Impact of WHO Labor Care Guide on reducing cesarean sections at a tertiary center: an open-label randomized controlled trial.

BACKGROUND: The World Health Organization Labor Care Guide was introduced in December 2020 to implement World Health Organization (WHO) guidelines on intrapartum care for a positive childbirth experience. OBJECTIVE: This study aimed to determine the effect of the WHO Labor Care Guide on labor outcomes, especially in reducing primary cesarean deliveries, and its acceptability by healthcare providers. STUDY DESIGN: This open-label randomized control trial was conducted from September 2021 to December 2021 on 280 low-risk antenatal women admitted for delivery at a busy tertiary care institute in North India. After informed consent, women were allocated into the study and control groups. Labor monitoring was performed using the WHO Labor Care Guide in the study group and the World Health Organization-modified partograph in the control group. Women who had a cesarean delivery in the latent phase of labor were excluded from the study. The primary outcome was mode of delivery, whereas the secondary outcomes were duration of active labor, maternal complications (postpartum hemorrhage and puerperal sepsis), duration of hospital stay, Apgar score at 5 minutes, and neonatal intensive care unit admission. The labor outcomes in both groups were compared. In the study group, the acceptability, difficulty, and satisfaction levels of the users were assessed using a 5-point Likert scale. The "learning curve" for the use of the Labor Care Guide (LCG) was determined. SPSS software (version 21.0; IBM Corporation, Chicago, IL) was used for statistical analysis. RESULTS: After excluding women who underwent cesarean delivery in the latent phase, 136 women in the study group and 135 women in the control group were observed for labor outcomes. The cesarean delivery rate was 1.5% in the study group vs 17.8% in the control group (P=.0001). The duration of the active phase of labor was significantly shorter in the study group than in the control group (P<.001). The 2 groups were similar in terms of maternal complications, duration of hospital stay, and Apgar score. The learning curve took average levels of 6.50 and 2.25 Labor Care Guide plots to shift from "very difficult" to "neutral" and "neutral" to "easy," respectively. After an initial learning curve, acceptability and satisfaction levels were found to be high in the WHO Labor Care Guide users. CONCLUSION: The WHO Labor Care Guide is a simple labor monitoring tool for the reducing primary cesarean delivery rate without increasing the duration of hospital stay and fetomaternal complications.

Clinico-epidemiological profile of COVID-19 patients admitted during third wave of pandemic in a tertiary care hospital in New Delhi, India.

Even nearly two years after the first reported case, the novel coronavirus (SARS-CoV-2) continues to ebb and flow around the world. A retrospective cohort study was carried out to determine the clinico-epidemiological profile and outcome of the cases. The study analyzed secondary data from 827 patients who presented to our center with COVID-19-related illnesses between December 15, 2021, and February 15, 2022 (third wave in India). There was a significant difference in the vaccination status of patients treated at home and those admitted, with 87.9% having received two doses compared to 74% in the second group being unvaccinated. Patients who were isolated at home recovered at a rate of 99.4%, while hospitalized patients died at a rate of 26.5%. Vaccination reduces the severity of COVID-19; however, constant vigilance for new variants, precautionary measures, and increased vaccination drives are critical moving forward.   *Other members of the Safdarjung Hospital COVID-19 working group: B. Lal (Medicine), Harish Sachdeva (Anaesthesiology), Santvana Kohli (Anaesthesiology), Amandeep Jaswal (Anaesthesiology), Sumitra Bachani (Obstetrics and Gynecology), Ajay Kumar (Pediatrics), Rohit Kumar (Pulmonary Medicine), Vidya Sagar Chaturvedi (Surgery), Vinod Chaitanya (Medicine).

Executive Summary of Evidence and Consensus-Based Clinical Practice Guidelines for Management of Obesity and Overweight in Midlife Women: An AIIMS-DST Initiative.

