Mental health issues in antenatal women with prior adverse pregnancy outcomes: Unmasking the mental anguish of rainbow pregnancy.

Background & objectives: Mental health issues in pregnancy have adverse implications on the quality of life, however still they go unevaluated and underreported. Women with previous history of abortions or stillbirth may have a higher risk of experiencing mental health problems. The present investigation was aimed to study the prevalence of depression, anxiety, stress and domestic violence in antenatal women with prior pregnancy losses and the need for interventions to treat the same. Methods: One hundred pregnant women with a history of prior pregnancy losses (group 1) and 100 women without obstetrical losses (group 2) were enrolled in this cross-sectional study carried out in a tertiary care hospital in India. Women were screened for depression, anxiety, stress and domestic violence using various questionnaires: EPDS (Edinburgh postnatal depression scale), PRAQ-2 (pregnancy-related anxiety questionnaire-revised 2), GAD 7 (generalized anxiety disorder-7) and PSS (perceived stress scale). Results: The prevalence of depression (EPDS scale) and pregnancy specific anxiety (PRAQ-2 scale) was significantly higher in group 1 than in group 2 (27 vs. 10%, P=0.008; and 15 vs. 6%, P=0.03). The prevalence of general anxiety (GAD 7 scale) and stress (PSS), however, was high and comparable in both the groups (33 vs. 29%, P=0.44; and 33 vs. 27%; P=0.35 respectively). Recurrent abortions was found to be an independent risk factor for depression [adjusted odds ratio=26.45; OR=28]. In group 1, 31 per cent required counselling in the psychiatry department and nine per cent required medication. Interpretation & conclusion: Mental health issues, especially depression, are prevalent in antenatal women with previous losses. Unrecognised and untreated, there is a need for counselling and developing screening protocols at India's societal and institutional levels.

Pregnancy in Eisenmenger syndrome: a case series from a tertiary care hospital of Northern India.

BACKGROUND: Despite advances in medical care, we still come across pregnancy in Eisenmenger syndrome. Eisenmenger syndrome represents the severe end of the spectrum for disease in pulmonary artery hypertension associated with CHD. Due to very high maternal and perinatal morbidity and mortality, pregnancy is contraindicated among these women. Current guidelines also recommend that the women who become pregnant should opt for early termination of pregnancy. Here, we present a case series of 11 women of Eisenmenger syndrome and their pregnancy outcome. METHODS: It was a retrospective analysis of 12 pregnancies among 11 women with Eisenmenger syndrome who were managed in a tertiary care referral centre of Northern India. RESULTS: The mean age of these women was 28 ± 4 years (range 22 to 36 years). Almost 80% of them (9/11) were diagnosed with Eisenmenger syndrome during pregnancy. The commonest cardiac lesion was Ventricular Septal defect (54.5%) followed by Atrial Septal defect (27.3%) and Patent Ductus arteriosus (9.1%). Only three women opted for medical termination of pregnancy, rest eight continued the pregnancy or presented late. Pregnancy complications found include pre-eclampsia (50%), abruption (22%), and fetal growth retardation (62.5%). There were three maternal deaths (mortality rate 27%) in postpartum period. CONCLUSION: This case series highlights the delay in diagnosis and treatment of CHD despite improvement in medical care. Women with Eisenmenger syndrome require effective contraception, preconceptional counselling, early termination of pregnancy, and multidisciplinary care.

Facility-based stillbirth surveillance review and response: an initiative towards reducing stillbirths in a tertiary care hospital of India.

