of this study was to evaluate the maternal characteristics and perinatal outcome in pregnancies complicated by abnormal umbilical artery Doppler.Methods: A retrospective study was designed to analyze the medical records of 50 singleton pregnant women who delivered in the labour ward of our institution from 1st July 2014 to 30th June 2015. The study population had abnormal umbilical artery Doppler velocimetry with varying degree of reduction in placental circulation. These patients were assessed for maternal complications and foetal outcome.Results: Results of present study revealed that majority of women who had abnormal placental Doppler flow were under 37 weeks of gestation (82%). Absent end diastolic flow was seen more in pre-eclampsia/ eclampsia (38%), gestational diabetes (19%) and oligohydramnios (52%) as compared to high systolic/diastolic (S/D) ratio. Higher incidence of abruption (25%), operative deliveries (50%), intrauterine deaths (25%) and still births (25%) was seen with increase in the severity of placental insufficiency. High frequency of pre-maturity (76%) was noticed in this study as a result of abnormal Doppler. Neonatal complications like jaundice, RDS (Respiratory distress syndrome), IVH (Intra-ventricular haemorrhage) and NEC (Necrotizing enterocolitis) were recorded in increasing trends in present study.Conclusions: Umbilical artery Doppler helps in the prediction of possible maternal and foetal complications in cases of compromised placental flow. Monitoring of antenatal parameters, availability of emergency facility for early surgical intervention and neonatal care pave a long way in curtailing perinatal morbidity and mortality

Knowledge, attitude and preferences of pregnant women towards mode of delivery in a tertiary care center

Background: Delivery mechanism is a spontaneous process and requires no intervention. Advances in medical technology in maternity care have drastically reduced maternal and infant mortality. Aim of the study was to determine maternal knowledge, attitude and preferences of pregnant women towards mode of delivery in a tertiary care center.Methods: This was a prospective study conducted on 100 antenatal women in third trimester who attended the antenatal clinic in Christian Medical College and Hospital, Ludhiana, Punjab from September 2015 to January 2016.The information regarding socio-demographic profile, obstetric history, knowledge and attitude statements towards vaginal and cesarean delivery was collected.Results: Total of 100 women was enrolled in the study. Out of these, majority (47%) had secondary education. Majority of the women (89%) interviewed had positive attitude towards vaginal delivery. High rate of cesarean section was seen in patients with primary and secondary infertility as they thought that babies born by cesarean section are healthier than those delivered by vaginal delivery. The most frequently mentioned source of information about mode of delivery was family and friends. Almost half of women agreed to the statement that vaginal delivery creates a more affectionate mother and baby relationship. Economic factors play an important role in deciding cesarean birth.Conclusions: Majority of pregnant women interviewed in our institution were keen to deliver vaginally, while the remaining women due to lack of knowledge or phobia of vaginal delivery wanted to undergo a cesarean section. Improving women’s knowledge about the risks and benefits of different modes of delivery can lead to a positive maternal attitude towards vaginal delivery

First trimester uterine artery Doppler screening in the prediction of adverse pregnancy outcomes

Background: Uterine artery Doppler waveform has been extensively studied as a predictive marker for the later development of preeclampsia and fetal growth restriction. Therefore, uterine artery doppler has emerged as a good test for the prediction of preeclampsia, being simple to perform, reproducible and non-invasive. The present study was done to evaluate the first trimester uterine artery Doppler in the prediction of adverse pregnancy outcome.Methods: This was a prospective cohort study for all pregnant women attending antenatal clinic during 11-14 weeks of gestation at Christian medical college and hospital, Ludhiana, during a period of 18 months. Study population of (n~270) was taken. A pre-designed case record was filled at the time of registration. After taking informed consent, these women underwent ultrasound for uterine artery Doppler pulsatility index along with nuchal translucency & nasal bone scan by transabdominal ultrasound. Patients were followed up throughout the gestation to find out the development of any adverse pregnancy outcomes (early onset preeclampsia, early onset fetal growth restriction, late onset preeclampsia, late onset fetal growth restriction, oligohydramnios, placental abruption and stillbirth).Results: In our study, about 75% of antenatal women were found to have normal first trimester uterine artery pulsatility index and the rest 25% had abnormal pulsatility index. About 40% of women with abnormal dopplers developed complications associated to hypertensive disorders and adverse pregnancy outcomes, while 60% went on to have a normal pregnancy. It was observed that 13.2% developed gestational hypertension, 10.29% developed pulmonary embolism, 1.47% developed eclampsia, 22.05% developed oligohydramnios, 42.64% developed fetal growth restriction, 4.41 % developed placental abruption and 5.88% delivered stillbirth neonates.Conclusions: As hypertensive disorders of pregnancy pose a great risk of maternal and fetal morbidity and mortality, an evolution of Doppler studies have proven to be beneficial. Doppler ultrasound was found to be a valuable modality in the evaluation of fetal and placental circulation as well as in the prediction of pregnancy outcomes. According to the receiver operating characteristic curve obtained in our study, sensitivity and specificity of first trimester uterine artery pulsatility index was predictive for pregnancy complications and adverse outcomes

