Optimal timing of prophylactic antibiotic for cesarean delivery: a randomized comparative study.

AIM: Cesarean delivery is associated with a significantly higher postoperative infection rate than that following vaginal birth and other surgical procedures. This study compared whether antibiotic prophylaxis administered preoperatively was more effective in preventing infectious morbidity following cesarean delivery than administration at cord clamping. MATERIAL AND METHODS: In a randomized comparative trial, 953 women with a period of gestation of more than 34 weeks, scheduled to have cesarean section, were randomly assigned to the prophylactic single-dose antibiotic administration either preoperatively (study group) or at cord clamping (control group). Primary outcome measure was postoperative maternal infectious morbidity and secondary outcome measures were neonatal complications, and postoperative maternal hospital stay and stay of neonates in the neonatal intensive care unit. RESULTS: Wound complications in the form of indurations, erythema and discharge, were significantly fewer in the study group as compared to the control group (10/476 vs 25/477, P = 0.010, conditional maximum likelihood estimate of odds ratio = 0.388 and 95% confidence interval = 0.175-0.805). Women in the study group also had fewer incidents of endomyometritis when compared to the control group (1.47% vs 3.56%; P = 0.041; conditional maximum likelihood estimate of odds ratio = 0.404). There was no significant difference in neonatal outcomes between the two groups. Mean postoperative stay of mothers in hospital was significantly shorter in the study group (P = 0.009, 95% confidence interval = -0.368 to -0.052) but neonatal intensive care unit stay of neonates was similar in both groups. CONCLUSION: Administration of prophylactic antibiotic at 30-60 min before skin incision resulted in better maternal outcome when infectious morbidity and postoperative hospital stay were concerned, without influencing the neonatal outcome.

Comparison of two doses of oral misoprostol with one, after mifepristone in early abortion.

A prospective randomised controlled study was conducted at RG Kar Medical College and hospital to compare the efficacy and side-effects of two doses of oral misoprostol, with one dose following mifepristone in early abortion. Two randomly allocated groups of seventy-five women each were formed, which were comparable in all respects and also conformed to the inclusion and exclusion criteria laid down in this study. Both groups received 200 mg of mifepristone on day one. After 48 hours, both groups received 400 microg of misoprostol and 3 hours later one group received 3 tablets of 200 microg misoprostol and the other group received 3 tablets of placebo. The women were then followed up to note the time of expulsion, completeness of the process, amount of bleeding encountered, side-effects if any or any other observation. The most important parameter ie, the completeness of the expulsion when compared showed no statistically significant difference between the two groups (p-value = 0.1025).

Perinatal outcome in pregnancies with intra-uterine growth restriction by using umbilical and middle cerebral artery colour Doppler.

There are various biophysical methods used for diagnosing and monitoring foetal well being using in intra-uterine growth restriction foetus, out of which Doppler velocimetry proved to possess the predictive capacity in diagnosing and management of intra-uterine growth restriction foetuses. The objectives were to study Doppler velocimetry of foetal umbilical artery and middle cerebral artery in diagnosing intra-uterine growth restriction and to correlate Doppler finding with perinatal outcome. Random 50 patients with singleton pregnancies admitted in RG Kar Medical College and Hospital were studied in a duration of 1 year. Umbilical artery and middle cerebral artery were studied during foetal inactivity and apnoea. Percentage of normal and abnormal Doppler velocimetry of umbilical artery and middle cerebral artery was observed and its relation with perinatal outcome analysed. Out of 50 patients, 30% had normal and 70% had abnormal umbilical artery Doppler velocimetry. Neonatal intensive care unit admission was 20% in normal and 71.42% in abnormal umbilical artery Doppler, 46.4% in normal and 68.1% in abnormal middle cerebral artery Doppler and 9.09% in normal and 69.23% in abnormal cerebroplacental index. Neonatal mortality was 0% in normal and 14.3% in abnormal umbilical artery Doppler velocimetry. Oligohydramnios was 26% in normal and 71% in abnormal umbilical artery Doppler. The study revealed that overall perinatal outcome was poor in abnormal Doppler velocimetry group in comparison to normal group. Doppler investigation of the foetal circulation not only plays an important role in monitoring of the growth restricted foetuses but also helps in detecting foetal compromises early in intra-uterine growth restriction foetuses and thereby helps to determine the optimal time for delivery.

A randomized comparative study on vaginal administration of acetic acid-moistened versus dry misoprostol for mid-trimester pregnancy termination.

PURPOSE: Absorption and effectiveness of vaginally administered misoprostol tablets may vary according to the medium in which it is placed. This study was directed to compare the outcomes of vaginal administrations of acetic acid-moistened misoprostol tablets with those of dry tablets for induction of second-trimester abortion. METHODS: A randomized comparative trial where 322 women at 13-20 weeks gestation, requiring medical abortion, were randomly assigned to vaginal administration of either acetic acid-moistened or dry misoprostol tablets with a dose schedule of 400 µg three-hourly, up to a maximum five doses over 24 h. The same doses were repeated for another 24 h in nonresponders. Primary outcome measure was complete abortion rate at 24 and 48 h, and the secondary outcome measures were induction-abortion interval, failure rate and side effects. A difference of 15% in success rates at 24 h was used to calculate the sample size required with a power of 0.8 at the 5% significance level. RESULTS: No statistically significant differences in the complete abortion rates were observed at 24 h (70.95 vs. 68.71%, P = 0.675) and at 48 h (86.49 vs. 84.35%, P = 0.604) when both groups were compared. The difference in mean induction-abortion interval was also statistically insignificant between the groups (12.5 ± 1.6 vs. 12.8 ± 1.5 h, P = 0.97). Other outcome measures were also comparable in both groups. CONCLUSION: Moistening misoprostol tablets with 5% acetic acid before vaginal application creates no difference in outcomes when compared with those after the vaginal application of dry tablets for the termination of second-trimester pregnancy.

