"TB - Mindedness"-the only way to beat "the great mimicker": A case series with atypical presentation of female genital tuberculosis.

BACKGROUND: Incidence of Tuberculosis (TB) cases in India reported in 2019 is 193 per 1 lakh population [National Tuberculosis Elimination Plan (NTEP)]. In India, annual extra pulmonary TB burden is 20-25%, of which 4% of cases are of urogenital origin (Revised National TB Control Programme, 2019; World Health Organization, 2019). The Ministry of Health and Family Welfare has made a target of eliminating tuberculosis by 2025 under the NTEP by the process of identification, notification and treatment of cases. Tuberculosis being a leading cause of infertility in developing countries, employing best clinical practices and being "TB-minded" will also save the patient of enormous anxiety and uncertainity and also decrease the time gap between clinical presentation and diagnosis to optimize fertility outcome. METHODOLOGY: A prospective cohort study of cases presenting with unusual findings and ultimately being diagnosed as genital tuberculosis was conducted in the gynaecology OPD, AIIMS, New Delhi, from November 2020 to November 2021 (1 year). Patients were investigated judiciously, diagnosis made and followed up for their response to anti tuberculosis therapy (ATT). RESULTS: This data comprises of conglomerate of ten cases with unconventional exhibition of genital tuberculosis. 70% of the cases presented with pain lower abdomen not specifically related to menstrual cycle and often confused with IBD. Tubo ovarian mass (70%) mimicking as simple ovarian cyst, ovarian carcinoma or endometriosis was the most common clinical finding we came across.

Comparison of Intraperitoneal Irrigation With Sodium Bicarbonate Versus Normal Saline in Reducing Pain After Operative Laparoscopy: A Randomized Controlled Trial.

Background It has been postulated that sodium bicarbonate can reduce postoperative pain by neutralizing the acidic peritoneal environment created by carbon dioxide. It also prevents phrenic nerve damage and peritoneal irritation. The present study is a randomized controlled trial aimed at studying the effects of sodium bicarbonate in reducing postoperative pain in laparoscopic gynecological surgeries. Materials and methods This was a single-center, prospective, two-arm, double-blinded randomized control trial in which intraperitoneal irrigation with sodium bicarbonate was compared with normal saline in operative laparoscopy. Group I (intervention group) consisted of 40 patients who received intraperitoneal sodium bicarbonate, and Group II (control group) consisted of 40 patients who received normal saline. All procedures were conducted under general anesthesia. Postoperative pain scores were compared between intervention and control groups.  Results The most common indication of laparoscopy was infertility. There was no difference in the duration of surgery between the two arms (p=0.27). The mean value of the visual analog scale (VAS) score at the shoulder tip was found to be significantly reduced in the intervention group at two hours (p=0.02), four hours (p=0.0009), and 12 hours (p=0.0002) after surgery. The mean VAS score at the abdomen and port sites was also found to be significantly reduced in the intervention group in the first 24 hours after surgery (p<0.05). With the increase in the time period from surgery, the mean VAS scores decreased in both intervention and control groups.  Conclusion Intraperitoneal irrigation with sodium bicarbonate is beneficial in reducing postoperative pain in operative laparoscopy. However, multicenter randomized trials with a greater number of participants will be helpful to confirm the findings.

Comparison of Outcomes following Vaginal Natural Orifice Transluminal Endoscopic Surgery and Laparoendoscopic Single-site Surgery in Benign Hysterectomy: A Systematic Review and Meta-analysis.

