Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Universal and timely access to a caesarean section is a key requirement for safe childbirth. We identified the burden of maternal and perinatal mortality and morbidity, and the risk factors following caesarean sections in low-income and middle-income countries (LMICs). METHODS: For this systematic review and meta-analysis, we searched electronic databases including MEDLINE and Embase (from Jan 1, 1990, to Nov 20, 2017), without language restrictions, for studies on maternal or perinatal outcomes following caesarean sections in LMICs. We excluded studies in high-income countries, those involving non-pregnant women, case reports, and studies published before 1990. Two reviewers undertook the study selection, quality assessment, and data extraction independently. The main outcome being assessed was prevalence of maternal mortality in women undergoing caesarean sections in LMICs. We used a random effects model to synthesise the rate data, and reported the association between risk factors and outcomes using odds ratios with 95% CIs. The study protocol has been registered with PROSPERO, number CRD42015029191. FINDINGS: We included 196 studies from 67 LMICs. The risk of maternal death in women who had a caesarean section (116 studies, 2 933 457 caesarean sections) was 7·6 per 1000 procedures (95% CI 6·6-8·6, τ2=0·81); the highest burden was in sub-Saharan Africa (10·9 per 1000; 9·5-12·5, τ2=0·81). A quarter of all women who died in LMICs (72 studies, 27 651 deaths) had undergone a caesarean section (23·8%, 95% CI 21·0-26·7; τ2=0·62). INTERPRETATION: Maternal deaths and perinatal deaths following caesarean sections are disproportionately high in LMICs. The timing and urgency of caesarean section pose major risks. FUNDING: Ammalife Charity and ELLY Appeal, Barts Charity, and the UK National Institute for Health Research.

Recurrence risk of preterm births: a retrospective Indian study.

Preterm birth (PTB) is the leading cause of neonatal deaths and India is the biggest contributor to the global burden of PTBs. This study aimed to determine the risk of recurrence of PTBs and factors associated with recurrence among mothers delivered at a tertiary care perinatal centre in India. This retrospective study comprised women who had delivered singleton preterm babies (24-37 weeks of gestation and weighing ≥500 g) in 2009 and 2010, and had subsequent deliveries beyond 24 weeks of gestation by the end of March 2016. Preterm births were stratified as spontaneous and those with an indication for delivery. Information on demographic data and maternal and neonatal outcomes was accessed from the case records or enquired over telephone. Among 291 eligible women, the recurrence rate of PTB was 31.6%; 29.1% for prior spontaneous and 34.0% for indicated preterm deliveries. This recurrence risk is similar to that in the western populations. In 75.0% of the cases, the type of recurrent PTB corresponded to the index PTB. Preeclampsia (PE) was significantly associated with recurrence (OR 7.10; 95% CI: 3.33, 15.11; p < .001); thus, prevention of PE is a key component in the prevention of PTB.Impact StatementWhat is already known on this subject? Preventing preterm birth (PTB) remains a challenge because the causes of PTBs are numerous, complex and poorly understood. Spontaneous PTB before 34 weeks of gestation is a strong predictor of subsequent spontaneous PTB. Spontaneous PTB is not only associated with increased recurrence of spontaneous but also medically indicated PTB and vice versa. Risk factors may vary by the clinical subtype of the most recent PTB.What the results of this study add? Despite the highest reported number of PTBs, there are no data on recurrence from India. This study reveals that the recurrence rate of PTBs in an Indian population appears to mirror the rates in the developed nations and preeclampsia (PE) is strongly associated with recurrence.What the implications are of these findings for clinical practice and/or future research? The results of this study are useful for counselling women who had previous PTBs regarding their future obstetric outcomes. Focussed research on prediction and prevention of PE is an essential element in the algorithm for prevention of PTBs.

Risk factors for obstetric anal sphincter injuries (OASI) at a tertiary centre in south India.

