Fertility Flash - Issue 7 by VASU

F e Flash ISSUE

HIGHLIGHTS Woman Receives the Gift of Second Motherhood from a 9 Year-old Frozen Embryo Double-stranded DNA Damage: Effect in Embryo Kinetics and its Relation to Implantation Rates Positive Association between Low Testosterone, Abnormal Sperm Morphology and Lower Birth Rates in Couples with Unexplained Infertility Autologous Platelet-Rich Plasma Treatment Improves In Vitro Fertilization Success and Pregnancy Outcomes BMI Restrictions and Fertility Treatments: National Survey of OB/GYN Subspecialists National Guidelines on Preterm Birth Prevention Practice has Laid a Positive Impact on the Clinical Practices Pertaining to Preterm Labour Importance of Combined Preeclampsia Screening In the First Trimester of Pregnancy High Risk of Pregnancy Experienced in Women with Intrahepatic Cholestasis Reversal of the Order Passed by the District Forum

expansion in world population. Attempts to control population growth have focused on reducing fertility with some apparent effect. Up to 30 % of infertile couples remain childless devoid of identifiable causes—leading to a diagnosis of unexplained infertility, even after extensive evaluation of both partners. Fertility Flash is an academic initiative from Corona Remedies to link medical fraternity with latest updated information in infertility. This is a bi-monthly series. Through this scientific information service to the Infertility specialists, we wish to contribute our part in fulfilling the dream of motherhood.

CASE REPORT Woman Receives the Gift of Second Motherhood from a 9 Year-old Frozen Embryo

EVIDENCE UPDATES Double-stranded DNA Damage: Effect in Embryo Kinetics and its Relation to Implantation Rates

CONTENTS

PREFACE

Fertility and its determinants have been urgent topics for research in recent decades with rapid

Positive Association between Low Testosterone, Abnormal Sperm Morphology and Lower Birth Rates in Couples with Unexplained Infertility

DIAGNOSTIC UPDATE Autologous Platelet-Rich Plasma Treatment Improves In Vitro Fertilization Success and Pregnancy Outcomes BMI Restrictions and Fertility Treatments: National Survey of OB/GYN Subspecialists

IMAGES OF THE MONTH

6 8

NEWER GUIDELINES National Guidelines on Preterm Birth Prevention Practice has Laid a Positive Impact on the Clinical Practices Pertaining to Preterm Labour

CONFERENCE UPDATE Importance of Combined Preeclampsia Screening In the First Trimester of Pregnancy High Risk of Pregnancy Experienced in Women with Intrahepatic Cholestasis

MEDICO LEGAL

Reversal of the Order Passed by the District Forum

TRAZER HUNT

CONFERENCE CALENDER

QUIZ

F e Flash CASE REPORT Woman Receives the Gift of Second Motherhood from a 9 Year-old Frozen Embryo Contributed by:

Dr. Hrishikesh Pai Gynaecologist and Infertility Specialist, Fortis Bloom IVF Centre, Fortis La Femme, New Delhi

In recent times, there has been a rapid increase in the number of Indian women opting for IVF and freezing eggs during early reproductive years. This is empowering women against the ticking biological clock, enabling them to choose the time of their ﬁrst and second child as well as helping many to become mothers. Here we present a rare case of realization of a 9-year-old frozen embryo into a baby using frozen embryo transfer.

Case Presentation Anita (name changed) a 38-year-old female approached the IVF Centre for a second child after several failed attempts at various IVF clinics abroad.

Medical History Ÿ

She had approached the facility 9 years back when 22 eggs were retrieved from her and 8 embryos were frozen.

Five of eight embryos were used for preparing blastocyst and were transferred to the uterus.

Of these, a single embryo attachment resulted in successful pregnancy and birth of her ﬁrst child.

6 years later, she tried for second pregnancy procedure which was deferred due to poor uterine lining.

A hysteroscopy performed before starting any assisted reproductive technology procedure was normal.

Gynecological/ ART Procedure The patient was routinely treated with exogenous estrogen in a step-up regimen to support the endometrial growth prior to frozen embryo transfer (FET) which was performed after a natural cycle. During the procedure, three frozen embryos (thawed and cultured) were transferred on the 5th day after LH surge. Six weeks later twin

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live pregnancy was conﬁrmed by the presence of intrauterine sacs. However, one of the embryos ceased to grow by the 11th week facing fetal demise. The second embryo survived and luteal support continued for another 2 weeks. Post this, the patient was referred for obstetric care. The pregnancy was uneventful, and the patient delivered a healthy baby by cesarean section, at 37 weeks.