Gradually increasing interest in laparoscopic surgeries has led to the advent of various lesser invasive techniques in the form of vaginal natural orifice transluminal endoscopic surgery (vNOTES) and laparoendoscopic single-site (LESS) surgery. Very few studies have analyzed the advantages and disadvantages of vNOTES over LESS surgeries in hysterectomy. After a comprehensive search, full texts of relevant manuscripts were obtained to assess eligibility for recruitment. A comprehensive meta-analysis was subsequently performed to compare the outcomes of vNOTES and LESS in hysterectomy, and forest plots were constructed. Four articles were rendered for review (three retrospective cohort studies and one randomized controlled trial). Three studies showed lesser postoperative pain in vNOTES compared to LESS. In one study, postoperative vaginal pain was higher in vNOTES due to additional suture between uterine artery and vaginal wall. The meta-analysis concluded that vNOTES could be better alternative to LESS hysterectomies. However, further large multicentric randomized trials are required for the standardization of the surgical method.

Compassionate Use of Remdesivir in Pregnancy: A Case Series From a COVID-19 Dedicated Center and Review of Literature.

Pregnancy is associated with immunological changes that could render an individual vulnerable to the severe coronavirus disease 2019 (COVID-19) disease. Even as we witnessed the third and most widespread pandemic wave, a conclusively advantageous treatment option still remained elusive. Remdesivir was one of the front-running therapeutic options that received emergency use authorization (EUA) and subsequent approval for the management of moderate to severe COVID-19 infections. Here, we report a series of moderate to severe COVID-19-infected pregnancies and the experience of remdesivir use on a compassionate basis. Four cases of pregnancy complicated with moderate to severe COVID-19 infections where remdesivir was administered were recruited into the study, and their outcome was assessed objectively. Of these cases, three women received remdesivir in addition to standard SARS-CoV-2 treatment in the antenatal period. One woman received remdesivir after delivery. One woman received tocilizumab in addition to remdesivir and standard SARS-CoV-2 care. Two women survived and were subsequently discharged to home care. Two succumbed to the disease. One baby who was exposed to remdesivir in utero is doing well at six months post-delivery. Remdesivir had been granted EUA for the treatment of suspected or laboratory-confirmed COVID-19 infection in adults and children who were hospitalized with severe disease or requiring supplemental oxygen and mechanical ventilation or extracorporeal membrane oxygenation (ECMO) in May 2020. This issuance allowed the use of the same dosing regimen in pregnant and parturient women as in the general adult population. Thus, this series of cases tried to assess the outcome of this drug among COVID-19-infected pregnant women. Early initiation of remdesivir in pregnancy in the viremic phase seems to provide some advantages in the survival outcome. Its use may be associated with transient elevation in hepatic transaminases in some cases. No detrimental effects on the ongoing pregnancies, fetuses, or neonates have been observed. Further large-scale studies may provide more conclusive evidence.

Application of a Negative Intrauterine Pressure Suction Device for Prophylactic Management of Atonic Postpartum Hemorrhage: A Quality Improvement Study.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. PPH-preventing interventions need to be prioritized and can be integrated with conventional methods of PPH prevention. The introduction of negative intrauterine pressure using a suction cannula can be one of the cheapest modalities to decrease PPH secondary to uterine atonicity. This method has brought a renaissance to practical obstetrics in low-middle income countries (LMIC), where the cost and availability of uterotonics are major health issues. METHODS: It was a prospective quality improvement (QI) study conducted in the labor and delivery wards of a tertiary care medical institute and teaching center over the duration of one year. We aimed to assess the decrease in the incidence of atonic PPH with a negative intrauterine pressure suction device (NIPSD) integrated with active management of the third stage of labor (AMTSL) in the prevention of atonic PPH following normal vaginal delivery in low-risk antenatal women. In the initial six months, routine AMTSL was instituted for all consenting women (group 1). In the next six months, NIPSD was integrated with AMTSL (group 2). Data pertaining to the amount of blood loss, the incidence of primary PPH, uterine tone, fall in hemoglobin and hematocrit levels post-delivery, need for blood transfusion, and doctor and patient satisfaction were tabulated for all patients. RESULTS: A total of 1324 consenting women were eligible for enrollment during the study time frame. In the initial six months (baseline period, group 1), 715 participants were subjected to routine AMTSL in the third stage of labor. During the intervention phase (group 2), 609 parturient women were recruited. There was no significant difference in baseline parameters between the two groups. With the introduction of NIPSD to routine AMTSL, there was a significant decrease in the average volume of blood loss during vaginal delivery (group 1 = 389.45+65.42 ml, group 2 = 216.66+34.27 ml; p-value = 0.012). The incidence of atonic PPH was reduced by more than 75% (group 1 = 13 women, group 2 = 3 women; p-value = 0.001) after the introduction of NIPSD complementing routine AMTSL. The introduction of NIPSD has also been instrumental in reducing the cost burden on patient and hospital expenditures. The net benefit of its introduction resulted in a reduction of the overall cost burden of blood transfusions by around 70%. CONCLUSION: PPH is a public health problem, and measures to reduce PPH must be implemented to decrease this health burden. In countries with low resources, complementing routine AMTSL with NIPSD can be instrumental in decreasing the incidence of PPH. Considering its cost-effectiveness and reusability, LMIC can adopt NIPSD as a routine measure in all vaginal deliveries.

