Ajog oct dec 2016 by IJCP

ISSN 0971-8788

Volume 2, Number 4, 2016

Asian Journal of

Obstetrics &

Gynaecology Practice In this Issue Role of DHA in Third Trimester Role of Resveratrol in Management of Endometriosis An Evaluation of Antepartum and Intrapartum Surveillance with nst in Cases of Fetal Growth Restriction and Its Correlation with Perinatal Outcome Postpartum Posterior Reversible Encephalopathy: A Diagnostic Dilemma Vaginal Leiomyoma: An Unusual Case Presentation Prolapsed Huge Cervical Fibroid with Acute Red Degeneration Mimicking Uterine Inversion Management of Medico-Legal Cases Issue 5 Resolving Patient-Doctor Conflict ACP Provides Guidance on Nonsurgical Treatment of Urinary Incontinence in Women Journal Scan

Asian Journal of

Online Submission

Volume 2, Number 4, 2016

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

Contents from the issue editor

Women More at Risk of Heart Disease Today

Alka Kriplani

Dr KK Aggarwal Group Editor-in-Chief IJCP Group, eMedinewS and eMediNexus 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

FROM THE DESK OF the GROUP EDITOR-IN-CHIEF

Can Women Get Heart Disease Before Premenopause?

KK Aggarwal

REVIEW ARTICLE

Role of DHA in Third Trimester

Alka Gahlot

Role of Resveratrol in Management of Endometriosis

Urman Dhruv, Alka Gahlot

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

Clinical Study

An Evaluation of Antepartum and Intrapartum Surveillance with nst in Cases of Fetal Growth Restriction and Its Correlation with Perinatal Outcome

Jain Meenal, Chandra Mukesh, Singh Saroj, Verma Urvashi, Agarwal Poonam

caSE REPORT

Postpartum Posterior Reversible Encephalopathy: A Diagnostic Dilemma 19 Ridhi Kathuria, MC Bansal

Asian Journal of Volume 2, Number 4, 2016

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

Vaginal Leiomyoma: An Unusual Case Presentation 23 Kavyashree G, Manohar R, Kala B

Printed at Bon Graphics, Chennai Copyright 2016 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.

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.

Prolapsed Huge Cervical Fibroid with Acute Red Degeneration Mimicking Uterine Inversion

Neerja Varshney, Meenakshi Sharma, Vandana Jain

Medicolegal

Management of Medico-Legal Cases Issue 5 Resolving Patient-Doctor Conflict

Practice guidelines

ACP Provides Guidance on Nonsurgical Treatment of Urinary Incontinence in Women Journal Scan

Journal Scan

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from the issue editor

Women More at Risk of Heart Disease Today

Dr Alka Kriplani

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

eart disease is no longer exclusive to men as we now know. Women, especially urban women, are more at risk of developing heart disease today. And, a heart attack is usually more severe in women than in men. An increasingly unhealthy lifestyle with a predominantly high trans fat, sugar and salt diet, more and more sitting, stress/depression, smoking and alcohol are some of the factors that have contributed to this rise in heart disease. Differences in the clinical presentation also make it difficult to establish a diagnosis in women. zz

Women generally present a decade later than men and with greater risk factor burden. They are less likely than men to have typical angina. Women with new onset of chest pain are approached and diagnosed less aggressively than men in the emergency department. Established risk factors in women are: Presence of history of heart blockages; age over 55 years; high low-density lipoprotein (LDL) (bad) or low high-

density lipoprotein (HDL) (good) cholesterol, diabetes, smoking, high blood pressure, peripheral artery disease or family history of heart disease. zz

Factors that considerably enhance the risk of heart disease in women in comparison to men are: Smoking is associated with 50% of all coronary events in women; diabetes confers more prognostic information in women than in men.

Symptoms of heart attack in women differ from those in men. Women may not know or recognize these symptoms as due to a heart attack. Rather than the classical presentation of chest pain, women are more likely to have extreme fatigue, sleep disturbances, lightheadedness, nausea/ vomiting, shortness of breath with or without chest discomfort, indigestion, pain or discomfort in one or both arms, the back, neck, jaw or stomach.

Treadmill test in women has a higher false positive rate.

Small vessel disease is more common in women than in men.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

FROM THE DESK OF the GROUP EDITOR-IN-CHIEF

Can Women Get Heart Disease Before Pre-menopause?

Dr KK Aggarwal

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

lder women have been at a higher risk end for developing cardiovascular diseases. It is reported that more than 75% of women aged 40-60 have one or more risk factors for CVD. Heart disease is the leading cause of death in women over age 40, especially after menopause. Up until now the notion had been that menopause is the only phase during a woman’s life cycle during which she is prone to increased risk of CVD, but now the idea is being challenged by increasing incidences of coronary heart diseases in pre-menopausal women. Recently, evidence has emerged that even the premenopause phase in a woman’s life cycle is prone to developing cardiovascular complications because of exacerbated risk factors. Complex hormonal and physiological changes take place during the transitory phase to menopause, the perimenopause. Estrogen and progesterone imbalance starts to set in, body fat starts getting redistributed, there are global changes in cholesterol levels and blood pressure starts to show a rise before menopause hits. It is seen that the risk factors associated with stroke and CVD increase more rapidly in the years leading up to menopause rather than afterwards. This is a result of a variety of physiological changes collectively known as the metabolic syndrome. The risk factors that together constitute the metabolic syndrome are a large waistline, high levels of blood fat (triglycerides), low levels of good cholesterol, high blood pressure and high fasting blood sugar. These changes are associated risk factors for CVD and if left unchecked, have the potential to develop into serious cardiovascular complications. This paradigm shift in the ‘at-risk’ population for heart disease is

due to modern lifestyle. In today’s age of technology and modernization, there are a plethora of comforts available, but the cost of every comfort is some or the other form of compromised health. According to a study conducted by Harvard Medical School, the major risk factors associated with modern lifestyle are smoking, high body mass index, a sedentary lifestyle, alcohol consumption and an unhealthy diet. “Lifestyle-related factors that increase the risk of heart disease are becoming increasingly common among girls, teenagers, and young adults. Physical activity drops sharply as girls approach teenage years and is significantly reduced by young-adulthood. Higher or lower than normal body mass index is an important determining factor for the course of cardiac complications in high risk individuals. The good news is that these hormonal and physiological changes during the pre-menopause period are reversible or in some cases, modifiable. Appropriate lifestyle changes can be incorporated to minimize the risk of developing heart disease during this period. “The notion that young adult women need not worry about heart health until they are ‘old enough’, needs to be abolished. Women approaching menopause need to be more proactive about following a hearthealthy lifestyle in order to minimize the effect of these associated risk factors. Your lifestyle is not only your best defense against cardiovascular diseases, it's also your responsibility towards yourself and your loved ones”. Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

Review Article

Role of DHA in Third Trimester Alka Gahlot

Abstract The role of DHA in the development of brain as well as in visual development is well established. Deficiency of (n-3) fatty acid may affect brain development at multiple levels, from membrane biogenesis, through gene expression, protection against oxidative stress, and altered neurotransmission. However, whether dietary DHA is important during human brain development is still an unresolved question. Keywords: DHA, fatty acid, maternal, trimester

hird trimester and the first two years of the life are important phases of rapid brain development known as “brain growth spurt”.1,2 During this period, polyunsaturated fatty acids of omega-3, mainly docosahexaenoic acid (DHA) plays a critical role in the growth and development of central nervous system of the developing baby. Additionally, DHA also confer beneficiary effect on mother’s health during pregnancy.3,4

It is one of the most abundant constituents of brain and retina of eye and is involved in visual and neural function and neurotransmitter metabolism.3,4 Rapid accumulation of DHA takes place during the entire period of brain growth spurt. However, it is required in highest concentrations (somewhere around 50-70 mg/ day) during the third trimester.1,3,5 The accumulation of DHA into the central nervous system takes place until about 18 months of age and both maternal DHA intake as well as circulating DHA concentrations are important determinants of fetal blood concentrations of DHA.3 Insufficient supply of DHA during this development phase can result into serious complications of central nervous system.1,3,5 Dr Alka Gahlot Associate Professor Dept. of Obstetrics and Gynecology Mahatma Gandhi University of Medical Sciences and Technology Jaipur, Rajasthan Address for correspondence Address for correspondence Dr Alka Gahlot 170, Heera Nagar, DCM, Ajmer Road, Jaipur, Rajasthan - 302 021

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

Docosahexaenoic Acid (DHA) - At a Glance As already described above, DHA is the most abundant structural fat in the brain and eyes but it is also present throughout the body. It is a long chain omega-3 fatty acid of 22 carbon atoms that represents about 97% and 93% of all omega-3 fatty acids in the brain and eyes, respectively. Natural sources of DHA are very limited and it is found in good quantity only in some foods, particularly fatty fish. Humans are also capable of synthesizing DHA from the essential fatty acid (EFA), α-linolenic acid (ALA). However, dietary inclusion is important for normal growth and development. Its deficiency can lead to a number of complications such as foetal alcohol syndrome, attention deficit hyperactivity disorder, cystic fibrosis, phenylketonuria, unipolar depression, aggressive hostility, and adrenoleukodystrophy. Reduction of DHA level in brain with aging is associated with cognitive decline and with the onset of sporadic Alzheimer disease.5,6 DHA is not only a key element of brain but it is also found in high abundance in heart.2 Epidemiological data positively link the consumption of fish, which are high source of DHA with reduced sudden death due to myocardial infarction. As much as 50% reduction in death has been observed with the consumption of 200 mg/day of DHA from fish. Furthermore, consumption of fish oil has also shown decreases in the proliferation of tumour cells and has a negative effect on inflammation associated with diseases like rheumatoid arthritis and asthma. The list of beneficial effect of DHA doesn’t end here. It also offers positive 7

review article effect on several other diseases such as hypertension, arthritis, atherosclerosis, depression, adult-onset diabetes mellitus, thrombosis, and some cancers.6 DHA is essentially required for the healthy visual and mental development during pregnancy and its demand increases exponentially with the gestation age and it reaches its peak in the third trimester.5,7 The World Health Organization (WHO) and the Food and Agriculture Organization of the United Nations (FAO) recommends a daily intake of 100-300 mg of DHA during pregnancy. A regular consumption of fish or omeag-3 fatty acid supplements during pregnancy results in increased circulating values of omega-3 polyunsaturated fatty acids in maternal blood, that is important for both fetal and maternal health.7 During the prenatal period, DHA is supplied to the fetus directly via placenta. Infants mainly gets DHA from breast milk however DHA requirement in infants can also be met though supplemented formula.1,2,5 Role of DHA During the Last Trimester Studies on the effect of maternal DHA supplementation during the last trimester of pregnancy on their health and on the development of infants are limited and the results from these studies are mixed. Some studies have shown that maternal DHA supplementation have positive effects on neonateâ&#x20AC;&#x2122;s health especially in terms of cognitive development whereas some have shown no beneficial effect on infantâ&#x20AC;&#x2122;s development. Maternal DHA Supplementation During Pregnancy and its Effects on the Development of Babies

