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Indian Journal of Obstetrics

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Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
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INDIAN JOURNAL OF OBSTETRICS


AND GYNECOLOGY
January - April 2016
Volume 4 Number 1
Content

Original Articles

Prevalence of Gestational Diabetes Mellitus and Associated Risk Factors at a


Tertiary Care Hospital in Karnataka 5
Chandana M. Puttaraju, Madhu M. Shankaregowda

Clinical Presentation and Management of Ectopic Pregnancy in Tribal


Population in South Rajasthan and Co-Relation with High Prevalence
of Sexually Transmitted Diseases 11
Brigadier P.K. Bhatnagar, Sushila Jain

Incidence of Hepatitis among Pregnant Women of North Indian


University Teaching Hospital 17
Uma Pandey

Review Articles

Bioethics in Multiple Pregnancies 23


Alka B. Patil, Nilay Patel

Thyroid Dysfunction in Pregnancy: A Pandora’s Box 31


Ashalata Bafna, Barkha Bafna M.S., Amit Bafna M.S.

Case Reports

Successfull Surgical Management of a Giant Condyloma Accuminata


in an Elderly Postmenopausal Woman 39
Amrita Singh, Prasanta Kumar Nayak, Subarna Mitra, Sarita Agrawal

Live Birth in an Unruptured Non-Communicating Rudimentary Horn 43


Savita Rani Singhal, Susheela Chaudhary, Anjali Gupta

Puerperal Rupture Uterus in A Primigravida: A Rare Case 47


Ananya Das

Fetal Gastroschisis: A Differential Diagnosis of Uterine Perforation 49


Savita Rani Singhal, Suresh Kumar Singhal, Ankita Agarwal

Pseudomyxoma Peritonei or Jelly Belly: Varied Presentations 51


Joylene D. Almeida, Ganesh Bongale, Sujaya V. Rao

Digoxin Therapy for Fetal Supraventricular Tachycardia Diagnosed


at 29 Weeks Gestation 57
Nitisha Lath, Savita Bansal, Pratibha Singh

Guidelines for Authors 63


Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
4

Indian Journal of Obstetrics and Gynecology

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Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Indian Journal of Obstetrics and Gynecology
5
Volume 4 Number 1, January - April 2016

Prevalence of Gestational Diabetes Mellitus and Associated Risk


Factors at a Tertiary Care Hospital in Karnataka

Chandana M. Puttaraju*, Madhu M. Shankaregowda**

Abstract Key Message: Education regarding the


diabetogenic potential of modifiable risk
factors such as raised BMI is essential to
Context: Gestational Diabetes prevent long term complications in both
Mellitus is associated with an mother and offspring.
increased risk of maternal and foetal
complications. Early diagnosis and
management of GDM improves Introduction
maternal and perinatal outcome;
thereby preventing the long term
risks of future diabetes in both the Gestational Diabetes Mellitus is defined
mother and her offspring. Aims: Our as carbohydrate intolerance of variable
study was undertaken to determine severity with recognition or onset during
the prevalence of gestational pregnancy [1]. It is estimated that about 4
diabetes mellitus and associated million women are affected by GDM in India,
risk factors in a tertiary care centre at any given point of time [2]. Ethnically
in Karnataka. Settings and Design: Indian women have highest propensity to
This was a prospective study develop GDM [3] . GDM shows a positive
carried out in a tertiary care association with increasing maternal age,
teaching institute in Karnataka. higher gravidity, increased BMI, past H/O
Material and Methods: Eight thirty Gestational Diabetes and family history of
nine fasting pregnant women with diabetes [4-7].The present study was
24-28 weeks of gestation underwent undertaken to find the prevalence and risk
WHO-75 gram OGTT. Proforma factors associated with GDM in a tertiary care
with information on demographic teaching institute in Karnataka, India.
characteristics, age, BMI, gravidity,
past obstetrical history, past history
Material and Methods
of gestational diabetes, family
history of diabetes was collected.
*Associate Professor, Statistical Analysis Used: Descriptive This study was carried out in a tertiary
Department of Obstetrics &
Gynaecology,
and inferential statistical analysis. care teaching institute in Karnataka from
Rajarajeshwari Medical Results: GDM was diagnosed in 53 November 2007 to October 2009. All women
College, Bangalore, India. women. Age >25 years, BMI >25 kg/ were informed about the nature of the study
**Assistant Professor, m2, higher gravidity, family history and informed consent taken. The inclusion
Department of
Anaesthesiology and
of diabetes, past history of criteria was pregnant women with
Intensive Care, BGS Global gestational diabetes, past history of gestational age between 24-28 weeks.
Institute of Medical intrauterine fetal demise and Exclusion criteria was pregnant women with
sciences, Bangalore, India. history of abortions were Pre-gestational diabetes.
Chandana M. P., #1495, significantly associated with higher
A total of 839 pregnant women were
Shree Residency prevalence of GDM. Conclusion:
screened for GDM. They underwent detailed
apartments, Flat no.203, 80 Prevalence of GDM was 6.32% in
feet double road, BEML clinical examination. Presence of risk factors
our study. Appropriate
Layout-5th stage, was noted. Details of family history of diabetes,
Rajarajeshwarinagar, interventions are required for
past history of Gestational diabetes mellitus,
Bangalore-560098, control and risk factor
history of previous pregnancies, history of
Karnataka. modification.
E-mail: previous fetal losses and socio-economic status
drchandanamp@yahoo.com Keywords: Age; BMI; Gravidity. were obtained. Blood pressure measurement

©Red
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JournalPublication Pvtand
of Obstetrics LtdGynecology / Volume 4 Number 1 / January - April 2016
Chandana M. Puttaraju et. al. / Prevalence of Gestational Diabetes Mellitus and Associated Risk Factors
6
at a Tertiary Care Hospital in Karnataka

and the body mass index were recorded. A total of 839 pregnant women with gestational
All 839 women were requested to have their regular weeks between 24-28 weeks were enrolled in our
diet for three days and observe overnight fast of 8-12 study. WHO-75 gram OGTT criteria was utilised to
hours for the 75 gram oral glucose tolerance test diagnose Gestational diabetes mellitus. Fifty three
(OGTT) recommended by WHO. Seventy five gram of pregnant women had 2hr blood sugar  140mg/dl
glucose was dissolved in 200-400 ml of water and the rendering them diabetics. The prevalence of GDM in
patient was asked to drink it over a five minute period our study was 6.32%. Only 1.2% (10/839) of pregnant
.Blood sample was drawn in the fasting state and 2 women had FBS>126mg/dl.
hours after ingestion of 75 gram glucose. A pregnant Thirty three urban pregnant women accounted for
woman was diagnosed with Gestational diabetes 62.3% of GDM patients. Rural women comprised of
mellitus if the Fasting plasma glucose 126 mg/dl, 37.7% (20/53) of GDM patients. Prevalence of GDM
and/or 2 hours plasma glucose >140 mg/dl. The
in Rural and urban population was 4.96% (20/403)
plasma glucose was estimated by glucose oxidation
and 7.56%(33/436) respectively.
and per-oxidation (GOD-POD) method by Eco-Pak
glucose kit. In our study, mean age of GDM patients was
23.71±3.88 years. The prevalence of GDM was 1.2%,
3.01%, 11.97% and 22.22% in age groups < 20 years,
Statistical Analysis < 25 years, >25 years and >30 years respectively.
Descriptive and inferential statistical analysis has Mean BMI of GDM patients was 20.87±6.61 kg/
been carried out in the present study. Results on m2. BMI >25 kg/m2 was observed in 43.39% (23/53)
continuous measurements are presented on Mean ±
of our GDM patients; of which 9.4 %( 5/53) were obese
SD (Min-Max) and results on categorical
and 34%(18/53) were overweight.
measurements are presented in Number (%).
Significance is assessed at 5 % level of significance. Amongst 53 GDM patients, 64.15%(34/53) were
multigravidas as compared to 35.8%(19/53)
Chi-square/ Fisher Exact test has been used to find
the significance of study parameters on categorical primigravidas.
scale between two or more groups. P value < 0.05 was Past history of gestational diabetes mellitus was
considered to be statistically significant. present in 17%(9/53) of diabetics in our study.
Positive family history of diabetes mellitus prevailed
in 18.9%(10/53) of the GDM women.
Statistical Software
Previous history of intrauterine fetal demise was
The Statistical software namely SAS 9.2, SPSS 15.0,
present in 13.2%(7/53) of GDM patients. Past history
Stata 10.1, MedCalc 9.0.1, Systat 12.0 and R
of neonatal deaths prevailed in 7.6%(4/53) of GDM
environment ver.2.11.1 were used for the analysis of
patients. A total of 11(20.75%) GDM patients had
the data. Microsoft word and Excel have been used
to generate graphs, tables etc. previous history of foetal loss.Past history of abortions
was observed in 39.62%(21/53) of GDM patients.
Previous History of Preterm delivery was identified
Results in 1.9% of GDM patients.

Table 1: Comparison of risk factors in GDM & Non diabetic population with P value

Non -Diabetics GDM P value


Risk Factors (n=786) (n=53)
No. (%) No. (%)
Age >25 yrs. 272(34.6%) 37(69.81) P<0.001
BMI >25 kg/m 2 24(3.05%) 23(43.39) P<0.001
Higher gravidity 408(51.9%) 34(64.15%) P=0.005
Past H/O IUFD 34(4.3%) 07(13.2%) P=0.004
Past H/O Neonatal death 31(3.9%) 04(7.6%) P=0.204
Past H/O Abortions 162(20.6%) 21(39.62) P<0.001
Past H/O Prematurity 27(3.4%) 01(1.9) P=0.570
Past H/O GDM 08(1%) 09(17) P<0.001
Family H/O DM 18(2.3%) 10(18.9) P<0.001
Obesity 04(0.5%) 05(9.4)

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Chandana M. Puttaraju et. al. / Prevalence of Gestational Diabetes Mellitus and Associated Risk Factors
7
at a Tertiary Care Hospital in Karnataka

Risk Factors Non Diabetics GDM


Age >25 yrs. 34.6 69.81
BMI >25 kg/m2 3.05 43.39
Higher gravidity 51.9 64.15
Past H/O IUFD 4.3 13.2
Past H/O Neonatal death 3.9 7.6
Past H/O Abortions 20.6 39.62
Past H/O Prematurity 3.4 1.9
Past H/O GDM 1 17
Family H/O DM 2.3 18.9
Graph 1: Comparison of risk factors in Non diabetic and
GDM population

Age in years Non Diabetics GDM


18-24 65.39 30.18
25-30 30.1 50.9
31-35 3.94 13.2
36-40 0.5 5.66

Graph 2: Prevalence of GDM by Age

BMI (kg/m2) Non Diabetic GDM


<18.5 10.8 1.9
18.5-25 86.1 54.7
25-30 2.5 34
>30 0.5 9.4

Graph 3: Prevalence of GDM by BMI

Gravidity Non Diabetics GDM


1 48.1 35.8
2 32.3 22.6
3 14 28.3
4 4.2 7.5
5 1 3.8
>5 0.4 1.9

Graph 4: Prevalence of GDM by Gravidity

Discussion another condition (future diabetes in the mother) and


also as prevention for condition in another person
(future diabetes in the unborn child) [11]. GDM,
GDM is associated with an increased risk of therefore is a perfect window of opportunity for
complications for mother and child during pregnancy prevention of diabetes.
and birth8.Gestational diabetes has serious, long-term
consequences for both baby and mother, including a In parallel with type 2 diabetes mellitus pandemic,
predisposition to obesity, metabolic syndrome, and the incidence of gestational diabetes mellitus has risen
diabetes later in life [9]. The risk of developing type 2 rapidly [12]. The prevalence of GDM has been reported
diabetes at 15 years of follow up is about 26% [10]. variably from 1.4 to 14% worldwide and differently
among racial and ethnic groups [13].The prevalence
GDM provides a unique model in which treatment of GDM is high in the Indian population as compared
for a medical condition acts as a prevention for to other populations of South East Asia [14]. The

