Comparison of intracervical Foley catheter combined with a single dose of vaginal misoprostol tablet or intracervical dinoprostone gel for cervical ripening: a randomised study.

We compared two combined methods for cervical ripening before induction of labour (IOL) Women (n = 150) were randomised into Foley's-misoprostol (n = 75) and Foley's-dinoprostone (n = 75) groups. A single dose of vaginal misoprostol tablet (25 µg) or intracervical dinoprostone gel (0.5 mg) were used alongwith intracervical Foley's. The primary outcome was induction-delivery interval (IDI) and secondary outcomes were change in Bishop's score, oxytocin requirement, caesarean section (CS) rate, chorioamnionitis and neonatal outcome. The mean parity, gestation and indications for IOL were similar in the two groups. The IDI (19 h 37 min and 19 h 20 min; p = .683), cervical ripening time, oxytocin requirement, CS rate (18.7 and 25.4%, p = .322) and neonatal outcome were similar. Hyperstimulation developed in 2.7% women with Foley's-misoprostol and in 1.3% with Foley's-dinoprostone (p = .55). No woman had chorioamnionitis. Thus, these two combined methods of cervical ripening and IOL were observed to be similarly efficacious. A low incidence of hyperstimulation and no chorioamnionitis may be attributed to using a single dose of prostaglandins. Misoprostol may be substituted for dinoprostone in resource limited countries.Impact statementWhat is already known on this subject? Combined methods for cervical ripening (intracervical Foley's plus prostaglandins) before induction of labour (IOL) may be similarly or more efficacious than individual methods. Most studies comparing various combined methods have used repeated doses of prostaglandins. A combined method using repetitive doses of prostaglandins may increase the risk of hyperstimulation and also of infection consequent to repeated vaginal examination to administer prostaglandins. These two concerns may be offset by combining a single dose of prostaglandin with intracervical Foley's catheter.What do the results of this study add? Two combined methods for cervical ripening using a single dose of vaginal misoprostol (25 µg) or intracervical dinoprostone gel (0.5 mg) co-administered with intracervical Foley's catheter were found to be similarly efficacious. The IDI (19 h 37 min and 19 h 20 min; p = .683), cervical ripening time, oxytocin requirement, CS rate (18.7 and 25.4%, p = .322) and neonatal outcome were similar. The incidence of hyperstimulation was low (2.7 and 1.3% with Foley's-misoprostol and Foley's-dinoprostone, respectively) and no woman had chorioamnionitis.What are the implications of these findings for clinical practice and/or further research? Combined methods for cervical ripening using a single dose of prostaglandins (misoprostol or dinoprostone) were observed to be similarly efficacious. Misoprostol is a cheaper alternative to dinoprostone and may be utilised in resource limited countries. These methods may be compared with each other in more number of women in order to identify which combined method is more efficient and safe. Clinical Trials Registry of India: CTRI/2017/12/010738.

COFS type 3 in an Indian family with antenatally detected arthrogryposis.

Fetal akinesia and contractures can be caused by mutations in various genes that lead to overlapping phenotypes with contractures, rocker bottom feet, cerebellar hypoplasia, ventriculomegaly, growth retardation, pulmonary hypoplasia, cystic hygroma and cleft palate in various combinations. Cerebro-oculo-facio-skeletal (COFS) syndrome is a condition resulting from defects in DNA repair pathway, and genes involved include ERCC1 (COFS), ERCC2 (XPD), ERCC5(XPG), and ERCC6 (CSB). It is a severe disorder presenting in fetal or neonatal period with microcephaly, arthrogryposis, prominent nose, and kyphoscoliosis, and leads to early death in childhood. We report a baby with antenatally identified arthrogryposis in which the homozygous pathogenic variant in exon 8 was identified in ERCC5 gene, by targeted next generation sequencing. This was predicted to cause premature chain termination in the protein. ERCC5 gene is mainly implicated in xeroderma pigmentosum, sometimes in COFS syndrome.

