Comparative evaluation of nebulised dexmedetomidine vs fentanyl for the treatment of post-dural puncture headache (PDPH) in parturients after caesarean section under spinal anaesthesia: A randomised controlled study.

Background and Aims: The incidence of post-dural puncture headache (PDPH) following spinal anaesthesia in the obstetric population is around 0.5%-2%. Hydration, bed rest, caffeine, paracetamol, non-steroid anti-inflammatory drugs, epidural blood patches, etc., are the various modalities used for its management. This study aims to compare nebulised dexmedetomidine versus fentanyl for the treatment of PDPH in parturients after caesarean section under spinal anaesthesia. Methods: Ninety obstetric patients aged 18-35 years with American Society of Anesthesiologists (ASA) physical status II/III and suffering from PDPH as per the criteria of the International Headache Society after caesarean section under spinal anaesthesia were recruited in this double-blinded randomised study. Patients were randomised to Group D (dexmedetomidine 1 µg/kg nebulisation), Group F (fentanyl 1 µg/kg nebulisation), and Group S (saline nebulisation 4mL). The nebulisation was done 12 hourly for 72 hours. Assessment parameters included pain score and the requirement of additional treatment such as paracetamol, caffeine, and epidural blood patch. Analysis of variance test was used for continuous quantitative variables, and the Kruskal-Wallis test was used for quantitative discrete data. Results: The pain scores at 1, 6, 12, 24, 48, and 72 hours following nebulisation were significantly lower in Group D in comparison to groups F and S (P < 0.001). The number of patients requiring additional analgesic therapy was lower in Group D in comparison to patients in other groups (P < 0.001). Conclusion: Dexmedetomidine nebulisation resulted in effective reduction in PDPH symptoms and pain scores. Nebulisation with fentanyl did not alleviate PDPH symptoms when compared to the control group.

Giant Colpolithiasis in Urogenital Sinus Anomaly with Urethral Duplication: A Case Report and Review of Literature.

ABSTRACT: Primary vaginal calculi are uncommon in children. Urethral duplication in females is seen to occur in association with complex congenital malformations. We report the case of perianal persistent urogenital sinus with a hypertrophied clitoris with phallic urethra, scrotum-like pouch, uterus didelphys with obstructed hemivagina, and giant colpolithiasis in 46XX female. A 16-year-old presented with pain abdomen and cyclic passage of blood clots per rectum. She had a tender lump in left iliac region, a phallus like protrusion and a ruggous sac below it. Vaginal opening was absent. Computed tomography showed two uterine horns with a separate cervix and distended non-communicating hemivaginas with a large calcified oval mass in the left hemivagina. On exploration, calculus was extracted from the left hemivagina. The large calculus found in the left hemivagina appears to be the cause of all presenting symptoms. It obstructed the left hemivagina, filling the left uterine horn with menstrual blood causing its gradual enlargement and secondary infection. The early diagnosis and prompt referral of such an anomaly can only be ensured in institutional deliveries. For a significant proportion of newborns in the developing world, the ability to afford or even be referred to institutes which deal with such cases is a luxurious affair. We hope to bridge bridging the knowledge, attitude and practice gap that exists in our health-care system with this report.

A Randomized Trial of Inpatient and Home-Based Maternal Oral Hydration Therapy in Isolated Oligohydramnios and Its Effect on Amniotic Fluid Index and Perinatal Outcome.

Background Isolated oligohydramnios, without any known fetal/maternal abnormality, may be associated with insufficient oral intake (such as water, glucose, and rehydration therapy). Therefore, the present study was conducted to assess the improvement following maternal hydration. Method A total of 50 cases of isolated oligohydramnios (other high-risk pregnancy conditions not present) were included in the study (25 in each group). Patients were encouraged for an additional 2 liters of oral rehydration solution intake daily along with regular diet. The fluid intake was unsupervised in the home group and supervised in the hospital group. Serial amniotic fluid index (AFI) measurements and fetal monitoring were performed. Birth weight and APGAR scores were recorded, and data were analyzed. Results The two groups were comparable in terms of demographics and baseline laboratory findings. AFI significantly improved in the hospital group compared to the home group (p-value: <0.001). Birth weight, placental weight, and APGAR scores were also significantly better in the hospital group than in the home group. Conclusion Maternal oral hydration therapy improves the amniotic fluid volume and subsequently improves the perinatal outcome. Due to poor compliance with home-based treatment, institution of supervised hydration therapy is recommended.