Weight gain is an independent risk factor for decline in cardiometabolic and overall health-related quality of life in midlife women. The AIIMS-DST initiative aims to develop and validate stepwise recommendations specific for weight management in midlife women. The key clinical questions specific to weight management in midlife women were finalized with the help of a multidisciplinary team of experts in the guideline development group. Phase I including a systematic and/or narrative review, grading of evidence, and expert opinion was sought to develop clinical practice recommendations for each clinical question. Phase II focused on validation of clinical practice recommendations using the peer-review, Delphi method, and GRADE approach. The guidelines provide clinical practice points to address challenges encountered by midlife women in their attempts to manage obesity via lifestyle modification techniques. The initiation of discussion would help the health-care provider to identify the weight management needs of the women, educate women on different modalities of weight management, and empower them to incorporate corrective lifestyle behaviors. Before initiating the management, a comprehensive assessment of clinical and lifestyle-related parameters should be completed. A personalized behavioral lifestyle modification program addressing the midlife-specific barriers for optimal metabolic, musculoskeletal, and mental health should be planned. A consistent follow-up is required for maintenance of corrective eating and activity habits by addressing midlife-specific barriers for sustenance of healthy weight. These recommendations will be useful in opportunistic screening and management of obesity in midlife women across health-care settings.

Stillbirth in COVID-19 Affected Pregnancies: A Double Whammy for the Mother.

Introduction Pregnant women represent a high-risk group especially during the COVID-19 pandemic, suffering at the expense of pandemic restrictions and landing up in adverse maternofetal outcomes including stillbirth. Fetal demise along with COVID-19 disease acts as a double blow to these mothers. Literature is still limited on its impact on maternofetal outcomes. Methods A prospective, observational study was conducted in a tertiary care hospital in Delhi, India from April 15, 2020 to April 14, 2021, wherein all pregnant mothers with SARS-CoV-2 infection in the hospital who delivered a stillborn baby were enrolled and analyzed for incidence of stillbirth. These women were evaluated for risk factors and causes for stillbirth. Results Out of 15859 deliveries in the institute, there were 330 viable births among COVID-19 affected pregnancies. The incidence of stillbirth was 7.2% (24/330). The institutional delivery rate fell by 43% during the pandemic. The majority of cases were unbooked, from rural areas and of low socioeconomic status (p<0.01). The most significant risk factor and cause for stillbirth was an associated comorbidity (75%, p<0.001), notably severe forms of hypertensive disorders of pregnancy (HDP, 41.6%, p=0.002), followed by preterm labour (58.3%) and preterm premature rupture of membranes (PPROM, 29.1%, p<0.001). HDP remained the main cause of macerated stillbirths while maternal fever (50%, p<0.001) was the main cause of fresh stillbirth. Major modifiable factors were lack of awareness of when to seek care (83.3%), financial reasons (75%), commutation problems (87.5%), distance to hospitals (50%) and delayed referral (41.6%). Conclusion Improved policy-making, with an emphasis on telemedicine, COVID-19 preparedness alongside amped up vaccination and healthcare workers training will help reduce adverse maternofetal outcomes.

Executive summary of evidence and consensus-based clinical practice guideline for management of obesity and overweight in postpartum women: An AIIMS-DST initiative.

INTRODUCTION: Postpartum obesity is a public health concern. There is a need to counsel women about their postpartum weight management, accounting for various barriers they face. Limited literature in the Indian context underscored the need to develop the clinical practice guideline to be used by healthcare providers in Indian healthcare settings. METHODS: The guideline was formulated by following the standardised methodology proposed by the National Health and Medical Research Council. Various steps such as identification of the patient population, assembly of the guideline development groups, identification of the key clinical questions, guideline development methods, grading the quality of evidence and recommendations and guideline translation were carried out to develop and validate the clinical practice recommendations. RESULTS: The evidence and consensus-based clinical practice guideline has been developed, providing recommendations for key topics of interest for first-line treatment of obesity (lifestyle-related management). Recommendations focus on screening and initiating discussion with overweight and obese postpartum women as well as those who had normal pre-pregnancy body mass index but have retained excessive weight in the postpartum period. Recommendations highlight the evaluation and management of dietary, physical activity and breastfeeding behaviour. Recommendations also account for behavioural modification techniques to improve adherence to the prescribed weight management advice. Duration and frequency of follow-ups as well as the advice to be disseminated have also been discussed in the recommendations. CONCLUSION: The guideline provides clinical practice points that can be used by healthcare providers, postpartum women and policymakers for opportunistic screening and management of postpartum obesity.