A comparative study on sublingual versus oral and vaginal administration of misoprostol for late first and early second trimester abortion.

To compare the effectiveness, side-effects and outcome of sublingual with oral and vaginal administrations of misoprostol for induction of abortion in late first and early second trimester of gestation (9 to 16 weeks), a comparative observational study was carried out among 258 women with a period of gestation between 9 and 16 weeks, scheduled to have medical abortion, and randomly allocated into three groups and offered sublingual, oral and vaginal routes of misoprostol administration (400 mcg of misoprostol 6 hourly, maximum up to four dosages) respectively. Primary outcome measure was complete abortion rate and the secondary outcome measures were incidence of cases where surgical evacuation required, failure rate and induction-abortion interval. Development of side-effects and subjective assessment of patient's comfort with the different routes of administration were also recorded. Rate of complete abortion was higher in sublingual group in comparison to oral (p = 0.0338) and vaginal route (p = 0.5627). Surgical evacuation was required in less number of cases in sublingual group. Induction-abortion interval was also least with the sublingual route le, p < or = 0.0001 (versus oral) and 0.0011 (versus vaginal). Failure rate was highest with the oral route and least with the sublingual route. The patients were least comfortable with the vaginal route. Gastro-intestinal side-effects were least with the vaginal route, but significant vaginal bleeding (> 250 ml) was little bit higher with this route. Though misoprostol is effective in inducing medical abortion irrespective of the route of administration, sublingual route gives better results as compared to oral (statistically significant) and vaginal routes (in some respects, not of much statistical significance).

Meckel-Gruber syndrome: a rare clinical entity.

Meckel-Gruber syndrome is an inherited genetic disorder of unknown aetiology. It is an autosomal recessive condition and its incidence is as rare as 1:13,250 to 1:140,000. Some population show an increased incidence of this condition eg, Finnish and Gujarati Indians. Since the time it was first reported by Meckel in 1822 and subsequently by Gruber in 1934, only 200 cases have been reported. Here the case was diagnosed antenatally by an ultrasound and termination of the pregnancy at an early stage was done as per the wishes of the parents. This interesting and rare case of Meckel-Gruber syndrome is reported here.

Sexual assault and its medical, medicolegal, and social aspects--a retrospective study.

A retrospective study of medical, medicolegal and social aspects was conducted in collaboration with the department of forensic medicine and toxicology during a period 2004-2009 among 42 victims of sexual assault who were admitted in the department of gynaecology and obstetrics of RG Kar Medical College, Kolkata. Majority (71%) of the victims were girls between age group 6-15 years. Sixty per cent of the victims were from poor family, 43% were illiterate and 72% had vaginal tear which required surgical management.

Complete perineal tear with rectal prolapse: an unusual case report.

The association of complete perineal tear and rectal prolapse is less reported in literature, although isolated complete perineal tear and the combinations of vaginal and rectal prolapse are not so unusual, where multiparity and unsupervised home deliveries are quiet common. An interesting case of long standing complete perineal tear with complete rectal prolapse is reported in a 60 years old lady along with review of literature, discussing the management and follow-up of the condition.

Comparative evaluation of perimenopausal abnormal uterine bleeding by transvaginal sonography, hysteroscopy and endometrial biopsy.

To evaluate the causes of abnormal uterine bleeding in perimenopausal women and to achieve the greatest diagnostic accuracy with the least risk, a cross-sectional study was done among 85 patients between the ages 40 and 55 years. Transvaginal sonography, hysteroscopy and histopathological examination of endometrium were done in all the cases. Kappa statistics was calculated to show the agreement between the different investigations. Considering histopathological report to be the gold standard, for diagnosis of hyperplastic endometrium, transvaginal sonography and hysteroscopy showed fair agreement (k=0.34) and good agreement (k=0.51) and hysteroscopic diagnosis of polyp showed strong agreement (k=0.81). Sensitivity, specificity, positive predictive value, negative predictive value for diagnosis of hyperplastic endometrium were 43.75%, 95.65%, 70% and 88% respectively whereas in polyp by transvaginal sonography they were 50%, 89.16%, 100%, 98.67% respectively; by hysteroscopy these were 50%, 95.78%, 70%, 90.36% respectively in hyperplasia and 71.43%, 100%, 100%, 94.67% respectively in polyp. Transvaginal sonography is most important for diagnosis of anatomical lesion. Hysteroscopy is most specific and sensitive for diagnosis of polyp but less specific for endometrial hyperplasia.

Study of drotaverine on first stage of labour and pregnancy outcome.

A prospective randomised study of 200 women with spontaneous onset of labour was carried out in 100 women who were given 40mg of drotaverine hydrochloride intravenously at > or = 3cm dilatation of the cervix, the other 100 were taken as control. The effects of the drug on the progress and outcome of labour were noted. The mean durations of active phase of labour in primigravida and multigravida were 148.9 minutes and 99.5 minutes in drotaverine group whereas in control group were 331.6 minutes and 227.9 minutes respectively. It was concluded that drotaverine is highly effective in reducing the duration of active phase of labour by hastening cervical dilatation, more effective when given in more dilated cervix than with less dilatation and more effective in multigravida than in primigravida. There was no interference with uterine contractility and no increase in operative delivery. It reduces the incidence of traumatic postpartum haemorrhage by reducing the incidence of cervical tear. It is a safe drug for the mother as well as for the baby.