A randomised trial to compare 200 mg micronised progesterone effervescent vaginal tablet daily with 250 mg intramuscular 17 alpha hydroxy progesterone caproate weekly for prevention of recurrent preterm birth.

For prevention of a recurrent preterm birth (PTB), intramuscular 17-α-hydroxy progesterone caproate (IM 17 OHPC) weekly is recommended. Vaginal progesterone is preferred for women at risk for PTB due to a short cervical length, but may be useful in women with a prior PTB. However, there is no consensus about the optimal vaginal formulation or its efficacy as compared to 17 OHPC to prevent recurrent PTB. We randomised 100 women with a singleton pregnancy between 16 and 24 weeks of gestation and ≥ one prior spontaneous PTB, of a singleton (>16 to <37 weeks of gestation) to receive the 200 mg vaginal progesterone effervescent tablet daily (Group A) or IM 17-OHPC, 250 mg weekly (Group B) till 37 weeks of gestation or delivery. The spontaneous PTB rate of <37 weeks was similar (20% in Group A and 20.8% in Group B, p = .918). The PTB rate of <34 weeks or <28 weeks were also comparable. The mean birth weight and other neonatal outcomes were similar in the two groups. Two neonates in Group A and four neonates in Group B required NICU admission, one of whom (Group B) died due to prematurity. Twenty percent of women in Group A and 29.2% in Group B reported adverse effects from their respective study medications (p = .408, NS). Thus, there did not appear to be a difference between vaginal progesterone and 17-OHPC when used for the prevention of a recurrent PTB. Impact statement What is already known on this subject? Progesterone administration is useful for prevention of a recurrent preterm birth (PTB) and these women are prescribed the intramuscular 17-α-hydroxy progesterone caproate (IM 17 OHPC), 250 mg, weekly. Some studies found that vaginal progesterone (once daily) is also beneficial in these women, but there is no consensus regarding its efficacy when compared to 17 OHPC, or its optimal formulation and dose. What do the results of this study add? In the present study, 100 women with a singleton pregnancy between 16 and 24 weeks of gestation and ≥ one prior spontaneous singleton PTB or mid-trimester abortion were randomised to receive 200 mg of vaginal progesterone effervescent tablet daily (Group A) or 250 mg IM 17-OHPC weekly (Group B) till 37 weeks of gestation or delivery. The spontaneous PTB rate <37 weeks was similar in the two groups (20% in Group A and 20.8% in Group B, p = .918). The PTB rate <34 weeks or <28 weeks were also comparable. The mean birth weight and other neonatal outcomes were similar. Twenty percent of women in Group A and 29.2% of women in Group B reported adverse effects from their respective study medications (p = .408, NS). Thus, there did not appear to be a difference between the vaginal progesterone effervescent tablet and 17-OHPC when used for the prevention of a recurrent PTB. What are the implications of these findings for clinical practice and/or further research? The vaginal progesterone effervescent tablet may be a suitable alternative to IM 17 OHPC to prevent recurrent PTB. Future studies should identify the most appropriate route (IM or vaginal) and vaginal progesterone formulation for PTB prevention in women at risk for a recurrent PTB and in women with a short cervical length.

Routine second trimester cervical length screening in low risk women identified women at risk of a 'very' preterm birth but did not reduce the preterm birth rate: a randomised study from India.

