Serum Vitamin D Levels and Dry Eye Disease in Postmenopausal Women: A Case-Control Study at a Tertiary Care Center in Rural Haryana.

Background: Despite the high prevalence of Vitamin-D insufficiency and high susceptibility to dry eye disease (DED) in postmenopausal women (PMW), correlation between DED and Vitamin D has not been explored in PMW in any Indian study. Aims and Objectives: To explore the correlation between serum Vitamin D levels in PMW with and without DED, in a hospital-based population in rural Haryana. Materials and Methods: Subjective (ocular surface disease index [OSDI] questionnaire) and objective clinical tests were undertaken for DED diagnosis. 25(OH) Vitamin D was measured in serum using enzyme-linked immunosorbent assay; insufficient (10-30 ng/ml) and deficient (<10 ng/ml). Descriptive statistics were analyzed by mean ± standard deviation for continuous and frequencies for the categorical variables; Student's t-test used to find out mean difference in Vitamin D levels; P < 0.05 was considered statistically significant. Results: One hundred and forty PMW (60.1 ± 5.32 years) were included; Group-A (Controls; no DED; n: 70); Group-B (Cases; DED diagnosed by OSDI scores; n: 70); Subgroup-B1 (clinical tests negative; n: 30) and B2 (clinical tests positive; n: 40). There was no statistically significant difference in OSDI scores between B1 and B2. Significantly lower mean Vitamin D levels were found in cases (14.36 ± 4.08 ng/ml) as compared to controls (19.19 ± 6.4 ng/ml) (P = 0.001) and in B2 (13.15 ± 3.51 ng/ml) as compared to B1 (15.57 ± 4.66 ng/ml) (P = 0.01). Conclusion: There were significantly low levels of Vitamin-D in clinically established DED. Evaluating Vitamin D levels as a part of the dry eye workup in PMW is recommended. OSDI scores were not aligned with the clinical test scores; questionnaire-based tests alone may not be sufficient for diagnosing DED.

Minilaparotomy hysterectomy: a worthwhile alternative.

AIM: To report the clinical merits and usefulness of minilaparotomy hysterectomy in comparison to the traditional abdominal approach. MATERIAL AND METHODS: A comparative study to review perioperative and postoperative outcomes and complications was conducted in 98 patients undergoing abdominal hysterectomy through Pfannenstiel incision for benign gynecological disease or pre-invasive pathology. Fifty of these patients (Group I) underwent hysterectomy by minilaparotomy approach (≤5 cm incision) and 48 patients (Group II) had standard/conventional methodology (>6 cm incision). RESULTS: Though there were no statistically significant differences between the patients' profile as well as the size and weight of the removed uterus in the two groups, the mean operating time was 41.3 min in Group I and 77.5 min in Group II (P<0.01) and the mean postoperative hospital stay of 3.1 days in Group I was significantly lower than in Group II patients (5.4 days), P<0.01. There was no major complication or mortality in either of the groups and the composite morbidity encountered was 4% versus 33.33% in Groups I and II, respectively. Two of the patients in Group II required blood transfusion whereas none of the patients in Group I had estimated blood loss over 500 mL. CONCLUSION: Minilaparotomy hysterectomy through ≤5 cm Pfannenstiel incision provides an appealing, effective, expeditious, minimal access and less invasive cost-effective option/alternative to the traditional abdominal approach obviating the need for any additional expensive equipment and, above all, improves upon the perioperative outcome, notwithstanding, whatsoever, on the quality of surgery.

Knowledge, Attitude and Perception of HIV/Aids Among Antenatal Women and its Correlation with their Socio-Demographic Profile: Study from a Tertiary Care Centre of Northern India.

PURPOSE OF STUDY: To evaluate the knowledge, attitude and perception of HIV/AIDS among antenatal women and to correlate them with their socio-demographic profile. METHODS: We conducted this study on 400 pregnant women attending the antenatal clinic of our hospital for the first time irrespective of their period of gestation, age and parity. All the participants were interviewed with the help of a predesigned questionnaire which included their socio-demographic details and questions to assess their knowledge and attitude toward HIV/AIDS. Data were analyzed using SPSS version 22 and expressed in the form of percentage, frequency distribution, mean, standard deviation and p value. RESULTS: Antenatal women of the study population were having unsatisfactory knowledge about HIV/AIDS and prevention of MTCT. 26% women were totally unaware of any entity like HIV. 44% participants did not know the most common way of spread of HIV. Only half of the subjects knew the correct preventive measures for HIV/AIDS. 54% knew about MTCT, but only 24% knew about its transmission through breast milk. Knowledge and attitude was found to be significantly improving with socioeconomic status. CONCLUSION: Indian antenatal women have poor awareness and wrong perception about HIV/AIDS and its mother to child transmission (MTCT). Targeted educational interventions can be formulated to increase awareness among antenatal women about prevention of vertical transmission of HIV.

