Effectiveness of Parental Preparedness Package among Couples Conceived with Artificial Reproductive Techniques.

Introduction: The problem of infertility is experienced as a crisis or major life stressor with potentially serious negative effects on the couple's relationship and preparation toward the parenthood. According to Sharlip et al., it has been estimated that about 15% of couple would have trouble in conception, and at present, 48.5 million couples experience infertility globally. To decrease the stress among parents to be and to promote healthy parenting for bringing out healthy parent-child relationships, an intervention of Parent Education Program was planned and executed. A study was conducted with the aim to assess the effectiveness of parental preparedness package (PPP) on physical health among couple conceived with artificial reproductive techniques (ART). Materials and Methods: The study was conducted to evaluate the effectiveness of PPP in fifty couples conceived with ART at Dayanand Medical College and Hospital, Ludhiana. Quantitative approach was used to collect the data of couples by doing pre- and postinterventional assessment of physical health of couple using the Structured Physical Health Assessment Scale. Analysis was done with the help of descriptive and inferential statistics. Results: The study revealed that mean score of physical health of couple (both husband and wife) increased significantly after the intervention which infers the effectiveness of PPP (P = 0.001). Conclusion: Our study concludes that PPP should be incorporated in the antenatal care protocol in all couples who conceive using ART.

To Evaluate the Effect of Increasing Maternal Age on Maternal and Neonatal Outcomes in Pregnancies at Advanced Maternal Age.

Introduction: Late pregnancies have been a sensitive issue in the society and medical field for many years. The reason for this development could be the increasing use of reproductive techniques, women empowerment and late conceptions. The increased level of education in women, having more responsibilities at work, giving priority to their professional career could be leading to delay in conception and childbearing. Many studies have investigated the effect of advanced maternal age on fetal outcome suggesting higher risk of poor neonatal outcome. Recent studies have debated these outcomes.[1234]. Aims and Objectives: To evaluate the effect of increasing maternal age on maternal and neonatal outcomes in pregnancies at advanced maternal age. Material and Methods: The study was conducted on 843 women above the age of 35 years who delivered at Dayanand Medical College and Hospital during 2015-2020. Patients were categorized into 2 groups, Group A comprised of pregnant women aged 35-40 years; group B included pregnant women aged >40 years. Various other parameters including parity, gestation at delivery, whether the pregnancies were spontaneous or conceived through ART (assisted reproductive techniques) and other associated co-morbid conditions were noted. The obstetrical, gynecological, medical, surgical, fetal and neonatal complications were studied in both the groups and the data was analyzed with release 9.4 (SAS Institute Inc, Cary, NC). Results: Out of 843 patients in our study, 81.4% (n=687) belonged to the age group of 35- 40 years. 18.5% (n=156) belonged to the age group of > 40 years. Patients more than 40 years underwent ART for conception more often as compared to group A. Co-morbid medical conditions including chronic hypertension, thyroid diseases, auto immune disorders and obstetric complications such as abortions, oligohydramnios, GDM, placenta previa, PPH was significantly more common in patients with group B. Cesarean delivery rate was significantly more in group B as compared to group A. Neonatal outcome in terms of NICU admissions and preterm birth at less than 35 weeks gestation was seen more frequently in group B as compared to Group A. Conclusion: Our study concludes that the decision to delay childbearing should be discouraged owing to increased maternal and fetal morbidity associated with advanced maternal age, the risks being higher with increasing maternal age.

Pregnancy-related acute kidney injury and urological comorbidities in morbidly adherent placenta: A potential challenge to AKI-0by25.

