Pregnancy and Vaginal Childbirth Followed by Reconstructive Vulval Surgery in a Woman with Giant and Isolated Vulval Elephantiasis.

Isolated elephantiasis of the vulva refers to a gigantic swelling of the vulva without concomitant swelling of the lower limbs. It is a rarely reported entity and its occurrence during pregnancy has been reported only once. We report a case of an isolated vulval elephantiasis during pregnancy and we discuss the possible etiologies and management issues. Our patient had a successful vaginal delivery followed by a satisfactory genital reconstruction at eight months postpartum and no recurrence thereafter.

Multimodality imaging of acute gynecological emergencies-a pictorial essay.

Gynecological emergencies can often present with a myriad of non-specific signs and symptoms, posing a diagnostic challenge to the clinician. They can be grossly divided into uterine or adnexal pathologies. Uterine pathologies can be secondary to intracavitary accumulation of blood [like in patients with transverse vaginal septum, Robert's uterus, accessory and cavitated uterine mass, unicornuate uterus with contralateral non-communicating functional horn], bleeding per vaginum [like in patients with retained products of conception, enhanced myometrial vascularity], pyometra [secondary to pelvic inflammatory disease, cervical obstruction secondary to benign and malignant causes] or complications of fibroids [like red degeneration, torsion of subserosal fibroid]. The adnexal pathologies can range from ectopic pregnancy in a urine pregnancy test (UPT) positive patient to haemorrhagic ovarian cyst, ovarian torsion, ruptured dermoid cyst and tubo-ovarian abscess in a UPT negative patient. Multimodality imaging including ultrasound (USG), computed tomography (CT) scan and magnetic resonance imaging (MRI) can narrow down the differentials and help in formulating an accurate diagnosis. The objective of this article is to familiarize the readers with multimodality imaging findings in common as well as uncommon acute gynecological emergencies and provide an algorithmic imaging approach for acute gynecological emergencies. USG is typically used as the first line diagnostic modality in diagnosis of acute gynecological emergencies. CT scan & MRI are helpful as a problem-solving tool in acute gynecological emergencies when USG findings are indeterminate.

Tall-columnar glandular cells in SurePath™ liquid-based cytology Pap sample: Learning from mimics/pitfalls.

We offer a comprehensive depiction of the cytomorphological characteristics of lobular endocervical glandular hyperplasia (LEGH) as observed in SurePath™ liquid-based cytology (LBC), subsequently confirmed on cone biopsy. Lobular endocervical glandular hyperplasia (LEGH), a precursor to gastric-type adenocarcinoma (GAE) of the endocervix, is rare and reports of it in cervical cytology are scarce. We provide a thorough description of the cytomorphological features of LEGH observed in SurePath™ liquid-based cytology (LBC), later confirmed by cone biopsy. To the best of our knowledge, this is the first report documenting cytology of LEGH in LBC of a Pap sample.

Role of Shear Wave Elastography of Placenta in Prediction of Preeclampsia in High-Risk Pregnancy.

ABSTRACT: The aim of our study was to compare the placental elasticity values between normal pregnancies and preeclamptic pregnancies and evaluate the utility of shear-wave elastography of the placenta as a predictor for preeclampsia in high-risk pregnancy. A prospective study was performed with 90 singleton high-risk pregnancies having any of the 7 risk factors for developing preeclampsia (primigravida, history of preeclampsia, family history of preeclampsia, history of pregestational diabetes, chronic hypertension, advanced maternal age [≥40 years], and body mass index ≥26 kg/m 2 ) were enrolled in the study. Shear-wave elastography was performed in all patients at 20 to 24 weeks' gestation and at 34 to 36 weeks' gestation, at 2 sites: center and edge of the placenta. The patients were divided into 2 groups: normal pregnancies (group A) or developed preeclampsia (group B). Women with posterior placentation, obstetric disorders other than preeclampsia, or multiple gestation were excluded from the study. Group comparisons were done using the χ2 test or Fisher exact test. Shear-wave elasticity values at 20 to 24 weeks' gestation for group B at the center of the placenta (21.73 vs 9.72 kPa) and at the edge of the placenta (21.6 kPa vs 10.15 kPa) were significantly higher than those for group A ( P < 0.05). Similar results were seen at 34 to 36 weeks' gestation. With a cutoff of 13.1 kPa, we attained sensitivity of 95.2%, specificity of 92.8% and diagnostic accuracy of 93.3% for predicting development of preeclampsia. Patients with preeclampsia have a significantly higher stiffness of the placenta. Shear-wave elastography is useful to evaluate placental function. Elastography can be used as a supplementary tool for prediction of preeclampsia.

