Evaluating contraceptive choice through the method-mix approach. An Indian Council of Medical Research (ICMR) task force study.

The method-mix approach was used to evaluate informed contraceptive choices in the present study. A total of 8,077 potential clients were given a balanced presentation of all available contraceptive methods in the national program, ie, the CuT 200 intrauterine device (IUD), low-dose combined oral pills (OC), condom, and sterilization (female/male) along with a new method, Norplant(R).(1) The majority of women opted for spacing methods; among them, the IUD was preferred by about 60% of clients, followed by condoms (9%), OC (6%), and Norplant (5%). Sterilization, mainly female, was accepted by about 17% of the women making an informed choice. The economic status of couples did not influence the contraceptive choices, as all the methods were offered free of cost in the present study, which is the current practice in the national program. Illiterate women more often accepted sterilization (about 25%) than did literate women (15%). This is because illiterate women had more children; about 30% of illiterate women had three or more children, as opposed to 16.2% of literate women. However, literacy status did not influence the choice of any specific spacing method. The study also revealed that, by encouraging potential clients to make an informed choice, they could override the provider's bias while accepting a particular type of spacing method. This is evident from the observation that Norplant was the first choice of the provider for 35% of the women, whereas only 5% of women preferred and accepted Norplant. The present study stresses an urgent need to promote the practice of informed choices in the national program with a variety of contraceptive options-especially, spacing methods for improving contraceptive prevalence and reproductive health in the country.

Thermal balloon endometrial ablator: a preclinical safety and effectiveness study.

OBJECTIVE: To evaluate the preclinical safety and efficacy of the thermal balloon endometrial ablator (TBEA). METHODS: Informed consent was taken from all patients for TBEA and hysterectomy at same sitting. TBEA was performed in vivo just before hysterectomy on 6 patients' uteri to determine uterine rupture, perforation and thermal damage to surrounding viscera and peritoneum. Temperatures in the pouch of Douglas, uterovesical peritoneum and serosa of uterus were taken by a sterile laboratory thermometer to note for any rise in temperature before, during and after the procedure. The extirpated uteri were then examined grossly for the nature and extent of thermal damage which was visible as a zone of erythema in the endomyometrium. Five extirpated uteri, 3 from the above group and 2 on whom TBEA was performed 3 months ago were histopathologically examined to study the nature and extent of damage to endomyometrial cells. A 5 mm longitudinal strip of uterus along with both the cornual ends were sectioned in such a way that it was representative of the entire uterus. RESULTS: There was no evidence of uterine perforation, rupture or any damage to the surrounding viscera and peritoneum. There was no rise in temperature in most sites while TBEA was performed. The only area that felt warm was the surface of the uterus and there too the measured rise was only 1 degree C. On gross examination the zone of erythema measured 5.4 mm (mean) (range 3-9 mm). In those uteri subjected to histopathology immediately after TBEA early evidence of thermal damage was visible as hemorrhage, congestion, edema, eosinophilic infiltration and necrosis in 2 out of 3 cases. Late changes of thermal damage after TBEA were seen as basal endometrium and areas of hyalinization. The changes in general were patchy and not uniform. CONCLUSIONS: TBEA is a safe device with no thermal damage to uterus and surrounding viscera. The mean zone of thermal damage in the endomyometrium is 5.4 mm. On histopathology, the early changes of thermal damage are hemorrhage, congestion, edema, eosinophilic infiltration and necrosis and the late changes are visible as areas of hyalinization and presence of basal endometrium.

Chlamydia trachomatis infection among pregnant women: prevalence and prenatal importance.

BACKGROUND: Chlamydia trachomatis infection in pregnant women is suspected to result in low birth-weight and premature infants. We conducted studies to ascertain the prevalence of this infection among pregnant women in our setting and whether its presence is a risk factor for low birth-weight or prematurity. METHODS: In the first study, 94 pregnant women between 26 and 30 weeks of gestation were screened for infection with Chlamydia trachomatis. The second investigated a cohort of 172 pregnant women presenting in spontaneous labour. The infection status was related to perinatal outcome in terms of birth-weight and gestation. In both the studies, Chlamydia trachomatis infection was diagnosed using the Chlamydiazyme test performed on endocervical swabs. RESULTS: The prevalence of Chlamydia trachomatis infection in mid-pregnancy and at labour was 17% (16/94) and 18.6% (32/172), respectively. Women with infection were relatively older than those without it [mean (SD) age: 26.6 (4.5) years v. 24.8 (3.6) years, p = 0.01]. The mean (SD) birth-weight [2869 (611) g v. 2814 (496) g], gestation [38.5 (2.6) weeks v. 38.3 (2.0) weeks], and incidence of low birth-weight [18.7% v. 20.7%] as well as prematurity [9.4% v. 10.7%] were similar among neonates born to women with or without infection. Neonates born to infected mothers experienced purulent conjunctivitis more frequently than those born to non-infected mothers [12.5% v. 2.8%, p = 0.04]. CONCLUSION: Chlamydia trachomatis is a relatively common infection in pregnant women. However, it was not associated with either low birth-weight or prematurity.