OBJECTIVES: India has the highest number of stillbirths in the world in 2019, with an estimated stillbirth rate of 13.9 per 1,000 births. Towards better identification and documentation, a stillbirth surveillance pilot was initiated with the World Health Organization Southeast Asia collaboration in Northern India in 2014. This study aimed to assess whether stillbirth surveillance is feasible and whether this approach provides sufficient information to develop strategies for prevention. METHODS: This study followed the framework provided in "WHO Making Every Baby Count" in which mortality audit is conducted in six steps; (1) identifying cases; (2) collecting information; (3) analysis; (4) recommending solutions; (5) implementing solutions; and (6) evaluation. RESULTS: A total of 5,284 births were examined between December 2018 and November 2019; 266 stillbirths were identified, giving a stillbirth rate of 50.6 per 1,000 births in a tertiary care referral hospital of northern India. Out of 266 stillbirths, 223 cases were reviewed and recommendations were formulated to strengthen obstetric triage, implementing fetal growth charts, strengthen the existing referral system and improve the communication skills of health care providers for better compliance with clinical practice guidelines. CONCLUSIONS: Conducting stillbirth surveillance review and the response of cases in low-middle income countries setting is feasible. As countries progress towards ending preventable mortality, this has the potential to serve as a key process in improving evidence-based and context-specific planning and preventive strategies towards improving the quality of care.

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.

Classifying stillbirths in a tertiary care hospital of India: International Classification of Disease-perinatal Mortality (ICD-PM) versus cause of death-associated condition (CODAC) system.

A number of classification system are available to classify stillbirths, but there remains a lack of a uniform global system of classification. This study evaluated the feasibility of the ICD-PM classification system and COD-AC to classify the stillbirths and to discuss the interpretation of "the newer" classification system (ICD-PM) over the COD-AC system. Over a period of one year, out of 5776 total births 314 were stillborns with a stillbirth rate of 54 per 1000 total births. As per ICD PM Classification System, 69.1% of stillbirths were ante partum and rest intrapartum. The associated maternal conditions at the time of foetal death were also classified into five groups and maximum mothers (44.3%) were grouped under M4-medical/surgical disorders. According to COD-AC system of classification 90% of cases were assigned the cause of death, rest 10% remained unexplained. The ICD-PM and CODAC classification both seem to be feasible but ICD-PM clearly defines the time of foetal death and correlates feto-maternal dyad together.IMPACT STATEMENTWhat is already known on this subject? Classifying stillbirths is crucial to recognise the actual cause of foetal death and to gather the relevant information for planning the preventive strategies especially in low middle-income countries (LMICs) which contribute to 98% of total global burden of 2.6 million stillbirths annually. In literature CODAC system was found most suitable for low middle-income countries. In 2016, WHO proposed a newer system, i.e., ICD-PM: WHO application of ICD-10 to deaths during the perinatal period.What do the results of this study add? With ICD-PM classification stillbirths were categorised more clearly in different groups and feto-maternal condition were linked together along with both intrapartum and ante partum stillbirth which can help to set the priorities and future planning for prevention. The proportion of unexplained stillbirth has also reduced significantly compared to CODAC system.What are the implications of these findings for clinical practice and/or further research? CD-PM system of classification seems feasible and would facilitate the uniform and consistent stillbirth data even from LMICs for global comparison although more number of studies are needed for conclusion. The system has been changed to ICD-PM in our institute.

Role of perfusion CT in the evaluation of adnexal masses.

The objective of this study was to evaluate the role of perfusion computed tomography (PCT) in differentiating benign from malignant adnexal masses. Twenty patients, each of pathologically proven malignant and benign adnexal masses who had undergone PCT on 64-slice CT scanner, were included in the study. The PCT parameters, viz. blood volume (BV), blood flow (BF), permeability surface index area (PS) and time to maximum of the tissue residue function (Tmax) of the adnexal masses were calculated. Statistical analysis to study the association between PCT parameters and histopathological diagnosis was done. In the malignant group, the mean PS, BV and BF values were elevated. The mean Tmax of the benign lesions was higher compared to that of the malignant lesions. There was a significant statistical difference in the PCT parameters between the malignant and benign groups (p value = .001). PCT can be a useful tool for differentiating benign and malignant adnexal masses. Impact statement What is already known on this subject? It is not always possible to distinguish benign from malignant adnexal lesions despite the application of various imaging techniques. Perfusion CT (PCT) is an imaging technique with which we can obtain both the morphological and functional information of tumours. Perfusion-based imaging enables us to objectively evaluate the neovascularity in a lesion. This helps in differentiating the benign lesions from aggressive malignant lesions. What do the results of this study add? The PCT parameters, viz. blood volume (BV), blood flow (BF), permeability surface index area (PS) and time to maximum of the tissue residue function (Tmax) were calculated from adnexal masses on a 64-multi-slice CT scanner and correlated with their histopathological diagnoses. The values of the mean PS, BV and BF values were significantly higher in the malignant adnexal masses. The mean Tmax in the benign masses was more compared to that of the malignant lesions. Significant statistical difference was seen in PCT parameters between malignant and benign groups. What are the implications of these findings for clinical practice and/or further research? PCT can be a useful tool for differentiating benign from malignant adnexal masses. However, more collaborative research and robust validation are imperative to further evaluate this innovative evolving technique.

