Is low dose vaginal misoprostol better than dinoprostone gel for induction of labor: a randomized controlled trial.

OBJECTIVE: To compare the efficacy and safety profile of low dose vaginal misoprostol with dinoprostone gel for induction of labor in term pregnancies. METHODS: The study was conducted at Lady Hardinge Medical College and Smt Sucheta Kriplani Hospital on 100 pregnant women with term pregnancy after application of inclusion and exclusion criteria. The women were randomized in 2 groups of 50 women each. Group I received misoprostol 25µg at every six hour vaginally for a maximum of five doses for induction of labor; while group II received dinoprostone gel 0.5 mg every six hourly for a maximum of three doses. Maternal outcomes such as mode of delivery and induction delivery interval; and fetal outcomes such as APGAR score and incidence of NICU admission were assessed in both the groups. Statistical analysis was done using student t-test and chi-square test. RESULTS: There was no significant difference in the mean induction to delivery interval in both the groups (14.32±0.13 hours in Group I and 14.92±0.18 hours in Group II, p=0.75), mode of delivery, indication of cesarean section and perinatal outcome. However, significant difference was observed in requirement of oxytocin augmentation in both the groups (32% in Group I and 68% in Group II, p=0.005). CONCLUSION: Vaginal misoprostol in low doses is similar in efficacy and safety to dinoprostone gel for cervical ripening and labor induction in term pregnancy.

Unusually High Levels of CA19-9 Associated with Mature Cystic Teratoma of the Ovary.

Introduction. Mature cystic teratoma is the benign tumor of the ovary. CA19-9 levels, although a marker of pancreatic malignancy, have been found to be raised in large ovarian mature cystic teratomas. Case Report. We report a case of a young female who had unusually high levels of CA19-9 in the blood associated with large ovarian mature cystic teratoma. The levels returned to normal 12 weeks after cystectomy was performed. Conclusion. This case highlights the fact that although raised tumor marker may be associated with a benign pathology thorough evaluation to rule out malignancy still must be done.

Health profile of urban adolescent girls from India.

CONTEXT: Adolescents comprise 22.5% of the population, which forms a significant part of the entire population. It is only recently that we have acknowledged the need for a separate specialty to handle adolescent problems and ailments. AIMS: The aim of the present study is to study the health profile of the adolescents girls presenting to the tertiary care hospital situated in New Delhi, India. MATERIALS AND METHODS: The study was conducted on 316 adolescent girls who presented to the adolescent clinic at Smt Sucheta Kriplani Hospital, New Delhi. Apart from recording the various health problems to which they presented, a detailed HEADSS assessment was done for each case. RESULTS: Majority of the adolescents (60.74%) presented with menstrual problems, 78.48% discussed their problems with their parents, and 91.77% agreed on common things with them. About 69.62% were attending school or college, while 30.37% had either left or never attended school. Majority of the adolescents (77.84%) had only a few friends, 62.96% watched TV in their free time, and only 7.27% performed regular exercise. In addition, 0.94% adolescents in the study group were married. Among the 313 unmarried adolescents, 3.83% were dating and 4.47% were sexually active. There was a low incidence of teenage pregnancy (0.94%) reported in the unmarried study population. History of contraceptive use was present in only 1.26% cases, and only 5.06% of the adolescents had knowledge of HIV. CONCLUSIONS: Adolescent health must be viewed with a comprehensive approach comprising of social, mental, physical and emotional aspects. The active involvement of the entire society, including parents and teachers, must also be encouraged towards the healthy development of adolescents.

MTHFR C677T polymorphism, folate, vitamin B12 and homocysteine in recurrent pregnancy losses: a case control study among North Indian women.

AIM: The present study attempts to understand the role of methylenetetrahydrofolate reductase C677T (MTHFR C677T) in recurrent pregnancy losses in North Indian women because of hyperhomocysteinemia in light of serum folate and vitamin B12. METHODS: One hundred and seven women with three or more consecutive unexplained recurrent pregnancy losses and 343 women with two or more successful and uncomplicated pregnancies were recruited. Plasma homocysteine, serum folate and vitamin B12 were analyzed using chemiluminescence. MTHFR C677T detection was completed in all subjects. RESULTS: MTHFR genotypic distribution among cases and controls showed no significant difference (P=0.409). However, MTHFR C677T polymorphism was found to be significantly associated with increased homocysteine in the case group (P=0.031). Hyperhomocysteinemia and vitamin B12 deficiency were found to be significant risk factors for recurrent pregnancy loss (RPL) (OR=7.02 and 16.39, respectively). Folate deficiency was more common in controls (63.47%) as compared to the case group (2.56%). CONCLUSION: Low vitamin B12 increases homocysteine, specifically among T allele carrying case mothers, suggesting T allele is detrimental with B12 deficiency. The study emphasizes the importance of vitamin B12 in the prevention of RPL in North Indian women.