INTRODUCTION AND HYPOTHESIS: Despite several studies that have reported risk factors for obstetric anal sphincter injuries (OASI), data from the Indian subcontinent are scarce. The purpose of this study was to identify risk factors for these sphincter injuries in an Indian population. METHODS: This was a case-control study within a retrospective cohort of vaginal deliveries at a tertiary care facility. All vaginal births beyond 24 completed weeks of gestation and birth weight ≥500 g from January 2008 to December 2012 were identified from the hospital electronic database. Cases were women with OASI sustained during vaginal delivery; the rest constituted controls. Potential risk factors for occurrence and severity of OASI were assessed initially using bivariate analysis and then a logistic regression model. RESULTS: The incidence of sphincter injury was 2.1% of vaginal births and 1.1% of all deliveries, and major-degree (3c and 4th-degree) tears constituted 20.9% of tears. After adjusted analysis, significant predictors for injury included primiparity, delivery at or beyond 41 weeks of gestation, epidural analgesia, instrumental delivery, shoulder dystocia, birth weight ≥4000 g, and head circumference ≥35 cm. Episiotomy protected against sphincter injuries, particularly in forceps and ventouse deliveries. Shoulder dystocia was significantly associated with major-degree tears, while episiotomy appeared to be protective. CONCLUSION: Risk factors are similar to those in other population groups; however, primiparity appears to be associated with lesser risk and forceps delivery with greater risk of sphincter trauma than previously reported.

Ovarian apoplexy resulting from ruptured heterotopic pregnancy following intrauterine insemination.

Heterotopic pregnancy is on the rise with the use of assisted conception and commonly involves the fallopian tube. Ovarian heterotopic pregnancy is rare, with fewer than 40 reported cases in PubMed/Medline; cases of ovarian ectopic pregnancy after intrauterine insemination are even rarer, with only seven published reports. We report here a case of ovarian heterotopic pregnancy following intrauterine insemination; this could possibly be the first such report. Our patient presented with circulatory collapse in the first trimester and laparoscopy disclosed an ovarian pregnancy with hemoperitoneum. Following resection of the ovarian pregnancy, the intrauterine gestation continued undisturbed and the patient delivered at term. Heterotopic pregnancy and unusual ectopic locations should be considered a possibility in pregnant women with pelvic pain, particularly following fertility treatment, including ovarian stimulation and intrauterine insemination.

Management of adnexal masses in pregnancy: our experience from a tertiary referral perinatal centre in South India.

PURPOSE: Adnexal masses in pregnancy are often incidentally detected during sonography and most resolve spontaneously by early second trimester. This study aimed to look at the prevalence and management of adnexal masses in pregnancy at a tertiary care referral perinatal hospital. METHODS: This is a retrospective study of all women with adnexal masses (excluding ectopic gestations and non-gynaecological lesions) identified pre-pregnancy or during pregnancy (antepartum/intrapartum) from January 2006 to August 2013 at the study institute. RESULTS: The study identified 252 women (0.6, 95 %, CI: 0.5, 0.7) with adnexal masses and mean (SD range) age of 27.1 (4.21, 18-39) years. Majority (80 %) of the masses were diagnosed incidentally. 170 (67.5 %) women were offered conservative management and cysts resolved in half of them. 87 (34.5 %) women had adnexal surgery and 15.1 % were operated during the antepartum period because of persistent abdominal pain or suspicious sonographic findings. Three (1.2 %) malignancies and five (2.0 %) borderline ovarian tumours were diagnosed on histopathological examination. 16 (6.3 %) women were lost to follow-up antenatally. Pregnancy carried to term in 175 (69.4 %) women. Perinatal mortality rate was 31.1/1,000 total births (caused by prematurity). Complications encountered were torsion (7.1 %), malignancy (1.2 %), rupture (0.4 %) and infection (0.4 %). CONCLUSION: Although conservative management was appropriate in the majority of cases, the study identifies the need to standardize diagnosis, investigations and management for a better evaluation of outcomes.