The role of DHA in the development of brain as well as visual development is well established. Deficiency of (n-3) fatty acid may affect brain development at multiple levels, from membrane biogenesis, through gene expression, protection against oxidative stress, and altered neurotransmission. However, whether dietary DHA is important during human brain development is still an unresolved question.1,8,9 The accumulation of DHA in the nervous tissue of retina and brain is highest during the period of fetal development and early infancy, its availability during this time is crucial and its deficiency may have long term consequences for later brain function.8,9 Effect of maternal DHA supplementation continued till the last stages of pregnancy on the visual and/or cognitive 8

development after birth has been studied in few clinical trials. Malcolm el al., studied the effect of maternal docosahexaenoic acid (DHA) supplementation from week 15 of pregnancy until delivery in 100 women. The outcomes from the study showed no significant difference in maturity of the retina at one week of age. Furthermore, visual function assessed by visual evoked potential (VEP) to flash and pattern reversal stimuli also did not show any marked difference at birth and at 10 and 26 weeks of age, between neonates born to mothers supplemented with fish oil versus those born to mothers supplemented with high-oleic acid sunflower oil. However, visual development was significantly correlated with DHA status of the infants at birth, suggesting a possible association between the DHA status of infants at term and early postnatal development and function of the retina.9-11 In a follow up study performed by Tofail et al., the investigators evaluated the effect of maternal supplementation of fish oil (1.2 g DHA+1.8 g eicosapentaenoic acid/d) or soy bean oil (2.25 g linoleic acid+0.27 g ALA/d) during the last trimester of the pregnancy until delivery on cognitive outcomes of infants. Cognitive development was assessed once the infants were 10 months of age. The results demonstrated that DHA supplementation provided no added benefit over soy-oil in the cognitive development in infants.9,12 Both these studies demonstrated no significant effect of maternal n-3 long chain PUFA supplementation during pregnancy on visual function or cognitive development in the first year of life. However, these studies were having their own difference and limitation in the designs such as low dose and/or short duration of supplementation.9 In a study conducted by Helland et al., the investigators studied the effect of supplementing mothers with either cod liver oil (1.2 g DHA/d) or corn oil (4.7 g LA)/d) from week 17-19 until the last trimester of pregnancy and continued for three months during lactation. Investigators reported no significant difference in electroencephalogram (EEG) maturity of the 2-day old neonates, 3-month old infants and for novelty preference at six and nine months of age among the two groups. However, at the age of 24, the children of mothers who received cod liver oil showed significantly (points) higher IQ. Outcomes of this study indicate that DHA supplementation in mother Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

Review article during second and third trimester of pregnancy and lactation can influence the infantsâ&#x20AC;&#x2122; DHA status and its effect may appear later in life with more matured cognitive function.9 Effect of DHA Supplementation on Motherâ&#x20AC;&#x2122;s Heath During the Third Trimester

DHA supplementation is not only important for the developing baby but also for fortifying mothers own heath during pregnancy. Role of DHA has also been studied in conditions like prenatal stress, pregnancy induced hypertension that usually occurs during the third trimester of pregnancy. Additionally, there have been investigations that have evaluated the maternal DHA supplementation continued during the end stages of delivery on condition like postpartum depression. As already mentioned, high accumulation of DHA in the foetus body takes place via placenta during the third trimester of pregnancy. This causes deficiency of DHA in mother's body. Without proper replenishment of DHA during this period, mother's body becomes susceptible to major depressive symptoms in the postpartum period. Results from a cross national study performed by Joseph R. Hibbeln on rates of postpartum depression among twenty-two countries showed that the lower the amount of DHA in the mother's blood, the higher is the chance that she will develop postpartum depression. These outcomes indicated that DHA supplementation especially during the later stages of pregnancy may be important in reducing major postpartum depressive symptoms.13 Keenan et al., in their study evaluated the link between DHA supplementation and perceived stress and cortisol response to a stressor during pregnancy in a sample of African American women living in low-income environments. The enrolled women were supplemented with 450 mg/day of DHA or placebo from 16-21 weeks continued till the last trimester of pregnancy. Pregnant women in the active group receiving DHA had a lower incidence of reduced perceived stress and lower levels of stress hormones in the third trimester. These results suggest a positive effect of DHA supplementation in easing the effect of maternal stress during the third trimester.14 Next, studies have also suggested that DHA may beneficially influence pregnancy induced hypertension during the end stages of pregnancy. In a study performed by Gerrard et al., Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

the investigators demonstrated that inuit women with a diet rich in fish and sea mammals, potent source of omega-3 fatty acids, had a lower blood pressure at the end of pregnancy and a lower incidence of gestational hypertension compared to controls.15 Additionally, there is growing evidence that suggests DHA role in modulating insulin resistance that might prove to be beneficial in gestational diabetes. Furthermore, diet rich in omega-3 may be beneficial in reducing the risk of developing pre-eclampsia during pregnancy. Results from clinical studies suggest that the risk of developing pre-eclampsia is 7.5 times higher in mother with extremely low levels of omega-3 fatty acids than the mother whose levels of omega-3 are the highest. Studies have also indicated that a diet change in favor of omega-3 from omega-6 may reduce the risk of preeclampsia by 46%.4 Conclusion DHA is an important constituent of human body and is found in high abundance in the cells of brain and retina. DHA accumulated in high concentration during the third trimester of pregnancy that makes dietary intervention of DHA supplementation in mothers essential and the same is recommended by the WHO and the FAO. Although DHA role in the retina and brain development is well elucidated in literature, the studies evaluating the effect of DHA during the third trimester are limited. Studies on maternal supplementation continued till the end stages of pregnancy alone have not demonstrated any significant improvement on the visual or cognitive development in the first year of life of infants. However, DHA supplementation during pregnancy/lactation does offer some beneficial effect on the cognitive function. Furthermore, role of DHA supplementation in maternal health during third trimester has also been evaluated in few studies and the results do suggest a beneficial effect of DHA in conditions like prenatal stress, pregnancy induced hypertension that commonly occur during the end stages of pregnancy and also in postpartum depression. References 1. McCann JC, Ames BN. Is docosahexaenoic acid, an n-3 long-chain polyunsaturated fatty acid, required for development of normal brain function? An overview of evidence from cognitive and behavioural tests in humans and animals. Am J Clin Nutr. 2005;82(2):281-95.

review article 2. Today’s Dietician. The Role of DHA and ARA in Infant Nutrition and Neurodevelopmental Outcomes. Available at: http://www.todaysdietitian.com/newarchives/092208p66. shtml Assessed on. 08/10/2016. 3. Greenberg JA, Bell SJ, and Ausdal WV. Omega-3 fatty acid supplementation during pregnancy. Rev Obstet Gynecol. 2008 Fall;1(4):162-9. 4. RM Berry Publications. Prenatal Omega-3 reseacrh Report. Available at: http://www.rmbarry.com/research/prenatal_ omega3.html Accessed on: 22/10/2016. 5. Martek Biosciences Corporation. The Importance of DHA in Infant Development. Available at: https://www.dsm.com/ content/dam/dsm/foodandbeverages/en_US/documents/ hnh/53331-mediakit-spread-infantdev-(2).pdf 6. Horrocks LA , Yeo YK. Health benefits of docosahexaenoic acid (DHA). Pharmacol Res. 1999 Sep40(3):21125. 7. Pietrantoni E, Del Chierico F, Rigon G, et al. Docosahexaenoic acid supplementation during pregnancy: a potential tool to prevent membrane rupture and preterm labor. Int J Mol Sci. 2014;15(5):8024-36. 8. Innis SM. Dietary (n-3) fatty acids and brain development. J Nutr. 2007;137(4):855-9. 9. Eilander A, Hundscheid DC, Osendarp SJ, et al. Effects of n-3 long chain polyunsaturated fatty acid supplementation on visual and cognitive development throughout childhood: A review of human studies. Prostaglandins Leukot Essent Fatty Acids. 2007 Apr;76(4):189-203.

10. Malcolm CA, McCulloch DL, Montgomery C, et al. Maternal docosahexaenoic acid supplementation during pregnancy and visual evoked potential development in term infants: a double blind, prospective, randomised trial. Arch Dis Child. 2003;88(5):F383-90. 11. Malcolm CA, Hamilton R, McCulloch DL, et al. Scotopic electroretinogram in term infants born of mothers supplemented with docosahexaenoic acid during pregnancy. Invest Ophthalmol Vis Sci. 2003;44(8): 3685-91. 12. Tofail F, Kabir I, Hamadani JD, et al. Supplementation of fish oil and soy oil during pregnancy and psychomotor development of infants. J. Health Pop Nutr. 2006;24(1): 48-6. 13. Hibbeln, J. Seafood consumption, the DHA content of mothers' milk and prevalence rates of postpartum depression: a cross-national, ecological analysis. Journal of Affective Disorders. 2002; 69(Issu 1-3):15-29. 14. Keenan K, Hipwell AE, Bortner J, et al. Association between fatty acid supplementation and prenatal stress in African Americans: a randomized controlled trial. Obstet Gynecol. 2014;124(6):1080-7. 15. Gerrard J , Popeski D, Ebbeling L, et al. Dietary omega 3 fatty acids and gestational hypertension in the Inuit. Arctic Med Res. 1991Suppl:7637.

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AZD1775 Demonstrates an Improved Carboplatin’s Antitumor Activity in Refractory or Resistant TP53-mediated Ovarian Cancer in Women According to a report published online in the Journal of Clinical Oncology, drug AZD1775—a WEE1 tyrosine kinase inhibitor demonstrates an improved carboplatin’s antitumor activity in refractory or resistant TP53-mediated ovarian cancer in women with epithelial ovarian cancer and TP53 mutations and who are non-responders to platinum plus paclitaxel therapy. The study highlighted that 225 mg oral dose of AZD1775 twice a day for three days plus IV carboplatin in 21-day cycles, produced the primary outcomes and overall response rate to 43% in twenty-one patients. Also, after two treatment cycles, one, eight, seven and five patients demonstrated a complete response, a partial response, a stable disease, and a progressive disease, respectively. The median progression-free survival and median overall survival was found to be 5.3 months was 12.6 months, respectively.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

REVIEW ARTICLE

Role of Resveratrol in Management of Endometriosis Urman Dhruv*, Alka Gahlot**

Abstract Endometriosis is one of the most mysterious and fascinating benign gynecological disorders. It is one of the commonest causes of chronic pelvic pain in women. It is also the most searched disease in cases of infertility. Despite availability of many new medical therapies and multidirectional surgical therapies of varying extents, the management of endometriosis is still far from perfect. Newer molecules with safer adverse effect profiles are being tried experimentally after understanding the etiopathogenesis of the disease in depth. Neovascularization has been thought to be one of the most essential necessities for the development of the disease and this has prompted scientists to try agents, which prevent development of new vessel formation. Resveratrol is one of such therapies which may be holding the future optimistic directions in managing endometriosis. It is found to be effective in mouse models and is a substance easily available and has no side effects. If the bigger trials in human beings will be successful, we will soon have a safe substance to manage endometriosis. Keywords: Resveratrol, endometriosis, transvaginal ultrasound

ndometriosis is defined as the occurrence of ectopic endometrial tissues outside the cavity of the uterus. These islands of endometriosis are composed of endometrial glands surrounded by endometrial stroma, which are capable of responding to a varying degree to cyclical hormonal stimulation. The disease owns an unique pathology of a benign proliferative growth process yet having the propensity to invade the normal surrounding tissues. The incidence varies from 1% to 7% in asymptomatic females to 15% of women with chronic pelvic pain. Endometriosis is a disease of childbearing age. It is extremely rare before menarche and disappears after menopause. Several theories of histogenesis have been proposed although the mechanism by which it develops is still not completely known and no single theory explains all cases of the disease. Trans-tubal regurgitation or retrograde menstruation with neovascularization have been the most accepted of multiple theories put

Dr Alka Gahlot Associate Professor Dept. of Obstetrics and Gynecology Mahatma Gandhi University of Medical Sciences and Technology Jaipur, Rajasthan Address for correspondence *Dr Urman Dhruv Consulting Physician Director, Dept. of Internal Medicine and Diabetes, HCG Hospitals, Mithakhali, Ahmedabad, India