Intergenotypic variation of endothelial dysfunction and inflammatory markers in eclampsia.

BACKGROUND: Cytokine imbalance and endothelial dysfunction are suggested to have a pivotal role in eclampsia. Pathophysiological processes are influenced by genetic factors and nitric oxide (NO) synthases seem to play important roles, although their role is still unclear. Endothelial NO synthase (eNOS) gene polymorphism may affect cytokine production. The aim of this study was to test the hypothesis that inflammatory cytokines impairs endothelium-dependent relaxation and NO production gets vitiated due to eNOs Glu298Asp gene polymorphism causing endothelial dysfunction in eclampsia. METHODS: This cross-sectional study included 100 women with eclampsia and 100 healthy pregnant women. Their blood samples were analyzed for NO (indirectly), and inflammatory cytokines and eNOS (Glu298Asp) gene polymorphism were determined by DNA extraction, followed by restriction fragment length polymorphism. RESULTS: Decreased NO metabolites and increased cytokines (tumor necrosis factor-α; interleukin-2, -6; and interferon-γ) levels were found in eclampsia (p < 0.001). Significant differences were found in genotype/allele distribution between the two groups. Occurrence of "T" allele frequency was found to be 0.27 among patients and 0.05 among controls (CI = 95%, OR = 0.7-0.9, p < 0.001). Significant negative correlation was seen between NO and cytokines levels (tumor necrosis factor-α and interferon-γ) in eclamptic women (p = 0.001). CONCLUSION: This study concluded that eclampsia is associated with decreased levels of NO and increased levels of circulating inflammatory cytokines, which might be contributed due to single-nucleotide polymorphism, pointing toward the role of endothelial and inflammatory components.

Genetic thromobophilia in pregnancy: a case-control study among North Indian women.

In the present study, an attempt is made to understand the role of genetic thrombophilias i.e. MTHFR C677T and FVL in the causation of various pregnancy complications like pregnancy induced hypertension (PIH), recurrent abortions, intra-uterine growth retardation (IUGR) and intra-uterine death on the whole and also individually along with the comparative assessment of pathophysiological basis of various pregnancy complications via the genetic proximities. One thousand and eleven (1,011) women of reproductive age group were recruited in the present study comprising various complications and controls. Recruitment criteria for all the pregnancy complications and controls was made and followed strictly. MTHFR C677T and FVL mutation detection was done in all the subjects. Vegetarianism was found to be significant risk factors for all the pregnancy complications and also when assessed individually. With respect to MTHFR C677T polymorphism, higher frequency of 677T allele was found among controls as compared to cases. 677T allele was found to pose decreased risk for various pregnancy complications on the whole and also individually. On adjusting the diet, regression analysis revealed no risk of mutant allele (T) for various pregnancy complications. FVL homozygous mutants were found to be absent among controls. In conclusion, the present study depicts dietary pattern as one of the most important factors in demonstrating the role of MTHFR C677T in various pregnancy complications and is indicative of a relatively deleterious effect of double dose of FVL in the presently studied population. Additionally, these polymorphisms play an important role in the orchestration of PIH to IUGR and vice versa.

Diabetic ketoacidosis occurring with lower blood glucose levels in pregnancy: a report of two cases.

BACKGROUND: Euglycemic diabetic ketoacidosis (DKA) during pregnancy is an unusual condition, but it can occur with normal or modest elevations in blood glucose levels. It is usually a complication of type I diabetes. CASES: We report two cases of euglycemic DKA, in type II diabetes mellitus and in gestational diabetes. Both patients showed blood glucose levels up to 9 mmoL/L (164 mg/dL), ketonuria and metabolic acidosis. They responded to initiation of correct insulin dosages. CONCLUSION: Euglycemic DKA in pregnancy may occur with type II diabetes or in gestational diabetes and requires prompt recognition and treatment.

Pregnancy outcome of women with gestational diabetes in a tertiary level hospital of north India.