A prospective study of a new prediction model of vaginal birth after cesarean section at a tertiary care centre.

OBJECTIVE: To create a new and simple model for predicting the likelihood of vaginal birth after cesarean (VBAC) section using variables available at the time of admission. MATERIALS AND METHODS: A prospective observational study was performed at a tertiary care centre in Haryana over a period of 12 months (January 2018 - December 2018) in pregnant women attending the labour room with one previous cesarean section fulfilling the criteria for undergoing trial of labour after cesarean (TOLAC). The sample size was 150. A VBAC score was calculated for each patient using a new prediction model that included variables available at the time of admission such as maternal age, gestational age, Bishop's score, body mass index, indication for primary cesarean section, and clinically estimated fetal weight. The results of the VBAC scores were correlated with outcomes i.e. successful VBAC or failed VBAC. The chi-square test and Student's t-test was used for comparison among the groups. Descriptive and regression analysis was performed for the study variables. RESULTS: Out of 150 TOLAC cases, 78% had successful VBAC and the remainder (22%) had failed VBAC. The observed probability of having a successful VBAC for a VBAC score of 0-3 was 34%, 4-6 was 68%, 7-9 was 90%, and ≥10 was 97%. The prediction model performed well with an area under the curve of 0.77 (95% CI: 0.68 to 0.85) of the receiver operating characteristics receiver operating characteristic curve. CONCLUSION: The present study shows that the proposed VBAC prediction model is a good tool to predict the outcome of TOLAC and can be used to counsel women regarding the mode of delivery in the current and subsequent pregnancies. Further studies of this model and other such models with different permutations and combinations of variables are required.

Obstetric outcome of induction of labor using prostaglandin gel in patients with previous one cesarean section.

OBJECTIVE: After globally acceptance of planned vaginal birth after cesarean section (VBAC), the mode of induction is still a matter of debate and requires further discussion. We aimed to study obstetric outcomes in post-cesarean patients undergoing induction of labor with prostaglandin gel compared with patients who developed spontaneous labor pains. METHODS: All patients at 34 weeks or more of gestation with previous one cesarean section eligible for trial of labor after cesarean section admitted in a labor room within one year were divided in 2 groups. Group one consisted of patients who experienced the spontaneous onset of labor pains and group 2 consisted of patients who underwent induction of labor with prostaglandin gel. They were analyzed for maternofetal outcomes. Descriptive statistics, independent sample t-test, and chi-square test were applied using SPSS 20 software for statistical analysis. RESULTS: Both groups were comparable in maternal age, parity, and fetal weight, but different in bishop score, mode of delivery, and neonatal outcome. Admisson bishop score was 6.61±2.51 in group 1 and 3.15±1.27 in group 2 (P<0.005). In the patients who experienced spontaneous labor, 86.82% had successful VBAC. In the patients with induced labor, 64.34% had successful VBAC with an average dose of gel of 1.65±0.75. Both groups had one case each of uterine rupture. The neonatal intensive care unit admission rate was 4.1% in group one and 10.4% in group 2. CONCLUSION: This study reflects that supervised labor induction with prostaglandin gel in previous one cesarean section patients is a safe and effective option.

Doppler changes as the earliest parameter in fetal surveillance to detect fetal compromise in intrauterine growth-restricted fetuses.

INTRODUCTION: It is estimated that 3-10% of infants are growth restricted. Growth disturbances may have long-term issues. Doppler allows insight into the fetal response to intrauterine stress. OBJECTIVE: The aim of this study was to detect fetal compromise in intrauterine growth-restricted (IUGR) fetuses by means of biophysical profile (BPP) vis-à-vis Doppler velocimetry studies of the fetal umbilical artery, and to find out which of the two is a better and earlier predictor of fetal compromise. METHODS: A prospective study was conducted on a total of 50 singleton pregnancies with IUGR between 28 and 42 weeks of gestation. Study patients were managed expectantly with nonstress testing and amniotic fluid assessment, BPP and Doppler velocimetry studies of the fetal umbilical artery. RESULTS: Fetal outcome was poor in 5/50 (10%) of the fetuses, defined as presence of all of the following: poor Apgar test score, neonatal intensive care unit stay, necrotizing enterocolitis, and low birth weight. Of the four with abnormal BPP, 50% had poor fetal outcomes. Out of 46 with normal BPP, 6.5% had poor fetal outcomes. CONCLUSION: Inference drawn from the study is that the Doppler technology provides us the opportunity for repetitive noninvasive hemodynamic monitoring in IUGR pregnancies.

Does basal luteinizing hormone help predict the fate of in vitro fertilization?