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Chandana M. Puttaraju et. al. / Prevalence of Gestational Diabetes Mellitus and Associated Risk Factors
8
at a Tertiary Care Hospital in Karnataka

prevalence of GDM in our study was 6.32%.This is Obesity as a risk factor was found in 25%, 33.3%,
comparable to 6%, 6.6%, 6.7%, 6.94% prevalence rates 50%, and 88% of GDM patients in studies by Das [22]
in studies by Nilofer [15] et al, Kalra [16] et al, Verma et al, Seshiah [20] et al, Gomez [23] et al and Nilofer
[4] et al and Wahi [13] et al respectively. [15] et al respectively.
Apart from ethnicity, high prevalence rate of GDM Amongst 53 GDM patients, 64.15% were
in Indian population is due to trending towards older Multigravidas as compared to 35.8% primigravidas,
maternal age, decrease in physical activity, adoption the prevalence being statistically significant, P=0.005.
of modern lifestyle, and increasing prevalence of The prevalence of GDM increased from 4.78% in
obesity and diabetes [17]. primi gravida to 25% in Gravida >5 in our study. The
GDM has been found to be more prevalent in urban prevalence of GDM in second, third and fourth gravida
areas than in rural areas [7,18]. In our study, were 4.51%, 12%, and 10.81% respectively in our
prevalence of GDM in Rural and urban population study. In our study, the prevalence of GDM in third
was 4.96%(20/403) and 7.56%(33/436) respectively. gravida was 12% which is comparable to 16.9% and
Urban pregnant women accounted for 62.3%( 33/53) 18.2% in studies by Seshiah [20] et al and Rajput M
of GDM patients. Rural women comprised of 37.7% [24] et al respectively. The prevalence of GDM in fifth
(20/53) of GDM patients. Though GDM was more gravida was 20% in our study comparable to 25.8%
prevalent in urban population compared to rural in a study by Seshiah [5] et al in 2004.
population, it did not reach statistical significance in The recurrence risk of GDM with future
our study( P=0.121). Seshiah [6] et al described GDM pregnancies has been reported as high as 68% [25]. A
prevalence of 9.9% and 17.8% in rural and urban areas significant association between history of GDM in
respectively in a community based study in South previous pregnancy and development of GDM in
India. index pregnancy was observed (P<0.001) in our study.
The prevalence of GDM increased significantly Past history of gestational diabetes mellitus was
with age in our study. Prevalence of GDM was 1.2%, present in 17% of diabetics in our study. This is in
3.01%, 11.97% and 22.22% in age groups <20 years, concurrence with rates of 12.12%, 11.1% and 10.9%
<25 years, >25 years and >30years respectively. This of GDM patients with a past history of GDM in studies
association is statistically significant with a P by Kalra [16] et al, Nilofer [15] et al and Murgia [26] et
value<0.001. Rajput R [19] et al described GDM al respectively. Past history of GDM was present in
prevalence rate of 4.53% in age group< 25 years, 4.65% of GDM patients in a study by Rajput R [19] et
comparable to 3.01% of our study. GDM prevalence al in Haryana.
in age group> 25 years was found to be 11.57%, 19.5% Positive family history of diabetes mellitus was
in studies by Rajput R [19] et al and Seshiah [20] et al present in 18.9% of the GDM women .There was a
respectively; which was similar to our study results. significant association (P<0.001) between family
Age >30 years as a risk factor was found in history of diabetes mellitus and occurrence of GDM
25%,32.1%, 34.8% of GDM patients in studies by among pregnant women in our study. This is similar
Seshiah20,5 et al and Rajput R [19] et al respectively to findings of Seshiah [6] et al, Rajput R [19] et al, and
concurring to our study findings. A high GDM Das [22] et al who report 19.2%, 16.3% and 14.3 % of
Prevalence of 84.84% was found in age group >25 diabetic pregnant women with positive family history
years in a study by Kalra P [16] et al in Western of DM in their studies respectively.Kalra [16] et al &
Rajasthan. Similarly Nilofer [15] et al described a Nilofer [15] et al found that 33% and 77.7% of GDM
prevalence of 77.7% in age group > 30 years. patients had positive family history of DM
GDM was found to be significantly higher in respectively.
women with higher BMI in study by Chu SY et al 21 . Detection and care of GDM is a public health
BMI>25 kg/m2 was recorded in 43.39 % of our GDM priority as the still birth rate is high in India and
patients; amongst whom 9.4% were obese and 34% Gestational Diabetes Mellitus is one of the causes [27].
overweight .This trend of increasing prevalence with 13.2% of our GDM patients had past history of
increasing BMI was found to be statistically Intrauterine fetal demise, which had significant
significant, P<0.001. association with occurrence of GDM , P=0.004.Our
Seshiah et al [6] & Rajput R [19] et al found that findings are in comparison with studies of Murgia C
28.4% & 22% of GDM patients were overweight [26] et al, Hoseini [28] et al and Kalra [16] et al who
respectively; which is in concurrence with our study. observed that 12.1%, 12.3% and 15.15% of GDM
Kalra P [16] et al observed that 18.18% of women with patients had history of previous foetal or early
GDM were obese which is comparable to 9.4% obese neonatal deaths respectively. Past history of abortions
GDM women in our study. was present in 39.62% of our GDM patients which
Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Chandana M. Puttaraju et. al. / Prevalence of Gestational Diabetes Mellitus and Associated Risk Factors
9
at a Tertiary Care Hospital in Karnataka

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748-52. Gynecol Obstet. 2009; 104(Suppll): S35-8.
4. Verma AK, Singh B, Mengi V. Gestational diabetes 19. Rajput R, Yogesh Y, Smiti N, Rajput M et al.
in rural women of Jammu. Indian J Comm Med. Prevalence of Gestational Diabetes Mellitus &
2008; 33: 54-5. associated risk factors at a tertiary care hospital in
5. Seshiah V, Balaji V, Balaji MS et al. Gestational Haryana. Indian J Med Res. 2013; 137: 728-33.
diabetes mellitus in India .J Assoc Physicians India. 20. Seshiah V, Balaji V, Balaji MS, Sekar A, Sanjeevi CB
2004; 52: 707-11. et al. One step procedure for screening and diagnosis
6. Seshiah V, Balaji V, Balaji MS et al .Prevalence of of gestational diabetes mellitus. J Obstet Gynecol
Gestational Diabetes Mellitus in South India (Tamil India. 2005; 55: 525-29.
nadu)-a community based study. J Assoc Physicians 21. Chu SY, Callaghan WM, Kin SY, Schmid CH, Lau J,
India. 2008; 56: 329-33. England LJ et al. Maternal obesity and risk of gestational
7. Zargar AH, Sheikh MI, Bashir MI, Masoodi SR, Laway diabetes mellitus. Diabetes Care. 2007; 30: 2070-6.
BA, Wani A I, Dar FA et al. Prevalence of gestational 22. Das V, Kamra S, Mishra A. Screening for gestational
diabetes mellitus in Kashmiri women from the diabetes and maternal and fetal outcome. J Obstet
Indian subcontinent. Diabetes Res Clin Pract. 2004; Gynecol India. 2004; 54: 449-51.
66(2): 139-145. 23. Gomez HL, Martinez ML, Rodriguez ZM. Clinical
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BE, Lowe LP, Dyer AR, Trimble ER, Chaovarindr U pregnancy, Isle of youth, 2008. MEDICC Rev. 2011;
et al. Hyperglycaemia and adverse pregnancy 13:29-34.

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Chandana M. Puttaraju et. al. / Prevalence of Gestational Diabetes Mellitus and Associated Risk Factors
10
at a Tertiary Care Hospital in Karnataka

24. Rajput M, Bairwa M, Rajput R. Prevalence of mellitus in a large group of Sardanian Women .
Gestational Diabetes Mellitus in rural Haryana. A Reprod Biol Endocrinol. 2008; 6: 26.
community based study. Indian J Endocr Metab. 2014; 18. 27. Pattinson R, Kerber K, Buchmann E, Friberg I K,
25. Spong CY, Guillermo L, Kuboshige J, et al. Belizan M, Lansky S, Lawn J E et al. Stillbirths: how
Recurrence of gestational diabetes mellitus: can health systems deliver for mothers and babies?
identification of risk factors. Am J Perinatol. 1998; The Lancet. 2011; 377(9777): 1610-1623.
15(1): 29-33. 28. Hoseini S, Hantoushzadeh S, Shoar S. Evaluating the
26. Murgia C, Berria R, Minerba L ,Sulis S , Murenu M , extent of pregravid risk factors of gestational
Portoghese E, Garau N et al. Risk assessment does diabetes mellitus I women in Tehran. Iran Red
not explain high prevalence of gestational diabetes Crescent Med J. 2011; 13: 407-14.

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Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Indian Journal of Obstetrics and Gynecology
11
Volume 4 Number 1, January - April 2016

Clinical Presentation and Management of Ectopic Pregnancy in Tribal


Population in South Rajasthan and Co-Relation with High Prevalence
of Sexually Transmitted Diseases

P.K. Bhatnagar*, Sushila Jain**

Abstract Conservative Surgery For Tubal Pregnancy;


Salpingostomy; Salpingectomy; Salpingo-
Opherectomy.
ECTOPIC PREGNANCY “ A
GREAT DECEIVER “ may present
with varied symptoms and signs []. Introduction
BETA HCG and
ULTRASONOGRAPHY has
Incidence of ectopic pregnancy is 0.5 -
revolutionized the diagnosis of
1.00% and is responsible for 6-10%of all
ectopic pregnancy and this has
maternal deaths in India [3]. Signs and
drastically reduced maternal
symptoms classically include amenorrhea,
morbidity and mortality[2]. Still in
abdominal pain and vaginal bleeding. 90%
rural, unaware , malnourished and
of women however have these symptoms.
severely anemic population it poses
The pain may be described as sharp, dull, or
diagnostic and management
cramp. Pain may also spread to the shoulder
dilemma. This is retrospective
if bleeding into the abdomen has occurred.
study, carried out at PIMS (Pacific
Severe bleeding may result in a tachycardia ,
Institute of Medical Sciences
extreme pallor and low blood pressure or
Umarda, Udaipur, Rajasthan) in
shock [4]. Risk factors for ectopic pregnancy
2014 and 2015. Total 32 cases were
include: pelvic inflammatory disease,
analyzed. 26(81.25%) had pelvic
chronic and acute often due to chlamydia
infection either acute or chronic
infection, gonorrhea, syphilis or tuberculosis,
including sexually transmitted
tobacco smoking, and the use of assisted
diseases and post abortal and
reproductive technology. Those who have
previous tubercular infections. All
previously had an ectopic pregnancy are at
patients had pain in the abdomen,
much higher risk of having another one. Most
28(87.50%) had history of
ectopic pregnancies (90%) occur in the
amenorrhea and 26(81.25%) had
fallopian tube which are known as tubal
uterine bleeding. USG in 28(87%)
pregnancies [5]. Implantation can also occur
was suggestive of fluid/clots in
on the cervix, ovaries, or within the abdomen.
peritoneum or tubo -ovarian Mass.
*Associate Professor, detection of ectopic pregnancy is typically
**Senior Resident, Dept. of
However Urine Pregnancy Test/Beta
by blood tests for human chorionic
Obst and Gynae, PPacific HCG were positive in 25(78.13%).
gonadotropin (BETA HCG) and ultrasound
Institute of Medical Salpingectomy was the most common
Sciences (PIMS), Ambua /TRANS VAGINAL SONOGRAPHY. This
surgery done in 31(98.67 %). There
Road, Village Umarda, may require testing on more than one
Girva, Udaipur
was no negative laparotomy in this
occasion. Ultrasound works best when
Rajasthan, 313015. study. There was no maternal
performed from within the vagina.
mortality in this series. Prevention of
Brigadier P.K. Bhatnagar Differential diagnosis include miscarriage,
sexually transmitted diseases, pelvic
Associate Professor in Obst ovarian torsion, and acute appendicitis [6].
and Gynae, Pacific infection, early diagnosis and prompt
Prevention is by decreasing risk factors such
Institute of Medical treatment helps in reducing mortality
as infections through screening and
Sciences (PIMS), Ambua and morbidity.
Road, Village Umarda, treatment. The use of the medication
Girva, Udaipur Keywords: Ectopic Pregnancy; methotrexate works as well as surgery in
Rajasthan, 313015. Sexually Transmitted Diseases In some cases. Specifically it works well when
E-mail: Ectopic Preg Ruptured Ectopic
Pk.Bhatnagar@Yahoo.Com,
the beta-HCG is low and the size of the
Pradeep.Bhatnagar51@Gmail.Com Prgnancy; Haemoperitoneum; ectopic is small. Surgery is still typically