Polypoid endometriosis of the cervix: a case report and review of the literature.

BACKGROUND: Giant and multilobular endocervical polyps are rare and need to be differentiated from cervical neoplastic lesions. CASE REPORT: The authors report a 29-year-old sexually inactive woman presenting with a prolapsed giant endocervical polyp, associated with malodorous discharge and menorrhagia. The wide-based polyp originated in part from the posterior lip of the exocervix and in part from the endocervix. This trilobular pedunculated mass (90 × 50 × 35 mm) had small cysts on the surface and focal areas of haemorrhage. Microscopic examination revealed areas with classic endocervical mucosal polyp histology intimately mixed with expanses of endometrial stroma and occasional endometrial glands. Immunohistochemically the endometrial stroma showed strong CD10 positivity, glands were oestrogen and progesterone receptor positive and Ki-67 proliferation index was low. CONCLUSION: Polypoid endometriosis of the cervix is a distinct form of endometriosis that may be mistaken for a neoplasm. Five earlier reports of this entity have not described a prolapsed polyp assuming gigantic proportions. We conclude that this condition be considered in the differential diagnosis of polypoid lesions of the cervix.

Outcomes of pregnancy in women who had rescue cerclage for cervical insufficiency: a single-center retrospective study.

AIM: The aim of this study was to evaluate outcome of pregnancies in women with rescue cerclage for cervical insufficiency. MATERIAL AND METHODS: A retrospective study of all women who underwent rescue cerclage between 2002 and 2011 at an advanced tertiary care perinatal institute in India was conducted. Data retrieved from medical records was used to explore potential associations with prolongation of pregnancy beyond 28 weeks. RESULTS: The mean (standard deviation) gestational age at cerclage was 21.9 (2.7) weeks for the 74 women in the study. The McDonald technique was the preferred method for rescue cerclage (91.9%). All women received antibiotics; tocolytics were used in 35.1% and progesterones in 62.2% of women. The mean prolongation of pregnancy was 7.4 weeks with 42.0% women delivering after 28 weeks and 30.4% after 34 weeks. The take-home-baby rate was 50.7% (95% confidence interval: 38.7-62.6%). Postoperative vaginal infection was present in 16.2% of women, preterm premature rupture of membranes in 31.1% of women and neonatal sepsis in 5.8% of neonates. Cerclage placement after 20 weeks and negative pathogenic organisms in vaginal swab culture were significantly associated with delivery beyond 28 weeks. CONCLUSIONS: Although half of the women had successful pregnancy outcomes after rescue cerclage, pregnancy extended from previability to prematurity in most of them.

Quality of life in Indian women with fertility problems as assessed by the FertiQoL questionnaire: a single center cross sectional study.

PURPOSE: Infertility and its treatment can significantly impact an individual's physical and psychological health; however, this has not been well-studied in the Indian population. This study aimed to assess the quality of life in women with infertility at a teaching hospital in Hyderabad, India. METHODS: In this cross sectional study of women with infertility, the quality of life was measured using the 'FertiQoL International' questionnaire (English/Hindi). RESULTS: The age ranged from 20 to 38 years and polycystic ovary syndrome was the most common cause of infertility. Core FertiQoL scores were analyzed in 215 women and Treatment FertiQoL in 156. The mean Total FertiQoL score in the study population was 66.1 (SD 13.0) and this overall score was not influenced by socio-demographic or infertility-specific factors. However, on subscale analysis, women who had living children and were university-educated had significantly better emotional scores while obese (≥35 kg/m2) women and those on ovulation induction treatment had poorer mind body and relational scores, respectively. Women with associated co-morbidities had worse quality of life on the Treatment Environment scale than those without. CONCLUSIONS: The results provide a baseline quality of life score in these women. Infertility had the greatest impact on the emotional domain.

The Role of Serum Beta hCG in Early Diagnosis and Management Strategy of Ectopic Pregnancy.