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.

Quality of recovery and analgesia after total abdominal hysterectomy under general anesthesia: A randomized controlled trial of TAP block vs epidural analgesia vs parenteral medications.

BACKGROUND AND AIMS: Parenteral analgesics and epidural analgesia are two standard options to treat postoperative pain after total abdominal hysterectomy (TAH). Fascial plane blocks such as transversus abdominis plane (TAP) block have gained popularity recently. However, effect of these analgesic regimens on quality of postoperative recovery (QoR) has not been studied. Hence we aimed to assess and compare the QoR with three different postoperative analgesic regimens---parenteral analgesia, epidural analgesia, and TAP block in patients undergoing TAH under general anesthesia. MATERIAL AND METHODS: Sixty female patients undergoing TAH were randomized into three groups of 20 each for postoperative analgesia. Epidural group received boluses of 0.125% bupivacaine for 24 h, parenteral group received injection diclofenac and injection tramadol alternately every 6 h for 24 h, and TAP group received bilateral TAP block with 0.25% bupivacaine at end of operation. QoR was assessed postoperatively by 40-item questionnaire-QOR-40 and pain was assessed by numerical rating scale (NRS). RESULTS: QOR-40 score was comparable across the three groups at 24, 48, and 72 h postoperatively. TAP block prolonged the time to first rescue analgesic (P = 0.02) and reduced the total 24-h postoperative morphine consumption by 2.4 (95% CI: 1.0, 3.8) mg (P = 0.002) and 7.8 (95% CI: 6.4, 9.1) mg (P < 0.001) when compared with epidural and parenteral groups, respectively. CONCLUSION: The QoR after abdominal hysterectomy is similar with either intravenous analgesics or epidural analgesia or TAP block when used with rescue analgesia to manage postoperative pain. TAP block provides superior analgesia and reduces 24-h morphine consumption when compared with parenteral and epidural analgesia.

Intraoperative Transesophageal and Postoperative Transthoracic Echocardiographic Evaluation of a Mechanical Heart Valve Prosthesis Implanted at Aortic Position.

OBJECTIVE: The aims of this study were to evaluate the intraoperative transesophageal echocardiographic (iTEE) characteristics and Doppler flow profile of aortic Chitra heart valve prosthesis (CHVP) under stable hemodynamic and loading conditions, and to compare and correlate the iTEE data with the postoperative transthoracic echocardiography (TTE) data obtained at 48 hours (TTE1) and 3 months (TTE2) after the surgery. DESIGN: Prospective, observational study. SETTING: University-level tertiary referral hospital. PARTICIPANTS: Forty patients between 18 years and 65 years of age undergoing elective aortic valve replacement (AVR) using CHVP during the period January 2015 to August 2016. INTERVENTIONS: After obtaining permission from institutional ethics committee, 40 patients undergoing elective AVR were studied prospectively. The iTEE examination was performed in the pre-cardiopulmonary bypass (CPB) and post-CPB period in all the study subjects. CHVP was subjected to iTEE two-dimensional (2D) echo, color Doppler, and spectral Doppler evaluation under stable hemodynamic and loading condition in the post-CPB period after the administration of protamine. The CHVP were re-evaluated using TTE in all the patients 48 hours after the surgery (TTE1) and 3 months after the surgery (TTE2). The iTEE and postoperative TTE Doppler values were compared and correlated. MEASUREMENTS AND MAIN RESULTS: The CHVP could be imaged adequately and interrogated with Doppler in all the patients. None of the patients had restriction of occluder mobility or unstable seating of the valve. The intraoperative flow dependent (peak velocity [PV] and mean pressure gradient [MPG]) and less flow dependent (Doppler velocity index, acceleration time, acceleration time/ejection time, effective orifice area [EOA] and indexed EOA) Doppler parameters of CHVP were measured as per the American Society of Echocardiography recommendations. The PV and MPG of CHVP measured by iTEE showed no statistical difference (p > 0.05) and were in limits of agreement when compared with TTE1 and TTE2 data. CONCLUSION: The iTEE features of CHVP were found compliant with the criteria set by the ASE defining normal functioning of an aortic valve prosthesis. The iTEE Doppler parameters obtained under stable loading conditions strongly predicted the postoperative values of Doppler parameters on TTE examination. The iTEE Doppler values can be used as the reference values for the postoperative follow up studies.

