Retraction: Implementation of Postpartum Hemorrhage Emergency Care Using a Bundle Approach at a Tertiary Care Hospital in North India.

[This retracts the article DOI: 10.7759/cureus.26819.].

Implementation of Postpartum Hemorrhage Emergency Care Using a Bundle Approach at a Tertiary Care Hospital in North India.

Background The major cause of maternal death globally is postpartum hemorrhage (PPH). When PPH develops, early detection of bleeding and rapid treatment with evidence-based guidelines can prevent most PPH-related severe morbidity and mortality. The bundle care approach for PPH management could be a potential solution to inefficient and uneven evidence-based practice implementation worldwide. Bundle care is a collection of discrete, evidence-based interventions given to every eligible person simultaneously or in quick succession and requires teamwork, communication, and cooperation. The primary objective of this study was to analyze whether implementing a PPH bundle of care may reduce maternal morbidity and mortality in our institution. Methods This was a single-center retrospective pre-post case-control study was carried out at a tertiary care center and teaching hospital in Varanasi, eastern Uttar Pradesh state, India. From January 2021 to June 2021, pretraining data (PRE) were collected retrospectively on all births from the department of Obstetrics and Gynecology, Sir Sunderlal Hospital, Institute of Medical Sciences, Banaras Hindu University. Subsequently, medical and paramedical personnel of our hospital were trained in Postpartum Hemorrhage Emergency Care Using a Bundle Approach (PPH EmC) as per the guidelines laid down by the World Health Organization (WHO) for PPH management and implemented in July 2021. Post-training data (POST) were then collected retrospectively on all deliveries at our hospital from August 2021 to January 2022. All the data within two periods were computed and analyzed. The results were then compared for any significant changes in the incidences of maternal mortality and morbidity in terms of the rates of blood transfusion required and the type of management used (medical or medical-surgical), use of tranexamic acid, and additional uterotonics. The results were expressed as proportions, and p≤0.05 was considered statistically significant using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, NY, USA). Results A total of 1304 women gave birth from January 2021 to January 2022, of whom 107 patients (61 in the PRE and 57 in the POST group) were diagnosed and treated for PPH. There was no significant difference in the incidence of PPH in the PRE and POST groups (p=0.581). There was a significant increase in the use of tranexamic acid (p=0.041) and a significant reduction in blood transfusion rates (p=0.032) after the implementation of bundled care in the POST group. The odds of PPH non-occurrence after pre- and post-test was 1.103 (95% CI=0.747 to 1.635). No significant difference was observed in maternal mortality in the PRE and POST groups (p=0.96). The requirement for radical surgical treatment of PPH, which included hysterectomies, was also significantly reduced, from 27.27% in the PRE group to 11.54% in the POST group (p=0.032). Conclusions PPH care bundles might improve the morbidity of PPH with the use of fewer resources and fewer interventions required. While these data are promising, further studies are needed to analyze bundle care's long-term effects.

Obstetric violence: Comparing medical student perceptions in India and the UK.

OBJECTIVE(S): Obstetric Violence refers to professional deficiencies in maternity care, which can occur in both low and high resource settings. Examples include non-dignified care, lack of respect when giving care, discrimination and abandonment of care. The objective of this study was to assess knowledge and attitudes towards obstetric violence in a cohort of medical students in India and the UK. STUDY DESIGN: An online survey was sent to 240 UK and 280 Indian medical students. This incorporated a video showing a dramatized scenario of obstetric violence. The survey assessed participant's demographics and prior knowledge of obstetric violence. Participants scored their perceptions of eight behaviours in the video on visual analogue scales. Participants were asked to reflect on their own practice and score this. Comparisons of survey responses between UK and Indian participants were made using chi squared/Student's t-test. RESULTS: 62 Indian medical students and 58 UK medical students completed the survey. Indian medical students were significantly more likely to be male (p < 0.001). 26 % of UK participants had previously heard the term obstetric violence, compared to 34 % of Indian participants (p = 0.15). Both were able to correctly define obstetric violence at similar rates (32 % versus 34 %). Indian medical students were significantly less critical (p < 0.001) of all eight scored behaviours in the video of obstetric violence compared to their UK counterparts. UK medical students were significantly less likely to agree that the video had changed their perception on how teams should behave and act in this context (p < 0.001). 90 % of UK participants and 38 % of Indian participants had received training in professional behaviours. 14 % of UK participants had seen examples of obstetric violence in clinical practice compared to 49 % of Indian participants. CONCLUSIONS: UK and Indian medical students were able to identify behaviours associated with obstetric violence, although the majority were previously unaware of the term. Indian medical students in this study were less critical of obstetric violence in the video, which may be because of cultural reasons, greater numbers of male students, greater exposure to obstetric violence or less training on professional behaviours. Standardised training to prevent obstetric violence should be part of undergraduate medical training internationally.