Discussion Infertility has been estimated to affect nearly 8-12% of reproductive-aged couples worldwide. Secondary infertility is the most frequent type of female infertility and refers to a failure in establishing pregnancy in women who with prior clinical pregnancy. In the current societal scenario, pregnancy has become an issue of personal preferences instead of biology and the mean maternal age at first birth is nearly crossing 30 years. However, female fertility decline starts around 25–30 years of age with age-related fertility loss being 12% at age 35 years and 20% at age 38 years. This is generally attributed to continuous depletion of oocyte reserve which completely expires at the onset of menopause.1 For the past 3 decades, In vitro fertilization (IVF) has been widely employed method for treating infertility resulting in more than 1 % of all births occurring from assisted reproductive therapies (ART).2 It is considered as the best treatment option for couples with multifactorial infertility problems.3 It involves techniques of controlled ovarian stimulation (COS) that produce multiple follicles for maximizing the chances of a positive outcomes. However, COS may lead to endometrial modifications that might be associated with poorer outcomes during fresh embryo transfer. But latest cryopreservation techniques have made possible to electively freeze all viable embryos of a fresh IVF cycle and later the frozen–thawed embryos can be transferred in a more favorable intrauterine environment, without facing any possible adverse effects of supraphysiologic hormonal levels over the endometrial receptivity. Several studies have demonstrated similar quality of the frozen embryos and potential for implantation to those observed with fresh embryos.2 Several theories have been put forth to explain better outcomes using Frozen Embryo transfer (FET) such as frozen replacement cycle offers a more natural uterine environment which is favorable for early placentation and embryogenesis, whereas ovarian stimulation in fresh cycles changes the endometrial angiogenesis and implantation. Another explanation is that the physical effects of freezing and thawing embryos may filter out weaker embryos and allow only good quality ones to survive, resulting in better fetal growth.4 The current case outcomes are also in coherence with the above statements where clinical pregnancy after frozen thawed ET produced favorable outcomes. The case also highlights the timely and wise decision to get embryos frozen during reproductive years for conceiving later in life. References 1. Vander Borght M, Wyns C. Fertility and infertility: Definition and epidemiology. Clin Biochem. 2018 Dec;62:2-10.; 2. Roque M. Freeze-all policy: is it time for that?. J Assist Reprod Genet. 2015;32(2):171–176.; 3. Huang JY, Rosenwaks Z. Assisted reproductive techniques. Methods Mol Biol. 2014;1154:171-231.; 4. Maheshwari A, Pandey S, Shetty A, Hamilton M, Bhattacharya S. Obstetric and perinatal outcomes in singleton pregnancies resulting from the transfer of frozen thawed versus fresh embryos generated through in vitro fertilization treatment: a systematic review and meta-analysis. Fertil Steril. 2012 Aug;98(2):368-77.e1-9.

F e Flash EVIDENCE UPDATES Double-stranded DNA Damage: Eﬀect in Embryo Kinetics and its Relation to Implantation Rates Researchers undertook an observational, double blind, prospective cohort study to determine the effect of singleand double-stranded sperm DNA fragmentation (ssSDF and dsSDF) on human embryo kinetics monitored under a time-lapse system. A total of 196 embryos from 43 infertile couples were used to analyze ssSDF and dsSDF in the same semen sample used for intracytoplasmic sperm injection. Then, using time-lapse technology, researchers monitored embryo kinetics and obtained the timing of each embryo division. Results from the study reported the following: Single- and Double-Stranded DNA Damage and Progressive Motility A negative correlation between progressive motility and single-stranded DNA fragmentation was found (r = –0.390; P = 0.037), while no correlation was found between progressive motility and double-stranded DNA damage.

14% 12% 10% 8% 6% 4% 2%

a c Bl y as st to cy st as

Bl g in at St

ssSDF dsSDF

or M

0% T2

Differences respect to normal samples (%)

Figure 1: Percentage of delay between low and high ssSDF and dsSDF.

