Executive Summary of Evidence and Consensus-Based Clinical Practice Guidelines for Management of Obesity and Overweight in Midlife Women: An AIIMS-DST Initiative.

Weight gain is an independent risk factor for decline in cardiometabolic and overall health-related quality of life in midlife women. The AIIMS-DST initiative aims to develop and validate stepwise recommendations specific for weight management in midlife women. The key clinical questions specific to weight management in midlife women were finalized with the help of a multidisciplinary team of experts in the guideline development group. Phase I including a systematic and/or narrative review, grading of evidence, and expert opinion was sought to develop clinical practice recommendations for each clinical question. Phase II focused on validation of clinical practice recommendations using the peer-review, Delphi method, and GRADE approach. The guidelines provide clinical practice points to address challenges encountered by midlife women in their attempts to manage obesity via lifestyle modification techniques. The initiation of discussion would help the health-care provider to identify the weight management needs of the women, educate women on different modalities of weight management, and empower them to incorporate corrective lifestyle behaviors. Before initiating the management, a comprehensive assessment of clinical and lifestyle-related parameters should be completed. A personalized behavioral lifestyle modification program addressing the midlife-specific barriers for optimal metabolic, musculoskeletal, and mental health should be planned. A consistent follow-up is required for maintenance of corrective eating and activity habits by addressing midlife-specific barriers for sustenance of healthy weight. These recommendations will be useful in opportunistic screening and management of obesity in midlife women across health-care settings.

Executive summary of evidence and consensus-based clinical practice guideline for management of obesity and overweight in postpartum women: An AIIMS-DST initiative.

INTRODUCTION: Postpartum obesity is a public health concern. There is a need to counsel women about their postpartum weight management, accounting for various barriers they face. Limited literature in the Indian context underscored the need to develop the clinical practice guideline to be used by healthcare providers in Indian healthcare settings. METHODS: The guideline was formulated by following the standardised methodology proposed by the National Health and Medical Research Council. Various steps such as identification of the patient population, assembly of the guideline development groups, identification of the key clinical questions, guideline development methods, grading the quality of evidence and recommendations and guideline translation were carried out to develop and validate the clinical practice recommendations. RESULTS: The evidence and consensus-based clinical practice guideline has been developed, providing recommendations for key topics of interest for first-line treatment of obesity (lifestyle-related management). Recommendations focus on screening and initiating discussion with overweight and obese postpartum women as well as those who had normal pre-pregnancy body mass index but have retained excessive weight in the postpartum period. Recommendations highlight the evaluation and management of dietary, physical activity and breastfeeding behaviour. Recommendations also account for behavioural modification techniques to improve adherence to the prescribed weight management advice. Duration and frequency of follow-ups as well as the advice to be disseminated have also been discussed in the recommendations. CONCLUSION: The guideline provides clinical practice points that can be used by healthcare providers, postpartum women and policymakers for opportunistic screening and management of postpartum obesity.

Executive summary of evidence and consensus-based Clinical Practice Guidelines for management of obesity and overweight in midlife women: An AIIMS-DST initiative.

BACKGROUND AND AIMS: Weight gain is an independent risk factor for decline in cardiometabolic and overall health-related quality of life in midlife women. The AIIMS-DST initiative aims to develop and validate stepwise recommendations specific for weight management in midlife women. METHODS: The key clinical questions specific to weight management in midlife women were finalised with the help of a multidisciplinary team of experts in the guideline development group (GDG). Phase I included a systematic and/or narrative review to gather evidence, grading of evidence and expert opinion was sought to develop clinical practice recommendations for each clinical question. Phase II focused on validation of clinical practice recommendations using the peer-review, Delphi method and GRADE approach. RESULTS: -The guidelines provide clinical practice points to address challenges encountered by midlife women in their attempts to manage obesity via lifestyle modification techniques. The initiation of discussion would help the healthcare provider to identify the weight management needs of the women, educate women on different modalities of weight management, and empower them to incorporate corrective lifestyle behaviours. Before initiating the management, a comprehensive assessment of clinical and lifestylerelated parameters should be completed. A personalised behavioural lifestyle modification program addressing the midlife specific barriers for optimal metabolic, musculoskeletal, and mental health should be planned. A consistent follow-up is required for maintenance of corrective eating and activity habits by addressing midlife specific barriers for sustenance of healthy weight. CONCLUSION: These recommendations will be useful in opportunistic screening and management of obesity in midlife women across healthcare settings.

