Systematic review analyzing significance of endometrial cavity fluid during assisted reproductive techniques.

OBJECTIVE: The objective of our study is to estimate the prevalence of endometrial cavity fluid (ECF) in Assisted Reproductive Techniques (ART) cycles and analyze its effects on pregnancy outcome in such cycles. DATA SOURCES: PubMed, Cochrane Central, Scopus, and clinicaltrials.gov were searched for articles. The reference lists of relevant publications were explored for other studies. STUDY ELIGIBILITY CRITERIA: Studies that had assessed the pregnancy outcome in ART cycles and had commented on ECF accumulation were included. Pregnancy outcomes were assessed in all ART cycles where ECF was observed and were compared to the non-ECF cycles. RESULTS: A total of nine studies were included in the meta-analysis for a total of 28,210 cycles. Pooled analysis of the prevalence of ECF cycles out of total cycles in females undergoing ART using a fixed effect model showed that it was 14% (95% CI is 13% to 14%; I2 = 99%, p = < 0.01). The random effect model prevalence of ECF cycles was around 7% (95% CI: 4% to 10%). There was a statistically significant (25%) decrease in pregnancy rates per cycle transfer in the ECF cycle versus the non-ECF cycle group during ART [OR = 0.75, 95% CI = 0.67-0.84), p < 0.001; moderate quality evidence]. When ECF size was compared, there was a statistically significant increase in pregnancy rates if ECF size was less than 3.5 mm versus greater than or equal to 3.5 mm [OR = 13.67, 95% CI = 1.43-130.40), p = 0.02; high quality evidence]. Sub-group analysis revealed that the ECF present at the time of embryo transfer significantly decreased the pregnancy rates by 26% as compared to the group where the ECF was not present at the time of embryo transfer [OR = 0.74, 95% CI = 0.65-0.85), p < 0.001]. CONCLUSIONS: This meta-analysis proposes that the presence of ECF significantly decreases the implantation and pregnancy rates of ART cycles, and even more so if its size is greater than 3.5 mm. Interventions to decrease ECF formation or treat it have enhanced the pregnancy outcome in ART cycles. PROSPERO REGISTRATION: Date: 17th September 2020; Number: CRD42020182262.

WITHDRAWN: Tranexamic acid to reduce postpartum blood loss after a vaginal delivery: a double-blinded, randomized controlled trial.

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.

Large Urethral Diverticular Calculus Clinically Mimicking a Metastatic Deposit in a Case of Ovarian Mass.

Calculus in the urethra of the female is very unusual. The patient remains asymptomatic or uncommonly presents with symptoms of dysuria, post-void urinary dribbling, and dyspareunia. If asymptomatic, it can be diagnosed incidentally on gynecological examination. Being hard in consistency, it may mimic metastatic lesion. We present a case of a female who presented to us for management of ovarian mass. On routine examination there was a hard mass in her vagina which was suspected to be a metastatic lesion. This mass on evaluation came out to be a urethral diverticulum with a large calculus. Very large urethral calculus are a very rare presentation in a female.

To Try or Not to Try: A Questionnaire Study among Women with Previous Lower Segment Cesarean Section.

Background: The recent increase in the cesarean section (CS) rate worldwide has led to global concerns and vaginal birth after CS (VBAC) as an effective way to reduce the CS rate. In this study, our main aim was to know about various factors that help women make their preferred mode of delivery following a previous CS. Material and Method: This was a questionnaire-based study conducted in the Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Jodhpur, among 200 women with previous one lower segment CS (LSCS). Results: Elective repeat cesarean delivery (ERCD) was found to be more among uneducated women and those who had complications in their previous babies. The most common reason for opting for ERCD was fear of labor pains. Women who were counseled by senior doctors were more likely to opt for a trial of labor after cesarean section (TOLAC). Conclusion: Improving the education levels of mothers, counseling about advantages associated with vaginal birth, counseling by senior obstetrician, and information regarding labor analgesia can decrease CS rates.

Pre-COVID and COVID experience of objective structured clinical examination as a learning tool for post-graduate residents in Obstetrics & Gynecology-a quality improvement study.

