Maternal Mortality and COVID-19 Pandemic: Looking Beyond SARS CoV-2 Infection.

Objective: To study the impact of COVID-19 pandemic on maternal mortality ratio, aetiological and modifiable factors for maternal mortality and key interventions performed. Method: Retrospective exploratory study evaluating maternal mortality between April to November 2020 (study group) and 2019 (control group). Results: Demographic variations existed in the two groups. Increased maternal age and illiteracy were significantly more in the study group. Maternal mortality ratio (MMR) was significantly high in the study group (792 vs. 296 p value = 0.0). Hemorrhage accounted for 20% and COVID-19-related maternal deaths accounted for 15% deaths in the study group. Level 3 delay (delay in receiving care/inadequate care) was observed in 35% in the study group and 28% in control group (p value = 0.349). 17.5% of mothers in the study group as compared to 8% of control group were dead on arrival to hospital though not statistically significant (p value = 0.28). Significantly more women in study group died within 24 h of admission (45% vs. 20%, p value 0.04). Among the key interventions, the use of supplemental oxygen was significantly high in study group (p value = 0.02). Conclusion: Maternal mortality ratio was high in the pandemic year because of a significant decline in hospital delivery rate. The lesson learnt from this pandemic needs to be documented to guide better planning in the future to face similar situations.

A case of acute-onset paraplegia due to spinal tuberculosis in term pregnancy.

Acute paraplegia in pregnancy is uncommon but can result from pathology including Guillain-Barre syndrome, acute transverse myelitis, and spinal tuberculosis, also known as Pott's disease of the spine. India has a high incidence of tuberculosis (2.8 million cases annually) therefore spinal tuberculosis is a particularly important disease to consider during pregnancy. Management of spinal tuberculosis in pregnancy poses a challenge especially at term gestation as immobilization of the spine and maintaining supination is difficult, particularly at delivery.

Are Cephalosporins Safe for Surgical Prophylaxis in Patients with Penicillin Allergy?

Cefazolin, also known as Ancef, is a first-generation cephalosporin antibiotic often used in surgery to treat or prevent bacterial infection of the surgical site. Ancef is safe for most of the population; however, many physicians use alternative, less effective medications in patients with penicillin allergy due to a fear of cross-reactivity between Ancef and one's penicillin allergy. In this article, we aim to examine if cefazolin is safe for patients with penicillin allergy.

Diabetic ketoacidosis occurring with lower blood glucose levels in pregnancy: a report of two cases.

BACKGROUND: Euglycemic diabetic ketoacidosis (DKA) during pregnancy is an unusual condition, but it can occur with normal or modest elevations in blood glucose levels. It is usually a complication of type I diabetes. CASES: We report two cases of euglycemic DKA, in type II diabetes mellitus and in gestational diabetes. Both patients showed blood glucose levels up to 9 mmoL/L (164 mg/dL), ketonuria and metabolic acidosis. They responded to initiation of correct insulin dosages. CONCLUSION: Euglycemic DKA in pregnancy may occur with type II diabetes or in gestational diabetes and requires prompt recognition and treatment.

Ultrasound as a Sole Modality for Prenatal Diagnosis of Placenta Accreta Spectrum: Potentialities and Pitfalls.