Executive summary of evidence and consensus-based Clinical Practice Guidelines for management of obesity and overweight in midlife women: An AIIMS-DST initiative.

BACKGROUND AND AIMS: Weight gain is an independent risk factor for decline in cardiometabolic and overall health-related quality of life in midlife women. The AIIMS-DST initiative aims to develop and validate stepwise recommendations specific for weight management in midlife women. METHODS: The key clinical questions specific to weight management in midlife women were finalised with the help of a multidisciplinary team of experts in the guideline development group (GDG). Phase I included a systematic and/or narrative review to gather evidence, grading of evidence and expert opinion was sought to develop clinical practice recommendations for each clinical question. Phase II focused on validation of clinical practice recommendations using the peer-review, Delphi method and GRADE approach. RESULTS: -The guidelines provide clinical practice points to address challenges encountered by midlife women in their attempts to manage obesity via lifestyle modification techniques. The initiation of discussion would help the healthcare provider to identify the weight management needs of the women, educate women on different modalities of weight management, and empower them to incorporate corrective lifestyle behaviours. Before initiating the management, a comprehensive assessment of clinical and lifestylerelated parameters should be completed. A personalised behavioural lifestyle modification program addressing the midlife specific barriers for optimal metabolic, musculoskeletal, and mental health should be planned. A consistent follow-up is required for maintenance of corrective eating and activity habits by addressing midlife specific barriers for sustenance of healthy weight. CONCLUSION: These recommendations will be useful in opportunistic screening and management of obesity in midlife women across healthcare settings.

Preeclampsia in COVID-19: A Masquerading Errant-An Exploration of Foeto-Maternal Outcome from a Tertiary Care Hospital In India.

Background: COVID-19 pandemic has shown that the multisystem involvement in COVID-infected patients is beyond the usual clinical manifestations of other respiratory viral illnesses. This study aims to evaluate the upshots of COVID-19 in women with preeclampsia. Methodology: This descriptive study was conducted in department of Obstetrics & Gynaecology at VMMC & Safdarjung Hospital (May-November 2020), wherein a retrospective review of the medical records of laboratory confirmed SARS CoV2-positive pregnant women (as per ICMR), with preeclampsia (as defined by ACOG guidelines), was done in the dedicated COVID labour ward. Primary outcome was incidence of preeclampsia in SARS CoV2 positive gravid females. Secondary outcomes were socio-demographic and maternal characteristics, severity of COVID-19 and foeto-maternal outcome. Results: During these 7 months, 38/302 (12.58%) SARS COV2-positive women presented with pre-eclampsia, either before or at the time of admission; amongst them 47.37% were primigravida. Severe preeclampsia was chronicled in 65.71% women. Around 20% women had severe COVID-19. All women with severe COVID19 required ICU stay, 5 requiring intubation. Three of these patients succumbed to their illness. Out of the 40 babies born to these women (including 2 twin pregnancies), 36.84% were premature deliveries. Seventeen (42.50%) babies had low birth weight. Although 82.50% were live births, five (12.50%) were intrauterine demise and 2 were early neonatal deaths. Conclusion: Gravid women with preeclampsia infected with SARS CoV2 have comparative more severe illness, requiring more intensive care requirement and high maternal and neonatal morbidity.

Anxiety and depression among women with COVID-19 infection during childbirth-experience from a tertiary care academic center.