Naturalistic Evaluation of ERAS Bundle Implementation Feasibility in Elective Cesarean Deliveries of Tertiary Care Hospital in a Low-Middle-Income Country.

The present study assessed whether applying enhanced recovery after surgery (ERAS) guidelines for cesarean delivery is feasible in the tertiary care setting with an add-on objective to identify barriers to successful implementation. The cross-sectional study included women undergoing elective CS and willing to participate. The study attempted to understand barriers to ERAS implementation through timely interviewing study participants. Sixty-two patients participated in the study. Antenatal and fetal complications were observed in 39(63%) and 32(51%) participants. The study observed that at least 80% of the proposed components could be applied to 71% of the study population. All 15 components could be applied to 7(11.2%) patients, and at least 50% could be applied to 58(94%) patients. The least applied component was minimizing starvation by taking clear liquids until 2 hrs before surgery in 26(42%) patients due to waiting hours outside the operation-theater (OT). When fitness-for-discharge was assessed against the percent components of ERAS implemented, the area under the curve (AUC) value was 0.75, with a specificity value of 95.65% and a positive predictive value of 94.12%. In the postoperative ERAS bundle, fitness-for-discharge on day-two was statistically associated with early and frequent breastfeeding (p = 0.000) and prevention of intra-op hypotension (p = 0.03). In conclusion, the primary barriers to implementing ERAS were resource limitations in the form of single functional OT and limited doctors.

Comparison of Vaginal Dinoprostone Pessary With Transcervical Balloon Catheter Plus Vaginal Misoprostol for Pre-induction Cervical Ripening: A Randomized Trial.

Aims and Objectives To compare the safety and efficacy of dinoprostone pessary with Foley plus vaginal misoprostol for cervical ripening. Materials and Methods We randomized 115 women to the pessary or Foley plus misoprostol group. Pessary was inserted for 24 hours, and in the Foley plus misoprostol group, intravaginal misoprostol 25 mcg was administered along with trans-cervical Foley insertion and repeated every six hours to a maximum dose of 100 mcg. Singleton pregnancies requiring labor induction at more than 34 weeks with a Bishop score of <6 were included. Study outcomes included induction-delivery interval (IDI), mode of delivery, change in the Bishop score, need for oxytocin augmentation, and patient discomfort as assessed by visual analog score. Results The IDI was similar between the groups (pessary vs Foley plus misoprostol; 21.27 vs 21.10 hours, p = 0.9). The mean change in the Bishop score and need for augmentation with oxytocin was significantly more in the Foley plus misoprostol group compared to pessary (2.72 vs 1.94, p = 0.001; 89.7% vs 57.9%, p = 0.0001). Pessary was better tolerated compared to Foley plus misoprostol (VAS 7.8 vs 6.68, p = 0.0001). Mode of delivery and maternal and neonatal outcomes showed no difference. Conclusion There was no significant difference between pessary and Foley plus misoprostol in the IDI and mode of delivery. Pessary was better tolerated, and augmentation with oxytocin was required less often. Foley plus misoprostol caused a faster change in the Bishop score, but oxytocin augmentation was used more often. Maternal and neonatal outcomes were similar.

Expediting labor induction in severe pre-eclampsia by earlier initiation of oxytocin after cervical ripening: A randomized study from India.