©Red
IndianFlower
JournalPublication Pvtand
of Obstetrics LtdGynecology / Volume 4 Number 1 / January - April 2016
Brigadier P.K. Bhatnagar & Sushila Jain / Clinical Presentation and Management of Ectopic Pregnancy in
12
Tribal Population in South Rajasthan and Co-Relation with High Prevalence of Sexually Transmitted Diseases

recommended if the tube has ruptured, there is a fetal those patients on whoom laparotomy was performed
heartbeat, or the person’s vital signs are unstable. suspecting ectopic pregnancy were included.
The surgery may be laparoscopic or through a larger Detailed history examination findings and
incision, known as a laparotomy. Outcomes are investigations were scrutinized. Investigations
generally good with treatment [7]. Incidence of ectopic included complete blood count HB, TLC, DLC, BT,
pregnancy is quite high in Tribal population. Ladies CT, PT ,INR, HIV ,HBSAG, VDRL ,TREPONEMA
are little less or uneducated with early marriage and TEST, VAGINAL SWAB, BLOOD GROUPING ,BLOOD
repeated childbirths and very high incidence of pelvic SUGAR URINE PREGNANCY TEST, BETA HCG,
inflammatory disease and local customs allow ULTRASONOGRAPHY ,TRAS ABDOMINAL AND
promiscuity and tobacco chewing and smoking. TRANS VAGINAL. Suspected patients were taken up
Studies show that safe sex works. When barrier for laparotomy and all patients underwent
contraceptive use goes up, both STDs and ectopic salpingectomy as the definitive treatment. Patients made
pregnancy rates go down. Using a condom and limiting uneventful recovery and there was no mortality.
your sexual partners is a good way to reduce your Thirtytwo patients with provisional diagnosis of ectopic
chances of experiencing an ectopic pregnancy [8]. pregnancy were studied. Physical examination, urine
pregnancy test, trans-abdominal scan using 5 MHz
transducer or trans-vaginal ultrasonography of 7 MHz
Material and Methods was done. The diagnosis of ectopic pregnancy was
confirmed by direct observation by laparotomy or
laparoscopy (which was taken as gold standard).
This has been a retrospective study at PIMS (pacific
Prevalence of Sexually transmitted disease in relation
institute of medical sciences) umardaudaipur. Period
to incidence of ectopic pregnancy was studied.
of study has been from 2014 to 2015 (two years)all
Observations
Table 1: Age distribution for ectopic pregnancy
Serial no Age in years Number of patients Percentage
1 Less than 20 2 6.25
2 20-25 3 9.37
3 26-30 22 68.75
4 31-35 5 15.63
5 36-40 0 0
Total 32 100
Result- maximum number of patients 22(68.75 %) belonged to age group of 26-30 years.

Table 2: Parity of patients affected by ectopic pregnacy


Serial number Parity Number of patients Percentage
1 Nulli para 0 0
2 Para one 4 12.50
3 Para two 18 56.25
4 Para three 3 9.37
5 Para four 6 18.75
6 Para five 1 3.13
Total 32 100
Result- Maximum number of patients were para two 18(56.75 %).

Table 3: Risk factors in ectopic pregnancy


Serial number Risk factors Number of patients Percentage
1 Pelvic infection 26 81.25
2 Previous ectopic 2 6.25
3 Asst repro tech 1 3.13
4 Copper t 0 0
5 Tobacco use 15 46.87
Result- Most 26(81.25%) had pelvic infection either acute or chronic including post aortal and previous tubercular.
Interestingly 15(46.87%) were using tobacco for chewing and BIDI smoking.

Table 4: Sexually transmitted diseases and pelvic inflammatory disease

S. No Positive Tests Number Percentage


1 Hiv 1 3.13
2 Hbsag 2 6.25
3 Vdrl 2 6.25
4 Vaginal Swab 2 6.25
Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Brigadier P.K. Bhatnagar & Sushila Jain / Clinical Presentation and Management of Ectopic Pregnancy in
13
Tribal Population in South Rajasthan and Co-Relation with High Prevalence of Sexually Transmitted Diseases
3 Vdrl 2 6.25
4 Vaginal Swab 2 6.25
5 History Suggestive Of 4 9.38
Total 11(34.38%) had chronic PID and sexually transmitted disease
Table 5: Clinical presentation
Serial number Symptoms and signs Number of patients Percentage
1 Amenorrhea 28 87.50
2 Uterine bleeding 26 81.25
4 Pain abdomen 32 100.00
5 Sync opal attack 8 25.00
6 Pallor ,HB < 8 gm% 12 37.50
7 Shock, BP<90 mmofHG 5 15.62
8 UPT, BETA HCG positive 25 78.13
9 USG POSITIVE 28 87.50
Result – All patients had pain in the abdomen, 28(87.50 %) had history of amenorrhoea and 26(81.25%) had
uterine bleeding. However upt/bhcg were positive in 25(78.13%)
Table 6: Site of ectopic pregnancy
Serial number Site of ectopic Number of patients Percentage
1 Ampullary 27 84.37
2 Interstitial 2 6.25
3 Cornual 2 6.25
4 Cervical 1 3.13
5 Ovarian 0 0
6 Abdominal 0 0
Result- 31(96.87%) were tubal pregnancies, and all were ruptured ectopics

Fig. 1:

Fig. 4:

Fig. 2:

Fig. 5:

Results

Total 32 cases were analyzed. Maximum number


of patients 22(68.75 %) belonged to age group of 26-
30, years, 5(15.63%) were 31 – 35 years, 3(9, 37%)
Fig. 3: were 20-25 years of age and 2 (6.25%) were less than
Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Brigadier P.K. Bhatnagar & Sushila Jain / Clinical Presentation and Management of Ectopic Pregnancy in
14
Tribal Population in South Rajasthan and Co-Relation with High Prevalence of Sexually Transmitted Diseases

20 years of age Maximum number of patients were One of the risk factor is a prior history of an ectopic
para two 18(56.75 %), para four were 6(18.75%) para pregnancy. Any disruption of the normal architecture
one were 4(12.50%), para three were 3 (9.37%) and 1 of the Fallopian tubes can be a risk factor for a tubal
patient was para five. Most 26(81.25%) had pelvic pregnancy. Previous surgery on the Fallopian tubes
infection either acute or chronic including post such as tubal sterilization or reconstructive,
abortal and previous tubercular. 11(34.38%) had procedures can lead to scarring and disruption of the
history suggestive of chronic pelvic inflammation normal anatomy of the tubes and increases the risk of
and sexually transmitted disease 2(6.25%) positive an ectopic pregnancy. Likewise, infection, congenital
vaginal swab for gonococci. 1(3.13%) was HIV abnormalities, or tumors of the Fallopian tubes can
positive 2(6.25%) were HBSAG positive and 2(6.25%) increase a woman’s risk of having an ectopic
were VDRL positive. 2(6.25%) had history of previous pregnancy. Pelvic infections are usually caused by
ectopic. 1(3.13%) was undergoing assisted sexually-transmitted organisms, such
reproduction technique treatment. Interestingly as chlamydia or N. gonorrhoeae, having multiple
15(46.87%) were using tobacco for chewing and bidi sexual partners increases a woman’s risk of pelvic
smoking. All patients had pain in the abdomen, 28 infections, multiple sexual partners also are
(87.50 %) had history of amenorrhoea and 26(81.25%) associated with an increased risk of ectopic
had uterine bleeding. 8(25%) had history of syncopal pregnancy.
attacks 12 (37.50%) were extremely pale and 5(15.62%) Like pelvic infections, conditions such
were in shock before being taken up for laparotomy. as endometriosis, fibroid tumors, or pelvic scar
ULTRA SONOGRAPHY in 28(87%) was suggestive tissue (pelvic adhesions), can narrow the Fallopian
of fluid/ clots in peritoneum or tubo ovarian mass. tubes and disrupt egg transportation, thereby
However URINE PREGNANCY TEST/BETA HCG increasing the chances of an ectopic pregnancy.
were positive in 25(78.13%). 31(96.87%) were tubal Approximately half of pregnancies in women using
pregnancies, and all were ruptured ectopic either intrauterine devices (IUDs) will be located outside of
acute or chronic with haemo-peritoneum and the uterus. Cigarette smoking around the time
required salpingectomy. 1(3.13%) was cervical of conception has also been associated with an
ectopic pregnancy in para five which got complicated increased risk of ectopic pregnancy [8]. Clinical
with uncontrollable haemorrhage and required presentation of ectopic pregnancy occurs at a mean
emergency obstetric total hysterectomy. The study of 7.2 weeks after the last normal menstrual period,
showed ectopic pregnancy was most common in with a range of 4 to 8 weeks. Later presentations are
gravida 2 and in age group 26–30 years with most of more common in communities deprived of modern
them having married life <10 years. One or more risk diagnostic ability. In the present study average
factors were found in 66 % of cases. 54% of cases detection was at 8-10 weeks. Differential diagnosis
presented with acute symptoms, 14% of cases in include acute appendicitis, salpingitis, rupture of a
shock. All patients had pain in the abdomen, 28(87.50 corpus luteum cyst, miscarriage, ovarian torsion or
%) had history of amenorrhoea and 26(81.25%) had urinary tract infection. Signs and symptoms of ectopic
uterine bleeding , abdominal tenderness, and tender pregnancy include vaginal bleeding (in varying
cervical movements.However urine pregnancy test/ amounts), abdominal pain, pelvic pain, a tender
BETA HCG were positive in 25(78.13%). Inv revealed cervix, an adnexal mass, or adnexal tenderness. In
high incidence of sexually transmitted diseases In the present study all patients had pain in the
the tribal population of south rajasthan. abdomen, 28(87.50 %) had history of amenorrhea and
ultrasonography, complex mass in adnexa was 26(81.25%) had uterine bleeding. Rupture of an
present in 60% of cases and haemo-peritoneum in ectopic pregnancy can lead to symptoms such as
50%. 96% of cases were tubal pregnancy with most of
abdominal distension, tenderness, peritonismand
them tubal rupture. In 98% of cases, radical surgery
hypovolemic shock. Risk factors include: pelvic
was done. Salpingectomy was the most common
inflammatory disease, infertility, use of an intrauterine
surgery done (90%). There was no negative
device (IUD), previous exposure to DES, tubal surgery,
laparotomy in this study. There was no maternal
intrauterine surgery (e.g. D&C), smoking, previous
mortality in this series.
ectopic pregnancy, and tubal ligation. Although older
texts suggest an association between endometriosis
Discussion and ectopic pregnancy this is not evidence based and
current research suggests no such association [9]. In
the present study- most 26(81.25%) had pelvic
There are multiple factors that increase a women’s infection. Of these 2(6.25%) had history of previous
likelihood of having an ectopic pregnancy. ectopic. 1(3.13%) was undergoing assisted

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Brigadier P.K. Bhatnagar & Sushila Jain / Clinical Presentation and Management of Ectopic Pregnancy in
15
Tribal Population in South Rajasthan and Co-Relation with High Prevalence of Sexually Transmitted Diseases

reproduction technique treatment. Interestingly pregnancy. An ovarian pregnancy is differentiated


