Antepartum Depression and Its Clinico-Social Correlates: A Cross Sectional Study in a Tertiary Hospital of North India.

Background: Maternal depression, the second leading cause of disease burden in women worldwide is often under-diagnosed and untreated. It can have consequences for pregnancy outcomes and child health. Objectives: (1) To estimate the prevalence of antepartum depression among females attending antenatal clinic of a tertiary hospital. (2) To determine its obstetric and clinico-social correlates. Methods: A cross-sectional study was conducted in antenatal clinic by consecutive sampling of 300 pregnant women. We included those in third trimester, aged 18-40 years and giving informed consent and excluded those with pre-diagnosed mental disorders. Pre-tested structured questionnaire and Edinburgh postnatal depression scale used. Score ≥ 10 indicated possible antepartum depression (APD). Chi-square test and logistic regression analysis applied using IBM SPSS version 22.0. P < 0.05 was considered statistically significant. Results: Prevalence of possible APD was 23.3%. It was higher among urban females (25.3%) than rural (17.7%) but the difference was not statistically significant. APD increased with increasing maternal age. Other socio-demographic and obstetric factors were not associated significantly with APD. History of recent stressful life event, domestic violence, marital conflict, lack of support from husband, and preference of male child were found to be the significant correlates. Conclusions: More than one out of five antenatal females had possible antepartum depression, but none had sought treatment for the same. Antenatal women of higher age and those afflicted with social pathologies are more at risk. Screening for APD should be included in the maternal and child health care programme to address this hidden 'iceberg' disease.

Introducing Birth Companion in Labour: A Quality Improvement Initiative.

Background: Birth companion (BC) has been globally recognised as an essential component of childbirth care. As our institution did not allow BC in labour, this study was planned as a quality improvement (QI) project to introduce the concept. We aimed to achieve birth companionship from existing 0 to 100% over a period of six months. Intervention: QI team was constituted, and an initial brainstorming session conducted. A fishbone diagram was drawn to analyse issues that need addressal before implementation of the initiative. The framework was defined, and team members assigned their roles and responsibilities. A series of five successive Plan-Do-Study-Act (PDSA) cycles were carried out over a period of six months, which included introduction of the concept, dissemination of information, infrastructural changes in labour room and introducing column for documentation in birth register. To achieve sustainability, comprehensive group counselling sessions were started for women during antenatal period, and sensitisation classes were regularly conducted for newly inducted trainees and faculty. Result: Birth companionship was achieved in 98% of cases. Conclusion: The QI tools helped in preparation and planning of changes by breaking down a large problem into smaller sections and covering all aspects of challenges in a systematic manner using team-based approach. National directives and recommendations, sensitisation of leadership and training of stakeholders were found to be important facilitators. Robust systems of monitoring and successive PDSA cycles were needed for continuous improvement and sustainability of the idea.

Stillbirths in India: Current Status, Challenges, and the Way Forward.

Stillbirth is a major public health challenge and a multifaceted issue that leads to significant financial, physical, mental, financial, and psychosocial implications. India has made substantial progress in stillbirth reduction. Yet, many challenges continue and the absolute number of stillbirths remain high. This paper presents the national and state level burden of stillbirths and discusses about the magnitude, risk factors, causes and inequities in stillbirths. A few additional approaches for reduction of preventable stillbirths have been suggested. The authors argue that the institutional mechanisms need to be developed to ensure all stillbirths are registered in a timely manner. There is a need for standard definition for classification of stillbirths and document the cause, to roll-out suitable interventions. There is a need for state specific interventions to address different causes, as Indian states have variable stillbirth rates. The stillbirth audits should be institutionalised as a continuous quality improvement exercise to bring local accountability and reduce stillbirth rate. The healthcare system and providers must be trained to offer bereavement support to the affected mothers and families. These approaches should be implemented through primary healthcare system as well.

Burden, Differentials and Causes of Stillbirths in India: A Systematic Review and Meta Analysis.

India contributes the highest absolute number of stillbirths in the world. This systematic review and meta-analysis was conducted to synthesize the burden, timing and causes of stillbirths in India. Forty-nine reports from 46 studies conducted in 21 Indian states and Union Territories were included. It was found that there was no uniformity/standardization in the definition of stillbirths and in the classification system used to assign the cause. The share of antepartum stillbirths was estimated to be two-third while remaining were intrapartum stillbirths. Maternal conditions and fetal causes were found to be the leading cause of stillbirth in India. The maternal condition was assigned as the commonest cause (25%) followed by fetal (14%), placental cause (13%), congenital malformation (6%) and intrapartum complications (4%). Approximately 20% of the stillbirths were assigned as unknown or unexplained. This review demonstrates that there is a paucity of quality stillbirth data in India. Other than the state level differences in stillbirth rates, no other data is available on inequities in stillbirths in India. There is an urgent need for strengthening availability and quality of stillbirth data in India on both stillbirth rates as well as the causes. There is a need to conduct additional research to know the timing of the stillbirths, causes of death and actual burden. India needs to strengthen stillbirth audits along with registry to find out the modifiable factors and delays for making country specific preventive strategies. The policy makers, academic community and researchers need to work together to ensure accelerated and equitable reduction in stillbirths in India.

