Pratima Mittal

Impact of sleep-disordered breathing on metabolic dysfunctions in patients with polycystic ovary syndrome

BACKGROUND Polycystic ovary syndrome (PCOS) is the most common endocrinological disorder among women in the reproductive age group. These women are prone to develop sleep-disordered breathing (SDB) and metabolic disorders. SDB is also associated with metabolic dysfunctions. We hypothesized that SDB is an independent risk factor contributing to metabolic dysfunctions in women with PCOS. METHODS Prospective cross-sectional study in which 50 women with PCOS and not on any treatment were selected. They were divided into two groups: Group 1 - PCOS with SDB and Group 2 - PCOS without SDB. RESULTS Thirty-three (66%) women with PCOS had SDB. Women in Group 1 had significantly higher systolic blood pressure (SBP) (P = 0.002); diastolic blood pressure (DBP) (P = 0.044); fasting blood sugar (P = 0.006), triglyceride levels (P = 0.014) and mean Ferriman-Gallwey score (P = 0.028). The HDL was significantly lower in group 1 (P = 0.006). In group 1, 42.4% of women had metabolic syndrome (P < 0.001). Excessive daytime sleepiness (EDS) was significantly higher in Group 1 (P = 0.04). Respiratory distress index significantly correlated positively with waist circumference (r = 0.551, P < 0.001), SBP (r = 0.455, P = 0.001), DBP (r = 0.387, P = 0.006), FBS (r = 0.524, P = 0.000), homeostatic model assessment (r = 0.512, P = 0.000), triglycerides (r = 0.384, P = 0.006), free testosterone (r = 0.390, P = 0.005), and negatively with HDL (r = -0.555, P < 0.001). CONCLUSION Women with PCOS and SDB had significantly increased metabolic abnormalities as well as more severe hyperandrogenism. Women with PCOS who have metabolic abnormalities or severe hyperandrogenism should undergo an overnight PSG.

A Dedicated Postpartum Intrauterine Device Inserter: Pilot Experience and Proof of Concept

Use of the inserter was found to be safe, with high fundal placement in 82% of cases. Complete expulsion occurred in 7.5% of cases and partial expulsion was detected in 10%, comparable with rates in other studies using standard IUD insertion techniques. Further study and use of the dedicated inserter may reveal increased convenience and reduced risk of infection among users and could improve acceptability of postpartum IUD provision among providers. Use of the inserter was found to be safe, with high fundal placement in 82% of cases. Complete expulsion occurred in 7.5% of cases and partial expulsion was detected in 10%, comparable with rates in other studies using standard IUD insertion techniques. Further study and use of the dedicated inserter may reveal increased convenience and reduced risk of infection among users and could improve acceptability of postpartum IUD provision among providers. ABSTRACT Objective: To assess the feasibility, acceptability, and safety of a dedicated postpartum intrauterine device (PPIUD) inserter specifically designed for the post-delivery setting. Primary objectives of fundal placement and expulsion rates were assessed. Secondary objectives were participant satisfaction and IUD retention. Methods: In this pilot proof of concept, we enrolled 80 women who presented for PPIUD insertion at 2 government hospitals in Delhi and Lucknow, India, between March and July 2015. PPIUD insertion was completed with the dedicated inserter in all cases, by trained providers with no prior experience in PPIUD insertion, followed immediately by ultrasound to assess location and fundal placement of the IUD. Follow-up took place at 6 to 8 weeks post-insertion, and ultrasound was used to assess IUD location. Providers and participants also completed satisfaction surveys. Results: High fundal placement (≤10 mm from uterine fundus) was achieved with the dedicated PPIUD inserter in 82% of cases (n = 65). There were no perforations or infections among the participants and no other complications associated with use of the dedicated inserter. The mean distance between the IUD and the endometrial verge immediately post-insertion was 5.8 mm (range, 0–31; N = 80); this distance at follow-up was also 5.8 mm (range, 0–25; n = 50). Complete expulsion was observed in 6 cases (7.5%), and asymptomatic partial expulsion in 8 cases (10%). Providers reported the majority (93%, n = 74) of insertions to be easy. The majority (74%, n = 59) of participants reported the same level of pain before and after insertion. Conclusions: This dedicated PPIUD inserter performed as intended and was found to be safe, with high acceptability among the participants and providers. Further study and use of the dedicated inserter may reveal reduced risk of infection among PPIUD users as well as increased convenience compared with standard PPIUD insertion techniques, and could improve acceptability of postpartum IUD provision among providers. The success of this study has led to the initiation of a formal randomized controlled trial in India to further investigate the acceptability of the dedicated inserter.

