Ajog jan march 2018 final by IJCP

Volume 2, Number 1, January-March 2018

ISSN 0971-8788

Asian Journal of

Obstetrics &

Gynaecology Practice In this Issue Conservative Surgical Techniques in Management of Morbidly Adherent Placenta: A 5-year Study Analysis of Cesarean Section in a Tertiary Care Center: A Retrospective Study A Comparative Study Between Oral Iron, Intravenous Iron Sucrose and Ferric Carboxymaltose in the Management of Postpartum Anemia A Rare Case Report of Amniotic Band Syndrome A Rare Case of Twin Pregnancy in the Non-communicating Rudimentary Horn of Unicornuate Uterus Rupture of Endometriotic Ovarian Cyst Causes Acute Hemoperitoneum in IVF Pregnancy

Asian Journal of

Online Submission

Volume 2, Number 1, January-March 2018

An IJCP Group Publication Corporate Panel Dr Sanjiv Chopra Prof. of Medicine and Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor Dr KK Aggarwal Group Editor-in-Chief IJCP Group, eMedinewS and eMediNexus

CONTENTS FROM THE ISSUE EDITOR

Link Between Saturated Fat Intake and Heart Rate Variability in Women with Polycystic Ovary Syndrome

Alka Kriplani

Dr Veena Aggarwal MD, Group Executive Editor AJOG Specialty Panel Dr Alka Kriplani Editor Consultant Editor Dr Urmil Sharma Assistant Editors Dr Nutan Agarwal (Delhi) Dr Neera Aggarwal (Delhi) Dr A Biswas (Singapore) Dr CS Dawn (Kolkata) Dr Gauri (Delhi) Dr Suneeta Mittal (Delhi) Dr S Mehra (Delhi) Dr Prashant Mangeshikar (Mumbai) Dr Prakash Trivedi (Mumbai) Dr Gita Ganguly

Mukherjee (Kolkata) Dr (Mrs) Prabha Arora (Delhi) Dr Hema Divakar (Bangalore) Dr Kamini A Rao (Bangalore) Dr Deepti Goswami (Delhi) Dr Neerja Bhatla (Delhi) Dr Bhawna Malhotra (Delhi) Dr Biswas Nicholas (Australia) Dr Sudhaa Sharma (Jammu) Dr Jaibhagwan Sharma (Delhi) Dr Veena Mathur (Agra) Dr Garima Kachhawa

Editorial Board

Obstetrics and Gynaecology Dr Alka Kriplani Dr Thankam Verma Dr Kamala Selvaraj

Cardiology Dr Praveen Chandra Dr SK Parashar Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses Dr Sidhartha Das Dr A Ramachandran Dr Samith A Shetty Dr Vijay Viswanathan Dr V Mohan Dr V Seshiah Dr Vijayakumar ENT Dr Jasveer Singh Dr Chanchal Pal

Dentistry Dr KMK Masthan Dr Rajesh Chandna Gastroenterology Dr Ajay Kumar Dr Rajiv Khosla Dr JS Rajkumar Dermatology Dr Hasmukh J Shroff Dr Pasricha Dr Koushik Lahiri Dr Jayakar Thomas Nephrology Dr Georgi Abraham Neurology Dr V Nagarajan Dr Vineet Suri Dr AV Srinivasan Oncology Dr V Shanta Orthopedics Dr J Maheshwari

Anand Gopal Bhatnagar Editorial Anchor Advisory Body Heart Care Foundation of India Non-Resident Indians Chamber of Commerce and Industry World Fellowship of Religions

FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF

Avoid Weight Gain at Younger Age to Stay Healthy in Your Old Age

KK Aggarwal

CLINICAL STUDY

Conservative Surgical Techniques in Management of Morbidly Adherent Placenta: A 5-year Study

Rekha Rani, Shikha Singh, Ruchika Garg, Urvashi Verma, Sangeeta Sahu, Saroj Singh, Surendra Kumar, Himani Goyel

REVIEW ARTICLE

Analysis of Cesarean Section in a Tertiary Care Center: A Retrospective Study

Gurdip Kaur, Parmjit Kaur, Ruby Bhatia, Satinder Kaur, Ramiti Gupta, Aman Dev

A Comparative Study Between Oral Iron, Intravenous Iron Sucrose and Ferric Carboxymaltose in the Management of Postpartum Anemia 20 Divya Yadav Sharma, Saroj Singh, Abhilasha Yadav, Asha Nigam, Deepti Tandon, Alok Sharma

Asian Journal of Volume 2, Number 1, January-March 2018

CONTENTS

Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E-219, Greater Kailash, Part-1 New Delhi-110 048 E-mail: editorial@ijcp.com

CASE REPORT

Rare Case Report of Amniotic Band Syndrome

Printed at Bon Graphics, Chennai

Deepika, Taru Gupta, Nupur Gupta

Copyright 2018 IJCP Publications Ltd. All rights reserved. The copyright for all the editorial material contained in journal, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

A Rare Case of Twin Pregnancy in the Noncommunicating Rudimentary Horn of Unicornuate Uterus

Nupur Gupta, Taru Gupta, Deepti Asthana

Editorial Policies The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article. Note: Asian Journal of Obs and Gynae Practice does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature in this issue.

Rupture of Endometriotic Ovarian Cyst Causes Acute Hemoperitoneum in IVF Pregnancy

Atul Ganatra, Vanashri Tatoba Bahade, Uday Kargar

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GM: General Manager Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

FROM THE ISSUE EDITOR

Link Between Saturated Fat Intake and Heart Rate Variability in Women with Polycystic Ovary Syndrome

Dr Alka Kriplani

Professor and Head of Unit II Dept. of Obstetrics and Gynecology AIIMS, New Delhi

study published in the journal of Annals of Nutrition and Metabolism revealed that lower saturated fatty acid intake is associated with improved cardiovascular autonomic function in polycystic ovary syndrome (PCOS). The researchers conducted this study with an aim of evaluating heart rate variability in women with PCOS (n = 84) and control (n = 54), based on the dietary intake of saturated fatty acid. The results demonstrated that body mass index, blood pressure, and HOMA-IR were higher in women with PCOS. Moreover, those with PCOS had higher testosterone, dehydroepiandrosterone sulfate, and free androgen

index, and lower sex hormone-binding globulin levels than controls. The clinical profile and calorie intake were similar between saturated fatty acid categories in both the groups. In PCOS group, testosterone level was lower when saturated fatty acid intake was less than 8.5%. PCOS women with SFA less than 8.5% consumed more beans, fruits, and vegetables. In addition, they had better frequency and time domain heart rate variability indices. On the other hand, in controls, no differences in heart rate variability were identified between saturated fatty acid categories. In PCOS group, age and saturated fatty acid intake were found to be the independent predictors of heart rate variability.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF

Avoid Weight Gain at Younger Age to Stay Healthy in Your Old Age

Dr KK Aggarwal

Group Editor-in-Chief IJCP Group, eMedinewS and eMediNexus

esults of the Chicago Healthy Aging study presented at the recent American Heart Association's (AHA) Epidemiology and Prevention | Lifestyle and Cardiometabolic Health 2017 Scientific Sessions in Portland, Oregon show that significant weight gain over time as well as obesity and overweight in younger age result in poor physical performance in older age. Researchers from Northwestern University in Chicago, Illinois evaluated 1,325 men and women who were initially examined in 1967-73 and then re-examined in 2007-10 in the Chicago Healthy Aging study. The mean age at baseline was 33 years and at followup was 71 years, when muscle strength (hand grip) and performance (4m gait speed and Short Physical Performance Battery [SPPB]) were measured. The short physical performance battery (SPPB) measures static balance, gait speed, and getting in and out of a chair and has been used to monitor function in older people. The scores range from 0 (worst performance) to 12 (best performance). At follow-up, subjects who were initially overweight and had gained the most weight (> 20lbs) were more likely to have a low SPPB score, slow walking speed (gait speed <0.8 m/s), or sex-specific handgrip strength (ORs: 4.55, 4.58, and 1.86, respectively) vs those study participants who had normal weight at baseline with

minimal weight change (-10lbs to 20lbs), independent of other risk factors for cardiovascular disease. Results of this study highlights the fact that prevention is better than cure. And preventive efforts of lifestyle diseases such as heart disease, obesity, type 2 diabetes and osteoporosis should start at a young age. Normal weight obesity is the new epidemic of the society. A person can be obese even if the body weight is within the normal range. An extra inch of fat around the abdomen can increase the chances of heart disease by 1.5 times. A waist circumference of more than 90 cm in men and 80 cm in women increases the risk of future heart attacks. Normal weight obesity is also associated with the same health risks as does somebody who is overweight and obese. Any weight gain after puberty is invariably due to fat. Though the overall weight can be in the acceptable normal range but any weight gain within that range will be abnormal for that person. Therefore, any individual who gains weight of more than 5 kg after the age of 18 years in girls and 20 years in boys is obese and overweight. Any weight gain at this age should be avoided. After the age of 50, the weight should reduce and not increase. To live more than 80 years without lifestyle diseases, keep your abdominal circumference, lower blood pressure, LDL (bad) cholesterol, pulse rate and fasting sugar all lower than 80.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CLINICAL STUDY

Conservative Surgical Techniques in Management of Morbidly Adherent Placenta: A 5-year Study Rekha Rani*, Shikha Singh†, Ruchika Garg*, Urvashi Verma*, Sangeeta Sahu‡, Saroj Singh#, Surendra Kumar¥, Himani Goyel$

ABSTRACT Objectives: To evaluate the role of various conservative surgical techniques in management of morbidly adherent placenta. To estimate the fertility and pregnancy outcomes after successful conservative surgical treatment for placenta accreta. Material and methods: This retrospective study included women with a history of conservative management for placenta accreta. The study was conducted in SN Medical College, Agra from December 2010 to November 2015 (5 years review) on 131 patients. The aim of our study was to estimate the postoperative and future reproductive outcomes after performing various successful conservative surgical techniques in management of morbidly adherent placenta. Results: Compressive sutures, intrauterine packing and vessel embolization, etc. may be considered life-saving procedures by achieving the best hemostatic efficacy. Data on restoration of menses and pregnancy rates after these procedures are limited by short-term follow-up and by the paucity of studies, especially for vascular ligation. Conclusion: Successful conservative treatment for placenta accreta does not appear to compromise the patients’ subsequent fertility or obstetrical outcome. Keywords: Placenta accreta, pelvic vessel embolization, compressive sutures, fertility

lacenta accreta/percreta is a leading cause of third trimester hemorrhage and postpartum maternal death. The current treatment for third trimester hemorrhage due to placenta accreta/percreta is cesarean hysterectomy, which may be complicated by large volume blood loss. The incidence of placenta accreta is increasing parallel with the increase in cesarean delivery.

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Material and Methods Type of Study ÂÂ

This retrospective study was conducted in SN Medical College, Agra from December 2010 to November 2015 (5 years review) on 131 patients.

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The present study was undertaken among all pregnant patients attending OPD and labor room.

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Success of conservative treatment was defined by uterine preservation.

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Data were retrieved from medical files and telephone interviews.

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An informed consent was taken from all women included in the study.

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Thorough history taking, physical examination and investigations were done in all patients.

Aim and Objectives ÂÂ

To evaluate the role of various conservative surgical techniques in management of morbidly adherent placenta.

*Assistant Professor † Associate Professor ‡ Lecturer # Professor and Head ¥ Consultant Anesthesia $ 3rd Year Junior Resident Dept. of Obstetrics and Gynecology, SN Medical College Agra, Uttar Pradesh Address for correspondence Dr Rekha Rani Assistant Professor Dept. of Obstetrics and Gynecology, SN Medical College, Agra - 282 003, Uttar Pradesh E-mail: drrekha.gynae@gmail.com

To estimate the fertility and pregnancy outcomes after successful conservative surgical treatment for placenta accreta.