INTRODUCTION: The presentation of Ectopic Pregnancy (EP) can be highly variable and serum Beta hCG estimation plays an important role in early diagnosis. AIM: Aim of the study was to determine the trends of hCG levels in EP and to explore the role of hCG in decisions related to management and follow-up of EPs. MATERIALS AND METHODS: A retrospective study of women who had EPs from January 2006 to December 2012 at an advanced tertiary care centre in southern India was carried out. These women had undergone treatment based on the hospital protocol. RESULTS: The study identified 337 women with EP. Thirty one surgically confirmed cases were diagnosed below the discriminatory zone of 1500 mIU/ml. Among women who had Beta hCG estimations 48 hours apart, plateauing was observed in 22.5% while decrease >15% was noted in 26.8%. Almost half (47.9%) of the cases had an increase >15% and a few (2.8%) demonstrated an initial fall followed by a rise in titres. In 23.9% of these women, there was a rise >53% similar to intrauterine pregnancy. The average pre-treatment Beta hCG was 429.8, 3866.2 and 12961.5 mIU/ml for those who received expectant, medical and direct surgical treatment respectively. 43 women with relative contraindications received medical management and 39 were lost to follow-up after medical and expectant management. Excluding them, the success rate of these two modalities was 76.6% and 85.0% respectively. CONCLUSION: No single level of Beta hCG is diagnostic of EP and serial levels can demonstrate atypical trends in some cases. Hence, interpretation of these results should be done in conjunction with clinical and sonographic findings to arrive at a correct diagnosis.

Familial Apple Peel Jejunal Atresia with Helical Umbilical Cord Ulcerations in Three Consecutive Pregnancies.

Apple peel deformity is a rare form of upper intestinal atresia of unknown etiology. Umbilical cord ulcers can occur secondary to reflux of gastric juice and bile as a result of the atresia and can cause lethal intrauterine hemorrhage. The authors report 3 instances of congenital apple peel jejunal atresia with helical umbilical cord ulcers afflicting all female offspring in consecutive pregnancies in a single nonconsanguineous family. There was no hemorrhage from the cord ulcers, but all 3 pregnancies resulted in perinatal death. Although familial occurrence is known, our case series is probably the 1st from the Indian subcontinent and warrants further research into the genetic mechanisms and possible ethnic differences of congenital upper intestinal atresia. The causation of sudden fetal demise in the absence of antecedent cord hemorrhage remains elusive.

Outcome of ovarian drilling in women with polycystic ovary syndrome.

OBJECTIVE: To determine the effectiveness and safety of laparoscopic ovarian drilling (LOD) in inducing ovulation in women with polycystic ovary syndrome (PCOS) who failed to conceive after medical methods of ovulation induction. MATERIALS AND METHODS: A retrospective study of all women who underwent LOD as a treatment for anovulatory infertility between January 2010 and December 2011 was conducted. Women diagnosed to have PCOS by the Rotterdam criteria were considered for the study. Those who had PCOS but were associated with male factor infertility, deep infiltrating endometriosis and submucous fibroids were excluded. RESULTS: A total of 43 women underwent LOD during the study period. Majority were aged 26 to 30 years and two-thirds were overweight or obese. Most (72%) of them had primary infertility. Other factors which could have contributed to infertility such as superficial endometriosis, septate uterus and unilateral tubal block were observed in 30.2% of the women, which were dealt with concomitantly. When we excluded the 14% who were lost to follow up, 23 of 43 (53.5%) women achieved pregnancy and almost 70% of them did so within the first 6 months. None of our study population had ovarian hyperstimulation or multiple pregnancy. CONCLUSION: LOD thus not only helps in regulating ovulation and enhancing conception rates but also provides an opportunity to assess the pelvis for other potential causes of subfertility which could be treated at the same time. We therefore believe that diagnostic hysteroscopy and laparoscopy should be offered quite high-up in the hierarchy of infertility investigations and treatment.

