Usage of postpartum intrauterine contraceptive device (postpartum-IUD) after an increase in the institutional delivery rate in India: time to re-visit the effect of timing of counselling on its acceptance.

PURPOSE: While increase in institutional deliveries brings an opportunity to counsel women for postpartum family planning (PPFP), its uptake remains low. Reasons for poor acceptance of postpartum intrauterine contraceptive device (postpartum-IUD), and its relation with the timing of counselling need to be investigated. METHODS: Women attending the antenatal clinic, reporting in labour, and within 48 h of delivery respectively were invited to participate. Eligible women were asked about awareness and choice for PPFP. After counselling, acceptance for PPFP was compared with the baseline. Acceptance and continuation of postpartum-IUD were compared between women counselled in the antenatal, intrapartum, and postpartum periods. RESULTS: Only 23% of 360 women were aware of postpartum-IUD. After counselling, acceptance for PPFP increased from 14% to 97% and for postpartum-IUD, from 0.5% to 33.9%. Acceptance of postpartum-IUD among women counselled in the antenatal, intrapartum and postpartum period was 45%, 35% and 21.7% respectively. Acceptance was higher among the antenatal-counselling group than the postpartum-counselling group (OR 0.45; CI 0.22-0.94; p = 0.03). CONCLUSION: Counselling, irrespective of its timing, improves acceptance for PPFP. Acceptance and continuation of postpartum-IUD are higher following counselling in antenatal period. All eligible women should be counselled irrespective of 'when' they approach the facility.

Acceptance for postpartum-IUD is maximum when women are counselled in the antenatal period. With a surge in institutional deliveries, the opportunity to counsel women in the intrapartum and postpartum period should not be missed as this also increases acceptance for PPFP and postpartum-IUD.

The unheard parental cry of a stillbirth: fathers and mothers.

PURPOSE: Our objective was to compare the prevalence of depression, anxiety, stress, and domestic violence among parents after a stillbirth vs. livebirths and assessing of the need for psychological and pharmacological interventions for the affected individuals. METHODS: This was a prospective cohort study conducted in a tertiary care public sector hospital Northern India. 150 consecutive couples with a recent stillbirth (group 1) and 150 couples with a recent live birth (group 2) were enrolled. They were screened for depression (EPDS scale), anxiety (GAD-7), stress (PSS). Apriori sample size was calculated. Screen positive mothers and fathers were compared for the presence of depression, anxiety and stress, domestic violence, and need for treatment interventions. RESULTS: Depression was higher in group 1 mothers (39.3 vs 14.0%, p < 0.001) as well as fathers (18.1 vs 6.7%, p value = 0.022). Anxiety and moderate to severe stress were also significantly higher in stillborn than liveborn groups respectively. Characteristics associated with higher risk are analyzed. Domestic violence was found in 6.7% in group 1 and 2.7% in group 2 mothers (p value 0.169). Pharmacotherapy and counselling were required by 11.3 and 18.0% in stillbirth versus 3.3 and 18.7% in livebirth group, respectively. CONCLUSION: Couples suffering stillbirths are at higher risk of depression, anxiety, and stress. We highlight this obstetrical public health issue, especially for the low middle income countries (LMIC) and advocate development of health policies for mental health screening of couples suffering stillbirths.

Second trimester medical abortion in a primigravida with lupus nephritis and rapidly progressive renal failure: challenges and outcome.

In the second trimester, medical abortion is preferred as it is less invasive, and the surgical method carries more risk. There is a paucity of published literature on medical abortion in women with renal failure requiring haemodialysis. We came across a woman who presented with rapidly progressive renal failure at 18 weeks of gestation and required therapeutic abortion. We are reporting the challenges, outcomes, and precautions to be taken while performing a medical abortion in such a case.

Factors affecting the outcome of pregnancy with rheumatic heart disease: an experience from low-middle income country.

