The optimal route of progesterone administration for luteal phase support in a frozen embryo transfer: a systematic review.

OBJECTIVE: To investigate the optimal route of progesterone administration for luteal phase support in a frozen embryo transfer. DESIGN: Systematic review. PATIENTS: Women undergoing frozen embryo transfer (FET). INTERVENTIONS: We conducted an extensive database search of Medline (PubMed), Embase, Web of Science, and Cochrane Trials Register using relevant keywords and their combinations to find randomized controlled trials (RCTs) comparing the routes (i.e., oral, vaginal, intramuscular) of progesterone administration for luteal phase support (LPS) in artificial FET. MAIN OUTCOME MEASURES: Clinical pregnancy, live birth, miscarriage. RESULTS: Four RCTs with 3245 participants undergoing artificial endometrial preparation (EP) cycles during FET were found to be eligible. Four trials compared vaginal progesterone with intramuscular progesterone and two trials compared vaginal progesterone with oral progesterone. One study favored of vaginal versus oral progesterone for clinical pregnancy rates (RR 0.45, 95% CI 0.22-0.92) and other study favored intramuscular versus vaginal progesterone for clinical pregnancy rates (RR 1.46, 95% CI 1.21-1.76) and live birth rates (RR 1.62, 95% CI 1.28-2.05). Tabulation of overall evidence strength assessment showed low-quality evidence on the basis that for each outcome-comparison pair, there were deficiencies in either directness of outcome measurement or study quality. CONCLUSION: There was little consensus and evidence was heterogeneous on the optimal route of administration of progesterone for LPS during FET in artificial EP cycles. This warrants more trials, indirect comparisons, and network meta-analyses. PROPERO NO: CRD42021251017.

Urogynecology Service at a District General Hospital in the United Kingdom - Changing Needs or a Better Understanding?

CONTEXT: The urogynecological problems in women increase with age. The National Health Services (NHS) is experiencing an increase in the demand for and costs of health and social care for women in midlife. It is a relatively new subspecialty which requires a holistic approach to a patient symptoms and expert skills to overcome demands from aging female population and fulfilling patient expectations. AIMS: The aim of the study was to analyze the referral pattern in relation to urogynecological symptoms referred to district general hospital in the United Kingdom and in turn to understand the gravity of the situation for improving the care of these women. SUBJECTS AND METHODS: This was a retrospective study of case notes of women attending the gynecological outpatient clinic led by an urogynecology subspecialist at district general hospital in the United Kingdom having attended the clinic with symptoms suggestive of pelvic floor dysfunction. RESULTS: We identified 777 women who attended the clinic with symptoms of pelvic floor dysfunction. The most frequently stated reason for referral was pelvic organ prolapse, followed by primary urinary incontinence. Majority of the patients (44%) had prolapse at diagnosis and 26% of the patients had multiple symptoms related to pelvic floor dysfunction after a urogynecologist's consultation, 5% of the patients had combined symptoms diagnosed at urogynaecology clinic. Majority of the referrals were from the general practitioners (43%). CONCLUSIONS: The study revealed that health practitioner referring the women needs better understanding of the urogynecological symptoms and with a better understanding and a thorough symptom treatment can be initiated for various symptoms at the same time. This allows patients' multiple symptoms improvement, avoids repeat referrals from primary care, avoids repeat visits to the clinics, avoids repeat interventions, and improves patients' satisfaction and therefore saves NHS resources.

Plasmacytoma of the ovary: additional role of 18F-FDG PET/CT.

We report a case of ovarian plasmacytomas where 18F-FDG PET/CT helped in staging by demonstrating increased FDG uptake limited to the ovary, and hence, surgical treatment was carried out as the disease was localized to the ovary.

Pseudoaneurysm of uterine artery: a rare cause of secondary postpartum hemorrhage, managed with uterine artery embolisation.

Uterine artery pseudoaneurysm is a rare cause of secondary postpartum hemorrhage but is potentially life-threatening and can occur after caesarean section (c-section) or a hysterectomy. A 28-year-old woman who developed secondary postpartum hemorrhage after c-section was diagnosed to have pseudoaneurysm from the left uterine artery on ultrasound (US) and computed tomography (CT) scan. She was treated with coiling of the pseudoaneurysm with stainless steel coil via selective catheterization of the uterine artery. The procedure was uneventful and the pseudoaneurysm was successfully obliterated. Angiographic embolization is a safe and effective method for treating postpartum hemorrhage due to pseudoaneurysm in hemodynamically stable patients. Therefore, it should be considered as a treatment option before resorting to surgery, in appropriately selected cases.

Second trimester abortion in women with and without previous uterine scar: Eleven years experience from a developing country.

OBJECTIVES: To study the safety of second trimester abortion in women with previous uterine scar. METHODS: We screened the records of 518 women who underwent an abortion between 12 and 20 weeks' gestation at the Postgraduate Institute of Medical Education and Research, Chandigarh, India, from January 2000 to December 2010. Methods used for abortion were: (i) vaginal misoprostol with or without pre-treatment with mifepristone, and (ii) intracervical dinoprostol gel or vaginal misoprostol ± extra-amniotic saline ± oxytocin infusion. Seventeen women, aborted by means of a hysterotomy, were excluded from further analysis. RESULTS: Of the remaining 501 women, 44 had a uterine scar (Group 1) and 457 had none (Group 2). In Group 1, 40/44 (91%) and in Group 2, 452/457 (99%) women aborted successfully. The mean induction-abortion interval (IAI) was similar in the two groups (15.03 ± 10.69 hours and 12.52 ± 9.0 hours in Groups 1 and 2, respectively; p = 0.083). There were three uterine ruptures, 1/44 (2%) in group 1 and 2/457 (0.4%) in group 2 (p = 0.132, NS); all three women had received mifepristone followed by vaginal misoprostol. CONCLUSION: In women with a scarred uterus, midtrimester abortion may be successfully achieved using any of the aforementioned regimens.

