Comparative analysis of simultaneous integrated boost and sequential boost radiotherapy in node-positive cervical cancer: dosimetric and radiobiological considerations.

For locally advanced cervical cancer, the standard therapeutic approach involves concomitant chemoradiation therapy, supplemented by a brachytherapy boost. Moreover, an external beam radiotherapy (RT) boost should be considered for treating gross lymph node (LN) volumes. Two boost approaches exist with Volumetric Intensity Modulated Arc Therapy (VMAT): Sequential (SEQ) and Simultaneous Integrated Boost (SIB). This study undertakes a comprehensive dosimetric and radiobiological comparison between these two boost strategies. The study encompassed ten patients who underwent RT for cervical cancer with node-positive disease. Two sets of treatment plans were generated for each patient: SIB-VMAT and SEQ-VMAT. Dosimetric as well as radiobiological parameters including tumour control probability (TCP) and normal tissue complication probability (NTCP) were compared. Both techniques were analyzed for two different levels of LN involvement - only pelvic LNs and pelvic with para-aortic LNs. Statistical analysis was performed using SPSS software version 25.0. SIB-VMAT exhibited superior target coverage, yielding improved doses to the planning target volume (PTV) and gross tumour volume (GTV). Notably, SIB-VMAT plans displayed markedly superior dose conformity. While SEQ-VMAT displayed favorable organ sparing for femoral heads, SIB-VMAT appeared as the more efficient approach for mitigating bladder and bowel doses. TCP was significantly higher with SIB-VMAT, suggesting a higher likelihood of successful tumour control. Conversely, no statistically significant difference in NTCP was observed between the two techniques. This study's findings underscore the advantages of SIB-VMAT over SEQ-VMAT in terms of improved target coverage, dose conformity, and tumour control probability. In particular, SIB-VMAT demonstrated potential benefits for cases involving para-aortic nodes. It is concluded that SIB-VMAT should be the preferred approach in all cases of locally advanced cervical cancer.

Growth Factor Independence-1 (GFI-1) Gene Expression in Hematopoietic Stem Cell Lineage Differentiation in Low Birth Weight Newborns Compared With Normal Birth Weight Newborns at Term Pregnancy.

Introduction Low birth weight (LBW), which is a risk factor for noncommunicable diseases throughout life, is a significant public health concern. In addition to regulating myeloid cell differentiation and proliferation, a transcriptional repressor identified as growth factor independence-1 (GFI-1) is essential for hematopoietic stem cell maintenance and self-renewal. The current study was designed to compare the expression of the GFI-1 gene in the differentiation of hematopoietic stem cells in newborns with LBW and those with normal birth weight (NBW). Methods A prospective comparative analytical study was carried out from September 2019 to September 2021 after obtaining Institute Ethical Committee approval at a tertiary care center in north India. The GFI-1 gene expression levels in 50 cord blood samples from women with term gestation and LBW newborns (<2500 grams) were measured using quantitative real-time polymerase chain reaction (RT-PCR) and compared to gene expression levels in 50 cord blood samples from women with term gestation and NBW newborns (≥2500 grams). The data were analyzed using IBM SPSS statistics software version 24.0 (IBM Corp., Armonk, NY). Results The median GFI-1 expression in LBW newborns is 3.1, whereas among NBW newborns it is 9.39. The difference is significant (P <0.001). The level of GFI-1 gene expression in LBW newborns was correlated with their birth weight. The coefficient of correlation was found to be weakly positive (r = 0.223). The birth weight of NBW newborns was correlated to the level of expression of the GFI-1 gene, which was found to be positively correlated (r = 0.332). Conclusion The levels of the GFI-1 gene and newborn birth weight were compared in LBW infants, which were weakly positively correlated. The level of GFI-1 gene expression at birth was compared to the birth weight of NBW newborns, which was positively correlated.

Antepartum hemorrhage and its maternal and perinatal outcome: An experience at a hospital in North India.

Introduction and Aim: Antepartum hemorrhage (APH) is one of the deadliest complications in obstetrics. It can complicate about 2-5% of pregnancies. It contributes significantly to maternal and perinatal mortality and morbidity during pregnancy and childbearing worldwide. The aim of this study was to determine maternal and fetal outcomes in patients presenting with APH. Materials and Methods: This was a retrospective study. Pregnant women with >28 weeks gestation reporting to the Department of Obstetrics and Gynecology from May 2021 to April 2022 were included in the study. Ethical approval from the institutional ethical committee was taken. Result: This study included 76 patients of APH. Most patients in the analysis were found to be second gravida (30%). Anemia was the most common associated morbidity (51.31%). 58% of these patients were of placenta previa, 14% were of abruption, and 10% were of accreta. Among all patients, 94.74% recovered well. 2.63% of cases could not be saved and resulted in maternal mortality. The proportions of babies alive, intra-uterine death (IUD), and intubated were 86.84%, 11.84%, and 1.32%, respectively. 17.1% of patients required a lifesaving cesarean hysterectomy. Conclusion: APH is an obstetrical emergency that requires timely diagnosis and early intervention. Swift management is required to improve maternal and fetal outcomes.