Modified WHO Partograph in Labour Room: A Quality Improvement Initiative to Find Out Concerns, Challenges and Solutions.

Every day many women die in pregnancy and childbirth, most of which are preventable. Regular and timely labour monitoring by partograph is of utmost importance. The aim of this study was to increase partograph use by residents in the Department of Obstetrics and Gynecology in all eligible women from existing 25% to 90% over six months through a quality improvement (QI) process. A team of six members including consultants, residents, and staff nurses did a root cause analysis through fishbone analysis to identify why the rate of use of partograph is only 25% of all cases. Many strategies were implemented through Plan-Do-Study-Act (PDSA) cycles for the cause identified. The interventions were allocation of triage area for timely identification of eligible women in the active phase of labour, training of residents, involving interns and nurses for use in shortage of staff, making departmental written policy, and assigning checking authority, to shift patients with attached partograph only; partograph has to be attached in the file right from the beginning when sisters make women admission file. These were done in five PDSA cycles and the outcome was measured by a control chart. The rate of partograph use increased from 25% to 92% over the study period of six months from September 2020 to February 2021. Regular audits were conducted to maintain the results. It can thus be concluded that partograph appears easy to implement and inexpensive, but its use still has enormous difficulties. But a QI approach can help in improving adherence to partograph use, by solving the root cause of the concern and challenges.

Study of Adaptability and Efficacy of Menstrual Cups in Managing Menstrual Health and Hygiene: A Descriptive Longitudinal Study.

Introduction Menstrual cup is a device made up of silicon for menstrual hygiene. Despite its being safe, eco-friendly, cheap, and durable its non-acceptability may be due to higher adoption barriers. We conducted this study to assess the adaptability and efficacy of menstrual cups. Methods It was a descriptive longitudinal study, conducted in a tertiary care institute in eastern India. Women of 18-50 years of age, educated till secondary level were included in the study, to be conducted over three months. The quantitative response for the satisfaction with the menstrual cup was measured on a five-point Likert scale after each menstrual cycle. Side effects, the quantity of blood flow and frequency of cleaning the menstrual cup, and how many participants will continue to use it were also asked. Results After the third menstrual cycle, 68.9% of participants stated that they would continue the menstrual cup usage. The mean total satisfaction score improved from 5.4 (first cycle) to 12.6 (third cycle) (p<0.001). The majority (67%) had no side effects, 10% had irritation and leakage, and 13% had an unpleasant odor. Conclusions The study shows that menstrual cups are a better alternative. Adaptability increases gradually through proper counseling, peer support, and practice.

Risk of vertical transmission of SARS CoV-2 infection to neonates born to covid positive mothers: A pilot study from a tertiary care hospital of North India.

OBJECTIVES: To assess the risk of neonatal SARS-CoV-2 infection born to the women with confirmed SARS-CoV-2 infection. MATERIALS AND METHODS: This prospective study was conducted at single tertiary hospital from September 2020 and May 2021. 50 pregnant women with confirmed SARS-CoV-2 infection and 50 neonates were included for analysis. We performed comprehensive testing of all biological samples for vertical transmission including the cord blood immunoglobulin. RESULTS: We detected SARS-CoV-2 in one fetal membrane and one amniotic fluid sample. We also demonstrated presence of anti-SARS-CoV-2 IgM antibodies in cord blood of 3 neonates. Though none of the samples of vaginal secretion, breast milk and nasopharyngeal swab from neonates were tested positive for covid infection via RT-PCR. We demonstrated presence of anti-SARS-CoV-2 IgG antibodies in the cord blood which had shown positive correlation with increasing disease to delivery interval and disease severity. CONCLUSION: Vertical transmission of SARS-CoV-2 is possible. As virus was not detected in cervicovaginal secretions and breast milk so vertical transmission through this mechanism seems unlikely. Presence of IgG in cord blood is suggestive of passive immunity acquired from mother. This finding has greater clinical implication as large number of expecting mothers are being vaccinated.