Status of Contraceptive Use for Birth Spacing After a Teenage Pregnancy: Where Do We Stand?

BACKGROUND: Adolescence is the most complex stage of reproductive health. The knowledge and awareness of adolescent-related reproductive issues are limited, particularly in lower-middle-income countries. Adolescent pregnancies are associated with major maternal and neonatal complications. Effective contraception use can prevent teenage pregnancy and subsequent complications. METHODS: It was a cross-sectional study conducted in a tertiary care hospital and teaching institute over a period of one year. Through this study, we aimed to assess the prevalence of postpartum use of approved standard methods of contraception for birth spacing among teenage mothers and to assess the reasons for their non-acceptance. A total of 133 consecutive consenting postpartum teenage mothers were recruited in the study. Participants were asked about their age at the time of marriage and delivery, marital status, parity, education and economic status, the number of antenatal visits, mode of delivery, and antenatal complications. Compliance with postpartum contraception was noted, and reasons for its non-acceptance were asked in detail. RESULTS: Among the 133 participants, contraceptive users were categorized into Group A and non-users into Group B. The mean age at the time of marriage was 17.6±0.4 and 17.5±0.6 years in Group A and Group B, respectively. Mothers in Group A were more educated than their counterparts in Group B (82.2% of mothers were educated up to 12th standard in Group A compared to 46.6% in Group B). Among the contraception users, 70% had four or more antenatal visits compared to 7.9% of the non-users. Reasons for non-acceptance of postpartum contraception were elicited in Group B: 42.0% had fear of becoming infertile, 38.6% feared that contraceptives interfere with breastfeeding and quality of breastmilk, 13.6% had opposition from family members, and 5.8% did not mention any reason. CONCLUSION: Teenage pregnancy is associated with increased feto-maternal complications. It also accounts for an increased incidence of unsafe abortions and maternal mortality. So it is crucial to make the adolescent group aware of effective methods of postpartum contraceptives to prevent adolescent pregnancies. Collaborative larger multicentric studies from different countries will help to reach a better, generalized conclusion regarding the same.

Assessment of Fertility Outcomes Following Combined Clomiphene and Letrozole Versus Letrozole Therapy for the Treatment of Polycystic Ovarian Syndrome Subfertility.