Role of Autopsy in Elective Termination of Pregnancy for Fetal Anomaly (ETOPFA): A Study from a Tertiary Care Hospital in India.

OBJECTIVE: To evaluate the fetal anomalies in all the patients who underwent elective termination of pregnancy for fetal anomalies (ETOPFA) before 20 weeks of gestation and to compare prenatal diagnosis with final diagnosis made after autopsy. METHODOLOGY: Prospective study done in a tertiary care hospital in India over a period of two years which include 252 women who underwent ETOPFA. The prenatal diagnosis was compared with final diagnosis made after autopsy. RESULTS: In 75.4% of cases autopsy findings were concordant with prenatal diagnosis where as in 21.6% of cases, additional findings were added. In 2.9 % of cases prenatal diagnosis was not confirmed by autopsy and found to be discordant. CONCLUSIONS: Autopsy plays an important role in completing the final diagnosis along with verification of prenatal diagnosis. To avoid discrepancy especially in cases of severe oligohydramnios, MRI or amnioinfusion could be offered for conformation of the diagnosis before offering ETOPFA.

Stillbirths: progress and unfinished business.

This first paper of the Lancet Series on ending preventable stillbirths reviews progress in essential areas, identified in the 2011 call to action for stillbirth prevention, to inform the integrated post-2015 agenda for maternal and newborn health. Worldwide attention to babies who die in stillbirth is rapidly increasing, from integration within the new Global Strategy for Women's, Children's and Adolescents' Health, to country policies inspired by the Every Newborn Action Plan. Supportive new guidance and metrics including stillbirth as a core health indicator and measure of quality of care are emerging. Prenatal health is a crucial biological foundation to life-long health. A key priority is to integrate action for prenatal health within the continuum of care for maternal and newborn health. Still, specific actions for stillbirths are needed for advocacy, policy formulation, monitoring, and research, including improvement in the dearth of data for effective coverage of proven interventions for prenatal survival. Strong leadership is needed worldwide and in countries. Institutions with a mandate to lead global efforts for mothers and their babies must assert their leadership to reduce stillbirths by promoting healthy and safe pregnancies.

Intraoperative assessment of transient and persistent regional left ventricular wall motion abnormalities in patients undergoing coronary revascularization surgery using real time three-dimensional transesophageal echocardiography: A prospective observational study.