BACKGROUND: Women with gestational diabetes mellitus (GDM) pose an important public health problem because diabetes not only affects the maternal and fetal outcome, but these women and their fetuses are also at an increased risk of developing diabetes and related complications later in their life. OBJECTIVES: The study was conducted to determine the maternal and fetal outcomes of 50 diabetic vs 50 normoglycemic pregnancies. MATERIALS AND METHODS: This was a retrospective analytical record-based study conducted in a tertiary level hospital. Detailed information regarding maternal, fetal, and labor outcome parameters was recorded in a prestructured proforma and compared in normoglycemic and diabetic pregnancies. RESULTS: Patients with obesity, history of diabetes in the family, spontaneous abortions, and gestational diabetes in previous pregnancies had a greater incidence of GDM in current pregnancy (P<0.05 for all). Hypertension, polyhydramnios, macrosomia, fetopelvic disproportion, and cesarean sections were more (P<0.001) among diabetic pregnancies. Congenital anomalies, polycythemia, hypocalcemia, and hyperbilirubinemia were also observed to be more (P<0.05) in neonates born to diabetics, suggesting an adverse effect of hyperglycemia in utero. CONCLUSION: Diabetes during pregnancy is associated with higher maternal and fetal morbidity. Therefore, early screening, detection, close monitoring, and intervention is essential to reduce maternal and fetal short- and long-term adverse effects, especially in high-risk groups. Pregnancy provides an opportunity to the clinician to control the disease process and inculcate healthy lifestyle practices in these patients.

Prevalence, risk factors and virological profile of chronic hepatitis B virus infection in pregnant women in India.

A large program was conducted by the Government of India to study the prevalence and profile of chronic hepatitis B virus (HBV) infection and its risk factors in pregnant women attending a tertiary care hospital in India. From September 2004 to December 2008 consecutive pregnant women attending the antenatal clinic were screened and those found positive for HBsAg were enrolled. Healthy non-pregnant women of child-bearing age, who presented for blood donation during the same period, served as controls. Women with symptoms of liver disease or those aware of their HBsAg status were excluded. Of the 20,104 pregnant women screened, 224 (1.1%) and of the 658 controls, 8 (1.2%) were HBsAg positive (P = ns). Previous blood transfusions and surgery were significant risk factors for infection with HBV. Of the women who were HBsAg positive, the ALT levels were normal in 54% of the women and HBV DNA levels were above 2,000 IU/ml in 71% of women. The median HBV DNA levels were higher in women who were HBeAg positive compared to the HBeAg negative group. The most common HBV genotype was D (84%) followed by A + D and A (8% each). In conclusion, the prevalence of HBsAg positivity among asymptomatic pregnant women in North India is 1.1% with 71% having high HBV DNA levels. These women may have a high risk of transmitting infection to their newborns.

Intergenotypic variation of nitric oxide and inflammatory markers in preeclampsia: a pilot study in a North Indian population.

Cytokines appeared to contribute to the development of pathologic condition and eNOS gene polymorphism may affect cytokine production. The aim of this study was to evaluate cytokines pattern in preeclampsia and whether there is any relationship between gene and cytokines production and cytokine with disease severity. This cross-sectional study included 100 women with preeclampsia and 100 healthy pregnant women. Their blood samples were analyzed for nitric oxide (NO), inflammatory cytokines, and eNOS gene polymorphism. Decreased NO and increased cytokine (tumor necrosis factor-α, interleukin-2, and interferon-γ) levels were found in preeclampsia (p < 0.001). Significant differences were found in genotype/allele distribution between the two groups. A significant negative correlation was observed between NO and cytokine levels (tumor necrosis factor-α and interferon-γ) in the preeclamptic group (p = 0.001). We conclude that preeclampsia is associated with decreased levels of NO and increased levels of circulating inflammatory cytokines due to single nucleotide polymorphisms, pointing toward the role of endothelial and inflammatory components.

Oxidative stress and eNOS (Glu298Asp) gene polymorphism in preeclampsia in Indian population.

Oxidative stress causing widespread endothelial dysfunction has been proposed as a key factor involved in the development of preeclampsia (PE). With this background our objective was to study oxidative stress biomarkers like nitric oxide and malondialdehyde (MDA) and to correlate these markers with endothelial nitric oxide synthase (eNOS) (Glu298Asp) gene polymorphism. This cross-sectional study included 300 pregnant women diagnosed with PE and 200 women with normal pregnancy. Plasma NO and MDA levels were analyzed using student's t test and eNOS gene polymorphism was studied by performing polymerase chain reaction amplification and restriction length polymorphism and frequencies were distributed by using χ(2) analysis. The mean plasma levels of NO were significantly lower in study group while MDA levels were significantly higher in study group (P < 0.001). Genotypic and allelic frequency of eNOS gene in both groups was found to be significant (P < 0.05). The intergenotypic variation of NO and MDA levels was found to be significant (P < 0.001). We concluded that the plasma levels of NO are decreased while MDA levels are increased in subjects with PE and that might contribute to the pathophysiology of PE. As observed in this study Glu298Asp eNOS gene polymorphism showed significant association with PE.