BACKGROUND: Pregnancy and postpartum are vulnerable periods for mental health problems and distress. Studies conducted worldwide have highlighted the role of the COVID-19 pandemic in adding to the rates of depression and anxiety in the perinatal period. However, there are very few reports on mothers who were identified as having COVID-19 infection at the time of childbirth. OBJECTIVE: Our study aimed to find the prevalence of depression and anxiety among pregnant women who were admitted for labor and tested positive for COVID-19 infection. We also aimed to study the association of various sociodemographic, social support, and obstetrical factors and that of COVID-19-related worries with depression and anxiety. STUDY DESIGN: The study was conducted at the obstetrics inpatient setting in a public hospital in New Delhi, which had a separate designated COVID-19 block. Pregnant and postpartum women >18 years of age who were admitted to the COVID-19 maternity ward for delivery were included for this study. The women were interviewed within the first week of admission and after 6 to 8 weeks of childbirth. The sociodemographic and obstetrical details and COVID-19-related worries and concerns were assessed. Depression and anxiety were assessed using the Patient Health Questionnaire version 9 and the Generalized Anxiety Disorder 7-item Scale, respectively.The normally distributed variables are expressed as mean±standard deviation and continuous variables with skewed distribution as median (interquartile range). The categorical data presented as proportions of categorical variables were compared using the chi-square or the Fischer exact test. All the tests are 2-sided, with a significance level of 5%. The data were analyzed using the SPSS software version 24. The rates of depression and anxiety were calculated and univariate analysis was done to identify the factors associated with moderate and severe anxiety and depression using various sociodemographic and obstetrical variables, the total COVID anxiety scale scores, and the social support score. RESULTS: The mean age of the women was 26.86 years (±4.31). Of the 243 women assessed using the Patient Health Questionnaire version 9, 168 (69.13%) had mild depressive disorder, and 29 (11.3%) had moderate depressive disorder. Of the 187 women who were assessed at the 6-weeks follow-up, 31 (16.57%) had minimal depression, 131 (70.05%) had mild depression, and 25 (13.36%) had moderate depression. Mild anxiety was seen in 121 cases (49.79%) and 13 (5.34%) had moderate anxiety symptoms. Women reported several worries, especially about the stigma of COVID-19 infection, support for infant care, and access to infant health services. CONCLUSION: Screening for common mental illnesses with the timely identification of associated risk factors should be done, with a liaison between obstetricians and mental health professionals. Obstetricians can address and reassure pregnant women regarding concerns about contracting the infection, worries about the possible effects of COVID-19 on the fetus and the newborn, and concerns about future consultations. In case the worries are out of proportion and necessitate intervention by mental health professionals, referral services should be made available. Hence, identifying and addressing the mental health concerns will help provide the optimum perinatal care during the pandemic.

COVID-19 in pregnancy: A preliminary 50-day review from India.

BACKGROUND: This retrospective review was done to gauge the preliminary experience of COVID-19 in pregnancy during first 50 days of lockdown in a tertiary care hospital of India. METHODS: This was a single-centered study, wherein all the suspected women (as defined by ICMR guidelines) who were tested for SARS-CoV 2 infection by nasopharyngeal/oropharyngeal swabs, and rendered to RT-PCR, were included. Parallel evaluation was performed for women in both groups for sociodemographic and obstetric attributes, risk factors, clinical presentation and feto-maternal outcome. Categorical variables were presented in number and percentage. Qualitative variables were equated using Chi-Square test/Fisher's exact test. A P value of < 0.05 was counted as significant. RESULTS: Amongst 112 suspected cases, seven (6.25%) were found to be positive for SARS COV2. Majority of COVID-19 positive women hailed from urban hotspot areas (57.7%) and were un-booked (57.1%). Most were mild cases, and symptomatic (85.7%), with fever (57.1%) being predominant feature in all suspects; no adverse effects seen on pregnancy and fetus, with uneventful postpartum period. CONCLUSION: No adverse outcome in mother and baby after acquiring SARS-COV2 infection was observed, with maximum cases being mild; fever was the predominant symptom in all suspects, with significantly higher percentage in COVID-19 positives.

A Clinical Study on Initial Experience of COVID-19 ARDS in Obstetric Patients at a Tertiary Care Centre in India.