Women (n = 300) at 'low risk' for a preterm birth (PTB), a singleton pregnancy and for a 16-24 week period of gestation (POG) were randomised to undergo cervical length (CL) measurement by transvaginal sonography (TVS) or not. The aim was to see if routine CL measurement and treatment of a short CL reduced the PTB rate. 'Low risk' was defined by an absence of a prior abortion or PTB of a singleton infant (>16 to <37 weeks) due to a spontaneous preterm labour (PTL) or a preterm pre-labour rupture of membranes (pPROM). The PTB rate was similar in the screened and unscreened group (10.3 and 8%, respectively, p = .433). In the screened group, women who delivered at 'term' or 'moderate to late' preterm (32 to <37 weeks) had a significantly higher mean CL (3.46 ± 0.41 and 3.48 ± 0.65 cm, respectively) than the women who delivered 'very' preterm (28 to 31 + 6 weeks; 2.05 ± 0.5 cm; p = .01). A short CL ≤2.5 cm was observed in two primigravidas (2/147 or 1.3%). They delivered at 28 + 3 and 30 + 6 weeks POG, respectively, despite treatment with vaginal progesterone and rescue cerclage in one. Their neonates were discharged in a good condition. In our low risk cohort, a routine second trimester CL measurement did not reduce the overall PTB rate. However, it identified two primigravidas at risk of having a 'very' PTB.Clinical Trials Registry (CTRI), India: Registration number CTRI/2016/01/010438 Impact statement What is already known on this subject? In women with a singleton pregnancy who are at a 'low risk' for preterm birth (PTB), a short cervical length (CL) at mid trimester measured by transvaginal sonography (TVS) identifies those at risk for a PTB. This risk may be reduced by the treatment with vaginal progesterone. At present, though evidence in favour of CL measurement in low-risk women exists, it is not established as a part of antenatal care. What do the results of this study add? A routine second trimester CL measurement in low risk women did not reduce the PTB rate. However, screening for a short CL helped to identify two primigravidas at risk for a 'very' PTB. It may be possible that detection and treatment of a short CL averted an 'extremely' PTB (<28 weeks) in these two women. What are the implications of these findings for clinical practice and/or further research? Future studies should assess the outcome of women with a short mid-trimester CL to see whether its treatment resulted in pregnancy prolongation and an improved neonatal outcome.

Overexpression of microRNA-122 enhances in vitro hepatic differentiation of fetal liver-derived stem/progenitor cells.

MicroRNAs (miRNAs) are a versatile class of tiny non-coding RNAs involved in regulation of various biological processes. miRNA-122 (miR-122) is specifically and abundantly expressed in human liver. However, the role of miR-122 in differentiation of fetal liver stem/progenitor cells into hepatocytes remains unclear. In this study, dual positive CD34+/CD117+ expressing human fetal liver stem/progenitor cells was enriched by magnetic cell sorting and cultured in vitro. The level of miR-122 was found to be increased at specific time intervals. Interestingly, during the differentiation process of hepatocyte-like cells, the increase in expression of miR-122 was positively correlated with expression of hepatocyte-specific genes. The status of differentiation process was improved by transfection of miR-122 into enriched stem/progenitor cells. The expression level of hepatic-specific genes as well as liver-enriched transcription factors (LETFs) was significantly increased by overexpression of miR-122 in fetal liver stem/progenitor cells. Thus, the study delineated the role of hepato-specific miR-122 in differentiation of fetal liver stem/progenitor cells into hepatocyte-like cells which could be used as a therapeutic target molecule to generate abundant hepatocytes.

Expediting labor induction in severe pre-eclampsia by earlier initiation of oxytocin after cervical ripening: A randomized study from India.

