JOURNAL BEST PAPER PRIZE FOR THE YEAR 2018

SENIOR CATEGORY

Thirteen Years of Experience with Opportunistic Bilateral Salpingectomy During TLH in Low-Risk Premenopausal Women.

Abstract

Background

Opportunistic bilateral salpingectomy (OBS), also called as prophylactic salpingectomy or risk-reducing salpingectomy is the concurrent removal of the fallopian tubes in premenopausal women. Though there are some studies comparing the intraoperative complications and effect of salpingectomy on ovarian reserve, limited data are available on long-term follow-up after OBS.

Purpose of the Study

To evaluate the surgical outcome of routine bilateral salpingectomy during total laparoscopic hysterectomy (TLH) in terms of intraoperative and postoperative complications. We also evaluated the incidence and reoperation rate for adnexal pathology after TLH.

Methods

A retrospective study of 1470 patients undergoing total laparoscopic hysterectomy (TLH) with opportunistic bilateral salpingectomy (OBS) over 13 years was carried out at Paul’s Hospital.

Results

The mean age of the subjects was 43.6 ± 4.2 years, mean body mass index was 27 ± 5.4 kg/m2, and median parity was 2 (range 0–7). 43% of women had at least one previous surgery. The most common indication for surgery was fibroid uterus (67%, n = 985). The total complication rate was 4.4% (n = 65). One specimen showed paratubal borderline serous malignancy. The follow-up period ranged from 6 months to 13 years during which 17 (1.1%) women had adnexal pathology, and eight women (1.1%) needed resurgery for it. No ovarian malignancies were reported on follow-up.

Conclusions

OBS is a simple and short surgical step during TLH without increasing morbidity. OBS eliminates the risk of future diseases of tubal origin, and there might be a possible reduction in incidence and reoperation rate for future ovarian pathologies.

Comparison of Efficacy and Safety of Intravenous Labetalol Versus Hydralazine for Management of Severe Hypertension in Pregnancy

Abstract:

Background

There is no consensus about the better intravenous drug between Hydralazine and Labetalol to control hypertension in cases of severe hypertension in pregnancy. Both drugs have their own advantages and disadvantages.

Methods

This is a prospective randomized controlled trial comparing the efficacy and safety of intravenous Labetalol versus Hydralazine for management of severe hypertension in pregnancy. A total of 152 eligible subjects were randomised in two groups consisting 76 subjects each by envelope method. Both the groups were comparable with respect to systolic, diastolic and mean arterial blood pressure at admission. One group received Labetalol and the other Hydralazine. The number of drug doses, the time taken to achieve target blood pressure and side-effects were noted.

Results

With a single dose, Labetalol (81.5%) was able to achieve target blood pressure in a significantly higher number of cases as compared to Hydralazine (69.5%). Labetalol could help in achieving the target blood pressure faster than Hydralazine. The incidence of maternal adverse effects was comparable between the groups. Fetal outcome was comparable in both groups.

Conclusion

Hydralazine and Labetalol both were found to be equally efficacious in reducing blood pressure in cases of severe hypertension in pregnancy. Labetalol achieved the target blood pressure faster than Hydralazine. The adverse effects of both the drugs were comparable.

Association of Thyroid Dysfunction and Autoimmunity in Pregnant Women with Diabetes Mellitus

Abstract                    

Purpose

This study was undertaken to find out the proportion of women with thyroid dysfunction in pregnancy complicated by diabetes mellitus; to find out the association, if any, of thyroid dysfunction and of antithyroid peroxidase (anti-TPO) antibodies during pregnancy in women with pregestational (PGDM) and gestational diabetes mellitus (GDM); and to find out the maternal and perinatal outcomes of pregnancies complicated by both diabetes mellitus and thyroid dysfunction.

Methods

A cross-sectional observational study was conducted in a tertiary care teaching hospital in Kolkata, India, for a period of 1 year. Sixty-four pregnant women with diabetes, both PGDM and GDM, were recruited from the antenatal clinic. They were managed and followed up till 6 weeks postpartum. Their plasma glucose levels were estimated, and thyroid function was evaluated periodically. All relevant data were recorded and analyzed statistically.

Results

Most (81.25%) women had GDM. Forty percent women suffered from some form of thyroid disorder, mostly (37.5%) hypothyroidism. Thyroid dysfunction was not associated with the type of diabetes mellitus (GDM or PGDM) (p > 0.05). The higher rate of anti-TPO titers was observed in pregnancies with PGDM compared to pregnancies with GDM; however, this difference was not statistically associated (p > 0.05). All pregnant women with combined endocrinopathy delivered by cesarean section, and the most common neonatal complication observed was jaundice.

Conclusions

Thyroid disorders are quite common during pregnancy complicated by diabetes mellitus. The study findings warrant routine screening for thyroid abnormalities in diabetic pregnant women. These women have increased rate of maternal and neonatal complications.

JUNIOR CATEGORY

There is Only a Modest Increase in Neonatal Respiratory Morbidity Following Early Term Elective Cesarean in a South Indian Population

Abstract:

Objectives

Elective cesarean deliveries (ECD) are still performed prior to 39 weeks. This study aimed to identify risk of neonatal respiratory morbidity (NRM) following ECD near term, in a South Indian population. Specifically, study aimed to measure the additional healthcare burden due to large number of ECDs performed prior to 39 weeks, in this local population.

Methods

We analyzed NRM among 1329 deliveries (584 ECD and 745 spontaneous vaginal delivery, SVD) in a tertiary hospital over 2 years. Neonates were grouped into: A: 35+0–36+6 weeks, B: 37+0–38+6 weeks, and C: ≥39 weeks. NRM was compared between ECD versus SVD.