OBJECTIVE: To observe whether induction of labor (IoL) among women with severe pre-eclampsia (PE) can be expedited by initiating oxytocin early (after 6 h) than after 12 h following cervical ripening with a combined method. METHODS: Women with severe PE and Bishop's < 6 (n = 96) were randomized into two groups. All women received cervical ripening with a combined method (intracervical Foley's plus dinoprostone gel 0.5 mg) following which Group 1 women received oxytocin after 6 h (with Foley's in-situ) and Group 2 after 12 h (after removing Foley's) RESULTS: Majority were nulliparous (63% in group 1 and 77% in group 2) and the mean gestation was similar (35.3 ± 2.98 weeks in group 1 and 35.5 ± 3.09 in group 2). Nearly half the women had partial HELLP/ HELLP (47.9% and 54.1%; in groups 1 and 2, respectively). The induction-delivery interval (IDI) was significantly reduced in group 1 (16 h 6 min vs 22 h 6 min in group 2; p = 0.001). The cesarean section (CS) rate was 37.5% in group 1 and 31.3% in group 2 (p = 0.525), but the study was underpowered to assess this outcome. The neonatal outcome was similar, 92/96 neonates were discharged after a hospital stay of 3-52 days. There were 4 neonatal deaths (1 in group 1 and 3 in group 2) of extreme or very preterm neonates (27-30 + 6 wks) with birth weight of 735-965 gm. CONCLUSION: Among women with severe PE undergoing IoL, initiating oxytocin 6 h after cervical ripening with a combined method reduced the IDI significantly as compared to initiating it after 12 h, with a similar CS rate and neonatal outcome.

Acute kidney injury and it's outcome following maternal near miss event: A prospective observational study from a tertiary care hospital.

Purpose: Haemorrhage, preeclampsia and sepsis are the leading causes of renal dysfunction in women with a maternal nearmiss(MNM) complication. The study aimed to assess the prevalence, pattern and follow up of these women. Methods: This was a hospital based prospective observational study, conducted over one year. All women with a MNM leading to acute kidney injury (AKI) were analysed for fetomaternal outcomes and renal function at 1 year of followup. Results: The incidence of MNM was 43.04 per 1000 livebirths. 18.2% women developed AKI. 51.1% women developed AKI in the puerperal period. Most common cause of AKI was haemorrhage seen in 38.3% women. The majority of women had s.creatinine between 2.1 to 5 mg/dl and 44.68% required dialysis. 80.8% women recovered fully when the treatment was initiated within 24 h. One patient underwent renal transplant. Conclusion: Early diagnosis and treatment of AKI results in full recovery.

Obstetric Teleconsultation by Using Mobile Phone Technology in COVID Pandemic.

Introduction: Obstetrics teleconsultation is a new concept to enable health-care services in the COVID pandemic by limiting in-person visits. This study describes the methodology of mobile-based teleconsultation, preliminary findings, and the experience of the obstetricians. Material and Methods: The data of pregnant women who got registered for teleconsultation in early phase of COVID pandemic lockdown were reviewed and analyzed. A qualitative analysis was performed to assess the experience of obstetricians (consultants, senior residents, and junior residents) via an online electronic survey. Results: The majority of obstetrics teleconsultations were for routine antenatal care (75%) and fetal medicine consultation (12.3%). Out of 187 women, 29.9% were advised to continue antenatal care at local hospitals, whereas 33.6% were asked to follow up via teleconsultation. Most of the obstetricians (73.68%) felt that they were able to satisfy the pregnant women and rated the teleconsultation satisfactory. Conclusion: Obstetrics telemedicine found to be beneficial for providing routine antenatal care services via reducing physical visits and overcrowding in outpatient departments, promoting antenatal care at local hospitals, and making specialized (maternal-fetal medicine) care accessible even during COVID-19 pandemic.

Multi-Institutional Trends in Gynecological Robotic Surgery in India: A Real-World Scenario.