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

forward to explain the pathogenesis of the disease. The symptoms vary according to the site, and do not correlate well with the extent of disease. The classic symptom complex includes dysmenorrhea, dyspareunia, menorrhagia and infertility. About 30% of patients are asymptomatic. Transvaginal ultrasound and laparoscopy generally clinch the diagnosis. Management Minimal asymptomatic cases should be observed for 6-8 months. Infertility should be investigated and treated as necessary. All symptomatic women need treatment, which depends on the age of the patient, need for preserving reproductive functions, severity of the symptoms, extent of disease, response to medical treatment, relief obtained with previous conservative surgery and attitude of the patient towards her problem. The objective of the treatment is to reverse and if possible, eliminate disease process, alleviate symptoms, facilitate childbearing and enable the patient to lead a good quality-of-life. The treatment, therefore, needs to be individualized. A combination of medical and surgical treatment may serve the purpose in most of the cases. The treatment of mild and moderate endometriosis with hormonal preparations may not offer any advantage over expectant management in promoting conception. The medical treatment includes the use of combined oral contraceptive pills, oral progestogens, danazol or

review article gestrinone, gonadotropin-releasing hormone (GnRH) and aromatic inhibitors. Role of Resveratrol in Management of Endometriosis Need for Better Molecules

Endometriosis is one of the most mysterious and fascinating benign gynecological disorders. Although it has been extensively investigated in the past century, it remains an enigmatic disease process. The often subtle and varied appearances of endometriosis can make recognition and surgical staging difficult, thereby casting doubt on the utility of the classification systems that have been developed. Nevertheless, the findings of well-designed clinical trials and recent studies that elucidated the pathogenesis of endometriosis, have enabled a more rational approach to the medical and surgical management of endometriosis. However, the association between endometriosis and infertility is still undefined, and there are scanty data to support the many hormonal and surgical therapies that have been proposed. All these controversies and uncertainties have led to use of certain unconventional or less documented therapies, which may be helpful in managing the disease or preventing the complications. The medical therapy for endometriosis is symptomatic rather than curative and most patients experience pain relapse at suspension of treatment because restoration of ovulation and of physiological levels of estrogen restore the metabolic activity of both eutopic and ectopic endometrium. Unfortunately, these approaches often have only modest success and are associated with significant risk of complications and side effects; consequently, the search continues for new, safe and effective long-term treatments. This leads to development of newer modalities in the management of disease. Pathogenesis of Endometriosis It is widely accepted that peritoneal endometriotic lesions develop from endometrial tissue fragments, which are retrogradley shed through the fallopian tubes during menstruation. During the past few years, numerous studies could demonstrate that the establishment and survival of these lesions is crucially dependent on the formation of blood vessels, which guarantee their oxygen supply. Accordingly, anti12

angiogenic agents of different substance groups are currently discussed as promising candidates for future endometriosis therapy. Besides specific growth factor antagonists, endogenous angiogenesis inhibitors, statins, cyclooxygenase-2 inhibitors and immunomodulators, these antiangiogenic agents also include several phytochemical compounds. The latter ones have been successfully used in traditional medicine without inducing severe side effects. Thus, in view of their favorable risk profile, they may be also highly preferable for the safe treatment of endometriosis patients. What is Resveratrol? Resveratrol is one such natural phytoalexin, which represents one of the most frequently analysed phytochemical compounds in life sciences during the last decades. Because resveratrol exerts a broad spectrum of beneficial effects under various pathological conditions, it has been suggested as a promising therapeutic agent for the treatment of cancer as well as several inflammatory, metabolic and cardiovascular diseases. Sources Resveratrol is a polyphenol synthesized by plants following ultraviolet radiation and fungal infections. Resveratrol (3,5,4â&#x20AC;&#x2122;-trihydroxy-trans-stilbene) is found in red grape skin, Japanese knotweed (Polygonum cuspidatum), peanuts, blueberries and some other berries. A large amount of resveratrol is produced in the skin of grapes to protect the plant against fungal diseases and sun damage; therefore, wine has higher levels of resveratrol compared to other natural food. Overall, red wine contains small amounts of resveratrol, <1-2 mg/8 ounces of red wine. However, red wine has more resveratrol than white wine because red wines are fermented with the grape skins longer than white wines. Hence, many of the antioxidants including resveratrol that are naturally present in the grape skins are extracted into the wine. Resveratrol is also present in the seeds and pomace of grapes. Mechanism of Action Resveratrol is a pleiotropic agent, which dosedependently suppresses the development of new blood vessels. Growing evidence indicates that this compound possesses antineoplastic, anti-inflammatory Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

Review article and antioxidant properties. Resveratrol has also been shown to exhibit profound in vitro and in vivo growth inhibiting and apoptosis - inducing activities in several biological systems, cancer cell lines and animal models of carcinogenesis. These properties have been linked to inhibition of proliferation in association with cell cycle arrest and, in some systems, with increased apoptotic cell death. Mechanisms of action of resveratrol further include multiple cellular targets affecting various signal transduction pathways, including AKT, RPS6KB2 (p70S6K), mitogen-activated protein kinase 1/3 (MAPK1/3; ERK1/2), STAT3, MAPK14 (p38), protein kinase C and peroxisome proliferator-activated receptors (PPARs)-gamma. Importantly, several of these pathways are relevant to the pathophysiology of endometriosis.

stop taking resveratrol two weeks before the surgery and not take it for two weeks after the surgery to reduce the risk of bleeding. Safety of the same has not been established in pregnant or lactating women. Resveratrol has mild estrogenic activity and until more is known, women with cancers and other conditions that are estrogen sensitive should seek medical advice before taking resveratrol.

Evidences

Although a large number of studies show encouraging results, it is still premature to recommend it as an accepted line of treatment because the dose, the purity and their possible adverse effects still remain largely unknown. Large population-based studies are required to establish the recommendation. Randomized controlled trials to establish doses and drug safety will give the answers to these questions in future. To date, although resveratrol is widely used as a nutritional supplement, it has not been approved by the Food and Drug Administration for any clinical application and its long-term safety has yet to be proven.

In a study carried out by Bruner-Tran et al, it was shown that resveratrol reduced development of experimental endometriosis, as evidenced by a decreased proportion of animals with endometriotic lesions, a lower number of lesions and a smaller volume of lesions. These protective effects of resveratrol may be related to various mechanisms such as reduction of proliferation of endometrial cells, increased cell death (e.g., apoptosis) and/or reduced ability to attach and to implant. As the duration of treatment did not matter as far as reduction in number of lesions or volume was concerned, it is likely that the primary mode of action of resveratrol may be related to prevention from, or at least reduction of, implantation of endometrial tissues. In another study, patients who remained symptomatic while using a continuous regimen of a combined pill containing drospirenone and ethinyl estradiol, the concomitant use of resveratrol at a daily dose of 30 mg resulted in a significant reduction in the number of patients reporting the occurrence of pain. This suggests that the combination of oral contraceptives with naturally occurring aromatase inhibitors may show promise for the treatment of endometriosis, particularly in patients who failed to respond satisfactorily to oral contraceptives alone because of the persistence of dysmenorrhea-like pain and breakthrough bleeding. Adverse Effects Patients who have blood disorders, which can cause bleeding, should be monitored by a physician while taking this product. People undergoing surgery should Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

Conclusion Resveratrol is a potent inhibitor of vascularization in endometriotic lesions. This, most probably, causes the suppression of lesion growth. Accordingly, resveratrol represents a promising candidate therapy for future phytochemical treatment of endometriosis.

References 1. Howkins & Bourne Shawâ&#x20AC;&#x2122;s Textbook of Gynecology. 2. TeLindeâ&#x20AC;&#x2122;s Operative Gynecology. 3. Giudice LC, Kao LC. Endometriosis. Lancet. 2004;364 (9447):1789-99. 4. Bruner-Tran KL, Osteen KG, Taylor HS, et al. Resveratrol inhibits development of experimental endometriosis in vivo and reduces endometrial stromal cell invasiveness in vitro. Biol Reprod. 2011; 84(1):106-12. 5. Rudzitis-Auth J, Menger MD, Laschke MW. Resveratrol is a potent inhibitor of vascularization and cell proliferation in experimental endometriosis. Hum Reprod. 2013; 28(5):1339-47. 6. Galle PC. Clinical presentation and diagnosis of endometriosis. Obstet Gynecol Clin North Am. 1989;16(1): 29-42. 7. Chen Y, Tseng SH. Review. Pro- and anti-angiogenesis effects of resveratrol. In Vivo. 2007;21(2):365-70. 8. Smoliga JM, Baur JA, Hausenblas HA. Resveratrol and health - a comprehensive review of human clinical trials. Mol Nutr Food Res. 2011;55(8):1129-41.

CLINICAL STUDY

An Evaluation of Antepartum and Intrapartum Surveillance with nst in Cases of Fetal Growth Restriction and Its Correlation with Perinatal Outcome Jain Meenal, Chandra Mukesh, Singh Saroj, Verma Urvashi, Agarwal Poonam

Abstract An abnormal CTG is an important prediction of poor fetal outcome and is statistically significant to adopt necessary measures to prevent fetal/perinatal morbidity or mortality. Keywords: Fetal growth, cardiotocography, Perinatal Outcome, NST

etal growth restriction (FGR) is one of those leading causes of high risk in pregnancy which can result in significant fetal/perinatal morbidity and mortality if not properly diagnosed and managed. FGR is challenging because of the difficulties in reaching a definitive diagnosis of the cause and planning management. The desire to prevent these complications has prompted the obstetricians to develop methods of assessing fetal condition in utero both antepartum and intra-partum. Fetal heart rate is normally increased or decreased on beat to beat basis by autonomic influences from brainstem centres. Besides cardio regulatory centres in brainstem, fetal heart rate also varies with various physiological and pathological conditions in pregnancy like FGR. Cardiotocography in itself is a useful and indispensable adjunct to monitor the condition of the (endangered) fetus. There has been a continuous debate regarding its usefulness compared with intermittent auscultation. Both methods in principle provide similar information. However, cardiotocography in comparison with intermittent

auscultation results in continuous versus spot-like and objective versus subjective data. Role of cardiotocography: It helps in assessing fetal wellbeing in the womb. The introduction of cardiotocography monitoring to the clinical practice has significantly reduced the incidence of birth asphyxia and other fetal complications. Although a CTG is assessed as reactive using criteria graded for gestational age, this is very reassuring. However, a non-reactive CTG has a poor correlation with fetal status unless overtly abnormal patterns are observed. As far as role of cardiotocography in cases of FGR is concerned, there are not enough evidences to recommend the use of antenatal CTG for fetal assessment in FGR, as CTG changes are manifested relatively late in the disease process and are usually proceeded by abnormal doppler velocity patterns. Despite the lack of evidence, this technique is widely used and provided its limitations are well recognised and traces are interpreted with caution and in combination with other evidence, it may be useful. In the proposed study, our focus will be to analyze the correlation between results shown by CTG (both antepartum and intrapartum) and fetal/perinatal outcome in normal cases as well as in cases of fgr. Material and Methods

*Assosciate Professor **Assistant Professor Dept. of Obstetrics and Gynaecology, Mandya Institute of Medical Sciences, Mandya â&#x20AC; Assosciate Professor Dept. of Pathology, Mandya Institute of Medical Sciences, Mandya Address for correspondence Dr Manohar R Assistant Professor, Dept. of Obstetrics and Gynaecology, Mandya Institute of Medical Sciences, Mandya

The present study was carried out in the Department of Obstetrics and Gynecology, S N Medical College, Agra in Nov. 2014. Selection of Cases Antenatal women of more than 32 weeks gestation with or without fetal growth restriction, attending Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

clinical study the outpatient department and labor room of Department of Obstetrics and Gynecology of S N Medical College, Agra were recruited for the study. Sample Size The study was carried out in the Department of Obstetrics and Gynecology, S N Medical College, Agra. Fifty antenatal patients with >32 weeks of gestation and intranatal cases diagosed as case of fetal growth restriction by USG or clinically formed the study group to be monitored by CTG. The control group on the other hand comprised of 50 antenatal patients (more than 32 weeks gestation or early labour without any FGR) to be monitored by CTG. The fetal outcome was assessed by thick meconium stained liquor, mode of delivery, Apgar score at one and five minutes, NICU admission and perinatal mortality. CTG was repeated weekly/ bi weekly depending upon the severity of disease. Observations According to Table 1, comparing the demographic profile of study and control group: Table 1. Demographic Profile Study group

Control group

27.16 ± 93.59

26.38 ± 103.16

1.66 ± 1.16

1.36 ± 1.02

Mean period of gestation (months)

37.18 ± 186.05

37.18 ± 171.36

Mean per capita income `

634.32 ± 429.93

Mean age (years) Mean parity

530.1 ± 402.99

The mean age in study group was 27.16 years and that in control group was 26.38 years. The mean period of gestation in study group was similar to control group i.e. 37.18 months. The mean per capita income in study group was ` 634.32 and that in control group was ` 530 Thus, the two group were comparable on the basis of demographic profile. According to Table (2) A; comparing the mean fetal heart rate in both groups fetal tachycardia was the

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

more common abnormal heart rate pattern in both the groups but the overall evidence of abnormal heart rate pattern was more common (32%) in study group as compared to control group. In Table 2 (B) comparing beat to beat variability 20% cases in study group showed decreased variability as compared to 8% cases in control group. Similarly, increased variability was more common in study group (10%) as compared to control group (4%). Table 2(A). Mean Fetal Heart Rate Baseline FHR (bpm)

Study group

Control group

No.