Pr 2n d o Pr nu po on cl la uc ei a r b le pp od id y is ear ap an pe ce a St ran c ar tin e g T2

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Single-Strand SDF and Embryo Kinetics Ÿ

Embryo kinetics results were classiﬁed according low or high ssSDF, expressed in median (range) of hours after fertilization.

Single-and Double-Strand Sperm DNA Damage Caused Diﬀerent Patterns of Delay in Embryo Kinetics Ÿ

A delay in embryo development and impairment in implantation were observed in correlation with doublestranded sperm DNA damage, however, embryo kinetics and implantation were not signiﬁcantly affected in correlation with single-stranded DNA damage.

Figure 1 displays these differences throughout the process of embryo development.

Implantation and Embryo Kinetics Ÿ

The embryo kinetics of those embryos that achieved implantation was similar to low dsSDF kinetics and different from high dsSDF kinetics.

Embryo kinetics from those embryos that did not achieve implantation was similar to high dsSDF kinetics and different from low dsSDF kinetics.

Researchers of the study opined that double-stranded sperm DNA damage caused a delay in embryo development and impaired implantation, while single-stranded DNA damage did not signiﬁcantly affect embryo kinetics and implantation.

Doub le-str an dama ge, an ded DNA dn strand ed DN ot singlehas an A damage , eﬀ embr yo kin ect in etics relate an d to i mplan d is rates. tation

Source: Casanovas A, Ribas-Maynou J, Lara-Cerrillo S, et al. Double-stranded sperm DNA damage is a cause of delay in embryo development and can impair implantation rates. Fertil Steril. 2019;111(4):699-707.e1.

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Positive Association between Low Testosterone, Abnormal Sperm Morphology and Lower Birth Rates in Couples with Unexplained Infertility The prospective, randomized, multicenter clinical trial, Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS), was secondarily analyzed to ascertain if abnormal spermatogenesis and lower fecundity are present in men with unexplained infertility and low total T (TT). AMIGOS included 900 couples with unexplained infertility. Of these, 781 men (mean age, 34.2 ± 5.7 years) with a median (interquartile range) TT of 411 (318–520) ng/dL were included in this secondary analysis. Semen analysis with an ejaculate of at least 5 million total motile sperm was required for enrollment. The association between low TT (deﬁned as <264 ng/dL), semen Figure 1: Comparison of TT <264 vs. TT > 264 with respect to semen parameters, and pregnancy outcome was analysis and pregnancy outcomes. assessed using logistic regression. Results from the study reported the following: Ÿ

Low TT was not identiﬁed to be correlated with semen volume < 1.5 mL, sperm concentration < 15 × 106/mL, or motility < 40%. Among couples whose male partner had low TT and couples with a male partner having TT > 264 ng/dL, a live birth was reported for 21 (18.8%) and 184 (27.5%), respectively (see Fig.1). Couples whose male partner had low TT showed reduction in odds of live birth by 40%. There was no association between low TT and semen volume < 1.5 mL, sperm concentration < 15 × 106/mL, or motility < 40%.

Normal Semen Volume Normal Sperm Concentration Normal Motility Normal Morphology Conception Clinical pregnancy Live birth 0

Odds Ratio (95% CI). Blue represents unadjusted models for semen parameters and models adjusted for treatment for pregnancy outcomes. Red represents models adjusted for age and BMI for semen parameters and models adjusted for treatment, age, and BMI for pregnancy outcomes

Researchers of the study concluded that low TT in the male partner was associated with abnormal sperm morphology and lower live birth rates in couples with unexplained infertility.

Source: Trussell JC, Coward RM, Santoro N, et al. Association between testosterone, semen parameters, and live birth in men with unexplained infertility in an intrauterine insemination population. Fertil Steril. 2019 Apr 11. pii: S0015-0282(19)30075-5.

F e Flash DIAGNOSTIC UPDATE Autologous Platelet-Rich Plasma Treatment Improves In Vitro Fertilization Success and Pregnancy Outcomes In reproductive medicine, repeated implantation failure (RIF) due to suboptimal endometrial lining is a major challenge for clinicians owing to lack of proven treatments to improve outcome. The present study assessed the effect of intrauterine platelet-rich plasma (PRP) treatment on frozen-thawed embryo transfer (FET) cycles in 273 patients whose endometrium was unable to achieve optimal lining in unexplained infertility patients with history of RIF. Figure 1: Clinical pregnancy rate, and live birth rate were higher in the PRP group.