Clinical Outcome of Postplacental Copper T 380A Insertion in Women Delivering by Caesarean Section.

INTRODUCTION Short interconception period after caesarean section and its associated risk of increased morbidity, mortality and surgical interventions could be avoided by postplacental IUCD insertion during the procedure. Despite the safety reports on intracaesarean IUCD insertion, obstetricians are still hesitant to extend the benefit of this long acting reversible contraception to women undergoing operative delivery. OBJECTIVE To study the clinical outcome (safety, efficacy, expulsion and continuation rates) of postplacental Copper T 380A insertion in primiparous women undergoing caesarean section. MATERIALS AND METHODS This study was a prospective observational study, carried out in the Department of Obstetrics and Gynaecology, Safdarjung hospital, which is a tertiary care hospital of Northern India. Primiparous women who delivered by caesarean section over a period of six months (July 2012 to December 2012), willing for postplacental intracaesarean IUCD insertion, and willing to comply with the study protocol, were recruited for the study. All these subjects fulfilled the WHO Standard Medical Criteria for PPIUCD insertion; follow up visits were scheduled at 1, 3, 6 and 12 months. RESULTS A total of 300 primiparous women underwent postpartum intracaesarean insertion of Copper T 380A. The mean age of women included in the study was 23.12 ± 2.42 years. Most common postinsertion complication observed in the immediate postoperative period was febrile morbidity (2%). Majority of women (94.33%) had hospital stay of less than 4 days. The common adverse events observed during follow-up of 12 months were menstrual complaints, excessive vaginal discharge and persistent pelvic pain. At the end of one year, there were 16 expulsions, 21 removals, and 2 pregnancies with gross cumulative expulsion, removal, failure and continuation rates of 5.33%, 7%, 0.67% and 91%, respectively. CONCLUSION Postplacental intracaesarean Copper T 380A insertion in primiparous women is a safe and effective method of reversible contraception, with low expulsion and high continuation rates.

Giant condyloma acuminatum of vulva treated by surgical excision and reconstruction of defect

Giant condyloma acuminatum (GCA) is a rare sexually transmitted disease caused by Human papilloma virus (HPV) and characterised by invasive growth. Very few cases of GCA of vulva have been reported till now in the English literature [1–3]. We report a case of 34-year-old lady with GCA of vulva who was successfully treated by simple vulvectomy and reconstruction of the defect by ‘‘four-flap technique’’. A 34-year-old, married woman presented with complaints of growth on her vulva for the last 8 months. The patient was 6 months pregnant when she first noted the lesion and did not seek any medical help. Two months after her caesarean delivery, she underwent cryosurgery, but with no improvement. She denied any history of sexual promiscuity. On examination there was a 14 cm 9 10 cm 9 6 cm friable, foul smelling growth on her vulva involving both labia majora, extending anteriorly to mons pubis and posteriorly to perianal region (Fig. 1a). There were a few satellite lesions on labia minora and perianal region. Clitoris, urethra and external anal sphincter were not involved. Colposcopic, proctoscopic and oropharyngeal examinations were normal. The patient and her partner were screened negative for sexually transmitted diseases and high-risk HPV DNA. Incisional biopsy showed squamous cell papilloma with koilocytic changes and it was positive for HPV DNA type 6. A simple vulvectomy, achieving wide margins, was performed. Small lesions in perianal area and labia minora were also excised. Reconstruction of vulva was performed using ‘four flap technique’ (personal communication by Dr. Prakash V, Department of plastic surgery, Safdarjung Hospital, New Delhi). In this technique, four random pattern flaps in the dimension of 1:1 or 1:2 were raised adjacent to the defect and advanced medially to resurface the defect. This resulted in defect being transferred laterally, but this defect was smaller than the original defect and could be closed primarily (Fig. 1b). Final histopathology report confirmed the diagnosis of condyloma acuminatum with mild degree of dysplasia. Functional outcome was good with no sexual complaints. She remained free of recurrence at 12 months of follow-up (Fig. 1c). Many treatment strategies have been documented in the literature for management of GCA, but mainly in the form of case reports. Complete surgical excision with histologically clear margins, with or without adjuvants, is the mainstay of the treatment for GCA, including that of vulva [1, 3]. Other modalities include combined radiotherapy and chemotherapy, topical agents (e.g. podophyllin, 5-FU, imiquimod, bleomycin) and intralesional injections of interferons [4–6]. The skin defects created after excision of GCA in the peri-anal region can be managed with mesh skin grafting, flaps and even healing by secondary intention [1, 7–9]. Flaps have been shown to give better results for reconstruction of vulva [8, 9]. The additional advantage of our ‘four flap technique is that the scars do not extend over the perineum or thighs. In our patient, the postoperative period P. Mittal (&) R. Gupta R. Dewan S. Singhal J. Suri Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Delhi 110029, India e-mail: drpratima@hotmail.com