Inclusion Criteria ÂÂ

Reproductive age group (21-35 years).

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Parity (≤4).

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CLINICAL STUDY ÂÂ

Elective cesarean cases.

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All pregnant patients with placenta previa in previous one or more than one cesarean section.

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Women with a history of conservative management for placenta accreta.

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Patients booked in antenatal period.

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Hemoglobin ≥11 g/dL in elective cases.

Ligation of individual vessels in the placental bed - Simple or box stitches where continuous oozing is present Temporarily packing of uterine segment. The stepwise surgical approach if preservation of fertility is desired

Exclusion Criteria ÂÂ

Age more than 35 years.

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Grand multipara more than 4 children.

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Patients undergoing emergency cesarean section.

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Patients with previous history of scar rupture or dehiscence in which repair of uterus or hysterotomy done.

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Any medical and coagulation disorders (diabetes, epilepsy, heart diseases), history of bronchial asthma.

Placenta

Figure 1. High resolution ultrasound with color Doppler findings at gestational Week 29 consistent with placenta accreta.

Diagnosis For diagnosis, high resolution ultrasound with color Doppler findings at gestational Week 29 consistent with placenta accreta, included irregularly shaped placental lacunae (vascular spaces) within the placenta, thinning of the myometrium overlying the placenta, loss of the retroplacental ‘clear space’, protrusion of the placenta into the bladder, increased vascularity of the uterine serosa bladder interface and turbulent blood flow through the lacunae on Doppler ultrasonography (Fig. 1). Uterine findings during laparotomy included cesarean section scar at uterine fundus and bulging isthmic part with placenta accreta/percreta (Fig. 2). In addition, placenta accreta was seen involving the urinary bladder (Fig. 3 a and b) .

Storm flow

Cesarean section scar

Prominent isthmic portion of uterus

Figure 2. Uterine findings during laparotomy. Note cesarean section scar at uterine fundus and bulging isthmic part with placenta accreta/ percreta.

Procedures There are some basic options for management of placenta accreta: ÂÂ

The cesarean hysterectomy

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Conservative treatment Localized packing of thinned placental site with absorbable gel (Abgel) followed by compression sutures

Figure 3 a and b. Placenta accreta/percreta invading lower uterine segment and bladder.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CLINICAL STUDY B-Lynch and Cho sutures Methotrexate adjuvant treatment to hasten the placental resolution. Whatever the option chosen, when placenta accreta is suspected before delivery in a woman with an anterior placenta previa, it is recommended to perform a vertical fundal uterine incision to avoid the placenta and reduce the risk of massive postpartum hemorrhage (PPH) (Fig. 4).

Placenta accreta

Cesarean Section Hysterectomy Performing a hysterectomy after the birth of the child without attempting removal of the placenta when placenta accreta is strongly suspected antenatally or after an attempted placental removal when the diagnosis of placenta accreta is not made until during delivery. Figure 5 shows opened hysterectomy specimen with placenta previa percreta left in situ.

Figure 5. Hysterectomy specimen opened. Note placenta previa percreta left in situ.

Conservative Treatment This option consists of delivering the child, tie and then cut the umbilical cord at its base to leave the placenta in place adhering either partially or totally to the myometrium, and to close the hysterotomy. Conservative treatment avoids a hysterectomy in about 75-80% of cases, but is associated with a risk of transfusion requirements, infection and severe maternal morbidity. Figure 6 shows image obtained 20 minutes after delivery. It is seen that if the placenta is not dislodged, bleeding does not occur. B-Lynch suture with intrauterine packing may be given to prevent PPH (Fig. 7).

Figure 4. After delivery of baby through vertical fundal uterine incision.

Figure 6. Image obtained 20 minutes after delivery. Note that if the placenta is not dislodged, bleeding does not occur.

Figure 7. B-Lynch suture with intrauterine packing.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CLINICAL STUDY The one step-conservative surgery (Fig. 8 a-c)

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Myometrial reconstruction in two planes

It consists of resecting the invaded area together with the placenta and performing the reconstruction as a one-step procedure. The main stages of this alternative technique achieved through a median or transverse suprapubic incision are:

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Bladder repair if necessary.

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Vascular disconnection of newly-formed vessels and the separation of invaded uterine from invaded vesical tissues

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Performing an upper-segmental hysterectomy

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Resection of all invaded tissue and the entire placenta in one piece with previous local vascular control

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Use of surgical procedures for hemostasis

To cover the uterine defect, a reabsorbable mesh is used. When fixed, it will allow an accurate uterine repair and prevent postoperatory injuries (Fig. 9). Sutures are placed on second layer. Fibrin glue and collagen are placed (Fig. 10). After the second layer has been closed uterine repair is performed (Fig. 11). Under temporary aortic clamping, the placenta is safely removed (Fig. 12). Localized Packing of Thinned Placental Site with Absorbable Gel (Abgel) After delivery of baby and placenta if there is local thinning of uterus with bleeding seen, you have to put Uterus body

Uterus body

Bladder a Absorbable mesh

Figure 9. To cover the uterine defect, a reabsorbable mesh is used. When fixed, it will allow an accurate uterine repair and prevent postoperatory injuries.

Fundal hysterotomy b

Figure 8 a-c. The one step-conservative surgery.

Figure 10. Sutures are placed on second layer. Fibrin glue and collagen are placed.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CLINICAL STUDY some pieces of Abgel to pack the involved area tightly and obliterate the cavity by putting compression sutures.

Follow-up ÂÂ

Full documentation of the case is imperative.

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Careful explanation of events and interventions must be given to the patient and family.

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Caregivers must be available and approachable for questions.

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Implications and recommendations for future pregnancies may be discussed during the postoperative stay and reinforced at the post-discharge visit.

Triple-P procedure Reconstruction of the uterine wall-as a safe and effective alternative to conservative management or peripartum hysterectomy. It involves: ÂÂ

Perioperative placental localization and delivery of the fetus via transverse uterine incision above the upper border of the placenta

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Pelvic devascularization

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Placental nonseparation with myometrial excision.

Main Outcome Measure(s) ÂÂ

Comparison of the effectiveness of conservative surgical techniques, separately or together, with respect to success rate (ability to stop bleeding and preserve the uterus).

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Fertility rate (subsequent pregnancies or the return of regular menstrual cycles).

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Complication rate of the procedure.

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The outcomes of subsequent pregnancies in terms of type of delivery and eventual delivery complications.

Results Follow-up data were available for 96 (73.3%) of the 131 women included in the study (Fig. 13).

Figure 11. After the second layer has been closed uterine repair is performed.

Fundus

Compressive sutures, intrauterine packing and vessel embolization, etc. may be considered life-saving procedures by achieving the best hemostatic efficacy. Data on restoration of menses and pregnancy rates after these procedures are limited by short-term

Round ligament 8- amenorrheic 96 patients

Figure 12. Under temporary aortic clamping, the placenta is safely removed. Through the uterine defect, the surgeon's fingers are clearly seen.

88-normal menses

27-wanted children

6 (placenta accreta) 4 asso. With placenta previa

21-3rd trim preg del healthy baby

3-attempting 24-preg

1ectopic

2miscarriages

4 developed PPH

Figure 13. Follow-up data of 96 of the 131 women included in the study.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CLINICAL STUDY Table 1. Demographic Characteristics at the First Conservative Treatment for the Women Included in the Study and those Lost to Follow-up Demographic characteristics

Women included in the study (n = 96)

Women lost to follow-up (n = 35)

P value

Age (years)

33.3 ± 4.6

32.5 ± 5.2

0.38

Parity

1 (0-8)

0 (0-5)

0.80

Number of pregnancies

3 (1-12)

3 (1-11)

0.82

Table 2. Obstetrical Characteristics at the First Conservative Treatment for the Women Included in the Study and those Lost to Follow-up Obstetrical characteristics

Women included in the study (n = 96)

Women lost to follow-up (n = 35)

P value

5 (5.2)

5 (14.3)

0.13

Gestational age at delivery (week)

33.9 ± 5.2

35.0 ± 4.4

0.27

Cesarean section

74 (77.1)

29 (82.9)

0.63

Placenta left entirely in situ

35 (36.4)

13 (37.1)

>0.99

Primary PPH*

41 (42.7)

15 (42.9)

>0.99

Additional uterine devascularization procedure†

66 (68.8)

21 (60.0)

0.40

Transfusion patients

30 (31.2)

9 (25.7)

0.67

Transfer to ICU

15 (15.6)

8 (22.3)

0.44

23 (24.0)

8 (22.3)

>0.99

1 (1.0)

>0.99

Placenta percreta

Infection

‡

Severe maternal morbidity

Data are mean ± SD, n (%) or median (range). *Primary PPH was defined as bleeding requiring medical or interventional treatment in the 24 hours after delivery. Uterine devascularization procedures included pelvic arterial embolization, surgical vessel ligation (uterine or hypogastric artery ligation, stepwise uterine devascularization) and/or uterine compression sutures (B-Lynch and Cho sutures). †

‡ Infection included endometritis, wound infection, peritonitis, pyelonephritis, vesicouterine fistula, uterine necrosis and isolated postpartum fever higher than 38.5°C for 24 hours.

Severe maternal morbidity was defined as any of the following: sepsis, septic shock, peritonitis, uterine necrosis, postpartum uterine rupture, fistula, injury to adjacent organs, acute pulmonary edema, acute renal failure, deep vein thrombophlebitis or pulmonary embolism, or maternal death.

follow-up and by the paucity of studies, especially for vascular ligation.

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Transfusion reactions.

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Demographic and obstetrical characteristics at the first conservative treatment for the women included in the study and those lost to follow-up is given in Table 1 and 2.

Other complications accompanying blood transfusion (human immunodeficiency virus [HIV] and hepatitis).

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Surgical complications (emergency hysterectomy, bowel injury, urological injuries, etc.).

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Pulmonary embolism.

Complications

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Adult respiratory distress syndrome (ARDS).

Immediate

Delayed ÂÂ

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Hemorrhage (3,000-5,000 mL).

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Disseminating intravascular coagulation (DIC).

Hypopituitarism following severe PPH (Sheehan syndrome) is due to critical ischemia of the hypertrophied pituitary.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CLINICAL STUDY ÂÂ ÂÂ

Complications like sterility, uterine perforation, uterine synechiae (Asherman syndrome). Venous thrombosis and embolic events.

Discussion Our results suggest that successful conservative treatment for placenta accreta does not appear to compromise women’s subsequent fertility or obstetric outcome, but that the risk of recurrence of placenta accreta during future deliveries is high. An additional strength is the systematic follow-up of a relatively large cohort (n = 96), including evaluation of desire and attempts to conceive, in order to obtain information about women with presumed preserved fertility who either had no desire for pregnancy, or did desire pregnancy but have not become pregnant. Their demographic and obstetric characteristics for the first conservative treatment did not differ from those of women who were included in the study. It is possible that some women did not actually have placenta accreta; pathological confirmation is of course impossible after successful conservative treatment (i.e., in cases without a hysterectomy specimen). Nevertheless, our results reflect the long-term consequences in real-life of conservative treatment for placenta accreta. Placenta accreta is thought to be due to an absence or deficiency of Nitabuch’s layer or the decidua spongiosa, following the failure of the endometrium/decidua basalis to re-form after trauma to the endometrium from surgical procedures. The pathophysiology of placenta accreta is therefore similar to that of intrauterine synechiae, based as it is on endometrial alteration that might promote abnormal implantation, resulting in infertility, miscarriage or recurrent placenta accreta. Our results are therefore reassuring in suggesting that successful conservative treatment for placenta accreta does not appear to compromise the patients’ subsequent fertility or obstetrical outcome. The absence of pregnancy complications observed in our study, except for abnormal placentation and PPH, is consistent with the few previous reports on pregnancy after conservative treatment for placenta accreta. Four earlier studies report similar results: women with a history of severe PPH requiring pelvic arterial embolization and/or uterine-sparing surgical procedures are likely to decide against another pregnancy because of their fear of another hemorrhage.

