Decoding the Genetics of Recurrent Molar Pregnancy.

Hydatidiform mole is a condition characterised by abnormal trophoblastic hyperplasia and failure of embryonic tissue development. The risk of recurrence is seen to be associated with biallelic maternal mutations in NLRP7, KHDC3 L and PAD16 genes. Women with such mutations have a major risk of reproductive failure and normal pregnancy is seen in only 1.8%. We report the case of a 31-year-old woman with previous three molar pregnancies who on genetic testing was found to be compound heterozygous for pathogenic variants in the NLRP7 gene (c.2738A>G and c.2078G>C). Accordingly, the woman was counselled regarding assisted reproduction with oocyte donation for a normal pregnancy outcome. At present, the patient has an ongoing 5-month pregnancy through oocyte donation.

Prevalence of human papilloma virus and Chlamydia trachomatis in endometrial and cervical carcinoma: a comparative study in North Indian women.

Cervical cancer (Cacx) is the second and endometrial cancer (Ec) is the third most common gynecological cancer worldwide. The present study aims to understand the complex and unexplored conditions occurring in cervix and endometrium of the female genital tract caused due to the infection of the human papilloma viruses (HPVs) and Chlamydia trachomatis (CT). A total of 300 tissue biopsy samples of cervix and endometrium were included in the present study and tested for the presence of HPV and CT deoxyribonucleic acid (DNA) by using polymerase chain reaction (PCR) technique. The odds ratios and 95% confidence interval were considered for the calculation of the association of HPV and CT infection with the risk of cervical or Ec. Among endometrial patients, samples were 5% positive for HPV and 5% positive for CT infection. Among endometrial control group, no sample was found positive for either HPV or CT infection. Among cervical patients, 72% samples were positive for only HPV infection and 1% samples were positive for only CT infection. Among control group, 7% of samples were positive for only HPV infection and 3% were positive for only CT infection. The co-infection of CT with HPV in 9% of Cacx cases and in 2% of cervical control samples was also observed. This is the first study in Indian women to detect the prevalence of HPV and CT infections in endometrium cases and control. An updated estimate regarding the HPV and CT prevalence in cervix cases and control samples was also provided.

Inferring bona fide Differentially Expressed Genes and Their Variants Associated with Vitamin K Deficiency Using a Systems Genetics Approach.

Systems genetics is key for integrating a large number of variants associated with diseases. Vitamin K (VK) is one of the scarcely studied disease conditions. In this work, we ascertained the differentially expressed genes (DEGs) and variants associated with individual subpopulations of VK disease phenotypes, viz., myocardial infarction, renal failure and prostate cancer. We sought to ask whether or not any DEGs harbor pathogenic variants common in these conditions, attempt to bridge the gap in finding characteristic biomarkers and discuss the role of long noncoding RNAs (lncRNAs) in the biogenesis of VK deficiencies.

Reusable sanitary napkins-time to revisit.

BACKGROUND: To assess knowledge, attitude and practices (KAP) of women regarding menstrual hygiene and to evaluate the use of reusable sanitary napkins as an alternative to disposable sanitary napkins. METHODS: A community-based cross-sectional study was done in two phases. In the first phase, 50 married women attending Gynecology OPD were asked to use reusable sanitary napkins for 2 months. A pre- and post-usage vaginal swab testing was done to rule out genital infection. This study was extended in the second phase to another 534 women after confirming that reusable sanitary napkins do not cause genital infection and are acceptable. KAP analysis regarding menstrual hygiene was done for all women. RESULTS: In phase 1 of the study, the microbiological evaluation revealed no pathological organisms on vaginal swab culture after 2 months of usage. KAP analysis of 584 women revealed that only 26% women had awareness about menstruation before attaining menarche; in 51.88%, the primary source of information was their mother; 76.54% women in the study used disposable sanitary pads of which 15% were disposing of them unhygienically; 80.49% women found the reusable napkins comfortable and easy to use and 83.6% women confirmed recommending these napkins to others. CONCLUSION: Reusable sanitary pads are an effective, environment friendly, and cost-effective alternative to disposable napkins.