A retrospective analysis of the symptoms and course of dengue infection during pregnancy

To assess outcomes among pregnant women diagnosed with dengue infection.

Psychosocial Implications of Stillborn Babies on Mother and Family: A Review from Tertiary Care Infirmary in India

BackgroundWhen a mother loses a baby after the period of viability, there is no way to fathom her grief, neither any words, nor an explanation. It is an unexpected event. Stillbirth presents a situation where the early activation of the grief process primarily in mother is exacerbated by the circumstances surrounding the loss. It thus becomes imperative for the healthcare providers to evaluate the significance of parent’s perception on the loss and the factors contributing to it before the initiation of therapy.ObjectiveTo evaluate the psychosocial impact of stillbirth among mothers and its contributing factors.Materials and MethodsA WHO-funded prospective study was conducted in VMMC and Safdarjung Hospital from September 2015 to August 2016 on all women who gave birth to a stillborn baby, using a questionnaire based on EPDS, after taking their written informed consent. Data were entered on the predesigned proforma and analyzed after applying Chi-square test, keeping a null hypothesis value of 15% for all the variables.ResultsOut of the 709 women who delivered stillborn babies, 645 respondents, who willingly consented to participate, were included in the study. There was a significant relationship between psychosocial impact after perinatal loss and support from caregiver and family.ConclusionMothers with stillborn fetuses should be screened for psychosocial impact and offered support when needed. Appropriate counseling by healthcare providers and continued psychosocial and emotional support by family members must be provided.

Burden of physical, psychological and social ill-health during and after pregnancy among women in India, Pakistan, Kenya and Malawi

Introduction For every woman who dies during pregnancy and childbirth, many more suffer ill-health, the burden of which is highest in low-resource settings. We sought to assess the extent and types of maternal morbidity. Methods Descriptive observational cross-sectional study at primary-level and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi to assess physical, psychological and social morbidity during and after pregnancy. Sociodemographic factors, education, socioeconomic status (SES), quality of life, satisfaction with health, reported symptoms, clinical examination and laboratory investigations were assessed. Relationships between morbidity and maternal characteristics were investigated using multivariable logistic regression analysis. Results 11 454 women were assessed in India (2099), Malawi (2923), Kenya (3145), and Pakistan (3287). Almost 3 out of 4 women had ≥1 symptoms (73.5%), abnormalities on clinical examination (71.3%) or laboratory investigation (73.5%). In total, 36% of women had infectious morbidity of which 9.0% had an identified infectious disease (HIV, malaria, syphilis, chest infection or tuberculosis) and an additional 32.5% had signs of early infection. HIV-positive status was highest in Malawi (14.5%) as was malaria (10.4%). Overall, 47.9% of women were anaemic, 11.5% had other medical or obstetric conditions, 25.1% reported psychological morbidity and 36.6% reported social morbidity (domestic violence and/or substance misuse). Infectious morbidity was highest in Malawi (56.5%) and Kenya (40.4%), psychological and social morbidity was highest in Pakistan (47.3%, 60.2%). Maternal morbidity was not limited to a core at-risk group; only 1.2% had all four morbidities. The likelihood of medical or obstetric, psychological or social morbidity decreased with increased education; adjusted OR (95% CI) for each additional level of education ranged from 0.79 (0.75 to 0.83) for psychological morbidity to 0.91 (0.87 to 0.95) for infectious morbidity. Each additional level of SES was associated with increased psychological morbidity (OR 1.15 (95% CI 1.10 to 1.21)) and social morbidity (OR 1.05 (95% CI 1.01 to 1.10)), but there was no difference regarding medical or obstetric morbidity. However, for each morbidity association was heterogeneous between countries. Conclusion Women suffer significant ill-health which is still largely unrecognised. Current antenatal and postnatal care packages require adaptation if they are to meet the identified health needs of women.