Studies on pregnancy with rheumatic heart disease (RHD), still common in the developing world, are relatively old and small. This retrospective study was conducted to study the outcome of pregnancy in women with RHD and factors associated with poor outcome. We studied 353 pregnancies in 273 women. In 35% of the patients, the diagnosis was first made during index pregnancy. Women with severe MS had lesser gestational age at delivery and birth weight than those with mild-to-moderate MS. Women with NYHA III-IV status delivered at lesser gestational age had lesser birth weight and had higher perinatal and maternal mortality than NYHA I-II status. Pregnancy outcome was better among women who underwent Balloon mitral valvotomy (BMV) when indicated than those who did not. Cardiac complications were higher in women with severe MS and poor NYHA status. Early booking is important for the optimal outcome. BMV is safe during pregnancy and should be done when necessary. Impact statement What is already known on this subject? Rheumatic heart disease continues to be the major cause of maternal morbidity and mortality in developing countries. Most of the recent studies discuss pregnancy with heart disease as a whole with RHD being a part. What do the results of this study add? A large number of women in developing countries conceive with unknown underlying heart disease. Late access to antenatal care is associated with poor outcome. Cardiac and obstetric complications are significantly higher in women with severe mitral stenosis and poor NYHA functional status. Balloon mitral valvotomy (BMV) during pregnancy is safe and technically feasible. BMV averts major complications that may occur due to severe disease. Patients with RHD can undergo labour and vaginal delivery under vigilant monitoring. What are the implications for clinical practice? Thorough clinical examination by the clinician at initial visit is important to detect unknown heart disease. Symptoms pointing towards underlying heart disease should prompt evaluation. This study provides evidence for population-based screening for heart disease in women. Optimal management of compensated mitral stenosis requires weighing the risks and benefits of pharmacological therapy versus BMV in the context of maternal condition. BMV should be performed when necessary.

Vitamin-D Deficiency Is Associated with Gallbladder Stasis Among Pregnant Women.

BACKGROUND: Pregnant women are at increased risk of gallbladder (GB) stasis, an important risk factor for gallstones (GS). In non-pregnant women, Vitamin-D deficiency (VDD) is associated with GB stasis, which improves on supplementation. Relationship of VDD with GB stasis among pregnant women is not known. METHODS: This is a prospective study in tertiary care centre. Consecutive healthy pregnant women (12-16 weeks gestation) were enrolled. Serum 25(OH) vitamin-D was estimated, and levels <20 ng ml(-1) were considered as VDD. Risk factors and clinical features of VDD were assessed. Gallbladder ejection fraction (GBEF) was assessed by ultrasound after a standard fatty meal, and <40 % was defined as stasis. Statistical analysis was performed to assess relationship of GB stasis and vitamin-D levels and identify factors associated with VDD. KEY RESULTS: Median serum vitamin-D in 304 women was 7.9 ng ml(-1) (IQR 5.7, 12). VDD afflicted 92 % of them. Women with VDD more often had GB stasis (20 % vs 0 %; p = 0.015) and had lower GBEF [53.7 ± 17 % vs 59 ± 10 %; p = 0.026] compared to those with normal vitamin-D. GBEF showed positive correlation with vitamin-D levels (r = 0.117; p = 0.042). Risk factors for low vitamin-D levels were urban residence (p = 0.001), lower sun-exposure time (p = 0.005), limited skin exposure (p < 0.001), higher BMI (p = 0.05) and higher socioeconomic status (p = 0.02). Vitamin-D deficiency was associated with low serum calcium (ρ = 0.457; p < 0.001). CONCLUSIONS: Vitamin D deficiency is highly prevalent among pregnant Indian women. It is associated with GB stasis and lower GBEF. The risk factors for VDD were reduced sun exposure, inadequate dietary intake and urban lifestyle.

Relationship between preeclampsia and vitamin D deficiency: a case control study.

PURPOSE: There is paucity of literature pertaining to association between vitamin D deficiency and preeclampsia from sunshine-rich countries like India. Further none of the studies have reported on relation with severity of preeclampsia. This study was carried out with a purpose of studying relation between vitamin D deficiency and preeclampsia and its complications. METHODS: Seventy-four nulliparous preeclamptic women with singleton pregnancy and without any known medical disorder and 100 healthy nulliparous controls of same age were enrolled. Serum vitamin D concentration of the two groups was compared. We also compared the vitamin D level of women with mild and severe preeclampsia and with or without various complications of preeclampsia. RESULTS: Eighty-four percent of women were vitamin D deficient. Mean serum vitamin D was significantly lower among cases (9.7 ± 4.95 ng/ml) as compared to controls (14.8 ± 6.68 ng/ml); p = 0.0001. Women with mild preeclampsia (9.44 ± 5.63 ng/ml) had similar vitamin D level as those with severe disease (9.8 ± 4.79 ng/ml) (p = 0.811). There was no difference in vitamin D level of women with eclampsia (p = 0.956) or imminent eclampsia (p = 0.310) and those without these complications. CONCLUSION: There is high prevalence of vitamin D deficiency among pregnant women in India. Women with preeclampsia had significantly lower vitamin D level as compared to normal women. Severity of the disease was not related to vitamin D level.

Pregnancy outcome in hyperthyroidism: a case control study.

