Socio-behavioural determinants of maternal near miss: a prospective case control study from a tertiary care centre of India.

Near miss occurs in far greater numbers than maternal deaths and allows a more robust quantification on risk factors and determinants of life-threatening complications. A 'Three delay model' has been proposed in identification of causes of near miss and maternal deaths. There may be delay in seeking and obtaining health care: delay in recognising danger signs and deciding to reach source of care, delay in reaching appropriate source of care and delay in obtaining appropriate and adequate treatments. We compared various delays between near miss cases (n = 100) and controls (n = 200). Women who fulfilled criteria of near miss were taken as cases. Women who had obstetrical complications like near miss but were managed successfully and did not reach near miss state were labelled as controls. Near miss were then compared with maternal death. For normally distributed measurable data, outcome was compared using Student's t-test, for non-normally distributed/ordinal data, outcome was compared using Mann-Whitney's test. For categorical/classified data, association with outcome was analysed using Chi-Square test/Fisher's exact test.Delay in all three levels was seen among the groups. Lack of knowledge, non-availability of decision maker, and concern of cost of transport were main contributors of these delays.Impact StatementWhat is already known on this subject? Nonavailability of healthcare and low socio-economic status strongly correlate with maternal morbidity and mortality.What do the results of this study add? Lack of knowledge, non-availability of the decision maker, and concern of cost of transport were the main contributors of delay in seeking medical care. Majority of the cases of near miss were attributed to poor utilisation of health resources, ignorance and lack of emergency obstetric care at the primary level.What are the implications of these findings for clinical practice and/or further research? Patient and attendant education to ensure follow-up visits, recognise danger signs and report without undue delay, compliance to dietary modifications, medications given needs to be addressed at every visit to reduce the impact of socio-behavioural determinants on maternal near miss and mortality which are preventable in majority of cases.

Prognostic role of uterine artery Doppler in early- and late-onset preeclampsia with severe features.

OBJECTIVE: To correlate uterine artery Doppler findings with maternal and neonatal outcomes in early- and late-onset preeclampsia with severe features. METHODOLOGY: Doppler scan was done in both uterine arteries. Maternal and neonatal outcomes in women with abnormal and normal Doppler results were compared. RESULTS: Abnormal Doppler results were present in 45 women (75%). Thirty-four (56.7%) women had abnormal RI, 19 (31.6%) had abnormal PI, and 36 (60%) had diastolic notch. Of the women who participated in the study, 21.6% developed maternal complications, and the majority belonged to the early-onset severe preeclampsia group. Diastolic notch was twofold more frequent in the early group. RI was abnormal in 63% of the early-onset and 50% of the late-onset group. CONCLUSION: Pregnancies with early-onset preeclampsia who had abnormal uterine artery Doppler findings were at high risk for both maternal and neonatal complications, whereas those who had late-onset preeclampsia with abnormal Doppler findings only had an increased risk of perinatal complications.

A Rare Case of Grade 1 Endometrioid Adenocarcinoma of the Uterus With Omental Metastasis with Brenner Tumor of the Ovary in a Postmenopausal Female.

Early-stage endometrial cancer may have microscopic omental metastases which is associated with a poor prognosis. There are no standard guidelines for omentectomy in early-stage endometrial cancer without risk factors. Brenner tumor is a rare ovarian tumor which is usually benign, but rarely, it may be malignant. Some Brenner tumors are endocrinologically active. Various studies have shown an association of Brenner tumor with endometrial hyperplasia, polyp, or early-stage carcinoma, probably due to its estrogen-secreting nature. We report a rare case of well-differentiated endometrioid adenocarcinoma of the uterus with <50% myometrial invasion with omental metastases associated with benign Brenner tumor of the ovary in a postmenopausal female.

A clinical and microbiological study of puerperal sepsis in a tertiary care hospital in India.

OBJECTIVE: This prospective study was carried out to evaluate the clinical profile and bacterial isolates among women with puerperal sepsis in a tertiary hospital in North India. MATERIALS AND METHODS: Women with puerperal sepsis (n = 45) admitted from January 2015 to April 2016 were followed prospectively. Cultures were obtained from cervix, blood, urine, and pyoperitoneum. Initial antibiotics were cefotaxime or piperacillin with tazobactam plus amikacin plus clindamycin or metronidazole and were changed according to sensitivity. RESULTS: Out of 7887 deliveries during this period, 45 (0.2%) women had puerperal sepsis. 16 (35.5%) delivered in the present hospital, 25 (55.5%) at another health care facility, and 4 (8.9%) at home. Delivery was by cesarean section (CS) in 24/45 (53.3%) and vaginal in 21/45 (46.6%). Grade 1 sepsis occurred in 21, grade 2 in two, and grade 3 in 22 women. Majority (29/45 or 64.5%) had no risk factor for puerperal sepsis. There were two (4.4%) deaths and 13/45 (28.8%) had near-miss morbidity. Pathogenic bacteria were isolated in 33/45 (73.3%) in cervical swab (69%), blood, urine, or pus culture with no significant difference in the bacterial yield or species isolated between cotton or polyester swabs (p > .05). Escherichia coli were the commonest isolate and was sensitive to amikacin in all. Five had stillbirths and 4/40 neonates developed sepsis but recovered. CONCLUSIONS: Escherichia coli was the commonest pathogen and was uniformly sensitive to amikacin, which may be included among the initial antibiotics to treat puerperal sepsis in India.