Clinical outcome (%)

A total of 302 cycles performed in 273 patients were retrospectively analyzed. Of 302 cycles, 232 cycles were excluded. After excluding, 34 patients who had no optimal endometrial lining and underwent PRP þFET were grouped as PRP group, 36 patients who had optimal lining and underwent only FET were grouped as control group.

50 40 30

41.2

35.2 22.2

16.7

20 10 0

Clinical pregnancy

Live birth rate

Results from the study reported that the endometrial thickness was higher after PRP group Control 48 hours from PRP when compared to endometrial thickness before PRP (10 mm vs. 6.25 mm, p <0.001). When compared to control group, clinical pregnancy rate, and importantly live birth rate were also signiﬁcantly higher in PRP group (see Fig. 1). Based on the key ﬁndings obtained from the study, researchers of the study opined that intrauterine autologous PRP infusion is a safe, inexpensive adjuvant treatment for optimizing endometrium especially in patients with RIF history. Besides, intrauterine PRP infusion improved not only endometrial lining but also in vitro fertilization success and pregnancy outcome. Source: Coksuer H, Akdemir Y, Ulas Barut M, et al. Improved in vitro fertilization success and pregnancy outcome with autologous platelet-rich plasma treatment in unexplained infertility patients that had repeated implantation failure history. Gynecol Endocrinol. 2019:1-4.

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BMI Restrictions and Fertility Treatments: National Survey of OB/GYN Subspecialists The present study was conducted to gather information on existing BMI cutoffs in fertility practices, and to investigate the opinions of both reproductive endocrinology and infertility (REI) and maternalâ&#x20AC;&#x201C;fetal medicine (MFM) physicians regarding the necessity and appropriateness of these restrictions. Besides, researchers compared characteristics of respondents who agreed with, versus those who disagreed with, BMI cutoffs for offering fertility treatment. The survey was distributed to members of the Society for Reproductive Endocrinology and Infertility (SREI) and the Society of Maternal Fetal Medicine (SMFM). The survey included questions about respondent demographics, geographic location, knowledge of existing institutional or clinic BMI policies, and personal opinions on BMI cutoffs for fertility treatment (oral ovulation agents, gonadotropins, and in vitro fertilization). Respondents included 398 MFMs and 201 REIs. Results from the study reported that the majority of REI and MFM providers agreed with upper limit BMI cutoffs (72.5% vs. 68.2%, p = 0.29). When compared to MFMs, REIs were twice as likely to support lower limit BMI Figure 1: Opinions on upper BMI restrictions for fertility treatment.

100 *

90 80

Percent

60 50 40 30 20 10 0

* p<0.05

BMI restrictions stigmatize overweight/ obese infertile women

BMI restrictions prevent timely access to fertility treatment

Older, obese Infertility women should providers should be offered recommend immediate fertility weight loss to treatment, due overweight or to shortened obese infertile reproductive women window

Agree with upper BMI restrictions

Infertility Infertility providers providers should recommend should bariatric surgery recommend consultation MFM consultation to morbidly obese to overweight infertile women or obese infertile women

Disagree with upper BMI restrictions

MFM

REI

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restrictions (56.2% vs 28.4%, p < 0.0001). As demonstrated by logistic regression, providers who agreed with upper BMI limits were more likely to be female, and report existing institutional BMI cutoffs. The majority of respondents recommended preconception MFM consultation for overweight or obese women, and agreed that morbidly obese infertile women should be offered consultation for bariatric surgery prior to attempting pregnancy (see Fig. 1). The vast majority of respondents (99.3%) believed that an ofďŹ cial statement or guideline on BMI cutoffs should be issued by a national professional organization. Researchers of the study opined that practice patterns are inconsistent among OB/GYN subspecialists in regard to BMI restrictions and fertility treatments. Majority of REIs and MFMs believe that there should be a BMI cutoff above which women should not be offered immediate fertility treatment. Source: Kelley AS, Badon SE, Lanham MSM, et al. Body mass index restrictions in fertility treatment: a national survey of OB/GYN subspecialists. J Assist Reprod Genet. 2019 Apr 8. doi: 10.1007/s10815-019-01448-3.