15(46.87%) were using tobacco for chewing and bidi from a tubal pregnancy by the Spielberg criteria [13].
smoking. Hair-like cilia located on the internal surface In the present study 31 (96.87%) were tubal
of the Fallopian tubes carry the fertilized egg to the pregnancies, and all were ruptured ectopic either
uterus. Women who smoke have a higher chance of acute or chronic with haemoperitoneum and required
an ectopic pregnancy in the fallopian tubes. Smoking salpingectomy. Early treatment of an ectopic
leads to risk factors of damaging and or killing cilia. pregnancy with methotrexate is a viable alternative
Women with pelvic inflammatory disease (PID) have to surgical treatment [14]. Which was developed in
a high occurrence of ectopic pregnancy. This results the 1980s.If administered early in the pregnancy,
from the build-up of scar tissue in the Fallopian tubes, methotrexate terminates the growth of the developing
causing damage to cilia. Intrauterine adhesions (IUA) embryo; this may cause an abortion, or the developing
present in Asherman’s syndrome can cause ectopic embryo may then be either resorbed by the woman’s
cervical pregnancy or, if adhesions partially block body or pass with a menstrual period.
access to the tubes via the ostia, ectopic tubal Contraindications include liver, kidney, or blood
pregnancy [10]. Asher man’s syndrome usually occurs disease, as well as an ectopic embryonic mass > 3.5 cm
from intrauterine surgery, most commonly after D&C. [15]. Surgeons use laparoscopy or laparotomy to gain
Endometrial/pelvic/genital tuberculosis, another access to the pelvis and can either incise the affected
cause of Asher man’s syndrome, can also lead to ectopic Fallopian and remove only the pregnancy
pregnancy as infection may lead to tubal adhesions in (salpingectomy) or remove the affected tube with the
addition to intrauterine adhesions [11]. Although some pregnancy (salpingectomy) [16]. In the present study
investigations have shown that patients may be at all but one case were treated by salpingectomy and
higher risk for ectopic pregnancy with advancing age, one required obstetric hysterectomy because of
it is believed that age is a variable which could act as a cervical ectopic pregnancy leading to uncontrolled
surrogate for other risk factors. An ectopic pregnancy hemorrhage.
should be considered as the cause of abdominal pain
or vaginal bleeding in every woman who has a positive
pregnancy test . An ultrasound showing a gestational Conclusion
sac with fetal heart in the fallopian tube has a very
high specificity of ectopic pregnancy. Transvaginal Present study clearly shows importance of acute
ultrasonography has a sensitivity of at least 90% for and chronic pelvic inflammatory disease in causing
ectopic pregnancy. An ultrasound showing a tubal damage which in turn is responsible for tubal
gestational sac with fetal heart in the fallopian tube ectopic pregnancy. High incidence of sexually
has a very high specificity of ectopic pregnancy. transmitted diseases was contributory to high
Transvaginal ultrasonography has a sensitivity of at incidence of ectopic pregnancy .Preventive measures
least 90% for ectopic pregnancy. Where no intrauterine should be directed towards awareness, early
pregnancy is seen on ultrasound, measuring -human diagnosis and prompt treatment. Any lady in
chorionic gonadotropin (-hCG) levels may aid in the reproductive age group should be considered as
diagnosis. A laparoscopy or laparotomy can also be potential candidate for ectopic pregnancy unless
performed to visually confirm an ectopic pregnancy. proved otherwise. Beta HCG, ultrasonography and
This is generally reserved for women presenting with immediate laparotomy and management of ectopic
signs of an acute abdomen and/or shock. Often if a pregnancy are key factors in reducing maternal
tubal abortion or tubal rupture has occurred, it is mortality and morbidity.
difficult to find the pregnancy tissue. A laparoscopy
in very early ectopic pregnancy rarely shows a normal
looking fallopian tubeThe vast majority of ectopic References
pregnancies implant in the Fallopian tube.
Pregnancies can grow in the fimabrial end (5% of all
ectopic pregnancies), the ampullary section (80%), the 1. Crochet JR, Bastian LA, ChireauMV . “Does this
isthmus (12%), and the cornual and interstitial part of woman have an ectopic pregnancy”.the rational
clinical examination systematic review”. JAMA. 2013;
the tube (2%) [12]. Mortality of a tubal pregnancy at the
309(16): 1722–9.
isthmus or within the uterus (interstitial pregnancy) is
higher as there is increased vascularity that may result 2. Cecchino, GN; Araujo Júnior, E; ElitoJúnior, J .
more likely in sudden major internal bleeding Two “Methotrexate for ectopic pregnancy: when and
percent of ectopic pregnancies occur in the ovary, how.”.Archives of gynecology and obstetrics. 2014;
290(3): 417–23.
cervix, or are intraabdominal. Transvaginalultrasound
examination is usually able to detect a cervical 3. Nama V Manyonda, . “Tubal ectopic pregnancy:

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Brigadier P.K. Bhatnagar & Sushila Jain / Clinical Presentation and Management of Ectopic Pregnancy in
16
Tribal Population in South Rajasthan and Co-Relation with High Prevalence of Sexually Transmitted Diseases

diagnosis and management.”.Archives of 2013; 122(2): 104–7.


gynecology and obstetrics. 2009; 279(4): 443–53. 11. 10. Shaw JL, Dey SK, Critchley HO, Horne AW
4. Farquhar CM . “Ectopic pregnancy”. Lancet. 2005; .”Current knowledge of the aetiology of human
366(9485): 583–91. tubal ectopic pregnancy”. Hum Reprod Update. 2010;
5. Majhi AK, Roy N, Karmakar KS, Banerjee PK . 16(4): 432–44.
“Ectopic pregnancy—an analysis of 180 cases”. J 12. 11. Mahboob U, MazharSB . “Management of ectopic
Indian Med Assoc. 2007; 105(6): 308, 310, 312. pregnancy: a two-year study”. Journal of Ayub Medical
6. Bogdanskiene G, Berlingieri P, GrudzinskasJG . College, Abbottabad: JAMC. 2006; 18(4): 34–7.
“Association between ectopic pregnancy and pelvic 13. Lozeau AM, Potter B. Diagnosis and management of
endometriosis”. Int J Gynaecol Obstet. 2006; 92: 157–8. ectopic pregnancy. Am Fam Physician. 2006; 72:
7. Tay JI, Moore J, Walker JJ .”Ectopic pregnancy”. West 1707–14.
J Med. 2000; 173(2): 131–4. 14. Dart RG, Kaplan B, Varaklis K. Predictive value of
8. Sherman KJ, Daling JR, sterachis A. sex tra disease history and physical examination in patients with
and tubal pregnancy. 1990; 17(3) :115- 121. suspected ectopic pregnancy. Ann Emerg Med. 1999;
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9. K³yszejko C, Bogucki J, K³ yszejko D, Ilnicki W,
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rate in the Republic of Korea”. Int J GynaecolObstet.

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Indian Journal of Obstetrics and Gynecology
17
Volume 4 Number 1, January - April 2016

Incidence of Hepatitis among Pregnant Women of North Indian


University Teaching Hospital

Uma Pandey

Abstract our catchment area. It also shows that the


very basic facilities are still the missing like
sanitation, education and income. We need
Background: Hepatitis is the liver to highlight and work on those areas. Blood
inflammation caused by A, B, C, D and blood products needs to be screened to
and/or E viruses. Hepatitis is a reduce hepatitis B and C. Pregnant mothers
major health issue in India and the should be managed as high risk group to
worldwide. The prevalence is improve their outcome. Neonatal
increasing among pregnant women immunisation should be both active and
in proportion to the increase passive even if government has to bear the cost.
worldwide. Hepatitis in pregnant
Keywords: Hepatitis; Screening;
women leads to increased maternal
Prevention; Screening.
and neonatal morbidity and
mortality. This led to collection of
data to formulate a better plan. Introduction
Methods: An observational study
was done was done at Sir Sunderlal
Hospital, Banaras Hindu Hepatitis is the liver inflammation caused
University, Varanasi, Uttar Pradesh, by A, B, C, D and/or E viruses. It is an acute
India from the month of January to illness with discrete onset of symptoms eg
December 2014. Women who fatigue, abdominal pain, loss of appetite,
attended our outpatients intermittent nausea, vomiting and jaundice [1].
department or delivered in our The incidence of hepatitis is ever
labour room and had Hepatitis were increasing in India. In the year 2012 nearly
included in this study. Blood 119,000 cases of all-cause hepatitis were
biochemistry and liver enzymes reported. A year later, in the 2013 Integrated
were done on all patients. Hepatitis Disease Surveillance Programme of the
markers were done as well. Results: National Centre for Disease Control received
The prevalence of hepatitis was notification of 290,000 cases of acute
2.82% in our study population hepatitis. Under this programme there were
(irrespective of whether Hepatitis A, 11.8% cases which were reported form Uttar
B, C or E). Hepatitis A was 28.8%, Pradesh from 2010 to 2013 [2].
hepatitis B was 40.7%, hepatitis C Hepatitis is a major health issue in India
was 18.6% and hepatitis E was and the worldwide. The prevalence is
Department of Obstetrics &
Gynaecology, Institute of
11.9% in our study population. increasing among pregnant women in
Medical Sciences, Banaras Lower educational status women proportion to the increase worldwide.
Hindu University, had higher incidence of hepatitis, Hepatitis in pregnant women leads to
Varanasi, Uttar Pradesh illiterate group had 35.59% and high increased maternal and neonatal morbidity
221005.
school educated had 42.37%. Low and mortality. Recently there is more
Uma Pandey socioeconomic status (SES) had emphasis on prevention and treatment of
Department of Obstetrics & 52.4% and middle SES had 47.45% hepatitis during pregnancy, as it leads to
Gynaecology, Institute of of hepatitis. There were 10.2% cases reduction in maternal and neonatal
Medical Sciences, Banaras
Hindu University, Varanasi,
of abruption, 8.5% cases of DIC and morbidity and mortality. Hepatitis with
Uttar Pradesh 221005. 5.1% case of preeclampsia. pregnancy is now a common disease among
E-mail: Conclusions: This study highlights pregnant women on the labour ward.
uma.pandey2006@yahoo.com the overall prevalence of hepatitis in Hepatitis B and C has more complications
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18

while Hepatitis E with pregnancy has higher The population prevalence of HCV in India is
mortality rate. 1%. HDV is not very common in our country and is
The global burden of HAV (Hepatitis A Virus) found in 10-20% of HBV positive patients. HAV
Infection is 1.4 million annually but the proportion of and HEV both of them are transmitted through
young adults at risk of HAV infection is very low in fecal-oral route. Hepatitis viruses B (HBV), D (HDV)
India. Hepatitis E Virus (HEV) infection is most and C (HCV) are transmitted through parenteral
prevalent in South East Asia accounting for 60% of route [2].
hepatitis E global incidence and 65% of global deaths. Perinatal transmission is prevalent in HBV but less
Most acute liver failures diagnosed in India are due frequent in HCV. It is about 10% if mother has HBs
to HEV and HEV is the most common cause of Ag and 90% when HBeAg is also positive. Neonates
hepatitis during pregnancy. In India, HBV is the who suffer from neonatal hepatitis B have almost 90%
second most common cause of acute viral hepatitis risk of developing HBs Ag carrier and chronic liver
after HEV. Our country is considered to have an disease [6].
intermediate level of HBV endemnicity with HDV co-infects with HBV. The ability of HBV &
population prevalence of around 4%. Globally 350 HCV to survive for prolonged periods on the external
million people remain chronically infected with surfaces at room temperature (nearly seven days)
hepatitis B and become carriers, out of which 1.5 increases their infectivity [7]. Table 6 shows the risk
million deaths occur each year due to cirrhosis & factors for HBV, HCV, & HDV.
hepatocellular carcinoma [3-5].
Table 6:
Transmission for HBV, HCV, & HDV
1. Transmission could be due to needle stick injury to paramedical staff, eye contamination.
2. Transfusion of unscreened blood, use of contaminated needles and syringes.
3. Homosexual and heterosexual contact.
4. Vertical transmission from mother to baby.
5. Caesarean, surgical abortions & other operations done by using contaminated equipment.
6. Tattooing.
7. Transplantation/dialysis of infected blood.

Hepatitis’ high prevalence in our hospital and depending upon the pregnant women’s clinical
increased morbidities and mortalities in patients with presentation and time of arrival. HAV and HEV were
hepatitis during pregnancy was the reason why we diagnosed by the presence of serum IgM antibodies.
thought of collecting the outcome data which could HbsAg was the serum marker to confirm active
help us in formulating better management plan. There Hepatitis B infection. HBeAg was taken as increased
are studies in which Hepatitis B data has been infectivity, appearance of IgM antiHBc confirmed
collected but so far but no studies have been done in acute infection. Appearance of anti-HBs implies
which data was collected regarding types of viral either natural immunity or vaccination. Presence of
hepatitis during pregnancy in Northern India. anti-HCV suggested infection by HCV.