Evaluation of Safety Concerns for COVID-19 Immunization of Pregnant Women: a Systematic Review of Emerging Evidence.

Objectives: There is an urgent need to review the status of COVID-19 vaccine immunization in pregnant women globally, so that adverse outcomes may be prevented. In this study, we performed a systematic review to evaluate the probable outcomes of COVID-19 vaccination in pregnant women. Materials and methods:An electronic search over three months (June 15-August 15, 2021) was conducted. Original studies evaluating safety concerns in pregnant women for COVID-19 vaccination were included. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guidelines were used for data collection and reporting of findings. Results:COVID-19 vaccination in pregnant women was not associated with increased adverse effects or complications to the mother as well as the developing fetus or new-born compared to non-vaccinated pregnant women. Vaccinated pregnant women showed a robust immune response against COVID-19 infection. Conclusion:COVID-19 vaccination during pregnancy causes no significant health risks for the mother or the developing fetus or new-born.

Endometrial stromal sarcoma with sex cord differentiation: An uncommon tumor posing diagnostic challenge.

Endometrial stromal sarcoma with sex cord differentiation is a very unusual neoplasm affecting the uterine cavity with an incidence of only 0.25%. They can cause difficulties in diagnosis due to it is histologic appearance and rarity of occurrence. Histopathological diagnosis still remains the cornerstone of diagnosis. Immunohistochemistry and molecular studies are also very helpful. We report a case of a 47-year-old patient who was diagnosed clinically and radiologically as intramural leiomyoma, but on histopathology examination and immunohistochemically proved to be endometrial stromal sarcoma with sex cord differentiation.

Rate of premalignant and malignant endometrial lesion in "low-risk" premenopausal women with abnormal uterine bleeding undergoing endometrial biopsy.

OBJECTIVE: To determine the incidence of endometrial hyperplasia and endometrial cancer (EH/EC) in low-risk premenopausal women with abnormal uterine bleeding (AUB) undergoing endometrial biopsy and to build a predictive model that includes clinical variables for predicting EH/EC in these women. METHODS: This retrospective study was conducted between January 2015 and March 2020. All premenopausal women aged <55 years with AUB who underwent endometrial sampling during a specified time period were included. Data regarding baseline characteristics, sonographic findings, and histological reports were collected from patient record sheets. RESULTS: During the specified time period, 1,089 premenopausal women underwent endometrial biopsy for AUB. Complete data analysis was done for 1,084 women. Of the endometrial samples, 95.3% revealed benign pathology, whereas 4.7% of the samples had major endometrial pathology EH/EC. On step-wise logistic regression analysis, intermenstrual bleeding (IMB) (OR, 3.15), body mass index (BMI) >25 kg/m2 (odds ratio [OR], 4.4705), age >40 years (OR, 1.14), endometrial thickness (ET) >13 mm (OR, 2.59), and hypothyroidism (OR, 1.35) were significantly associated with EH/ EC. Considering the pretest probability for an EH/EC of 4.7%, this prediction model with a likelihood ratio of 14.2% demonstrated a post-test probability of 41% in the presence of the above-mentioned variables. CONCLUSION: The risk of EH/EC was lower in low-risk premenopausal women with AUB. However, premenopausal women with IMB aged >40 years, hypothyroidism, BMI >25 kg/m2, and thickened endometrium (ET >13 mm) are at high risk of EH/EC; therefore, endometrial biopsy should be considered early in their management plan.

Excretion of SARS-CoV-2 in breast milk: a single-centre observational study.