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

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

Extra hepatic portal vein obstruction and pregnancy outcome: largest reported experience.

AIM: Evaluate pregnancy outcome in women with extra hepatic portal vein obstruction (EHPVO). MATERIAL & METHODS: A total of 26 pregnancies in 14 women with EHPVO were evaluated for maternal and perinatal outcomes in a tertiary centre of Northern India. Fourteen pregnancies were evaluated prospectively while the details of 12 previous pregnancies in the same women were studied retrospectively. RESULTS: Mean age of pregnant women with EHPVO was 24.5 years and approximately one-third were primigravidae. Only one patient was diagnosed as EHPVO in the index pregnancy. The presenting event was hematemesis in 71% of the patients; others presented with thrombosis, pain abdomen and jaundice or incidental splenomegaly. The incidence of abortion, preterm deliveries and still births was 20%, 15.4% and 7.7%, respectively. Underlying hypercoagulable and prothrombotic state was diagnosed in around one-fifth of the patients. Half of these women required platelet transfusion in the intrapartum period due to hypersplenism resulting in thrombocytopenia. Anemia was seen in 40% of the patients; however, no other major complications were seen as a result of EHPVO. The vaginal delivery rate and obstetrical outcome were similar as in general population. CONCLUSION: Pregnancy outcome is expected to be successful in women with EHPVO if disease is adequately controlled prior to pregnancy.

Prevalence and related risk factors of osteoporosis in peri- and postmenopausal Indian women.

AIM: We undertook this study involving 200 peri- and postmenopausal women to determine the prevalence of osteoporosis, and in turn increase the awareness, education, prevention, and treatment of osteoporosis. SETTING AND DESIGN: Postgraduate Institute of Medical Education and Research, UT Chandigarh, India, and a clinical study. MATERIALS AND METHODS: A detailed medical, obstetrical, menstrual, and drug history was recorded in a proforma designated for the study. Height and weight was measured, weight-bearing exercise was assessed, and sunlight exposure per day for each woman was recorded. Food intake was estimated by using the 24-hour dietary recall method, and calcium and vitamin D consumption pattern was assessed. Bone mineral density (BMD) at postero-anterior lumbar spine and dual femurs was assessed by densitometer. Women were classified according to the WHO criteria. STATISTICAL ANALYSIS USED: Student's t-test, multiple logistic regression analysis. RESULTS: The prevalence of low BMD was found in more than half of this population (53%). The mean age in group I (normal BMD) was found to be 50.56 ± 5.74 years as compared to 52.50 ± 5.94 in group II with low BMD (P=0.02). The two groups were similar with respect to parity, education, socioeconomic status, family history of osteoporosis, hormone replacement therapy, and thyroid disorders. 46.8% of the women in group I and 33% of the women in group II had low physical activity and there was no statistically significant difference in sunlight exposure between the groups. Parity or the number of children and type of menopause was not seen to have much association with low BMD in our study. Lack of exercise and low calcium diet were significantly associated with low BMD. Multiple logistic regression analysis showed that age, exercise, menopause, and low calcium diet acted as significant predictors of low bone density. CONCLUSION: The findings from the study suggest the need for large community-based studies so that high-risk population can be picked up and early interventions and other life style changes can be instituted if there is delay in implementing national or international health strategies to tackle this increasing global health problem. Strategies to identify and manage low BMD in the primary care setting need to be established and implemented.

Pregnancy outcome in systemic lupus erythematosus: Asia's largest single centre study.

AIM: To evaluate pregnancy outcome in women with systemic lupus erythematosus (SLE). METHODS: A total of 71 pregnancies in 35 women with SLE were evaluated for maternal and perinatal outcomes in a tertiary centre of Northern India. Thirty-five pregnancies were evaluated prospectively while details of previous 36 pregnancies in the same women were studied retrospectively. RESULTS: The Mean age of pregnant women with SLE was 26.89 ± 2.7 years and 14.57% were nulliparous. The presenting event was arthritis in 60% of the patients; others presented with febrile illness, renal manifestation and cutaneous manifestation. One woman was lupus anticoagulant positive. All women conceived while on disease quiescence period and were continued on the same pre-pregnancy dose of pharmacological agents. Hypertensive disorders of pregnancy were seen in 28.5% while chronic hypertension was seen in 5.6%. The incidence of abortion, preterm deliveries and perinatal loss was 33.8, 29.57 and 12.67%, respectively. Vaginal delivery rate was 47.88 and 18.3% underwent caesarean section. There was no case of neonatal lupus and none had disease flare-up in the postpartum period. CONCLUSION: A better pregnancy outcome can be expected if clinical remission is achieved and disease activity is adequately controlled prior to pregnancy.