A validation study of early warning system in high-risk pregnant women.

High-risk obstetric patients have chances of deterioration which can be detected by any early warning score. This study was aimed to assess the suitability of the Obstetrics National Early Warning System (ONEWS) for the pregnant women. This prospective study was conducted on 500 high-risk pregnant women attending a tertiary care teaching hospital. The ONEWS charts were plotted for each of them. The primary outcome measure was composite adverse maternal outcome (CAMO) in the form of one or more among mortality, severe maternal morbidity and intensive care unit admissions. Of the 500 women who participated, 200 (40%) had a score ≥3 (triggered an intervention). The CAMO among the triggered group [59.5% (n=119)] was significantly higher compared to that in the non-triggered group [13.3% (n=40) (P=0.001)]. The area under the receiver operating characteristic curve was 0.800 (95% confidence interval 0.752-0.847). The sensitivity of the ONEWS in predicting CAMO was 74.8 per cent, specificity 76.2 per cent, positive predictive value 59.5 per cent and negative predictive value 86.7 per cent at a cut-off score of 3. ONEWS appears to be a useful tool for predicting adverse maternal outcomes in high-risk pregnant women.

Role of intravenous iron sucrose in correction of anemia in antenatal women with advanced pregnancy.

The aim of this study is to observe rise in haematological parameters after treatment with iron sucrose in antenatal patients with moderate anemia with period of gestation 32 to 35 weeks. The study included 45 antenatal patients with period of gestation from 32 to 35 weeks having iron deficiency anemia with haemoglobin levels 7-9 g% and serum ferritin levels less than 12 ng/mL. Intravenous iron sucrose was given in the dose of 200 mg on alternate days, according to the calculated dose. The mean haemoglobin and red blood cell indices were compared on days 7, 14, 21, 28 and at the time of delivery from the baseline value. There was a statistically significant rise in haemoglobin value from baseline on days 14, 21, 28 as well as at the time of delivery (p value <0.0001). The mean rise in haemoglobin values was 0.56 g% on day 14, 1.44 g% on day 21 and 2.0 g% on day 28. At the time of delivery, mean haemoglobin was 11.24 g%. After 28 days of treatment, there was a statistically significant rise in the levels of serum ferritin from 10.33 ± 3.8 ng/mL to 36.89 ± 5.7 ng/mL. Thus, earlier response achieved by iron sucrose can be utilised in the patients presenting at an advanced period of gestation with iron deficiency anemia.

A randomised controlled trial to compare intravenous iron sucrose and oral iron in treatment of iron deficiency anemia in pregnancy.

The aim of this study was to compare the efficacy and safety of intravenous iron sucrose with oral iron therapy in pregnant patients with anemia. The primary outcome of the study was increase in haemoglobin on day 7, 14 & 28 and rise of serum ferritin over 28 days. The study population consisted of 100 patients with singleton pregnancy between 24 and 34 weeks, hemoglobin levels between 7.0-9.0 gm/dL and serum ferritin levels less than 15 ng/mL. The participants in the oral group were given daily 180 mg elemental iron in three divided oral doses for 4 weeks. Total calculated dose of iron sucrose with a target hemoglobin of 11 gm %, was given in 200 mg dose on alternate days. Mean haemoglobin rise was 0.58 gm/dL in the IV group as compared to 0.23 gm/dL in the oral group on day 14 and 1.9 gm/dL in the IV group & 1.3 gm/dL in the oral group on day 28, (p <0.05). In the IV group, 76% of the subjects achieved haemoglobin levels of ≥11 gm% at the time of delivery, as compared to only 54% of the subjects in the oral group who achieved these levels. Serum ferritin value was significantly higher in the IV group, 37.45 ± 5.73 ng/mL as compared to 13.96 ± 1.88 ng/mL in the oral group at 4th week (p <0.001). There was no major side effect in the IV group. 36% subjects in the oral group developed gastrointestinal side effects & 10% of the subjects were non compliant. The rate of hemoglobin rise is faster with intravenous iron sucrose therapy as compared to oral iron therapy which can be beneficial in pregnant women presenting with anemia at a later period of gestation. Intravenous iron sucrose is very well tolerated during pregnancy.

Facility-based review of 296 maternal deaths at a tertiary centre in India: could they be prevented?