Background: Breast feeding by SARS-CoV-2-infected mothers has been a concern because of the possibility of excretion of virus in breast milk. Objective: To detect SARS-CoV-2 in expressed breast milk (EBM) of mothers infected with SARS-CoV-2 and clinical outcome of neonates delivered and breast fed by them. Design: A single-centre, prospective observational study involving 50 SARS-CoV-2-infected mothers and their 51 neonates. Setting: A tertiary care hospital in Eastern India. Participants: SARS-CoV-2-infected mothers and neonates delivered by them. Main outcome measures: We investigated the presence of SARS-CoV-2 in the breast milk of mothers, who tested positive for this virus in their nasopharyngeal swab (NPS). Clinical outcome was assessed in neonates breast fed by these mothers after 1 month of the postnatal period. Results: 50 SARS-CoV-2-positive expectant mothers were enrolled for the study. One out of 51 neonates, who delivered through lower segment caesarean section at term gestation and tested SARS-CoV-2 negative, died due to severe birth asphyxia. One sample of EBM was collected from each of the 49 mothers within 4 days of delivery. All EBM samples tested negative for SARS-CoV-2 through real-time reverse transcriptase-PCR (RT-PCR). All the newborns were screened twice for presence of SARS-CoV-2 RNA in their NPS, by RT-PCR. 2 of 51 neonates had COVID-19 infection after 24 hours of life. Caregivers of 37 of 50 alive neonates responded to follow-up via telephone. Except for minor feed intolerance in one (1 of 37) neonate, all neonates were reported well after 1 month of their age. Conclusion: All the samples of breast milk were negative for SARS-CoV-2. Most of the neonates remained asymptomatic on breast feeding, whose mothers had SARS-CoV-2 infection before delivery.

Are myths surrounding long-acting reversible contraception the reason for a huge unmet need for spacing pregnancies?

Background: Long-acting reversible contraceptives (LARC), a highly effective class of contraceptives, has a limited uptake by few couples due to lack of awareness, unavailability, and myths surrounding their application and side effects. Aims: This study was undertaken to understand and to clear myths of LARC among patients as well as to assess the knowledge, attitudes, practices, and preference. Materials and Methods: A hospital-based cross-sectional study using a semistructured questionnaire was conducted in the out-patient Department of Obstetrics and Gynecology, in a tertiary level hospital in Eastern India. A total of 600 women responded to the structured validated questionnaire. Results: High prevalence of teenage marriages (64%), teenage pregnancies (44%), and unwanted pregnancy (41%) was noted among responders. The knowledge scores were low in 66.7%, moderate in 26.66%, and only 6.66% had high level >80% scores in the 15 questions about LARC methods. While 41% had a positive attitude to future use of LARC, a majority (59%) had a strong negative attitude due to many myths of genital tract infections, discharges, and cancer, changed menstrual bleeding patterns, delayed conception after discontinuation, and altered sexual functions. Out of those with a positive attitude, 21% of women had a preference for intrauterine devices, 19.5% of women for injectables, and only 0.5% of women preferred contraceptive implants. 24.5% of women had used LARC in their lifetime but a meager 5% were currently using them. Conclusions: The study shows that there is a huge unmet need for spacing contraceptive methods as childbearing spacing is not maintained. There were lack of correct knowledge and awareness, and numerous myths surrounding LARC methods.

Two Distinctively Rare Syndromes in a Case of Primary Amenorrhea: 18p Deletion and Mayer-Rokitansky-Kuster-Hauser Syndromes.

Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome and 18p deletion syndrome, two genetic disorders having distinct genetic etiologies, have an exceedingly rare likelihood of coexistence. Vaginal agenesis or MRKH syndrome, the developmental failure of Mullerian ductal system-derived structures in a genotypic female fetus (46, XX), leads to congenital absence of uterus and vagina in variable degree. The 18p deletion syndrome is a rare chromosomal disorder, characterized by dysmorphic features, stunted growth, and mental retardation, which is caused by deletion of a part or all of the short arm of chromosome 18. A detailed evaluation of primary amenorrhea in a 16-year-old girl yielded both MRKH syndrome and 18p deletion syndrome. Extensive literature search could not identify any reported case bearing this combination of syndromes. This case presentation and review emphasizes on the importance of karyotyping in MRKH patients having atypical features.