Pregnancy-related acute kidney injury (PRAKI) and urological complications can significantly increase the maternal morbidity and mortality, and morbidly adherent placenta (MAP) has been found to increase the risk of both. This is a four-year prospective study, conducted on patients with MAP. Baseline parameters (demographic/antenatal/perinatal), operative details (obstetric/urological/hemostatic), peri-operative complications (AKI/urological), and maternal/fetal outcomes were studied till six weeks after delivery. Statistical analysis was done using IBM SPSS Statistics version 21.0, and P <0.05 was considered statistically significant. Out of the 5475 deliveries conducted in the study period, 64 had adherent placentation. AKI occurred in 39.1% of patients, with severe AKI (AKIN-2, 3) in 10.9%, and significantly higher incidence in placenta percreta (P = 0.021, relative risk [RR] - 2.34), urological injuries (P = 0.001, RR - 2.86), and high blood loss (P = 0.001) on univariate analysis, but placenta percreta was the most statistically significant factor P = 0.049) on multivariate analysis. Urological involvement/injuries requiring intervention were encountered in 22 patients, with statistically significantly high incidence in placenta previa (P = 0.023, RR - 1.62), placenta percreta (P = 0.000, RR - 17.18), and patients undergoing hysterectomy (P = 0.000, RR - 2.01) on univariate analysis, but placenta percreta was most statistically significantly implicated on multivariate analysis (P = 0.017). AKI and urological injuries significantly increased the need for intensive care and days of hospitalization. On six-week follow-up, all AKI patients recovered completely; no urinary leak or vesico-vaginal fistula was seen in urologically intervened patients and no maternal mortality occurred. There is an alarmingly high incidence of PRAKI and urological complications in MAP, posing a great threat to their worldwide improving statistics. Awareness of this condition among renal fraternity can significantly improve the maternal renal and overall prognosis.

Intra-operative uterine artery embolization with caesarean delivery in an adjoining operating theatre and catheter lab (OT/CL) complex vs. conventional management in patients with abnormally invasive placenta: a retrospective case control study.

Patients of abnormally invasive placenta (AIP) undergoing caesarean delivery are at increased risk of haemorrhage. Conventional management includes piecemeal removal of placenta or placenta left in situ. However, they often require hysterectomy after delivery. Post-delivery prophylactic uterine artery embolisation (UAE) can help reduce morbidity and preserve fertility. We created an adjoining operating theatre and catheter lab (OT/CL complex). This is a retrospective case control study in which 37 patients of AIP were evaluated. Sixteen subjects (cases) had UAE immediately after caesarean delivery, and 21 subjects (controls) had usual care with traditional methods of controlling postpartum haemorrhage and hysterectomy where required. The hysterectomy rate (18.7% vs. 85.7%), mean duration of hospital stay (6.8 ± 2.6 vs. 13.9 ± 8.1) and number of units of blood transfusion required were significantly less in the case group as compared with controls. UAE is an effective conservative treatment along with caesarean delivery in patients with AIP.Impact statementWhat is already known? AIP is associated with high rates of PPH, maternal morbidity and mortality and need for hysterectomy after delivery. UAE has been advocated to preserve fertility and reduce PPH in these patients along with caesarean delivery.What does the study add? We created an adjoining operating theatre and catheter lab (OT/CL complex) in a tertiary care centre and managed these patients with prompt UAE after caesarean delivery with team approach. We have shown significant reduction in morbidity and hospital stay with this coordinated management.What are the implications for clinical practice and/or further research? UAE with caesarean delivery is a preferred mode of delivery for patients of AIP. These patients should be diagnosed and referred to tertiary care centres with such facilities electively so as to provide optimal care to these patients. Cooperation between interventionist and obstetrician and adjoining availability of OT and catheter lab can further help in reducing the time to embolisation after delivery. A hybrid operating theatre with digital subtraction angiography (DSA) facilities would be ideal for the management of such patients.

A Rare Case of Transvesical Cesarean Section.

Cesarean section, also commonly known as C-section, is a surgical procedure in which incision is made through a mother's abdomen and uterus to deliver one or more babies. According to urgency, they are classified either as elective or emergency. According to technique, they have been classified as classical, lower uterine segment and cesarean hysterectomy. Intentional transvesical cesarean though not a routinely practiced technique is used for delivery in women born with imperforate anus, ectopic intravaginal urethra, vaginal and urethral strictures, and bladder adherent completely over the uterus. Since such cases are very rare, we are reporting one such case of transvesical cesarean section.

Rupture of Noncommunicating Rudimentary Horn of Uterus.

Rudimentary horn pregnancy though an extremely rare condition can be associated with high morbidity. We report a case of ruptured noncommunicating rudimentary horn with unicornuate uterus.

Intraoperative diagnosis of hydatid cyst of the ovary masquerading as tumor.