Retraction: Implementation of Postpartum Hemorrhage Emergency Care Using a Bundle Approach at a Tertiary Care Hospital in North India.

[This retracts the article DOI: 10.7759/cureus.26819.].

Implementation of Postpartum Hemorrhage Emergency Care Using a Bundle Approach at a Tertiary Care Hospital in North India.

Background The major cause of maternal death globally is postpartum hemorrhage (PPH). When PPH develops, early detection of bleeding and rapid treatment with evidence-based guidelines can prevent most PPH-related severe morbidity and mortality. The bundle care approach for PPH management could be a potential solution to inefficient and uneven evidence-based practice implementation worldwide. Bundle care is a collection of discrete, evidence-based interventions given to every eligible person simultaneously or in quick succession and requires teamwork, communication, and cooperation. The primary objective of this study was to analyze whether implementing a PPH bundle of care may reduce maternal morbidity and mortality in our institution. Methods This was a single-center retrospective pre-post case-control study was carried out at a tertiary care center and teaching hospital in Varanasi, eastern Uttar Pradesh state, India. From January 2021 to June 2021, pretraining data (PRE) were collected retrospectively on all births from the department of Obstetrics and Gynecology, Sir Sunderlal Hospital, Institute of Medical Sciences, Banaras Hindu University. Subsequently, medical and paramedical personnel of our hospital were trained in Postpartum Hemorrhage Emergency Care Using a Bundle Approach (PPH EmC) as per the guidelines laid down by the World Health Organization (WHO) for PPH management and implemented in July 2021. Post-training data (POST) were then collected retrospectively on all deliveries at our hospital from August 2021 to January 2022. All the data within two periods were computed and analyzed. The results were then compared for any significant changes in the incidences of maternal mortality and morbidity in terms of the rates of blood transfusion required and the type of management used (medical or medical-surgical), use of tranexamic acid, and additional uterotonics. The results were expressed as proportions, and p≤0.05 was considered statistically significant using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, NY, USA). Results A total of 1304 women gave birth from January 2021 to January 2022, of whom 107 patients (61 in the PRE and 57 in the POST group) were diagnosed and treated for PPH. There was no significant difference in the incidence of PPH in the PRE and POST groups (p=0.581). There was a significant increase in the use of tranexamic acid (p=0.041) and a significant reduction in blood transfusion rates (p=0.032) after the implementation of bundled care in the POST group. The odds of PPH non-occurrence after pre- and post-test was 1.103 (95% CI=0.747 to 1.635). No significant difference was observed in maternal mortality in the PRE and POST groups (p=0.96). The requirement for radical surgical treatment of PPH, which included hysterectomies, was also significantly reduced, from 27.27% in the PRE group to 11.54% in the POST group (p=0.032). Conclusions PPH care bundles might improve the morbidity of PPH with the use of fewer resources and fewer interventions required. While these data are promising, further studies are needed to analyze bundle care's long-term effects.

Fetal hyperhomocysteinemia is associated with placental inflammation and early breakdown of maternal-fetal tolerance in pre-term birth.

PROBLEM: Hyperhomocysteinemia (hypHcy) due to impaired folate metabolism is shown to be a risk factor for preterm birth (PTB) and low birth weight (LBW) in mothers. However, the relationship of fetal hypHcy with adverse pregnancy outcomes is under-represented. The present study aims to investigate the association of fetal hypHcy with oxidative stress and placental inflammation that can contribute to an early breakdown of maternal-fetal tolerance in pre-term birth (PTB). METHODS: Cord blood and placenta tissue were collected from PTB and term infant group. Levels of homocysteine, folic acid, vitamin B12 and oxidative stress markers (MDA, T-AOC, 8-OHdG) were measured in cord blood serum using ELISA and respective standard assay kits. Relative expression of candidate genes (TNF-α, IL-6, IL1-ß, VEGF-A, MMP2 and MMP9) was also checked using RT-PCR and immunoblotting/immunohistochemistry. RESULTS: PTB infants showed significantly higher levels of homocysteine (P = .02) and lower levels of vitamin B12 (P = .005) as compared to term infants. We also found that PTB infants with hypHcy had lower T-AOC (P = .003) and higher MDA (P = .04) levels as compared to term infants with normal homocysteine levels. The mRNA and protein levels of TNF-α, VEGF-A, MMP2 and MMP9 were significantly higher in hypHcy PTB infants. CONCLUSION: Our results show that fetal hypHcy is associated with oxidative stress and an increase in inflammatory markers in the placenta. Thus, in conclusion, our study demonstrates that fetal hypHcy during pregnancy is a potential risk factor that may initiate an early breakdown of uterine quiescence due to activation of inflammatory processes leading to PTB.

Maternal and fetal outcomes of COVID-19 infection in pregnant women with chronic rheumatic heart disease in a South Asian population: A case series.