Conclusions Successful conservative treatment for placenta accreta does not appear to compromise the patients’ subsequent fertility or obstetrical outcome. Nevertheless, patients should be advised of the high-risk that placenta accreta may recur during future pregnancies. Intrauterine packing, pelvic vessel embolization and compressive sutures are associated with high rates of restoration of regular menses and successive pregnancies. Randomized trials would be desirable to define the best management of PPH. A review of the literature demonstrates a 76.9% success rate and an 11% complication rate. Suggested Reading 1. AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol. 1994;171(3):694-700. 2. Alanis M, Hurst BS, Marshburn PB, Matthews ML. Conservative management of placenta increta with selective arterial embolization preserves future fertility and results in a favorable outcome in subsequent pregnancies. Fertil Steril. 2006;86(5):1514.e3-7. 3. Committee on Obstetric Practice. ACOG committee opinion. Placenta accreta. Number 266, January 2002. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 2002;77(1):77-8. 4. Bretelle F, Courbière B, Mazouni C, Agostini A, Cravello L, Boubli L, et al. Management of placenta accreta: morbidity and outcome. Eur J Obstet Gynecol Reprod Biol. 2007; 133(1):34-9. 5. Daskalakis G, Anastasakis E, Papantoniou N, Mesogitis S, Theodora M, Antsaklis A. Emergency obstetric hysterectomy. Acta Obstet Gynecol Scand. 2007;86(2):223-7. 6. Eller AG, Porter TF, Soisson P, Silver RM. Optimal management strategies for placenta accreta. BJOG. 2009; 116(5):648-54. 7. Kayem G, Pannier E, Goffinet F, Grangé G, Cabrol D. Fertility after conservative treatment of placenta accreta. Fertil Steril. 2002;78(3):637-8. 8. Kayem G, Davy C, Goffinet F, Thomas C, Clément D, Cabrol D. Conservative versus extirpative management in cases of placenta accreta. Obstet Gynecol. 2004;104(3): 531-6. 9. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol. 1997;177(1):210-4.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CLINICAL STUDY 10. Nizard J, Barrinque L, Frydman R, Fernandez H. Fertility and pregnancy outcomes following hypogastric artery ligation for severe post-partum haemorrhage. Hum Reprod. 2003;18(4):844-8. 11. Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol. 2006;107(4):927-41. 12. Salomon LJ, deTayrac R, Castaigne-Meary V, Audibert F, Musset D, Ciorascu R, et al. Fertility and pregnancy outcome following pelvic arterial embolization for severe post-partum haemorrhage. A cohort study. Hum Reprod. 2003;18(4):849-52. 13. Sentilhes L, Trichot C, Resch B, Sergent F, Roman H, Marpeau L, et al. Fertility and pregnancy outcomes following uterine devascularization for severe postpartum haemorrhage. Hum Reprod. 2008;23(5):1087-92. 14. Sentilhes L, Gromez A, Razzouk K, Resch B, Verspyck E, Marpeau L. B-Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization. Acta Obstet Gynecol Scand. 2008;87 (10):1020-6. 15. Sentilhes L, Gromez A, Descamps P, Marpeau L. Why stepwise uterine devascularization should be the first-line conservative surgical treatment to control severe

postpartum hemorrhage? Acta Obstet Gynecol Scand. 2009a;88:490-2. 16. Sentilhes L, Gromez A, Clavier E, Resch B, Verspyck E, Marpeau L. Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage. Obstet Gynecol. 2009;113(5):992-9. 17. Sentilhes L, Ambroselli C, Kayem G, Provansal M, Fernandez H, Perrotin F, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526-34. 18. Sentilhes L, Gromez A, Clavier E, Resch B, Verspyck E, Marpeau L. Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage. BJOG. 2010;117(1):84-93. 19. Sentilhes L, Descamps P, Marpeau L. Has B-Lynch suture hidden long-term effects? Fertil Steril. 2010;94(4):e62. 20. Tseng JJ, Hsu SL, Wen MC, Ho ES, Chou MM. Expression of epidermal growth factor receptor and c-erbB-2 oncoprotein in trophoblast populations of placenta accreta. Am J Obstet Gynecol. 2004;191(6):2106-13. 21. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol. 2005;192(5):1458-61.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

REVIEW ARTICLE

Analysis of Cesarean Section in a Tertiary Care Center: A Retrospective Study Gurdip Kaur*, Parmjit Kaur†, Ruby Bhatia*, Satinder Kaur‡, Ramiti Gupta#, Aman Dev¥

ABSTRACT Objective: The aim of the study was to assess the prevalence and different indications of cesarean delivery in a tertiary care center. Material and methods: The present study was a retrospective study conducted in Dept. of Obstetrics and Gynecology, Government Medical College and Rajindra Hospital, Patiala from January 2016 to June 2016. Results: A total of 1,656 births occurred during this period, out of these 718 were by cesarean section. Thus, prevalence of cesarean section was 43.36% during the given period of study in our institution. Most of the cesarean deliveries were referrals (76.1%) done in emergency and not booked at our institute. It was seen that 67.9% of women were in 21-30 years age group, 29% were between 31-40 years, while only 3.06% were less than 20 years of age. Also, 52.78% were between gravida 2-4, while 44.29% were primigravida and only 2.92% pregnant women were grand multipara. Majority were primary cesarean deliveries (64.62%), while 35.38% were secondary cesarean sections. Commonest indication of cesarean delivery was previous one cesarean section in 27.3% followed by fetal distress in 17.27%. However, commonest indication in primigravida was fetal distress (27.99%). Cesarean section due to previous 2 or more cesarean section was done in 8.08%, while in 7.66% it was done for cephalopelvic disproportion. Conclusion: Prevalence of cesarean section was 43.36%. Commonest indication of cesarean delivery was previous one cesarean section in 27.3% followed by fetal distress in 17.27%. Keywords: Cesarean delivery, indication, prevalence, trial of labor after cesarean delivery, vaginal delivery

regnancy and delivery are considered normal physiological phenomena in women but still childbirth by its very nature carries potential risk for both the woman and her baby. Advancement in healthcare system and access to medical facilities has greatly reduced the maternal and perinatal mortality due to complications of pregnancy and childbirth. Cesarean section is the surgical intervention in serious delivery complications and has been lifesaving for

*Associate Professor † Professor ‡ Assistant Professor # Postgraduate Student Dept. of Obstetrics and Gynecology ¥ Postgraduate Student Dept. of Preventive and Social Medicine Govt. Medical College and Rajindra Hospital, Patiala, Punjab Address for correspondence Dr Ramiti Gupta Postgraduate Student Dept. of Obstetrics and Gynecology Rajindra Hospital, Patiala, Punjab E-mail: gupta.ramiti@gmail.com

a long period of time. In the past century, the most common change in obstetric practice that has came, is the increase in cesarean delivery rate, to ensure a healthy outcome of the mother and newborn. According to World Health Organization (WHO), cesarean section rates should not be more than 15%1 (with evidence that cesarean section rates above 15% are not associated with additional reduction in maternal and neonatal mortality and morbidity).2 But, both in developed and developing countries, cesarean section rate is on the rise. In 2011, one in 3 women who gave birth in United States did so by cesarean section. The advent of better anesthesia, availability of improved surgical technique and prophylactic antibiotics have made cesarean section, a relatively safer and common procedure. The study aims at analyzing the incidence and indications of cesarean section performed in a tertiary care center over a period of 6 months. Material and Methods It is a retrospective study conducted in Dept. of Obstetrics and Gynecology, Government Medical College and Rajindra Hospital, Patiala, a tertiary care hospital.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

REVIEW ARTICLE The study period was from January 2016 to June 2016. A total of 718 cesarean deliveries were analyzed from data on case sheets. Data collected included the age, parity, booked or unbooked cases, elective or emergency procedure and indications of cesarean section.

Table 3b. Sociodemographic Characteristics (Total Cesarean Deliveries 718 = 100%) Age distribution (years)

No. of cases

Percentage (%)

<20

3.06

21-30

488

67.9

31-40

208

Results and Observations A total of 1,656 women delivered during the study period, of which 718 had undergone cesarean section (Table 1). The prevalence of cesarean section at our hospital comes to be around 43.36% during the study period. Out of these, 125 patients (17.4%) had elective cesarean deliveries, while 593 (82.6%) had emergency cesarean deliveries (Table 2). Majority of the patients, 546 in number (76.1%) were unbooked, while only 172 (23.9%) were booked (Table 3a). Demographic analysis showed maximum number of patients i.e., 488 cases (67.9%) were between 21-30 years. Those less than 20 and more than 30 years were 22 (3.06%) and 208 (29%), respectively (Table 3b). Out of 718, 318 patients (44.29%) were primi and 379 patients (52.78%) were G2-G4, while 21 patients (2.92%) were grand multipara (Table 3c). Table 1. Proportion of Cesarean Deliveries (Total Births 1,656 = 100%) No. of cases

Percentage (%)

Deliveries by cesarean section

718

43.36

Vaginal deliveries

938

56.64

Total deliveries

1,656

100

Table 2. Proportion of Elective/Emergency Cesarean Deliveries (Total Cesarean Deliveries 718 = 100%) No. of cases

Percentage (%)

Elective cesarean section

125

17.4

Emergency cesarean section

593

82.6

Total cesarean sections

718

100

Table 3a. Sociodemographic Characteristics (Total Cesarean Section 718 = 100%)

No. of cases

Percentage (%)

Booked

172

23.9

Unbooked

546

76.1

Table 3c. Sociodemographic Characteristics (Total Cesarean Deliveries 718 = 100%) Parity

No. of cases

Percentage (%)

Primi

318

44.29

G2-G4

379

52.78

>G4

2.92

Table 4. Proportion of Primary/Repeat Cesarean Section (Total Cesarean Deliveries 718 = 100%) No. of cases

Percentage (%)

Primary cesarean deliveries

464

64.62

Repeat cesarean deliveries

254

35.38

Detailed analysis of cases showed that number of patients who underwent primary section were 464 (64.62%) and repeat cesarean were 254 (35.38%) (Table 4). Table 5 showing the indications of cesarean deliveries reveals that overall the commonest indication for cesarean delivery was previous one cesarean section (27.3%) followed by fetal distress (17.27%). Previous two or more cesarean section (8.08%) and cephalopelvic disproportion (7.66%) were next common indications. Table 6 shows that the commonest indication for cesarean section among primigravida was fetal distress (27.99%) and among multigravida patients was previous one cesarean section (49%). Discussion Prevalence rate of cesarean deliveries at our center during the study period was 43.36%, as it is a tertiary care hospital catering to all high risk referred cases. The increase in LSCS rate has been a global phenomenon. There has been a steady increase in the rate of lower segment cesarean section (LSCS) in both developed and developing countries. LSCS rate in USA was 32% in 2014,3 while it was 26.2%

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

REVIEW ARTICLE Table 5. Indications for Cesarean Deliveries (Total = 100%) Indication of cesarean section

No. of cases among primi patients (total = 318)

No. of cases among multi patients (total = 400)

Total no. of cases (718)

Total % (100%)

Emergency no. of cases (total = 593)

Elective no. of cases (total = 125)

196

27.3

150

124

17.27

124

8.08

Previous one cesarean section Fetal distress

Previous 2 or more cesarean sections CPD

7.66

Breech presentation

7.1

Severe pre-eclampsia

6.68

Obstructed labor

4.32

Nonprogress of labor

4.04

Eclampsia

3.34

Placenta previa

3.34

IUGR

2.65

Abruptio placenta

2.51

Malpresentations other than breech

2.51

Multiple pregnancy

1.11

Failed induction

0.84

Medical disorders complicating pregnancy

0.69

Cervical dystocia

0.56

CPD = Cephalopelvic disproportion; IUGR = Intrauterine growth restriction.

