ABSTRACT
ObjectivesGrey zones exist in the management of gestational trophoblastic neoplasia(GTN). An analysis stratified into four risk groups is presented.MethodsRetrospective descriptive study of WHO risk groups;low risk(≤6);low(0–4) and intermediate(5–6), high risk(≥7);high(7–12) and ultra-high risk(≥13). Chemotherapy regimens, cycles for remission, side effects and cumulative delay were assessed.ResultsOf 22 cases of GTN, 13.6%(n=3) were low risk, 36.4%(n=8) intermediate risk, 40.9%(n=9) were high risk and 9.1(n=2) ultra-high risk. Presentations included vaginal bleeding 90.9%(n=18), lung metastasis 50.0%(n=11) and pulmonary artery thrombosis 13.6%(n=3). Low risk GTN received single agent methotrexate for mean 4.7±1.5 cycles. Women with WHO score 5(n=2) received methotrexate for mean 7.5±3.5 cycles. Women with score 6 (n=6);one received 8 cycles of methotrexate, one crossed over to EMACO and received 8 cycles. Three cases received EMACO for a mean of 8.7±4.5 cycles. Of high risk GTN(n=9), three received mean 6 cycles EMACO, another received 3 cycles induction with cisplatin/etoposide followed by 6 cycles EMACO, one required 9 cycles EMACO followed by pneumonectomy and 21 cycles of second-line chemotherapy but succumbed to disease. Two were lost to follow-up while two are on treatment. Ultra-high risk GTN(n=2), responded to 9 cycles of EMACO. Surgical interventions were needed in four. 15 achieved remission, two lost to follow up, two succumbed to disease and three on treatment. Grade1–2 toxicity were seen in majority. COVID 19 pandemic caused cumulative delay of 146 days in one with ultra-high risk GTN.ConclusionsResearch into newer and effective chemotherapy/targeted regimens for intermediate and high-risk GTN are needed.
ABSTRACT
Objective We aim to implement the practice of birth companions (BC) (from 0% to 90%) during labor to provide respectful maternity care (RMC) during the coronavirus disease 2019 (COVID-19) pandemic. Methods This was a prospective quality improvement (QI) study conducted in the Department of Obstetrics and Gynecology at All India Institute of Medical Sciences (AIIMS), Rishikesh, India. The methodology given by the World Health Organization (WHO)'s Point of Care Continuous Quality Improvement (POCQI) manual was followed, and standard tools of quality improvement were used to attain the objective. Results The QI team conducted a cause and effect analysis to understand the reasons why birth companions were not allowed during childbirth. The Pareto principle derived at three most important causes of the problem: absence of a defined policy, ignorance of guidelines promoting BC even during the pandemic, and relatives could enter wards only after a negative reverse transcriptase polymerase chain reaction (RTPCR) report, which could take up to 48 hours. Multiple change ideas were tested by means of Plan-Do-Study-Act (PDSA) cycles that were successful in bringing about desired change and improvement in the delivery of quality healthcare. Conclusion QI methodology was effective in promoting and achieving more than 90% birth companionship in labor and thus helpful in providing respectful maternity care even during the COVID-19 pandemic.