Cesarean Scar Ectopic Pregnancy: The Lurking Danger in Post Cesarean Failed Medical Abortion.

Cesarean scar pregnancy (CSP) is a potentially life threatening ectopic pregnancy where a missed diagnosis is commoner than an accurate diagnosis. Incidence of Ectopic pregnancy is 1 - 2 % and cesarean scar ectopic occurs in about (0.05%) 1 in 2000 of all pregnancies. With increasing cesarean section rates worldwide, CSP is bound to increase with its dreaded complications like uterine rupture and catastrophic hemorrhage. Three patients misdiagnosed as incomplete miscarriages in post cesarean pregnancies in other centers were found to be CSP in Gynaecology department of a tertiary level hospital. All three patients were managed successfully, two surgically and one medically.

Cervical length measurement in nulliparous women at term by ultrasound & its relationship to spontaneous onset of labour.

Background & objectives: Data on serial cervical length (CL) measurements in pregnancy at term to predict spontaneous labour onset are scarce and conflicting. This study was conducted to observe CL changes preceding spontaneous onset of labour, by serial transvaginal sonography (TVS) and transabdominal sonography (TAS), in nulliparous Indian women near term. Methods: Only nulliparous women with a singleton foetus in cephalic presentation and who confirmed their gestational age were recruited. Sonographic CL measurements were taken at weekly intervals from 36 wk gestation onwards by a single ultrasonologist. Transabdominal and transvaginal measurements were undertaken using the suitable transducer probes with the women in the supine position. Results: A total of 104 women with spontaneous onset of labour were evaluated. There was substantial variation in CL measurements, both by TVS and by TAS, from 36 to 40 wk gestation, although the two sets of measurements correlated closely. Mean CL changed significantly over the last three weeks before delivery. However, only one-third of the women showed CL change of >5 mm per week in the last three weeks. There was poor correlation between gestational age at delivery and the last measured CL, either by TVS or TAS. Length >3.1 mm, measured by TVS at 38 wk gestation, predicted post-dated pregnancy to a limited extent. Interpretation & conclusions: Inter-individual variations in CL and in CL changes were large. Thus, it was not practical to predict spontaneous onset of labour by sonographic CL measurement near term. Post-dated pregnancy may be predicted with limited success. Further studies should explore other parameters, in addition to CL.

Normative data of cervical length in singleton pregnancy in women attending a tertiary care hospital in eastern India.

BACKGROUND & OBJECTIVES: The length of cervix predicts the risk of preterm delivery. The objective of this study was to assess cervical length in pregnancy by transvaginal ultrasonography for generating normative data for nulliparous women at no special risk of preterm labour. METHODS: An observational study was carried out in a tertiary care teaching hospital in eastern India in nulliparous women who delivered at term. A single sonologist assessed 224 women (once per subject) between 20 and 34 wk of gestation. Nulliparous women carrying a single foetus of confirmed gestational age were included; 216 subjects were finally considered for generation of normative data, excluding those delivering earlier than 37 or later than 42 wk. Other exclusion criteria were history of cerclage, any previous cervical surgery, smoking, or any medical disorder complicating pregnancy. RESULTS: Cervix length at each week of gestation gradually decreased over the study period. Length at 20 and 34 wk was 40.5 ± 1.14 mm (mean ± SD) and 34.8 ± 1.34 mm respectively. The overall shortening over this 14 wk period was 5.7 mm, with 0.58 mm per week median rate of shortening. Pearson's correlation coefficient was -0.69 (95% CI -0.75 to -0.60; P< 0.001) for cervical length vis-à-vis gestational age. INTERPRETATION & CONCLUSIONS: The serial normative data generated in our setting can be used to decide cut-off points for predicting risk of preterm labour in future studies. Validity of such prediction needs to be tested in larger cohorts of women assessed at specific gestational ages.