BACKGROUND: Data comparing pregnancy outcome in hyperthyroid women with euthyroid women are scarce. Hence, this study was carried out to assess the maternal and fetal outcome in pregnant women with hyperthyroidism to ascertain the effect of disease on pregnancy. METHODOLOGY: This retrospective study was conducted over a period of 28 years. We compared the maternal and fetal outcomes of 208 hyperthyroid women with 403 healthy controls, between women with well-controlled and uncontrolled disease and amongst women diagnosed with hyperthyroidism before and during pregnancy. RESULTS: Maternal outcome: women with hyperthyroidism were at increased risk for preeclampsia (OR = 3.94), intrauterine growth restriction (OR = 2.16), spontaneous preterm labor (OR = 1.73), preterm birth (OR = 1.7), gestational diabetes mellitus (OR = 1.8), and cesarean delivery (OR = 1.47). Hyperthyroid women required induction of labor more frequently (OR = 3.61). Fetal outcome: newborns of hyperthyroid mothers had lower birth weight than normal ones (p = 0.0001). Women with uncontrolled disease had higher odds for still birth (OR = 8.42; 95% CI: 2.01-35.2) and lower birth weight (p = 0.0001). CONCLUSIONS: Obstetrical complications were higher in women with hyperthyroidism than normal women. Outcome was worsened by uncontrolled disease. Women with pregestational hyperthyroidism had better outcomes than those diagnosed with it during pregnancy.

Stump Ectopic Pregnancy: A Rare Presentation.

Ectopic pregnancy is a significant cause of maternal morbidity and mortality in women of reproductive age group. Tubal ectopic in an unstable patient is a medical emergency. Tubal stump ectopic is a rare presentation. It is difficult to diagnose. Early diagnosis can prevent significant morbidity and mortality. Here, we present a case of ruptured tubal stump ectopic pregnancy in a 33-year-old female who had undergone salpingectomy previously for ectopic pregnancy.

Retroperitoneal Hemorrhage: A Rare Cause of Severe Acute Maternal Morbidity and Perinatal Mortality.

Retroperitoneal hemorrhage in the form of spontaneous adrenal hemorrhage or bleeding into a renal tumor can have varied and non-specific presentations in pregnancy. In the absence of risk factors, these life-threatening conditions are rarely suspected. We present our experience with three patients who presented to us in the third trimester of pregnancy with hemorrhage in retroperitoneal organs. One of the patients had a spontaneous adrenal hemorrhage and the other two had a hemorrhage in the renal tumor. None of the patients was known to have pre-existing tumors, coagulopathy, or trauma. Both the patients with hemorrhage in the renal tumor had intrauterine fetal demise at the time of presentation. Immediate resuscitation and recruitment of a multidisciplinary team resulted in optimal maternal outcomes in all cases and a healthy fetal outcome in the patient with adrenal hemorrhage.

Legal Limits Relaxed: Time to Look at Other Barriers Faced by Women Seeking Termination of Pregnancy for Fetal Anomalies.

Introduction Advancements in prenatal diagnostic techniques have led to an increase in demand for termination of pregnancy for fetal anomalies (TOPFA). While relaxation in the legal gestational age limits across various countries relieves an important barrier, there is a need to identify the reasons that lead to delays in seeking abortion for fetal anomalies, because abortion-related complications increase with gestational age. Methods In this hospital-based qualitative study, antenatal women referred to a tertiary care institute in North India because of major fetal anomalies were explained about the study. Those women who fulfilled the inclusion criteria were recruited after taking consent. Details of antenatal care and prenatal tests were recorded. An in-depth inquiry was made into the reasons for the delay in prenatal tests, the delay in the decision for abortion, and specific problems that they faced in seeking TOPFA. Results Out of 80 women who met the inclusion criteria and consented to participate, more than 75% had received antenatal care in public healthcare facilities. Less than 50% of women received folic acid in the first trimester while 26% had first contact with healthcare facilities in the second trimester. Only 21 women underwent screening for common aneuploidies. Second-trimester anomaly scan was delayed in 35 women due to women-centered reasons (n = 17) or provider-centered (n = 19) reasons. Only 37.5% of women were counseled about fetal anomalies by their primary care provider. Owing to delay at multiple levels, 40 women (50%) could receive counseling about fetal abnormality for the first time after 20 weeks. These women could not be offered abortion because this study was carried out before the amendments in the Medical Termination of Pregnancy Act in India. The older act allowed abortion up to 20 weeks of gestation. Seventeen women could obtain permission for an abortion from a court of law. Arrangements for travel and stay and dependence on family members were the main problems faced by women seeking TOPFA. Conclusions Delay in diagnosis of a fetal anomaly due to delay in seeking antenatal care, irregular follow-up, and lack of pre-test counseling are the major reasons for the delay in the decision for abortion. This is further compounded by inadequate post-test counseling. Lack of awareness, failure or delay in counseling, need to travel to another facility for abortion, dependence on family members, and financial issues are the major barriers.