Development of a hub and spoke model for quality improvement in rural and urban healthcare settings in India: a pilot study.

OBJECTIVE: Hub and spoke model has been used across industries to augment peripheral services by centralising key resources. This exercise evaluated the feasibility of whether such a model can be developed and implemented for quality improvement across rural and urban settings in India with support from a network for quality improvement. METHODS: This model was implemented using support from the state and district administration. Medical colleges were designated as hubs and the secondary and primary care facilities as spokes. Training in quality improvement (QI) was done using WHO's point of care quality improvement methodology. Identified personnel from hubs were also trained as mentors. Both network mentors (from QI network) and hub-mentors (from medical colleges) undertook mentoring visits to their allotted facilities. Each of the participating facility completed their QI projects with support from mentors. RESULTS: Two QI training workshops and two experience sharing sessions were conducted for implementing the model. A total of 34 mentoring visits were undertaken by network mentors instead of planned 14 visits and rural hub-mentors could undertake only four visits against planned 18 visits. Ten QI projects were successfully completed by teams, 80% of these projects started during the initial intensive phase of mentoring. The projects ranged from 3 to 10 months with median duration being 5 months. DISCUSSION: Various components of a health system must work in synergy to sustain improvements in quality of care. Quality networks and collaboratives can play a significant role in creating this synergy. Active participation of district and state administration is a critical factor to produce a culture of quality in the health system.

Emergency Peripartum Hysterectomy: Indications and Outcome in a Tertiary Care Setting.

INTRODUCTION: Emergency Peripartum Hysterectomy (EPH) is an important lifesaving procedure, mostly reserved for conditions deemed to be serious and life threatening, and not amenable to conservative methods. In the present scenario, the advent of newer medical and conservative surgical methods for controlling obstetric haemorrhage has influenced the incidence, trend and the outcomes of the procedure. AIM: To evaluate the demographic profile, indications, operative details, maternal morbidity and mortality and neonatal outcomes of women undergoing EPH. MATERIALS AND METHODS: A descriptive analysis of case records of women who underwent EPH between September 2006 to July 2014, at Guru Teg Bahadur Hospital Delhi, India was done. Data were collected from the medical records department. RESULTS: A total of 194 cases (n) were identified among 1,00712 deliveries, an incidence of 1.92 per 1000 deliveries. Majority of the women were unbooked i.e., they did not receive any form of antenatal care and were gravida 3 and above. The indications were atonic PPH in 89 (45.87%), rupture of unscarred uterus in 36 (18.56%), morbidly adhered placenta in 30 (15.46%), scar rupture in 20 (10.31%) and gangrenous uterus 19 (9.79%). The mean blood loss was around 1.6±0.45 litres. Approximately 14% cases underwent stepwise devascularisation prior to hysterectomy and in only 2% women, B-Lynch suture was applied. Thirteen (6.7%) cases had bladder injury and 22 (11.34%) needed re-laparotomy for hysterectomy. Around 76 (39%) women were shifted for ICU care. Nineteen (9.79%) women developed Disseminated Intravascular Coagulation (DIC). The case fatality rate was 7.2% and perinatal mortality was 30%. CONCLUSION: Atonic PPH remains the leading cause of EPH in our analysis. Surprisingly rupture of unscarred uterus was more common compared to scar rupture. Creating awareness among women to seek health services in time with facilities for early referral, teaching younger obstetricians with conservative surgical procedures like stepwise devascularisation steps and compressive sutures should be of utmost priority.

A Ten Year Audit of Maternal Mortality: Millennium Development Still a Distant Goal.