BACKGROUND: Poly Cystic Ovarian Syndrome (PCOS) affects 8-13% of women in their reproductive age and is one of the foremost causes of female subfertility. Traditionally, clomiphene citrate has been the first-line treatment for ovulation induction in PCOS. However, the European Society of Human Reproduction and Embryology (ESHRE) international evidence-based guidelines in 2018 recommended the use of letrozole as first-line therapy for ovulation induction in anovulatory PCOS women, due to better pregnancy and live birth rates. Here we aimed to evaluate the effect of combined - clomiphene and letrozole versus letrozole for the treatment of PCOS subfertility. METHODS: It was a retrospective cohort study conducted on reproductive-age women fulfilling Rotterdam Criteria for PCOS with a history of subfertility. All participants receiving at least one cycle of letrozole and clomiphene combination were recruited as cases. However, women receiving letrozole only for ovulation induction were taken as controls. Hospital records were abstracted for data on baseline characteristics such as age, duration of infertility, PCOS phenotype, body mass index (BMI), past medical and fertility history, treatment with ovulation induction agents, and metformin use. The mean size of the largest follicle, number of dominant follicles of size greater than 15 mm and endometrial thickness on Days 12-14 or on the day of the luteinizing hormone (LH) surge were recorded. A cycle was termed ovulatory if serum progesterone levels were > 5.0 ng/ml on the seventh day after the LH surge or day 22 in the absence of the LH surge. Data pertaining to therapy-associated side effects were also abstracted from the clinical records. RESULTS: Amongst the ovulatory cycles in both groups, there was no significant difference in the day of the LH surge. Serum progesterone levels on the seventh day post-ovulation were higher with combination therapy (19.35 v/s 26.71, p=0.004). The number of ovulatory cycles was also greater with combination therapy, but the difference was just short of significant (25 vs 18, p=0.08). The mean diameter of the largest follicle, incidence of multi-follicular ovulation, and thin endometrium were similar in both groups. The adverse effect profile was similar in both groups. CONCLUSION: Combination treatment of clomiphene citrate with letrozole may potentially improve fertility outcomes in PCOS subfertility in terms of the likelihood of ovulation and higher post-ovulatory progesterone levels, however, larger studies are required.

Addressing the high prevalence of uterine fundal pressure in low-middle income country during vaginal delivery through a quality improvement initiative: Road to respectful maternity care.

BACKGROUND: Intrapartum care is of paramount importance in overall respectful maternity care (RMC). Uterine fundal pressure maneuver (UFPM) is the most controversial obstetric maneuver considered obsolete in many countries. UFPM is associated with adverse life threatening maternal and fetal effects. The baseline prevalence of UFPM in our tertiary care teaching hospital with a heavy patient load was 78.4% which was quite high. Our aim was to reduce the prevalence of UFPM by 75% from baseline over a period of 10 months. METHODS: After root cause analysis, we formulated the departmental Standard Operating Procedures on safe vaginal delivery and birth practices and initiated the Labour Room Quality Improvement Initiative. We sensitized and created awareness among the resident doctors and nursing staff regarding the high prevalence of UFPM through dedicated lectures, intercommunication via WhatsApp groups and strict vigilance in the labor wards. The point of care quality improvement (QI) methodology was used. The primary outcome was decrease in the prevalence of UFPM. RESULTS: The prevalence of UFPM reduced from the baseline value of 78.4%-4% over the period of 7 months. Post intervention it gradually increased and sustained at 21.2% over a follow-up period of 3 months. CONCLUSION: QI methods can effectively and rapidly improve the acceptance and adherence to newer initiatives in a busy tertiary care health facility to reduce the prevalence of UFPM and eventually improve the overall RMC.

Pharmacotherapeutic treatment options for recurrent epithelial ovarian cancer.

INTRODUCTION: Almost 80% of epithelial ovarian cancer present in advanced stage at diagnosis and despite excellent response to surgery and chemotherapy, more than 70% cancers recur. Subsequent therapies become decreasingly effective in controlling the disease, with each successful therapy being effective for a shorter duration. As a result, there is a need for novel therapeutic strategies to effectively treat recurrence. AREAS COVERED: In this extensive literature review of high-quality articles, we have focused on surveillance strategy to detect recurrence early, classification of recurrence based on timeline, role of surgery, chemotherapy, and targeted agents such as anti-angiogenetic drugs, PARP inhibitors, and immune checkpoint inhibitors in platinum-sensitive and platinum-resistant disease, respectively. EXPERT OPINION: Recurrent ovarian cancers (ROC) are represented by a heterogenous group of patient population in terms of platinum-free interval (PFI), histology, molecular characteristics and immune recognition. In today's era of precision medicine, chemotherapy should be combined with appropriate targeted agent in a multipronged approach to prolong survival and provide better quality of life outcomes by minimizing side effects.