Image of the month

T h e o b j e c t i ve h e re i s to describe a new approach to visualize the rectovaginal septum and posterior vaginal fornix by three-dimensional transvaginal ultrasound (3DTVUS) that complements standard ultrasonographic protocol for evaluation of deep inďŹ ltrating endometriosis.

Transvaginal ultrasound in sagittal view (A) and 3D (B) showing rectovaginal septum (arrow), cervix (star), rectum (*) and posterior fornix (arrow head).

F e Flash NEWER GUIDELINES National Guidelines on Preterm Birth Prevention Practice has Laid a Positive Impact on the Clinical Practices Pertaining to Preterm Labour A Postal Survey of Clinical Practice was conducted in UK to identify the current status of specialist preterm labour (PTL) clinics and recognize changes in management trends over the last 5 years following release of the NICE preterm birth (PTB) guidance. A questionnaire was sent by post to all 187 NHS consultant-led obstetric units. Further six questions deﬁning their protocol for risk stratiﬁcation and management were asked for units with a specialist PTL clinic. The main outcome measure was to assess the current practice in specialist PTL clinics and to assess the changes in treatment trends over 5 years. Results from the study reported the following: Ÿ

About 33 PTL prevention clinics were identiﬁed, with 73% running weekly.

Over 5 years there has been an increase in specialist PTL clinics, possibly reﬂecting a growing focus on these services following publication of national guidance and increased patient demand.

The majority of clinics run weekly and is led by NHS obstetric consultants, with a noticeable reduction in university staff leading the clinic from 69% to 21% over ﬁve years in favor of NHS staff (84%).

The most popular treatment choice for short cervix is cervical suture (30%).

An equally popular alternative to cerclage is to offer women choice of multiple therapies (30%) with combination of vaginal progesterone and cervical cerclage being the most common.

It was concluded that over the last 5 years there has been 44% increase in the number and geographical spread of specialist preterm birth clinics in the UK. Although variation in practice remains, there appears to be increasing consensus in cut-offs for cervical length treatment, referral criteria to clinic and the gestation at first appointment. Source: Care A, Ingleby L, Alfirevic Z, et al. The influence of the introduction of national guidelines on preterm birth prevention practice: UK experience. BJOG. 2019;126(6):763-769.

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F e Flash CONFERENCE UPDATE Importance of Combined Preeclampsia Screening In the First Trimester of Pregnancy The present study was conducted in the Perinatal Center of Rostov Region from 2015 to 2018 to assess the effectiveness of combined preeclampsia (PE) screening in the first trimester of pregnancy for PE prediction and prevention. A total of 63 patients who underwent combined PE screening in 11–13.6 weeks of pregnancy were enrolled in the study. Preeclampsia Predictor software was used. To determine final risk, mean blood pressure, Pi of uterine arteries, biochemical markers (PAPP-A+PLGF) were added to primary risk factors. The program calculates both the risk of early and late PE. The high-risk boundary is defined as 1:20. Of 63 patients of combined first trimester PE screening, 11 patients were found to have high risk of PE. From 12 weeks to 32 weeks, about 8 patients received acetylsalicylic acid in a dose of 75–100 mg. As prophylactic dosage, 2 patients Rese received low molecular weight heparins (LMWH). In that c archers of the ond patients receiving LMWH or acetylsalicylic acid, PE was allow ucting a co study conc s to l mbin not developed. PE was recorded only in one patient ed PE uded patien identify a scre h t who had the risk of early PE 1: 5, late PE 1: 5, and to ma s for the d igh-risk gr ening evelo oup o ke a p didn't receive either acetylsalicylic acid or LMWH. p f Source: Kuznetsova N, Bushtyreva I, Barinova V, et al. EP0037 | Combined Preeclampsia Screening In The First Trimester Of Pregnancy. Obstretics Gynecol. 2018;143(S3):158-542.

rop m of thi s grou hylaxis to ent of PE, t p he a drug aggre nd avoid u patients ssion njusti to a w ﬁed of pre ider r gnant a nge wome n

