Aruna Nigam

Trial of labour after previous caesarean section: The predictive factors affecting outcome

A prospective observational study was conducted at Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, India on 300 pregnant women with one previous caesarean section fulfilling the eligibility criteria for trial of labour, to study the predictive factors and the outcome of trial of labour. The data obtained were analysed according to mode and outcome of labour and was then subjected to statistical analysis. The success rate of trial of labour was found to be 53.6%. Favourable Bishops score (p = 0.000), spontaneous onset of labour (p = 0.005) and history of previous delivery after caesarean (p = 0.007) were significantly associated with a successful outcome of trial of labour. Higher chances of vaginal delivery were found with breech as an indication of previous caesarean section, i.e. 67.1% as compared to 39% with non-progress of labour as an indication.

Polycystic ovary syndrome: Is obesity a sine qua non? A clinical, hormonal, and metabolic assessment in relation to body mass index.

Objective: To determine the proportion of polycystic ovarian syndrome (PCOS) patients who have normal body mass index (BMI) and to compare the clinical, hormonal, and metabolic profile between lean and overweight patients of PCOS. Materials and Methods: One hundred consecutive infertile women with PCOS were studied and divided into lean (BMI between 18.5 and 23) and overweight (BMI ≥ 23). Metabolic and hormonal profile (serum FSH, LH, testosterone, prolactin, TSH on days 2–3 of menstrual cycle; serum progesterone premenstrually; serum insulin—fasting and 2 hours postglucose, glucose tolerance test, and fasting serum lipid profile) was performed along with pelvic sonogropahy; and clinical features, viz. waist hip ratio, hirsutism, acne, acanthosis nigricans, and clitoromegaly were recorded. Results: 42% of the PCOS subjects had normal BMI. Average age, hirsutism (80.9% vs. 89.7%), irregular cycles (92.8% vs. 96.6%), acne (9.5% vs. 15.5%), clitoromegaly (2.3% vs. 3.4%), endometrial thickness >4 mm (9.5% vs. 15.5%), and hormonal profile were similar in the lean and overweight PCOS groups. Family history of diabetes (9.5% vs. 24.1%), abnormal glucose tolerance test (GTT) (4.7% vs. 10.3%), deranged lipid profile (14.2% vs. 31%), and 2-hour postprandial insulin levels were higher in the overweight PCOS (P < 0.05). Insulin resistance was observed in 83.3% of lean PCOS but was still lower than 93.1% seen in overweight PCOS (P < 0.05). Conclusion: 42% of the PCOS had normal BMI, but clinical and hormonal profile was similar to PCOS patients with elevated BMI (overweight/obese). However, insulin resistance is observed in 83.3% of lean PCOS. Family history of diabetes, impaired GTT, deranged lipid profile, and insulin resistance were more prevalent in overweight PCOS.

Efficacy of 2-hour post glucose insulin levels in predicting insulin resistance in polycystic ovarian syndrome with infertility

BACKGROUND: Insulin resistance (IR) is central to the pathogenesis of polycystic ovarian syndrome (PCOS), but tests for determining IR are elaborate, tedious and expensive. AIMS: To evaluate if “2-hour post-glucose insulin level” is an effective indicator of IR and can aid in diagnosing IR in infertile PCOS women. SETTINGS AND DESIGN: Observational study at infertility clinic of a tertiary care center. MATERIALS AND METHODS: 50 infertile women with PCOS and 20 females with tubal/male factor infertility were evaluated for the presence of IR, as defined by the fasting/2-hour post-glucose insulin levels cutoffs of >25/>41 μU/mL, respectively. The clinical, metabolic and endocrinologic profile was determined in both the groups. STATISTICAL ANALYSIS: Statistical analysis was performed using SPSS (Chicago, IL, USA). RESULTS: Body mass index, post load glucose, insulin, glucose/insulin ratio, area under curve (AUC) of glucose and insulin and insulinogenic index were significantly lower in the controls as compared to the PCOS group. “2-hour post-glucose insulin levels” were elevated in 88% of PCOS individuals but were normal in all females not suffering from PCOS. These levels significantly correlated with AUC of glucose and insulin, and insulinogenic index and inversely correlated with 2-hour glucose to insulin ratio (r=0.827, 0.749 and –0.732, respectively). CONCLUSIONS: “2-hour post-glucose insulin levels” appears to be a good indicator of IR. It can be a useful tool, especially in low resource setting where a single sample can confirm the diagnosis, thus reducing cost and repeat visits.

HPV Vaccination in India: Critical Appraisal

Cervical cancer is the third most common cancer in women worldwide. The role of human papilloma virus (HPV) in the genesis of cervical carcinoma is well documented. The HPV 16 and 18 are found to be most commonly associated with invasive cervical carcinoma. The advent of cervical carcinoma vaccine has advanced the hopes that eradication of cervical carcinoma might be possible in future. The scenario of prevention of cervical carcinoma is completely different in developed and developing countries. The implementation of the vaccination as a routine in India is still controversial. Here we have tried to critically analyse these issues in Indian context. However it is clear that cervical cancer vaccine is not an immediate panacea and cannot replace the cervical cancer screening which is mandatory in Indian context.

Pregnancy outcome of women with gestational diabetes in a tertiary level hospital of north India.