Table 6. Commonest Indication for Cesarean Delivery in Primigravida/Multigravida (Primigravida 318 = 100%, Multigravida 400 = 100%) Parity

Total no. of cesarean sections N (%)

Most common indication

No. of cases with this indication

Percentage (%)

Primigravida

318 (100)

Fetal distress

27.99

Multigravida

400 (100)

Previous one cesarean section

196

during (2013-2014) in England.4 Haider et al from Hyderabad-Pakistan and Shamshad from Abbottabad reported cesarean section rate as high as 67.7% and 45.1% in 2007, respectively.5,6 Prevalence of repeat cesarean deliveries was 35.38%, while primary cesarean was done in 64.62%. In our study, previous 1 cesarean section accounted for 27.3% and previous

2 or more cesarean sections accounted for 8.08% of cases. Repeat sections, constitute the commonest indication for LSCS in most countries. It varies from 35% of all LSCS in the USA to 23% in Norway, the lowest 18% being in Hungary.7 After 1 LSCS, there is 67% chance of having repeat cesarean delivery.8 The low threshold for performing vaginal birth after

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

REVIEW ARTICLE cesarean (VBAC) delivery is probably due to fear of uterine rupture in labor, which is 5.2/1,000 for VBAC as compared to 1.6/1,000 elective repeat cesarean deliveries (ERCD) and it can be catastrophic leading to perinatal death (1/2,000) and very rarely maternal death.9-11 High prevalence of repeat cesarean deliveries in our study is because of unbooked emergency admissions in labor with multiple high risk factors. In our study, trial of labor after cesarean (TOLAC) delivery was given very judiciously as many patients had more than one risk factors and were not having records and of previous LSCS so were not candidates for TOLAC delivery. We are working on this group to decrease the rate of repeat cesarean deliveries. In our setup, no trial for vaginal delivery was given to previous two or more cesarean deliveries due to presumed risk of maternal and fetal complications.12 Fetal distress was the second most common indication (17.27%) of LSCS. Strengthening of staff, availability of round the clock nurse and doctor and better facilities (cardiotocography, electronic fetal monitor) has made the detection of fetal distress possible at the earliest. Computerized interpretation of cardiotocography or use of scalp pH can be applied to definitely diagnose distress, which could save a few cesarean sections.13 Breech presentation, as indication for cesarean delivery, accounted for 7.1% cases, which is higher than the average incidence of breech at term. This might be due to higher referral from periphery after diagnosing malpresentation. More skills in vaginal assisted breech delivery should be practiced and breech presentation with favorable Zatuchni-Andros score may be given trial of vaginal delivery. Severe pre-eclampsia accounted for significant proportion of cesarean deliveries (6.68%) indicating the need for early detection and so better control of pre-eclampsia before it progresses to severe pre-eclampsia leading to intrauterine growth restriction (IUGR) and eclampsia, both of which accounted for 2.65% and 3.34% of cesarean deliveries, respectively. Nonprogress of labor was another major indication contributing 4.04% of cesarean deliveries. Failure to progress is an ill-defined terminology, arrest of dilatation or arrest of descent are often over diagnosed. We used partogram to definitely diagnose nonprogress of labor, which helped us to reduce cesarean deliveries. 18

Different studies from India showed incidence of emergency cesarean deliveries to be 82.7% and 85.92%.14 In our study, we found 83.94% cases underwent emergency cesarean delivery, corroborating with previous studies as ours is a tertiary care referral institute. The high cesarean section rate in our study was because of the fact that majority of the pregnant women were referred with more than one high risk factor from peripheral public and private hospitals of rural and urban Patiala district and adjoining states. Conclusion Though cesarean delivery is becoming increasingly safer due to improved surgical technique and modern anesthetic skill, it still carries a slightly greater risk than normal vaginal delivery and the risk is more in subsequent pregnancies. Attempt should be made to decrease the rate of primary cesarean deliveries and judicious use of trial of labor after cesarean delivery should be used to decrease rate of repeat cesarean deliveries. In subsequent pregnancies, risks can be decreased by providing regular antenatal care and doing elective repeat cesarean deliveries if the indications are recurrent ones.15 References 1. World Health Organization. Monitoring Emergency Obstetric Care: A Handbook. Geneva, Switzerland; 2009. 2. Althabe F, BelizĂĄn JM. Caesarean section: the paradox. Lancet. 2006;368(9546):1472-3. 3. Hamilton BE, Martin JA, Osterman MJK, Curtin SC. Births: Preliminary data for 2014. Hyattsville, MD: National Center for Health Statistics. National Vital Statistics Reports. 2015;64:66. 4. Health and Social Care Information Centre (2015). NHS Maternity Statistics â&#x20AC;&#x201C; England, 2013-2014. Available at: http://www.hscic.gov.uk/catalogue/PUB16725/nhs-mateeng-2013-14-summ-repo-rep.pdf 5. Haider G, Zehra N, Munir AA, Haider A. Frequency and indications of cesarean section in a tertiary care hospital. Pak J Med Sci. 2009;25(5):791-6. 6. Shamshad. Factors leading to increased caesarean section rate. Gomal J Med Sci. 2008;(1):1-5. 7. Magann EF, Winchester MI, Carter DP, Martin JN Jr, Bass JD, Morrison JC. Factors adversely affecting pregnancy outcome in the military. Am J Perinatol. 1995;12(6):462-6.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

REVIEW ARTICLE 8. Thomas J, Paranjothy S. Royal College of Obstetricians and Gynaecologists. Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press; 2001. 9. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med. 2001;345(1): 3-8. 10. Mozurkewich EL, Hutton EK. Elective repeat cesarean delivery versus trial of labor: a meta-analysis of the literature from 1989 to 1999. Am J Obstet Gynecol. 2000;183(5):1187-97. 11. Rageth JC, Juzi C, Grossenbacher H. Delivery after previous cesarean: a risk evaluation. Swiss Working Group

of Obstetric and Gynecologic Institutions. Obstet Gynecol. 1999;93(3):332-7. 12. Nizam K, Haider G, Memon N, Haider A. A caesarean section rates much room for reduction. Rawal Med J. 2010;35:19-2. 13. Chanthasenanont A, Pongrojpaw D, Nanthakomon T, Somprasit C, Kamudhamas A, Suwannarurk K. Indications for cesarean section at Thammasat University Hospital. J Med Assoc Thai. 2007;90(9):1733-7. 14. Pardey JS, Jain M, Pandy LK. Ten years profile of LSCS. J Obstet Gynaecol India. 1986;36:448. 15. Nahar K. Indications of caesarean section - study of 100 cases in Mymensingh Medical College Hospital. J Shaheed Suhrawardy Med Coll. 2009;1(1):6-10.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

REVIEW ARTICLE

A Comparative Study Between Oral Iron, Intravenous Iron Sucrose and Ferric Carboxymaltose in the Management of Postpartum Anemia Divya Yadav Sharma*, Saroj Singhâ&#x20AC; , Abhilasha Yadav, Asha Nigam, Deepti Tandon, Alok Sharma

ABSTRACT Introduction: Parenteral iron helps to restore iron stores faster and more effectively than oral iron. Intravenous (IV) iron sucrose is safe, effective and economical in comparison to oral iron. IV ferric carboxymaltose (FCM) has a neutral pH, physiological osmolarity, is dextran free, which makes it possible to administer its higher single doses over shorter time periods. Material and methods: A total of 90 postnatal women were randomly categorized in three groups of 30 each to receive oral iron (ferrous sulfate) equivalent to elemental iron 100 mg daily (Group I), IV iron sucrose (Group II) or IV FCM (Group III) after calculating their doses. Changes in hemoglobin (Hb) and serum ferritin levels after 1 week and after 4 weeks of treatment were measured. Results: In our study, an increase in 0.8 g/dL was achieved in 4 weeks of oral iron therapy; an increase of 1.4 and 2.1 g/dL was seen at the end of 1 week and 4 weeks, respectively of IV iron sucrose, which was significant (p < 0.0001); an increase of 2.5 g/dL and 4.9 g/dL was observed after 1 week and 4 weeks of IV FCM, which was again significant (p < 0.0001). Conclusion: Intravenously administered iron elevates serum Hb and restores iron stores better that oral iron (ferrous sulfate). Both drugs are effective and offer a rapid normalization of Hb after delivery. The single administration of FCM shows advantages of lower incidence of side effects at the injection site, a shorter treatment period and better patient compliance. Keywords: Ferric carboxymaltose, iron sucrose, intravenous, postpartum anemia

he World Health Organization (WHO) has defined postpartum anemia (PPA) as hemoglobin (Hb) <10 g/dL in postpartum period. PPA may aggravate puerperal sepsis, thromboembolic complications and lead to subinvolution of uterus, delayed wound healing and failure of lactation. It is associated with an impaired quality-of-life, lactation failure, reduced cognitive abilities, emotional instability and depression. Oral iron therapy was conventionally the treatment of choice but it has disadvantages. Parenteral iron helps to restore iron stores faster and more effectively than oral iron. Intravenous (IV) iron sucrose is safe, effective and economic in comparison to oral and repeated, painful intramuscular iron injections; however, multiple doses and hospital visits are typically required. IV ferric carboxymaltose (FCM)

*Lecturer â&#x20AC; Professor and Head (Principal) Dept. of Obstetrics and Gynecology SN Medical College, Agra, Uttar Pradesh Address for correspondence Dr Divya Yadav Sharma Lecturer SN Medical College, Agra, Uttar Pradesh

has a neutral pH, physiological osmolarity, is dextran free, which makes it possible to administer its higher single doses over shorter time periods. Iron is released slowly thereby reducing toxicity and oxidative stress. The objective of the present study was to compare the safety and efficacy of FCM, and IV iron sucrose in the treatment of PPA. Material and Methods This randomized control trial was carried out in the Dept. of Obstetrics and Gynecology, SN Medical College, Agra from July 2015 to February 2016. After informed, written consent and attaining permission from Ethical Committee, a total of 90 postnatal women, diagnosed as cases of iron deficiency anemia (IDA) (Hb <8 g/dL), were randomly categorized in three groups of 30 each to receive oral iron (ferrous sulfate) equivalent to elemental iron 100 mg daily (Group I), IV iron sucrose (Group II) or IV FCM (Group III). Patients with types of anemia other than IDA and known hypersensitivity to iron were excluded from the study. Detailed history of age, parity, socioeconomic status, type of delivery, obstetric complications like pregnancy-induced hypertension (PIH), postpartum hemorrhage (PPH), history of blood

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

REVIEW ARTICLE transfusions, etc. were obtained. Patients were examined in detail and initial Hb, serum ferritin, iron studies and peripheral smear to diagnose the type of anemia was done in all patients. Changes in Hb and serum ferritin levels after 1 week and after 4 weeks of treatment were measured. The adverse effects to drugs in the three groups were noted and treated. The cumulative dose required for Hb restoration and repletion of iron stores was calculated by Ganzoni formula: Cumulative iron deficit (mg) = 2.4 × W × D + 500, Where W= body weight in kg, D = Target Hb - Actual Hb. 2.4 derived from blood volume, which is 7% of body weight and iron content of Hb, which is 0.34%. 0.07 × 0.0034 × 100 = 2.4 (conversion from g/dL to mg). ÂÂ

In patients receiving iron sucrose, 200 mg of elemental iron diluted in 100 mL saline, was the maximum dose given in 30 minutes period, on alternate days, when necessary.