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High Risk of Pregnancy Experienced in Women with Intrahepatic Cholestasis A cohort study was conducted to compare the outcome of pregnancy in women with intrahepatic cholestasis of pregnancy to women with low risk pregnancy in terms of mode of delivery, meconium- staining of the liquor, preterm birth, birth weight, neonatal intensive care unit admission. Besides, the effectiveness of ursodeoxycholic acid in symptomatic relief of pruritus in women with intraheaptic cholestasis of pregnancy was assessed. A total of 45 pregnant women diagnosed to have intraheaptic cholestasis of pregnancy were compared with 45 low risk pregnant women considered as control. Pregnant women enrolled were who attended the antenatal clinic during the period from June 2015 to June 2017. Women diagnosed with intraheaptic cholestasis were treated with ursodeoxycholic acid and all had labour induced after 37 completed weeks of gestation depending on the fetomaternal status, symptoms and serum bile acid levels.

Abnormal fetal heartbeat and the uterine contractions were experienced by 28.9% of women with intraheaptic cholestasis of pregnancy when compared to 17.8% in the control group with not statistical difference. Similarly, the incidence of meconium staining of liquor was 20% in study group when compared to 24.4% in the control group with no signiﬁcant statistical difference. Women with intraheaptic cholestasis experienced higher caesarean rates (42.2% vs. 13.3%) when compared to control group.

Figure 1: Outcome of pregnancy in women with intrahepatic cholestasis of pregnancy

Pregnancy outcomes (%)

Results from the study reported the following:

50 40 30 20 10 0

42.2 28.9 17.8

Abnormal cardiotocogram

24.4 13.3

Higher caesarean Incidence of rates meconium staining of liquor

Women with intraheaptic cholestasis of pregnancy

Control group

Researchers emphasized the importance of monitoring labour to prevent unnecessary morbidity to both mother and fetus. At times caesarean section may be required to ensure fetal wellbeing. Depending on the maternal status, serum bile acid levels, liver function tests and fetal wellbeing, timing of delivery should be based on person to person.

Source: Kalyansundaram U. Ep0095 | Intrahepatic Cholestasis Of Pregnancy And Fetomaternal Outcome - A Prospective Comparative Study. Obstretics Gynecol. 2018;143(S3):158-542.

F e Flash MEDICO LEGAL Reversal of the Order Passed by the District Forum

Facts of the case Ÿ

7/10/2011 - Complainant was admitted in opposite party (OP) no.1 hospital in the morning, where she delivered a child through cesarean section.

11/10/2011 - The complainant was discharged from OP no.1 hospital against charges of Rs.19,000/- for her entire delivery process.

14/10/2011 – The complainant complained of pain in her lower abdomen near the stitches. She approached OP no.1 hospital about her abdominal pain problem, where doctor told her that it was routine pain and it would be alright within few days. Her pain started increasing instead of subsidizing.

19/10/2011 – The complainant visited OP no.1 hospital, where she was given some pain killers. She got some doubt in her mind and went to Hospital 2 in Ludhiana for further consultation. The ultrasound performed in that hospital revealed something wrong in her reports and asked her to go to Hospital 3.

19/10/2011 – The complainant went to Hospital 3, where she was further referred to Hospital 4 Ludhiana for further treatment, as her condition was not good.

20/10/2011 – The complainant was taken to Hospital 4 Ludhiana by her husband on with severe pain in her abdomen and her condition was worse.

Investigations and tests were carried out on her in the next 2-3 days revealed the presence of some abdomino pelvic collections in her uterus.

There was presence of blood mass in the uterus, which was infected and puss was found near stitches in lower uterus.

The complainant contended that: Ÿ

The complainant stated that the OP no.2 stole the previous record of scan and MRI of the complainant, when he visited the complainant at Hospital 4.

OP no.1 and its doctors were negligent in conducting her cesarean operation.

Consequently, she had to spend Rs.3,50,000/- on her treatment in Hospital 4 and Rs.19,000/- in Hospital 1 (OP no.1) She spent Rs.50,000/- on miscellaneous expenses.

She suffered mental harassment as well. She ﬁled the complaint against OPs praying that they be directed to pay her the amount of Rs.4 lakhs incurred on her treatment at Hospital 4; further to pay Rs.10 lakhs as compensation for mental harassment for medical negligence of OPs; and Rs.11,000/- as litigation expenses.

Case of the opposite party Ÿ

The OPs upon notice, appeared and ﬁled written reply and strongly contested the complaint of the complainant.