Maternal Cardiac Diastolic Dysfunction by Doppler Echocardiography in Women with Preeclampsia.

INTRODUCTION: Preeclampsia may lead to heart failure in late pregnancy and early puerperium. Diastolic dysfunction may be the cause of heart failure in these patients. There is paucity of data on diastolic dysfunction in patients with preeclampsia. AIM: To assess cardiac diastolic dysfunction in women with preeclampsia by Doppler echocardiography and to correlate severity of dysfunction with severity of preeclampsia. MATERIALS AND METHODS: One hundred and fifty nulliparous women in age group of 20-35 years were recruited for the study. Among these, 120 women with preeclampsia were taken as cases and 30 normotensive women as controls. Doppler echocardiography was carried out between 28-36 weeks of gestation in both groups to assess and grade severity of diastolic dysfunction. RESULTS: Of 120 women with preeclampsia, 61 had mild preeclampsia and 59 had severe preeclampsia. Diastolic dysfunction was seen in 25(20.8%) cases. Among these, grade I diastolic dysfunction was seen in 40% and the rest 60% had grade II diastolic dysfunction. In the mild preeclampsia group, only 2(3.3%) patients had diastolic dysfunction. Both had grade I dysfunction. Of severe preeclampsia patients, 8(13.6%) had grade I and 15(25.4%) had grade II diastolic dysfunction (p=0.001). None of these progressed to heart failure or pulmonary oedema. Systolic function assessed by left ventricular ejection fraction was normal in all cases. All controls had normal systolic and diastolic functions. CONCLUSION: Cardiac diastolic dysfunction occurred in one-fifth of women with preeclampsia. Grade of diastolic dysfunction correlated with the severity of preeclampsia.

Peri and post-menopausal women with complex adnexal masses, ascites, and raised CA-125: Is it ovarian cancer or tuberculosis?

Pelvic and peritoneal tuberculosis may resemble advanced ovarian cancer due to the presence of ascites, complex adnexal masses, peritoneal deposits and raised CA-125 level, especially in peri- and postmenopausal women. Other common features among women with these two conditions are abdominal pain and distension, weight loss and reduced appetite. As the treatment of pelvic-peritoneal tuberculosis is completely different from that of ovarian cancer, it is important to reach a correct diagnosis. Sometimes women with pelvic-peritoneal tuberculosis may be subjected to a laparotomy for suspected ovarian cancer which is likely to increase their morbidity. In the present article, we report ten women in the peri- and post-menopausal age group where this diagnostic dilemma arose of whom seven were diagnosed only after a laparotomy had been performed for suspected ovarian cancer due to adnexal masses with ascites and raised CA-125 level. Ascitic fluid showing lymphocytic predominance, raised ADA level and absence of malignant cells are pointers to consider the possibility of pelvic- peritoneal tuberculosis, especially in endemic countries like India. In such situations, an effort should be made to obtain a cytological or histopathological diagnosis of either condition by ultrasound guided needle biopsy or laparoscopically obtained biopsy rather that proceeding with laparotomy for suspected ovarian cancer.

Endometriosis presenting as carcinoma colon in a perimenopausal woman.

Endometriosis is a common benign disease of reproductive age women, and can involve the intestinal tract. Inconsistent clinical presentation, similar features on radiological imaging and colonoscopy with other inflammatory and malignant lesions of the bowel makes the preoperative diagnosis of bowel endometriosis difficult. We present a case of a 42-year-old perimenopausal female clinically presented, investigated and managed in the lines of carcinoma of sigmoid colon. She underwent terminal ileac resection with end to end anastomoses, Hartmann's procedure and total hysterectomy with bilateral salpingoophorectomy. The histopathological report revealed endometriosis of small intestine, large intestine, mesentery, right ovary and adenomyoma of uterus. Thus, bowel endometriosis should also be considered as differential diagnosis in reproductive age women with gastrointestinal symptoms or intestinal mass of uncertain diagnosis.