Background Robot-assisted laparoscopic surgery in gynecology has grown exponentially compared to laparoscopic surgery. The probable reasons for the increased uptake of robotics are a shorter learning curve, three-dimensional vision, and increased dexterity compared to laparoscopic surgery, and precise surgery as compared to open surgery. This study compares the time trends of various parameters in robotic gynecological surgery in India over a decade. Material and methods In India, a retrospective analysis of all robot-assisted laparoscopic surgery for gynecologic diseases in five tertiary care hospitals was conducted between July 2011 and June 2021. Data were collected regarding demographic profiles, clinical and disease characteristics, and indications for surgery. Details related to surgery were collected, such as the number of ports, console and docking time, the procedure performed, total operative time, average blood loss, blood transfusion, and length of hospital stay. All the parameters collected were grouped into five years, and a comparison was made between the first five years (2011-2015) and the second five years (2016-2021). Statistical analysis, including descriptive statistics and trend analysis, was performed. Results During the 10 years, the total number of cases included was 1,501, out of which 764 were benign cases and 737 were pre-malignant/malignant cases. The common indications were uterine leiomyoma (31.2%) and carcinoma endometrium (28%). The mean age for benign cases was significantly lower than that for malignant cases (40.84 years and 55.42 years, respectively). Mean blood loss was significantly lower for benign indications (97.48 mL) than for oncological surgery (184.67 mL) and needed fewer transfusions. The mean length of stay (LOS) for benign (2.07 days) and malignant/ pre-malignant cases (2.32 days) and the mean BMI for benign (28.40) and for oncological patients (28.47) were similar in both groups. The docking time reduced significantly in the last five years. Conclusion The current retrospective study demonstrates an increasing uptake of robotic technology in gynecological surgery in India. Of the total cohort of cases, 70.9% of patients underwent gynecological robotic surgery in the last five years. A burst of adaptability happened for malignant cases in 2017 and benign cases in 2018, probably due to the increased availability of robotic platforms and improved awareness of technology and training among medical professionals. The number of cases has grown exponentially over the last five years in both benign and malignant/ pre-malignant scenarios; however, there has been a downward trend in the robotic surgery performed in the previous couple of years due to the uncertainty of the COVID pandemic.

Fetal Echocardiogram and Detailed First Trimester Obstetric Ultrasound: ICD-10 Indications.

The American Institute of Ultrasound in Medicine and multiple national organizations have published the indications for fetal echocardiogram and for the detailed first trimester obstetric ultrasound. We present the corresponding International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes for those indications. KEY POINTS: · The ICD-10 indications to perform a fetal echocardiogram are summarized.. · The ICD-10 indications to perform a Detailed First Trimester Obstetric Ultrasound are summarized.. · As the guidelines have stated, these indications are not all inclusive..

Prospective assessment of mental and physical health of maternal near-miss women: A low-middle-income country's experience.

Background: Traumatic birth experience is an unaddressed arena, especially in Asian women, with several societal stigmas lingering around. Aim: A study was undertaken to simultaneously assess the post-partum mental and physical health follow-up of maternal near-miss (MNM) women and compare it with women of uneventful deliveries. Materials and Methods: The prospective cohort study enrolled 88 MNM women (case cohort) and 80 women with an uneventful peri-partum period (control cohort) at the same time. The participants were followed up with Edinburgh Postnatal Depression Scale (EDPS), PTSD Checklist - Civilian Version (PLC-C), and a 36-item short-form-survey form over 6 months after the delivery. Results: The case group had higher mean EPDS and PLC-C scores, with poor quality of life (QOL) performance, compared to the control group at 6 weeks and 3 months, and 6 months follow-up (P < 0.05). At the sixth-week follow-up visit, the study observed that 28 (31.8%) women from the case group required a psychiatry consultation compared to the control group with only two (2.5%) participants (P < 0.001). At 3 months, an evident difference was noted on various QOL parameters, such as limitations due to physical health and emotional problems, energy fatigue, general health, and health change parameters between the two groups (P < 0.05). The difference persisted at 6-month follow-up as well for limitations due to physical health, energy fatigue, and general health parameters only (P < 0.05). Conclusion: There is an urgent need for a multi-departmental collaborative approach at the hospital level and policy-making decisions at higher levels for the mental health of Asian women facing MNM events.