Hydatid disease, caused by the larval stage of Echinococcus granulosus, is found most commonly in the liver and lungs, but no organ is immune. The ovarian involvement is often secondary to a cyst's dissemination localized in a different site. Occasionally, the cyst enlarges, thus mimicking an ovarian tumor. Patients with hydatid cysts at unusual locations present with atypical presentations and pose a diagnostic dilemma. A high index of suspicion is required in order to make a correct diagnosis pre-operatively to prevent spillage of the cyst contents during surgery. We report a case of hydatid cyst in the ovary in a young female. Diagn. Cytopathol. 2017;45:267-269. © 2016 Wiley Periodicals, Inc.

Successful pregnancy after excision of cesarean scar endometriosis with uterovesicocutaneous fistula: A rare case report.

Scar endometriosis is an infrequent type of extrapelvic endometriosis. The most common extrapelvic form of endometriosis is cutaneous endometriosis, involving scar tissues occurring after obstetric or gynecologic procedures such as episiotomy, hysterotomy, cesarean section, and even laparoscopic surgery. The clinical presentation of scar endometriosis, i.e., tender swellings, mimics other dermatological and/or surgical conditions and delays the diagnosis. Scar endometriosis very rarely can get complicated with uterocutaneous fistula with a reported incidence of very few cases in world literature. We report a case of a 36-year-old woman presenting with scar endometriosis with complicated uterocutaneous fistula 11 years after her last lower segment cesarean section, managed successfully with laparotomy-fistulectomy and sleeve resection of the bladder with repair followed by successful subsequent spontaneous conception and pregnancy terminated by lower segment cesarean section.

A change in the management of intractable obstetrical hemorrhage over 15 years in a tertiary care center.

CONTEXT: Peripartum hysterectomy was the gold standard to save a woman with persistent obstetrical bleeding, but compromised the menstrual and reproductive functions. Bilateral internal iliac artery ligation (BIAL) is a potentially effective, fertility preserving means of controlling pelvic hemorrhage, but with surgical and anesthetic risks and low success. Angiographic embolization has the potential to arrest severe pelvic hemorrhage without removing the uterus and without hazarding general anesthesia in a hemodynamically unstable patient. AIMS: The aim of this study is to discuss change in the management of intractable obstetrical hemorrhage from removing to conserving the uterus over 15 years. SETTINGS AND DESIGN: A retrospective analysis of 122 cases of intractable obstetrical hemorrhage over a period of 15 years (January 1997 to December 2011) was done. We started uterine artery embolization (UAE) in 2007 for obstetrical hemorrhage. The patients were analyzed for maternal characteristics, indications, treatment modality, maternal morbidity, and mortality. STATISTICAL ANALYSIS USED: Descriptive. RESULTS: We analyzed 12,055 deliveries, (6029 cesarean sections; 6026 vaginal deliveries). One hundred and twenty-two cases of intractable obstetrical hemorrhage were managed with obstetrical hysterectomies in 63, UAE in 53 cases and BIAL in six cases. During the period between 1997 and 2006 intractable obstetrical hemorrhage was managed by hysterectomy/internal iliac artery ligation. The last 5 years of the study period had 80 patients with intractable obstetrical hemorrhage, 53 patients underwent arterial embolization and 35 had a hysterectomy and two had internal artery ligation. There was no mortality and significantly less morbidity in embolization group in our study. CONCLUSIONS: Embolization should be tried in patients with intractable obstetrical hemorrhage before proceeding for surgical intervention.

Angiographic embolization for intractable obstetrical bleeding.

AIMS AND OBJECTIVES: The objective of this study is to review the clinical profile and outcome in patients requiring the angiographic embolization in obstetrics. METHODS: The retrospective data of patients requiring uterine artery embolization for control of obstetrical hemorrhage was studied during the period from August, 2005 to August, 2010. RESULTS: A total of 35 patients with obstetrical hemorrhage (seven post lower segment caesarean section, 13 post vaginal delivery, 13 postabortal, one with cervical pregnancy and one patient post laparotomy for abdominal pregnancy) underwent angiographic embolization for control of bleeding. In all patients, hemorrhage was successfully controlled; none required post procedure hysterectomy and one patient subsequently became pregnant with in a year. CONCLUSION: Our clinical experience suggests that embolization is superior first-line alternatives to surgery for control of obstetric hemorrhage including postpartum, post-cesarean and postabortal bleeding and prevents hysterectomy.