OBJECTIVE: Due to its comprehensive, reliable, and valid format, the objective structured clinical examination (OSCE) is the gold standard for assessing the clinical competency of medical students. In the present study, we evaluated the importance of the OSCE as a learning tool for postgraduate (PG) residents assessing their junior undergraduate students. We further aimed to analyze quality improvement during the pre-coronavirus disease (COVID) and COVID periods. METHODS: This quality-improvement interventional study was conducted at the Department of Obstetrics and Gynecology. The PG residents were trained to conduct the OSCE. A formal feedback form was distributed to 22 participants, and their responses were analyzed using a five-point Likert scale. Fishbone analysis was performed, and the 'plan-do-study-act' (PDSA) cycle was implemented to improve the OSCE. RESULTS: Most of the residents (95%) believed that this examination system was extremely fair and covered a wide range of clinical skills and knowledge. Further, 4.5% believed it was more labor- and resource intensive and time-consuming. Eighteen (81.8%) residents stated that they had learned all three domains: communication skills, time management skills, and a stepwise approach to clinical scenarios. The PDSA cycle was run eight times, resulting in a dramatic improvement (from 30% to 70%) in the knowledge and clinical skills of PGs and the standard of OSCE. CONCLUSION: The OSCE can be used as a learning tool for young assessors who are receptive to novel tools. The involvement of PGs in the OSCE improved their communication skills and helped overcome human resource limitations while manning various OSCE stations.

Deriving a prediction model for emergency cesarean delivery following induction of labor in singleton term pregnancies.

OBJECTIVES: To derive a prediction model combining various clinical factors associated with increased risk of emergency cesarean section following induction of labor in women with unfavorable cervix. METHODS: All women with singleton term pregnancies undergoing induction of labor and fulfilling inclusion criteria were included in this cross-sectional study after supplying consent. Women with a Bishop score of 6 or less were induced with dinoprostone gel. Multiple regression analysis was used to find the most significant independent predictive factors and these factors were used to develop the predictive model and calculator. RESULTS: After multiple logistic regression, risk of emergency cesarean after induction of labor was significantly associated with the following variables: height (adjusted odds ratio [aOR] 0.955, P = 0.033), nulliparity (aOR 3.987, P < 0.001), closed cervix (aOR 2.030, P = 0.030), fetal station -3 above ischial spine (aOR 2.719, P = 0.043), firm or medium cervical consistency (aOR 2.028, P = 0.004), cervical length 3 cm or longer (aOR 3.090, P = 0.015), posterior cervix (aOR 2.112, P = 0.002). CONCLUSION: Use of a prediction model would help to reduce the number of emergency cesarean sections secondary to unsuccessful inductions and help in the reduction of maternal and perinatal morbidity.

Explaining the Unexplained: Examining the Predictive Value of Semen Parameters, Sperm DNA Fragmentation and Metal Levels in Unexplained Infertility.

Background: There is ongoing research to find an optimum modality to predict male fertility potential. Aims: To compare the semen parameters, sperm DNA damage and seminal metal levels of Zinc, Lead and Aluminium among the male partners of couples with unexplained infertility and men with proven fertility. Settings and Design: Prospective case-control study at a tertiary level teaching hospital. Materials and Methods: One hundred male partners of couples with unexplained subfertility and 50 men with proven fertility were included in the study. Male partners of unexplained infertility couples and fertile men were compared for their semen parameters, sperm DNA Fragmentation Index (DFI) and seminal metal levels in semen. Statistical Analysis Used: Chi-square test, Student's t-test, sensitivity and specificity analysis, binomial logistic regression analysis. Results: Fertile men had statistically significantly higher mean progressive sperm motility than male partners of unexplained infertility (53.12 ± 9.89% vs. 44.81 ± 19.47%, P = 0.005). Semen volume and sperm concentration were comparable among the cases and control population. The mean sperm DFI was significantly lower among fertile men (10.83 ± 6.28 vs. 21.38 ± 10.28, P < 0.0001). Plotting the receiver-operating characteristic curve the threshold for discrimination was calculated to be 18% DFI. The sensitivity specificity and overall accuracy were 43%, 84% and 56.67%, respectively when the DFI cut-off was set at 18%. Zinc concentration in the semen had a strong positive correlation (Point Biserial correlation coefficient = 0.831) with fertility, whereas lead and aluminium had a moderate negative correlation. Conclusion: Conventional semen analysis had limited differentiating ability for unexplained infertility. The sperm DFI may be employed for explanatory purposes among couples with unexplained subfertility. A lower discriminatory threshold of DFI (18%) has better overall accuracy as opposed to a 30% cutpoint for unexplained subfertility. Among metals, Zinc was strongly correlated with fertility status.

Maternal and Perinatal Outcome in Pregnancy Complicated by Intrahepatic Cholestasis.

