Anaemia in pregnancy: prevalence and treatment response to various modalities: a prospective study

Background: Anaemia seen in pregnancy are largely preventable and easily treatable if detected in time, despite this, anaemia still continues to be a common cause of maternal and perinatal morbidity and mortality in India.Methods: A prospective observational study of 200 pregnant women with anaemia was carried out from Jun 2017 to December 2018 at a Tertiary care hospital with pan India population. Patients underwent clinical examination and laboratory tests to find out the severity and type of anaemia and were treated accordingly. Iron deficiency anaemia was treated with oral or intravenous iron therapy depending upon the hemoglobin concentration. Patients were followed up after 28 days of treatment and hemoglobin estimation was done to monitor the treatment response.Results: A total 36.49% pregnant women had hemoglobin less than 10 gm%. 151 out of 200 women had serum ferritin <12 ng/ml which indicates that iron deficiency anaemia is the commonest type of anaemia in pregnancy. Overall, out of 200 patients 5.5% patients were found to have hemoglobinopathies (β thalassemia trait). After 28 days of treatment mean increase in hemoglobin was 2.40 gm% and 4.24 gm% in patients receiving oral and intravenous iron therapy respectively.Conclusions: A total 36.49% pregnant women were found to have anaemia during pregnancy and iron deficiency anaemia is the commonest type of anaemia. Therefore, there is still a need for dietary counselling and health education in the community. 5.5% patients were found to have beta thalassemia trait which was detected only after conducting hemoglobin electrophoresis. Both oral and intravenous iron therapy are effective in treatment of iron deficiency anaemia but intravenous iron therapy results in a more rapid resolution of anaemia.

Maternal and fetal outcome in placenta previa: our experience

Background: Placenta previa contributes substantial maternal and neonatal morbidity including management challenges for obstetrician. This study was to evaluate the potential risks factors and feto-maternal, outcome in placenta previa. This study was done with the intent of developing insight into risk factors, clinical presentation, various interventions and management for overall improvement in maternal and fetal outcome in placenta previa.Methods: A prospective observational study, where 30 cases of placenta previa confirmed after 28 weeks POG, treated in a public sector tertiary care hospital from June 2016 to June 2018 were included. Authors analyzed the data to evaluate the potential risks factors and maternal and fetal outcome in placenta previa.Results: In this study, major contributing risk factors for placenta previa were associated with multiparity (76.7%), maternal age >30 in 50%, previous LSCS in 46.7%, repeated uterine procedure like suction evacuation/curretage. There was a high rate of maternal morbidity mainly due to haemorrhage. Perioperative uterine artery embolization (UAE) in 3 (10%), intra-operative procedures namely devascularization, internal iliac ligation in 66.6% cases, peripartum hysterectomy in 2 (6.66%) were done to control haemorrhage. Blood and blood products transfusion required in 26.7% of cases. Fetal morbidity included prematurity in 9 (33.3%), NICU admission in 11 (36.6%) majority of which included 8 (26.7%) babies of birth weight <2000 grams.Conclusions: Placenta previa contributes to significant maternal and neonatal morbidity. Multiparity, post LSCS pregnancy constitute major factor for placenta previa. Management requires high-risk obstetrical care with frequent antenatal visits. Serial ultrasonography in reported cases of low-lying placenta is mandatory to exclude over diagnosis or migration. All cases of placenta previa need to be managed in a higher centre with facility of blood component therapy and neonatal intensive care unit. Prematurity and low birth weight remain a significant cause for neonatal morbidity.

Vaginal birth after cesarean

Background: A heightened awareness must be present among the clinicians while taking the decision to perform the first cesarean section, as it decides the future obstetric career of the women. Because of the rise in cesarean section rate in recent decades, the question of how to manage the subsequent deliveries becomes important. Vaginal birth after cesarean (VBAC) has long been proposed as an alternative measure to reduce repeat cesarean rate. Our present study aims to assess the predictive factors of successful VBAC and study the risks and benefits involved.Methods: A prospective observational study was conducted to assess the success of VBAC and its outcome in GMERS Medical College and Hospital, Ahmedabad. A total of 100 pregnant women with history of previous one cesarean section who fulfilled the criteria for vaginal delivery were recruited for study and the outcome was analyzed.Results: The success rate of VBAC was 58% while failed TOLAC which ended up in emergency repeat cesarean section was 42%. Vaginal delivery either before or after the history of previous cesarean section, neonatal birth weight between 2.5-3kg, and admission during active phase of  labour were associated with successful VBAC. There were 2 cases of partial scar rupture diagnosed peroperatively. The commonest indication of repeat cesarean section was non progress of labour (45.2%) followed by fetal distress (16.7%). The neonatal morbidity rate was similar in both groups due to limited prolonged unsuccessful trial in our study. There was no maternal and neonatal mortality.Conclusions: To reduce the escalating rate of total cesarean section worldwide, VBAC is an alternative option which should be encouraged in carefully selected patients. However, it should be carried out in a well equipped institute with close fetal monitoring and availability of blood and trained personnel. Thus “once a cesarean section, always a hospital delivery” and not, “once a cesarean section, always a cesarean section”.