Coronavirus disease 2019 (COVID-19) is caused by a novel coronavirus (severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) which causes severe viral pneumonia rapidly leading to acute respiratory distress syndrome (ARDS). Pregnant women are considered more vulnerable to severe viral respiratory infections owing to the physiological changes in pregnancy. In COVID-19, patient can present with a variety of symptoms of which dyspnoea is one that is also commonly seen in the late stages of pregnancy. The clinical presentation as well as response to therapy is highly variable, and since no conclusive proven treatment is available yet, prevention and symptomatic treatment remains the mainstay of management. Thus, we report a case series of four SARS-CoV-2-positive obstetric patients who presented with severe ARDS in a tertiary care hospital, posing diagnostic and therapeutic challenges to the clinician, and were managed with a holistic multidisciplinary stepwise approach. Through this, an effort has been made to sensitize the attending obstetrician on diverse presentation of COVID-19 disease and to emphasize the importance of prevention, early pick up, and timely optimal management of pneumonia in pregnant females with COVID-19. The clinical presentation of respiratory illness due to SARS-CoV-2 in pregnancy can be mistaken for exaggerated physiological changes of pregnancy leading to delay in seeking medical care. During the current pandemic, high suspicion for COVID-19 should be kept. If found symptomatic, immediate care should be sought in a designated facility and managed accordingly preferably with a multidisciplinary approach.

Clinical Profile, Viral Load, Maternal-Fetal Outcomes of Pregnancy With COVID-19: 4-Week Retrospective, Tertiary Care Single-Centre Descriptive Study.

OBJECTIVE: The COVID-19 pandemic raises a major concern about its severity in pregnancy, maternal-fetal outcomes, and risk of vertical transmission. We report a retrospective descriptive study of the clinical course and maternal-fetal outcomes of pregnant women with COVID-19. METHODS: This is a single-centre, retrospective study performed in a tertiary care hospital for pregnant women with COVID-19 in India. The medical records of all women who delivered in the COVID19 facility from May 5, 2020, to June 5, 2020, were reviewed independently. Data extracted from the records included demographic characteristics, obstetric details, comorbidities, disease severity, investigations, management, and information on neonates (birthweight, Apgar score, and perinatal complications). RESULTS: Among 348 women tested for SARS-CoV-2, 57 women (16.3%) were confirmed as positive based on quantitative reverse transcriptase polymerase chain reaction of the nasopharyngeal specimen. Most women (45; 78.9%) had a mild infection with favourable maternal-fetal outcomes. Three maternal deaths were associated with comorbidities. Five neonates tested positive for SARS-CoV-2, remained hemodynamically stable, and were subsequently discharged. CONCLUSIONS: A majority of pregnant women with COVID-19 had mild disease and recovered with good perinatal outcomes. Women with comorbidities may have an increased risk of severe morbidity and mortality. The cycle threshold signifying the viral load and degree of infectivity can modify management during pregnancy. Long-term outcomes and the potential mother-to-child vertical/horizontal transmission need further study.

Validation of Polymerase Chain Reaction-Based Assay to Detect Actual Number of CGG Repeats in FMR1 Gene in Indian Fragile X Syndrome Patients.

Molecular genetic testing for fragile X (FX) is complicated due to the large variation in the size of CGG expansion. The aim of this study was to apply this new technique using AmplideX FMR1 PCR assay, which is considered a better diagnostic tool for detecting expanded alleles in Indian population. The primary objective was to identify the carrier status of females and to correlate the instability of premutation alleles in females with the repeat sizes. 24 children with FX based on rapid PCR and 29 female relatives of these patients were included. Out of the 29 females screened, those whose child (or children) was affected by FX, were all premutation carriers confirming their role in transmission. The smallest PM allele that expanded into FM in the next generation was 78 repeats and the smallest PM allele detected was 63 repeats, and when transmitted from mother to offspring remained in the premutation range. In 4 families, the repeat size of the allele reduced from PM to normal repeat numbers in their daughters and in 1 case to borderline PM range. Thus, apart from the reduced turnaround time, this PCR based assay offers advantage by its sensitivity to detect CGG repeats in the intermediate region and lower range of premutation alleles. It also provides added information of AGG interruptions, which may have an impact on the counseling of women with intermediate and PM alleles.