OBJECTIVE: To observe whether induction of labor (IoL) among women with severe pre-eclampsia (PE) can be expedited by initiating oxytocin early (after 6 h) than after 12 h following cervical ripening with a combined method. METHODS: Women with severe PE and Bishop's < 6 (n = 96) were randomized into two groups. All women received cervical ripening with a combined method (intracervical Foley's plus dinoprostone gel 0.5 mg) following which Group 1 women received oxytocin after 6 h (with Foley's in-situ) and Group 2 after 12 h (after removing Foley's) RESULTS: Majority were nulliparous (63% in group 1 and 77% in group 2) and the mean gestation was similar (35.3 ± 2.98 weeks in group 1 and 35.5 ± 3.09 in group 2). Nearly half the women had partial HELLP/ HELLP (47.9% and 54.1%; in groups 1 and 2, respectively). The induction-delivery interval (IDI) was significantly reduced in group 1 (16 h 6 min vs 22 h 6 min in group 2; p = 0.001). The cesarean section (CS) rate was 37.5% in group 1 and 31.3% in group 2 (p = 0.525), but the study was underpowered to assess this outcome. The neonatal outcome was similar, 92/96 neonates were discharged after a hospital stay of 3-52 days. There were 4 neonatal deaths (1 in group 1 and 3 in group 2) of extreme or very preterm neonates (27-30 + 6 wks) with birth weight of 735-965 gm. CONCLUSION: Among women with severe PE undergoing IoL, initiating oxytocin 6 h after cervical ripening with a combined method reduced the IDI significantly as compared to initiating it after 12 h, with a similar CS rate and neonatal outcome.

Obstetric Teleconsultation by Using Mobile Phone Technology in COVID Pandemic.

Introduction: Obstetrics teleconsultation is a new concept to enable health-care services in the COVID pandemic by limiting in-person visits. This study describes the methodology of mobile-based teleconsultation, preliminary findings, and the experience of the obstetricians. Material and Methods: The data of pregnant women who got registered for teleconsultation in early phase of COVID pandemic lockdown were reviewed and analyzed. A qualitative analysis was performed to assess the experience of obstetricians (consultants, senior residents, and junior residents) via an online electronic survey. Results: The majority of obstetrics teleconsultations were for routine antenatal care (75%) and fetal medicine consultation (12.3%). Out of 187 women, 29.9% were advised to continue antenatal care at local hospitals, whereas 33.6% were asked to follow up via teleconsultation. Most of the obstetricians (73.68%) felt that they were able to satisfy the pregnant women and rated the teleconsultation satisfactory. Conclusion: Obstetrics telemedicine found to be beneficial for providing routine antenatal care services via reducing physical visits and overcrowding in outpatient departments, promoting antenatal care at local hospitals, and making specialized (maternal-fetal medicine) care accessible even during COVID-19 pandemic.

A randomized controlled trial comparing parenteral normal saline with and without 5% dextrose on the course of labor in nulliparous women.

OBJECTIVE: The objective of this study was to compare intravenous normal saline with and without 5% dextrose on the course of labor in nulliparous women in active phase of spontaneous labor. STUDY DESIGN: In a randomized controlled trial, term, nulliparous women with singleton pregnancy in active labor were randomized into one of two groups receiving either normal saline or normal saline alternating with 5% dextrose at rate of 175 ml/h. The primary outcome was total length of labor from onset of study fluid in vaginally delivered women. Maternal and neonatal outcomes were also analyzed. RESULTS: Of 250 women enrolled, in vaginally delivered subjects, there was significant difference in the duration of labor (p=0.0) and prolonged labor (p=0.01), with favorable results for women in 5% dextrose alternating with normal saline. No statistically significant differences were observed in the cesarean section rates between the groups. The cord pH was significantly higher in neonates born to women in 5% dextrose alternating with normal saline infusion as compared to normal saline alone (p=0.01), however, no neonate in the study had acidemia. CONCLUSION: Administration of a 5% dextrose solution alternating with normal saline is a better parenteral fluid for significantly decreasing duration of labor in term vaginally delivered nulliparous women in spontaneous active labor as compared to normal saline alone.

Second-Trimester Medical Abortion with Misoprostol Preceded by Two Sequential Doses of Mifepristone: An Observational Study.