Background Placenta accreta spectrum (PAS) is a significant cause of maternal and neonatal mortality and morbidity. Its prevalence has been rising considerably, primarily due to the increasing rate of primary and repeat cesarean sections. Accurate prenatal identification of PAS allows optimal management because the timing of delivery, availability of blood products, and recruitment of skilled anesthesia, and surgical team can be arranged in advance. Aims and Objectives This study aimed to (1) study the ultrasound and color Doppler features of PAS, (2) correlate imaging findings with clinical and per-operative/histopathological findings, and (3) evaluate the accuracy of ultrasound for the diagnosis of PAS in patients with previous cesarean section. Materials and Methods This prospective study was conducted in radiology department of a tertiary care hospital. After screening 1,200 pregnant patients, 50 patients of placenta previa with period of gestation ≥ 24 weeks and history of at least one prior cesarean section were included in the study. Following imaging features were evaluated: (1) gray scale covering intraplacental lacunae, disruption of uterovesical interface, myometrial thinning, loss of retroplacental clear space, and focal exophytic masses; and (2) color Doppler covering intraplacental lacunar flow, hypervascularity of uterine serosa-bladder wall interface, and perpendicular bridging vessels between placenta and myometrium. Study Design Present study is a prospective one in a tertiary care hospital. Results Of the 19 PAS cases, 18 were correctly diagnosed on ultrasonography (USG) and confirmed either by histopathological analysis of hysterectomy specimen or per-operatively due to difficulty in placental removal. PAS was correctly ruled out in 27 of 31 patients. The diagnostic accuracy of USG was 90%. The sensitivity, specificity, positive, and negative predictive values were 94.7, 87.1, 81.8, and 96.4%, respectively. Conclusion Ultrasound is indispensable for the evaluation of pregnant patients. It is an important tool for diagnosing PAS, thereby making the operating team more cautious and better equipped for difficult surgery and critical postoperative care. It can be relied upon as the sole modality to accurately rule out PAS in negative patients, thereby obviating unnecessary psychological stress among patients due to possible hysterectomy.

Notes from the Field: Dynamic Triaging Using Quality Improvement (QI) Methodology to Prevent the Admission of Asymptomatic COVID Positive Obstetric Patients in New Delhi, India.

A single undiagnosed COVID-19 positive patient admitted in the green zone has the potential to infect many Health Care Workers (HCWs) and other patients at any given time with resultant spread of infection and reduction in the available workforce. Despite the existing triaging strategy at the Obstetric unit of a tertiary hospital in New Delhi, where all COVID-19 suspects obstetric patients were tested and admitted in orange zone and non-suspects in green zone, asymptomatic COVID-19 positive patients were found admitted in the green zone. This was the trigger to undertake a quality improvement (QI) initiative to prevent the admission of asymptomatic COVID-19 positive patients in green zones. The QI project aimed at reducing the admission of COVID-19 positive patients in the green zone of the unit from 20% to 10% in 4 weeks' time starting 13/6/2020 by means of dynamic triaging. A COVID-19 action team was made and after an initial analysis of the problem multiple Plan-Do-Study-Act (PDSA) cycles were run to test the change ideas. The main change ideas were revised testing strategies and creating gray Zones for patients awaiting COVID-19 test results. The admission of unsuspected COVID-19 positive cases in the green zone of the unit reduced from 20% to 0% during the stipulated period. There was a significant reduction in the number of HCWs, posted in the green zone, being quarantined or test positive for COVID-19 infection as well. The authors conclude that Quality Improvement methods have the potential to develop effective strategies to prevent spread of the deadly Corona virus.

Incidence, Management and Outcomes in Women Undergoing Peripartum Hysterectomy in a Tertiary Care Centre in India.