Induction of labor in women with unfavourable cervix: comparison of efficacy of intracervical Foley catheter with PGE2 gel

Background: The aim of our study was to compare the efficacy, safety and patient’s satisfaction of intracervical Foley catheter with intracervical dinoprostone gel (PGE2 gel) for cervical ripening for successful induction of labor.Methods: Prospective study was conducted in Department of Obstetrics and Gynaecology, M P Shah Medical College, Jamnagar, Gujarat. 317 women with term pregnancy with bishop score of less than 4 with various indications for induction were included. Intracervical foley catheter was kept in 162 women for cervical ripening (group A) while intracervical PGE2 gel was kept in rest 155 women (group B).  The change in the bishop score, progress of labor, adverse effects and outcome of labor along with the patient’s satisfaction were assessed.Results: With regard to the obstetrical parameters, the two groups were comparable with respect to maternal age, gestational age, parity, indication for induction and initial bishop score. At 12 hours, both the groups showed significant improvement in bishop score, 5.2±1.81 and 4.8±1.76 in Foley catheter and PGE2 gel respectively. Mean induction to delivery interval was 18.8±5.5 in group A and 17.9±5.3 in group B, which was statistically insignificant.  No significant differences in side effects, mode of delivery and APGAR score were noted in both the groups. However, the incidence of hyperstimulation and tachysystole was higher in PGE2 gel group.Conclusions: This study shows that both Foley catheter and dinoprostone gel appear to be equally effective agents for cervical ripening. Infect foley catheter is cheap, causes less fetal distress and is safer than PGE2 gel.

A Comparative Study on Outcomes of Adjuvant and Neoadjuvant Chemotherapy on Locally Advanced Breast Cancer

Breast cancer is among the leading cause of cancer related deaths in women. The treatment of locally advanced breast cancer requires a combination of systemic chemotherapy, surgery, and radiotherapy to optimize the chance of cure. The aim of present study is to compare the effect of Adjuvant Chemotherapy and Neo-adjuvant Chemotherapy on Locally Advanced Breast cancer (LABC). Methods: The study included 35 female patients presenting to the surgery OPD of SVBP hospital with locally advanced breast cancer proven on biopsy out of which 17 patients received Neoadjuvant chemotherapy based on high tumour breast ratio, fixed lymph nodes in the axilla, fixed to the chest wall and multiple sattelite lesions. And 18 patients were operated as modified radical mastectomy and then they received the six cycle of adjuvant chemotherapy. The data collected was statistically analysed by WILKOXONS SIGNED RANK TEST for neoadjuvant chemotherapy and percentage evaluation for results of adjuvant chemotherapy. Results: Clinically measured size of tumour correlates well with the radiological assessment of the same. There was significant reduction of tumour size both clinically and radiologically. There was significant reduction of tumour size both clinically and radiologically in ER/PR+ve as well as ER/PR-ve patients but more decrease in ER/PR+ve patients means receptor positivity is a good prognostic sign. 88.9% of patients who have receive adjuvant chemotherapy showed no local recurrence both clinically and radiologically. 88.9% of patients who have receive adjuvant chemotherapy showed no recurrence of axillary Lymphadenopathy. 94.45% of patients who have receive adjuvant chemotherapy showed no involvement of liver, brain, lung and bone both clinically and radiologically. Conclusion: It is concluded that both Radiological and Clinical response are same by both therapies. But, local recurrence, recurrence of axillary Lymphadenopathy and involvement of liver, brain, lung and bone both clinically and radiologically are less with adjuvant chemotherapy.

Role of single serum progesterone assay in threatened abortion as a predictor of viable pregnancy.

Background: Low progesterone levels have been linked to increased risk of miscarriage in first trimester of pregnancy. Methods: The observational, cross-sectional study was conducted over 100 pregnant females in first trimester of pregnancy < 12 weeks. All patients were subjected to sonography to confirm pregnancy & serum progesterone level testing immediately after admission and before initiation of treatment. Result: After analysis of the results, cut off value of serum progesterone as determined in this study came out to be 9.9 ng/ml with 94.9% sensitivity & 92.7% specificity. Conclusion: The value of serum progesterone estimation was of great help in differentiating between viable and non-viable pregnancy.