Table 1. Patient Profile Parameters

Mean age (years) Mean BMI

Oral iron (Group I)

Iron sucrose (Group II)

FCM (Group III)

24.5

23.6

24.9

21.3

22.3

23.1

Class III

Mean parity

2.6

3.1

2.9

Presence of antenatal anemia (%)

67.9

Percentage of LSCS (%)

17.7

18.8

History of PPH (%)

PIH (%)

Socioeconomic status

BMI = Body mass index; LSCS = Lower segment cesarean section; PPH = Postpartum hemorrhage; PIH = Pregnancy-induced hypertension.

ÂÂ

In patients receiving FCM, maximum single dose of 1,000 mg (20 mL), diluted in 250 mL saline, infused in 15 minutes, not more than once a week.

Observations and Results The mean age and body mass index (BMI) in the three groups were comparable i.e., 24.5 years, 23.6 years, 24.9 years and mean BMI was 21.3, 22.3, 23.1 in the oral iron, iron sucrose and FCM group, respectively. All the patients belonged to Class III socioeconomic status, according to BJ Prasad Classification. The mean parity was 2.6, 3.1 and 2.9 in the three groups. Antenatal anemia was present in 68% patients in Group I, 69% cases in Group II and 67.9% cases in Group III. The percentage of cesarean section was 20%, 17.7% and 18.8% in Group I, Group II and Group III, respectively. Thirty-one percent patients in Group I, 33% cases in Group II and 36% cases in Group III had history of PPH of any cause in this delivery. Twenty-eight percent patients in Group I, 32% patients in Group II and 27% patients in Group III had a history of PIH (Table 1). Table 2 shows the comparison of initial Hb and rise of Hb after 1 week and after 4 weeks. The mean initial Hb was similar in all the three groups i.e., 7.1 g/dL, 7.1 g/dL and 7 g/dL in Group I, Group II and Group III, respectively. After 1 week of treatment, the Hb rose to 7.2 g/dL, 8.5 g/dL and 9.4 g/dL in Group I, II and III, respectively. After 4 weeks, the Hb rose to 7.9 g/dL, 10.6 g/dL and 11.9 g/dL in Group I, Group II and Group III, respectively. Table 3 shows the mean difference of Hb. The mean difference of Hb from initial to 1 week was 0.1 g/dL, 1.4 g/dL and 2.4 g/dL in Group I, Group II and Group III, respectively. The difference of Hb from 1 week to 4 weeks of treatment was 0.7 g/dL, 2.1 g/dL and 2.5 g/dL in Group I, Group II and Group III, respectively. After 4 weeks, the difference of Hb from initial level (i.e., 0-4 weeks) was 0.8 g/dL, 3.5 g/dL and 4.9 g/dL in Group I, Group II and Group III, respectively. Table 4

Table 2. Comparison of Mean Hemoglobin with Different Iron Preparations Time period

Oral iron (Group I)

Iron sucrose (Group II)

FCM (Group III)

Day 0 (g/dL)

7.1

After 1 week (g/dL)

7.2

8.5

9.4

After 4 weeks (g/dL)

7.9

10.6

11.9

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

REVIEW ARTICLE shows the comparison of mean initial ferritin levels and rise of ferritin after 1 week and after 4 weeks. The mean initial ferritin was similar in all the three groups i.e., 35 ng/mL, 36 ng/mL and 35 ng/mL in Group I, Group II and Group III, respectively. After 1 week of treatment, the ferritin levels rose to 43 ng/mL, 122 ng/mL and 143 ng/mL in Group I, Group II and Group III, respectively. After 4 weeks, the ferritin levels rose to 52 ng/mL, 156 ng/mL and 164 ng/mL in Group I, Group II and Group III, respectively. Table 5 shows the side effect profile of the different iron preparations. It was observed that most common side effect with oral iron was constipation, nausea and vomiting. Eight had diarrhea and 6 had abdominal pain; while few patients (2 each) had headache, joint pain and tingling sensation. In the patients receiving Table 3. Comparison of Rise in Mean Hb Difference of Hb at

Oral iron (Group I)

Iron sucrose (Group II)

FCM (Group III)

0-1 week (g/dL)

0.1

1.4

2.4

1-4 weeks (g/dL)

0.7

2.1

2.5

0-4 weeks (g/dL)

0.8

3.5

4.9

Table 4. Mean Ferritin Levels Time period

Oral iron Iron sucrose FCM (Group I) (Group II) (Group III)

Day 0 (ng/mL)

After 1 week (ng/mL)

122

143

After 4 weeks (ng/mL)

146

164

Table 5. Side Effects of Different Iron Preparations Drug-related adverse effects

Adverse effects

Oral iron (n = 30)

Iron sucrose (n = 30)

FCM (n = 30)

Injection site pain

Headache

Nausea/vomiting

Constipation

Sensation of heat

Shivering

Diarrhea

Abdominal pain

Joint pain

Tingling sensation

iron sucrose, maximum patients i.e., 9 had injection site pain, 7 had tingling sensation, 6 had joint pain, 3 had headache, nausea/vomiting and 2 each had shivering of heat sensation and abdominal pain. Those receiving FCM, maximum patients i.e., 10 had injection site pain, 5 had tingling sensation, 2 each had joint pain and headache. Discussion Postpartum anemia imposes a substantial disease burden during a critical period of maternal-infant interaction and may give rise to lasting developmental deficits in infants of the affected mothers. IDA is the most common cause of anemia world-wide. Each mL blood loss results in loss of 0.5 mg of iron. This study was conducted to compare the safety and efficacy of IV FCM, IV iron sucrose and oral iron in the treatment of PPA. This comparative study was conducted in SN Medical College, Agra on 90 patients of PPA. Patients were equally divided in three groups and were given 100 mg oral iron daily or IV iron sucrose or FCM after calculating their dose. It was observed that maximum patients in the study were parous and belonged to Class III socioeconomic status because anemia mainly affects low income parous women. More than half of the patients were already anemic in their antenatal period because antenatal anemia is a risk factor of PPA. Other risk factors of PPA are PPH and PIH, which was present in many patients in our study. The initial Hb was comparable in all the three groups. Various studies had reported increase of Hb level by 2-3 g/dL within 4-12 weeks of oral iron therapy (Table 6). In our study, an increase of 0.8 g/dL was achieved in 4 weeks of oral iron. Giannoulis et al reported an increase of Hb by 4-6 g/dL in patients receiving iron sucrose, whereas in our study an increase of 1.4 and 2.1 g/dL is seen at the end of 1 week and 4 weeks, respectively, which was significant (p < 0.0001). Rathod et al reported an increase of Hb 2.4 g/dL and 3.4 g/dL after 2 weeks and 6 weeks of iron sucrose, respectively. Van Wyck et al reported an increase of Hb by 2 g/dL in 7 days and 3 g/dL in 2-4 weeks, while Rathod et al reported an increase of Hb 3.2 g/dL and 4.4 g/dL after 2 weeks and 6 weeks, respectively in patients receiving FCM. Similarly, in our study, an increase of 2.5 g/dL and 4.9 g/dL was

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

REVIEW ARTICLE Table 6. Comparison of Our Study with Various Other Studies Done in the Past Study

Time (weeks) period

Rise of Hb (g/dL) Iron sucrose

FCM

Rise in serum ferritin by FCM (ng/mL)

Van Wyck et al

Seid et al Rathod et al

4 6 2

2.4

3 3 3.2

238

6 1 4 1

3.4

4.4

Breymann et al Giannoulis et al Our Study

4-6 1.4

2.4

143

3.5

4.9

184

568

observed after 1 week and 4 weeks of FCM, which was again significant (p < 0.0001). Seid et al reported that ferritin levels replenished in 42 days in FCM group but not in oral iron group, similar to our study in which there is only minimal rise of ferritin in oral iron group. Adverse reactions do occur with various iron therapies. Gastrointestinal disorders are the most common with various oral iron preparations. This led to poor compliance among these patients. The incidence of adverse effects reported by various studies is between 6.8% and 24.2%. The adverse drug reactions were least in the parenteral preparations (p < 0.0001). Few patients (9 in Group II and 10 in Group III), had injection site pain, which subsided by itself after discontinuation of the drug. Some patients in IV iron group had joint pain, tingling sensation, which too subsided by itself. Patient satisfaction and general well-being was highest in subjects treated with FCM followed by iron sucrose and lastly with oral iron. The incidence of adverse effects reported by various studies is between 6.8% and 24.2%. Aggarwal reported fever, arthritis, dysgeusia and anaphylaxis Grade I in patients receiving iron sucrose therspy. In our study, 30% had injection site pain and 20% had tingling sensation in patients receiving iron sucrose and FCM. All patients made an uneventful recovery after receiving treatment in the form of analgesics. Conclusion The prophylaxis of PPA should begin early in pregnancy in order to ensure a good iron status prior

to delivery and preventing further PPA. In India, 36% of total maternal deaths are attributable to PPH or anemia. IV FCM is as safe as iron sucrose in the management of postpartum IDA despite five times of higher dosage. Both iron sucrose and FCM are a safe and effective treatment option for PPA, but the ability to administer 1,000 mg doses in a single sitting, fewer adverse reactions and better compliance makes FCM, the first-line drug in the management of postpartum IDA, causing a faster and higher replenishment of iron stores and correction of Hb levels. So, we conclude that, intravenously administered iron elevates serum Hb and restores iron stores better than oral iron (ferrous sulfate). Both drugs are effective and offer a rapid normalization of Hb after delivery. The single application of FCM shows advantages of lower incidence of side effects at the injection site, a shorter treatment period and better patient compliance. Out of the two different IV iron preparations used in this study, FCM proved to be statistically better than iron sucrose. Suggested Reading 1. Sutherland T, Bishai DM. Cost-effectiveness of misoprostol and prenatal iron supplementation as maternal mortality interventions in home births in rural India. Int J Gynaecol Obstet. 2009;104(3):189-93. 2. Giannoulis C, Daniilidis A, Tantanasis T, Dinas K, Tzafettas J. Intravenous administration of iron sucrose for treating anemia in postpartum women. Hippokratia. 2009;13(1):38-40. 3. Van Wyck DB, Martens MG, Seid MH, Baker JB, Mangione A. Intravenous ferric carboxymaltose compared with oral iron in the treatment of postpartum anemia: a randomized controlled trial. Obstet Gynecol. 2007;110(2 Pt 1):267-78. 4. Seid MH, Derman RJ, Baker JB, Banach W, Goldberg C, Rogers R. Ferric carboxymaltose injection in the treatment of postpartum iron deficiency anemia: a randomized controlled clinical trial. Am J Obstet Gynecol. 2008;199(4):435.e1-7. 5. Aggarwal RS, Mishra VV, Panchal NA, Patel NH, Deshchougule VV, Jasani AF. Comparison of oral iron and IV iron sucrose for treatment of anemia in postpartum Indian Woman. Natl J Commun Med. 2012;3(1):48-54. 6. Rathod S, Samal SK, Mahapatra PC, Samal S. Ferric carboxymaltose: A revolution in the treatment of postpartum anemia in Indian women. Int J Appl Basic Med Res. 2015;5(1):25-30.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CASE REPORT

A Rare Case Report of Amniotic Band Syndrome Deepika*, Taru Gupta†, Nupur Gupta‡

ABSTRACT Amniotic band syndrome (ABS) is a destructive fetal complex caused by the disruption of the amnion followed by entanglement of the fetal parts in the amniotic bands resulting in bizarre and asymmetrical defects. Probable mechanisms involved include germ disc disruption, genetic disruption, vascular disruption and amniotic disruption. We report the case of a 25-year-old female G3P2L2 with 29-week period of gestation was referred from a peripheral center in view of severe oligohydramnios. Patient was induced in view of severe oligoamnios with ? abruption. She delivered a preterm female baby of weight 1.2 kg. Baby had left foot amputated with no bleeding from stump. Cyanosed baby foot was expelled separately from uterine cavity, which was suggestive of ABS. Keywords: Amniotic band syndrome, rupture of the amnion, oligohydramnios, destructive fetal complex

mniotic band syndrome (ABS) and/or limb body wall complex (LBWC) is considered to be caused by rupture of the amnion with secondary effects on the fetus producing malformation due to interruption of normal morphogenesis, deformation due to distortion of established structures and disruption of structures already formed.1,2 It may be associated with loss of amniotic fluid, producing secondary effects due to oligohydramnios.3 It is seen in 1 in 70 spontaneous abortions.4,5 In newborns, it has been estimated to occur 1 in 1,300-2,000 births.6,7 The syndrome is underdiagnosed and its presentation is so variable that no two cases are exactly alike. Pathogenesis of this defect is probably heterogeneous. Probable mechanisms involved include germ disc disruption,8-11 genetic disruption, vascular disruption12 and amniotic disruption.