It was claimed that the complainant was got admitted by her husband at full terms amenorrhea with labour pain in OP no.1 hospital on 07.10.2011 at 6 AM.

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Routine tests revealed meconium staining in the afternoon on that very day and emergency LSCS had to be done.

There were no preoperative or postoperative complications in the procedure of complainant.

Patient was taking orally, walking normally, passing urine and stool, dressing was healthy.

Patient was asked to arrange two units of blood, as the HB of the patient was 7gms.

Husband of complainant refused to arrange blood and was not buying medicines, as prescribed by the OPs.

Her husband insisted upon her discharge and to waive off the remaining amount of Rs.8000/- payable to OPs out of Rs.19,000/-.

On insistence of complainant side, that care would be taken of the patient by giving medicines on time, OPs allowed to discharge the complainant, as she left against medical advice (LAMA) on humanitarian ground waiving outstanding amount of Rs.8000/-.

After four days therefrom, complainant again visited the Hospital 1 (OP1) along with her husband with complaint of pain in her abdomen.

She was examined by a doctor of Hospital 1 (OP1), as she was looking pale, abdomen soft and she was passing stool and urine.

Ultrasound was performed by OP no.2 revealed a pelvic mass anterior to the uterus, which required MRI to ﬁnd out the exact origin of the mass.

The patient was referred to a Hospital 5 for MRI pelvis, blood transfusion, IV antibiotic etc., but the patient was reluctant to go to that hospital on that night.

The patient was admitted by giving one shot of injection of pipracillin and tazobactum 4.5. gms in I.V. infusion to prevent further septicemia.

Instead of getting herself admitted in Hospital 5, she went to Hospital 2 on her own accord against the advice of OPs.

The complainant had not followed by the advice of OPs due to her own negligence.

It is settled principle that before closing the abdomen, stitch line is observed and abdomen was closed only when there was proper homeostasis (no bleeding at the site).

Postoperative hematoma can occur because of infection, anemia, in case of rupture of membranes as in this case.

The OPs contested the complaint of the complainant on the above averments and prayed for dismissal of complaint by denying any medical negligence on their part.

Points of discussion Ÿ

The counsel heard the points of both parties at considerable length and also examined the record of the case.

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The District Forum held OPs negligent only on one count that they were not having blood bank with them amounting to deﬁciency in service on their part, particularly in case of cesarean operation.

It was also held that OPs failed to assess the problem of complainant when she visited them second time, later on referring her to some other hospital.

The OPs challenged the ﬁndings of the District Forum by preferring this appeal.

A qualiﬁed witness who has been working in OP no.1 hospital for the last 20 years denied any medical negligence on the part of OPs in this case in the case of complainant.

This witness further stated that complainant herself and her family members failed to comply with the directions and instructions given by the deponent at the time of leaving the hospital against medical advice (LAMA) and complainant concealed this fact from the Forum intentionally and dishonestly.

She also deposed in her statement that complainant required 3-4 days more of hospitalization in OP no.1 hospital for her proper treatment, but husband of complainant remained adamant on her discharge.

This witness further stated that her parameters were stable, when she was admitted in Hospital 4.

The counsel stated that there is nothing on the record that doctors were not qualiﬁed in their ﬁelds.

There were mere affidavits of complainant and her husband on the record to this effect, which is not by an expert body of doctors holds no field, when there is no such affidavit of enquiry officer on the record.

On the next point that OPs were not equipped with blood bank, the complainant approached them post operatively, in this case no such surgical procedure was carried by the OPs on her at that stage and rather complainant was referred Hospital 5 and complainant had not followed the advice of OPs.

Primary health care with basic medical facilities supported by availability of a hierarchy of higher levels of medical treatment in appropriate cases is generally accepted model of public health facilities.

It is so held as no ground for holding the hospital medically negligent by the District Forum on this point.

The complainant could not prove it on the record that OPs followed that treatment, which was not acceptable to medical protocol.

There is nothing on the record that OPs have not exercised the reasonable degree of skill or knowledge possessed by them was inadequate, while treating the complainant.

Simply because the patient had not responded to a particular surgery, a doctor cannot be held liable therefor on that count.

The complainant could not prove it on the record that there was particular duty cast upon OPs and they have failed to discharge the same.