OBJECTIVE: To evaluate the feasibility of intraoperative real time three-dimensional echocardiography (RT3DE) for identification and quantification of transient and persistent regional wall motion abnormalities (RWMAs) in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG). DESIGN: A prospective observational study SETTING: Single-center study in an academic tertiary care hospital PARTICIPANTS: A series of 42 patients undergoing elective CABG over a 2-year period were included. INTERVENTION: After induction of anesthesia, a comprehensive transesophageal echocardiography (TEE) examination was performed to evaluate regional wall motion using two-dimensional wall motion score index (WMSI) and RT3D echocardiographic parameters at three specific time points during the operative phase. MEASUREMENTS AND MAIN RESULTS: The 3D assessment of LV function was based on the quantification of change in LV chamber volume over time from each segment excursion. Patients were divided into two groups and subgroups based on TEE findings. There was significant mechanical dyssynchrony in patients with RWMAs (WMSI > 1; systolic dyssynchrony index [SDI] = 7.0 ± 3.66) as compared to the patients having normal wall motion (WMSI = 1; SDI = 2.0 ± 0.95; P = .001). Patients with contractile dysfunction were found to have low values of segmental excursion and high values of negative excursion on parametric imaging. Persistent RWMAs due to hibernating myocardium showed significant resolution of mechanical dyssynchrony after revascularization. Parametric imaging could detect transient RWMAs due to stunning and graft dysfunction. Early activating segments (EAS) on "timing bull's-eye" may represent hypercontractile segments and may influence inotrope administration. CONCLUSION: The RT3DE is a valuable modality for precise quantification of regional wall motion during revascularization procedure.

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.

Evisceration as fetal destructive operation: an art revisited.

Fetal destructive operation is a vanishing art today. In an era of increasing cesarean deliveries it has become a historic event. Incidence of destructive operation has varied from various Indian hospitals 0.09-0.28%. Evisceration is one of the rarest of all destructive operations, performed in cases of cephalopelvic disproportion with large fetal abdominal or thoracic tumors and fetal malformations, which are incompatible with life. Less than 50 cases of fetal evisceration have been reported in the literature so far. We are presenting a case of gross fetal abdominal malformation in a multigravida woman, which necessitated internal podalic version followed by evisceration and breech extraction.

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.

Obstetrical catastrophe averted: successful outcome of an abdominal pregnancy.

Abdominal pregnancy is defined as an implantation in peritoneal cavity, exclusive of tubal, ovarian, or intraligmentary pregnancy.These pregnancies are rarely encountered and can go undiagnosed until advanced period of gestation [1]. Frequency of abdominal pregnancy has been directly related to the frequency of ectopic gestation as constituting 2% of ectopics and nearly 0.01% of all pregnancies [2-4]. These pregnancies are seen more commonly in developing countries and poses special challenges to the clinician. Advanced abdominal pregnancy is life-threatening condition and carries high risk of hemorrhage, disseminated intravascular coagulation, bowel injury, and fistulae [5]. The perinatal outcome is mainly influenced by the availability of blood supply and site of implantation [6]. Most of the fetus die in utero because of compromised environment, and those who survive face problems due to congenital malformations [3,7]. Patients of abdominal pregnancy can have variable clinical presentation, and physical examination may be inconclusive for making diagnosis [7,8]. Clinical features like irregular bleeding per vaginum, abdominal pain, dyspepsia, altered bowel habits, malpresentation, and extremely anteriorly placed cervix should raise the suspicion [2,3,8,9]. Diagnostic challenge with oxytocin stimulation, abdominal x-ray, hysterosalpingography, and ultrasonography has been used as tools to assist in diagnosis [10,11]. Magnetic resonance imaging is found to complement sonography in making accurate diagnosis and can be useful to demonstrate the relationship between fetus, the cervix, and the myometrium [12]. We hereby report a successful operative delivery of a live baby after a term extrauterine abdominal pregnancy in a multigravida in whom the diagnosis was made after laparotomy.

A study of obstetricians' knowledge, attitudes and practices in oral health and pregnancy.

BACKGROUND: Many studies have reported an association between periodontitis and adverse pregnancy outcomes, but there has been little research on the knowledge of obstetricians regarding oral care. The aim of the study was to assess the knowledge and attitudes of practicing obstetricians in India about the relationship between oral health and pregnancy outcomes, as well as their practice behaviors regarding oral healthcare in pregnant women in Indian settings. METHODS: A structured online questionnaire was sent to 130 obstetricians in the city of Chandigarh and adjoining areas of the union territory. The questionnaire was prepared by dentists and obstetricians and was validated in a prior pilot study. Obstetricians' knowledge of the effects of pregnancy on oral health, and vice versa, were correlated with their experience and practices. RESULTS: A total of 79.2% responded to the questionnaire. More than 70% of respondent obstetricians correctly knew of the effects of periodontitis on preterm birth and low birth weight babies. Only 40% recommended dental examination during pregnancy and 47% advised patients about oral care during pregnancy. There were significant correlations between knowledge of dental health effects on pregnancy and referrals of patients to dentists. CONCLUSIONS: This study found that although obstetricians generally were knowledgeable about appropriate dental care practices during pregnancy as well as the relationship between oral health and pregnancy outcomes, this knowledge often did not translate into appropriate practice behavior.