AIMS: The aim of this study was to identify causes of maternal mortality at the facility and to assess the standard of care, deficiencies in health services and preventability of these deaths using facility-based maternal death reviews. MATERIAL AND METHODS: This was a prospective study at a tertiary care hospital that included all women who died during pregnancy or within 42 days of being pregnant during 2005-2010. RESULTS: A review of 296 maternal deaths revealed that 59% of these occurred in medical wards. Indirect maternal deaths (54%) outnumbered the direct deaths (46%). Main causes were hepatitis (18%), hemorrhage (10%) and puerperal sepsis (10%). Only 5% of the women had received antenatal care at the facility. One-third (34%) were referred from other centers. The majority (74%) were critically sick at admission. Most of the women (62%) died postpartum. Substandard care and deficient health services were identified in 8% and 20% of the cases, respectively. Sixteen (5%) maternal deaths were deemed preventable and another 36 (12%) possibly preventable. Since most of the preventable deaths (12/16) were due to hemorrhage, measures to control postpartum hemorrhage were promoted at the facility. Findings of the maternal death reviews were regularly conveyed to the State Health Department for prioritization and resource allocation to prevent maternal mortality. CONCLUSION: More maternal deaths occurred in the medical than in the obstetrics wards at the facility. The leading causes were hepatitis, hemorrhage and puerperal sepsis. Most of the deaths were non-preventable as the women were critically sick at admission; however, substandard care and health service deficiency were contributory in some of the cases.

Ascariasis presenting as acute abdomen during pregnancy and puerperium.

Ascariasis can have various clinical presentations. We present three cases of ascariasis in pregnant or postpartum women, presenting with acute abdomen. The diagnosis of ascariasis was made clinically with the passage of ascaris worms in the vomitus or stool and was supported by ultrasonography. All three patients were treated successfully using anthelmintics. One patient underwent exploratory laparotomy.

Uterine tamponade using condom catheter balloon in the management of non-traumatic postpartum hemorrhage.

AIM: To study the efficacy and complications of uterine tamponade using condom catheter balloon in non-traumatic postpartum hemorrhage (PPH). MATERIAL AND METHODS: This prospective study was conducted in a tertiary care teaching hospital in India. Eighteen patients with non-traumatic PPH not responding to medical management were included in the study. Uterine tamponade was achieved by a condom catheter balloon filled with saline and kept in situ for 8-48 h. The main outcome measures were success rate in controlling hemorrhage, time required to stop bleeding, subsequent morbidity and technical difficulties. Data was analyzed using appropriate statistical methods. RESULTS: The success rate of condom catheter balloon in controlling hemorrhage was 94%. The mean amount of fluid filled in the condom catheter balloon was 409 mL. The average time taken to control bleeding was 6.2 min. The mean duration for which condom catheter balloon was left in situ was 27.5 h. The average amount of blood loss was 1330 mL. Five patients (28%) had infective morbidity. CONCLUSION: Condom catheter balloon is effective in controlling non-traumatic PPH in 94% cases. It is effective, simple to use, easily available and is a cheap modality to manage non-traumatic postpartum hemorrhage, especially in limited resource settings.

Emergency contraception: knowledge, attitude, and practices among health care providers in North India.

AIMS: The present study was conducted to assess knowledge, attitude, and practice of emergency contraception in health care providers and users in North India. METHODS: A survey was carried out with the help of a predesigned questionnaire comprising of two groups of clients (abortion seekers at Family Welfare center, and non-medical college students (prospective clients)); and 4 groups of health care providers (gynecologists, general practitioners, paramedical workers, and medical students). RESULTS: Practically none of the clients were familiar with the concept of emergency contraception and so the rest of the information could not be obtained from them and hence this was excluded from further analysis. Many providers (84.8% gynecologists, 41.0% general practitioners, 2.7% paramedical workers, and 64.4% medical students) were vaguely familiar with the concept of emergency contraception, very few knew accurately about timing and doses. The majority of these thought it to be an essential component of contraceptive services but preferred distribution through health care providers only. The practice of emergency contraception as reported in the present survey was inconsistent. Yuzpe regimen was the most commonly used method and nausea/vomiting were the commonest side-effects. The question of efficacy of emergency contraception was not answered reliably by the health care providers. CONCLUSIONS: Awareness about emergency contraception among the general population and paramedical workers studied is practically nonexistent. Precise knowledge about emergency contraception among doctors (both gynecologists and general practitioners) is also inadequate. Prescription practices can improve by generating demand and training of health care providers.