Baseline Assessment of Evidence-Based Intrapartum Care Practices in Medical Schools in 3 States in India: A Mixed-Methods Study.

INTRODUCTION: Implementation research with pre- and post-comparison was planned to improve the quality of evidence-based intrapartum care services in Indian medical schools. We present the baseline study results to assess the status of adherence to intrapartum evidence-based practices (IP-EBP) in study schools in 3 states in India and the perception of the faculty. METHODS: A concurrent mixed-methods approach was used to conduct the baseline assessment in 9 medical schools in Rajasthan, Gujarat, and Union Territory from October 2018 to June 2019. IP-EBP among pregnant women in uncomplicated first (n=135), second (n=120), and third stage (n=120) of labor were observed using a predesigned, pretested checklist quantitatively. We conducted in-depth interviews with 33 obstetrics and gynecology faculty to understand their perceptions of intrapartum practices. Quantitative data were analyzed using SPSS (version 22). COM-B (Capability, Opportunity, and Motivation Behavior) model was used to understand the behaviors, and thematic analysis was done for the qualitative data. FINDINGS: Unindicated augmentation of labor was done in 64.4%, fundal pressure applied in 50.8%, episiotomy done in 58.3%, and delivery in lithotomy position was performed in 86.7% of women in labor. CONCLUSIONS: Intrapartum practices that are not recommended were routinely practiced in the study medical schools due to a lack of staff awareness of evidence-based practices and incorrect beliefs about their impact.

Leptospirosis as a cause of intrauterine fetal demise: short report of rare presentation.

We present a rare severe leptospirosis in a patient who presented with fever, jaundice, coagulopathy and intrauterine fetal demise. Possibility of leptospirosis should be kept in an obstetric patient with such clinical profile particularly in endemic areas or if there is recent outbreak of disease.

Rupture of Unscarred Uterus With Intestinal Prolapse From Vagina Following Criminal Abortion.

A 21-year-old unmarried and primigravida female indulged in criminal abortion at 18 weeks of gestation with the help of a village midwife. Instrumentation was done, and it led to uterine perforation with prolapse of 200 cm of small bowel through vagina. She was managed with resection of 160 cm of necrotic small bowel, repair of the uterine defect, and end jejunostomy, which was anastomosed with distal ileum three months later. This case highlights the risks of illegal abortion and the primitive societal mindset that forces unmarried women to resort to such means.

An alternate surgical approach to reduce hemorrhage and complications during cesarean hysterectomy for adherent placenta.

BACKGROUND: Cesarean hysterectomy for adherent placenta is associated with increased maternal morbidity due to massive hemorrhage requiring large volume blood transfusion, bladder or ureteric injury, intensive care unit (ICU) admission and prolonged hospital stay. There is an ongoing effort to improve the outcome of these women and measures to reduce blood loss. OBJECTIVE: The purpose of the present study was to develop an alternate surgical approach for performing a Cesarean hysterectomy in women with adherent placenta in order to reduce hemorrhage and urinary tract injuries, and thereby improve the maternal outcome. STUDY DESIGN: A prospective observational study in a tertiary care hospital in North India. The surgical approach described in the present study was practiced in 12 women who underwent Cesarean hysterectomy for adherent placenta previa. In this approach, dissection of the bladder flap as close as to the cervix was made prior uterine incision and delivery of the baby. During dissection of the bladder flap, the blood vessels traversing between uterus and bladder were ligated and divided. RESULT: These 12 women underwent Cesarean hysterectomy under general anesthesia. The interval from induction of anesthesia to delivery of the baby ranged from 40 to 79 min, and none of the babies had birth asphyxia. No woman had bladder or ureteric injury. All women had histopathological proven adherent placenta, 5 had placenta percreta, one had placenta increta and 6 had placenta accreta. The average blood loss was 1.46 l and the mean number of blood transfusions was 2.1 units. None of the women required post-operative ventilatory support or ICU admission, and all women were discharged from hospital between 4 to 7 days following Cesarean hysterectomy CONCLUSION: The present series describes an alternate surgical approach for Cesarean hysterectomy in adherent placenta. Dissection of the bladder flap prior to delivery of the baby followed by hysterectomy reduced the hemorrhage and there was no bladder or ureteric injury. This surgical approach requires no additional resources and may easily be followed in a low-resource setting.