110-160

Tachycardia (>160)

Bradycardia (<110)

Table 2(B) Beat to beat variability (bpm)

Study group

Control group

No.

Decreased (<5)

Normal (5-25)

Increased (>25)

Total

100

Table 3 showing types of deceleration in both group, it was found that 72% had no deceleration in study group as compared to 90% in control group. While the most common types of deceleration in study group was late deceleration (16%) as compared to early deceleration (4%) and variable deceleration (8%). In control group, 8% cases had early deceleration 2% had late deceleration and none had variable deceleration. Table 4 elucidates the interpretation of cardiotocography (antepartum and intrapartum) in both groups. 15

clinical study Table 3. Types of Deceleration in Both Groups Deceleration

Study group

Control group

No.

Absent

Early

Late

Variable

Total

100

Table 5 shows the correlation of CTG change with perinatal outcome. In the study group 15% of cases showing reassuring trace had MSL while 80% cases showing nonreassuring trace had MSL. Similarly in the control group only 2% of reassuring trace had MSL as compared to 83.3% cases showing non-reassuring trace. The mean apgar score in study cases with reassuring trace was 6.26 as compared

Table 4. CTG in Both Groups Deceleration

Study group

Control group

Antepartum

Intrapartum

Antepartum

Intrapartum

Reassuring

Nonreassuring

Total

In study group, 60% cases showed reassuring trace in antepartum period and 20% during intrapartum period, Test was non-reassuring in 6% subjects in antepartum period which increased to 14% during the intrapartum period. In control group, 72% cases had a reassuring trace in antepartum period while 2% cases had a non reassuring trace in antepartum period which increased to 10% in intrapartum period. The results were statistically significant.

to 8.26 in control cases showing reassuring trace. The mean apgar score in study cases showing nonreassuring trace was 5.56 as compared to 6 in control group. In both the study and control group only 5% cases underwent cesarean delivery when showing reassuring trace as compared to 60% cases showing non-reassuring trace in study group and 33.31% in control group. In study group 8% of cases showing reassuring trace were admitted in NICU as compared to 4% cases in control group. In cases showing non-reassuring

Table 5. Correlation of Ctg Changes and Perinatal Outcome Study group Reassuring

Non-reassuring

Reassuring

Non-reassuring

83.3

6.26

5.56

6.0

a) Mode of delivery - Caesarean (in %)

33.3

b) Vaginal (in %)

66.6

NICU admission (in %)

20%

Occurrence of MSL (%) Mean Apgar score

Perinatal % mortality (in %)

Control group

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

clinical study pattern 20% cases in study group and 4% cases in control group underwent admission in NICU.

Worker

Year

In study group in cases showing non-reassuring trace the perinatal mortality was 8% as compared to 4% in control group.

Ivanovski et al3

2005

Discussion In our study most of the cases were multigravida between age group 21-25 years. The mean age group in study by padmagirison et al (2006)1 was 27.7. The mean period of gestation was 37.18 weeks. The mean period of gestation in study by padmagirison et al (2000)1 was 34 weeks. Most of the cases in our study belonged to class IV of B J Prasad classification. It is the lower socioeconomic class which is subject to most of the risk factors because of poor nutrition and ignorance about various obstetrical problems. Thirty two percent cases in study group had abnormal fetal heart rate while fetal heart rate in control group was abnormal in 20% cases with statistically significant results. Again 20% cases in study group had abnormal fetal heart rate variability as compared to only 12% cases in control group. In our study group 28% cases showed one or the other types of deceleration in which 4% had early, 16% had late and 8% had variable decelaration while in the control group only 10% had decelarations (8% had early and 2% had late deceleration). Late deceleration indicative of uteroplacental insufficiency were the most common type. In Mahomed K, et al (1994)2 study also the late deceleration were the commonest type of pattern observed in study group. In our study group 60% had a reassuring CTG in ante partum period whereas 6% subject had a non-reassuring trace in antepartum period which increased to 14% in antepartum period. This is a comparison of results of studies of other workers. Coming to the parameters deciding perinatal outcome. It was found that there was 80% chance of having MSL when CTG was found to be nonreassuring in study group. Similarly Apgar scores Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

No of high Interpretation risk cases 78

Reassuring 49 Non-reassuring 29

Pad magirison et al1

2006

Reassuring 35 Non-reassuring 20

Piyamongkol et al4

2006

270

Reassuring 228 Non-reassuring 42

Present study

2012

Reassuring 40 Non-reassuring 42

were lower with non-reassuring CTG as compared to reassuring CTG. In study group cases showing non-reassuring NST 60% cases had a caesarean delivery while 40% cases were delivered vaginally. Of these, two cases had an associated CPD, one patient had complete placenta previa and two patients had malpresentations. In a study by M Moga, L Ples, A Martinesce (2007) 5 in the reactive group, the rate of caesarean was <1.96% but in pathological NST group, it was 92.9%. The number of NICU admission were far greater in cases showing non-reassuring pattern in study group (20%) as compared to those in control group (4%). According to a study by Sood (2002), 6 admission in NICU were 20%. Similarly the percentage of perinatal deaths were greater (8%) in study group as compared to control group. Thus, CTG findings surely are important to assess perinatal outcome. Conclusion Cardiotocography is an effective means for fetal surveillance for pregnancies complicated by fetal growth restriction. An abnormal CTG is an important prediction of poor fetal outcome and is statistically significant to adopt necessary measures to prevent fetal/perinatal morbidity or mortality. References 1. Padmagirison R, Rai L. Fetal Doppler versus NST as predictors of adverse prenatal outcome in severe pre eclipser and fetal growth restriction. J Obst Gyne India. 2006;56(2):134-8.

clinical study 2. Mohamed K, Nyoni R, Mcambo T, et al. Randomized controlled trial of intrapartum fetal heart rate monitoring. BMJ 1992;19:308.

non stress test: A randomized controlled trial. J Med Asia Thai. 2006;89(12):1999-2002.

3. Ivanovski MJ, Lazarevski S, Popovie M. Meddle cerebral artery flow velocity waveform in prediction of adverse outcomes intrauterine growth retarded fetuses. Gynecol Perinatal 2005;14(3):133-99.

5. Moga M, Ples M, Martinescu A. Current- Interpretation and importance of fetal cardiotocographic monitory Available at: http://but.unitbv.ro/BU2008/Arhiva/ BU2006/BULETIN%20B%20PDF/035-BMOGA_06.pdf. Accessed on 22 Oct, 2016..

4. Piyamongkol W, Trungtawatchai S, Chanprapaph P, et al. Comparison of the manual stimulation test and

6. Sood AK. Evaluation of non-stress test in hug risk pregnancy. J Obst Gyne India. 2002;52(2):71-5.

■■■■

Novel Method to Enhance the Outcomes of Assisted Reproduction in Subfertile Women The dream of every married couple is to have their own child, but this beautiful dream becomes a nightmare when possibility of subfertility arises. Assisted reproduction (AR) is highly recommended in this case. In some cases pregnancy occurs after AR, but in most cases the proportion of embryo transferred in the uterus remains small. To overcome this problem, scientist discovered a novel method wherein administration of human chorionic gonadotropin hormone (HCG, synthetic or natural) in the uterus of women undergoing assisted reproduction is performed. Researchers did an extensive online literature search of medical database to scrutinize the results of this novel method. The post hoc analysis demonstrated an increase in live birth rate in subgroup of women having embryo transfer (ET) with HCG dose of 500 IU or greater than those without HCG. Despite the positive results, concrete conclusion could not be drawn due to small size of clinical trials and variable quality of trials.

New Updated ACOG-SMFM Guidelines on Severe Maternal Morbidity The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) have jointly issued a consensus statement on severe maternal morbidity “Severe Maternal Morbidity: Screening And Review” published in the September 2016 issue of Obstetrics and Gynecology. The guidelines have recommended two screening criteria for severe maternal morbidity: Transfusion of 4 or more units of blood and admission of a pregnant or postpartum woman to an ICU.

Good News for Women who Take Estrogen Containing Contraception According to a study, published in Journal of Clinical Endocrinology & Metabolism, it was found that women who use estrogen containing contraception were less prone to vitamin D deficiency than those who don’t. The study revealed that women taking estrogen containg contraception have 20 percent higher plasma level of vitamin D (25-hydroxy vitamin D). Moreover, the level of vitamin D in current users of contraception was higher and was average in women who used contraception in the past. So, all the women around, if you are planning to discontinue your birth control pills, make sure to take adequate amount of vitamin D supplements and consult your doctor.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

caSE REPORT

Postpartum Posterior Reversible Encephalopathy: A Diagnostic Dilemma Ridhi Kathuria*, MC Bansal†

Abstract The disease entity described as posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological diagnosis. Clinical characters include variety of non specific symptoms viz, headache, delirium or confusion, visual disturbances, auditory difficulties, and most important seizures. Vasogenic edema, mostly in the posterior cerebral hemispheres, is thought to be the main cause of the radiological findings. Both the findings and symptoms are largely reversible if appropriate treatment in offered in time. Here is reporting of a case of PRES diagnosed post partum based on clinical signs and findings on MRI scan. This was following an uneventful lower segment caesarean section in a marginally hypertensive patient. The patient was successfully treated with anti-hypertensives, anticonvulsants and supportive therapy. The differential diagnosis of convulsions in the post-partum period is discussed herein. Keywords: PRES; Clinicoradiological; Vasogenic oedema; Postpartum; Hypertensive; MRI.

lthough posterior reversible encephalopathy syndrome (PRES) has gained substantial recognition since its initial description by Hinchey et al1 in 1996, both its clinical spectrum and underlying pathophysiology remain poorly defined. A clinical diagnosis of PRES includes the presence of headache, seizures, encephalopathy, and visual disturbances, as well as radiologic findings of focal reversible vasogenic edema, best seen on magnetic resonance imaging (MRI) of the brain. The syndrome is most commonly encountered in association with acute hypertension, preeclampsia or eclampsia, renal disease, sepsis, and exposure to immunosuppressants.2-8 It has been less commonly described in the setting of autoimmune disease.9-13 The distinctive role of autoimmune disease in the pathophysiology of PRES is often clouded by concurrent hypertension, renal disease and/or the use of immunosuppressants. Despite the syndrome's name, radiographic lesions in PRES are rarely isolated to the “posterior” parieto*Resident Deptt. of Obstetrics and Gynaecology † Professor Deptt. of Obstetrics and Gynaecology National Institute of Medical Sciences, Jaipur, Rajasthan Address for correspondence Dr Ridhi Kathuria C/o Vijay Nursing Home F - 24/25, Sector -3, Rohini New Delhi - 110085. Email: ridhi.kathuria@yahoo.com