Materials and Methods Results

An observational study was done was done at Sir Total number of deliveries was 2089 during that
Sunderlal Hospital, Banaras Hindu University, year. Number of women who were positive for any
Varanasi, Uttar Pradesh, India from the month of type of hepatitis was 59. The prevalence of hepatitis
January to December 2014. Women who attended was 2.82% in our study population (irrespective of
our outpatients department or delivered in our labour whether Hepatitis A, B, C or E). There were of 38
room and had Hepatitis were included in this study. multigravid (64.4%) and 21 primigravid (35.6%)
Informed consent was taken from patients regarding pregnant women out of the total 59 pregnant women
their data collection. Socio-demographic details, who were included in this study.
clinical details and risk factors were noted while the Hepatitis A was 28.8%, hepatitis B was 40.7%,
patients were on the ward. Neonatal immunisation hepatitis C was 18.6% and hepatitis E was 11.9% in
was also noted. our study population (Table 1). Lower educational
Blood biochemistry and liver enzymes were done status women had higher incidence of hepatitis,
on all patients. Hepatitis markers were done either illiterate group had 35.59% and high school educated
on the labour room or in the outpatient’s department had 42.37% (Table 2). Low socioeconomic status (SES)
Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Uma Pandey / Incidence of Hepatitis among Pregnant Women of North Indian University Teaching Hospital
19

had 52.4% and middle SES had 47.45% of hepatitis


(Chart 1).
There were total of 11 cases of hepatitis C due to
blood/blood products transfusion in our study. INR
was deranged in 13.55% patients (8/59) as shown in
Table 3. There were total of 10 preterm babies (16.9%),
14 IUDs (23.7%) and one low birth weight (1.7%) as
shown in Table 4 and Chart 4. There were 10.2%
cases of abruption, 8.5% cases of DIC and 5.1% case
of preeclampsia (Table 5).
Risk factors of hepatitis are depicted in Chart 2,
use of contaminated syringes was in 37.5% cases of Chart 1: Socioeconomic status
hepatitis B (total 24 cases) while 20.83% followed
abdominal surgeries. 11 husbands of hepatitis B
positive patients were positive for Hepatitis B, while
10 were negative and 3 husbands declined the testing.
Neonatal intake of hepatitis B vaccine was 100%
among the hepatitis B positive mothers but only 45%
had immunoglobulin due to cost factor.

Table 1: Types of hepatitis


Types of hepatitis Number Percentage
A 17 28.8%
B 24 40.7%
C 11 18.6%
E 7 11.9%
Total 59 100% Chart 2: Risk factors of hepatitis B
Table 2: Educational status of the study group
Educ Status No %
Illiterate 21 35.59%
High School 25 42.37%
Under graduate 7 11.86%
Post graduate 6 10.16%
Total 59 100%
Table 3: Deranged INR
Hepatitis A 0
Hepatitis B 1
Hepatitis C 2
Hepatitis E 5

Table 4: Fetal/Neonatal complications


Chart 3: Husband’s hepatitis B status
Preterm LBW IUD
Hepatitis A 3 0 2
Hepatitis B 2 1 4
Hepatitis C 3 0 4
Hepatitis E 2 0 4

Table 5: Maternal complications

Complications Number Percentage


Abruption 6 10.2%
Ascites 1 1.7%
Cholestasis 2 3.4%
DIC 5 8.5%
Fulm hepatic failure 1 1.7%
GI bleed 2 3.4%
Hepatic encephalopathy 1 1.7%
Mat death 2 3.4%
Preeclmpsia 3 5.1% Chart 4: Fetal/Neonatal complications

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Uma Pandey / Incidence of Hepatitis among Pregnant Women of North Indian University Teaching Hospital
20

Discussion difference may be because of population studied,


catchment area, unscrupulous blood products and
socioeconomic status [8]. The prevalence rate is
In this study the overall prevalence of hepatitis is higher in multigravida as it is found in study by
2.8% during the year of January to December 2014, Sharma et al,similar finding were observed regarding
but hepatitis B positivity was almost 40%. 2.8% is hepatitis B risk factors [6]. Table 7 represents the
below the Indian mainland prevalence but higher management protocol we used.
than the neighbouring Allahabad region (0.9%). This

Management offered was:


1. Isolation: blood/body fluids and excretory materials.
2. Dextrose 10% or Oral Glucose.
Avoid hepatotoxic drugs ( eg Acetoaminophen, Diclofenac, Amiodarone, M Dopa, OCPs, Amoxycillin,
Ciprofloxacin, Erythromycin, Fluconzole, Valproic acid, Chlorpromazine, Isoniazid, Rifampicin.
3. Pruritus: Treat with Cholestyramine or Ursodeoxycholic acid.
4. Lactulose 15-30 mL thrice a day (reduces absorption of ammonia from the colon and act as osmotic laxative.
5. Oral Neomycin 1 gram 6 hourly to prevent toxic nitrogenous compounds.
6. Vit K 0.5 mg IM to improve Prothrombin level.

Management Offered was 0.06 mL im dose single dose, it is safe in pregnancy.


1. Isolation: blood/body fluids and excretory Immunoglobulin 0.01ml/ kg can be given within 2
materials. weeks of exposure. For Hepatitis B: Universal
vaccination with HBV vaccines for all. Thorough
2. Dextrose 10% or Oral Glucose. Avoid hepatotoxic screening of blood products should be done. Active
drugs ( eg Acetoaminophen, Diclofenac, and passive immunity of neonates who were born to
Amiodarone, M Dopa, OCPs, Amoxycillin, hepatitis B positive mothers is by: HBV vaccine (10
Ciprofloxacin, Erythromycin, Fluconzole, microgram) and hepatitis immunoglobulin (0.5 ml)
Valproic acid, Chlorpromazine, Isoniazid, within 12 hours of birth.
Rifampicin.
3. Pruritus: Treat with Cholestyramine or
Ursodeoxycholic acid. Statistical Analysis

4. Lactulose 15-30 mL thrice a day (reduces It was done in the Department of Community
absorption of ammonia from the colon and act as Medicine, Institute of Medical Sciences, Banaras
osmotic laxative. Hindu University by Prof G P Singh. His contribution
is greatly acknowledged.
5. Oral Neomycin 1 gram 6 hourly to prevent toxic
nitrogenous compounds.
6. Vit K 0.5 mg IM to improve Prothrombin level. References

Conclusions 1. Collier JD, Webster G. Liver and biliary tract disease.


In: Davidson’s Principles and Practice of Medicine
21st Edition. Churchill Livingstone Elsevier. 2010;
This study highlights the overall prevalence of 947-954.
hepatitis in our catchment area. It also shows that the 2. NCDC Newsletter, January-March 2014; 3(1).
very basic facilities are still the missing like sanitation, 3. Awole M, Selassie SG. Seroprevalence of HBsAg and
education and income. We need to highlight and work its risk factors among pregnant women in Jimma,
on those areas. Blood and blood products needs to be Southwest Ethiopia. Ethiop J Health Dev. 2005; 19
screened to reduce hepatitis B and C. Pregnant (1): 45-50.
mothers should be managed as high risk group to 4. Parveen S, Shyamala R, Roa JR, Roa RMV.
improve their outcome. Neonatal immunisation Seroprevalence of hepatitis B surface antigen among
should be both active and passive even if government pregnant women attending antenatal clinic in a
has to bear the cost. teaching hospital. J Microbiol Biotech Res. 2012; 2(2):
343-45.
The way forward forHepatitis A and Hepatitis E is
: improvements in sanitation and sewage disposal. 5. Tandon BN, Acharya SK, Tandon A. Epidemiology
of hepatitis B Virus in India. Gut. 1996; 38 Suppl: 556-9.
HAV can also be prevented by live attenuated vaccine
although not routinely recommended due to high 6. Sharma C, Bhardwaj A, Sharma S, Kharkwal S.
sero-prevalence in India. Vaccine is available and of Seroprevalence of hepatitis B surface antigen and its

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Uma Pandey / Incidence of Hepatitis among Pregnant Women of North Indian University Teaching Hospital
21

risk factors among pregnant women in Bundelkhand pregnancy and risk of perinatal transmission. Indian
region. The Journal of UP Chapter Obstetrics and J Gastroenterol. March-April 2011; 30(2): 66-71.
Gynecology. Dec 2014; 22(2): 37-40. 8. Sriprakash I, Anil TP. Routine prenatal screening of
7. Dwivedi M, Misra SP, Misra V, Pandey A. Indian women for HBsAg: benefits derived versus
Seroprevalence of hepatitis B infection during cost. Trop Doct. 1997; 27(3): 176-7.

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Volume 4 Number 1, January - April 2016

Bioethics in Multiple Pregnancies

Alka B. Patil*, Nilay Patel**

Abstract dilemmas in medicine, have become the


guiding lights of ethical issues. These are as
follows.
Bioethics is essential dimensions
of Obstetrics practice. Modern era 1. Autonomy of the person
has witnessed many technological 2. Beneficence
advances like Assisted 3. Nonmalificence
Reproductive Techniques. Presence
of Higher Order Multiples is higher 4. Justice
with ART. Multiple pregnancies The professional behaviour and
are associated with many maternal performance of all physicians should be
and fetal risks. Ethical issues in towards upholding of these principles [1].
multiple pregnancy are
Ethics is an essential dimension of the obst
multidimensional having many
practice. Ethics is the disciplined study of
aspects.These are related to fetal
moratilty. Ethical principles and virtues
reduction and selective termination
should be applied by all the physicians,
of pregnancy, congenital
regardless of their personal, religious and
malformations in multiple
spiritual beliefs [2]. Ethical issues are
pregnancy, impact on parents and
identified and framed through a
physicians perspective. Multiple
“naturalized bioethics” approach. This
pregnancy has impact on
approach critiques traditional bioethics and
parents,community and health
gives attention to everyday ethics and the
resources. Adequate support is
social, economic, and political context within
essential to tide over the situation.
which ethical problems exist [3].
Keywords: Ethics; Multiple
The prevalence of high-order multiple
Pregnancy; Fetal Reduction;
(HOM) pregnancies has increased because
Selective Termination of Pregnancy;
of ovulation induction, assisted reproductive
Congenital Malformations.
technologies, and spontaneous conceptions
in older mothers [4]. The number of multiple
Introduction births would be higher if it were not for
selective reduction, spontaneous reduction
or early gestation sacs or embryonic loss of
Ethics has always formed basis
one or more conceptus [5]. Assisted
of good practice in medicine. In
reproductive technology has made great
*Professor & HOD recent years ethical issues have
progress during the last three decades. After
**Resident, Dept of Obst & gained more importance in public
Gynec, ACPM Medical the initial enthusiasm, many ethical, legal
eyes, due to several significant
College, Dhule. and social issues related to the application
developments.
of these procedures began to evolve [6].
Alka B. Patil, Professor & Medicine when practiced at its
HOD, Dept. of Obst & best, seeks to do what is right and
Gyne. ACPM Medical Ethical Issues in Multiple Pregnancy are
good, and ethics help in defining
College At Post: Morane, Multidimensional having Many Aspects
Sakri Road Dhule - and achieving that goal. The
Maharashtra (India). contemporary construction of bio- Fetal Reduction and Selective Termination
Pin Code: 424001. ethics is based on four main pillars. of Pregnancy Congenital malformations in
E-mail: multiple gestation Fetal Therapy in multiple
alkabpatil@rediffmail.com These principles which are intended
to help in solving of all the ethical gestation Impact on parents Physicians