A study of oxidative stress in cervical cancer- an institutional study.

Cervical cancer is the second most common cause of cancer-related death among women worldwide, especially in developing countries. Oxidative stress has been associated with cervical cancer. Many studies demonstrated that the low level of antioxidants induces the production of free radicals that cause lipid peroxidation, DNA, and protein damage leading to mutations that favors malignant transformation. This is a case-control institutional study conducted to evaluate the level of oxidative stress in cervical cancer patients and the age-matched healthy controls. We measured level of TBARS expressed as MDA, activity of SOD and GSH level by the spectrophotometric method, and level of 8-OHdG was estimated using a competitive sandwich ELISA assay. Our results showed a significant increase in the level of lipid peroxidation in group IV when compared to the control, group II and group III (p < 0.001). The activity of SOD was also significantly higher in group IV when compared to the control group (p < 0.001), group II (p < 0.001), and group III (p < 0.001). The level of GSH was also significantly lower in group IV when compared to the control group (p < 0.01), group II (p < 0.01), and group III (p < 0.01). The level of 8-OHdG was significantly higher in group IV than in the other groups (p < 0.01). The results suggest that oxidative stress is involved in the pathogenesis of cervical cancer, which is demonstrated by an increased level of lipid peroxidation and higher levels of 8-OHdG and an altered antioxidant defense system.

Anxiety, Depression and Behavioural Changes in Junior Doctors and Medical Students Associated with the Coronavirus Pandemic: A Cross-Sectional Survey.

INTRODUCTION: Medical students are known to have high levels of depression, anxiety and stress from the high-pressure environments that they study and train in. The coronavirus pandemic presents source of stress and anxiety to large populations in general, and to healthcare professionals in particular. This study was undertaken to assess the psychological effects of this pandemic on the mental health of medical students and trainees. MATERIALS AND METHODS: An online questionnaire was designed to capture information on the participant's anxieties related to the pandemic and included a validated tool for the assessment of anxiety and depression symptoms (GAD-7 and PHQ-9, respectively). The questionnaire was prepared on Google Forms, and the link to the questionnaire was disseminated to 113 medical students and junior doctors on 19 April 2020, and the survey closed on 22 April 2020 midnight. RESULTS: The survey was sent to 113 students, and 83 students participated. Of the participants, 47 (56.6%) were female and 36 (43.4%) were male, and 80 (96.4%) were aged less than 30 years old. Formal anxiety and depression scores using the GAD-7 and PHQ-9 tools indicated 15/82 (18.3%) had anxiety scores of 0 (lowest possible) and 21/82 (25.6%) had the lowest possible depression score of 0. However, 6/82 (7.3%) had scores that were classified as severe depression. Females had significantly higher median anxiety (5 v 2, p < 0.002) and depression scores (5 v 3, p = 0.025) than male participants. Direct patient care and care of patients with Covid-19 did not result in significant deterioration in anxiety and depression. CONCLUSION: Female students/junior doctors showed higher anxiety and depression scores than males. Direct patient care and care of patients with Covid-19 did not result in a measurable deterioration in anxiety and depression in this study. In this stressful pandemic situation, it is imperative to look after the mental health of healthcare workers as well as patients.

Pyruvate Kinase M2 and Cancer: The Role of PKM2 in Promoting Tumorigenesis.