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

occipital white matter and instead often involve the cortex, frontal lobes, basal ganglia, and brainstem.14,15 No conclusive evidence supports a clear relationship between clinical conditions and specific imaging findings of severity or location of edema,16 although some studies have suggested correlations such as greater vasogenic edema in normotensive patients5 and a trend for basal ganglia involvement in patients with preeclampsia or eclampsia.16 The underlying pathophysiology of PRES remains elusive. Several theories have been proposed, the most widely accepted of which states that rapidly developing hypertension leads to a breakdown in cerebral autoregulation, particularly in the posterior head region (where there is a relative lack of sympathetic innervation). Hyperperfusion ensues with protein and fluid extravasation, producing focal vasogenic edema.1,10,17 An alternative theory, which has been best characterized in preeclampsia, eclampsia, and sepsis, implicates endothelial dysfunction.18,19 A third theory proposes that vasospasm with subsequent ischemia may be responsible Case Report A 27-year-old G3 P1 L1 A1 patient was a booked case with Antenatal Care being taken at regular intervals. Her BP was recorded in the ranges of 120-140 mmHg (sBP) and 80-90 mmHg (dBP) throughout her ANC period. 19

Case Report She underwent an elective lower segment caesarean section under Spinal anaesthesia. Her blood pressure remained within normal limits through the surgery and in the post-operative recovery period until discharge on the 5th post-operative day. She reported back to OPD on post-operative day 9 with complaints of - bilateral fronto-parietal and occipital headache, moderate to severe in nature, remaining throughout the day. Her BP at presentation was 180/110 mmHg. She was admitted for observation and investigatory work up. Meanwhile, Antihypertensive therapy was started (Inj. Labetalol 20 mg i.v bolus dose, followed by titrated doses based on BP), along with routine supportive therapy and good hydration, to combat post spinal headache, which although was unlikely. On the 10th postoperative day, her BP was recorded at 170/110 mmHg, and she complained of severe constricting headache with 1 episode of GTSC recorded lasting for few seconds. Promptly, treatment on the lines of post partum eclampsia was started, including, Inj Magnesium Sulphate, following the Pritchard Regimen. Her specific investigations included, coagulation profile, renal and liver function tests, serum calcium, serum electrolytes. Investigations for proteinuria were negative. Her Serum uric acid was found elevated (7.5 mg/dl), Serum creatinine was 2.6 mg/dl and blood urea was 72 mg/dl. Fundoscopy did not reveal any papilloedema. CT brain and MRI venogram were normal. MRI-Brain (T2 weighted axial image) revealed hyperintense areas within the cerebellar hemispheres, gray and white matter of bilateral frontal, parietal, occipital regions, suggesting the likelihood of posterior reversible encephalopathy syndrome Her treatment was changed accordingly and she was started on anticonvulsants, anti-hypertensives (calcium channel blockers), anti-oedema measures, supportive therapy - proton pump inhibitors and antibiotics. The patient stabilized by the second day of treatment. Her neurological symptoms completely resolved by the 8th day. 20

She was discharged on anti-hypertensive and anticonvulsive medications. She complied well with the therapy offered. She was followed up for two years and was free of neurological symptoms. Discussion The myriad of differential diagnosis for convulsions in the late post-partum period include - eclampsia, thrombo-embolic events, intracerebral haemorrhage, subarachnoid haemorrhage, intracranial space occupying lesions, head trauma, idiopathic epilepsy, infection (meningo-encephalitis), amniotic fluid embolism, postpartum angiopathy.20,21 There was no past history of epilepsy or head injury. Infection due to dural puncture at the time of spinal anaesthesia could be a possibility, but the total leukocyte count within range of 7,900-9,000 cells/ cumm on various reports, largely rules it out. Post dural puncture spinal headache usually presents within 24-48 hours and adequate hydration generally aids the same. Amniotic fluid embolism generally occurs within 48 hours post partum and symptoms of cardiopulmonary collapse and coagulopathy predominate, which was not seen in the present case. Any intracranial bleed, ischemia due to thromboembolism, vasospasm or space occupying lesions was ruled out with Brain MRI with venogram. One shall consider the possibility of postpartum angiopathy in a post-partum patient with hypertension and headache without proteinuria. Post-partum angiopathy is a form of reversible cerebral segmental vasoconstriction characterised by severe â&#x20AC;&#x153;thunderclapâ&#x20AC;? headaches, seizures, focal neurological deficits and segmental narrowing and dilatation of large and medium sized arteries. Typically, scanning reveals ischemic lesions.20 Posterior reversible encephalopathy syndrome mostly secondary to late post partum eclampsia was suggested as she presented with headache, followed by seizures, with raised serum uric acid levels, raised blood urea due to hypertension most likely but without protienuria. The clinical confusion arises in diagnosis whether the diagnosis should be eclampsia or hypertensive Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

Case Report encephalopathy due to other reasons? What should be the correct treatment? With multi-disciplinary approach we were able to scale down the differential diagnosis. MRI was typically consistent with vasogenic edema, involving typical areas - bilateral occipital, parietal, frontal and cerebellar region. PRES is mostly an under diagnosed and hence untreated condition. The incidence in the peripartum setting is still not known. Literature reports an incidence of PRES in both males and females. Mostly it affects the hypertensive group of patients, followed by patients of Metabolic Syndrome. A few rare cases of normotensive female patients being affected is also reported.22-24 The newer age literature defines eclampsia as a form of posterior reversible encephalopathy syndrome. Although it is seizure that defines eclampsia, some neurologic symptoms can precede the onset of seizure, such as persistent headaches, blurred vision, photophobia and altered mental status. These also define the hallmarks of PRES. The uncertainty also increases because imaging findings of eclampsia have shown varying degrees of hemorrhage, cerebral edema, and vasculopathy.25 However, the reversibility of clinical neurologic signs and neuroradiologic lesions within a few days or weeks postpartum in most cases argues against the existence of true cerebral ischemic necrosis. In fact, the clinical and neuroimaging findings are more consistent with edema.25 This supports the diagnosis of PRES and Eclampsia being a subset of PRES itself. Postpartum reversible encephalopathy syndrome (PRES) following an uneventful pregnancy is a very rare clinical entity. Recognition at the earliest and prompt initiation of the supportive measures can prevent permanent neurologic damage and thereby the associated morbidity. Multidisciplinary care forms the corner stone to achieve a safe motherhood in these women. References 1. Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334(8):494-500. 2. Hauser RA, Lacey DM, Knight MR. Hypertensive encephalopathy: Magnetic resonance imaging

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demonstration of reversible cortical and white matter lesions. Arch Neurol. 1988;45(10):1078-83. 3. Schwaighofer BW, Hesselink JR, Healy ME. MR demonstration of reversible brain abnormalities in eclampsia. J Comput Assist Tomogr. 1989;13(2):310-12. 4. Raroque HG, Jr, Orrison WW, Rosenberg GA. Neurologic involvement in toxemia of pregnancy: Reversible MRI lesions. Neurology 1990;40(1):167-9. 5. Bartynski WS, Boardman JF, Zeigler ZR, et al. Posterior reversible encephalopathy syndrome in infection, sepsis, and shock. AJNR Am J Neuroradiol. 2006;27(10): 2179-90. 6. Furukawa M, Terae S, Chu BC, et al. MRI in seven cases of tacrolimus (FK-506) encephalopathy: utility of flair and diffusion-weighted imaging. Neuroradiology 2001; 43(8):615-21. 7. Small SL, Fukui MB, Bramblett GT, et al. Immunosuppression-induced leukoencephalopathy from tacrolimus (FK506). Ann Neurol. 1996;40(4): 575-80. 8. Appignani BA, Bhadelia RA, Blacklow SC, et al. Neuroimaging findings in patients on immunosuppressive therapy: Experience with tacrolimus toxicity. AJR Am J Roentgenol. 1996;166(3):683-8. 9. Kur JK, Esdaile JM. Posterior reversible encephalopathy syndromeâ&#x20AC;&#x201C;an underrecognized manifestation of systemic lupus erythematosus. J Rheumatol. 2006;33(11):2178-83. 10. Primavera A, Audenino D, Mavilio N, et al. Reversible posterior leucoencephalopathy syndrome in systemic lupus and vasculitis. Ann Rheum Dis. 2001;60(5):534-7. 11. Pozo-Rosich P, Villoslada P, Canton A, et al. Reversible white matter alterations in encephalopathy associated with autoimmune thyroid disease. J Neurol. 2002;249(8):1063-5. 12. Tateishi Y, Iguchi Y, Kimura K, et al. A case of autoimmune thyroid disease presenting posterior reversible encephalopathy syndrome. J Neurol Sci. 2008;271(1-2): 203-6. 13. Bohnen NI, Parnell KJ, Harper CM. Reversible MRI findings in a patient with Hashimoto's encephalopathy. Neurology. 1997;49(1):246-7. 14. Lee VH, Wijdicks EF, Manno EM, et al. Clinical spectrum of reversible posterior leukoencephalopathy syndrome. Arch Neurol. 2008;65(2):205-10. 15. Bartynski WS, Boardman JF. Distinct imaging patterns and lesion distribution in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol. 2007;28(7):1320-7.

Case Report 16. Mueller-Mang C, Mang T, Pirker A, et al. Posterior reversible encephalopathy syndrome: Do predisposing risk factors make a difference in MRI appearance? Neuroradiology 2009;51(6):373-83.

21. Krishnamoorthy U, Sarkar PK, Nakhuda Y, et al. Posterior reversible encephalopathy syndrome (PRES) in pregnancy: A diagnostic challenge to obstetricians. J Obst Gynaec. 2009;29(3):192-4.

17. Schwartz RB, Jones KM, Kalina P, et al. Hypertensive encephalopathy: Findings on CT, MR imaging, and SPECT imaging in 14 cases. AJR Am J Roentgenol. 1992;159(2):379-83.

22. Servillo G, Striano P, Striano S, et al. Posterior reversible encephalopathy syndrome (PRES) in critically ill obstetric patients. Inten Care Med. 2003;29(12):2323-6.

18. Dekker GA, Sibai BM. Etiology and pathogenesis of preeclampsia: Current concepts. Am J Obstet Gynecol. 1998;179(5):1359-75.

23. Jamie MN, Shervin E. Late Postpartum Eclampsia with Posterior Reversible Encephalopathy Syndrome. Hospital Physician. June 2007;45-49.

19. Aird WC. The role of the endothelium in severe sepsis and multiple organ dysfunction syndrome. Blood 2003;101(10):3765-77.

24. Shakuntala PN, Isaac P, Rashmi, et al. A rare case of reversible encephalopathy syndrome accompanying late postpartum eclampsia or hypertensive encephalopathyA clinical dilemma. Online Journal of Health and Allied Sciences. 2012;11(1):20.

20. Prout RE, Tuckey JP, Giffen NJ. Reversible posterior leucoencephalopathy syndrome in a peripartum patient. Inter J Obst Anes. 2007;16:74- 76.