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JournalPublication Pvtand
of Obstetrics LtdGynecology / Volume 4 Number 1 / January - April 2016
Alka B. Patil & Nilay Patel / Bioethics in Multiple Pregnancies
24

perspective Pregnancy management via fetal from beta agonists used to


reduction (FR) has witnessed considerable changes 5. halt preterm labor
over the last 25 years . These changes have taken place
in medical technology outcomes, patient choices, and 6. Incompetent cervix,
the larger demographic and cultural shifts that are 7. Placental abruption
driving the pace and direction of change [7].
8. Caesarean section
Selective Termination of some of the embryos
9. Postpartum hemorrhage [4]
to increase the viability of remaining ones and
reducing the risk of morbidity and mortality for the 10. Increase risk of abnormal baby.
mother was approach to this situation. Indications 11. Increase loss of a baby (still birth).
transformed from the crisis of ‘life and death’ into
Mothers may be hospitalized on bed rest for
issues of quality of life [8].
prolonged periods [11]. Those risks do not only
The occurrence of higher-order multiples may be concern the newborn status at birth, but also carry
thought of unintended consequence of the major long term consequences for childhood and adult
development of in vivo and in vitro fertilization life, since preterm delivery and intrauterine growth
techniques. Their occurrence then stimulated changes retardation are the major risk factors for
in medical technology and procedures that over neurodevelopmental disorders [12]. Even more
time have afforded greater control of the clinical significantly, perinatal morbidity is greater for HOMs,
situation [9]. chiefly because of premature delivery. More than 90%
of HOMs are born prematurely, with mean gestational
ages for triplets of 32.2 weeks, quadruplets, 29.9
Changing Perspectives weeks, and quintuplets, 28.5 weeks [4]. Premature
Outcomes have steadily improved over the past HOMs may develop respiratory distress syndrome,
two decades as: (1) a better understanding of the intraventricular hemorrhage, necrotizing
clinical situation has emerged, (2) there is a smaller enterocolitis, retinopathy of prematurity, mental
percentage of very high-order multiples that have retardation, developmental delay, and cerebral palsy.
worse outcomes even with reduction, (3) better For unclear reasons, poor outcomes for Higher Order
ultrasound allows for better visualization, and use of Multiples may be more common after fertility
CVS reduces the risk of leaving behind treatment than in spontaneous multiples [13].
sonographically or chromosomally abnormal fetus.
There has also been a shift in the dialog between Congenitally Malformed Foetus in Multiple Gestation
patients and physicians over the last 25 years. The
Parents have a desire to have a child of a certain
most obvious change has been the shift from questions
quality. Bringing up the child with disability can cost
of mortality to questions of morbidity. These
money and use up resources. Congenital anomalies
differences in turn appear to be changing due to
contribute a significant proportion of infant morbidity
advances in IVF technology and fundamental
and mortality, as well as fetal mortality. A debate
demographic changes in the age at which mothers
regarding aborting a malformed fetus still
are having their first child. A further consequence of
exists,Information regarding the abnormal
these trends has been the increased use of donor eggs
ultrasound findings should be delivered to women
and prenatal diagnosis.
in a clear, sympathetic, and timely fashion, and in a
There has been a strong trend of increasing age at supportive environment that ensures privacy [14].
which women give birth to their first child [10]. There has been a suggestion that ART births have
a small but significantly increased incidence of birth
Complications of Multiple Pregnancy defects [5]. Some authors have reported in infants
conceived with ART small increases in specific birth
Multiple pregnancies are associated with many
defect rates, such as neural tube defects, omphaloceles
maternal and fetal risks.
and hypospadias. ART births are also associated
Women expecting HOMs are at an increased risk with an increased incidence of chromosomal
of Miscarriage: abnormalities and imprinting defects [16]. This risk
1. Pregnancy-induced hypertension,Eclampsia estimates among women receiving ART is readily
confounded by overlapping risk factors including
2. Anemia multiple pregnancies, underlying causes of infertility
3. Gestational diabetes and factors associated with ART themselves (i.e., the
4. Preterm labor and delivery, pulmonary edema avoidance of natural selection mechanism of sperm

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Alka B. Patil & Nilay Patel / Bioethics in Multiple Pregnancies
25

during the course of a natural conception, the delayed Individual patients assess risks differently. Patients
fertilization of the oocyte, the freezing and thawing who oppose abortion for all reasons may find these
of embryos [17]. procedures unacceptable. An ethical concern in
Approximately one fifth of families with triplets Selective Termination is the risk for normal
and one half of those with quadruplets have at least comultiples. At skilled centers, total pregnancy loss
1 disabled child (due to anomalies and prematurity). rates after Selective Termination are similar to
The chance of at least 1 fetus in a multifetal pregnancy spontaneous pregnancy loss rates, and deliveries occur
having an anomaly or chromosomal defect is higher at a better gestational age than would be expected with
simply because more fetuses are present. Furthermore, the original number of fetuses [20]. The reduction of
an increase in anomalies in children conceived via twins to a singleton is acceptable in cases of maternal
IVF or intracytoplasmic sperm injection has been disease, poor obstetric outcome and compelling social
suggested, and monozygotic multiples have a greater and psychological reasons of the woman [12].
than usual rate of malformations. Monochorionic If two embryos have been detected, spontaneous
multiples in a Higher Order Multiple pregnancy are embryo reduction has been reported to occur in 38%
at risk for twin-to-twin transfusion syndrome and of cases when the pregnancy was achieved by ART
monoamniotic or conjoined twinning. For these and and in 7.3% of spontaneous pregnancies [21].
other reasons, zygosity must be determined as early
The “vanishing twin” phenomenon must also be
as possible [4].
considered when counselling patients to make a
For anomalies, that are nonlethal but may result decision about multifoetal pregnancy reduction
in serious handicap, parents must decide whether (MFPR), regarding the timing of the procedure in
the burden of handicapped child is enough to risk particular. Spontaneous reabsorption, which occurs
the loss of healthy twin from feticide related earlier in gestation, may eliminate the need for
complication. Such a dilemma is illustrated by twin reduction in some cases. Given the low probability of
discordant for anencephaly which is always lethal spontaneous embryonic demise later in the first
but because of associated polyhydramnios places the trimester, however, the majority of procedures are
healthy co-twin at risk of severe preterm delivery. performed at 10–13 weeks [22].
Whereas in dichorionic twins expectant management
may be preferable for anomalies with a high risk of in
utero demise, in monochorionic twins this specifically Which Fetus To Select
warrants selective foeticide [18]. Monochorionic twins tend to have a higher
percentage of increased nuchal translucency
compared to dichorionic twins, Enlarged NT in
Multifetal Reduction and Selective Termination
monochorionic twins may instead indicate heart
Fetal reduction has been approached through the defects, malformations, twin-to-twin transfusion or
lifeboat analogy: fetuses in the womb are like an early placental fluid imbalance without
passengers in a lifeboat. In both situations, there is subsequent complications [21]. The foetus with
not enough room and/or not enough resources for increased nuchal translucency (NT) is typically
all of them to survive [19]. chosen. Enlarged NT is a risk factor for congenital
Ethical controversy concerns 2 procedures that may abnormalities and genetic syndromes as well as
chromosomal disorders; however, the choice should
avert complete pregnancy termination and improve
fall on the foetus with the larger NT, if it is possible to
outcomes for Higher Order Multiples pregnancies.
make this determination technically. In fact, from a
The first of these, selective termination (ST), is usually
technical point of view, it is preferable to select the
performed in the second trimester and is considered
foetus nearest to the anterior uterine wall and furthest
when one or more fetuses in a multiple pregnancy from the internal uterine orifice. Foetal loss is strongly
have an anomaly that is unacceptable to parents. It related to the number of foetuses before and after the
enables the healthy birth of unaffected comultiples. procedure, as it increases with the number of foetuses
The second procedure, Multifoetal Pregnancy reduced [23]. It should be understood that
Reduction, is usually performed in the first trimester appropriate informed consent Should be obtained
to terminate one or more fetuses in a high-order before undertaking these procedures [1].
gestation so that a smaller number of remaining
fetuses will more likely reach a viable gestational age
TTTS and Ethical Issues
and escape disability. Evans et al believe these
procedures enable pregnancy to continue with the Occasionally, diagnosed abnormalities are found
least harm and most benefits to all involved. initially even in the third trimester, which poses

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Alka B. Patil & Nilay Patel / Bioethics in Multiple Pregnancies
26

ethical issues .Much of this literature focuses on siblings, especially in the presence of marital, family,
twins – many of which have twin-to-twin transfusion or financial disturbance, parental depression,
syndrome in which laser therapy has become the prematurity, neonatal complications, or isolation [4].
mainstay of therapy, but selective termination is still Families who experience the death and/or disability
sometimes necessary [9]. Whether fetal therapy can of multiples, grieve the loss of their expected outcome
be judged to be the standard of care on ethical grounds while caring for any survivors, and parents with these
depends on the clinical implications of the concept of burdens have higher rates of depression [26].
fetus as patient. Such fetal therapy must reliably be Parents may experience prolonged, complicated
thought, on the basis of documented clinical grief when they lose all of their multiple-birth children,
experience, to benefit the future child [24]. Whether especially after fertility treatment. Moreover, couples
such therapy is, on ethical standard of care for her who lose 1 multiple grieve as deeply as parents who
fetus is entirely a function of the pregnant woman’s lose a singleton, but their grief may be delayed while
autonomy. Obligations to the fetus must be negotiated they attend to their remaining children [32]. Maternal
with obligations to the pregnant woman. Fetal autonomy justifies reduction to a singleton if parents
therapy necessarily involves risks to the pregnant only want 1 child. Guilt, grief, or depression persists
woman; she is ethically obligated to accept reasonable in one fourth to one third of parents. Patients who
risks to herself only to attempt to benefit her fetus. An see the fetuses more on ultrasound or who are more
ethical standard must take account not only of the religious or younger may be more at risk for prolonged
benefit to the fetus but also of both the benefit to and psychological distress. It is still undetermined
the autonomy of the pregnant woman [25]. whether parents should tell remaining children about
Selective Termination for severe twin-to-twin the MFPR. If told, the living children could
transfusion syndrome may be contemplated when conceivably feel they survived arbitrarily at a sibling’s
death of 1 twin is imminent, but must be timed expense.Couples need better information about
carefully to avoid death or morbidity to the remaining possible multiples before ART, and thorough
fetus. In making their decision for or against Selective counseling before reduction and as long as desired
Termination, parents consider medical aspects of afterward, because many couples keep ART or MFPR
the fetus’s condition, plus its short- and long-term secret and cannot confide in anyone else [4]. Similarly,
impact on healthy fetuses and the family [4]. physicians and nurses must strictly protect parents’ secrets
about MFPR when remaining children are born [32].

Family Consequenses The great paradox of multifetal pregnancy


reductions is that couples who were desperately trying
Raising HOMs is exhausting and stressful, and to conceive are obliged to consider termination of some
parents’ coping abilities vary. Mothers of multiples embryo to allow the others to survive. The fear that
leave the workforce more often than mothers of all foetuses would be lost after interventions also can
singletons. A family’s financial status may decline, not be dismissed Most women report guilt and mixed
with reduced income and increased costs of medical feeling when faced with the dilemma of multiple
care and home help. Socioeconomic status influences pregnancy reduction.
outcomes [26]. Although a secure marriage promotes
mental health for a mother of multiples, relationships Negative feelings are pervasive during and after
may be compromised by struggles with subfertility multiple reduction. Some women express guilt that
and ART [27]. Parents of multiples often become they sacrificed one (or more) embryo to save the other.
isolated from peers, and they may feel incapable of Negative feelings are still expressed after delivery,
meeting the competing needs of several, often mainly in the form of guilty and grief for lost child.
premature or disabled children [28]. Multiples’ The surviving children are living reminders of the
interactions with peers may be affected by having a loss of the others. Despite these grave symptoms, the
built-in social group [29]. MZ multiples may be very initial emotional conflicts seem to have no deleterious
close, whereas DZ comultiples may feel their MZ effects on mother-child bonding [33].
wombmates exclude them. Single siblings born before
multiples may feel neglected [30]. Multiples have a Physicians Perspective
greater risk of learning difficulties [31]. Joint parental and professional responsibility
If one multiple is disabled, healthy comultiples may towards the future children are considered. In normal
be close allies, but they also may envy the attention circumstances, the physician and the prospective
the disabled child receives . Depressed parents have parents reach an agreement on the modalities of the
lower-quality interactions with their children, and treatment. This should enable them to balance the
child abuse occurs more often to multiples and their reproductive autonomy of the parents and the
Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Alka B. Patil & Nilay Patel / Bioethics in Multiple Pregnancies
27

professional autonomy of the physician. reduction of the risk of multiple pregnancies in non-
Two Situations Arise in which these Rights may Confict IVF cycles [12].