Basic Hemodynamic and Cardiac Monitoring in Obstetrics

The cardiovascular system undergoes a series of changes during pregnancy, puerperium, and labor. These changes are beneficial for the mother and the fetus and ensure optimum fetal growth and development as well as protect the mother during the normal bleeding in the postpartum period. An understanding of these changes is imperative as the physiologic and anatomic adaptations to pregnancy influence the interpretation and evaluation of the pregnant woman’s cardiac evaluation and hemodynamic monitoring.

Menopause: But Where’s the Pause?

Menopause which is defined as complete cessation of menstruation for twelve months or more is a normal physiological change. It is an important phase in a woman’s life and its association with psychosomatic symptoms is a growing cause of concern. Vasomotor symptoms, sleep disturbances and depressed mood affect a significant proportion of menopausal women. The most common explanation is oestrogen deficiency. Although hot flushes may be distressing, psychosocial factors, including stressful life events have more impact upon mood than does menopause itself. But often these menopause related problems are underreported as most of the women do not come up with their symptoms because of personal and social reasons. Clinicians who interact with women at the time of menopause have an invaluable opportunity that should be utilized. There is not much literature which is available highlighting this aspect. So, a study was undertaken at our tertiary care centre which is one of the Asia’s busiest hospitals to study the prevalence of various psychological, somatic and urinary symptoms in menopausal women. Material and Methods

Pain relief during minor procedures: a challenge for gynaecologists.