*Senior Resident † Professor ‡ Assistant Professor Dept. of Obstetrics and Gynecology ESI-PGIMSR, Basaidarapur, New Delhi Address for correspondence Dr Nupur Gupta Assistant Professor Dept. of Obstetrics and Gynecology ESI-PGIMSR, Basaidarapur, New Delhi - 110 015 E-mail: drnupurgupta@gmail.com

Case Report A 25-year-old female G3P2L2 with 29-week period of gestation was referred from a peripheral center in view of severe oligohydramnios. She had previous two normal vaginal deliveries, both babies were alive and healthy. She conceived spontaneously with no history of drug intake or fever in first trimester. She reported quickening at 5th month of gestation and received two doses of tetanus toxoid. The obstetric scan revealed presence of severe oligohydramnios amniotic fluid index (AFI) <2 (estimated fetal weight [EFW]1,419 g). Two doses of injection betamethasone 12 mg IM, 24 hours apart were given for lung maturity. She had no significant past medical or surgical history. Her menstrual cycles were regular. On examination, there was no pallor, icterus, cyanosis or clubbing. Her vitals were stable. Systemic examination was normal. On per abdomen examination, uterus corresponded to 26 weeks, relaxed with cephalic presentation. Clinically liquor was decreased. Fetal heart rate was 140 bpm and regular. On per speculum examination, liquor mixed with blood was seen through os. On p/v, cervix was soft, uneffaced, dilated one finger, membrane present and flat over vertex at -3 station blood mixed liquor(+). Her laboratory parameters were all within normal range. Her hemogram, urine routine, serum electrolytes, liver function tests and kidney function tests were normal.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CASE REPORT Discussion

Figure 1. Baby with left foot amputated.

Amniotic band syndrome is a destructive fetal complex caused by the disruption of the amnion followed by entanglement of the fetal parts in the amniotic bands resulting in bizarre and asymmetrical defects that can involve several organs, especially limbs, cranium or spine.1 At present, we consider that defective neoangiogenesis results in the disruption of vascular supply and internal organ dysfunction.13,14 Typically, ABS is associated with rupture of the amnion either due to spontaneous rupture or possible iatrogenic septostomy. Rupture of the amnion can lead to entrapment of fetal structures by sticky mesodermic bands that originate from the chorionic side of the amnion, followed by disruption.1 Entrapment of fetal parts may cause amputation or slash defects in random sites, unrelated to embryologic development. The estimated date of insult ranges from 8 to 18 weeks after the last menstrual period.15 However, the case presented here is an evidence of late occurring destruction never described elsewhere. This may give an insight about the pathogenesis of ABS. Amniotic band theory of Torpin (1965)1 supports the exogenous nature of defects that result from rupture of the amniotic sac. He supposed that once the amnion is ruptured the fetus lies outside amniotic cavity. From the chorionic side of amnion, mesodermal bands emanate, which entrap various parts of the fetus and disturb normal development. Early rupture would lead to more severe malformations (e.g., craniofacial and visceral), whereas later rupture would lead to milder forms. Oligohydramnios may aggravate the deformity through compression.

Figure 2. No bleeding from stump seen.

USG obstetric revealed single live intrauterine fetus biparietal diameter (BPD) 29 weeks pog, cephalic placenta posterior upper segment, no retroplacental clot seen, severe oligohydramnios (<2). Patient was induced in view of severe oligoamnios with ? abruption. She delivered a preterm female baby of weight 1.2 kg normally with Apgar score 6/10, assessed by pediatrician. Baby had left foot amputated with no bleeding from stump (Figs. 1 and 2). Cyanosed baby foot was expelled separately from uterine cavity, which was suggestive of ABS; baby was shifted to nursery.

Higginbottom in 1979, described 79 patients that supported the band theory resulting from observations of unusual facial clefts, which were not along the planes of facial closure.2Â Also in support of the band theory Bhat, in his case report, described the presence of a well-formed amputated distal portion of one leg and fibrous bands coiling around the fingers of the amputated segment. Russo and colleagues have tried to divide this entity into two distinct phenotypes, the first consisting of craniofacial defects with amniotic bands and the second lacking craniofacial defects, though associated with urogenital anomalies, anal atresia, abdominal placental

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CASE REPORT attachment and persistence of the extraembryonic coelom. The number of cases of miscarriages that can be attributed to ABS is unknown, although it has been reported that it may be the cause of 178 in 10,000 miscarriages. Bands which wrap around fingers and toes can result in syndactyly and amputations of the digits. In other instances, bands can wrap around limbs causing restriction of movement resulting in clubbed feet. In more severe cases, the bands can constrict the limb causing decreased blood supply and amputation. Amniotic bands can also sometimes attach to the face or neck causing deformities such as cleft lip and palate. If the bands become wrapped around the head or umbilical cord it can be life-threatening for the fetus. Conclusion Amniotic band syndrome is often difficult to detect before birth as the individual strands are small and hard to see on ultrasound. Often the bands are detected indirectly because of the constrictions and swelling upon limbs, digits, etc. Misdiagnosis is also common, so if there are any signs of amniotic bands, further detailed ultrasound tests should be done to assess the severity. 3D ultrasound and magnetic resonance imaging can be used for more detailed and accurate diagnosis of bands and the resulting damage/danger to the fetus. The prognosis depends on the location and severity of the constricting bands. Every case is different and multiple bands may be entangled around the fetus. Amniotic band syndrome is considered an accidental event and it does not appear to be genetic or hereditary, so the likelihood of it occurring in another pregnancy is remote. The cause of amnion tearing is unknown and as such there are no known preventative measures.

rupture and variable spectra of consequent defects. J Pediatr. 1979;95(4):544-9. 3. Torpin R. Fetal malformations. In: Amniotic Bands. 1st Edition, Springfield, Illinois: WB Saunders Co.; 1968. pp.130-7. 4. Byrne J, Blanc WA, Baker D. Amniotic band syndrome in early fetal life. Birth Defects Orig Artic Ser. 1982;18 (3B):43-58. 5. Kalousek DK, Bamforth S. Amnion rupture sequence in previable fetuses. Am J Med Genet. 1988;31(1):63-73. 6. Ossipoff V, Hall BD. Etiologic factors in the amniotic band syndrome: a study of 24 patients. Birth Defects Orig Artic Ser. 1977;13(3D):117-32. 7. Froster UG, Baird PA. Amniotic band sequence and limb defects: data from a population-based study. Am J Med Genet. 1993;46(5):497-500. 8. Streeter GL. Focal deficiency in fetal tissues and their relation to intrauterine amputation. Contrib Embryol. 1930;33:41. 9. Herva R, Karkinen-Jääskeläinen M. Amniotic adhesion malformation syndrome: fetal and placental pathology. Teratology. 1984;29(1):11-9. 10. Bamforth JS. Amniotic band sequence: Streeter’s hypothesis reexamined. Am J Med Genet. 1992;44(3):280-7. 11. Hartwig NG, Vermeij-Keers C, De Vries HE, Kagie M, Kragt H. Limb body wall malformation complex: an embryologic etiology? Hum Pathol. 1989;20(11):1071-7. 12. Miller ME, Graham JM Jr, Higginbottom MC, Smith DW. Compression-related defects from early amnion rupture: evidence for mechanical teratogenesis. J Pediatr. 1981;98(2):292-7.

References

13. Donnai D, Winter RM. Disorganisation: a model for ‘early amnion rupture’? J Med Genet. 1989;26(7):421-5.

1. Torpin R. Amniochorionic mesoblastic fibrous strings and amnionic bands: associated constricting fetal malformations or fetal death. Am J Obstet Gynecol. 1965;91:65-75.

14. Lockwood C, Ghidini A, Romero R, Hobbins JC. Amniotic band syndrome: reevaluation of its pathogenesis. Am J Obstet Gynecol. 1989;160(5 Pt 1):1030-3.

2. Higginbottom MC, Jones KL, Hall BD, Smith DW. The amniotic band disruption complex: timing of amniotic

15. Seeds JW, Cefalo RC, Herbert WN. Amniotic band syndrome. Am J Obstet Gynecol. 1982;144(3):243-8.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CASE REPORT

A Rare Case of Twin Pregnancy in the Noncommunicating Rudimentary Horn of Unicornuate Uterus Nupur Gupta*, Taru Gupta†, Deepti Asthana‡

ABSTRACT Background: Twin pregnancy in a noncommunicating rudimentary uterine horn is rare and is difficult to diagnose antenatally. Case report: We report a case of twin pregnancy in a noncommunicating rudimentary uterine horn. The patient presented at 9 weeks’ gestation with acute abdominal distress and was antenatally diagnosed as a case of twin tubal ectopic pregnancy. On laparotomy, it was detected to have a noncommunicating thinned out left rudimentary horn with twin pregnancy. Conclusion: Pregnancies in a rudimentary uterine horn rarely reach viability and often result in rupture of the horn, causing significant fetal and maternal mortality and morbidity. The incidence, diagnosis and management of such cases are discussed. Keywords: Twin pregnancy, noncommunicating rudimentary uterine horn, acute abdominal distress, laparotomy, fetal, mortality

unicornuate uterus is a mullerian anomaly of which the true incidence is unknown. According to recent calculation, it appears higher than previously estimated, accounting for about 4%. Most unicornuate uteruses have a rudimentary horn without communication to the uterine cavity. Pregnancy in the rudimentary horn is rare1 and occurs most commonly in the noncommunicating horn. The incidence of rudimentary horn pregnancy is difficult to calculate. However, an incidence of 1 in 76,000-1,50,000 pregnancies has been reported in the literature. A twin pregnancy with both fetuses in the rudimentary horn is extremely rare. Case Report A 29-year-old female, G3P2L2 with 10 weeks amenorrhea presented to our casualty with complaint of pain abdomen. On elaborate history-taking, it was

*Assistant Professor † Professor ‡ Senior Resident Dept. of Obstetrics and Gynecology ESI-PGIMSR, Basaidarapur, New Delhi Address for correspondence Dr Nupur Gupta Assistant Professor, Dept. of Obstetrics and Gynecology ESI-PGIMSR, Basaidarapur, New Delhi - 110 015 E-mail: drnupurgupta@gmail.com

revealed that she had consumed MTP pills, taken over-the-counter, about 1 month back. There was no history of bleeding after that. Previous two deliveries of the patient were full-term normal vaginal deliveries not associated with any pre- or postpartum complications. On per vaginum examination, uterus was felt to be of multiparous size, with about 6 × 6 cm left adnexal mass, which was tender to touch. Diagnosis of left ectopic pregnancy was suspected. Pelvic ultrasound showed normal size uterus with unruptured twin gestational sac in left fallopian tube of 9 weeks 5 days. No free fluid was present. After baseline investigations and arranging adequate blood, patient was taken up for laparotomy. On laparotomy, instead of finding twin sacs in fallopian tube, rudimentary horn with unicornuate uterus was discovered with both gestational sacs in left horn and a nonpregnant right horn. Serosa of left horn was much thinned out and about to rupture. To check the communication from vagina, patient was put in lithotomy position and dilatation of cervix was done. Vagina had communication with only right horn of uterus and left horn with twin sacs was noncommunicating. Patient was again laid straight and decision of left horn excision was taken after taking consent from the husband. Need for hysterectomy, if bleeding gets uncontrolled, was also explained. Left horn was ligated at the base and excision done. Complete hemostasis was checked. Simultaneously

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CASE REPORT

Figure 1. Rudimentary horn showing two fetuses.