Rheumatic heart disease (RHD) is associated with an increased risk of adverse maternal, fetal, and neonatal outcomes, particularly in developing countries. The current COVID-19 pandemic has also affected pregnant women, probably increasing the adverse effects. It is speculated that COVID-19 infection in pregnant women would further increase the risk of complications. However, factual data is still lacking, especially from resource-constrained countries. We conducted a case series of 20 pregnant women with RHD and COVID-19 infection and compared their outcomes with 40 with RHD but without COVDI-19. We observed a high risk of adverse cardiac and pregnancy effects across the whole cohort of 60 patients. However, the comparative study between the two groups failed to show any incremental risk of complications due to COVID-19 infection. Although the sample size was limited; the results are encouraging, particularly for developing countries.

Variations in the central corneal thickness during the menstrual cycle in Indian women.

PURPOSE: To determine the changes in central corneal thickness (CCT) during the menstrual cycle in Indian women. METHODS: A prospective observational clinical study at a tertiary care center between December 2015 and December 2018. One hundred and twenty sixty women between 18 and 45 years were included. The CCT was measured using an ultrasound pachymeter at three specific timelines of the menstrual cycle: at the beginning (1st to 3rd day), during ovulation time (14th to 16th day), and at the end of the cycle (28th to 33rd day). Phases of the cycle were confirmed by the urine luteinizing hormone level. RESULTS: The mean CCT of both eyes was 541.76 ± 4.21 µm, 559.21 ± 4.50 µm, and 544.52 ± 8.06 µm at the beginning, mid, and end of cycle, respectively. The mean CCT of the right eye was 541.68 ± 4.15 µm, 559.08 ± 4.50 µm, and 544.44 ± 8.06 µm and of the left eye was 541.84 ± 4.27 µm, 559.35 ± 4.50 µm, and 544.61 ± 8.06 µm at the beginning, mid, and end of cycle, respectively. CONCLUSION: The CCT value was significantly (P < 0.001) higher during ovulation compared to the beginning and end of the menstrual cycle. Our study recommends adding menstrual history in the workup of women undergoing refractive surgery as physiological variations in the CCT may result in unexpected surgical outcomes.

A Systematic Review Evaluating the Efficacy of Intra-Ovarian Infusion of Autologous Platelet-Rich Plasma in Patients With Poor Ovarian Reserve or Ovarian Insufficiency.

The emergence of autologous platelet-rich plasma (PRP) therapy reflects a break-through for infertile patients with premature ovarian failure. To study the efficacy of intra-ovarian infusion of autologous PRP on the improvement of ovarian reserve parameters and the subsequent artificial reproductive technique (ART) cycle outcomes in infertile women with poor ovarian reserve or premature ovarian insufficiency, a systematic search in electronic databases like Medline (through PubMed), Embase, Scopus, Web of Science, and Cochrane was done using relevant search terms. Except for case series, case reports, and review articles, all other types of studies, those evaluated for the effects of intra-ovarian infusion of PRP in subfertile women for decreased ovarian reserve (DOR) or premature ovarian insufficiency (POI) were included in our systematic review. The data were extracted from each eligible study and cross-checked by two authors. Intra-ovarian PRP infusion appears to be effective in ovarian rejuvenation, and the results of the subsequent intracytoplasmic sperm injection (ICSI) cycle are encouraging. PRP intervention was found to be beneficial in terms of an improvement in ovarian reserve parameters (increase in serum anti-mullerian hormone or antral follicle count or decrease in serum follicular stimulating hormone). ICSI cycle performance in terms of the total number of oocytes retrieved, number of two-pronuclei embryos, fertilization rate, number of cleavage stage embryos, number of good quality embryos, and cycle cancellation rate were found to be improved after intra-ovarian PRP infusion as compared to their previous cycle without PRP infusion.

Obstetric use of nitroglycerin: Anesthetic implications.

Nitroglycerin has been used in anesthetic practice for induced hypotension and managing perioperative hypertension and myocardial ischemia. Contrary to the continuous low dose infusions (5-20 mcg/min) used for the same, intravenous bolus dosages are sometimes administered at the behest of obstetricians for removal of retained placenta. Use of nitroglycerine in managing retained placenta is undertaken as a last resort when other measures fail to relax the uterine smooth muscles. Intravenous nitroglycerine relaxes smooth muscle cells by releasing nitric oxide thus causing prompt cervico-uterine relaxation. However, administration of nitroglycerine in this manner is not without risks which should be kept in mind while using it for obstetric purposes. We hereby report a case of 22-year-old female scheduled for manual removal of placenta where unpredictable and unexpected hypoxemia was observed following nitroglycerine administration.

Successful outcome in preeclamptic rudimentary horn pregnancy.

Unicornuate uterus with rudimentary horn is an uncommon type of mullerian duct malformation associated with various gynecological and obstetrical complications. Rudimentary horn pregnancy is a rare entity and the majority have rupture of gravid horn leading to maternal and fetal morbidity and mortality. A case of rudimentary horn pregnancy at 32 weeks and 6 days with pregnancy induced hypertension is reported where proper management results in successful pregnancy outcome.