Factors influencing occurrence of postpartum haemorrhage in pregnant women with hepatitis E infection and deranged coagulation profile.

Coagulopathy is an important complication associated with hepatitis E virus (HEV) infection in pregnant women. Postpartum haemorrhage (PPH) remains a serious risk while managing the labour of these women. The aim of this paper is to study the factors influencing the occurrence of PPH in pregnant women with hepatitis E infection with coagulopathy. The labours of 38 pregnant women with hepatitis E and deranged coagulation profile were followed. Factors that may predict postpartum bleeding complications in women with HEV infection and deranged coagulation profile were statistically analysed. Of 38 pregnant women with acute viral hepatitis due to HEV, 13 (34%) suffered a PPH while 25 (66%) did not. On univariate analysis low alanine aminotransferase (P = 0.016), high international normalized ratio (P = 0.003), high levels of d-dimer (P = 0.008), presence of hepatic encephalopathy (P = 0.028), intrauterine fetal death (P = 0.001) and gastrointestinal bleeding (P = 0.004) were found to predict PPH. However, on multivariate analysis the only independent variable that predicted PPH was the presence gastrointestinal (GI) bleeding (odds ratio [OR] 11.363; 95% CI: 1.003, 125; P = 0.050). Women with GI bleeding have 11 times higher risk of PPH than those without a GI bleed; however, the confidence interval is very wide. Administration of fresh frozen plasma in the peripartum period reduces the risk of PPH. In conclusion, early recognition of factors which predict the risk of PPH and timely intervention with judicious use of blood and blood components in the peripartum period can improve the outcome of pregnant women with HEV infection with deranged coagulation.

Septate uterus with hypoplastic left adnexa with cervical duplication and longitudinal vaginal septum: Rare Mullerian anomaly.

A large analysis of all the studies in the period from 1950 to 2007 suggests that the prevalence of congenital uterine anomalies in the general population is 6.7%; and in the infertile population, 7.3%. We report a rare case of unilateral hypoplastic fallopian tube and ovary with septate uterus, cervical duplication, longitudinal vaginal septum. To the best of our knowledge, this is the first report of such a congregation of anomalies.

Labour induction with 25 micrograms versus 50 micrograms intravaginal misoprostol in full term pregnancies.

We undertook this study in order to compare the efficacy of 25 microg versus 50 microg of intravaginal misoprostol for cervical ripening and labour induction at term. The study population consisted of 120 women with term singleton pregnancies in vertex presentation booked for caesarean section. They had a Bishop scoring of <6 and a reactive fetal heart rate tracing. They were randomized into two groups, A and B, to receive 25 microg and 50 microg of vaginal misoprostol, respectively, 4 hourly with a maximum of five doses until the patient had three contractions in 10 minutes. There was no significant difference in the induction delivery interval between the two groups (12.52+/- 7.05 h in the 25 microg group versus 11.72+/- 6.74 h in the 50 microg group; P = 0.58). Of the women in the 25 microg group, 83.3% delivered vaginally as did 71.67% of those in the 50 microg group, but the difference was not statistically significant (P = 0.128). There were significantly more women requiring oxytocin augmentation in the 25 microg group than in the 50 microg group (P = 0.03). However, there were no significant differences in the rates of caesarean and operative vaginal delivery, meconium stained liquor, fetal distress or in the incidences of hyperstimulation between the two groups. Neonatal outcomes were similar. The intravaginal administrations of 25 microg, as well as 50 microg of misprostol, are equally efficacious in inducing labour. The 25 microg group more often required oxytocin as an adjunct.

Possible role of male factors in recurrent pregnancy loss.