Introduction Intrahepatic cholestasis of pregnancy (IHCP) is characterized by pruritus of the hand and sole with abnormal liver function test and bile acid metabolism. IHCP occurs in the second and third trimesters of pregnancy and usually resolves after delivery. The overall prevalence is about 1.2 to 1.5%. This study was conducted to assess the fetomaternal outcome according to maternal serum bile acids levels and its correlation with liver function tests in patients with IHCP. Material and methods This ambispective observational study was conducted in the department of Obstetrics and Gynecology (OBG) for two years at AIIMS Jodhpur, Rajasthan. It included all the pregnant women attending the outpatient department of OBG with the complaint of pruritis in the palm and sole after 28 weeks of pregnancy and diagnosed with intrahepatic cholestasis of pregnancy after investigations. Results Only 152 patients were diagnosed with IHCP out of 4,148 deliveries, with a prevalence of 3.6%. Among these, 140 (92.11%) had mild IHCP, 10 (6.58%) had moderate IHCP and two (1.32%) had severe IHCP. There was a significant difference between the birth weight in mild, moderate and severe IHCP (P-value 0.004). About 12.5% (n=19) of patients had meconium-stained liquor during delivery. Two patients (1.32%) with moderate IHCP had intrauterine fetal death in the third trimester, and 6.58% (n=10) neonates were kept on continuous positive airway pressure. Conclusions IHCP is associated with adverse fetal outcomes like spontaneous or iatrogenic preterm delivery, low birth weight, increase in the rate of lower section cesarean section (LSCS) and intrauterine death of a fetus. A significant correlation found between raised bile acid levels and variables of liver function test, hence cost-effectiveness and feasibility of liver function test (LFT) should be considered for the management of IHCP.

Awareness and understanding of COVID-19 among pregnant woman in Northern India.

BACKGROUND: The severe acute respiratory syndrome coronavirus (SARS-CoV-2) has become a public health concern worldwide. It is important for pregnant women to know about the mode of transmission, symptoms, and preventive measures against COVID-19. The aim of this study was to evaluate the awareness and outlook of pregnant women and practical measures taken by them against COVID-19. MATERIALS AND METHODS: This cross-sectional questionnaire-based study was conducted for 1 month (June 10, 2020- July 10, 2020) in the Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India. A prevalidated questionnaire was given to 109 pregnant women to assess the knowledge, attitude, and practice acquired against COVID-19 infection. The Chi-square test or Fischer's exact test was used to compare categorical data. RESULTS: Among 109 participants, 103 (94.5%) had good knowledge, 4 (3.7%) had average knowledge and 2 (1.8%) had poor knowledge about COVID-19. Majority of them had a positive attitude for the protective measures taken for the prevention of disease. CONCLUSIONS: Since there is no valid treatment for COVID-19, prevention is the only key to curve this infection. In the present study, 94.5% pregnant women had overall good knowledge score about the mode of transmission, symptoms, and preventive measures against COVID-19.

The role of vaginal progesterone in established pre-term labor: A randomized controlled trial.

Background: Pre-term birth (PTB) is the leading cause of mortality and morbidity in newborn and infants. One of the proposed theories is the withdrawal of progesterone, either actual or functional, to be an antecedent to the onset of labor. The aim of the study is to evaluate the role of vaginal progesterone in delaying delivery following an episode of arrested pre-term labor. Methods: This is a pragmatic open-label randomized controlled trial that was conducted in the Department of Obstetrics and Gynecology at All India Institute of Medical Sciences, Jodhpur. Hundred patients with singleton pregnancies presenting with pre-term labor between 24 and 34 weeks of gestation and treated successfully with acute tocolysis for 48 hours and steroids covered were randomized to receive either progesterone 400 mg vaginal suppository or no treatment. Results: The primary outcome was the duration of randomization to delivery interval, which was significantly higher in the study than in the control group (28 days versus 10 days). The secondary outcomes such as gestational age at delivery was also higher in the study group compared to the control group (82% versus 60% delivered after 37 weeks in the study group and control group, respectively). The neo-natal outcomes such as birth weight (2802 grams versus 2324 grams), incidence of respiratory distress syndrome (RDS) (13% versus 26%), and newborn intensive care unit (NICU) admission (17% versus 31%) were lower in the study group, which signifies decreased neo-natal morbidities and mortalities in pre-term labor treated with maintenance tocolysis in the form of vaginal progesterone. Conclusion: Administration of vaginal progesterone (400 mg, daily) following an episode of arrested pre-term labor significantly increased the duration to delivery interval; that is, it reduced the rate of PTB before 37, 32, and 28 weeks of gestation among women. It further reduced the neo-natal morbidities such as RDS and NICU admission and increased the birth weight among infants of women assigned to progesterone treatment.

In it together: A dyadic approach to assessing the health-related quality of life and depression among infertile couples.

