Evaluation of nitric acid donor, transdermal glycerol trinitrate patches for facilitating cervical ripening: a randomised controlled trial.

PURPOSE: To evaluate the efficacy and safety of transdermal glycerol trinitrate skin patches as an additive and effective agent for facilitating cervical ripening for labour induction. METHODS: This was a double-blinded prospective randomised clinical trial carried out in a major obstetric unit in India. Women who planned for labour induction were randomly allocated for induction either by combined application of glycerol trinitrate skin patches [GTN patch] and intracervical dinoprostone gel or by the gel only. Sample randomisation was done using a stratified block randomisation technique with a sealed envelope. The numbers designating the group allocation sequence were concealed from doctors, research staff, and investigators. Six hourly improvements were assessed in the modified Bishop's score, induction-delivery time interval, the need for oxytocin, maternal side effects and foetal outcomes. Data were analysed using SPSS software. RESULTS AND DISCUSSION: Recruitment Bishop scores, parity and gestational age were matched in both cases and the control group. The modified Bishop's score was statistically improved in study groups, as evidenced compositely and irrespective of parity. The two groups appeared to have no significant differences regarding other outcomes. The additional application of the GTN patch seems helpful to accelerate the progress of labour but could not yield any favourable labour outcome. The GTN patch does not impose additional feto-maternal adverse effects apart from increased incidences of headaches.

Evaluation of isosorbide-5-mononitrate as a cervical ripening agent prior to induced abortion in contrast to misoprostol- a randomized controlled trial

OBJECTIVE: To determine whether vaginal application of 40 mg isosorbide-5-mononitrate (ISMN) has a comparable cervical ripening efficacy to and lesser side effects than 400 µg misoprostol in women scheduled for the first trimester induced abortion using a manual vacuum aspirator (MVA). METHODS: We conducted a prospective randomized open- label study in 70 women at 6–12 weeks of pregnancy at the R G Kar Medical College and Hospital, Kolkata, India, over a period of two years from 2015 to 2017. Forty milligrams of ISMN and 400 µg misoprostol were vaginally applied for cervical priming. The primary outcome measure was the cervical response assessed by the passage of the appropriate and largest sized MVA cannula through the internal os without resistance, at the beginning of the procedure. RESULTS: The base line cervical dilatation was found to be significantly higher in the misoprostol group than in the ISMN group (7.65±1.38 vs. 6.9±1.26 mm; P=0.025, 95% confidence interval, −1.4046 to −0.953). However, when the women were sub-analyzed based on parity, there was no statistically significant difference in the same parameters among the multigravid women. The need for further cervical dilatation was significantly higher in the ISMN group when the primigravid women were compared, although the multigravid women responded favorably to ISMN. CONCLUSION: In the primigravid women, misoprostol appears to exert a higher efficacy as a cervical ripening agent in contrast to ISMN. However, ISMN can be used in multigravid women for the same purpose as in this group, misoprostol did not show any significant improvement in efficacy over ISMN.

An approach to evaluate the efficacy of vaginal misoprostol administered for a rapid management of first trimester spontaneous onset incomplete abortion, in comparison to surgical curettage.

PURPOSE: The purpose of this study is to evaluate the efficacy and safety of the medical method in the management of first trimester spontaneous onset incomplete abortion, by using misoprostol vaginal tablets, in comparison to surgical evacuation, with an intention of completing the procedure within 24 h. METHODS: In this prospective, randomised study of 100 women admitted with features suggestive of incomplete abortion, 50 women received misoprostol vaginal tablets, while another 50 underwent suction curettage of products of conceptus. They were followed up after 24 h of last dosage of misoprostol or surgical intervention. Statistical analysis was done with respect to efficacy, safety and procedure-related side effects. RESULTS: In this study, when analysed after 24 h of treatment allocation, the efficacy of misoprostol was 91.3%, and the efficacy of the surgical method was 96%, with the statistical difference being insignificant. Procedure-related blood loss and pain perception between the two groups were statistically insignificant. However, the incidence of fever in the misoprostol group statistically appeared higher. CONCLUSIONS: Misoprostol could be a safe and easily accessible alternative to surgical evacuation, in cases of first trimester spontaneous onset incomplete miscarriage, and could be administered by the patient herself at home.