i. The decision about the number of embryos to be More accurate and simpler methods are awaited
transferred. to identify the embryo most likely to implant. In the
transitional period, the risk of twins is accepted as a
ii. The decision about the performance of a multifetal compromise between a strongly reduced pregnancy
pregnancy reduction. rate and the increased risk of a multiple pregnancy of
The emotional stress of the infertility, combined a higher order. For the present time, in selected
with the lack of information on the consequences of patients (<38 years of age, with normal ovarian
multiple pregnancies and the strong wish for a child, response and good fertilization rate) a maximum of
may reduce the ability of patients to make the most one or two embryos should be transferred.
appropriate choice. In addition, the financial reason Further studies should be conducted in order to
and the knowledge that they will only be able to pay evaluate the appropriate number of embryos to be
for a limited number of IVF cycles, may bring the transferred in other groups of patients (older women,
couple to demand the replacement of a higher number poor responders, bad implanters). Therefore
of embryos. When patient is counselled about the additional research is recommended on the impact
risks of a multiple pregnancy and about the effect of of factors such as age, diagnostic categories and
the transfer policy on their chances to become oocyte quality. There is also a need to improve the
pregnant, the conflicts between physician and effciency of the cryopreservation protocols. In all
patients will be limited. In case of disagreement, the cases, priority should be given to the reduction of the
lowest number indicated by one of the parties should multiple pregnancy rates [12].
be followed so that no more embryos are replaced
than wanted by either the physician or the parents. Obstetrician-gynecologists have an important
responsibility to make both the public as well as their
MFPR is morally acceptable if the physician has patients aware of the many hazards associated with
acted according to the rules of good clinical practice multiple pregnancy, especially with triplets and
and has tried to minimize the risk of a multiple higher order pregnancies. In addition, they must make
pregnancy. The benefts for the remaining embryos of the public and their patients aware that the high risk
reducing a higher order multiple pregnancy exceed nature of multiple pregnancies requires an expertise
the disadvantages of carrying the pregnancy to term that may not be available in some rural or smaller
or risking miscarriage. With triplets, opinions vary town areas. Couples seeking treatment for infertility
according to personal experience and access to must be fully informed in writing risks of multiple
neonatal care [12]. pregnancy, both to the woman and to her potential
progeny. Counselling should also be available from
Societal Implications experienced members of perinatal teams.
The high number of multiple pregnancies after In order to monitor and regulate professional
ART is also a public health issue. There should be practice, audit of the use of these technologies should
public funding for a number of cycles that gives the include not only the fertility success rate but also
patients a reasonable chance of having a healthy statistics on singleton live births, the incidence of
singleton birth. Given the acute and long-term needs multiple pregnancy, the maternal and perinatal
of preterm infants, reimbursement of infertility mortality and morbidity rates, the incidence of preterm
treatment aiming at singleton pregnancy may be cost- delivery and low birth weight, the occurrence of long
effective at a national level [12]. term disabilities among offspring, and the use of fetal
reduction. Couples should have access to reliable and
Prevention standardized local centre statistics as well as national
and international comparative statistics [34].
Prevention of multiple gestation is preferable to an
emotionally and ethically challenging reduction.
MFPR creates a conflict between the duty to preserve
Counselling
a wanted pregnancy and the duty not to destroy
human life [4]. The prevention of multiple The principle of reproductive autonomy give every
pregnancies in ovarian stimulation is a more complex woman the right to decide for herself whether or not
task, although careful monitoring of the follicular to be submitted to a termination of pregnancy. In the
phase and specific interventions such as not injecting case of a multiple pregnancy, the woman should be
hCG, selective aspiration of supernumerary follicles fully informed about the risks for her, the pregnancy
and conversion to IVF cycles allows the drastic and the remaining embryos when an embryo

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Alka B. Patil & Nilay Patel / Bioethics in Multiple Pregnancies
28

reduction is performed. Every woman, however, treatments must be balanced against obligations to
should also have the right to have a reduction if she prospective children and society. Selective
estimates the social, psychological and medical risks termination of abnormal fetuses and multifetal
for herself or the offspring as too high [12]. pregnancy reduction are ethically justifiable, but may
contradict parents’ or clinicians’ethical concepts.
Decisions for moribund multiples are difficult. Media
Discussion coverage is often inaccurate or intrusive, but benefits
some families. Skilled care, accurate information, and
practical resources optimize outcomes [4].
Right to life is inherent in person,a human being.
Damages are claimed if injury is caused to the fetus In order to monitor and regulate professional
in womb.It would mean that fetus is a person. Can practice, audit of the use of these technologies should
the life of a person be ended by procedures approved include not only the fertility success rate but also
by others?[35]. statistics on singleton live births, the incidence of
multiple pregnancy, the maternal and perinatal
The common practice of physicians is to transfer
mortality and morbidity rates, the incidence of
to the uterus only two or three embryos in any cycle,
preterm delivery and low birth weight, the occurrence
although many embryos are produced during a single
of long term disabilities among offspring, and the use
IVF cycle. Then human embryo cryopreservation has
of fetal reduction. Couples should have access to
become integral part of ART and there is little
reliable and standardized local centre statistics as
knowledge about the limits of storage period and the
well as national and international comparative
possible effects of long term storage.
statistics [34].
Fetal reduction offers hope for a good outcome in
an otherwise adverse situation, such as a multiple
pregnancy where its continuation represents a threat Conclusion
to the life or health of the mother [36].
Several approaches are needed to better address Recently,there has been a dramatic increase in
real risk for ART complications: guidelines on the multiple pregnancies throughout the world. The use
number of embryos that should be transferred, of ovulation inducing drugs and of multiple embryo
detailed information on the use of specific ART transfer in the treatment of infertility are the main
techniques, ART registry data, the linkage of the latter etiological factors for this rising trend. The increase
to birth defects registry data, prospective studies of
in twin pregnancies may also be due to trends
ART births.
towards increased maternal age at conception.
Couples who want to use ART should be Multiple pregnancy has many adverse effects on
counselled about the risk/benefit associated with mother and her offspring with serious consequences
these techniques. In spite of the developments in to family, community and health services. Multifetal
reproductive medicine and structural changes in reduction is not medically considered as terminating
the society, a number of medical and ethical issues that pregnancy, but rather as a procedure to secure
remain unresolved. Furthermore socioeconomic its best outcome. Whether the couple decide to
aspects are also important [6]. maintain or to reduce High Order Multiple
The prevalence of High-Order Multiple (HOM) pregnancies, they should be assured that they will
pregnancies has increased because of ovulation receive the best available medical care. Adequate
induction, assisted reproductive technologies, and support to the parents will definitely reduce the
spontaneous conceptions in older mothers. Higher complications.
Order Multiples increase morbidity and mortality
risks for mothers and children. Although many
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of patients, competitive pressures of clinics, and Obst and Gynaecology Rule of Ethics for
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3. Jennifer M Torres, MA and Raymond G De Vries, 16. Owen CM, Segars JH Jr: Imprinting Disorders
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Nursing Reviews. June, 2005; 5(2): pp 69–76 69. Intervention in complicated multiple
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Catenazzi, Antonio Scorrano, Costantino Pregnancies. Mt Sinai J Med. 1998; 65: 185–190.
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STATEMENT ABOUT OWNERSHIP AND OTHER PARTICULARS


“Indian Journal of Obstetrics and Gynecology” (See Rule 8)

1. Place of Publication : Delhi

2. Periodicity of Publication : Quarterly

3. Printer’s Name : Asharfi Lal


Nationality : Indian
Address : 3/258-259, Trilok Puri, Delhi-91

4. Publisher’s Name : Asharfi Lal


Nationality : Indian
Address : 3/258-259, Trilok Puri, Delhi-91

5. Editor’s Name : Asharfi Lal (Editor-in-Chief)


Nationality : Indian
Address : 3/258-259, Trilok Puri, Delhi-91

6. Name & Address of Individuals : Asharfi Lal


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shareholders holding more than one per cent
of the total capital

I Asharfi Lal, hereby declare that the particulars given above are true to the best of my
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Sd/-
(Asharfi Lal)

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Indian Journal of Obstetrics and Gynecology
31
Volume 4 Number 1, January - April 2016

Thyroid Dysfunction in Pregnancy – A Pandora’s Box

Ashalata Bafna*, Barkha Bafna M.S.**, Amit Bafna M.S.***

Abstract Introduction

Thyroid diseases affect upto 5% of Maternal thyroid function changes during


all pregnancies. The repercussions pregnancy and inadequate adaptation to
of maternal thyroid dysfunction these changes results in thyroid dysfunction
during pregnancy causes numerous [1,2]. Some of these alterations occur due to
maternal and fetal adverse outcomes thyroid hormone- binding globulin (TBG)
just like the Pandora’s box. Adequate concentration, increased iodine clearance in
treatment of these situations is the kidneys and thyrotropic effect of human
thought to reduce the risks. chorionic gonadotropin (hCG) [3,4].
Hypothyroidism is commonly treated Pregnancy can be considered as stress test of
with levothyroxine, with advancing maternal thyroid function where woman
pregnancy the levothyroxine with limited thyroid reserve may develop
requirement also increases. dysfunction [5]. Diagnosing thyroid
Hyperthyroidism is often treated with diseases in pregnancy can be difficult as the
antithyroid drugs in pregnancy. clinical signs and symptoms mimic those of
However they are not completely safe pregnancy. Hypothyroidism is associated
to use during pregnancy but benefits with weight gain, fatigue, constipation while
of treatment with these drugs is found hyperthyroidism causes nausea and
to outweigh the minor risks of side- increased appetite [6,7]. Current
effects. The treatment goal for recommendations suggest targeted TSH
hypothyroidism and hyperthyroidism screening for women at high risk for thyroid
is to achieve euthyroidism quickly disease before or during early pregnancy,
and maintain it throughout with other thyroid function tests to confirm
pregnancy. Autoimmune thyroiditis and grade the severity [5,8]. However,
and isolated maternal hyper- reference ranges of TSH or free thyroxin (fT4)
thyroxemia do not currently warrant obtained from non-pregnant populations do
treatment during pregnancy, unless not reflect normal values in pregnant women
hypothyroidism ensues. Treatment of because of their physiologic changes in
thyroid nodules and differentiated pregnancy [5,8]. Repeat laboratory sampling
thyroid cancer can generally be safely within a week is advisable in cases with
postponed until after delivery. isolated increases in TSH or decreases in fT4
Keywords: Thyroid Dysfunction; in pregnancy (especially in borderline
Hyperthyroidism; Autoimmune values) to confirm diagnoses.
Thyroiditis; Thyroid Hormone- As diagnosing thyroid diseases during
Binding Globulin (TBG). pregnancy may be difficult, adequate

*Lecturer, ACPM medical Table 1: Typical symptoms associated with hypothyroidism and hyperthyroidism
college, Dhule. **Consultant Hypothyroidism Hyperthyroidism
Bafna Hospital, Dhule. Weight gain Goiter
Constipation Palpitations, Tremors
Ashalata Bafna Fatigue Heat intolerance
Lecturer ACPM Medical Muscle cramps, Muscle weakness Weight loss
College, Dhule. Intolerance to cold Insomnia, Nervousness, Irritability
E-mail: Dry skin, Hair loss Frequent bowel movements
barkhajainbafna@yahoo.com Voice changes Eye symptoms

©Red
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JournalPublication Pvtand
of Obstetrics LtdGynecology / Volume 4 Number 1 / January - April 2016
Ashalata Bafna et. al. / Thyroid Dysfunction in Pregnancy – A Pandora’s Box
32

preconception diagnostics and management of endocrinologists, paediatricians and other healthcare


thyroid diseases crucial. Pregnant women with professionals can jointly work together to reduce risks
thyroid diseases should be managed preferably in of adverse pregnancy and neonatal outcomes
multidisciplinary clinics, where obstetricians, associated with thyroid diseases.
Table 2: The current recommendations for targeted screening for women at high risk for thyroid dysfunction
The American thyroid association5 The Endocrine scociety8
Age 30 years / older Age over 30 years
History of thyroid dysfunction and/ or thyroid surgery Family history of autoimmune thyroid disease or
hypothyroidism
Family history of thyroid disease Goiter
Goiter Thyroid antibodies primarily (TPO-Ab)
Thyroid antibodies Symptoms or signs of thyroid hypofunction
Symptoms and signs suggestive of hypothyroidism Type 1 diabetes / other autoimmune disorders
Type 1 diabetes History of miscarriage / preterm deliveries
Autoimmune disorders Infertility
History of miscarriage / preterm delivery Prior head / neck irradiation or prior surgery
Infertility Current levothyroxine replacement
Prior head or neck radiation Living in region with iodine deficiency
Morbid obesity
Treated with amiodarone
Recent exposure to iodinated radiological contrast agents (in
past 6 weeks)