Chorangioendothelioma of the Placenta: A Myth or Reality?

Chorangiomas of the placenta are often discovered incidentally and, although they are not common (1 in 9000 to 1 in 50 000 placentas), these tumors may be found in 0.5% to 1% of carefully examined placentas. The vast majority are of no clinical importance and complications are seen only in association with tumors measuring more than 4 cm in diameter. In contrast, hemangioendotheliomas are vascular tumors with varying grades of malignant potential and hardly ever involve the placenta. Here we describe a large placental chorangioma causing fetal hydrops and demonstrating distinctive intravascular luminal endothelial proliferation and tufting. To the best of our knowledge, this is probably only the second case of a placental hemangioendothelioma reported in the literature.

Malignant Transformation of Pelvic Endometriosis: Case Series and Review of the Literature.

Endometriosis affects 4% to 13% of all women of reproductive age although its true incidence is unknown. The ability of endometriosis to transform into malignancy, first described by Sampson in 1925, is a rare occurrence affecting 1% of lesions with ovary being the primary site in 79%. The authors describe 3 premenopausal women without risk factors for malignancy presenting with ovarian and/or extraovarian endometrioid adenocarcinoma. All of them demonstrated features of pre-/coexisting endometriosis but malignancy was preoperatively suspected in only 1 instance. Postsurgical follow-up of the cases did not document any recurrence. The propensity for malignant conversion occurring in women 10 to 20 years younger vis-a-vis those affected by de novo ovarian cancer, destruction of the endometriotic foci, and underreporting vindicate close follow-up and scrutiny of women with endometriosis and ovarian endometriomas.

Primary abdominal pregnancy in the uterosacral ligament with haemoperitoneum: a near miss.

Primary abdominal pregnancy has a higher mortality rate than other ectopic gestations. Delayed diagnosis can be associated with catastrophic haemorrhage. This report describes a spontaneous conception which occurred in the uterosacral ligament in a woman with no known risk factors for an ectopic pregnancy. Extrauterine pregnancy was diagnosed by ultrasound and laparoscopy was performed secondary to haemoperitoneum, which revealed a pregnancy implanted in the right uterosacral ligament. The rarity of this condition signifies the need for reporting all cases to facilitate future research and clinical management.

Bilateral ovarian metastatic squamous cell carcinoma arising from the uterine cervix and eluding the Mullerian mucosa.

Bilateral ovarian metastasis from invasive squamous cell carcinoma of the cervix is a rare phenomenon with very few clinically significant cases described in the literature. Ovarian metastases when present are usually seen in association with bulky, advanced cervical squamous cell carcinomas with extensive involvement of the uterus.We describe a 48 year old woman with clinically normal cervix whose hysterectomy and bilateral salpingo-oophorectomy performed for abnormal uterine bleeding, demonstrated high grade squamous intraepithelial lesion, moderately differentiated squamous cell carcinoma involving the deeper stroma of the uterus and bilateral ovarian metastases. Gross examination of the cervical canal and the uterine cavity did not show tumor while well circumscribed pearly white metastatic deposits were distinguished within the parenchyma of both the ovaries. Microscopy ascertained high grade squamous intraepithelial lesion with malignant cells invading the deeper cervical stroma and disseminating further as lymphovascular tumor emboli within the myometrium of the corpus uteri without involving the endometrium. Both the fallopian tubes exhibited lymphovascular tumor emboli without epithelial involvement while the parenchyma of both the ovaries showed metastatic deposits.Although an isolated case of endophytic squamous cell carcinoma of the cervix with extensive lymphovascular invasion of the corpus uteri, both the fallopian tubes and bilateral ovarian deposits without involving either the endometrium or the tubal mucosa does not form a paradigm, this case brings to light the capricious behavior of cervical squamous cell carcinoma. VIRTUAL SLIDES: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1214687069122755.