Early abortion by mifepristone (RU 486) followed by vaginal gel (meteneprost) versus oral (misoprostol) prostaglandin.

The present study was conducted to compare the therapeutic regimens of low-dose mifepristone (200 mg) plus vaginal meteneprost versus oral misoprostol in terms of efficacy and safety for medical termination of early pregnancy. A randomized clinical trial was conducted by the Department of Obstetrics and Gynecology at the All India Institute of Medical Sciences, New Delhi. A total of 101 subjects were enrolled within 56 days of amenorrhea. A single dose of 200 mg of mifepristone (RU 486) was given and, 48 hr later, prostaglandin was administered as either 5 mg of 9 methylene PGE2 vaginal gel, meteneprost (classified as group I) or 600 microg of oral PGE1 derivative misoprostol (classified as group II). In group I, 50 subjects and in group II, 51 subjects were treated with the respective schedule. The success rate with mifepristone + misoprostol (group II) was 88.63% which was significantly higher than that with mifepristone + meteneprost (group I) which was 82% (p < 0.05). The average duration of bleeding in cases with complete abortion was 8.95+/-5.67 and 9.77+/-6.51 in group I and II, respectively. There were no serious side-effects. Only one subject in group I (2%) required blood transfusion for heavy bleeding. This study indicated that oral prostaglandin after a low dose of mifepristone (200 mg) could be developed into an effective method to terminate early pregnancy. Oral administration of both drugs would be a more convenient, feasible, private and acceptable regimen.

Polymyositis--an unusual presentation of ovarian malignancy: a case report.

A unique case of carcinoma of ovary with an unusual presentation is reported here. Her presenting complaint was in no way related to ovarian malignancy. She presented to the neurologist with the features suggestive of polymyositis. She did not respond satisfactorily to the conventional treatment by steroids and on investigation, was found to have an underlying advanced ovarian malignancy.

Uterine balloon therapy to treat menorrhagia.

OBJECTIVE: To study the clinical efficacy, safety and acceptability of the thermal balloon endometrial ablation (TBEA) in patients with dysfunctional uterine bleeding. METHODS: Thirteen patients with DUB who did not respond to medical treatment and dilatation and curettage consented to a trial of TBEA with EASY model of balloon catheter by Gynecare. All procedures were done under intravenous (i.v.) sedation and paracervical block. Patients were mostly discharged within 48 h. Follow-up of 2-19 months is reported. Transvaginal ultrasound and hysteroscopy were performed in six patients after 6 months of TBEA. RESULTS: Twelve patients (92.3%) reported a significant reduction in bleeding. Two patients (15.4%) experienced amenorrhea. Only two patients (15.4%) underwent subsequent hysterectomy, one for persistent menorrhagia and the other for severe pelvic pain. In successful patients of TBEA, transvaginal ultrasonography revealed marked reduction in endometrial thickness and no endometrium was visible in one patient who had developed amenorrhea. In successful cases follow-up hysteroscopy revealed scarring in more than two-thirds of the endometrium. CONCLUSIONS: Thermal balloon endometrial ablation is a safe, simple, effective, easy and minimally invasive procedure which can be done under i.v. sedation and paracervical block in an office setting. It has several advantages over hysterectomy, including preservation of the uterus, avoidance of surgical incision and potential to perform on an outpatient basis. It is a good alternative to hysteroscopic endometrial ablation with a comparable success rate with minimal risk and no limiting factors except the cost of the balloons. However, large scale randomized controlled studies are needed with TBEA and other endometrial ablation procedures.

Can amniotic fluid distribution predict fetal outcome?