Clinical Outcome of Postplacental Copper T 380A Insertion in Women Delivering by Caesarean Section.

INTRODUCTION: Short interconception period after caesarean section and its associated risk of increased morbidity, mortality and surgical interventions could be avoided by postplacental IUCD insertion during the procedure. Despite the safety reports on intracaesarean IUCD insertion, obstetricians are still hesitant to extend the benefit of this long acting reversible contraception to women undergoing operative delivery. OBJECTIVE: To study the clinical outcome (safety, efficacy, expulsion and continuation rates) of postplacental Copper T 380A insertion in primiparous women undergoing caesarean section. MATERIALS AND METHODS: This study was a prospective observational study, carried out in the Department of Obstetrics and Gynaecology, Safdarjung hospital, which is a tertiary care hospital of Northern India. Primiparous women who delivered by caesarean section over a period of six months (July 2012 to December 2012), willing for postplacental intracaesarean IUCD insertion, and willing to comply with the study protocol, were recruited for the study. All these subjects fulfilled the WHO Standard Medical Criteria for PPIUCD insertion; follow up visits were scheduled at 1, 3, 6 and 12 months. RESULTS: A total of 300 primiparous women underwent postpartum intracaesarean insertion of Copper T 380A. The mean age of women included in the study was 23.12 ± 2.42 years. Most common postinsertion complication observed in the immediate postoperative period was febrile morbidity (2%). Majority of women (94.33%) had hospital stay of less than 4 days. The common adverse events observed during follow-up of 12 months were menstrual complaints, excessive vaginal discharge and persistent pelvic pain. At the end of one year, there were 16 expulsions, 21 removals, and 2 pregnancies with gross cumulative expulsion, removal, failure and continuation rates of 5.33%, 7%, 0.67% and 91%, respectively. CONCLUSION: Postplacental intracaesarean Copper T 380A insertion in primiparous women is a safe and effective method of reversible contraception, with low expulsion and high continuation rates.

Evaluation of isosorbide mononitrate for cervical ripening prior to induction of labor for postdated pregnancy in an outpatient setting.

OBJECTIVE: To determine the safety and effectiveness of self-administered treatment with isosorbide mononitrate (IMN) for cervical ripening in Indian women with postdated pregnancies. METHODS: A randomized, placebo-controlled study was conducted with 200 women with postdated pregnancies and unfavorable cervices who self-administered vaginally either 2 40-mg tablets of IMN or 2 40-mg tablets of pyridoxine as placebo prior to admission for induction of labor. The main outcome variables were change in Bishop score, time from admission to delivery, and presence or absence of fetal and maternal morbidity. RESULTS: The Bishop score was significantly improved 24 hours after initiation of the outpatient IMN treatment (P<0.001) and the needs for further cervical ripening and oxytocin infusion were less in the study than in the control group (P<0.001 and P=0.008). The time from admission to delivery was also less (P<0.001). Moreover, the IMN treatment had no major adverse maternal or fetal effects. The vast majority of women in both groups were either satisfied or very satisfied with the outpatient treatment. CONCLUSION: The self-administration, at home, of isosorbide mononitrate leads to a safe and effective cervical ripening prior to labor induction in women with postdated pregnancies. CTRI Registration No.:CTRI/2011/091/000121.

Bleeding diathesis as a cause of menorrhagia: a report of 3 cases.

Bleeding diathesis as a cause of menorrhagia should not be overlooked at any age even in the perimenopausal woman. Three cases have been presented, wherein bleeding diathesis was the cause of menorrhagia. Two of these patients had acute myeloid leukaemia and the third had immunothrombocytopaenic purpura. A noteworthy point of this series is that one patient was in her teens, the second in the peak reproductive age group and the third in the perimenopausal age.