Pyruvate kinase plays a pivotal role in regulating cell metabolism. The final and rate-limiting step of glycolysis is the conversion of Phosphoenolpyruvate (PEP) to Pyruvate, which is catalyzed by Pyruvate Kinase. There are four isomeric, tissue-specific forms of Pyruvate Kinase found in mammals: PKL, PKR, PKM1, and PKM2. PKM1 and PKM2 are formed bya single mRNA transcript of the PKM gene by alternative splicing. The oligomers of PKM2 exist in high activity tetramer and low activity dimer forms. The dimer PKM2 regulates the rate-limiting step of glycolysis that shifts the glucose metabolism from the normal respiratory chain to lactate production in tumor cells. Besides its role as a metabolic regulator, it also acts as protein kinase, which contributes to tumorigenesis. This review is focused on the metabolic role of pyruvate kinase M2 in normal cells vs. cancerous cells and its regulation at the transcriptional level. The review also highlights the role of PKM2 as a potential diagnostic marker and as a therapeutic target in cancer treatment.

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

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

Heat-Stable Carbetocin versus Oxytocin to Prevent Hemorrhage after Vaginal Birth.

BACKGROUND: Postpartum hemorrhage is the most common cause of maternal death. Oxytocin is the standard therapy for the prevention of postpartum hemorrhage, but it requires cold storage, which is not available in many countries. In a large trial, we compared a novel formulation of heat-stable carbetocin with oxytocin. METHODS: We enrolled women across 23 sites in 10 countries in a randomized, double-blind, noninferiority trial comparing intramuscular injections of heat-stable carbetocin (at a dose of 100 µg) with oxytocin (at a dose of 10 IU) administered immediately after vaginal birth. Both drugs were kept in cold storage (2 to 8°C) to maintain double-blinding. There were two primary outcomes: the proportion of women with blood loss of at least 500 ml or the use of additional uterotonic agents, and the proportion of women with blood loss of at least 1000 ml. The noninferiority margins for the relative risks of these outcomes were 1.16 and 1.23, respectively. RESULTS: A total of 29,645 women underwent randomization. The frequency of blood loss of at least 500 ml or the use of additional uterotonic agents was 14.5% in the carbetocin group and 14.4% in the oxytocin group (relative risk, 1.01; 95% confidence interval [CI], 0.95 to 1.06), a finding that was consistent with noninferiority. The frequency of blood loss of at least 1000 ml was 1.51% in the carbetocin group and 1.45% in the oxytocin group (relative risk, 1.04; 95% CI, 0.87 to 1.25), with the confidence interval crossing the margin of noninferiority. The use of additional uterotonic agents, interventions to stop bleeding, and adverse effects did not differ significantly between the two groups. CONCLUSIONS: Heat-stable carbetocin was noninferior to oxytocin for the prevention of blood loss of at least 500 ml or the use of additional uterotonic agents. Noninferiority was not shown for the outcome of blood loss of at least 1000 ml; low event rates for this outcome reduced the power of the trial. (Funded by Merck Sharpe & Dohme; CHAMPION Australian New Zealand Clinical Trials Registry number, ACTRN12614000870651 ; EudraCT number, 2014-004445-26 ; and Clinical Trials Registry-India number, CTRI/2016/05/006969 .).

Effect of Mula Bandha Yoga in Mild Grade Pelvic Organ Prolapse: A Randomized Controlled Trial.

BACKGROUND: Pelvic organ prolapse is the growing health issue related to women of the reproductive and postmenopausal age group in India and across the globe. Treatment option for pelvic organ prolapse includes both surgical and non-surgical intervention. The development of pelvic organ prolapse is an indication for major surgery among 20% of all women. Nevertheless, the recurrence of pelvic organ prolapse is detected among 58% of the patient after surgery. This highlights the need for preventive measures for reducing the impact of pelvic organ prolapse. AIMS AND OBJECTIVE: To study the effect of 3 months yoga therapy in female patients suffering from mild pelvic organ prolapse. MATERIAL AND METHODS: 50 Participants were allocated into two groups (25 in each group) by generating Random allocation sequence. Women aged 20-60 with symptomatic mild pelvic organ prolapse in the yoga group were offered Mulabandha yoga therapy along with other conventional treatment modalities, while the control group was only on conventional treatment. All participants gave written informed consent. An assessment was done by improvement in chief complaints and Pelvic Floor Distress Inventory-20 (PFDI-20) & Pelvic floor impact Questionnaire-7 (PFIQ-7) at baseline and at the end of 4, 8 & 12 weeks. Results At the end of 12 weeks, Post-study comparison between the two groups showed a significant improvement in chief complaints like perennial pain, P/V discharge, Perineal muscle laxity and Feeling of something coming out P/V (P < 0.001). Participants in the yoga group improved by (on average) 5.7 (95% confidence interval 3.1 to 14.7) points more on the PFDI-20 than did participants in the control group (P = 0.1) and a mean score of PFIQ-7 was also improved significantly. CONCLUSIONS: Although Mulabandha (Root Lock) yoga therapy led to a significantly greater improvement in PFDI-20 & PFIQ-7 scores the difference between the groups was below the presumed level of clinical relevance (15 points). More studies are needed to identify factors related to the success of Mulabandha (Root Lock) yoga therapy and to investigate long-term effects.