Decreasing the Rate of Surgical Site Infection in Patients Operated by Cesarean Section in a Tertiary Care Hospital in India: A Quality Improvement Initiative.

Background Surgical site infections (SSIs) are a substantial cause of maternal morbidity and are associated with a significant increase in hospital stay and cost. The prevention of SSI is complex and requires the integration of a range of measures before, during, and after surgery. Jawaharlal Nehru Medical College (JNMC), Aligarh Muslim University (AMU) is one of the referral centers of India with a huge influx of patients. Methods The project was undertaken by the Department of Obstetrics and Gynaecology, JNMC, AMU, Aligarh. Our department was sensitized to the need for quality improvement (QI) through Laqshya, a Government of India initiative for labor rooms in 2018. We were facing problems like a high surgical site infection rate, poor documentation and records, no standard protocols, overcrowding, and no admission discharge policy. There was a high rate of surgical site infections, leading to maternal morbidity, increased days of hospitalization, more usage of antibiotics, and increased financial burden. A multidisciplinary quality improvement (QI) team was formed comprising obstetricians and gynecologists, the hospital infection control team, the head of the neonatology unit, staff nurses, and multitasking staff (MTS) workers. Results The baseline data were collected for a period of one month and it was found that the rate of SSI was around 30%. Our aim was to decrease the rate of SSI from 30% to less than 5% over a period of six months. The QI team worked meticulously, implemented evidence-based measures, regularly analyzed the results, and devised measures to overcome the obstacles. The point-of-care improvement (POCQI) model was adopted for the project. The rate of SSI decreased significantly in our patients and the rates are around 5% persistently. Conclusion The project not only helped in decreasing the infection rates but also led to vast improvements in the department with the formulation of an antibiotic policy, surgical safety checklist, and admission-discharge policy.

An insight into genes responsible for fosfomycin resistance among uropathogens of asymptomatic bacteriuria during pregnancy: A North Indian study.

Purpose: Asymptomatic bacteriuria (ASB) is a common finding during pregnancy. Effective antibiotic treatment could reduce its adverse effects on both mother and fetus. However, emerging antimicrobial resistance limits the treatment options. Fosfomycin might be a promising drug in this regard, as its resistance is still low. The aim of the study was to determine the antimicrobial susceptibility pattern of fosfomycin in isolates causing ASB by disc diffusion and agar dilution (in selected isolates), determine minimum inhibitory contribution (MIC) by agar dilution in isolates resistant by disc diffusion and detect the genes responsible for fosfomycin resistance. Methods: This was a 2-year study carried in the Department of Microbiology, Jawaharlal Nehru Medical College and Hospital (JNMCH), Aligarh Muslim University (AMU), Aligarh. A total of 10 252 urine samples from asymptomatic pregnant females (18-45 years) attending the antenatal care (ANC) outpatient department (OPD) were submitted. Identification of pathogen and antimicrobial susceptibility testing (AST) was carried out as per standard methods of CLSI. There was phenotypic detection of methicillin-resistant Staphylococcus aureus (MRSA) and other Staphylococcus species (MRSS), high-level aminoglycoside resistance (HLAR), vancomycin resistant Enterococci (VRE) and S. aureus (VRSA), extended spectrum ß-lactamase (ESBL) and carbapenem-resistant Enterobacterales (CRE). All the fosfomycin-resistant isolates (by disk diffusion) were tested by agar dilution. Conventional PCR was performed for murA, fosA, uhpT and glpT genes on all resistant isolates. Result: In this study, the prevalence of ASB among pregnant females was 1173(11.4 %), in which Escherichia coli 495(42 %) was the predominant organism. The overall sensitivity of fosfomycin among Gram-positive cocci (GPC) and Gram-negative bacilli (GNB) was 99 % and 97.6 %, respectively. MRSA and MRSS accounted for 50 (66.6 %) and 71 (76 %), respectively. The highest rates of MIC >2048 µg ml-1 were shown by most isolates (mainly E. coli ) on agar dilution. PCR studies revealed four E. coli strains possessed both murA (also present in one K. pneumoniae strain) and glpT genes. While only one isolate ( E. faecalis ) was positive for fosA gene. But none of the strain possessed the uhpT gene. Conclusion: According to this study, murA and glpT genes were more frequent than fosA. We cannot comment on the prevalence and regional distribution of fosfomycin-resistant genes based on this preliminary study. Therefore, more Indian studies should be carried out to create awareness about the presence of genes in a particular area.