Introduction: Based upon the pharmacokinetics of mifepristone, we postulated that repeating a dose after its half-life period may potentiate its abortifacient effect. Methods: We administered mifepristone (200 mg) on days one and two, and misoprostol on day three (200 or 400 µg, vaginally, six-hourly, upto three doses in 12 h) in 100 women (intervention group). We compared their outcome with that of another 100 women who received the one-dose mifepristone regimen (mifepristone on day one and misoprostol on day three) during the months immediately preceding the study period (historical controls). Results: The mean age, parity and gestation (18 weeks) were similar in the two groups. On day three (before initiating misoprostol), cervix admitted one finger in significantly more women in the intervention group (36 versus 8% in historical controls; p = 0.001). All women aborted successfully in the two groups. The IAI of the intervention group was significantly shorter than the IAI of historical controls (10.45 vs 13.75 h; p = 0.013), and the misoprostol requirement was also significantly lower (mean 434 vs 500 µg among historical controls, p = 0.04). Conclusions: Second-trimester medical abortion using two sequential doses of mifepristone followed by misoprostol reduced the IAI and misoprostol requirement without adding any extra days to the existing regimen. Further randomized studies can assess if the 'two-dose' mifepristone regimen is more efficient than the 'one-dose' regimen.

Descriptive study of blood transfusion practices in women undergoing cesarean delivery.

AIM: To study the blood transfusion practices in women undergoing cesarean delivery at a tertiary care centre in northern India. METHODS: This was a prospective study conducted in 1769 women who underwent cesarean section at a tertiary centre hospital from May 2008 to November 2009. A comprehensive predesigned proforma was filled in for each woman. Data related to antenatal, intrapartum and postnatal events was recorded and compared between women receiving blood transfusion during cesarean section and women not receiving blood transfusion. RESULTS: The cesarean section rate was 26% and the blood transfusion rate was 12.21%. The overall crossmatch transfusion ratio in our study was 5.46:1. After multiple regression logistic analysis factors, like placenta previa (OR 15.19, 95% CI 9.28-24.82), anemia (OR 9.93, 95% CI 5.17-19.06), blood loss >1000 mL (OR 5.97, 95% CI 4.32-8.24), abruptio (OR 4.18, 95% CI 2.02-8.62), intraoperative complications, like uterine incision extension, uterine atony, hysterectomy (OR 2.69, 95% CI 1.70-4.24), general anesthesia (2.48, 95% CI 1.70-3.61) and inadequate antenatal supervision (OR 1.59, 95% CI 1.05-2.42) were found to be significantly associated with a higher risk for blood transfusion during cesarean section. CONCLUSION: Routine crossmatching of blood for all women prior to cesarean section needs to be reviewed. Cesarean sections performed on women with high risk factors for blood transfusion can have sudden and significant blood loss and thus adequate blood arrangement prior to cesarean section is justified only in this group of women and not in all women.

A Randomized Clinical Trial of Levonorgestrel Intrauterine System with or without Metformin for Treatment of Endometrial Hyperplasia without Atypia in Indian Women.

BACKGROUND: Endometrial cancer is the second most frequent genital malignancy in women, which is showing a constant rise all over world. Endometrial hyperplasia is the precursor of endometrial cancer. Levonorgestrel intrauterine system is the first line management in patients with endometrial hyperplasia without atypia. Metformin has shown to reverse endometrial hyperplasia, but its effectiveness and safety in endometrial hyperplasia is uncertain. OBJECTIVE: To compare the efficacy in terms of histopathological response, clinical response and safety at the end of 6 months in patients with endometrial hyperplasia without atypia managed with Levonorgestrel intrauterine system alone versus patients managed with Levonorgestrel intrauterine system plus metformin. METHODS: The randomized control trial was conducted on 51 cases of endometrial hyperplasia without atypia. Twenty-five subjects were prescribed metformin 500mg twice daily with Levonorgestrel intrauterine system and 26 subjects, with Levonorgestrel intrauterine system only for 6 months. At the end of 6 months, endometrial sampling was performed for histopathological response. RESULTS: Clinical response was observed in 23 of 25 subjects in metformin group and 22 of 24 in Levonorgestrel only group. The metformin group responded significantly with amenorrhea (p= 0.0053), while Levonorgestrel only group responded with regular cycles (p=0.027). At the end of study, of 46 subjects available for histopathological evaluation, 100% subjects in metformin group and 95.45% in Levonorgestrel only group (p=0.47826) showed complete response. The metformin group had a significant reduction in body mass index at end of study [P = 0∙023, 95% confidence interval (-1.7802, -0.1418)]. CONCLUSION: No significant difference in regression of endometrial hyperplasia was observed on adjunctive use of metformin but a significant reduction in BMI was observed. Use of metformin in obese patients may improve the treatment response.