OBJECTIVE: This study was designed to determine whether the distribution pattern of amniotic fluid (AF) within the uterine cavity is related to perinatal outcome. STUDY DESIGN: One-hundred women in labor with intact membranes underwent a real time ultrasound examination to measure the AF index. Patients were divided into two groups based on liquor distribution. Those with > 50% liquor distributed in upper quadrants formed the 'upper greater' group whereas the rest of the patients constituted the 'lower greater' group. Pregnancy outcome was assessed with respect to incidence of fetal heart rate (FHR) abnormalities, operative delivery, meconium stained liquor, Apgar score < 7 at 1 and 5 min and neonatal intensive care unit admissions. RESULTS: A total of 100 patients were evaluated. The 'upper greater' group had a higher incidence of cesarean for non-reassuring FHR (40.74% vs. 9.6%, P < 0.001), persistent variable deceleration (14.8% vs. 0%, P < 0.001) and bradycardia (25.9% vs. 4.1%, P < 0.001). There was no statistically significant difference in the Apgar score < 7 at 1 min and neonatal intensive care unit admissions in the two groups. CONCLUSIONS: Distribution of less liquor in the lower quadrants of the uterus predisposed to abnormalities in FHR and hence, cesarean section. The distribution pattern did not have a predictive value for the perinatal outcome.

Pelvic examination, transvaginal ultrasound and transvaginal color Doppler sonography as predictors of ovarian cancer.

OBJECTIVE: To assess and compare the efficacy of pelvic examination, transvaginal ultrasound and transvaginal color Doppler imaging in differentiating benign and malignant ovarian tumors. METHODS: 34 patients with ovarian tumors scheduled for laparotomy underwent pelvic examination and a diagnosis of benign or malignant tumor was made. Transvaginal ultrasound was carried out to study the ovarian morphology followed by color Doppler imaging. A score of > or = 9 on Sassone scoring system or a pulsatility index < 1 was taken as suspicious for malignancy. RESULTS: Of all the three indicators (pelvic examination, transvaginal sonography and Doppler) transvaginal sonography had the highest sensitivity (100%) and Doppler had maximum specificity (96.29%) for predicting malignancy. However, statistical analysis did not show any difference in the predicting ability of these three modalities. CONCLUSION: Pelvic examination, transvaginal sonography and Doppler all had similar ability to predict malignancy in an adnexal mass.

Histologic chorioamnionitis & its association with prematurity in a hospital-based study.

This prospective study was undertaken to study the occurrence of histologic chorioamnionitis and determine its association with prematurity; and to assess whether colonization of the genital tract of pregnant women by genital mycoplasmas or Chlamydia trachomatis is a risk factor for histologic chorioamnionitis. A total of 268 women with singleton pregnancies of over 26 weeks gestation were subjected to high vaginal cultures of genital mycoplasmas and endocervical specimens for chlamydia antigen. Placental histopathology was performed on multiple sections. Histologic chorioamnionitis was documented in 22.4 per cent (60/208) placentae. Genital tract colonization with Ureaplasma urealyticum or C. trachomatis was not a risk factor for histologic chorioamnionitis. Neonates born in association with histologic chorioamnionitis had a mean birth weight 111 g lower than those born without this lesion (2626.9 +/- 702 g vs 2737.8 +/- 500 g, NS). The relative risk (95% confidence interval) of prematurity in the presence of histologic chorioamnionitis was 1.49 (0.87-2.53). Analysis of linear trend in proportions for prevalence of histologic chorioamnionitis with decreasing gestation showed a significant association (P = 0.047, 1-tail). These results taken together suggest that histologic chorioamnionitis may be a risk factor of prematurity, but of only a modest magnitude.

Foetal compromise by spontaneous foetal heart rate deceleration in reactive non-stress test and decreased amniotic fluid index.

One hundred and sixty-three consecutive pregnant women with > 32 weeks gestation, undergoing non stress test (NST) and amniotic fluid index (AFI) determination were divided into six groups according to the amniotic fluid index and the nature of decelerations of foetal heart rate. Foetuses with antepartum decelerations had statistically significantly increased incidence of intrapartum decelerations, caesarean section due to intrapartum foetal distress, cord complications and small for gestational age infants. More so with decreased amniotic fluid index (p < 0.001). Low 5 minute apgar score was also significantly increased (p < 0.05). Prediction of foetal compromise might be done by spontaneous decelerations in reactive non-stress tests and with an amniotic fluid index < or = 5 cm.

Impact of roles of women on health in India.

