Suresh Verma

Oral nifedipine or intravenous labetalol for hypertensive emergency in pregnancy: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of orally administered nifedipine and intravenously administered labetalol for acute blood pressure control in hypertensive emergency of pregnancy. METHODS: In this double-blind, randomized, controlled trial, pregnant women with sustained increase in systolic blood pressure of 160 mm Hg or higher or diastolic blood pressure of 110 mm Hg or higher were randomized to receive nifedipine (10 mg tablet orally up to five doses) and intravenous placebo saline injection or intravenous labetalol injection in escalating doses of 20, 40, 80, 80, and 80 mg and a placebo tablet every 20 minutes until the target blood pressure of 150 mm Hg systolic and 100 mm Hg diastolic, or lower, was achieved. Crossover treatment was administered if the initial treatment failed. The primary endpoint of the study was time necessary to achieve target blood pressure. Secondary endpoints were number of dosages required, adverse maternal and neonatal effects, side effect profile, and perinatal outcome. RESULTS: From October 2012 to April 2013, we enrolled 60 patients. The median time taken to achieve target blood pressure was 40 minutes (interquartile range, 20–60 minutes) compared with 60 minutes (interquartile range 40–85 minutes) for nifedipine and labetalol, respectively (P=.008). The median dose required was two (interquartile range 1–3) compared with three (interquartile range 2–4.25) for nifedipine and labetalol, respectively (P=.008). No serious adverse maternal or perinatal side effects were witnessed in either group. CONCLUSION: As administered in this trial, oral nifedipine lowered blood pressure more quickly than did intravenous labetalol during hypertensive emergency in pregnancy. CLINICAL TRIAL REGISTRATION: Clinical Trials Registry—India, www.ctri.nic.in, CTRI/2013/02/003350. LEVEL OF EVIDENCE: I

A prospective observational study of trial of labor after cesarean in rural India

To determine the success rate of trial of labor after cesarean (TOLAC) in rural India.

Hydralazine vs nifedipine for acute hypertensive emergency in pregnancy: a randomized controlled trial

Background There is a paucity of good quality evidence regarding the best therapeutic option for acute control of blood pressure during acute hypertensive emergency of pregnancy. Objective We sought to compare the efficacy of intravenously administered hydralazine and oral nifedipine for acute blood pressure control in acute hypertensive emergency of pregnancy. Study Design In this double‐blind, randomized, controlled trial, pregnant women (≥24 weeks period of gestation) with sustained increase in systolic blood pressure of ≥160 mm Hg or diastolic blood pressure of ≥110 mm Hg were randomized to receive intravenous hydralazine injection in doses of 5, 10, 10, and 10 mg and a placebo tablet or oral nifedipine (10 mg tablet up to 4 doses) and intravenous saline injection every 20 minutes until the target blood pressure of 150 mm Hg systolic and ≤100 mm Hg diastolic was achieved. Crossover treatment was administered if the initial treatment failed. The primary outcome of the study was time necessary to achieve target blood pressure. The secondary outcomes were the number of dosages required, adverse maternal and neonatal effects, and perinatal outcome. Results From December 2014 through September 2015, we enrolled 60 patients. The median time to achieve target blood pressure was 40 minutes in both groups (intravenous hydralazine and oral nifedipine) (interquartile interval 5 and 40 minutes, respectively, P = .809). The median dose requirement in both groups was 2 (intravenous hydralazine and oral nifedipine) (interquartile range 1 and 2 doses, respectively, P = .625). Intravenous hydralazine was associated with statistically significantly higher occurrence of vomiting (9/30 vs 2/30, respectively, P = .042). No serious adverse maternal or perinatal side effects were witnessed in either group. Conclusion Both intravenous hydralazine and oral nifedipine are equally effective in lowering of blood pressure in acute hypertensive emergency of pregnancy.

Rupture of Uterus in Mid Trimester of Pregnancy: A Case Series & Review of Literature

With the increasing rates of cesarean section (CS) worldwide, pregnant women with previous CS are also rising at an alarming rate. This is leading to increase in previously rare complications of pregnancy e.g. cesarean scar pregnancy, placenta accreta and rupture uterus. One such complication is mid trimester rupture of uterus, which previously used to be a rare possibility. Now a day’s more and more pregnant women are presenting in shock in mid trimester of pregnancy. Hence, this case series is being reported to highlight this complication of pregnancy and to remind managing obstetricians and sonologists regarding these rare possibilities which should be kept in mind while doing routine sonographic assessment of pregnant women, so as to prevent catastrophe of rupture uterus.

Gynecological diseases in rural India: A critical appraisal of indications and route of surgery along with histopathology correlation of 922 women undergoing major gynecological surgery

Objective: The aim of the study was to generate baseline data for indications of gynecological surgeries, and to assess route of surgery and histopathology correlation in women undergoing major gynecological surgery in a rural tertiary level teaching hospital in India. Materials and Methods: Surgical indications, route of surgery and histopathology findings were reviewed and analyzed retrospectively, in 922 patients (≥35 years age) who underwent gynecological surgery at Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India from January 1, 2011 to May 31, 2013. Results: Of 922 surgeries, 65 had malignancy (7%). Pelvic organ prolapse (POP) (32.3%) and leiomyoma uterus (29%) were two most common benign indications for hysterectomy. Ovarian tumors were present in 13% (25% of these were malignant). Postmenopausal bleeding (PMB) was seen in 5.5% (55% of these were malignant). Conclusions: All except 10% surgeries were done in the absence of definite histopathology diagnosis that is dysfunctional uterine bleeding (n = 42 [45%]), chronic pelvic pain/severe dysmenorrhea (n = 34 [36%]) and recurrent PMB (n = 17 [19%]). Majority of surgeries had histopathological correlation except for six cases (0.6%) of malignancy, which were missed on initial work-up. Majority of the surgeries were done abdominally. In rural areas of developing countries poverty, lack of regular follow-up, resource constraints and lack of technical skills (with respect to laparoscopic/robotic surgeries) pose major challenge in providing quality health care.

Pelvic Organ Prolapse during Pregnancy: A Case Series and Review of Literature

Pelvic organ prolapse during pregnancy is extremely rare. Limited cases (less than 30) have been reported since 1980. From a very benign presentation of heaviness in perineum, it can present as uterine rupture with fetal and maternal mortality. No standard guidelines of care have been established for this rare presentation. There is gross variation in management ranging from conservative measures, laparoscopic surgery to cesarean section followed by peri-partum hysterectomy and abdominal sacral colpopexy. This case series report five cases of pelvic organ prolapse during pregnancy and outlines an approach of watchful expectancy with favorable maternal & fetal outcomes.