Bilateral ruptured tubal pregnancy: a case report

The infrequency with which Bilateral Tubal Pregnancy (BTP) occurs makes it a rare entity with an estimated incidence of 1 in 2,00,000 of all pregnancies and about 0.1 percent of all ectopic pregnancies. In the last few decades enhancement in the rate of occurrence has been reported in literature which has been attributed to Assisted Reproductive Technology (ART), Intra-Uterine Devices (IUD) and Pelvic Inflammatory Diseases (PID). We report a case of ruptured BTP where rupture of one tube preceded the rupture of contralateral side by approximately 3 weeks. 30 years old G4P2L1A1 presented with complaints of nausea and vomiting, vaginal bleeding and pain lower abdomen. There was no history of ART, IUCD or PID. A presumptive diagnosis of ruptured tubal pregnancy was made on the basis of clinical examination and ultrasound findings and patient was taken up for laparotomy. There was a right tubo-ovarian mass with bleeding from ruptured tube. Right salpingo-oophrectomy was done. Left tube on examination revealed a mass with a bleeding rent. Left salpingectomy was done because of extensive damage. Bilateral ruptured tubal ectopic pregnancy was confirmed on histopathological examination. BTP is likely to be missed even during USG as was in this case. This emphasizes the need to thoroughly examine pelvis for any other ectopic gestation during laparotomy

H1N1 in pregnancy: Experience in a tertiary care hospital

Introduction: The serious complication of influenza infection during pregnancy has been recognised for over a century. Because it is associated with high morbidity and mortality, we decided to undertake this study. Objectives: To assess maternal and perinatal outcome in women with H1N1 infection in pregnancy. Materials and Methods: This was a 1-year retrospective study conducted in Christian Medical College (  CMC) and Hospital, Ludhiana. All women infected with H1N1 virus anytime during pregnancy were included in the study. Results and Analysis: A total of 26 patients were included in our study. A majority of patients were in the age group of 20-25 years (84.61%). A total of 61.54% were primigravida and 69.23% were in the third trimester. Comorbidities like diabetes, asthma, and obesity were present in 19.23% patients. The commonest symptoms were cough (92.37%), sore throat, and breathlessness. The commonest maternal complication was preterm labor (30.76%), and fetal complication was intrauterine death (19.23%). The majority delivered vaginally (57.7%). There were seven maternal deaths in our study. Conclusions: H1N1 remains a grave risk in pregnancy, underlining the need for greater awareness, early diagnosis, and prompt treatment

Thrombocytopenia in pregnancy in a tertiary care hospital: a retrospective study

Background: To investigate the etiology, obstetrical risk factors, complications and outcomes of pregnancies affected by thrombocytopenia.Methods: A retrospective surveillance study was conducted on the basis of hospital records of 1532 women who delivered during a period of one year, in Christian Medical College and Hospital, Ludhiana, India. Clinical data including basic history, physical examination and investigations of those women who had thrombocytopenia, was evaluated and compiled into three groups depending upon the etiological factors.Results: Sixty four of 1532 women (4.2%) had thrombocytopenia of varying severity. 77.8% of these women had gestational thrombocytopenia (GT) as the commonest cause. Pregnancy specific hypertension and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) accounted for 20.6% cases whereas in 3.2% of pregnant women, idiopathic thrombocytopenic purpura (ITP) was the causative factor. A higher rate of IUGR (Intrauterine growth restriction), placental abruption and labor induction was noted among those gravidas who had moderate to severe thrombocytopenia. Maternal mortality, bleeding complications and adverse perinatal outcomes were not seen in this study.Conclusions: Commonest cause of thrombocytopenia in pregnancy is GT, followed by preeclampsia, eclampsia and HELLP syndrome. ITP is a rare cause of this disorder in pregnancy. Early detection and treatment of expected complications is the key focus in management of such cases