OBJECTIVE: To assess various causes of maternal mortality over a ten year period. DESIGN: Retrospective audit of hospital case records. SETTING: Tertiary care hospital. POPULATION: Pregnant women who expired in the premises of GTB Hospital. MATERIALS AND METHODS: A retrospective audit of case records of maternal deaths was conducted for a ten year period (January 2005 to December 2014). RESULTS: There were a total of 647 maternal deaths out of 1,16,641 live births. Sixty-eight percent (n = 445) of women were aged 21-30 years, while 10.5% (n = 68) were <20 years of age. The most common direct causes of maternal mortality were preeclampsia/eclampsia in 24.4% (n = 158), obstetric hemorrhage in 19.1% (n = 124) and puerperal sepsis in 14.5% (n = 94). With regards to indirect causes, anemia accounted for 15.3% (n = 99) mortality. There was only 1 (0.1%) mortality because of HIV/AIDS. Other notable causes of maternal mortality were infective hepatitis in 7.1% (n = 46). Tuberculosis, that is a disease of tropical countries, accounted for 3.0% (n = 20) of the total deaths. CONCLUSION: High maternal mortality in GTB hospital can be due to it being a tertiary hospital with referrals from all neighbouring states. Accessible antenatal care can help prevent these maternal deaths. Female education can be of immense help in dealing with the problem and improving the utilization of public health facilities. KEY MESSAGE: Preeclampsia/eclampsia and obstetric hemorrhage have been the main causes of maternal mortality for ages. Regular antenatal visits and the judicious training of grassroot level workers to pick-up complications early on in the pregnancy can be an effective way to deal the morbidity and mortality associated with these problems. The Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakaram (JSSK) in India are pioneer steps in this direction.

Pregnancy with Pemphigoid Gestationis: A Rare Entity.

Pemphigoid Gestationis (PG) is a rare autoimmune blistering disease with an incidence of 1/50000 pregnancies. Presentation in the second or third trimester is most common and tends to recur in subsequent pregnancies with earlier onset and a more severe course. Direct Immunofluorescence (DIF) staining is confirmatory on skin biopsy specimen. A 24-year-old female presented at 6 months period of gestation with increased blood pressure records. On examination, there were fresh bullous lesions along with old healed scar marks on the abdomen and limbs. Termination of pregnancy was done due to high BP. Patient delivered a fresh still birth weighing 750 gm. No postpartum flare ups were seen and she was discharged on prednisolone in a satisfactory condition.

Materno-Fetal Outcomes with Viral Hepatitis in Pregnancy.

OBJECTIVE: To evaluate materno-fetal outcomes in pregnant women with jaundice. METHODS: A prospective study was conducted over a period of 6 months in a tertiary care hospital of Delhi, India. 82 pregnant women with jaundice were included. The serum was screened for viral markers, liver function tests, and coagulation status. RESULTS: The mean age of women was 27.3 ± 4.3 years. 43.9 % (n = 36) women were HEV positive, 36 % (n = 27) HBsAg positive, 4 % (n = 3) HAV positive and 1.3 % (n = 1) HCV positive. Intrahepatic cholestasis was diagnosed in 10.8 % (n = 8) of women. Maternal morbidity was evaluated in terms of chorioamnionitis (5.4 %, n = 3), encephalopathy (26.8 %, n = 15), and coagulopathy (67.9 %, n = 38). There were five maternal deaths, and all were unbooked with HEV-positive status and a bilirubin >15 mg/dl with deranged coagulogram and encephalopathy and IUDs. 79 women delivered vaginally, and three had cesarean section. Of the vaginal deliveries, 59.8 % (n = 49) went into spontaneous labor, and 25.5 % (n = 21) were induced for varied reasons (BPS < 6/10 (38 %, n = 8)) and progressive derangement of LFT (38 %, n = 8). Among the 71 deliveries, 29 (40.8 %) were IUD and 42 (59.1 %) were live born. On analyzing the morbidity data, it was found that HEV-positive women (deranged coagulogram 71.05 %, IUD 75.86 %, encephalopathy 80 %) had a poorer outcome as compared to their HBsAg positive counterparts (deranged coagulogram 10.52 %, IUD 13.79 %, encephalopathy 6.66 %). CONCLUSION: Urgent redressal of issues pertaining to sanitation and provision for clean drinking water for citizens of India is the need of the hour as HEV is fecooral in transmission.

Indwelling Catheterization in Caesarean Section: Time To Retire It!