25. Cipolla MJ. Cerebrovascular Function in Pregnancy and Eclampsia. Hypertension - Am Heart Assoc. 2007;50: 14-24.

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Possibility of Spread of Zika Virus Infection Via Sexual Exposure The outbreak of zika virus infection has created a chaos around everywhere. It is transmitted through mosquito bite (Aedes aegypti and Aedes albopictus) and mothers infected with it give birth to babies with a congenital defect called microcephaly. Around the globe, clinical trials on zika virus are still in progress, hitherto there is no potential drug against zika virus infection. Recently in a journal Cell, a study was published that put forward an important fact about zika virus that it can also flourish in vagina because vaginal fluid provides best habitat for growth of zika virus. The following study was conducted on mice but not on human, yet people should be aware of the fact that there is a possibility of zika infection via sexual exposure with infected female.

Fracking Chemicals are ‘Fracturing’ Rocks and Female Reproductive System Simultaneously A study published in journal, Endocrinology, demonstrates the effects of exposure to fracking chemical (FC) on the reproductive system of female mice. FC is used in the process of hydraulic fracturing of the rocks, to extract shale gas/oil from it. The evidentiary support revealed that even a minimal amount of FC is capable of producing developmental and reproductive disorders in the mice. As compared to control group the level of hormones prolactin, luteinizing hormone and follicle stimulating hormone (FSH) was found lower in female mice exposed to FC. Moreover fewer ovarian follicles, inappropriate follicle activation and finally death of ovarian follicles occurred in test female mice.

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caSE REPORT

Vaginal Leiomyoma: An Unusual Case Presentation Kavyashree G,* Manohar R,** Kala Bâ&#x20AC;

Abstract Vaginal leiomyomas are rare to exist as a primary tumor of vagina. Approximately 300 cases have been reported in world literature. They usually arise from anterior vaginal wall and are firm to hard in consistency with varied clinical presentations. Here, we report a case of vaginal leiomyoma presenting as mass per vagina, diagnosed post operatively with the help of histopathological and immuno histochemical studies. Keywords: Vaginal Leiomyomas, solid tumors, Microscopy, leiomyomas

aginal leiomyomas are rare benign solid tumors of the vagina. It is usually located in the anterior wall and rarely in the lateral wall and vulvar region. Its etiology is unknown, though some authors have speculated that it could be due to residual embryonic blood vessel tissues and smooth muscle fibres.1 Case Report Smt. XX, a 45-year-old lady was referred from surgery OPD as a case of prolapse uterus. She gave history of mass per vagina since two years, which was not associated with white discharge per vagina, menstrual disturbances and urinary symptoms. Her medical and surgical history were unremarkable.

1 cm below the external urethral meatus and upto the cervico-vaginal junction and was non-tender on palpation. Under spinal anaesthesia patient was put in lithotomy position, bladder was catheterized. A semi-circular incision was made at the anterior vaginal wall and mass was enucleated and removed easily. Anterior vaginal wall closure was done using 2-0 vicryl and hemostasis secured. Specimen was sent for histopathological examination.

O/E - A mass about 5*4 cm, cystic-firm in consistency was situated in the anterior vaginal wall, about Gross morphology: Oval grey white firm soft tissue mass, measuring 5*3 cm.

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Cut section: Shows well circumscribed homogenous grey white having whorling. 23

Case Report

Microscopy â&#x20AC;&#x201C; Spindle cells showing nuclear palisading mimicking neurofibroma. Initial histopathological report was in favour of neurofibroma of the anterior vaginal wall which is a rare entity. (H & E, 40X). Further immuno-histochemistry studies and smooth muscle markers were studied which was in favor of leiomyoma of the anterior vaginal wall.

posterior wall and may present even after hysterectomy and in the form of ischiorectal abscess too. Very often diagnosis of them is difficult to made pre-operatively.2 Vaginal leiomyomas vary from 0.5-15 cms in diameter. They may occur anywhere within the vagina and usually arise in the smooth muscle layer of the midline anterior vaginal wall. Vaginal leiomyomas can be asymptomatic or present with symptoms, such as dyspareunia, pain, or dysuria. Usually the tumor is single and most are small and slow growing. Vaginal leiomyomas are estrogendependent tumors. These tumors can grow rapidly during pregnancy and regress after menopause.3 The tumors are usually moderately firm, but since they may undergo degenerative changes that occur in the uterus, they may vary in consistency from firm to soft.4 Surgery through the vaginal approach has generally been recommended as the treatment of choice for these tumors.5 In this case the diagnosis of anterior vaginal wall cyst was made pre operatively as the mass was cystic-firm in consistency and situated in the anterior vaginal wall. Thus, histopathological and immuno-histochemical studies play a major role in diagnosing the leiomyomas. Conclusion

Figure 1. Spindle cells in fascicles with elongated nuclei and eosinophilic cytoplasm (H&E, 40X).

Vaginal leiomyomas can rarely present as mass per vagina and it should be kept in mind as a differential diagnosis. The pre-operative diagnosis of vaginal leiomyomas is difficult and can be diagnosed post operatively with the help of histopathological examination and immune histochemical studies. References

Figure 2. Strong cytoplasmic membrane positivity for SMA (40X).

Discussion Vaginal leiomyomas are very rare with approximately 300 cases reported in the world literature. In the vagina they commonly present through the anterior wall and next through the lateral wall. They may arise from the

1. Dane C, Kiray RM, Ozkuvanci U, et al. Vaginal leiomyoma in pregnancy presenting as a prolapsed vaginal mass. Honkong Med J. 2012;18(6):533-5. 2. Shrivastava D, Bhute S, Kakani A, et al. A rare case of vaginal leiomyoma diagnosed post operatively. J South Asian Fed Obst and Gyna. 2011;3(3):143-4. 3. Jeong-Hoon Bae, Choi SK, Kim JW. Vaginal leiomyoma: A rare case report and review of the literature. J Womenâ&#x20AC;&#x2122;s Med. 2008;1(2):92-4. 4. Oruc S, Karer O, Kurtul O. Coexistence of a prolapsed pedunculated cervical myoma and pregnancy complications: a case report. J Rep Med. 2004;49:575-7. 5. Hameed N: leiomyoma of the vagina. Journal Ayub Medical College Abbottabad 2003;15(2):63-4.

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caSE REPORT

Prolapsed Huge Cervical Fibroid with Acute Red Degeneration Mimicking Uterine Inversion Neerja Varshney*, Meenakshi Sharma**, Vandana Jainâ&#x20AC;

Abstract Acute red degeneration in a large prolapsed cervical hemorrhage can mimick uterine inversion and presents as emergency where an emergency hysterectomy can be life saving. Keywords: Cervical Fibroid, Uterine, Vaginal myomectomy, hysterectomy

ervical leiomyoma are usually single, interstitial or subserous but rarely become sub mucous and can rarely present as prolapsed or inverted uterus. We present a case report of huge prolapsed cervical fibroid with acute red degeneration requiring emergency hysterectomy. Case Report Mrs X, 45-years, P3L3, presented in gynecological OPD with the complaints of a painless mass coming out per-vaginum for two months associated with offensive purulent discharge and menometrorrhagia, loss of weight and appetite. There was no history of bowel or bladder complaints or any history of significant medical or surgical illnesses in the past. The patient was thin built (BMI 17.15 Kg/m2), pale and malnourished. The vitals and systemic examination were within normal limits. On abdominal examination, pelvic mass 14 weeks gravid uterus size was palpated in suprapubic region. Per speculum examination showed an oblong, 6 x 7 cm size, firm, non tender mass in vagina and a portion (3 x 4 cm) of it was lying outside the introitus. The mass was irreducible with areas of ulceration, hemorrhage, and offensive purulent discharge. On bimanual examination the mass was arising from right lip of cervix and posterior wall of

*CMO, (NFSG), Incharge, Dept. Obs and Gynae ** Junior Specialist, Dept. Obs and Gynae â&#x20AC; Senior Resident, Dept. Obs and Gynae Address for correspondence *CMO, (NFSG), Incharge, Dept. Obs and Gynae Dr Hedgewar Arogya Sansthan, Govt NCT New Delhi

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uterus. The uterus was multiparous size separately from the mass and bilateral fornices were free. Investigations showed Hb - 8.0 gm%, TLC-14,400/ cm3, ESR - 70 mm with microcytic hypochromic anemia. Transvaginal sonograph revealed enlarged uterus showing multiple hypoechoic lesions within the myometrium with submucosal component. Surgery was planned after controlling the local infection and blood transfusions. One day after admission patient complained of sudden acute increase in the prolapsed mass outside the vagina with bleeding from the fibroid. On examination uterus was not palpable per abdominally and the prolapsed mass had increased in size upto 15 x 20 cm with active bleeding from the prolapsed mass. She was immediately taken up for emergency hysterectomy by a combined abdomino-perineal route in view of the active bleeding and suspicion of uterine inversion. Intraoperatively uterus was bulky and the contour of fundus maintained. Ligation of uterine vessels was tried but it was not approachable because of the prolapsed mass pulling down the uterus. Vaginal myomectomy was performed and the rest of the hysterectomy was completed abdominally. Cut section of the uterus revealed cervical fibroid polyp of 15 x 20 cm with red degeneration arising from the posterior wall of uterocervical junction weighing 1.1 kg. The histopathology of the resected specimen showed leiomyoma of uterus with areas of hemorrhage and infarction. Post operative period of patient was uneventful. Discussion Cervical leiomyoma may elongate, prolapse and present with emergency like acute retention of urine 25

Case Report and hemorrhage. Prolapsed fibroid also has been reported after use of GnRH therapy1and uterine artery embolization2. In our case there was an acute increase in size of prolapse spontaneously with hemorrhage requiring emergency hysterectomy. Vaginal myomectomy has been recommended as the initial treatment of choice for prolapsed pedunculated submucous myoma, except in those cases in which other indications necessitate an abdominal approach3. In patients requiring hysterectomy, vaginal route is preferable to abdominal route as the operating-time, cost, post operative fever, and need for analgesia are reported to be less without any significant difference in blood loss or other complications4,. In our case, abdominoperineal approach was used due to acute hemorrhage and the confusion in diagnosis with suspicion of uterine inversion and inaccessibility of

the pedicle of cervical myoma by a solitary vaginal route. References 1. Kriplani A, Agarwal N, Parul D, instead, write et al. Prolapsed leiomyoma with severe haemorrhage after GnRH analogue therapy. J Obstet Gynaecol. 2002;22(4):449-51. 2. Pollard RR, Goldberg JM. Prolapsed cervical myoma after uterine artery embolization. A case report. J Reprod Med 2001;46:499-500. 3. Ben-Baruch G, Schiff E, Menashe Y, instead, write et al. Immediate and late outcome of vaginal myomectomy for prolapsed pedunculated submucous myoma. Obstet Gynecol 1988; 72:858-61. 4. Benassi L, Rossi T, Kaihura CT, et al. Abdominal or vaginal hysterectomy for enlarged uteri: A randomized clinical trial. Am J Obstet Gynecol. 2002;187:1561-156.

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Effect of Letrozole on Moderate and Severe Early-Onset Ovarian Hyperstimulation Syndrome in High Risk Women Letrozole is more effective than aspirin in decreasing the incidence of moderate and severe early-onset ovarian hyperstimulation syndrome, suggests a new study published online in the American Journal of Obstetrics and Gynecology. Researchers noted that the incidence of ovarian hyperstimulation syndrome was 90.2% in women receiving aspirin, compared to 80.4% in women receiving letrozole. Moderate and severe ovarian hyperstimulation syndrome was also higher in the aspirin group (45.1%), compared to the letrozole group (25.0%). The duration of luteal phase was shortened in letrozole group compared to aspirin group (8.1±1.1 days versus 10.5±1.9 days). The vascular endothelial growth factor level was significantly higher in letrozoletreated group than aspirin-treated group (0.49±0.26 versus 0.42±0.22).

Laparoscopic Management of Adnexal Pathology Complicating Pregnancies Laparoscopy is the preferred option for exploration and treatment of adnexal masses especially between 14 to 25 weeks of gestation, reported a new study published in the International Journal of Reproduction, Contraception, Obstetrics and Gynecology. There was no intra- or post-operative complication and successful obstetric outcome was noted in all the patients with no complications.