OBJECTIVE: Evaluate the role of baseline serum luteinizing hormone (LH) in predicting the success of in-vitro fertilization (IVF) in terms of clinical pregnancy and live birth rate. METHODS: Women who underwent IVF and/or intracytoplasmic sperm injection (ICSI), following either the agonist or the antagonist protocol, were retrospectively evaluated over a period of two years at the All India Institute of Medical Sciences, New Delhi. We investigated the correlation of serum LH levels in the follicular phase with pregnancy outcomes. A P-value lower than 0.05 was considered as statistically significant. RESULTS: The individuals (351) were divided into four groups based on LH and FSH baseline values, and the levels were correlated with clinical pregnancy and live births. The highest clinical pregnancy rate (25%) was achieved in women with low LH (< 2IU/l); whereas the miscarriage rate was almost similar in all the groups. The pregnancy rate was the lowest (16%) in women with high LH levels (> 8IU/L). Pregnancy rates were intermediate (20%) if LH was intermediate (2-8IU/L). However, none of the results had statistical significance. CONCLUSIONS: Early follicular serum LH levels before an IVF/ICSI treatment cycle did not have any clear relationship with clinical pregnancy or live birth rates.

A rare case of Endometriosis in vaginal hysterectomy scar.

Presented hereunder is probably the first reported case of endometriosis at the vaginal apex following vaginal hysterectomy. No other similar case could be traced in the review of the literature.

A rare case of retroperitoneal leiomyoma.

Introduction. Leiomyoma uteri is one of the most common benign conditions for which women undergo hysterectomy every year. Fibroids found retroperitoneally are a rare entity, especially, primary retroperitoneal fibroid. Case Presentation. We report a case of 42-year-old para 1 who presented to our hospital with recurring retention of urine, lower abdominal and pelvic pain, and dyspareunia . Provisional diagnosis on the basis of examination and imaging was large subserosal fibroid with mild right-sided hydroureteronephrosis, due to pressure effect of the fibroid. Abdominal hysterectomy was done for the patient, and intraoperatively, a bulky uterus was found with multiple small fibroids on anterior and posterior walls, and a large fibroid approx. 10 × 8 cm was found arising from the posterior surface at the level of internal os retroperitoneally, which was confirmed by histopathology as leiomyoma. Conclusion. Retroperitoneal fibroids are rare neoplasms and treatment is surgical removal. Preoperative imaging can only give provisional diagnosis and can be misguiding. Final diagnosis of retroperitoneal fibroid can be made only intraoperatively.

Shortening the induction delivery interval with prostaglandins: a randomized controlled trial of solo or in combination.

OBJECTIVE: To compare the efficacy and safety of misoprostol alone with dinoprostone followed by misoprostol, all inserted intravaginally in induction of labor at term and the obstetrical outcome. MATERIAL AND METHODS: A pilot study comprising 111 primigravidae, >37 gestational weeks with singleton pregnancy in cephalic presentation having an unfavorable Bishop score admitted for labor induction, were considered and randomly allocated into two groups. In group I (n=55) with intravaginal 25mcg misoprostol 4 hourly (six doses at the most) and and group II (n=56), with dinoprostone 0.5mg followed eight hours later by 25mcg misoprostol induction to vaginal delivery time was found to be significantly different, being 14.8 h in group-I and shorter in group-II with a mean of 11.6 h. Vaginal delivery rates within 12 h (groups-I and -II: 47.2%, as compared to 60.7%, respectively) were found to be higher with dinoprostone-misoprostol induction, as well as vaginal delivery rates in 24 h, 80.0% and 91.1%. The need for oxytocin augmentation was more frequent in the misoprostol than in the dinoprostone-misoprostol group, (61.8%, and 39.3%), and all these observations were statistically significant. Abnormal foetal heart rate pattern occurred more frequently (18.2%) in group-I in contrast to 5.3% in group-II, as was the incidence rate of (18.2%) who had passage of meconium in group-I, this rate being significantly different from group-II having meconium passage in 3 cases, a rate of 5.3%. CONCLUSION: Using dinoprostone followed by vaginal misoprostol is safe and effective for induction of labor with less need for oxytocin augmentation and shorter induction delivery interval.

At times, myomectomy is mandatory to effect delivery.

BACKGROUND: Excision of a leiomyoma has never been a choice during caesarean section. METHOD: Myomectomy of a massive fibroid was necessitated prior to delivering the baby. RESULTS: Delivery of a healthy was effected by Classical caesarean section. CONCLUSION: Leiomyoma in pregnancy is not an unknown entity and is a cause of concern for being a source of excruciating pain, at times, during the ongoing gestation.Although performed rarely, it is sometimes necessary to remove a large myoma to effect delivery of the baby during Cesarean section as is depicted in the case being presented hereunder.