Figure 2. Rudimentary horn with unicornuate uterus.

Figure 3 a and b. Twin ectopic in rudimentary horn.

right fallopian tube ligation was done. Postoperative period was uneventful and patient was discharged in a weeks time. Discussion

Figure 4. Ectopic pregnancy in rudimentary horn.

A rudimentary horn with a unicornuate uterus results from the failure of the complete development of one of the mullerian ducts and incomplete fusion with the contralateral side. In 83% of the cases, the rudimentary horn has been found to be noncommunicating. Pregnancy in a noncommunicating rudimentary horn occurs through the transperitoneal migration of the sperm or the fertilized ovum.2 The prevalence of associated urological anomalies is as high as 50-60%. It is associated with intrauterine growth retardation, Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CASE REPORT intraperitoneal hemorrhage and uterine rupture.3 A diagnosis prior to the rupture is unusual, but it could be made with ultrasonography and magnetic resonance imaging. Tsafrir et al outlined a set of criteria for diagnosing pregnancy in the rudimentary horn.4 They are: (1) A pseudo pattern of asymmetrical bicornuate uterus; (2) absent visual continuity tissue surrounding the gestational sac and the uterine cervix and (3) presence of myometrial tissue surrounding the gestational sac. Nonetheless, most of the cases remain undiagnosed until it ruptures and presents as an emergency. The patient in our case also was misdiagnosed as twin tubal pregnancy. The usual outcome of the rudimentary horn pregnancy is rupture in the second trimester in 90% of the cases, with fetal demise. In our case, laparotomy was performed just on time, when rudimentary horn was about to rupture. However, cases of pregnancies which progressed to the third trimester and resulted in live births after cesarean section have been documented.3

performed whenever a diagnosis of pregnancy in a rudimentary horn is made, even if it is unruptured.6 However, conservative management until viability is achieved, has been advocated in very few selected cases with a larger myometrial mass, if emergency surgery can be performed anytime and if the patient is well-informed. Pregnancy in a rudimentary horn carries a grave risk to the mother. There is a need for an increased awareness on this rare condition and to have a high index of suspicion, especially in developing countries where the possibility of an early detection before the rupture is unlikely.

A rare case of twin pregnancy in the same horn of a bicornuate uterus has been documented by Narlawar et al.5 In this the patient’s uterine malformation was detected for the first time when she experienced abdominal pain at 6 weeks of amenorrhea. Transabdominal and transvaginal sonographic examinations were performed. Both embryos showed cardiac motion on transvaginal sonography. The patient was re-examined monthly. Her pregnancy ended in spontaneous abortion at 22 weeks. Two live male fetuses were delivered, but they both died immediately after their birth. It has been recommended by most of the obstetricians, that immediate surgery must be

3. Shin JW, Kim HJ. Case of live birth in a non-communicating rudimentary horn pregnancy. J Obstet Gynaecol Res. 2005;31(4):329-31.

References 1. Ural SH, Artal R. Third trimester rudimentary horn pregnancy. A case report. J Reprod Med. 1998;37: 919-21. 2. Panayotidis C, Abdel-Fattah M, Leggott M. Rupture of rudimentary uterine horn of a unicornuate uterus at 15 weeks’ gestation. J Obstet Gynaecol. 2004;24(3):323-4.

4. Tsafrir A, Rojansky N, Sela HY, Gomori JM, Nadjari M. Rudimentary horn pregnancy: first-trimester prerupture sonographic diagnosis and confirmation by magnetic resonance imaging. J Ultrasound Med. 2005;24(2):219-23. 5. Narlawar RS, Chavhan GB, Bhatgadde VL, Shah JR. Twin gestation in one horn of a bicornuate uterus. J Clin Ultrasound. 2003;31(3):167-9. 6. Jayasinghe Y, Rane A, Stalewski H, Grover S. The presentation and early diagnosis of the rudimentary uterine horn. Obstet Gynecol. 2005;105(6):1456-67.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CASE REPORT

Rupture of Endometriotic Ovarian Cyst Causes Acute Hemoperitoneum in IVF Pregnancy Atul Ganatra*, Vanashri Tatoba Bahade†, Uday Kargar‡

ABSTRACT Endometriosis occurs in about 10% of women of reproductive age and carries an infertility rate of 50%. Severe endometriosis used to be a rare event in patients with spontaneously conceived pregnancies; however, during the last decade, the increased use of assisted reproductive technologies has led to higher fertility rates in patients with endometriosis and to a higher incidence of multiple gestations. Therefore, the number of pregnant women with endometriosis and associated complications is bound to rise. We report an interesting case of an acute hemoperitoneum caused by a ruptured ovarian cyst in a late in vitro fertilization (IVF) pregnancy in a woman who presented to us at RJ Ganatra Nursing Home, Mulund West, Mumbai with acute abdominal pain. The woman had a history of surgery for endometriosis and was currently pregnant after IVF. USG and MRI-revealed a massive hemoperitoneum that was caused by ruptured endometriotic ovarian cyst. Diagnostic laparoscopy followed by emergency laparotomy was performed. Laparotomy led to operative hemostasis, pregnancy was conserved, maternal and fetal monitoring was performed till 37 weeks, and elective LSCS performed at 37 weeks. Keywords: Hemoperitoneum, endometriosis, pregnancy, ultrasound, MRI, in vitro fertilization

ndometriosis occurs in about 10% of women of reproductive age and is frequently associated with variable abdominal pain, infertility and early pregnancy complications. Rupture of endometriotic lesions is a rare event but may cause acute hemoperitoneum.1 Although endometriosis has been the subject of wide investigation, only a few cases of massive hemoperitoneum in late pregnancy are mentioned in literature.2-4 We report a case of spontaneous rupture of an endometriotic ovarian lesion leading to hemoperitoneum in an advanced in vitro fertilization (IVF) pregnancy. Case Report A 28-year-old primipara at 29 weeks of gestation with IVF pregnancy came to our hospital in 1st week of

*Obstetrician and Gynecologist and Laparoscopic Surgeon † Clinical Fellow ‡ Ex-Clinical Fellow RJ Ganatra Nursing Home, Mulund, Mumbai, Maharashtra Address for correspondence Dr Vanashri Tatoba Bahade A-1 605, Sai Paradise Building, Khadakpada, Kalyan (West), Maharashtra E-mail: dr.vanashribahade@gmail.com

September 2013, complaining of acute pain all over abdomen, starting from epigastric region and spreading to right iliac fossa region. The woman had a history of hospitalization for severe dysmenorrhea and pain in abdomen with clinical diagnosis of endometriosis with bilateral ovarian endometriotic cysts for 6 years and operated on 27/9/2008 in view of bilateral endometriotic cysts with severe dysmenorrhea. Laparoscopy was carried out and it demonstrated a distinctive endometriosis with adhesions between the sigmoid colon. Bilateral endometrioma drainage, cyst wall fulguration and adhesiolysis were performed. There was evidence of adhesions on posterior wall of uterus, both ovaries showed endometriomas and both ovaries were adherent to the tubes. Both fallopian tubes were dilated and adherent to uterus and ovaries. Pouch of Douglas showed dense adhesions and endometriotic spots. Subsequent IVF treatment led to present pregnancy in February to March 2013. After admission to our hospital, there were no signs of uterine contractions, vaginal bleeding, rupture of membranes or abdominal trauma; however, the woman complained of pain of variable intensity in

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CASE REPORT was kept as per surgery reference. All other parameters were within the normal range and fetal heart rate was reassuring. Magnetic resonance imaging (MRI) was advised; till then patient was kept on conservative management. MRI report suggested appendicular lump as diagnosis.

Decision of laparoscopic appendicectomy was taken after taking consent from the patient. Diagnostic laparoscopy was done by introducing opti-port from incision taken midway between epigastrium and uterus. Two side ports were also created; findings were suggestive of hemoperitoneum with clotted blood seen in right iliac fossa, pelvis and both paracolic gutters (Fig. 1 a-c). Bowel and omentum appeared normal, clots were suctioned with 10 mm suction cannula. Near about 700 cc total plus liquid blood of 200-300 cc was drained out. Decision of laparotomy was taken. Oblique incision was taken in right iliac fossa, abdomen opened in layers and laparoscopic findings were confirmed. Bowel and appendix appeared normal. About 400 g of blood clots were again suctioned out. There was evidence of bleeder at right ovarian fossa, bleeder was identified, cauterized and hemostasis achieved till bleeding stopped. There was evidence of endometriotic spots over posterior of surface of uterus. Blood transfusion was given postoperatively. Patient was managed well postoperatively, fetal monitoring done, fetal well-being assured and patient was discharged on 12/9/2013. Patient had regular antenatal check-up (ANC) followup, after surgery. ANC period was uneventful for both mother and fetus. Elective lower segment cesarean section (LSCS) was performed at 37 weeks to give a healthy female child of 2.45 kg; a positive outcome. Discussion

Figure 1 a-c. Laparoscopic pictures showing evidence of massive blood collection in the form of clots in both paracolic gutters, anterior aspect of gravid uterus, amongst coils of intestines, upper and under surface of liver too.

lower abdomen. Therefore, an urgent abdominal ultrasound was performed and surgery reference also performed. Ultrasound displayed a hint of free fluid in lower abdomen. Differential diagnosis of appendicitis

Acute hemoperitoneum is a rare obstetrical emergency that definitely requires rapid diagnosis and immediate surgical intervention. Interpretation of abdominal or pelvic pain as uterine contractions as well as hasty administration of analgesics may delay definite diagnosis and lead to life-threatening situations for mother and fetus. Symptoms are often nonspecific and laboratory values may remain stable for a long period, which requires additional diagnostic tools; ultrasound as well as MRI assessment of the maternal abdomen

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

CASE REPORT seems to be a valuable modality for detecting hemoperitoneum. The technique is readily available and without teratogenic impact and offers a high sensitivity and specificity in detecting abdominal fluid accumulation, especially when used in serial manner.5-7 Moreover, ultrasound can be performed without major time loss or need for patient transfer; however, sensitivity may be limited by maternal obesity or impaired visualization due to advanced gestational age. Endometriosis occurs in about 10% of women of reproductive age8 and carries an infertility rate up to 50%. Severe endometriosis used to be a rare events in patients with spontaneously conceived pregnancies; however, during the last decade, the increased use of assisted reproductive technologies9 has led to higher fertility rates in patients with endometriosis and to a higher incidence of multiple gestations. Therefore, the numbers of pregnant women with endometriosis and complications may rise. There is little knowledge about growth dynamics and activity of ovarian endometriotic lesions in pregnancy. Most investigators report regression or cessation of growth during pregnancy.10 Women with a history of endometriosis may carry an elevated risk for hemorrhagic complications, but enlargement and rupture remain rare events, nevertheless a patient with a history of endometriosis needs close monitoring. In most cases,11 the source of active bleeding is reported to be ruptured uterine or utero-ovarian vessels. As a result, the first approach during operative investigation is to look for a ruptured vessel. In addition, Ueda et al10 reported an incidence of 0.52% for ovarian endometriotic mass during pregnancy and Evangelinakis et al,12 calculated that the incidence of hemoperitoneum caused by ruptured endometriotic cysts in a group of nonpregnant women in reproductive age is 2.22%. In our case, it was not a single bleeding vessel but a solid mass with diffuse massive hemorrhage that was located. Despite these data, little is known about the incidence of ovarian ruptures caused by endometriosis in late pregnancy and further investigation is required.