India's population has more than doubled since 1961. Although India has been a leader in developing health and population policies, there have been major implementation problems due to poverty, gender discrimination, and illiteracy. Yet, three-quarters of the food produced annually in India is because of women. In 1991, only 39.3% of Indian women were literate. The literacy level of women can affect reproductive behavior, use of contraceptives, health and upbringing of children, proper hygienic practises, access to jobs and the overall status of women in the society. Early marriage and childbirth was a major determinant of women's health and was also responsible for the prevailing socioeconomic underdevelopment in India. The overall maternal mortality for India is 572.3 per 100,000 births, ranging from 14.9% in Bihar to 1.3% in Kerala. Anemia is an indirect factor in 64.4% of the maternal deaths. Trained birth attendants currently assist in about 60-80% of all births in women at the time of delivery. Socioeconomic factors are responsible for maternal deaths to a large extent - money in 18.3%, transport in 13.7%. When the mother dies it doubles the chances of death of her surviving sons and quadruples that of her daughters. Among the avoidable factors in maternal deaths, lack of antenatal care is the most important. Women, if educated and aware, can improve the health of their children by simple measures like good hygiene, exercise and dietary habits. Because of poverty, many of the young children, especially girls living on streets are easy prey for criminal prostitution rings, drug trafficking and consequences of HIV infection, and severe emotional and mental disturbances. Women are responsible for 70-80% of all the healthcare provided in India. Female healthcare providers can play an important role in educating society to recognize their health and nutrition needs. Women professionals and empowerment of women at all levels are required for improvement of the health and nutrition structure in India.

Micronized flavonoid therapy in internal hemorrhoids of pregnancy.

OBJECTIVE: To assess the safety, efficacy and acceptability of a micronized flavonoid formulation in the treatment of internal hemorrhoids of pregnancy. METHODS: In an open study on hospital outpatients, we studied therapy with micronized diosmin 90% and hesperidin 10% for a median of 8 weeks before delivery and 4 weeks after delivery, in 50 women with acute hemorrhoids. The outcome measures were symptoms and signs of hemorrhoids; adverse effects; and acceptability of treatment. RESULT: On intention to treat analysis, 66% (95% confidence interval, range 79.1-52.9) had relief from acute symptoms by the 4th day; 53.6% (95% confidence interval, range 70-37.1, P < 0.001) fewer patients had relapse in the antenatal period. Treatment was well accepted, and did not affect pregnancy, fetal development, birth weight, infant growth and feeding. CONCLUSION: In the short term, micronized diosmin 90% and hesperidin 10% is safe, acceptable, and effective in the treatment of hemorrhoids of pregnancy.

An analytical framework for the study of proximate determinants of maternal mortality.

PIP: A country's level of maternal mortality is a sensitive index of the provision and quality of health and obstetric services. It is important to understand the determinants of maternal mortality in order to take measures which will effectively quicken the pace of its decline. The authors present an analytical framework of factors which affect the risk of maternal mortality, using an epidemiological approach adopted to identify risk factors at the microlevel. The relative risk of each key factor was then estimated based upon empirical data using odds ratio. The study population was comprised of all 252 maternal deaths and 252 matched maternal survivors at Safdarjung hospital, New Delhi, between January 1, 1983, and December 31, 1985. Cases and controls were matched by age, parity, and registration status for antenatal care. The empirical findings of the study are consistent with the notion that maternal mortality is affected by demographic, socioeconomic, medical, and obstetric factors.^ieng

An interesting unusual case of endometrial stromal sarcoma.

An interesting case with an unusual presentation of endometrial sarcoma is described. This patient presented with a history of continuous vaginal bleeding 3 months following a full term caesarean section and perception of an enlarging abdominal mass. The physical examination revealed an enlarged uterus with a leiomyoma though there was no evidence of the same at the time of the caesarean section. A laparotomy was undertaken and the patient was found to have a large tumor with multiple polypoidal growths invading the myometrium through to the serosa. This was proven to be an endometrial stromal sarcoma on histopathology.

Intravenous immunoglobulin as primary therapy or adjuvant therapy to intrauterine fetal blood transfusion: a new approach in the management of severe Rh-immunization.

Maternal high dose intravenous immunoglobulin (IVIG) has shown promise in the management of severe Rh-immunization. Intravenous immunoglobulin, blocks Fe mediated antibody transport across the placenta and blocks destruction of fetal red cells and reduces maternal antibody levels. We have tried this new therapy in 6 patients with severe Rh-immunization, with high maternal antibody titres and previous hydrops and intrauterine deaths. Intravenous immunoglobulin was given from 13-18 weeks of gestation 3-4 weekly, till intrauterine transfusion (IUT) or delivery. Intensive fetal monitoring was done. No fetal hydrops or deaths occurred in any of the 6 cases. Only 2 cases needed intrauterine transfusion. IVIG delayed the onset of fetal anemia by 8-17 weeks thus deferring the need for IUT. All pregnancies continued till 32-36 weeks and all 6 babies did well in the neonatal period.