Common gynaecological problem as abnormal uterine bleeding and postmenopausal bleeding require evaluation by sampling of the endometrial tissue which was initially done by dilatation and curettage (D&C). The D&C has been substituted by outpatient procedures like endometrial suction curette biopsy, aspiration by Karmans cannula or fractional curettage or hysteroscopically guided biopsy. Other minor procedure which can be conducted in outpatients settings are suction termination, cervical biopsy, saline infusion sonography, etc. The major limitation in successful completion of the procedure is pain management. Patients frequently experience moderate to severe pain during these gynaecologic procedures and in some cases the severity of pain makes it impossible to take adequate sample in biopsy. Most patients can tolerate pain to complete necessary procedures but studies show that pain scores with cervical biopsy and cervical curettage range from four to six on a 10-point visual analogue scale (VAS)1,2. Endometrial biopsies have shown VAS scores ranging from five to seven3,4. Pain on VAS more than six suggests the need of pain relief. The choice of anaesthesia and analgesia is dependent on effectiveness, cost, safety, and side effects. Other factors are related to the patients and physicians preferences. General anaesthesia provides analgesia, amnesia and a hypnotic effect and provides adequate operating conditions for cervical dilatation and uterine intervention but it is associated with increased mortality and morbidity. Lichtenberg et al5 showed that only 10 per cent of clinics use general anaesthesia, so local anaesthesia becomes a dominant method with 58 per cent use in clinics and 32 per cent use of intravenous sedation with local anaesthesia. The paracervical block with local anaesthetic agents is one of the most common procedures used since 19256. Paracervical anaesthetics block transmission of pain through sympathetic and parasympathetic sensory fibres, before these fibres enter the uterus at the level of the internal cervical os6. Most commonly used agent is one per cent lignocaine injected at 5 and 7 O’clock position on the cervix. Paracervical block is a convenient, safe, simple, and effective anaesthetic technique for curettage being used by most clinicians with or without additional analgesia. Tangsiriwatthana et al6 assessed the efficacy of paracervical block for cervical dilatation and uterine intervention, and stated that no local anaesthetic agent prevented pain as well as general anaesthesia. There was no evidence that paracervical block reduced pain compared to alternative regional anaesthetic methods or systemic analgesics and sedatives. In most studies pain score was more than six during the procedure when using placebo implying the need of pain relief6. The study of Acmaz and colleagues7 assessed the analgesic efficacy of preoperative oral dexketoprofen trometamol, intravenous paracetamol, lidocaine spray, pethidine and diclofenac sodium on fractional curettage procedure. A total of 144 mutiparous women were randomly allocated to the six groups. Though significant pain reduction was achieved for both intra- and postoperative periods by using analgesics but lidocaine spray was the best choice for reducing pain score during curettage procedure. All analgesic procedures were significantly effective for reducing pain in post operative period. The authors advocated the use of lidocaine spray as the first choice analgesic and pethidine as the second choice analgesic in the fractional curettage procedure. Lidocaine spray produces significant pain relief even in the absence of clinically significant serum levels as it is proposed to act by reduction of generation and conduction of peripheral pain impulses in dysfunctional or damaged nociceptors situated directly below the application site2. The addition of 10 per cent lidocaine spray to a paracervical block safely decreased perceived pain during first-trimester surgical abortion, as compared to paracervical block alone8. Non steroidal anti-inflammatory drugs (NSAIDs) show their effect by cyclooxygenase inhibition, thereby decrease the release of prostaglandins and do not discriminate between the two enzymes cyclooxygenase (COX)-1 and -29. The administration of oral NSAIDs like tramadol, naproxen, ibuprofen, and mefenamic acid with or without the adjunctive use of paracervical block or intrauterine anaesthesia prior to minor gynaecologic surgery has been introduced in recent years. Dexketoprofen trometamol, the active enantiomer of racemic ketoprofen, is a relatively new NSAID with analgesic and antipyretic properties9. When compared with ketoprofen, dexketoprofen it possesses the advantages of faster onset of action, increased potency, and fewer gastrointestinal side effects. Diclofenac also belongs to NSAID group and has been shown to be effective in reducing intra- and post operative pain after fractional curettage as in the present study7. This has been consistent with a prior study which has demonstrated effectiveness of NSAIDs in such procedures9. Pethidine is a phenylpiperidine derivative with a chemical structure similar to local anaesthetics. Because of its local anaesthetic effect on peripheral nerves it may be the ideal analgesic for curettage. In the present study, pethidine was given subcutaneously while in previous studies, it was given intramuscularly or intrathecally for postoperative pain after caesarean section or other perineal surgery10,11,12. Paracetamol primarily acts upon the central nervous system by inhibiting central cyclooxygenase. It probably has an indirect effect on the serotoninergic system13. Paracetamol is considered safe and can cross the blood brain barrier13. Most of the analgesics are effective in providing post-procedure pain relief in gynaecological procedures. The analgesics led to a reduction in pain score by 40-50 per cent in the study of Acmaz et al7, but lidocaine puffs provided the best pain relief than the other analgesics or placebo. It is observed that during colposcopy treatment cocaine spray before treatment resulted in better pain relief14. In the recent Cochrane reviews6,14 the existing literature regarding pain control for intrauterine interventions as hysteroscopy, first trimester abortion, intrauterine device (IUD) insertion and hysterosalpingography (HSG) has been evaluated, and both the reviews have concluded that optimal methods for pain control are unclear as results of different researches in this field are not consistent. This could be due to heterogeneity in methods and reporting. Many studies were not well designed, the comparator used varied as placebo, local block or no medication. Measurement of pain relief varied as multiple outcomes were used as 10 or 20 cm VAS. While most studies compared difference in mean or median pain scores between intervention and control groups, several compared proportions of patients who reported pain above a predefined cut-off point. Many studies gave importance to need of additional analgesics as a criterion of pain relief measurement. Pain measurements were taken at different times across studies, ranging from one measurement during the procedure to a total of seven measurements prior, during, and after procedures6,14. The analgesics have complications like nausea, vomiting, rashes, bradycardia, and stomach complaints reported in 2-10 per cent cases5. This study7 also had similar rate of complications in all the groups. Strengths of the study by Acmaz et al7 were: randomized placebo controlled trial which was double blind with a power of 80 per cent, many confounding variables were taken into consideration as stringent inclusion criteria, no misoprost or analgesics prior to intervention, only multiparous patients enrolled, exclusion of patients of chronic pelvic pain and performance of procedure by same gynaecologist. The study had limitations also. The number of patients in control group receiving placebo via different modes of administration was small to make adequate comparisons with each study group. The authors in their previous study2 recommended paracervical block as the best method for reducing pain scores in intra- and postoperative periods during curettage procedures. So paracervical block should also have been taken into account while recommending the suitable pain relief technique. Operators perception of analgesics and patients satisfaction should also have been included as a parameter for making a choice of best available pain relief modality. In conclusion, though topical lidocaine spray appears promising, there is still no consensus established on which type of analgesia should be used in patients undergoing fractional curettage and endometrial biopsy. More randomized controlled trials with large number of subjects are needed for its use to be recommended.