Lignocaine augments the in-vitro uterine contractions involving NO-guanylyl cyclase dependent mechanisms.

AIMS: Lignocaine is used during intrapartum and postpartum period but there are conflicting reports regarding the effect of lignocaine on uterine contractility. Therefore, this study was undertaken to delineate the effect of lignocaine on uterine contractility and the underlying mechanisms. MAIN METHODS: The in vitro contractions were recorded from the uterine segments obtained from adult rats (in estrous phase) and also from human myometrial tissue. Effect of lignocaine on spontaneous uterine contractions was recorded in the absence or presence of antagonists. Effect of sodium nitroprusside (SNP, NO donor) on uterine contractility was assessed. The NO2- was assayed (indicator of NO activity) from the supernatant after exposing the myometrial tissue to lignocaine in the absence or the presence of L-NAME or hemoglobin. KEY FINDINGS: Lignocaine (100µM) increased the amplitude of uterine contractions by 75% with no alterations in frequency. Similar magnitude of increase was seen with human myometrial tissue also. The spontaneous activities were absent in Ca2+-free or in nifedipine (10µM) containing medium. Heparin (IP3 blocker, 10IU/ml), but not the indomethacin (10µM) blocked the lignocaine-induced augmentation. L-NAME (NOS inhibitor, 10µM) or methylene blue (guanylyl cyclase inhibitor, 100µM) partially blocked the lignocaine-induced augmentation. SNP (30µM) increased the amplitude of spontaneous uterine contractions. Lignocaine increased the NO2- content (indicator of NO activity) of uterine tissue and the increase was blocked by L-NAME or hemoglobin. SIGNIFICANCE: Present observations indicate that lignocaine augments the amplitude of uterine contractions via Ca2+-dependent mechanisms involving NO-G cyclase-dependent mechanisms.

Perceived Efficacy and Intentions Regarding Seeking Mental Healthcare: Impact of Deepika Padukone, A Bollywood Celebrity's Public Announcement of Struggle with Depression.

The current research examines the impact of Deepika Padukone's (one of the most popular Bollywood celebrities) public announcement of struggle with depression on people's perceived efficacy and intentions to seek help for mental healthcare. A survey conducted with 206 participants from India, the country with the highest depression rates in the world, revealed that parasocial interaction with the celebrity mediated the effect of exposure on intentions and efficacy perceptions regarding seeking mental healthcare. Our study expands the research on celebrity influence on health conditions in an international realm and in a mental health context. The findings have immense practical implications and may raise awareness about mental health in India given the popularity and reach of Bollywood among audiences in India and beyond, the level of stigmatization attached to mental health issues in India, and the lack of available resources for care. Theoretically, the study explores processes and effects of involvement with a celebrity and discusses potential implications for the behaviors related to health.

Outcome of Diabetic Pregnancies in a Tertiary Referral Centre, Varanasi.