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Medicolegal

Management of Medico-Legal Cases Issue 5 Resolving Patient-Doctor Conflict

A complaint was filed by the wife of a patient in the medical council stating that the treating doctors of the hospital, to which her husband was referred to, were negligent in their treatment; as a result of which her husband died on the same day he was hospitalized.

Judge: Proceed

Course of Events

Complainant: My patient died after a cardiac intervention. Both this GP and the specialist he referred me to did not explain to us about the outcome.

Patient X was referred to Hospital 1 from Hospital 2 on 8.6.2005. He had extensive anterior wall MI and was in cardiogenic shock (on dopamine support) on admission. The patient was taken to cath lab for examination. He developed complete heart block in transit and became breathless, consequent to which he was put on ventilator and a temporary pacemaker was implanted. An intra-aortic balloon pump was also placed. A coronary angiography was done.

Doctor: It may have been a misunderstanding. We did counsel the relatives of the patient present at that time. Judge: Misunderstanding might have caused agitation in the mind of the complainant that has resulted in this complaint. Since most of the misunderstandings have been cleared to the satisfaction of both parties and they have agreed to amicably resolve the financial issue, the case is dismissed. Lesson: In an order DMC/DC/F14/237/2006, the DMC mediated and resolved the conflict between the patient and the team of doctors. The council also allowed them to resolve their financial issues amicably outside the DMC. Case Overview A complaint was submitted to the Delhi Medical Council by the Complainant alleging medical negligence in the treatment administered to her husband (Patient X) at Hospital 1, subsequent to which the patient died. The complaint was forwarded to DMC by the Medical Council of India The council examined the complaint, written statements of Dr A, Dr B including a copy of medical records of Hospital 1 and Hospital 2. Drs C, D and E were heard in person. The son and sister-in-law of the patient were also heard in person. Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

Coronary angiography findings: Double vessel disease with 100% proximal occlusion in left anterior descendingÂ artery (LAD) with thrombus burden and left circumflex (LCX) 90% stenosis in distal atrioventricular groove. Procedure undertaken: Percutaneous transluminal coronary angioplasty (PTCA) and stenting along with thrombosection of LAD with integrilin infusion + other drug support. However, despite the measures taken, patient X succumbed to his illnesses on the same day (8.6.2005) at 8.40 p.m. Council Observations

The Council observed that angioplasty was the only treatment option for the patient at that point when he came to Hospital 1. It was therefore the right management approach. The patient was in a serious condition and there were associated risks with the management, which were communicated to the relatives of the patient present at that time. 27

Medicolegal The treatment given to the patient was in line with known professional practices and so, no medical negligence can be established. The complaint may have been filed due to misunderstanding, which might have caused distress to the complainant.

Council Judgment

The complaint was disposed as most of the misunderstandings were cleared to the satisfaction of both parties during the hearing. The two parties also agreed to amicably resolve the financial issue. Reference 1. DMC/14/2/Comp. 237/2006 dated 22nd August2006.

Principles of Informed Consent Three essential elements of a valid informed consent are:1 zz

Information disclosure: The patient must be properly informed

Voluntariness: Consent must be voluntary

Decision making capacity: The patient must have the mental capacity to give consent

The level of disclosure for each patient is individualized. The relevant information must be provided truthfully and conveyed in a language that the patient can understand using non-scientific terms.2 The information disclosed should include:2,3 zz zz zz zz zz zz zz zz

The condition/disorder/disease that the patient is having/suffering from Necessity for further testing Natural course of the condition and possible complications Consequences of non-treatment Treatment options available Potential risks and benefits of treatment options Duration and approximate cost of treatment Expected outcome

Follow-up required

Inability to accurately predict results

Exceptions to informed consent

Informed consent is not required4

In emergency situations, where a delay in treatment in order to obtain consent would harm the patient. When the patient waives the consent process: Waivers should be documented in writing to protect the doctor. If a doctor believes that the patient’s emotional and physical condition could be adversely affected by full disclosure of the treatment risks, then disclosure may be legally withheld. This principle is called “therapeutic privilege.” References 1. Gupta UC. Informed consent in clinical research: Revisiting few concepts and areas. Perspect Clin Res 2013;4(1):26-32. 2. Satyanarayana Rao KH. Informed consent: An ethical obligation or legal compulsion? J Cutan Aesthet Surg 2008;1(1):33-5. 3. Abbott R, Cohen M. Medico-legal issues in cardiology. Cardiol Rev. 2013;21(5):222-8. 4. Tan SY. Medical malpractice: A cardiovascular perspective. Cardiovasc Ther. 2012;30(3):e140-5.

What the Supreme Court of India has to Say In Samira Kohli vs Dr. Prabha Manchanda and Anr SCI, Civil Appeal No. 1949 of 2004, 16.01.2008, the Supreme Court of India has observed: “32 (ii). The ‘adequate information’ to be furnished by

the doctor (or a member of his team) who treats the patient, should enable the patient to make a balanced judgment as to whether he should submit himself to the particular treatment or not. This means that the

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Medicolegal Doctor should disclose a) Nature and procedure of the treatment and its purpose, benefits and effect; b) Alternatives if any available; c) An outline of the substantial risks; and d) Adverse consequences of refusing treatment.

which may persuade a patient to undergo a fanciful or unnecessary treatment. A balance should be achieved between the need for disclosing necessary and adequate information and at the same time avoid the possibility of the patient being deterred from agreeing to a necessary treatment or offering to undergo an unnecessary treatment.”

But there is no need to explain remote or theoretical risks involved, which may frighten or confuse a patient and result in refusal of consent for the necessary treatment. Similarly, there is no need to explain the remote or theoretical risks of refusal to take treatment

“22. (iii) In order to recover damages for failure to give warning the plaintiff must show not only that the failure was negligent but also that if he had been warned he would not have consented to the treatment.”

What does the MCI Code of Ethics Regulations 2002 has to Say Regulation 2.3 Prognosis of Chapter 2 (Duties of physicians to their patients) states: “The physician should neither exaggerate nor minimize the gravity of a patient’s condition. He should ensure himself

that the patient, his relatives or his responsible friends have such knowledge of the patient’s condition as will serve the best interests of the patient and the family.”

Communication Strategies to Redirect an Emotionally Charged Clinical Encounter Strategy Active listening

Physician actions

Examples

Understand the patient’s priorities, let the patient talk without interruption, recognize that anger is usually a secondary emotion (e.g., to abandonment, disrespect)

“Please explain me the issues that are important to you right now.” “Help me to understand why this upsets you so much.”

Validate the emotion and empathize Name the emotion; if you are wrong, the “I can see that you are angry.” with the patient (understanding, not patient will correct you; disarm the intense “You are right—it’s annoying to sit and wait necessarily sharing, the emotion with emotion by agreement, if appropriate in a cold room.” the patient) “It sounds like you are telling me that you are scared.” Explore alternative solutions

Engage the patient to find specific ways to “If we had told you that appointments were handle the situation differently in the future running late, would you have liked a choice to wait or reschedule?” “What else can I do to help meet your expectations for this visit?” “Is there something else you need to tell me so that I can help you?”

Provide closure

Mutually agree on a plan for subsequent “I prefer to give significant news in person. visits to avoid future difficulties Would you like early morning appointments so you can be the first patient of the day?” “Would you prefer to be referred to a specialist, or to follow up with me to continue to work on this problem?” Adapted from Am Fam Physician. 2013 Mar 15;87(6):419-25.

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Practice guidelines

ACP Provides Guidance on Nonsurgical Treatment of Urinary Incontinence in Women

he prevalence of urinary incontinence (UI) ranges from 25% in females 14 to 21 years of age to 75% in women 75 years and older, although it may actually be higher than reported because some evidence has shown that one-half or more of women with UI do not tell their physicians about symptoms. There is an increased risk of UI with pregnancy and with pelvic floor trauma from delivering vaginally, as well as in women who are menopausal or obese; who have a urinary tract infection, functional or cognitive impairment, chronic cough, or constipation; or who have had a hysterectomy. There are two categories of UI: stress, which is caused when the urethral sphincter does not work because of intra-abdominal pressure, and urgency, which is associated with the urgent need to urinate. Stress UI can cause urine to leak when laughing, coughing, or sneezing. Mixed UI is stress and urgency UI combined. The American College of Physicians (ACP) has provided recommendations for nonsurgical treatment of UI in women. Treatment of UI is aimed at achieving, or at least improving, symptoms. It is deemed effective if it reduces the number of episodes by at least one-half.

Nonpharmacologic Therapy Nonpharmacologic therapy options for UI, which have been shown to be effective and have a lower risk of adverse effects, include lifestyle changes (weight loss and physical activity), bladder training, pelvic floor muscle training (PFMT), continence services, vaginal cones, and medical devices. There have not been enough data to compare various types of nonpharmacologic therapies or to compare nonpharmacologic with pharmacologic therapies.

Bladder Training Bladder training, which is behavioral treatment that entails having women lengthen the time between urinating, is recommended in women with urgency UI, with low-quality evidence indicating improvement vs. no treatment. Pelvic Floor Muscle Training Based on high-quality evidence, PFMT consisting of educating women on the voluntary contraction of pelvic floor muscles should be first-line treatment for stress UI, and PFMT combined with bladder training is recommended for mixed UI. Studies have shown that, compared with no treatment, PFMT improved continence rates and quality of life in women with stress UI. It was also shown to have an effectiveness greater than five times that of no treatment for improving stress UI. Additionally, PFMT can be combined with biofeedback from vaginal electromyography, which allows patients to see when they are contracting their pelvic floor muscles correctly; this also has been shown to improve stress UI. In women with mixed UI, PFMT plus bladder training led to continence and improved UI more often than no treatment. Continence Services

Lifestyle Changes

Continence services enlist the assistance of health care professionals who have knowledge and experience in diagnosing and managing UI; however, studies have shown that, compared with no treatment, it provided no statistically significant improvement in continence or UI.

In women with UI who are obese, weight loss and exercise are recommended, with moderate-quality

Vaginal Cones, Medical Devices, And Other Treatments

Address for correspondence xxxx

evidence indicating improvement in symptoms. Additionally, no associated harms were apparent with this intervention.

Data are insufficient to make a conclusion about the effectiveness, compared with no treatment, of vaginal cones, pessaries, or intravaginal and intraurethral Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

PRACTICE GUIDELINES devices for treating stress UI, or of programs for behavioral changes, diets supplemented with soy, or acupuncture for mixed UI. Pharmacologic Treatment

Systemic pharmacologic therapy is not recommended in women with stress UI; however, based on highquality evidence, it is recommended in women with urgency UI in whom bladder training has failed. Decisions regarding medication should be based on tolerability, adverse effects, ease of use, and cost. Although it has some effectiveness, it should be noted that pharmacologic therapy has adverse effects, with evidence indicating that women may discontinue therapy as a result. Medication options include antimuscarinics, beta3-adrenoceptor agonists, duloxetine (Cymbalta), and estrogen. Data are insufficient to conclude which medications are most effective and safe. Stress UI There are not enough data on topical estrogen preparations regarding the effectiveness for treating stress UI; however, vaginal estrogen appears to improve continence and UI. Compared with placebo, transdermal formulations made stress UI worse and estradiol implants did not provide improvement. Estrogen tablets and ovules improved UI compared with placebo, with tablets also increasing continence. Intravaginal estriol combined with PFMT was more effective for attaining continence compared with estriol monotherapy, based on low-quality evidence. Highquality evidence showed that there was no statistically significant improvement in UI with duloxetine vs. placebo; however, based on low-quality evidence, it was shown to improve quality-of-life in women without severe UI or overactive bladder.