Spectrum of neurological complications in HELLP syndrome.

BACKGROUND: Hemolysis (H), elevated liver enzymes (EL), and low platelets (LP), HELLP syndrome is the extended spectrum of severe preeclampsia and is associated with high mortality. A large proportion of mortality can be attributed to catastrophic central nervous system events. AIMS: The purpose of this study was to access the clinical manifestations, radiological abnormalities and outcome in patients of HELLP syndrome with neurological manifestations. SETTING: Obstetric unit and neurology intensive critical unit (ICU) of an academic medical center. STUDY DESIGN: Retrospective study. SUBJECTS AND METHODS: Case records of all obstetrical patients who were admitted between January 2012 and December 2012 were screened and data was collected from those patients who were diagnosed with HELLP syndrome with neurological complications. It was entered into a structured performa and analyzed using percentages . RESULTS: During the study period; 1,166 deliveries were conducted, 108 patients had pregnancy-induced hypertension (PIH); and of the 12 patients with HELLP, eight (66%) patients had neurological complications. The presenting neurological features were seizures (four), focal neurological deficits (two), and encephalopathy (two). Of the eight patients, in six patients neuroimaging showed features of posterior reversible encephalopathy syndrome (PRES), three of them had associated hemorrhage, and two patients had isolated intracranial hemorrhage. All except two were discharged home. CONCLUSIONS: Neurological complications are not uncommon in patients with HELLP syndrome and a high index of suspicion is essential. Aggressive multidisciplinary approach is the key to reduce the morbidity and mortality.

Acute pancreatitis in pregnancy: A treatment paradigm based on our hospital experience.

BACKGROUND: Acute pancreatitis (AP) is a rare event in pregnancy, occurring in approximately 3 in 10 000 pregnancies. The spectrum of AP in pregnancy ranges from mild pancreatitis to serious pancreatitis associated with necrosis, abscesses, pseudocysts, and multiple organ dysfunction syndromes. As in any other disease associated with pregnancy, AP is associated with greater concerns as it deals with two lives rather than just one as in the nonpregnant population. AP is most often associated with gall stone disease or hypertriglyceridemia. MATERIAL AND METHODS: We present 2 years of experience during which we had eight patients of AP. RESULTS: Of the eight patients, three underwent laparoscopic cholecystectomy and five were treated conservatively. One had multiple cysts in the abdomen which were drained. All the patients delivered at term. Prophylactic tocolysis was given for 48-72 h to only those patients who had laparoscopic cholecystectomy. All the patients recovered completely. There was no maternal or fetal mortality. CONCLUSION: When properly managed AP in pregnancy does not carry a dismal prognosis as in the past.

Prevalence of hypothyroidism in infertile women and evaluation of response of treatment for hypothyroidism on infertility.

CONTEXT: Prevalence of hypothyroidism is 2-4% in women in the reproductive age group. Hypothyroidism can affect fertility due to anovulatory cycles, luteal phase defects, hyperprolactinemia, and sex hormone imbalance. AIMS AND OBJECTIVES: To study the prevalence of clinical/sub-clinical hypothyroidism in infertile women and the response of treatment for hypothyroidism on infertility. MATERIALS AND METHODS: A total of 394 infertile women visiting the infertility clinic for the first time were investigated for thyroid stimulating hormone (TSH) and prolactin (PRL). Infertile women with hypothyroidism alone or with associated hyperprolactinemia were given treatment for hypothyroidism with thyroxine 25-150 µg. RESULTS: Of 394 infertile women, 23.9% were hypothyroid (TSH > 4.2 µIU/ml). After treatment for hypothyroidism, 76.6% of infertile women conceived within 6 weeks to 1 year. Infertile women with both hypothyroidism and hyperprolactinemia also responded to treatment and their PRL levels returned to normal. CONCLUSION: Measurement of TSH and PRL should be done at early stage of infertility check up rather than straight away going for more costly tests or invasive procedures. Simple, oral hypothyroidism treatment for 3 months to 1 year can be of great benefit to conceive in otherwise asymptomatic infertile women.