References 1. Brosens IA, Fusi L, Brosens JJ. Endometriosis is a risk factor for spontaneous hemoperitoneum during pregnancy. Fertil Steril. 2009;92(4):1243-5. 2. Tourette C, Carcopino X, Taranger-Charpin C, Boubli L. An unexpected aetiology of massive haemoperitoneum during pregnancy. J Gynecol Obstet Biol Reprod (Paris). 2011;40(1):81-4. 3. Passos F, Calhaz-Jorge C, Graça LM. Endometriosis is a possible risk factor for spontaneous hemoperitoneum in the third trimester of pregnancy. Fertil Steril. 2008;89(1):251-2. 4. Ismail KM, Shervington J. Hemoperitoneum secondary to pelvic endometriosis in pregnancy. Int J Gynaecol Obstet. 1999;67(2):107-8. 5. Nordenholz KE, Rubin MA, Gularte GG, Liang HK. Ultrasound in the evaluation and management of blunt abdominal trauma. Ann Emerg Med. 1997;29(3):357-66. 6. Sirlin CB, Brown MA, Andrade-Barreto OA, Deutsch R, Fortlage DA, Hoyt DB, et al. Blunt abdominal trauma: clinical value of negative screening US scans. Radiology. 2004;230(3):661-8. 7. Blackbourne LH, Soffer D, McKenney M, Amortegui J, Schulman CI, Crookes B, et al. Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma. J Trauma. 2004;57(5):934-8. 8. Holoch KJ, Lessey BA. Endometriosis and infertility. Clin Obstet Gynecol. 2010;53(2):429-38. 9. Barri PN, Coroleu B, Tur R, Barri-Soldevila PN, Rodríguez I. Endometriosis-associated infertility: surgery and IVF, a comprehensive therapeutic approach. Reprod Biomed Online. 2010;21(2):179-85. 10. Ueda Y, Enomoto T, Miyatake T, Fujita M, Yamamoto R, Kanagawa T, et al. A retrospective analysis of ovarian endometriosis during pregnancy. Fertil Steril. 2010;94 (1):78-84. 11. Ginsburg KA, Valdes C, Schnider G. Spontaneous uteroovarian vessel rupture during pregnancy: three case reports and a review of the literature. Obstet Gynecol. 1987;69(3 Pt 2):474-6. 12. Evangelinakis N, Grammatikakis I, Salamalekis G, Tziortzioti V, Samaras C, Chrelias C, et al. Prevalence of acute hemoperitoneum in patients with endometriotic ovarian cysts: a 7-year retrospective study. Clin Exp Obstet Gynecol. 2009;36(4):254-5.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

JOURNAL SCAN

News and Views

Transabdominal cerclage (TAC) for patients with ultra-short uterine cervix after uterine cervix surgery. A new study published in The Journal of Obstetrics and Gynaecology Research examined the safety of transabdominal cerclage (TAC) of the uterine cervix and its impact on pregnancy. In this retrospective study, TAC was performed in 11 patients before pregnancy: in six after large cervical operations, such as repeated conization; and in five for difficulties with cervical cerclage after radical trachelectomy (RT). After laparotomy, a Teflon thread was placed in the avascular space between the uterine vessels and the uterine muscle, and tied. The results revealed that the mean operative duration was 53 ± 10 min, and the mean blood loss during the operation was 49 ± 64 mL. In addition, seven women conceived within 2 years after TAC; and their pregnancy courses were favorable. Five among these underwent scheduled cesarean sections, while the outcomes of two pregnancies are awaited. From the findings, it was inferred that although there are risks of various complications as a result of the use of non-absorbable thread and the need for two extra laparotomies, TAC can be a safe and useful option for patients who show cervical incompetence after large uterine cervical operations, such as RT or large conization. Fetal overgrowth in women with type-1 and type-2 diabetes mellitus. The purpose of a new study published PLoS One was to determine the relative contribution of risk factors, such as poor glycemic control, obesity, and excessive gestational weight gain, for large-for-gestationalage (LGA) in women with diabetes mellitus type-1 (T1DM) and type-2 (T2DM), after controlling for important confounders such as age, smoking, and parity. This retrospective chart review analyzed the medical files of pregnant women with T1DM and T2DM who attended the antenatal care program at Skåne University Hospital, between 2006 and 2016. Glycated hemoglobin (HbA1c) was used as a measure

of glycemic control. LGA was defined as birth weight >2 standard deviations of the mean. During the study period, 308 singleton pregnancies were identified in 221 women with T1DM and in 87 women with T2DM. The findings revealed that the rate of LGA was 50% in women with T1DM and 23% in women with T2DM. Gestational weight gain and secondtrimester HbA1c were risk factors for LGA in T1DM pregnancies, while gestational weight gain was a risk factor in T2DM pregnancies, independent of body mass index. Hence, it was concluded that gestational weight gain was associated with LGA in women with T1DM and T2DM, independent of maternal body mass index. The findings suggest that monitoring and regulation of gestational weight gain is important in the clinical care of these women, to minimize the risk of fetal overgrowth. Origin and clinical relevance of chromosomal aberrations other than the common trisomies. A recent article published Genetics in Medicine reported on the origin, frequency, and clinical significance of other chromosome aberrations, besides fetal trisomies 21, 18, and 13, found in pregnancies at risk for these trisomies. This experiment entailed wholegenome shallow massively parallel sequencing, and an analysis of all autosomes. It was observed that in 3.1% of cases non-invasive prenatal screening (NIPS) was indicative of trisomy 21, 18, or 13, and in 1.6% cases of other chromosome aberrations. Other aberrations were documented to be either fetal (n = 10), placental (n = 22), maternal (n = 1) or unknown (n = 7). Whereas, one case lacked cytogenetic follow-up. While nine of the 10 fetal cases were associated with an abnormal phenotype; 13 of the 22 placental aberrations were associated with fetal congenital anomalies and/or poor fetal growth, which was severe in six cases. Thus, it was stated that genome-wide NIPS in pregnancies at risk for trisomy 21, 18, or 13, reveals a chromosomal aberration other than trisomy 21, 18 or 13 in about one-third of the abnormal cases. A majority of these

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

JOURNAL SCAN cases involve a fetal or placental chromosome aberration with clinical relevance for pregnancy management. Relationships between 25(OH)D concentration, sarcopenia, and HOMA-IR in postmenopausal women. A new study published in Climacteric aimed to investigate the relationship between 25-hydroxyvitamin D concentration, sarcopenia, and insulin resistance in postmenopausal Korean women. The findings showed a strong inverse association between 25-hydroxyvitamin D concentration and sarcopenia in postmenopausal Korean women. Additionally, a significant association was noted between sarcopenia and insulin resistance, independent of vitamin D and obesity status. Whereas, there was no significant association between 25-hydroxyvitamin D concentration and insulin resistance. In the subgroup analysis, insulin resistance was found to be determined by sarcopenic rather than vitamin D status. Thus, it was concluded that sarcopenia was associated with both insulin resistance and 25-hydroxyvitamin D concentration in postmenopausal Korean women, regardless of obesity status. However, 25-hydroxyvitamin D concentration was not associated with insulin resistance. Hence, it was stated that sarcopenia is of greater clinical importance due to its close relationship with insulin resistance. Maternal Dyslipidemia in Pregnancy with Gestational Diabetes Mellitus. A new article published in the Current Vascular Pharmacology reported that dyslipidemia occurs in pregnancy in order to secure fetal development. The mother shows a physiological increase in plasma total cholesterol and triglycerides (TG) as pregnancy progresses. However, in some women pregnancyassociated dyslipidemia exceeds this physiological adaptation. The consequences of this condition on the developing fetus include endothelial dysfunction

of the feto-placental vasculature and development of fetal aortic atherosclerosis. It was stated that gestational diabetes mellitus (GDM) associates with abnormal function of the feto-placental vasculature due to fetal hyperglycemia and hyperinsulinemia, and associates with development of cardiovascular disease in adulthood. Furthermore, supra-physiological dyslipidemia could be detected in GDM pregnancies. This article elaborated on the results of a literature reviewed which suggested that dyslipidemia in GDM pregnancy should be an additional factor contributing to worsen GDM-associated endothelial dysfunction by altering signaling pathways involving nitric oxide bioavailability and neonatal lipoproteins. Effects of programmed exercise on depressive symptoms in midlife and older women. A new study published in Maturitas was based on a systematic review and meta-analysis aimed at the clarification of the effect of programmed exercise on depressive symptoms (DSs) in midlife and older women. Here, a structured search was conducted on PubMed-Medline, Web of Science, Scopus, Embase, Cochrane Library and Scielo, from database inception through June 29, 2017, without language restriction. Eleven publications were included for analysis related to 1943 midlife and older women, who were not on hormone therapy. The results revealed that seven midterm exercise interventions (MTEIs) were associated with a significant reduction in DSs when compared to controls. The reduction in DSs was also significant in six long-term exercise interventions (LTEIs). While heterogeneity of effects among studies was moderate to high. Additionally, less perceived stress and insomnia (after exercise) were noted as secondary outcomes. Hence, it was inferred that exercise of low to moderate intensity reduces depressive symptoms in midlife and older women.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

Asian

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OBSTETRICS & GYNAECOLOGY Practice

Information for Authors

Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767). Asian Journal of Obstetrics and Gynaecology Practice strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so. The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript. Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper. Covering letter -

- -

The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper. Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors. Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript.

Manuscript - Three complete sets of the manuscript should be submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures). - The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures. - All pages should be numbered consecutively beginning with the title page. Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors. Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed, name of the corresponding authors, acknowledgment of financial support and abbreviations used.

The title should be of no more than 80 characters and should represent the major theme of the manuscript. A subtitle can be added if necessary.

A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included.

- The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page. -

A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text.

Summary - The summary of not more than 200 words. It must convey the essential features of the paper. - It should not contain abbreviations, footnotes or references. Introduction - The introduction should state why the study was carried out and what were its specific aims/objectives. Methods - These should be described in sufficient detail to permit evaluation and duplication of the work by others. - Ethical guidelines followed by the investigations should be described. Statistics The following information should be given: - The statistical universe i.e., the population from which the sample for the study is selected. -

Method of selecting the sample (cases, subjects, etc. from the statistical universe).

Method of allocating the subjects into different groups.

Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques.

Confidence intervals for the measurements should be provided wherever appropriate.

Results -

These should be concise and include only the tables and figures necessary to enhance the understanding of the text.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 1, January-March 2018

Discussion -

This should consist of a review of the literature and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g. practicality and cost.

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses). At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution. Examples of common forms of references are:

Do not use clips/staples on photographs and artwork.

Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as ‘Fig.’. Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)_______________________________

Articles

2. Total number of pages ________________________

Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes. Q. J. Expt. Physiol. 1955;40:89-111.

3. Number of tables ____________________________

Books

Indian 1.____________Foreign 1.________________

Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985.

2.____________ 2.________________

3.____________ 3.________________

Articles in Books

4.____________ 4.________________

Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470.

7. All authors’ signatures________________________ 8. Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________

Tables -

These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table.

Legends - These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text. -

Figures - Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat. - All photomicrographs should indicate the magnification of the print. - Special features should be indicated by arrows or letters which contrast with the background. - The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen. - Color illustrations will be accepted if they make a contribution to the understanding of the article.

The legend must include enough information to permit interpretation of the figure without reference to the text.

4. Number of figures ___________________________ 5. Special requests _____________________________ 6. Suggestions for reviewers (name and postal address)

Online Submission Also e-issue @ www.ijcpgroup.com For Editorial Correspondence

Dr KK Aggarwal

Group Editor-in-Chief Asian Journal of Obstetrics and Gynaecology Practice E - 219, Greater Kailash, Part - 1, New Delhi - 110 048. Phone: 011-40587513 E-mail: editorial@ijcp.com, Website: www.ijcpgroup.com

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