Immunohistopathological changes in the placenta of malaria-infected women in unstable transmission setting of Aligarh.

INTRODUCTION: Pregnant women are more susceptible to malaria due to a combination of physiological and immunological changes. The infection may even affect the growth and survival of the foetus, which mainly occur when parasite enters the placenta. The sequestration of infected erythrocytes may trigger the host response, leading to placental inflammation and altered development, affecting the structure and nutrient transport of placenta. These factors collectively impair placental functions and affect foetal growth. METHODS: Pregnant women with peripheral parasitaemia for P. falciparum and P. vivax (20 each) were included in the present study, along with 15 age-matched uninfected healthy pregnant women. Placentae were analysed for the presence of local parasitaemia along with pathological lesions caused due to the parasite. Immunohistochemical staining for CD20, CD45 and CD68 cells was performed for examining the specific leucocytes in the intervillous space of the placenta. RESULTS: Of the 20 individuals with P. falciparum, only seven placentae showed parasitaemia, whereas individuals with P. vivax showed no placental infection. The pathological changes observed in the P. falciparum-infected placenta include syncytial knotting, excess fibrinoid deposition, syncytiotrophoblast necrosis, syncytial rupture, thickening of trophoblast basement membrane and increased collagen deposition. Immunohistochemical staining showed a significant increase in B cells (CD20), leucocytes (CD45) and monocytes and macrophages (CD68) in the P. falciparum-infected placenta (p < 0.0001). DISCUSSION: The result implies that P. falciparum is responsible for pathological alterations in placenta, affecting the nutrient transport across placenta and foetal growth. The immune cells also migrate to the placenta and accumulate in the intervillous space to show humoral and cell-mediated immunity against the parasite.

Decreased Foetal Movements Secondary to Uterine Septum: A Case Report and Proposed Algorithm of Management.

Congenital uterine anomaly has been well established as cause of infertility and recurrent pregnancy loss. However, only few studies have reported the association of mullerian anomalies and adverse pregnancy outcome in third trimester. We are hereby reporting a case of 25-year- old female second gravida who presented at 36 weeks six days pregnancy with complaint of decreased foetal movements for the past two weeks. The female had previous history of multiple admissions on account of decreased foetal movements in the third trimester. Ultrasonography for biophysical profile and cardiotocography were done on each admission which revealed normal findings. Decision to terminate the pregnancy was taken because of persistent decreased foetal movements. She was induced with dinoprostone gel 0.5 mg intracervically; however she underwent lower segment caesarean section on account of non reassuring cardiotocography. Peroperative findings confirmed the presence of partial uterine septum.

Abdominal pregnancy: Methods of hemorrhage control.

Abdominal pregnancy is an extremely rare form of ectopic pregnancy, mostly occurring secondarily after tubal rupture or abortion with secondary implantation anywhere in the peritoneal cavity. Massive intra-abdominal hemorrhage is a life threatening complication associated with secondary abdominal pregnancy. Various methods and techniques have been reported in the literature for controlling hemorrhage. Here, we report a case of massive intraperitoneal haemorrhage following placental removal controlled by abdominal packing and review the literature for diagnostic and management challenges.

Foetal autopsy-categories and causes of death.

INTRODUCTION: Intrauterine death(IUD)/ Stillbirth forms a major part of perinatal mortality which thereby is a good indicator of pregnancy wastage as well as quality of healthcare available. The key objectives of autopsy examination are to know the cause(s) of death, elucidation of pathogenic mechanism and quality control of clinical management. The aim of this study was to identify the prevalent causes of IUD, thereby taking appropriate measures to prevent them and decrease the perinatal mortality rate. MATERIALS AND METHODS: The study included 14 cases of IUD received for autopsy in the Department of Pathology over a period of five years. Autopsies were performed as per standard protocol and included full anthropometric profile, external examination, gross and microscopic evaluation of different organs and placenta. RESULTS: Total number of 14 fetal autopsies were performed over a period of 5 years. The causes were broadly classified as fetal, maternal and placental. Placental causes were seen in majority of cases (48.57%) followed by fetal (35.72%) and then maternal (21.42). Most prevalent cause of death was congenital anomalies (28.6%) followed by placental insufficiency (21.4%) and chorioamnionitis (14.2%). CONCLUSION: Determination of causes of fetal death would prove beneficial to the clinicians and parents for better management and care in future pregnancies as well as in genetic counseling.

Acquired gynatresia.