A Rare Case of Grade 1 Endometrioid Adenocarcinoma of the Uterus With Omental Metastasis with Brenner Tumor of the Ovary in a Postmenopausal Female.

Early-stage endometrial cancer may have microscopic omental metastases which is associated with a poor prognosis. There are no standard guidelines for omentectomy in early-stage endometrial cancer without risk factors. Brenner tumor is a rare ovarian tumor which is usually benign, but rarely, it may be malignant. Some Brenner tumors are endocrinologically active. Various studies have shown an association of Brenner tumor with endometrial hyperplasia, polyp, or early-stage carcinoma, probably due to its estrogen-secreting nature. We report a rare case of well-differentiated endometrioid adenocarcinoma of the uterus with <50% myometrial invasion with omental metastases associated with benign Brenner tumor of the ovary in a postmenopausal female.

Disengagement of the deeply engaged fetal head during cesarean section in advanced labor: conventional method versus reverse breech extraction.

Maternal and fetal morbidity of two different methods of delivering the baby during cesarean section performed in advanced labor when the fetal head is deeply engaged was assessed retrospectively, i.e. delivering as 'cephalic' with or without assistance to push up the fetal head from the vagina (head first or push method) and 'reverse breech extraction' (feet first or pull method). Records of 182 women with a single fetus in cephalic presentation, who had undergone cesarean section at cervical dilatation at > or =7 cm, with the vertex at or below zero station, were reviewed. Extension of the uterine incision occurred in significantly more women during 'cephalic' delivery as compared to 'reverse breech extraction' (22.8% versus 2.2%; p=0.001). Use of 'reverse breech extraction' is an attractive and safe alternative to the standard methods for intra-operative disengagement of a deeply impacted fetal head in order to reduce maternal and fetal morbidity.

Evanescence of Endometrial Carcinomas in Hysterectomy Specimens: Observations on the "Vanishing Cancer" Phenomenon.

BACKGROUND: The phenomenon of vanishing carcinomas, first described in context of prostatic carcinomas, has been documented in endometrial carcinomas as well. METHODS: The archives of the department were searched for case files of endometrial carcinoma diagnosed on endometrial curetting/biopsy but which did not reveal any cancer on the subsequent hysterectomy specimen. Clinical and pathological correlation was established. RESULTS: A total of 5 cases were retrieved with biopsy-diagnosed endometrial carcinomas, 4 endometrioid and 1 serous type, which on subsequent hysterectomies did not reveal any tumor. These 5 cases represented 1.56% of total hysterectomies in our series. All were Stage Ia tumors, which on follow-up (mean = 18.2 months) did not show any local reoccurrence. Adjuvant therapy was instituted in 1 case in the form of pelvic irradiation in view of the serous histology. In all cases, the primary diagnosis was reconfirmed and any remote possibility of incorrect patient identification, laboratory errors, and institution of hormonal therapy were adequately ruled out along with an extensive endometrial sampling in hysterectomy. CONCLUSION: The recognition of "vanishing endometrial carcinoma" as a distinct entity is of utmost importance to avoid mislabeling them as medical errors.

Niemann-Pick Disease: An Underdiagnosed Lysosomal Storage Disorder.