Background Peripartum hysterectomy (PRH) is the surgical removal of the uterus performed in obstetrical complications such as uncontrolled postpartum haemorrhage (PPH), unrepairable uterine rupture, and sepsis. Its incidence has increased in recent years. The objective of this study was to review all the cases of PRH in a tertiary care teaching hospital over three years (January 2017-December 2019) to determine its incidence and analyse clinico-demographic characteristics in these women. Method All women undergoing PRH from January 2017 to December 2019 were included in the study. Data were collected retrospectively from medical records, of patients who underwent a PRH at the time of delivery, or within 24 hours, or performed any time before discharge from the same hospitalization and obstetric event. The total number of deliveries including caesarean and vaginal deliveries were recorded. Main outcome measures were the incidence of PRH, indication for hysterectomy, management option used, maternal outcomes (PPH, bladder injury and maternal death) and fetal outcomes (stillbirth). Results There were a total of 3904,4 deliveries; 27,337 vaginal and 11,697 caesarean sections in three years. A total of 50 patients underwent a PRH. The incidence of PRH in our study was 1.3 per 1,000 deliveries and 3.5/1,000 caesareans, respectively. PRH was found to be more common following cesarean sections than vaginal deliveries (odds ratio 22.86 [95% CI: 8.16 to 63.98]). Morbid adherent placenta (MAP) (n=30, 62%) was the most common indications of PRH. Seven (15%) women had PRH due to uterine rupture. Twenty-seven women of the 30 women (90%) with the MAP had a previous caesarean delivery. The case fatality rate per hysterectomy was 4%. Stillbirth rate (SBR: n=8,16%) among women having PRH was seven-fold higher than overall SBR in our country. Conclusion There has been a rise in MAP as an indication of PRH in our study for a decade in comparison to uterine atony. Caesarean delivery is a significant risk factor for PRH. Previous caesarean section and major placenta previa were common occurring obstetric risk factors present in the MAP in our cohort. Our maternal mortality in PRH was low and the stillbirth rate was high when compared with national data.

Visceral Adiposity Index: Simple Tool for Assessing Cardiometabolic Risk in Women with Polycystic Ovary Syndrome.

AIM: To study visceral adiposity index (VAI) and its association with cardiometabolic risk in different phenotypes of polycystic ovary syndrome (PCOS). MATERIALS AND METHODS: It is a case-control cross-sectional study where 100 reproductive age (18-35 years) women with PCOS were classified in different phenotypes as per Rotterdam criteria and compared with age and Body mass index (BMI) matched 50 eumenorrheic and nonhirsute women. Various anthropometric, clinical, biochemical, and hormonal parameters were measured in both women with PCOS and controls. VAI was calculated using waist circumference (WC), BMI, serum triglyceride, and High density lipoprotein (HDL) cholesterol levels in all the subjects and compared between cases and controls. Subsequently, women with PCOS were assessed for cardiometabolic risk according to androgen excess society statement 2010 as "at risk" and "at high risk." Finally, risk was correlated with VAI for all the phenotypes of PCOS. RESULTS: Mean VAI was significantly higher (P < 0.001) in cases than controls (2.07 vs. 1.27). Mean VAI in phenotype A (O+P+HA), B (O+HA), C (P+HA), and D (O+P) was 2.46, 2.48, 1.47, and 1.70, respectively. A total of 56% of women with PCOS were at risk and 12% at high risk for cardiometabolic disease. Metabolic syndrome was prevalent in 11% of cases and 1% had type 2 diabetes mellitus. Phenotypically, 88% of women with PCOS with phenotype A (O+P+HA), 67% of B (O+HA), 67% of C (P+HA), and 55% of D (O+P) were at increased risk. VAI was found to be positively correlated with WC (r, 0.550), waist to hip ratio (r, 0.295), Homeostasis model assessment of insulin resistance (HOMA IR) (r, 0.455), and cardiometabolic risk (r, 0.399). Also, it was the best factor associated with cardiometabolic risk (area under curve, 0.793). CONCLUSION: This study concluded that visceral adiposity index can be used as simple and effective tool for assessing the cardiometabolic risk in women with PCOS as higher VAI values were observed in those cases who were at high risk for developing cardiometabolic disorder in future.

Indian National Association for the Study of the Liver-Federation of Obstetric and Gynaecological Societies of India Position Statement on Management of Liver Diseases in Pregnancy.