An effective and safe innovation for the management of vault prolapse.

OBJECTIVE: Considering the great variety of techniques and disagreement about the ideal route, there is a need for a simple, safe and effective method for the management of vault prolapse. STUDY DESIGN: 51 cases of post- hysterectomy vault prolapse: 45 following vaginal and 6 after total abdominal hysterectomy were treated surgically by anterior abdominal wall colpopexy with autogenous rectus fascia strips. RESULTS: Except for minor complaints like vomiting, fever and urinary retention in 3.92% cases each (n = 2 each), no major complications were encountered. Moreover, no recurrence, thus far, on follow-up. CONCLUSION: Using autogenous rectus fascia strips in anterior abdominal wall colpopexy is not only simple, cheap and effective method of treating apical prolapse but is also devoid of any serious complications as described with other techniques.

Rectus fascia colpopexy for post-hysterectomy vault prolapse: a valid option.

OBJECTIVE: Considering the great variety of techniques and disagreement about the ideal route, there is a need for a safe, simple and effective method for the management of apical prolapse. MATERIAL AND METHODS: Twenty seven cases of post- hysterectomy vault prolapse (twenty four following vaginal and three after total abdominal hysterectomy) were treated surgically by anterior abdominal wall colpopexy with autogenous rectus fascia strips. RESULT: Except for minor complaints like- vomiting, fever and urinary retention in 3.7% cases each (n=1), no major complications were encountered. Moreover, no recurrence, on follow-up thus far. CONCLUSION: Using autogenous rectus fascia strips in anterior abdominal wall colpopexy is not only a simple, cheap and effective method of treating vault prolapse but is also devoid of any serious complications such as described with other techniques.

Shortening the second stage of labor?

OBJECTIVE: To evaluate the benefits and risks of using uterine fundal pressure in shortening the second stage of labor and on the obstetrical outcome. MATERIAL AND METHODS: A pilot study comprising 209 primigravidae between 37 and 40 gestational weeks with singleton fetus in cephalic presentation admitted to the delivery suite were considered and were randomly allocated into two groups: I (n=101) and II (n=108), with or without manual fundal pressure, respectively, during the second stage of labor. Main observation measures considered were: duration of the second stage of labor was the primary outcome measure and the secondary outcome measures were severe maternal morbidity/mortality, neonatal trauma, admission to neonatal intensive care unit, and neonatal death. RESULTS: There were no significant differences in the mean duration of the second stage of labor and secondary outcome measures. Significant adverse findings having no mention in the earlier literature, were noticed which were: one case each of retained placenta and uterine prolapse besides increased evidence of maternal exhaustion and perineal injuries (including one case of complete perineal tear) in the group where fundal pressure was exercised. CONCLUSION: Application of uterine fundal pressure in a delivering woman was not only ineffective in shortening the second stage of labor but added to the risks during parturition.

Is uterine prolapse a cause of primary infertility?

Presented in this report is apparently the first case of its kind in the medical literature where a woman with 11 years of primary infertility not only conceived following conservative surgery for uterine prolapse but also had a successful obstetrical outcome.

Preservation of fertility following abnormally adherent placenta treated conservatively: a case report.

INTRODUCTION: One of the ensuing complications of placenta accreta includes loss of fertility. CASE PRESENTATION: An Asian origin Indian national patient with history of placenta accreta at the time of previous delivery and had conservative management with injection methotrexate after the failure of surgical intervention, conceives again and has uneventful antenatal period and parturition. CONCLUSION: Conservative strategy of leaving the excessively adherent placenta in-situ alongwith adjuvant therapy in the form of injection methotrexate, not only prevents dreadful complications but also retains fertility in haemodynamically stable patients desirous of future pregnancy.

Hysterectomy through minilaparotomy for benign gynaecological conditions: a valid option.

OBJECTIVE: Efforts are continuously being made for surgery to be less invasive with a minimal access approach. This article reports our experience with minilaparotomy hysterectomy in patients with benign gynecological disease or preinvasive pathology. MATERIAL AND METHODS: A prospective study to analyse the outcome and per-operative and post-operative complications was conducted in 69 patients undergoing hysterectomy by the minilaparotomy approach through 4-5cm Pfannenstiel incision. RESULTS: The mean operating time and postoperative hospital stay were 41.3 min and 3.1 days, respectively. Composite morbidity was encountered in 12 women (17.4%) with no major complications or mortality. None of the patients had an estimated blood loss over 500ml. CONCLUSION: Minilaparotomy hysterectomy in benign gynecological disease provides an appealing, effective, expeditious, minimal access and cost-effective option/alternative to the traditional abdominal hysterectomy. It obviates the need for any additional expensive equipment and above all improves upon the per-operative and post-operative outcomes without compromising, whatsoever, the quality of surgery.