A randomized comparative study on modified Joel-Cohen incision versus Pfannenstiel incision for cesarean section.

OBJECTIVE: Pfanennstiel incision is the most commonly used incision for cesarean section, but may not be the best. This study compared the modified Joel-Cohen incision with the Pfannenstiel incision to evaluate whether techniques to open the abdomen might influence operative time, and maternal and neonatal outcomes. MATERIAL AND METHODS: In a randomized comparative trial, 302 women with gestational age >34 weeks, requiring cesarean section, were randomly assigned to either modified Joel-Cohen incision or Pfannenstiel incision for entry into the peritoneal cavity. The primary outcome measure was total time required for performing operation and secondary outcome measures were baby extraction time, number of haemostatic procedures used in the abdominal wall, postoperative morbidity, postoperative hospital stay and neonatal outcome. RESULTS: Mean total operative time was significantly less in the modified Joel-Cohen group as compared to the Pfannenstiel group (29.81 vs 32.67 min, p<0.0001, 95%CI=2.253 to 3.467). Time taken to deliver the baby and haemostatic procedures required during operation were also significantly less in the modified Joel-Cohen group as compared to the Pfannenstiel group. Requirement of strong analgesics was higher in the Pfannenstiel group (53.64% vs 21.85%, p<0.0001). There was no statically significant difference in the incidence of postoperative wound complications but postoperative stay in hospital was significantly less in the modified Joel-Cohen group (p=0.002). Neonatal outcomes were similar in both groups. CONCLUSION: The modified Joel-Cohen incision for entry into peritoneal cavity during cesarean section is associated with reduced mean total operative and baby extraction times with less postoperative pain and shorter hospital stay, which may be beneficial and cost effective.

Large sacrococcygeal teratoma hindering vaginal delivery attempted at home.

Sacrococcygeal teratoma in fetus is rare. If it remains antenatally undiagnosed, it may cause sudden arrest of an otherwise uncomplicated vaginal delivery because of the tumor mass. This poses a challenge to obstetricians. In this era of widespread antenatal care, this type of complication is very rare; however, in such cases, if met unexpectedly, an urgent laparotomy followed by a reduction of the tumor mass might help in completion of the delayed delivery.

Metastatic vulvo-vaginal choriocarcinoma mimicking a Bartholin cyst and vulvar hematoma-two unusual presentations.

Metastatic choriocarcinoma may present solely as a vulvo-vaginal growth. It may pose initial diagnostic dilemmas and thus treatment delay. Two cases of metastatic choriocarcinoma which presented as vulvo-vaginal swelling are described here. Both the cases were initially misdiagnosed. Later, unresponsiveness to treatment alerted us to the possibility of metastatic choriocarcinoma. Combination chemotherapy was started following diagnosis by serum ß-HCG titer. In spite of initial responsiveness in both cases, one could not be saved due to poor compliance. Suspicion of metastatic choriocarcinoma should be kept in mind while dealing with any recent onset vulvovaginal swelling following a pregnancy. It may initially mislead the clinician due to its apparent benign appearance.

Prediction of preeclampsia by midtrimester uterine artery Doppler velocimetry in high-risk and low-risk women.

OBJECTIVE: To observe the role of uterine artery Doppler flow velocimetry at midtrimester in prediction of preeclampsia. METHOD: 179 women carrying <16 weeks of pregnancy, with singleton fetus and without any fetal anomaly were recruited and were divided in high-risk and low-risk group. Doppler velocimetry of uterine artery was done at 24-26 weeks. Any notch in uterine artery, unilateral or bilateral, or RI > 0.6, was considered abnormal. Women were followed up and development of preeclampsia noted. RESULT: Sensitivity and specificity of abnormal uterine artery Doppler study for prediction of preeclampsia were 73.33 and 86.48 % in high-risk and 57.14 and 95.83 % in low-risk group, respectively. Relative risk with 95 % confidence interval was 5.427 (2.272-12.958) in high-risk and 13.65 (5.669-32.865) in low-risk women. CONCLUSION: Doppler velocimetry of uterine artery at 24 weeks can be used as a reliable screening test for prediction of preeclampsia in both high-risk and low-risk women.