BACKGROUND: Routine placement of indwelling catheter preoperatively in Caesarean Section is being practiced without justified scientific evidence. AIM: To evaluate the effect of routine indwelling catheterization on the postoperative ambulation, morbidity and hospital stay in women undergoing Caesarean section. SETTINGS AND DESIGN: Case-Control study carried in a tertiary teaching hospital. MATERIALS AND METHODS: This study was carried over 150 women undergoing primary Caesarean section without any medical complication or pre-existing Urinary Tract Infections (UTI). The subjects were randomly allocated to 2 groups i.e. Group 1(Non-Catheterized; NC) and Group 2 (Catheterized for 24 hours postoperatively; C). Parameters noted were; duration of surgery, time of ambulation, postoperative voiding discomfort {graded as - no, mild, moderate-severe, by Visual Analog Scoring (VAS)}, incidence of UTI, postoperative urinary retention, need of postoperative antibiotics and duration of hospital stay. STATISTICAL ANALYSIS: Results were analysed using unpaired t-test. RESULTS: There was no significant difference in duration of surgery and postoperative urinary retention in both groups. However, it was seen that non-catheterized patients had significantly earlier ambulation, shorter hospital stay, took less time for first voiding, lesser voiding discomfort, less incidence of UTI and lesser use of postoperative antibiotics. CONCLUSION: The routine use of indwelling catheter in Caesarean section is unscientific and unnecessary. There should be selective rather than routine catheterization.

Alterations in microRNAs miR-21 and let-7a correlate with aberrant STAT3 signaling and downstream effects during cervical carcinogenesis.

BACKGROUND: Present study provides clinical evidence of existence of a functional loop involving miR-21 and let-7a as potential regulators of aberrant STAT3 signaling recently reported by our group in an experimental setup (Shishodia et al. BMC Cancer 2014, 14:996). The study is now extended to a set of cervical tissues that represent natural history of human papillomavirus (HPV)-induced tumorigenic transformation. MATERIALS AND METHODS: Cervical tissues from histopathologically-confirmed pre-cancer (23) and cancer lesions (56) along with the normal control tissues (23) were examined for their HPV infection status, expression level of miR-21 & let-7a and STAT3 & pSTAT3 (Y705) by PCR-based genotyping, quantitative real-time PCR and immunoblotting. RESULTS: Analysis of cancer tissues revealed an elevated miR-21 and reduced let-7a expression that correspond to the level of STAT3 signaling. While miR-21 showed direct association, let-7a expression was inversely related to STAT3 expression and its activation. In contrast, a similar reciprocal expression kinetics was absent in LSIL and HSIL tissues which overexpressed let-7a. miR-21 was found differentially overexpressed in HPV16-positive lesions with a higher oncoprotein E6 level. Overexpression of miR-21 was accompanied by elevated level of other STAT3-regulated gene products MMP-2 and MMP-9. Enhanced miR-21 was found associated with decreased level of STAT3 negative regulator PTEN and negative regulator of MMPs, TIMP-3. CONCLUSION: Overall, our study suggests that the microRNAs, miR-21 and let-7a function as clinically relevant integral components of STAT3 signaling and are responsible for maintaining activated state of STAT3 in HPV-infected cells during cervical carcinogenesis.

Laparoscopy:as a first line diagnostic tool for infertility evaluation.

INTRODUCTION: The role of diagnostic and therapeutic hystero-laparoscopy in women with infertility is well established. It is helpful not only in the identification of the cause but also in the management of the same at that time. MATERIALS AND METHODS: In this study, the aim was to analyse the results of 203 women on whom laparoscopy for the evaluation of infertility was done. This study was carried out at a tertiary level hospital from 2005 to 2012. The study group included 121 women with primary infertility and 82 women with secondary infertility. Women with incomplete medical records and isolated male factor infertility were excluded from the study. RESULTS: It was observed that tubal disease was the responsible factor in 62.8% women with primary infertility and 54.8% women with secondary infertility followed by pelvic adhesions in 33% and 31.5%, ovarian factor in 14% and 8.5%, pelvic endometriosis in 9.9% and 6.1% women respectively. Thus tubal factor infertility is still a major cause of infertility in developing countries and its management at an early stage is important to prevent an irreversible damage. At the same time, it also directs which couples would be benefited from assisted reproductive technologies (ART).

Changing trends in use of laparoscopy: a clinical audit.