INTRODUCTION: The study aimed to assess the perceived quality of life (QOL) and to estimate the prevalence of depression among infertile couples as well as to study the congruence of the outcome among both partners. The sociodemographic factors influencing these outcomes were also examined. METHOD: A prospective, cross-sectional study of 130 infertile couples over 1 year at a tertiary level teaching hospital. Couples were requested to complete the WHOQOL-BREF instrument and Beck Depression Inventory (BDI). Data was analyzed using paired t test, 1-way multivariate linear variance analysis, and regression, and correlation models. RESULTS: Mean QOL scores between men and women showed a strong agreement within psychological, social, environmental, and physical domains (r = .70, .67, .69, and .59 likewise). The presence of depressive symptoms was associated with significantly impaired QOL scores through all domains. Depression was present in 30.6% of female partners and 27.2% in male partners. Pearson correlation between female partner BDI scores and male partner scores was highly statistically significant with a correlation coefficient of .745. The presence of depression was not found to be significantly associated with sociodemographic and clinical parameters. CONCLUSIONS: QOL and depression scores of 1 partner were reflected in the scores of the other partner. Henceforth, screening and psychoeducation should be couple based considering the couple as 1 unit which is likely to improve the mental wellbeing of the couple. The presence of depression is not influenced by the sociodemographic profile of couples therefore all infertile couples should be screened and offered counseling. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Detection of nerve fibers in the eutopic endometrium of women with endometriosis, uterine fibroids and adenomyosis.

OBJECTIVE: The primary objective of this study was to establish the presence of nerve fibers in the eutopic endometrium of women with endometriosis and to determine whether these nerve fibers are exclusive to endometriosis or are also found in other pelvic pathologies associated with dysmenorrhea. METHODS: Endometrial tissue was obtained by aspiration (Pipelle), endometrial curettage, or following hysterectomy in women with endometriosis confirmed through histopathological examination, leiomyomas, and adenomyosis. The eutopic endometrium was subjected to immunohistochemical staining to detect PGP 9.5, which is a highly specific pan-neuronal marker. The nerve fiber density was correlated with the patient's pain score, as indicated by the Visual Analog Scale. A control group was formed by staining the endometrium of women presenting with dysmenorrhea but without the above-mentioned disorders. RESULTS: Nerve fibers were observed in sections of the endo-myometrium (in the deep endometrium) in 68% of patients with endometriosis who underwent hysterectomy or a deep endometrial biopsy. Nerve fibers were not observed in the aspirated endometrium of women with endometriosis. Only 13.7% of women with adenomyosis and 3.3% of women with fibroids had nerve fibers in their endometrium. Nerve fiber density was correlated with pain score in women with endometriosis. CONCLUSION: Nerve fibers were found in the functional layer of eutopic endometrium in women with endometriosis; hence, we concluded that the presence of nerve fibers in the eutopic endometrium could diagnose endometriosis with a fairly good specificity of 92.7%. However, the absence of nerve fibers does not always exclude the disease.

Risk of incidental genital tract malignancies at the time of myomectomy and hysterectomy for benign conditions.

OBJECTIVE: To determine the incidence of accidentally diagnosed genital malignancies in women undergoing gynecological surgeries for pathologies presumed to be benign. METHODS: Data of all women who underwent hysterectomy for benign indications were retrieved from hospital records. A total of 628 cases of hysterectomy and 35 cases of myomectomy were included. The final histopathology was accessed through the computer records, and the total number of genital tract malignancies was included. RESULTS: The incidence of occult uterine, ovarian, and cervical malignancies in women undergoing hysterectomy was 0.47%, 0.31%, and 0.15%, respectively. The incidence of uterine corpus malignancies in women undergoing myomectomy was 2.8%, and 3 cases of smooth muscle tumor of uncertain malignant potential (STUMP) were also identified. Endometrial stromal sarcomas were the most common pathology among uterine malignancies, followed by leiomyosarcoma and endometrial adenocarcinoma. CONCLUSION: Postoperative diagnosis of malignancies in women undergoing surgery for benign indications poses great challenges to the treating surgeon. Occult malignancies must be ruled out by thorough preoperative assessment, especially in some subsets of women. Morcellation is an inevitable technique and complement to laparoscopic surgeries, although little chances of malignancy spread is related to its use. Nevertheless, thorough preoperative investigations and always ensuring contained morcellation can minimize these chances.

Postmenopausal Bleeding as a Late Sequela of Pelvic Fracture.