Lipiodol as a Fiducial Marker for Image-Guided Radiation Therapy for Bladder Cancer

Purpose To evaluate Lipiodol as a liquid, radio-opaque fiducial marker for image-guided radiation therapy (IGRT) for bladder cancer.Materials and Methods Between 2011 and 2012, 5 clinical T2a-T3b N0 M0 stage II-III bladder cancer patients were treated with maximal transurethral resection of a bladder tumor (TURBT) and image-guided radiation therapy (IGRT) to 64.8 Gy in 36 fractions ± concurrent weekly cisplatin-based or gemcitabine chemotherapy. Ten to 15mL Lipiodol, using 0.5mL per injection, was injected into bladder submucosa circumferentially around the entire periphery of the tumor bed immediately following maximal TURBT. The authors looked at inter-observer variability regarding the size and location of the tumor bed (CTVboost) on computed tomography scans with versus without Lipiodol.Results Median follow-up was 18 months. Lipiodol was visible on every orthogonal two-dimensional kV portal image throughout the entire, 7-week course of IGRT. There was a trend towards improved inter-observer agreement on the CTVboost with Lipiodol (p = 0.06). In 2 of 5 patients, the tumor bed based upon Lipiodol extended outside a planning target volume that would have been treated with a radiation boost based upon a cystoscopy report and an enhanced computed tomography (CT) scan for staging. There was no toxicity attributable to Lipiodol.Conclusions Lipiodol constitutes a safe and effective fiducial marker that an urologist can use to demarcate a tumor bed immediately following maximal TURBT. Lipiodol decreases inter-observer variability in the definition of the extent and location of a tumor bed on a treatment planning CT scan for a radiation boost.

Efficacy of Yoga and Swimming in Reducing Anxiety: A Comparative Study.

Different exercise modules and yogic practices have been claimed to reduce anxiety. However, there are very few longitudinal studies to assess and to compare improvement in mental health of subjects performing yogic asanas and breathing exercises versus those performing endurance exercises like swimming. Therefore, present study was designed to compare reduction in anxiety levels with yogic postures and breathing exercises with that of swimming. This study was conducted in the Department of Physiology. Study design used was prospective randomized comparative Study. Hundred volunteers were included in the study and randomly divided into two groups; one practiced yogic asanas and breathing exercises and other practised swimming for 12 weeks. Beck’s Anxiety Inventory was used to assess anxiety level of subjects. Anxiety levels were assessed prior to the training and then after 12 weeks of training. The total score was calculated from 21 items and high scores indicated higher anxiety levels. The average anxiety scores decreased significantly (p<0.0001) in both the groups after training. In yoga group. average pretraining score of 24.25 decreased to post training score of 20.27, whereas in swimmer group it decreased from 23.57 to 20.8. However, the decrease in anxiety was similar with both modalities of exercise (p>0.05).

Molecular phenotypes of ductal carcinoma-in-situ and invasive ductal carcinoma: A comparative study.

Aims and Objectives: This study was aimed at analyzing the prevalence of molecular phenotypes in invasive ductal carcinoma (IDC) and coexisting ductal carcinoma-in-situ (DCIS) and to correlate with clinicopathological features. Materials and Methods: In this study, 75 cases of IDC with coexisting DCIS were included. Molecular phenotype was determined using expression of estrogen receptor, progesterone receptor, HER2/neu, and cytokeratin 5/6. Statistical analysis was performed for correlation between molecular phenotypes and clinicopathologic parameters. Results: Of the 75 cases, the invasive component in all cases was IDC-not otherwise specified. About one-third of our patients were post-menopausal. The most common molecular phenotype was luminal A (45.3%) followed by HER2-expressing type (24%). In all cases, the molecular phenotype was identical in DCIS and the invasive component. HER2-expressing tumors were found to be larger in size with frequent nodal involvement. On statistical analysis, tumor size and grade were found to correlate with the molecular phenotype. Conclusion: In conclusion, the molecular phenotype in DCIS correlates well with that of coexisting IDC, suggesting that DCIS is a precursor lesion in these tumors. This correlation of molecular phenotype can be utilized in prediction of phenotype of the invasive component in a case with in-situ carcinoma.

Malnutrition is not an etiological factor in the development of tropical pancreatitis – A case-control study of Southern Indian patients.

Background and Aim: Malnutrition is implicated as an etiological factor in tropical pancreatitis (TP). The aim of the present study was to elucidate whether malnutrition is the cause or the result of TP. Methods: Consecutive recently diagnosed patients with TP were evaluated for their nutritional status and dietary patterns before and after the onset of TP. The nutritional status of patients before the onset of TP was compared with that of healthy controls to demonstrate the role of malnutrition as an etiological factor for TP. Results: Of 256 consecutive patients with chronic pancreatitis, 89 were diagnosed as TP patients with disease duration of less than 1 year (mean age 32.14 ± 14 years; 60 % males) and comprised the study group. The nutritional status before the onset of TP was comparable with that of controls (n=101) with 15% of patients and 12% of the controls being malnourished (BMI <18.5kg/m2). However, after the onset of TP, 52% (n=46) of patients lost weight and the percentage of malnourished patients increased from 15% to 38% (p=<0.001) indicating that there was significant weight loss after the disease onset. When the causes of weight loss were evaluated, it was found that low calorie intake significantly contributed to weight loss (p=0.001). Conclusion: Malnutrition is not an etiological factor of TP and weight loss occurred as a result of low calorie intake after the onset of TP.