Impact of covid 19 pandemic on severe maternal outcomes -An observational study from a referral institute of India.

Introduction: Covid 19 pandemic has taken the world by storm. As far as maternal health is concerned, it has been affected both directly and indirectly. Not only are the women getting affected by COVID disease but also the health services are suffering in terms of availability, approachability and access. The study aimed to analyze the change in the trends of maternal near and maternal mortality comprising severe maternal outcome (SMO) between 2019 and 2020 in the department of obstetrics and gynaecology of our hospital due to COVID pandemic. Methods: This retrospective study was conducted in the Obstetrics and Gynaecology department of Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. The maternal death review data and maternal near miss statistics were analysed. This included assessing the change in the number of maternal deaths and obstetric near miss, their respective causes, and case fatality rate specific to COVID during pregnancy. Results: The total births decreased from 6056 in 2019-4140 in 2020 whereas women with severe maternal outcomes increased from 4.6% in 2019 to 6.5% in 2020(p value < 0.001). The incidence of nearmiss increased significantly from 3.5% in 2019 to 5.1% in 2020(p value < 0.0001) and maternal mortality ratio increased from 1122 per 1 lakh births to 1425 per 1 lakh births. Haemorrhage was the most common cause of maternal near miss with 45.8% in 2019 and an increase to 50.2% in 2020. The percentage of illiterate patients with near miss statistically reduced in 2020(p value - 0.004). Average hospital stay also reduced from 16.5+/-2.1 days to 12.6+/-6.3 days (p value < 0.0001). The average time taken to reach the hospital, however, increased from 27+/-3 h to 36+/-4 h (p value < 0.0001). The rate of direct maternal deaths increased from 45.6% to 52.5% between 2019 and 2020(p-value-0.434). Conclusion: Covid 19 pandemic has affected both maternal mortality and morbidity. Keeping the current situation in mind, it becomes increasingly important to develop patient education via electronic media and teleconsultations. One-stop portals and helplines which involve multidisciplinary teams should be available to all such pregnancies.

Second-Trimester Medical Abortion with Misoprostol Preceded by Two Sequential Doses of Mifepristone: An Observational Study.

Introduction: Based upon the pharmacokinetics of mifepristone, we postulated that repeating a dose after its half-life period may potentiate its abortifacient effect. Methods: We administered mifepristone (200 mg) on days one and two, and misoprostol on day three (200 or 400 µg, vaginally, six-hourly, upto three doses in 12 h) in 100 women (intervention group). We compared their outcome with that of another 100 women who received the one-dose mifepristone regimen (mifepristone on day one and misoprostol on day three) during the months immediately preceding the study period (historical controls). Results: The mean age, parity and gestation (18 weeks) were similar in the two groups. On day three (before initiating misoprostol), cervix admitted one finger in significantly more women in the intervention group (36 versus 8% in historical controls; p = 0.001). All women aborted successfully in the two groups. The IAI of the intervention group was significantly shorter than the IAI of historical controls (10.45 vs 13.75 h; p = 0.013), and the misoprostol requirement was also significantly lower (mean 434 vs 500 µg among historical controls, p = 0.04). Conclusions: Second-trimester medical abortion using two sequential doses of mifepristone followed by misoprostol reduced the IAI and misoprostol requirement without adding any extra days to the existing regimen. Further randomized studies can assess if the 'two-dose' mifepristone regimen is more efficient than the 'one-dose' regimen.

Society for Maternal-Fetal Medicine Special Statement: Best-practice recommendations for ultrasound network connectivity.