Aim. To find out the changing trends in indications for use of laparoscopy for diagnostic or operative procedures in gynaecology. Methods. This was a clinical audit of 417 women who underwent laparoscopic procedures over a period of 8 years from January 2005 to December 2012 in the Department of Obstetrics and Gynaecology at a tertiary care centre in Delhi. Results. A total of 417 diagnostic and operative laparoscopic procedures were performed during the period from January 2005 to December 2012. Out of 417 women, 13 women were excluded from the study due to inadequate data. 208 (51.4%) women had only diagnostic laparoscopy whereas 196 (48.6%) patients had operative laparoscopy after the initial diagnostic procedure. Change in trend of diagnostic versus operative procedures was observed from 2005 to 2012. There was increase in operative procedures from 10 (37.03%) women in 2005 as compared to 51 (73.91%) in 2012. The main indication for laparoscopy was infertility throughout the study period (61.38%), followed by chronic pelvic pain (CPP) (11.38%) and abnormal uterine bleeding (AUB) (9.4%). Conclusion. Over the years, there has been a rise in the rate of operative laparoscopy. Though the indications for laparoscopy have remained almost similar during the years, laparoscopy for diagnosis and treatment of CPP and AUB has now increased.

Ascorbic Acid concentration and preterm premature rupture of membranes.

INTRODUCTION: Preterm premature rupture of membranes (PPROM) complicates 1-5 % of all pregnancies and is the major contributory factor for perinatal morbidity and mortality. Micronutrient deficiency (vitamin C) is associated with increased risk of PPROM. This study was conducted to establish the association between maternal plasma vitamin C concentration in women with PPROM and women without PPROM and to study the difference in maternal morbidity, neonatal morbidity, and mortality. METHODS: A prospective study was conducted where 40 women (20 in each study and control group) with singleton pregnancies between 28 and 37 weeks gestation were recruited. Women with anemia, diabetes, UTI, RTI, vaginal infection, bleeding, h/o PPROM in previous pregnancy, polyhydramnios, and smoker were excluded from the study. Maternal plasma vitamin C levels were measured. RESULTS: Ascorbic acid levels were low in women with PPROM 0.41 ± 0.08 versus 0.84 ± 0.19 mg/dl. There is a linear decline in plasma vitamin C levels as the pregnancy advances. Inverse relationship was observed between duration of rupture of membranes and vitamin C levels. There was a significant difference in maternal morbidity, neonatal morbidity, and mortality. CONCLUSION: Ascorbic acid concentration was low in women with PPROM. Thus, vitamin C supplementation should be made mandatory along with iron and calcium to antenatal women to avoid the complications of PPROM.

Thyroid dysfunction during pregnancy and in postpartum period: treatment and latest recommendations.

Thyroid dysfunction is the second most common endocrine disorder, only after diabetes mellitus, affecting females in reproductive age group. Pregnancy is associated with profound repercussions on the thyroid status of a lady. Thyroid dysfunctions such as hypothyroidism, thyrotoxicosis and thyroid nodules may develop during pregnancy leading to abortion, placental abruptions, pre-eclampsia, preterm delivery and reduced intellectual function in the offspring. Thus, maintenance of euthyroid state is of utmost important for maternal and fetal well being during pregnancy as well as after. The Endocrine Society has issued latest guidelines regarding the diagnosis and management of thyroid dysfunction related to pregnancy. All the clinicians should be well aware of the latest recommendations regarding management of thyroid dysfunction in pregnancy and in postpartum phase and practice them accordingly.

Proximal femoral focal deficiency revisited: a case report.

Proximal femoral focal deficiency (PFFD) is a rare anomaly with an estimated incidence of < 0.2/ 10,000 births. The aetiology of PFFD is unknown though various agents have been implicated including anoxia, ischaemia, mechanical or thermal injury. Herein is reported a case of a 22-year-old primigravida who delivered a baby with PFFD. This patient had developed high grade fever and had undergone ischiorectal abscess drainage at 7 weeks of gestation; maternal hyperthermia combined with anoxic injury might have been contributory factors in the causation of this disorder. So, it is of prudent importance to do prenatal targeted ultrasonography in patients who develop febrile illness in early pregnancy.