Vaginal stenosis (gynatresia) is commonly congenital, occurring as a part of Mayer-Kustner-Hauser syndrome. Those occurring postabortal or postpartum are rarely seen nowadays. Here, we report two cases, one in which there was complete stenosis postpartum following a retained gauze and another case, with chemical vaginal burns following attempted abortion by a local untrained midwife.

A study on antioxidant and apoptotic effect of Azadirachta Indica (neem) in cases of cervical cancer.

PURPOSE: To study the anti-oxidant properties of neem (Azadirachta indica) in inducing apoptosis of cervical cancer cells and estimation of caspase activity and TNF-α and IFN-γ levels in monocytes of cervical cancer patients and controls. METHODS: Monocytes were cultured from blood samples of 65 study cases and 30 controls for the estimation of caspase 3, 8 and 9 with specific inhibitors and TNF-α and IFN-γ levels in culture supernatant of monocytes. Two cervical biopsies were taken from 18 cases of moderately differentiated SCC. One biopsy was formalin fixed for histopathology and the other for tissue culture was kept in RPMI-1640 medium to evaluate the apoptotic effect of neem extract on malignant cells. RESULTS: Neem-treated monocytes from cervical cancer patients showed high activity levels of caspase 3, 8, and 9. A decrease in TNF-α and an increase in IFN-γ levels was seen in culture supernatant of monocytes. Cyto- and histomorphology of neem-treated cervical cancer cells exhibited increased apoptosis. CONCLUSION: Neem is a potent inducer of apoptosis in biopsies of cervical cancer patients.

Smear patterns and spectrum of premalignant and malignant cervical epithelial lesions in postmenopausal Indian women: a hospital-based study.

Cervical cancer is one of the leading causes of morbidity and mortality among women but can be prevented through simple cost-effective measures, such as creating awareness, and regular screening with the Pap smear, both in the premenopausal and postmenopausal age group. This study was carried out to study the cervical smear patterns and type of cervical epithelial lesions in a group of postmenopausal Indian females and the relationship with clinical profile of patients. Pap smears were taken from 320 postmenopausal Indian females and meticulously screened. Lesions were classified according to type of postmenopausal pattern. 120 smears showed varying degrees of premalignant and malignant changes, which were classified using the Bethesda system. The findings were correlated with duration of menopause, parity, and duration of sexual activity and significance was derived. Histopathological correlation was conducted in those cases where biopsies were available. It was found that as the age of the patients increased, the incidence of low-grade and high-grade squamous intraepithelial lesions and carcinoma also increased with the relationship being statistically significant. The occurrence of these lesions also showed an association with increasing parity and period of sexual activity. Thus, it can be concluded that it is important to create widespread awareness about the necessity of regular screening, including the postmenopausal period. Conventional cytology or the Pap smear is a cost-effective and efficient method for screening of patients but requires training and experience to minimize errors. It is suitable for developing regions where costlier techniques are not in routine use.

A primary ovarian pregnancy with a contralateral ruptured corpus luteum: a case report.

A primary ovarian pregnancy is one of the rarest varieties of ectopic pregnancies. The conditions which are most commonly confused with an ovarian pregnancy are, a ruptured corpus luteal cyst, a haemorrhagic corpus luteum and a ruptured endometriotic cyst. This case presents the clinical and the histological findings of a ruptured ovarian pregnancy, along with a ruptured corpus luteal cyst in the contralateral ovary.

Neoplastic and nonneoplastic ovarian masses: Diagnosis on cytology.

OBJECTIVE: To evaluate the role of fine needle aspiration cytology (FNAC) in the distinction between neoplastic and nonneoplastic ovarian masses. MATERIALS AND METHODS: One hundred and twenty patients with ovarian masses were studied. After detailed history and clinical examination, ultrasound (USG)-guided FNAC was performed in 92 clinical benign cases while FNAC and/or imprints of surgically resected ovarian masses was performed in 28 clinically suspected malignant cases. The smears were stained with Papanicolaou stain and histopathological sections were stained with hematoxylin and eosin stain with inclusion of special stain whenever required. Serum ß-human chorionic gonadotrophin and α-fetoprotein estimations were carried out in cytologically diagnosed germ cell tumors. RESULTS: The overall sensitivity, specificity and diagnostic accuracy of FNAC in diagnosing various ovarian masses were 79.2%, 90.6% and 89.9%, respectively. CONCLUSIONS: The clinical examination, pelvic ultrasound and FNAC were complementary and none of the methods was, in itself, diagnostic. However, USG-guided FNAC was found to be a fairly specific and accurate technique and should be employed as a routine, especially in young females with clinically benign ovarian lesions. The reasons for false diagnosis and limitations of USG and FNAC have been analyzed.