Prenatal ultrasound is an indispensable tool used by obstetrical care providers to assist in the everyday care of their pregnant patients. Alongside advancements in imaging, the electronic systems that support this technology have become more advanced. However, it is currently difficult for these individual systems to communicate with each other "out of the box." There is also minimal standardization of the type and format of data transmitted within these systems. Clinicians and system vendors must work collaboratively to create clinical and technical standards to serve as the foundation for increased interoperability among the various systems within each institutional network. Therefore, the Society for Maternal-Fetal Medicine Clinical Informatics Committee established an Ultrasound Electronic Health Record Subcommittee to facilitate collaboration between clinicians, including maternal-fetal medicine subspecialists, and ultrasound network component vendors. Based on the work of this subcommittee, the purpose of this document is to provide: (1) a basic understanding of ultrasound network architecture and capabilities, and (2) best-practice recommendations for electronic health record order design, obstetrical clinical data standards, and billing and coding practices.

Human activity recognition in artificial intelligence framework: a narrative review.

Human activity recognition (HAR) has multifaceted applications due to its worldly usage of acquisition devices such as smartphones, video cameras, and its ability to capture human activity data. While electronic devices and their applications are steadily growing, the advances in Artificial intelligence (AI) have revolutionized the ability to extract deep hidden information for accurate detection and its interpretation. This yields a better understanding of rapidly growing acquisition devices, AI, and applications, the three pillars of HAR under one roof. There are many review articles published on the general characteristics of HAR, a few have compared all the HAR devices at the same time, and few have explored the impact of evolving AI architecture. In our proposed review, a detailed narration on the three pillars of HAR is presented covering the period from 2011 to 2021. Further, the review presents the recommendations for an improved HAR design, its reliability, and stability. Five major findings were: (1) HAR constitutes three major pillars such as devices, AI and applications; (2) HAR has dominated the healthcare industry; (3) Hybrid AI models are in their infancy stage and needs considerable work for providing the stable and reliable design. Further, these trained models need solid prediction, high accuracy, generalization, and finally, meeting the objectives of the applications without bias; (4) little work was observed in abnormality detection during actions; and (5) almost no work has been done in forecasting actions. We conclude that: (a) HAR industry will evolve in terms of the three pillars of electronic devices, applications and the type of AI. (b) AI will provide a powerful impetus to the HAR industry in future. Supplementary Information: The online version contains supplementary material available at 10.1007/s10462-021-10116-x.

Socio-behavioural determinants of maternal near miss: a prospective case control study from a tertiary care centre of India.

Near miss occurs in far greater numbers than maternal deaths and allows a more robust quantification on risk factors and determinants of life-threatening complications. A 'Three delay model' has been proposed in identification of causes of near miss and maternal deaths. There may be delay in seeking and obtaining health care: delay in recognising danger signs and deciding to reach source of care, delay in reaching appropriate source of care and delay in obtaining appropriate and adequate treatments. We compared various delays between near miss cases (n = 100) and controls (n = 200). Women who fulfilled criteria of near miss were taken as cases. Women who had obstetrical complications like near miss but were managed successfully and did not reach near miss state were labelled as controls. Near miss were then compared with maternal death. For normally distributed measurable data, outcome was compared using Student's t-test, for non-normally distributed/ordinal data, outcome was compared using Mann-Whitney's test. For categorical/classified data, association with outcome was analysed using Chi-Square test/Fisher's exact test.Delay in all three levels was seen among the groups. Lack of knowledge, non-availability of decision maker, and concern of cost of transport were main contributors of these delays.Impact StatementWhat is already known on this subject? Nonavailability of healthcare and low socio-economic status strongly correlate with maternal morbidity and mortality.What do the results of this study add? Lack of knowledge, non-availability of the decision maker, and concern of cost of transport were the main contributors of delay in seeking medical care. Majority of the cases of near miss were attributed to poor utilisation of health resources, ignorance and lack of emergency obstetric care at the primary level.What are the implications of these findings for clinical practice and/or further research? Patient and attendant education to ensure follow-up visits, recognise danger signs and report without undue delay, compliance to dietary modifications, medications given needs to be addressed at every visit to reduce the impact of socio-behavioural determinants on maternal near miss and mortality which are preventable in majority of cases.