A Survey on Relation of Menopause to Metabolic Syndrome - SAFOMS STUDY (South Asian Federation of Menopause Societies) - Interim Analysis.

Background: Metabolic syndrome (MS) is a spectrum of disorders that includes dysglycemia, dyslipidemia, central obesity, and hypertension. South Asian Indians are more prone to harbor MS at a younger age compared to Caucasians. However, there is a lack of large-scale data correlating menopause to MS in South Asian settings. Aims and Objectives: The study aimed to determine the prevalence of MS and its components in pre- and postmenopausal women. It also assessed the relationship of age, menopausal status, personal and family history, anthropometric parameters, and biochemical markers to MS. Materials and Methods: It was an interim analysis of a multicountry cross-sectional study in the South Asian Federation of Menopause Society (SAFOMS) countries: India, Pakistan, Bangladesh, Nepal, and Sri Lanka conducted through both online and physical methods. The survey questionnaire consisted of questions about details of personal history, demographics, and family history related to MS. Anthropometric measurements such as height, weight, basal metabolic index (BMI), waist circumference, and blood pressure readings were noted. Relevant history, history of polycystic ovarian syndrome, hypertensive disorders of pregnancy, and vasomotor symptoms were enquired. Biochemical evaluation of markers associated with MS was undertaken. Results: In this interim analysis, 638 women were recruited. Out of them, 406 (63.6%) women were premenopausal and 232 (36.4%) were postmenopausal. 392 (61.4%) women had MS, while 246 (38.6%) women did not have MS. Increasing age, BMI, and visceral adiposity (waist circumference) were significantly correlated with incidence of MS. Raised fasting blood sugar, hemoglobin A1C, total cholesterol, low-density lipoprotein, serum triglyceride, and reduced high-density lipoprotein levels were significantly associated with the incidence of MS in both pre- and postmenopausal women. Peri- and postmenopausal hot flashes, night sweats, and sleep disturbances were also significantly associated with MS. Personal history of hypertension, diabetes, and dyslipidemia were the strongest factors to be associated with MS with a significantly high odds ratio. Conclusion: The study has highlighted the role of BMI and waist circumference as the first warning signs, which will encourage to go for regular biochemical screening through lipid profile and fasting blood glucose measurements. Our study is a stepping stone for all future studies for relation of menopause to MS.

Early Initiation of Breastfeeding Among Adolescent Mothers: A Quality Improvement Study.

BACKGROUND: The prevalence of early initiation of breastfeeding (EIBF) was found to be low among adolescent postnatal mothers. EIBF is associated with improved parenting skills and better neurodevelopment in babies. We aimed to improve the prevalence of EIBF among teenage mothers to at least 90% through a quality improvement (QI) initiative. MATERIALS AND METHODS: It was a QI intervention conducted over a period of 15 months involving mothers under the age of 20 years at the time of present delivery. Six Plan-Do-Study-Act (PDSA) cycles consisting of multiple interventions, each lasting for one month, were conducted to improve the prevalence of EIBF. Rate of improvement in EIBF was noted and plotted against time. Post-intervention follow-ups of observations were done for six months. RESULTS: The prevalence of EIBF among adolescent mothers was 28.5% during the pre-intervention baseline phase. QI team meeting was held and the barriers to EIBF among the adolescent mothers were discussed and depicted in the form of a fish-bone analysis model. The prevalence of EIBF increased during each intervention cycle to 50%, 60%, 62.5%, 72.7%, 88%, and 100%. At the end of six months follow-up phase, the prevalence of EIBF sustained at around 100%. CONCLUSION: This QI initiative has proven to be effective in improving the prevalence of EIBF with simple but effective measures. Adolescent women comprise of a vulnerable sub-population of high-risk mothers. Proper counseling and respectful maternity care will help them face the challenges of motherhood boldly.