Results

Majority (433/584) of ECDs were performed between 37+0 and 38+6 weeks. Overall, 32% received steroid prophylaxis. Of 1329 newborns, 18/584 (3.82%) in ECD and 6/745 (0.8%) in SVD group developed NRM (p value of 0.004, OR 3.9, CI 1.54–9.93). Need of respiratory support among ECD was 4.28% compared to 0.53% in SVD (p < 0.001, OR 8.28; CI 2.86–23.94). However, comparing neonates born by ECD between groups B Vs C; there was only a modest increase in NRM (2.07 vs 0.9%; p 0.48, OR 2.3 with CI 0.29–18.4) and in need of respiratory support (2.54 vs 0.9%; p 0.47, OR 2.84; CI 0.36–22.2).

Conclusion

NRM following early term ECD continues to be a healthcare burden in India. Interestingly in this South Indian population, early term ECDs caused only modest increase in NRM, and this ethnic variation requires further evaluation to determine ideal time for ECD in local population.

Predicting Successful Trial of Labour After Cesarean Delivery: Evaluation of Two Scoring Systems

Abstract

Background

Attempting vaginal birth after cesarean section (VBAC) places women at an increased risk of complications. Trial of labor after cesarean (TOLAC) calculators aim to predict the chance of successful vaginal birth after cesarean (VBAC) based on the patient’s preexisting demographic and clinical factors.

Objective

To assess the rate of successful TOLAC using two calculators: FLAMM and the Grobman calculator, and to compare the performance of the two calculators in the successful prediction of VBAC.

Methods

Prospective cohort study in subjects with previous one caesarean section using well-defined inclusion and exclusion criteria.

Results

A total of 280 subjects with previous one cesarean section were enrolled. One hundred thirty-nine subjects consented for TOLAC, 90 (67%) underwent successful trial of vaginal birth, and 49 (32.8) required cesarean section. Cervical dilatation (p < 0.0001) and effacement (p < 0.0001), and any prior vaginal delivery (p < 0.02) were significantly associated with a successful outcome. At a cutoff score of 5, the sensitivity of the FLAMM score was 72% and specificity was 76%. For the Grobman calculator, the best sensitivity (69%) and specificity (67%) were seen at a cutoff score of 85%.

Conclusion

Both prediction models, the FLAMM and the “close to delivery” nomogram, recommended by Grobman et al. are easy to use and could successfully estimate the chances of vaginal birth in previous caesarean, in this small cohort. The decision for women opting for TOLAC can be individualized, and patient-specific chances of success can be predicted by the use of these prediction models.

Comparison of Cervical Length Measured by Transvaginal Ultrasonography and Bishop Score in Predicting Response to Labor Induction

Abstract

Background

This study aims to compare the value of the Bishop score and cervical length measurement by transvaginal ultrasonography in predicting active labor within 6 h, induction-to-delivery interval, and the duration of active labor and to estimate the most useful cutoff points for the two methods.

Methods

This is a prospective comparative study of Bishop score and cervical length measured by transvaginal sonography on 62 nulliparous subjects who underwent induction of labor.

Results

The Bishop score of the subjects ranged from two to seven (2–7). The mean Bishop in this study population was 4.37 + 1.23. The mean cervical length in this study was 25.59 + 6.07. Bishop score was highly significant (P value < 0.0001) in predicting active phase of labor as compared to cervical length (P = 0.004). The best cutoff value for Bishop score to predict induction of labor within 6 h was more than 4 with sensitivity of 69% and specificity of 79%. Similarly, best cutoff value for cervical length to predict induction of labor within 6 h was less than or equal to 25 mm with sensitivity of 51% and specificity of 70%. Bishop score was more significant (P = 0.001) in predicting induction-to-delivery interval within 12 h as compared to cervical length (P = 0.01).

Conclusion

The Bishop score was superior in predicting the response to induction as compared to the cervical length measured by transvaginal ultrasonography.

Endocrine Abnormalities in Adolescents with Menstrual Disorders

Abstract

Purpose

To look for endocrine abnormalities like thyroid disorders, hyperprolactinemia, hyperandrogenism and PCOS among adolescents with menstrual disorders and to compare the above endocrine status with those without menstrual disorders.

Methods

This was a case–control study carried out in adolescent girls aged 10–19 years in gynecology outpatient department of a tertiary care hospital. Sample of venous blood (5 ml) was taken for hormonal studies as clinically indicated—thyroid function test, serum prolactin, total testosterone, which were analyzed by chemiluminescence system.

Results

Oligomenorrhea was the most common menstrual abnormality in our study, the prevalence being 61.0% in cases followed by primary amenorrhea (16.4%). Thyroid dysfunction was found in 13.6% girls with menstrual disorders compared to 3.5% in those without menstrual disorders, and this was statistically significant (p = 0.006). Biochemical hyperandrogenism was seen in 9.04% cases compared to 0.7% controls (p = 0.001). The overall prevalence of hyperprolactinemia was 0.94%, and there was no statistically significant difference in girls with and without menstrual disorders. The prevalence of PCOS was 12.4% in the study population and 22.6% cases. Oligomenorrhea and PCOS were the most prevalent phenotypes in 52.5% of PCOS girls. No endocrine abnormality was detected in cases of polymenorrhea, hypomenorrhea and intermenstrual bleeding.

Conclusion

Although immaturity of hypothalamic pituitary ovarian axis is considered to be the most common cause of menstrual irregularities in adolescent girls, endocrine abnormalities, namely thyroid dysfunction and hyperandrogenism, may be responsible in some cases, thus warranting further evaluation.