AIM: The study was done to determine the maternal and fetal outcome of pregnancies complicated by maternal diabetes either Gestational Diabetes Mellitus (GDM) or preexisting (type 1 or type 2) diabetes over a period from March 2011 to Feb 2013 in a tertiary care hospital, Varanasi. METHODS: This is a retrospective audit of the maternal and fetal outcome of women who presented to the Sir Sundar Lal Hospital, Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India from March 2011 to Feb 2013, with GDM or pre-existing type 1 or type 2 Diabetes with pregnancy. The audit group comprised 65 pregnancies (67 babies), of whom 27 had preexisting diabetes and 38 cases developed gestational diabetes. Pregnant women who were found to be diabetic preconceptionally or in the first trimester were classified as 'pre-existing diabetes'. RESULTS: There were total of 65 diabetic women in this retrospective study, 39 women were GDM (60 %) while 26 women (40 %) were having pre-existing diabetes (24 type 1 diabetes and 2 women were in type 2 diabetes group). There were 35 multigravid women (53.85 %) and 30 primigravid women (46.15 %). There were 39 (60 %) women on Insulin. There were 42 Lower Segment Caesarean Section (64.62 %) and 23 Spontaneous Vaginal Delivery (35.38 %). In fetal and neonatal complications, there were three still births, one case of intrapartum death, and one case of shoulder dystocia. Fetal anomalies were less frequent, one case of Gastroschisis with Hydrocephalus associated with Menigomyelocoele, there was one case of isolated Hydrocephalus, and there was also one case of Truncus arteriosus. CONCLUSIONS: The study analyses maternal and fetal complication in the GDM group and also preexisting diabetes group. In our centre, the 60 % women were GDM while 40 % were having pre-existing diabetes. Total rate of fetal/neonatal complication rate was 7.69 % and of congenital anomaly rate it was 9.23 %. Proportion of still birth, Intrauterine death, and congenital malformations was higher in the pre-existing diabetes group although the data are not large enough to draw a statistically significant conclusion. LSCS rate was little higher in the GDM group (69.23 %) in comparison to the preexisting diabetes group where it was 57.69 %. SVD (Spontaneous Vaginal Delivery) rate was 30.77 % in GDM and 42.31 % in the pre-existing diabetes group. HbA1c was within normal range 84.62 % of GDM group while in 15.38 % it was raised >6 %. In the pre-existing diabetes group, only 19.23 % of women had HbA1c within acceptable range and 80.77 % had it >6. The aim of St Vincent Declaration is to 'achieve pregnancy outcome in the diabetic woman that is similar to that of the non-diabetic woman.' But, so far we have not been able to achieve this. Our HbA1c level is remarkably high in the pre-existing diabetes group. Only 3 out of 65 patients' women took Folic Acid periconceptionally. We need to work to achieve it our best. It is well known that insulin treatment during pregnancy results in reduction in the rate of macrosomia, fetal/neonatal, and maternal complications. Therefore, we need to use insulin judiciously and advocate its usage in the situations where it is needed.

Role of oxidative stress and low-grade inflammation in letrozole-induced polycystic ovary syndrome in the rat.

The aims of the current study were to examine the effects of temporal changes in oxidative stress (OS) and low-grade inflammation in letrozole-treated rats and to correlate these changes with the development of polycystic ovary syndrome (PCOS)-like features. Rats were treated with letrozole for 7, 15 and 21 days to induce PCOS. On day 7 of the treatment, a significant increase in serum testosterone and high sensitive C-reactive protein (hsCRP), the low-grade inflammatory marker, was found in the letrozole treated rats compared to control rats. Moreover, a decreased immunoexpression of insulin receptor coincided with increased body weight. The strong correlation between the levels of hsCRP and lipid peroxidation (LPO) suggests simultaneous development of low-grade inflammation and OS in response to hyperandrogenism, and the role of OS in a formation of cystic follicles in the letrozole animal PCOS model. Therefore, the results of the present study suggest that OS and low-grade inflammation (hsCRP) are the major causes of PCOS induction in this model.

Acute intermittent porphyria in pregnancy: a case report and review of literature.

The porphyrias are a group of rare metabolic disorders, each arising from a predominantly hereditary catalytic dysfunction of one of the eight enzymes in the porphyrin-haem biosynthetic pathway. Acute intermittent porphyria is the commonest type of porphyria worldwide. The disease is more common in women than men. It is therefore important for the obstetricians to know about this entity as many women present with abdominal pain during pregnancy. This case shows that if acute intermittent porphyria is properly treated in a mother there is normal maternal and foetal outcome. A case of acute intermittent porphyria known before pregnancy has been reported in a patient who had three spontaneous abortions in the past, she was delivered by elective caesarean section. The pathogenesis of the disease, its' symptoms, diagnosis, therapeutic approach both during and out of pregnancy have been also discussed.