Assessment of Risk Factors and Obstetric Outcome of Adolescent Pregnancies Through a Prospective Observational Analysis.

Background Adolescence is the most crucial stage of life. Early marriage and teenage pregnancy infringe on adolescent girls' social and humanitarian rights. Moreover, it leads to school dropouts and decreased self-autonomy. Through this study, we aimed to analyze the risk factors and obstetric and neonatal outcomes resulting from adolescent pregnancies conceived by Indian girls less than 20 years of age. Materials and methods It was a prospective observational study conducted over a period of two years. Consecutive consenting adolescent mothers visiting the antenatal clinic or the delivery wards were recruited into the study. Adolescent pregnancies constituted all pregnancies where the maternal age was between 14 and 19 years at the time of presentation. Participants were followed prospectively till delivery and postpartum visit at six weeks to assess the obstetric and puerperal outcomes. Treating obstetricians asked about the causes responsible for current teenage pregnancy. At the time of delivery, data pertaining to antenatal complications, pregnancy outcome, mode of delivery, and birth weight were noted. All women were counseled for postpartum contraception at the time of delivery. Compliance with postpartum contraception was noted, and reasons for non-acceptance were asked. Results A total of 133 antenatal women in the adolescent age group were recruited during the study time frame. The mean age at the time of delivery was 18.4 years. Most of the women were educated between the sixth and 12th standards and belonged to the upper-lower economic class. Early marriage, increased family pressure, and school dropout at a young age were the predominant risk factors for teenage pregnancy in the study population. The majority of them suffered from anemia. Pregnancy-induced hypertension, hypothyroidism, fetal growth restriction, and oligohydramnios were a few other complications seen in adolescent pregnancies. Despite counseling, only 33.8% of adolescent mothers accepted postpartum contraception (any of the standard methods). Conclusion Pregnancy has concerning health consequences on adolescent girls and their babies. For example, adolescent mothers face increased risks of pregnancy-induced hypertension, obstructed labor, and puerperal sepsis. So, it is time to create awareness through mass educational campaigns and widespread family planning services.

A Prospective Quality Improvement Initiative to Address the Barriers to Postpartum Tubal Ligation Among Multiparous Women.

BACKGROUND: Unmet need for postpartum tubal ligation (PPTL) is still high in low-middle income countries. The commonly observed barriers are issues with the consent forms, non-availability of operation theater, lack of knowledge, patient desire for more children, partner opposition and social non-acceptance. Considering the unmet need and the barriers, this quality improvement (QI) initiative was conducted to increase the frequency of PPTL among multiparous women by 50% from baseline. MATERIALS AND METHODS: This QI was conducted at a tertiary care teaching hospital over a period of 18 months. The study consisted of three phases. Baseline observations during the pre-intervention phase over six months, intervention phase consisting of three Plan-Do-Study-Act (PDSA) cycles over 12 months and post-intervention surveillance phase over a period of three months. In the first PDSA cycle, hospital and provider barriers were focused on. The patient barrier was addressed in the second cycle. The barrier at the level of partner and family members was addressed in the third cycle. RESULTS: The baseline prevalence of PPTL in the studied population over a period of six months was 30.2%. After the first PDSA cycle, the prevalence of PPTL performed increased from 30.2% to 49.5%. The prevalence increased to 68.8% after the second cycle. A further increase to 74.4% was observed after the third intervention. There was a satisfactory continuation rate of 72% at the end of the post-intervention follow-up phase conducted over four months. CONCLUSION: This QI initiative proved effective and sustainable over time. There was continuous motivation among the service providers to educate and counsel women for PPTL. Ultimately, we were able to address the low prevalence of PPTL through minor modifications in our hospital strategies.