Judgement points Ÿ

In view the above discussion, the State Commission held that that OPs are qualiﬁed doctors and performed procedure in accordance with settled medical practice and protocol, which is acceptable to the medical fraternity and medical literature. 14

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There is nothing on the record to prove that OPs failed to exercise the reasonable and fair degree of care in the treatment of the complainant.

Consequently, the order passed by the District Forum was held to be erroneous and was ordered to be reversed in this appeal.

As a result of our above discussion, the appeal of the appellants was accepted by setting aside the order of the District Forum under challenge in this appeal.

Resultantly, the complaint of the complainant stands dismissed.

Source: Reversal of the order passed by the District Forum. Available at: https://indiankanoon.org/doc/17739228/. Accessed on: June 10, 2019

TRAZER HUNT 1

Across 3.

Tissue that typically lines the uterus then begins to grow in the muscle wall of the uterus

A short cut made at the base of the vaginal opening to allow an infant to be born more easily.

An instrument that is used to hold the vagina open during a vaginal exam

2 3

Down 4

A medical diagnostic procedure to examine an illuminated, magniﬁed view of the cervix and tissue of the vulva and vagina

Fluid-ﬁlled sacs in the ovary which contain the eggs released at ovulation

6 7

Difﬁcult or painful periods.

A pattern characteristic of dried cervical mucus viewed on a slide

Vaginal bleeding that lasts for several days after the birth of a child

Answers for TRAZER HUNT on page 16

F e Flash CONFERENCE CALENDER July - December 2019 8th International Congress Academy of Clinical Embryologists Date: 19-21 July Place: Chennai, India ICE 2019 Date: 2-4 Aug

Place: Chennai, India

YUVA ISAR 2019 Date: 16-18 Aug

Place: Agra, India

2nd World Congress on Gynecology & Obstetrics (WCGO-2019) Date: 19-20 Sep 2019 Place: Miami, USA 12th Annual Congress Of The European Urogynaecological Association 2019 Date: 16-18 Oct 2019 Place: Tel Aviv, Israel IVF and Embryology 2019 Date: 25-26 Oct 2019 Place: Paris, France International Meeting of the European Society of Gynaecological Oncology Date: 2-5 Nov 2019 Place: Athens, Greece 48th AAGL Global Congress on MIGS Date: 9-13 Nov 2019 Place: Vancouver, BC Canada 27th World Congress on Controversies in Obstetrics, Gynecology & Infertility (COGI) Date: 21-23 Nov 2019 Place: Paris, France 15th Annual Congress of Fertility Society Date: 6-8 Dec 2019 Place: New Delhi, India

Answers for TRAZER HUNT: Across: (3) Adenomyosis (4) Episiotomy (7) Speculum Down: (1) Colposcopy (2) Follicles (5) Dysmenorrhea (6) Ferning (8) Lochia

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Your Thought QUIZ 1. Which of the following are considered to be sonographic markers of placenta accreta spectrum (PAS) in the ﬁrst trimester? a) A gestational sac implanted in the lower uterine segment b) A gestational sac implanted in a cesarean delivery scar c) Multiple hypoechoic spaces within the placenta d) B & C

Source: OBG Manag. 2018 October;30(10):34-36, 38-44.

2. Which of the following best describes the cause of primary dysmenorrhea? a) Chronic noncyclic pelvic pain not speciﬁcally associated with menstruation b) Structural abnormalities or disease processes outside the uterus, within the uterine wall, or within the uterine cavity causing painful menstruation c) Excess prostaglandins causing painful uterine contractions Source: Beckman CRB, Casanova R, Chuang A, et al. Chapter 32: Dysmenorrhea and Chronic Pelvic Pain. Obstetrics and Gynecology. 7th ed. New York

3. The American College of Obstetricians and Gynecologists (ACOG) recommends the use of low-dose aspirin prophylaxis for the prevention of which of the following conditions? a) Preclampsia b) Early Pregnancy Loss c) Fetal Growth restriction d) Stillbirth Source: Obstet Gynecol. 2018;132:e44-52.

4. In addition to the total hip, at which sites can BMD by dual energy x-ray absorptiometry (DXA)

be measured in premenopausal women? a) b) c) d) e)

Lumbar spine Femoral neck Distal radius B&C All of the above Source: https://www.radiologyinfo.org/en/info.cfm?pg=dexa

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