Postmenopausal bleeding is one of the common presenting complaints in the gynecological outpatient department. The common causes of which are atrophic endometritis, vaginitis, estrogen therapy, cancer endometrium, and cancer cervix. Hereby, we present a rare case of a 65-year-old female presented with postmenopausal bleeding who had history of trauma 1 year back with pelvic bone fracture. The cause of postmenopausal bleeding, in this case, is abnormal bony protrusion secondary to malunited pelvic fracture causing laceration of the right lateral vaginal wall. The case was managed by local osteotomy and vaginal wall repair.

Role of birth companion in COVID-19: indispensable for her and an auxiliary hand for us.

The pandemic of COVID-19 has proved to be a global catastrophe. Pregnant females could be more vulnerable to the infection owing to the immune modulation. According to the World Health Organization (WHO), pregnant females including those with COVID-19 suspicion or confirmed status have right to 'safe and positive childbirth experience' which includes a companion. The birth companion, is present at all times with the patient, from the initiation of labor till breastfeeding. The COVID-19 crisis has taken its toll on the healthcare system. The number of infected antenatal females are expected to increase. If a birth companion is trained in basic intrapartum and postpartum observation and care, he/she can be utilised to minimize unnecessary patient-clinician interface and optimize manpower in this critical time.

Blood lead levels in antenatal women and its association with iron deficiency anemia and adverse pregnancy outcomes.

OBJECTIVES: Lead is one of the most toxic heavy metal prevalent in the environment, which affects almost all major organs including heart, brain, intestines, kidneys as well as reproductive organs. It has been known that serum iron deficiency is associated with increased serum lead levels as lead is a particularly pernicious element to iron metabolism. Lead is also known to freely cross the placenta too; hence, this study was planned to determine any association between antenatal iron deficiency anemia (IDA), raised blood lead levels (BPb), and adverse pregnancy outcomes. MATERIALS AND METHODS: This was an observational study done on 99 antenatal women with IDA and 41 nonanemic antenatal women. Lead levels were assessed in these 140 antenatal women and they were followed for adverse pregnancy outcomes. Chi-square test was used to find a difference in quantitative variables and Pearson's correlation test was used to assess association between BPb and hemoglobin levels. RESULTS: We found that in 11 out of 99 (11.11%) women with IDA, BPb levels were high as compared to high BPb levels in only 1 out of 41 (2.4%) women without IDA and the high BPb levels ranged from 4 µg/dl-16.9 µg/dl with a mean BPb of 8.1 µg/dl. The difference in BPb among anemic and nonanemic antenatal women was significant (P < 0.05) and there was a negative dose effect relationship between BPb levels and hemoglobin levels. This difference in antenatal outcomes among women with and without high BPb levels was also significant with increased incidence of pre-eclampsia, FGR, and preterm deliveries in women with raised BPb levels. The incidence of NICU admission was also higher in the neonates of mothers with high BPb levels. CONCLUSIONS: We propose screening of high-risk women based on their social, occupational, environmental, and personal factors, with serum lead levels in the preconception period itself. All public and personal measures must be taken to reduce lead consumption and exposure in the preconception and antenatal period.

Tuberculosis and ovarian malignancy: Sometimes mimics, sometimes coexists.

Tuberculosis is a disease prevalent all over the world with India contributing to a larger share. Pulmonary tuberculosis presents with generalized symptoms of malaise, low grade fever and cough. On the other hand, genital tuberculosis presents with a variety of symptoms in each age group and is often underdiagnosed and missed. In an unmarried female, the usual presentations are menstrual complaints or presence of a solid cystic mass and ascites. In reproductive age group, patients may present with primary or secondary infertility or rarely with tubo-ovarian masses with peritoneal deposits, omental thickening and lymph node enlargement, hence mimicking ovarian carcinoma. In postmenopausal females, it can present as postmenopausal bleeding, leucorrhea or pyometra giving suspicion of endometrial carcinoma. We hereby report two cases operated with provisional diagnosis of ovarian malignancy but final histopathology ruled out malignancy in first and confirmed coexistence of malignancy and tuberculosis in another.

'How COVID 19 imposed a new normal outlook in reproductive health care of patients, research, teaching and assessment'- Perspective of a Gynecologist.

With the frequently changing guidelines on Pregnancy care, management of obstetric patients remains a major challenge during COVID-19 Pandemic. The department of Obstetrics and Gynecology had a huge responsibility to provide respectable maternity care to all women irrespective of their virologic status and at the same time protect the frontline warriors dealing with patient care during the COVID-19 pandemic. We would like to share our perspective regarding the challenges faced and the solutions sought for, in both patient care and teaching and research.