OBJECTIVE: To evaluate various causes possibly contributing towards recurrent pregnancy loss (RPL), particularly male factors. Prospective study of 75 couples with history of RPL who were investigated for genetic, anatomic, immunological, infective and systemic causes in both partners. Functional sperm capacity was assessed by the Hypo-osmotic swelling test (HOS), Acrosomal Reaction (AR), Nuclear condensation-decondensation test (NCD) and Seminal Total Leukocyte Count (TLC) along with semen analysis. Twenty male volunteers with recently proven fertility were also included for detailed sperm morphology and sperm functions test as controls. Amongst male partners 3 (4%) had varicocele, 23 (30.6%) had infection, 1 (1.3%) immunological and 1 (1.3%) had genetic abnormality. Sperm motility, viability and sperm function tests were significantly lower in the RPL group as compared to the control group (P = 0.000). Male factor might be a possible contributing factor towards RPL. Both the partners should be evaluated and treated simultaneously in order to achieve desirable outcome.

Maternal and fetal outcomes in pregnant women with acute hepatitis E virus infection.

BACKGROUND: Hepatitis E virus (HEV) infection is known to cause severe liver disease in pregnant women. It is unclear whether obstetric and fetal outcomes are worse in pregnant women with HEV infection than in women with other forms of viral hepatitis. OBJECTIVE: To compare maternal, obstetric, and fetal outcomes in pregnant women with acute viral hepatitis caused by HEV and other hepatitis viruses. DESIGN: Observational cohort. SETTING: Tertiary care hospital, New Delhi, India. PATIENTS: 220 consecutive pregnant women presenting with jaundice caused by acute viral hepatitis. MEASUREMENTS: Maternal mortality and medical complications, obstetric complications, deliveries, and fetal outcomes. RESULTS: Infection with HEV caused acute viral hepatitis in 60% of included women. Fulminant hepatic failure was more common (relative risk, 2.7 [95% CI, 1.7 to 4.2]; P = 0.001) and maternal mortality was greater (relative risk, 6.0 [CI, 2.7 to 13.3]; P < 0.001) in HEV-infected women than in non-HEV-infected women. Women with HEV infection were more likely than those with other forms of viral hepatitis to have obstetric complications (relative risk, 4.1 [CI, 1.7 to 10.2] for antepartum hemorrhage and 1.9 [CI, 1.3 to 2.7] for intrauterine fetal death; P < 0.001 for both) and poor fetal outcomes (relative risk, 1.2 [CI, 1.0 to 1.4] for preterm delivery [P = 0.005] and 1.8 [CI, 1.2 to 2.5] for stillbirth [P = 0.026]). LIMITATIONS: The findings may not apply to community settings, to women who are asymptomatic or have only minor symptoms, or in the setting of an HEV epidemic. CONCLUSIONS: Pregnant women with jaundice and acute viral hepatitis caused by HEV infection had a higher maternal mortality rate and worse obstetric and fetal outcomes than did pregnant women with jaundice and acute viral hepatitis caused by other types of viral hepatitis.

Prospective study of saline infusion sonohysterography in evaluation of perimenopausal and postmenopausal women with abnormal uterine bleeding.

AIM: To evaluate saline infusion sonohysterography as an investigative modality in abnormal uterine bleeding in perimenopausal and postmenopausal women. METHODS: Fifty-eight patients, 52 perimenopausal and six postmenopausal women, with abnormal uterine bleeding were selected from the department of Obstetrics and Gynecology of Shrimati Sucheta Kriplani Hospital. After complete work-ups, transvaginal examinations were performed followed by sonohysterographies. The sensitivity, specificity, positive predictive values and negative predictive values were calculated for transvaginal sonography (TVS) and saline infusion sonohysterography as compared with findings of hysteroscopy/hysterectomy. RESULTS: Saline infusion sonohysterography was performed in 56 cases. It could not be done in one perimenopausal and one postmenopausal woman. Cavity was normal in 41 perimenopausal and five postmenopausal women. Ten women displayed abnormalities. Two had submucosal fibroids, two had intramural fibroids, one had fibroid polyp, three had endometrial polyps and two patients had endometrial growths. We found that TVS missed three endometrial polyps and one endometrial growth and led to mislabeling two intramural fibroids as submucosal. On comparing the sonohysterographic findings with those of hysteroscopy or hysterectomy, one endometrial polyp and one endocervical polyp was missed on sonohysterography, and one false positive growth was observed on sonohysterography. The sensitivity, specificity, positive predictive value and the negative predictive value of TVS were 84.8%, 79%, 82.4% and 82%, respectively. The sensitivity, specificity, positive predictive value and the negative predictive value of saline infusion sonohysterography were 94.1%, 88.5%, 91.4% and 92%, respectively. CONCLUSION: Saline infusion sonohysterography is a safe, convenient, time conserving, cost effective, easily accessible and acceptable investigative modality. It definitely enhances the diagnostic potential of TVS in assessment of endometrium and intracavitary pathologies.