Background: Women with gestational diabetes mellitus (GDM) pose an important public health problem because diabetes not only affects the maternal and fetal outcome, but these women and their fetuses are also at an increased risk of developing diabetes and related complications later in their life. Objectives: The study was conducted to determine the maternal and fetal outcomes of 50 diabetic vs 50 normoglycemic pregnancies. Materials and Methods: This was a retrospective analytical record-based study conducted in a tertiary level hospital. Detailed information regarding maternal, fetal, and labor outcome parameters was recorded in a prestructured proforma and compared in normoglycemic and diabetic pregnancies. Results: Patients with obesity, history of diabetes in the family, spontaneous abortions, and gestational diabetes in previous pregnancies had a greater incidence of GDM in current pregnancy (P<0.05 for all). Hypertension, polyhydramnios, macrosomia, fetopelvic disproportion, and cesarean sections were more (P<0.001) among diabetic pregnancies. Congenital anomalies, polycythemia, hypocalcemia, and hyperbilirubinemia were also observed to be more (P<0.05) in neonates born to diabetics, suggesting an adverse effect of hyperglycemia in utero. Conclusion: Diabetes during pregnancy is associated with higher maternal and fetal morbidity. Therefore, early screening, detection, close monitoring, and intervention is essential to reduce maternal and fetal short- and long-term adverse effects, especially in high-risk groups. Pregnancy provides an opportunity to the clinician to control the disease process and inculcate healthy lifestyle practices in these patients.

Labour induction with 25 micrograms versus 50 micrograms intravaginal misoprostol in full term pregnancies

We undertook this study in order to compare the efficacy of 25 µg versus 50 µg of intravaginal misoprostol for cervical ripening and labour induction at term. The study population consisted of 120 women with term singleton pregnancies in vertex presentation booked for caesarean section. They had a Bishop scoring of <6 and a reactive fetal heart rate tracing. They were randomized into two groups, A and B, to receive 25 µg and 50 µg of vaginal misoprostol, respectively, 4 hourly with a maximum of five doses until the patient had three contractions in 10 minutes. There was no significant difference in the induction delivery interval between the two groups (12.52± 7.05 h in the 25 µg group versus 11.72± 6.74 h in the 50 µg group; P = 0.58). Of the women in the 25 µg group, 83.3% delivered vaginally as did 71.67% of those in the 50 µg group, but the difference was not statistically significant (P = 0.128). There were significantly more women requiring oxytocin augmentation in the 25 µg group than in the 50 µg group (P = 0.03). However, there were no significant differences in the rates of caesarean and operative vaginal delivery, meconium stained liquor, fetal distress or in the incidences of hyperstimulation between the two groups. Neonatal outcomes were similar. The intravaginal administrations of 25 µg, as well as 50 µg of misprostol, are equally efficacious in inducing labour. The 25 µg group more often required oxytocin as an adjunct.

Effect of metformin therapy on 2-h post-glucose insulin levels in patients of polycystic ovarian syndrome.

AIMS: To evaluate if 2-h post glucose insulin level is an effective tool to monitor insulin resistance in response to metformin therapy, in infertile women with polycystic ovarian syndrome (PCOS). SETTINGS AND DESIGN: This prospective observational study was carried out in a tertiary care infertility clinic. MATERIALS AND METHODS: 40 women with PCOS were categorized as having insulin resistance if fasting or 2-h post glucose insulin levels were >25 or >41μU/ml respectively. Post glucose insulin was compared before and after six months of metformin therapy along with other clinical, hormonal and metabolic parameters by using McNemar and the Student’s t-test. RESULTS: Fasting insulin was elevated in 4 (10%) and post-load insulin in 34 (85%) patients; after metformin therapy respective values were 2 (5%) and 16 (40%). Metformin therapy reduced post glucose insulin levels (P<0.001), improved the regularity of periods (P<0.001) and resulted in reduction of LH levels (P<0.001), total testosterone (P<0.001) and mean Body mass index (BMI) (P=0.047). Metformin therapy did not alter waist-hip ratio and fasting insulin levels. CONCLUSION: 2-h post glucose insulin level is an effective tool to monitor insulin resistance in PCOS patients and improves significantly after metformin therapy, similar to improvements observed in clinical, hormonal and metabolic parameters.

Fetal ascites and hydrometrocolpos due to persistent urogenital sinus and cloaca: a rare congenital anomaly and review of literature

Fetal ascites can occur due to many heterogeneous disorders. Its association with hydrometrocolpos because of persistent urogenital sinus and cloaca is extremely rare. A 29-year-old primigravida presented at 32 weeks of gestation with ultrasonographic evidence of fetal ascites, a cystic pelvic mass, hydronephrosis and oligohydramnios. Fetal ascites in this case was due to fetal urine draining through fallopian tubes into the abdomen as a result of vesicovaginal fistula and distal vaginal atresia. The antenatal ultrasound results along with autopsy findings are discussed. Though rare, a persistent urogenital sinus is to be suspected in isolated fetal ascites cases where the viral tests are negative and there is no evidence of cardiac anomalies as this is a treatable anomaly if diagnosed at early gestational age.

Septate uterus with hypoplastic left adnexa with cervical duplication and longitudinal vaginal septum: Rare Mullerian anomaly.

A large analysis of all the studies in the period from 1950 to 2007 suggests that the prevalence of congenital uterine anomalies in the general population is 6.7%; and in the infertile population, 7.3%. We report a rare case of unilateral hypoplastic fallopian tube and ovary with septate uterus, cervical duplication, longitudinal vaginal septum. To the best of our knowledge, this is the first report of such a congregation of anomalies.

Twisted Ovarian Fibroma Mimicking as an Ectopic Pregnancy

Ovarian fibromas are benign tumors arising from the stromal component of the ovary. They mostly are asymptomatic. These tumors are often detected as incidental finding detected on routine gynaecological examination, transvaginal ultrasound, computer tomography or magnetic resonance imaging. We report a case of twisted ovarian fibroma with raised HCG levels and ascites mimicking ruptured ectopic pregnancy in young nulliparous married female.