Liver diseases occurring during pregnancy can be serious and can progress rapidly, affecting outcomes for both the mother and fetus. They are a common cause of concern to an obstetrician and an important reason for referral to a hepatologist, gastroenterologist, or physician. Liver diseases during pregnancy can be divided into disorders unique to pregnancy, those coincidental with pregnancy, and preexisting liver diseases exacerbated by pregnancy. A rapid differential diagnosis between liver diseases related or unrelated to pregnancy is required so that specialist and urgent management of these conditions can be carried out. Specific Indian guidelines for the management of these patients are lacking. The Indian National Association for the Study of the Liver (INASL) in association with the Federation of Obstetric and Gynaecological Societies of India (FOGSI) had set up a taskforce for development of consensus guidelines for management of patients with liver diseases during pregnancy, relevant to India. For development of these guidelines, a two-day roundtable meeting was held on 26-27 May 2018 in New Delhi, to discuss, debate, and finalize the consensus statements. Only those statements that were unanimously approved by most members of the taskforce were accepted. The primary objective of this review is to present the consensus statements approved jointly by the INASL and FOGSI for diagnosing and managing pregnant women with liver diseases. This article provides an overview of liver diseases occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and the recommended treatment options.

Ruptured Malignant Ovarian Tumor in an Adolescent Girl: A Rare Case Report.

Germ cell tumors which arise mainly in pediatric and adolescent age group, account for 30% of all ovarian tumors, but constitute only 5% of all malignant ovarian tumors. The presentation is usually insidious with the patient presenting with abdominal swelling and dull aching pain. We report a rare case of a malignant germ cell tumor in a 12-year-old girl who presented with acute abdomen due to spontaneous rupture of tumor resulting in hemoperitoneum. The patient was taken up for emergency laparotomy and left salpingo-opherectomy with omentectomy and drainage of hemoperitoneum was done. The authors conclude that ruptured malignant ovarian tumor should be considered in the differential diagnosis of any young girl presenting with abdominal mass and acute abdominal pain.

Botryoid rhabdomyosarcoma of common bile duct.

Common bile duct is an unusual site for occurrence of botryoid rhabdomyosarcoma. Clinically it is often misdiagnosed as infectious hepatitis. Early diagnosis and treatment has greatly improved the prognosis of this aggressive neoplasm. Here the authors present a case report of Bortroyid Rhabdomyosarcoma of CBD in a two and half year old child masquerading as obstructive jaundice.

Solitary intramuscular nasal Juvenile Xanthogranuloma: a case report with review of literature.

Juvenile Xanthogranuloma is a non-langerhans cell histiocytosis characterized by yellowish cutaneous nodules that usually appear in early infancy and childhood. Intramuscular variant is a rare form, with only eight reported cases, and none reported in ala of nose. Sheets of histiocytes, few touton giant cells and infiltrative borders makes it susceptible to misdiagnosis as childhood sarcomas or lymphoproliferative disorders. Awareness of the lesion aided by immunohistochemistry helps in reaching the proper diagnosis.

Recommendations on recognition and response to child abuse and neglect in the Indian setting.

JUSTIFICATION: Pediatricians are usually the first point of contact of children with the health system. Studies worldwide have shown that there is insufficient knowledge about child abuse recognition and management among health workers. Presently no uniform guidelines exist in India for pediatricians regarding the appropriate response to child abuse. PROCESS: As part of the Child Rights and Protection Programme (CRPP) under IAP VISION 2007 of Indian Academy of Pediatrics, a Training of Trainers Workshop on Child Rights and Protection was held in Mumbai in January 2007. It was attended by participants from all over the country. The workshop recommended developing country-specific teaching and training material. A Task force of IAP CRPP was formed and it developed a module for Training of Trainers Workshops for Pediatricians. A National Consultative Meet was held in October, 2007 at New Delhi, where the program was discussed and ratified. OBJECTIVES: To train pediatricians to: recognize and respond to child abuse; engage in a multidisciplinary networking mode to deal with child abuse; and, document, record and report instances of child abuse. RECOMMENDATIONS: Guidelines for recognition and management of child abuse are presented. All pediatricians should assess suspected harm with the same thoroughness and attention as they would do with a life threatening condition. Poor management after disclosure can increase psychological damage. Pediatrician should believe, support, reassure, treat and ensure rehabilitation of victims of child abuse, keeping the best interest of the child as the primary goal.