Thoracotomy Patients Under General Anesthesia: A Comparison on Intra-Operative Anesthetic and Analgesic Requirements, When Combined with Either Epidural Analgesia or Continuous Unilateral Paravertebral Analgesia.

BACKGROUND AND OBJECTIVE: Regional analgesia is effective for post-thoracotomy pain. The primary objective of the study is to compare the intraoperative requirement of isoflurane and fentanyl between general anaesthesia (GA) with epidural analgesia and GA with paravertebral analgesia. METHODS AND MATERIAL: A prospective observational comparative study was conducted on 56 patients undergoing open thoracotomy procedures. The patients were divided into two groups of 28 by assigning the study participants alternatively to each group: Group GAE - received thoracic epidural catheterization with GA, and Group GAP - received ultrasound guided thoracic paravertebral catheterization on the operative side with GA. Intraoperative requirement of isoflurane, fentanyl, postoperative analgesia, stress response, need of rescue analgesics and adverse effects were observed and analysed. RESULTS: 25 patients in each group were included in the data analysis. The intraoperative requirement of isoflurane (32.28 ± 1.88 vs 48.31 ± 4.34 ml; p < 0.0001) and fentanyl (128.87 ± 25.12 vs 157 ± 30.92 µg; p = 0.0009) were significantly less in the GAE group than in the GAP group. VAS scores and need of rescue analgesics and blood glucose levels were not statistically significant during the postoperative period (p > 0.05). The incidence of adverse effects was comparable except for hypotension and urinary retention which were significantly higher in the GAE group. CONCLUSION: GA with epidural analgesia resulted in significant reduction in the intraoperative consumption of isoflurane and fentanyl in comparison to GA with paravertebral analgesia. However, both the techniques were equally effective in the postoperative period.

Recommended measurement instruments for genitourinary symptoms associated with menopause: the COMMA (Core outcomes in menopause) consortium.

OBJECTIVE: The aim of the study is to identify appropriate definitions and patient-reported outcome measures (PROMs) for each of the eight core outcomes previously selected for genitourinary symptoms associated with menopause: pain with sex, vulvovaginal dryness, vulvovaginal discomfort or irritation, discomfort or pain when urinating, change in most bothersome symptom, distress, bother or interference of genitourinary symptoms, satisfaction with treatment, and side effects. METHODS: We conducted a systematic review to identify possible definitions and PROMs, including their measurement properties. Identified definitions and relevant PROMs with acceptable measurement properties were entered into an international consensus process involving 28 participants from 10 countries to achieve final recommendations for each core outcome. RESULTS: A total of 87 publications reporting on 34 PROMs were identified from 21,207 publications screened. Of these 34 PROMs, 29 were not considered to sufficiently map onto the core outcomes, and 26 of these also had insufficient measurement properties. Therefore, only five PROMs corresponding to two core outcomes were considered for recommendation. We recommend the PROMIS Scale v2.0 - Sexual Function and Satisfaction: Vaginal Discomfort with Sexual Activity to measure the outcome of "pain with sexual activity" and the Day-to-Day Impact of Vaginal Aging (DIVA) Questionnaire to measure "distress, bother or interference" from genitourinary symptoms. Six definitions of "side effects" were identified and considered. We recommend that all trials report adverse events in study participants, which is a requirement of Good Clinical Practice. CONCLUSIONS: Suitable PROMs and definitions were identified to measure three of eight core outcomes. Because of the lack of existing measures, which align with the core outcomes and have evidence of high-quality measurement properties, future work will focus on developing or validating PROMs for the remaining five core outcomes.