Lysosomal storage disorders (LSDs) collectively constitute a significant public health burden in developing countries. Commoner LSDs include Gaucher, Fabry, and Niemann-Pick disease (NPD), but many cases remain undiagnosed. With the high incidence of consanguineous marriages, South East Asian countries are expected to have high prevalence of these LSDs. Here we report 4 cases of NPD type A/B in 3 families presenting with hepatosplenomegaly and cytopenias including one family with two sibs having hypertension and mitral valve prolapse. The diagnosis of NPD was proven by mutation analysis with identification of novel mutations, including a novel 4 bp insertion mutation (C>CCTGG) in exon 2 of the SMPD1 gene. We also had two cases of NPD type C, confirmed on mutation analysis.

Randomized controlled trial of cefazolin monotherapy versus cefazolin plus azithromycin single dose prophylaxis for cesarean deliveries: A developing country's perspective.

AIM: To compare the efficacy of pre-incision intravenous single doses of cefazolin versus cefazolin plus azithromycin as an antibiotic prophylaxis in cesarean delivery (CD). METHODS: This was a single-center, double blind, randomized controlled trial conducted in the PGIMER, Chandigarh. 200 women undergoing elective/emergency cesarean section were randomized. Group A received single dose of cefazolin plus placebo while Group B received single dose of cefazolin plus azithromycin. Primary outcome evaluated was occurrence of surgical site infections (SSI); secondary outcomes included incidence of febrile morbidity, UTI, endometritis, neonatal outcome, total cost of antibiotics, and duration of hospital stay in both the study arms. Descriptive statistics and χ2 tests were used for analysis of the data. RESULT: There was an overall significant reduction in the incidence of SSI (15% vs 3%; P = 0.03), endometritis (8% vs 2%; P = 0.048), and post-operative febrile morbidity (17% vs 3%; P = 0.001) with the addition of azithromycin to cefazolin. Duration of hospital stay was almost two days lesser for the cefazolin plus azithromycin group. Subgroup analysis of patients with SSI showed the age, duration of ruptured membranes, and type of anesthesia as important predictors of infection rate. Study observed statistically significant reduction in requirement of additional post operative antibiotics, phototherapy for neonates, hospital stay and cost of therapy in cefazolin plus azithromycin group (P < 0.05). CONCLUSION: Tertiary care hospitals in developing countries such as India can opt for the cefazolin plus azithromycin as antimicrobial prophylaxis during CD to maximize the efficacy as well as for decreasing the cost burden of postoperative infections.

Early versus delayed amniotomy during labor induction with oxytocin in women with Bishop's score of ≥6: a randomized trial.

OBJECTIVE: To study the effect of "early amniotomy" {initiating induction of labor (IOL) with amniotomy followed by oxytocin} versus "late amniotomy" (initiating IOL with oxytocin followed by amniotomy 4-8 h later) in induced labor. METHODS AND MATERIALS: One hundred and fifty women with Bishop's score of ≥6 undergoing IOL were randomized into "early amniotomy" and "delayed amniotomy". RESULTS: Early amniotomy resulted in a reduced induction-delivery interval (IDI) (7.35 versus 11.66 h with delayed amniotomy, p = .000) but higher the caesarean section (CS) rate was observed (10.7 versus 2.7% with delayed amniotomy, p = .049). With early amniotomy, the proportion of women delivering within 12 h was higher (86.7 versus 60%, p = .000) and the maximum oxytocin concentration used was lower (30.05 versus 39.68 mU/min, p = .001) as compared to delayed amniotomy. The neonatal outcomes were similar in the two groups. Early amniotomy detected meconium prior to initiating uterine contractions with oxytocin in three women who underwent CS for meconium. CONCLUSION: Initiating IOL with amniotomy in women with a favorable cervix was efficacious in expediting delivery, but it resulted in a higher CS rate. The higher CS rate was partly due to CS for meconium detected as a result of early amniotomy. Clinical Trials Registry (CTRI), India: Registration number CTRI/2015/01/005418.

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.