Urgency UI Antimuscarinics. Based on high-quality evidence and in comparison with placebo, darifenacin (Enablex), fesoterodine (Toviaz), and tolterodine (Detrol) improved UI; darifenacin improved quality of life; and oxybutynin (Ditropan XL), solifenacin (Vesicare), tolterodine, and trospium attained continence more often. Additionally, fesoterodine improved UI more than tolterodine. Based on moderate-quality evidence and in comparison with placebo, fesoterodine attained continence more often, and oxybutynin and propiverine (not available in the United States) improved UI. Additionally, fesoterodine attained continence more often than tolterodine. Beta3-adrenoceptor Agonists. Based on moderate-quality evidence and in comparison with placebo, mirabegron (Myrbetriq) improved UI and attained continence more often. Other. There are not enough data to make conclusions about the effectiveness of resiniferatoxin or nimodipine (Nimotop) as UI therapy. Adverse Effects Among the different classes of medication, adverse effects tended to be similar. Common adverse effects of antimuscarinics were dry mouth, constipation, and blurred vision. In addition, tolterodine also increased the likelihood of hallucinations in the patient. With regard to beta3-adrenoceptor agonists, patients taking mirabegron experienced more nasopharyngitis and gastrointestinal problems than those taking placebo. Although pharmacologic therapy can improve UI, and possibly can provide complete continence, patients may stop treatment because of adverse effects.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

Journal Scan

Predicting the Effect of Maternal DHA Supplementation to Reduce Early Preterm Birth: Results of Within Country Randomized Controlled Trials from Australia and USA The DHA to Optimize Mother Infant Outcome (DOMInO) and Kansas DHA Outcomes Study (KUDOS) were two randomized controlled trials wherein mothers were supplemented with 800 and 600 mg DHA/day, respectively, or a placebo during pregnancy. DOMInO was conducted in Australia while KUDOS in the United States. Both trials noticed an unforeseen and statistically significant reduction in early preterm birth (ePTB; i.e., birth before 34 weeks gestation). Yell and and colleagues employed a novel Bayesian approach to estimate statistically derived low, moderate or high risk for ePTB, and to investigate the differences between the DHA and placebo groups. In both trials, the model predicted that DHA would significantly reduce the expected proportion of deliveries in the high risk group under the trial conditions of the parent studies. Researchers estimated that among the next 300,000 births in Australia, 1112 ePTB (95% credible interval 51-2189) could be avoided by providing DHA. Likewise in the USA, researchers estimated that 106,030 ePTB (95% credible interval 6400 to 175,700) could be avoided with DHA. Source: Yelland LN, Gajewski BJ, Colombo J, et al. Predicting the effect of maternal docosahexaenoic acid (DHA) supplementation to reduce early preterm birth in Australia and the United States using results of within country randomized controlled trials. Prostaglandins Leukot Essent Fatty Acids. 2016 Sep;112:44-9.

Impact of DHA-enriched Formula on Maternal and Fetal Blood DHA Levels: An Analysis of Pregnant Women with Gestational Diabetes Mellitus The level of docosahexaenoic acid (DHA) in phospholipids of maternal and fetal red blood cells and fetal plasma is generally jeopardized due to gestational diabetes mellitus (GDM). This may have a detrimental effect since DHA is significant for 32

fetal neuro-visual development. Researchers, in this study, evaluated whether this abnormality could be corrected by supplementation with DHA-enriched formula. In all, 138 women with GDM were recruited from Newham University Hospital, London. All the participants were given two capsules of DHAenriched formula (active-group) or high oleic acid sunflower seed oil (placebo-group) from diagnosis until delivery. Researchers assessed maternal (baseline and delivery) and fetal (cord blood) red blood cell and plasma phospholipid fatty acid composition, and neonatal anthropometry. Overall, 114 women (58 active, 56 placebo) completed the trial. The active-group demonstrated significantly higher level of DHA in plasma phosphatidylcholine (4.5% vs 3.8%), red blood cell phosphatidylcholine (2.7% vs 2.2%) and phosphatidylethoanolamine (9.5% vs 7.6%) in comparison with the placebogroup. There was no difference in cord plasma and red blood cell phospholipid DHA between the two groups. The neonates of the two groups of women exhibited comparable anthropometric measurements at birth. Daily supplementation of 600Â mg DHA seemed to improve maternal but not fetal DHA status in pregnancy complicated by GDM. This points out that DHA transfer across the placenta maybe impaired in women with GDM. Researchers advocated that babies of women with GDM, especially those not suckling, like the babies born prematurely, require formula milk fortified with a higher DHA concentration. Source: Min Y, Djahanbakhch O, Hutchinson J, et al. Efficacy of docosahexaenoic acid-enriched formula to enhance maternal and fetal blood docosahexaenoic acid levels: Randomized double-blinded placebo-controlled trial of pregnant women with gestational diabetes mellitus. Clin Nutr. 2016 Jun;35(3):608-14.

Prenatal DHA Supplementation and Infant Attention There have been mixed results from randomized trials on the effects of prenatal docosahexaenoic

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

jOURNAL sCAN acid (DHA) on infant cognition. Most of the trials have used global standardized outcomes, which may not be sensitive to effects of DHA on specific cognitive domains. Therefore, in the present study, women were randomized to 600 mg/d DHA or a placebo for the last two trimesters of pregnancy. Infants of these mothers were followed on tests of visual habituation at 4, 6, and 9 months of age. DHA supplementation did not appear to influence look, duration or habituation parameters; however, infants of supplemented mothers maintained high levels of sustained attention (SA) across the first year; SA declined for the placebo group, on the contrary. Infants of supplemented mothers also demonstrated significantly reduced attrition on habituation tasks, especially at six and nine months. Therefore, it appears that prenatal DHA may positively affect infants' attention and regulation of state. Source: Colombo J, Gustafson KM, Gajewski BJ, et al. Prenatal DHA supplementation and infant attention. Pediatr Res. 2016 Jul 27.

Environmental and Occupational Exposure to Bisphenol A and Endometriosis The current study was designed to give a first data set of bisphenol A (BPA) levels in the peritoneal fluid of patients suffering from endometriosis. The study also aimed to explore the relationship between BPA exposure and endometriosis. Sixty eight patients with endometriosis and 60 endometriosis-free subjects (control group) were given a questionnaire investigating the occupational context, life environment, and habits. Urine and peritoneal fluids samples were collected and analyzed by GC/MSMS for BPA dosage. Out of all the factors explored, some of the environmental/lifestyle risk factors, including closeness to industries/activities at risk, were associated with an increase in endometriosis; smoking resulted as protective factor; use of food plastic boxes did not appear to affect the onset of pathology. There was a statistically significant association between occupational exposure summarising all examined risk factors (working activity, personal protective Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

equipment, seniority) and endometriosis. Contrasting results were obtained when specific activities were evaluated. Detectable levels of urinary BPA were found in all analyzed samples (patients: 1.17-12.68 pg/µl; mean ± SD, 5.31 ± 3.36 pg/µl; control group: 1.28-2.35 pg/µl; mean ± SD, 1.64 ± 0.49 pg/µl; median; 1.46 pg/µl), with a statistically significant difference between patients and controls, pointing towards an association between BPA exposure and endometriosis. Only a minority of subjects from the control group provided peritoneal fluid; therefore, no comparison test with patients (range 0.39-1.46 pg/µl; mean ± SD, 0.67 ± 0.30 pg/µl; median, 0.58 pg/µl) could be done. To conclude, a potential association between BPA exposure and endometriosis is evident. Additionally, the findings also underline the lack of knowledge regarding occupational exposure to BPA and the need of epidemiological studies focused on single activities/occupations, such as housewives, cleaners, students, etc. Source: Simonelli A, Guadagni R, De Franciscis P, et al. Environmental and occupational exposure to bisphenol A and endometriosis: urinary and peritoneal fluid concentration levels. Int Arch Occup Environ Health. 2016 Oct 7.

Gonadotropin-releasing Hormone Agonist with Add-back Treatment to Prevent Pain Recurrence after Laparoscopic Surgery for Endometriosis Lee et al designed a study to compare the efficacy and tolerability of Gonadotropin-releasing Hormone Agonist (GnRH) agonist with add-back therapy versus dienogest treatment in preventing pelvic pain recurrence after laparoscopic surgery for endometriosis. Sixty-four reproductive-aged women who had undergone laparoscopic surgery for endometriosis were recruited in the study. Twenty eight of these women received post-operative medical treatment with GnRH agonist and 17β-estradiol and norethisterone acetate while 36 received dienogest for 6 months. The pre- to post-treatment changes in pain were evaluated using a visual analogue scale, and changes in quality-of-life and menopausal symptoms were quantified using a questionnaire. Visual analogue scale pain score significantly declined for both treatments with no significant differences 33

jOURNAL sCAN between groups. Neither physical, psychological, social, and environmental components of quality-oflife nor menopausal rating scale score appeared to be significantly different between the two groups. Bone mineral density at the lumbar spine declined significantly in both treatment groups (-2.5% for GnRH agonist plus add-back and -2.3% for dienogest), with no significant difference between the two groups.

Sixty-four pregnant, African American women were included at 16-21 weeks of gestation. The participants were allocated to receive either 450 mg/day of DHA (22:6n-3) (n = 43) or a soybean placebo (n = 21). Four women (6.3%) withdrew from the study: two participants from each study arm; complete data were obtained for 49 infants (76.5%) at the 3-month assessment. DHA or placebo was supplemented right from the beginning of enrolment through delivery.

It was concluded that GnRH agonist and add-back therapy using 17β-estradiol and norethisterone acetate was as effective and tolerable as dienogest for preventing pelvic pain recurrence after laparoscopic surgery for endometriosis.

Data on birth outcomes were accumulated from medical records. At approximately three months post-partum, the infants were analyzed with the Bayley Scales of Infant Development (BSID-III) and cortisol response to the Face-to-Face Still-Face (FFSF) paradigm.

Source: Lee DY, Lee JY, Seo JW, et al. Gonadotropin-releasing hormone agonist with add-back treatment is as effective and tolerable as dienogest in preventing pain recurrence after laparoscopic surgery for endometriosis. Arch Gynecol Obstet. 2016 Aug 22.

Infants of mothers who received DHA supplementation had higher birth weight (3.174 g versus 2.890 g) than infants of mothers given placebo, and were more likely to have a 1-min Apgar score >8. Additionally, infants of mothers who received DHA had lower levels of cortisol in response to the FFSF paradigm, in comparison with infants of placebo supplemented mothers. There was no difference in any of the scores on the BSID-III as a function of active supplement versus placebo.

The Effect of Prenatal DHA Supplementation on Infant Outcomes in African American Women Living in Lowincome Environments Keenan et al designed the Nutrition and Pregnancy Study (NAPS), a double-blind, randomized controlled trial, to investigate the effectiveness of prenatal docosahexaenoic acid (DHA) supplementation on birth outcomes and infant development in a sample of African American women with Medicaid insurance and living in the city of Pittsburgh. The trial was conducted between 2012 and 2014. Participants were recruited from obstetric clinics at the University of Pittsburgh Medical Center.

Infants of women living in urban, low-income environments who received DHA supplementation had more optimal birth outcomes and more modulated cortisol response to a stressor, concluded the trial. DHA supplementation thus seems to be effective in crippling the negative effects of prenatal stress on offspring development. Source: Keenan K, Hipwell A, McAloon R, et al. The effect of prenatal docosahexaenoic acid supplementation on infant outcomes in African American women living in low-income environments: A randomized, controlled trial. Psychoneuroendocrinology. 2016 Sep;71:170-5.

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Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

Asian

Journal of

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 -

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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.

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016

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.

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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.

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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:

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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

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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.

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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

Asian Journal of Obstetrics and Gynaecology Practice, Vol. 2, No. 4, 2016