Hypothyroidism hypothyroidism during pregnancy with early


Hypothyroidism complicates upto 3% of pregnancy sampling and longitudinal follow up will
pregnancies, of which 0.3 -0.5 % is overt and 2- 2.5% provide new information on natural history of
is subclinical hypothyroidism [5,8]. Overt and untreated subclinical hypothyroidism and indicate
subclinical hypothyroidism as well as increases in whether levothyrorixne treatment is beneficial in
maternal TSH concentrations have been associated reducing adverse outcomes.
with increase risk of miscarriages / fetal losses [9-
16], hypertensive disorders of pregnancy [14,17-20], Treatment of Hypothyroidism
placental abruptions [18,21], preterm birth [15,16,21-
24], and poor neurological development in the Levthyroxine is treatment of choice in
offspring [16,26,27].Overt hypothyroidism has also hypothyroidism with a goal of normalizing serum
been associated with maternal anaemia and TSH levels, using the pregnancy specific refrence
postpartum hemorrhage [18],and subclinical intervals [5]. In pregnancy treatment should be started
hypothyroidism with caesarean sections [14], with a dose as close to the final estimated dose as
gestational diabetes [21,27],breech presentation possible to minimise time with hypothyroidism [16].
[28,29], infants being small for gestational age [15], Women with levothyroxine treatment should have
fetal distress [26], neonates needing intensive care preconception TSH levels less than 2.5mIu/l to
treatment [21,23], and respiratory distress syndrome minimise the probability of hypothyroidism during
[23]. Adequately treated hypothyroidism still appears pregnancy [5]. However, even with adequate
to increase risk of cesarean sections but is not preconception management, upto 27% of women had
associated with other adverse outcomes [36]. elevated TSH concentrations in early pregnancy [38].
Therefore, the current recommendation is for women
Due to well established associations between overt to increase their levothyroxine dose by 20 – 30% upon
hypothyroidism and adverse pregnancy outcomes, it missed periods. Tighter control of hypothyroidism
should be promptly treated in an attempt to mitigate before pregnancy might reduce the risk of elevated
these known risk [5,8]. However, there is debate about TSH levels in pregnancy.
whether to treat all women with subclinical
hypothyroidism. Two different strategies are The etiology of thyroid disease also affects the need
proposed: to treat everyone [8] or to treat women with of levothyroxine dose adjustments in pregnancy.
positive thyroid antibodies [5]. In a study evaluating Women with post ablative or surgical hypothyroidism
treatment for subclinical hypothyroidism, 44% of require higher dose increases than those with primary
women with initially high TSH had normal thyroid hypothyroidism or thyroid cancer, irrespective of
function tests in a repeat sample taken 1 week later good baseline management of hypothyroidism [39].
[37]. An ongoing randomised placebo controlled trail An individualised approach based on baseline TSH
of levothyroxine treatment for subclinical concentrations and etiology of hypothyroidism could

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Ashalata Bafna et. al. / Thyroid Dysfunction in Pregnancy – A Pandora’s Box
33

be utilised when counselling women treated with dose of levothyroxine postpartum, with assessment
levothyroxine who are planning pregnancy, as lower of TSH levels 6 weeks following the dose reduction to
baseline TSH levels could potentially reduce the risk ensure euthyroidism [5]. Women with positive thyroid
of TSH elevations during pregnancy. Given that antibodies are at higher risk of exacerbation of
pregnant women are at increased risk of TSH autoimmune thyroid dysfunction postpartum, and
elevations, tests for thyroid function should begin in over 50% of women with Hashimoto’s thyroiditis
early pregnancy, continuing every 4 weeks until mid- continued to require doses of levothyroxine in
gestation and at least once between 26 and 32 weeks postpartum period [47]. Women with subclinical
among those with levothyroxine treatment to ensure hypothyroidism during pregnancy may not require
euthyroidism throughout pregnancy [5,8]. Newly treatment during the postpartum period, unless
diagnosed overt hypothyroidism in pregnancy postpartum thyroiditis ensues or the women is
require almost double the dose of levothyroxine planning to conceive again soon. These women are
compared to those treated for subclinical at high risk for thyroid dysfunction in their
hypothyroidism [40]. Either weight based starting subsequent pregnancies and require adequate
dose or a steady starting dose based on the severity of preconception consultation and management. They
newly diagnosed hypothyroidism determined by are also at higher risk of developing permanent
baseline TSH concentration seem to be appropriate thyroid disease later in life [32].
in reaching euthyroidism.
In a systematic review, treatment of clinical Hyperthyroidism
hypothyroidism was shown to reduce risk of
miscarriage and preterm birth [41]. There is currently Hyperthyroidism develop in 0.1 -1% of all
insufficient evidence to show clear benefits of treating pregnancies and is diagnosed when TSH
subclinical hypothyroidism [42]. Among women concentrations are low or suppressed along with
undergoing assisted reproduction, levothyroxine elevated free fT4 or triiodothyronine (in overt disease)
treatment of subclinical hypothyroidism has been or with normal thyroid hormone levels (in subclinical
shown to reduce miscarriages at least in some cases disease) [5]. Grave’s disease an autoimmune
[42], if not all [43]. condition characterised by stimulation of the thyroid
glands by TSH receptor antibodies (TRAbs), is the
Only about 62-82% ofall ingested levothyroxine is most common cause of hyperthyroidism among fertile-
absorbed, with concurrent ingestion of food, caffeine aged women. Other reasons include toxic
and iron and calcium supplements decreasing the
multinodular goiter, toxic adenoma, thyroiditis or
absorption further [44]. Levothyroxine should be
struma ovarii. As untreated Grave’s disease can lead
ingested in the morning at least 60 minutes before
to ovulatory dysfunction and infertility, a new onset
eating [44]. Additionally, there should be a 4 to 6 hours
of Grave’s is thought to be rare in pregnancy. A more
gap between levothyroxine ingestion and
common condition gestational (transient)
administration of other medications that decrease
hyperthyroidism occurs in up to 1-3% of all
levothyroxine absorption [44]. In addition several
chronic conditions including celiac disease, lactose pregnancies and is probably due to the physiologic
intolerance and atrophic gastritis decrease thyroidal stimulation by high hCG levels in early
levothyroxine absorption if untreated [44]. pregnancy [5,8]. Notably, up to 50% of women with
Compliance with medication as well as hyperemesis gravidarum (severe nausea and vomiting
gastrointestinal conditions and medication in early pregnancy) have transient hyperthyroidism.
interference should be evaluated in women with Distinguishing between new-onset or recurring
persistent hypothyroidism requiring higher than Grave’s disease in pregnancy and gestational
normal doses of levothyroxine [44]. Different hyperthyroidism may be difficult. Symptoms
levothyroxine products are not clinically associated with Grave’s disease (goiter or eye
interchangeable and there might be more than 12.5% symptoms) as well as previous history of thyroid
difference in levothyroxine doses between products disease help in differentiating between Grave’s
[45,46]. For optimised therapy, patients are often disease and transient hyperthyroidism, gestational
advised to stay on the same brand of levothyroxine. If hyperthyroidism is more common among women
products are switched, thyroid function tests should without history of thyroid disease [5,8]. Elevated
be performed to ensure euthyroidism [46]. Staying TRAb titers are rarely present in gestational
under the same brand might be especially crucial in hyperthyroidism, so their presence can help confirm
pregnancy where adverse effects of hypothyroidism Grave’s disease in pregnancy [5,8].
are well established. Hyperthyroidism is associated with increased risk
Most women with hypothyroidism can reduce their of pregnancy complications, including miscarriages,
Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Ashalata Bafna et. al. / Thyroid Dysfunction in Pregnancy – A Pandora’s Box
34

preeclampsia [48], low birth weight or fetal growth associated with teratogenicity, including aplasia cutis
restriction [48], and maternal cardiac dysfunction [49], and choanal atresia and esophageal atresia [53].
with risks increasing with poor hypothyroidism However, these specific malformations are very rare
control [48]. However, even in populations with on a population level. The other commonly used
treated hyperthyroidism, the risks of some neonatal antithyroid drug, propylthyiouracil, is not associated
outcomes seemed to be higher [50,51]. However, with teatogenicity butin rare instances
gestational hyperthyroidism has not been associated propylthiouracil may increase the risk of
with adverse pregnancy outcomes [5,35,36]. hepatotoxicity in the mother. Current
recommendations suggest using propyltiouracil
during preconception and in the first trimester of
Treatment of Hyperthyroidism in Pregnancy pregnancy to reduce tertogenicity in and switching
As the associations between untreated persistent to methimazole in later pregnancy to avoid
hyperthyroidism and adverse pregnancy outcomes hepatotoxity [5,8]. However, if one antithyroid drug
are well established, hyperthyroidism should be is not available or there are tolerance issuses, either
adequately managed before and during pregnancy propylthiouracil or methimazole can be used
[5,8]. In non-pregnant patients, the management throughout pregnancy as the neonatal and maternal
options for Graves’ disease include radioactive iodine risks of untreated maternal hyperthyroidism
ablation, anti thyroid drug treatment and/or surgery outweigh the small risks of malformations or liver
[6]. Whereas only anti thyroid drugs and surgery are toxicity [5,8].
options in pregnant patient [5,8]. Radioactive iodine Both anti thyroid drugs have been found to be
ablation results in long latency of 2-6 months before similarly effective in treating hyperthyroidism [5,8].
development of hypothyroidism as well as in an After switching between products, thyroid function
increase in TRAb titres. As such, this treatment option should be promptly tested (within 2 weeks) with a
is not generally recommended for hyperthyroid subsequent follow up every 4-6 weeks once euthyroid
women planning pregnancy in near future (within 6 state is reached. Surgery is also an option for pregnant
months of the treatment) as it is unlikely to achieve patients where rapid control of hyperthyroidism is
stable euthyroid state during that time [5,6]. Surgery required or antithyroid drugs cannot be used.6
is an option for patients hoping to conceive soon after However anaesthetic agents are teratogenic in the first
the operation, but even then, the optimal management trimester and surgery is associated with increased
of hypothyroidism after total or near total fetal loss in the third trimester, the late second trimester
thyroidectomy should be reached before conception is thought to be the safest period to perform
to reduce risks of adverse pregnancy outcomes [5,6]. thyroidectomy in a pregnant woman [6]. Women with
In non-pregnant women with hyperthyroidism, gestational hyperthyroidism generally do not require
antithyroid drugs are often recommended as these treatment as the condition is transient and not
patients have high likelihood of remission [6]. associated with adverse outcomes [5,31,32].
Notably, upto 30% of patients with Graves’ disease Propranolol, a beta blocker, can be used in short-term
may achieve remission without treatment [6]. symptom management as it has some direct
Generally antithyroid drugs are used in non- antithyroid activity by blocking iodide transport to
pregnant patients for up to 12 – 18 months, after which the thyroid. However, if women do not reach
they are discontinued if TSH is normal at that time. euthyroidism as pregnancy progresses or there are
Women who have achieved remission of other symptoms, Graves’ disease should be suspected
hyperthyroidism before pregnancy with antithyroid and a treatment trail with antithyroid drugs may be
drug therapy seem to have a low risk of useful [5].
hyperthyroidism relapse during pregnancy but a high All antithyroid drugs cross placenta and may have
relapse risk postpartum [6]. Still such women with deleterious impacts on the fetal thyroid function.
history of treated hyperthyroidism need to be carefully When treating pregnant women with antithyroid
monitored during pregnancy for clinical or drugs the treatment goal is to maintain fT4 values at
biochemical signs of relapse as well as to be tested for or above the upper non-pregnant reference limit or
TRAb positivity at mid – gestation [5]. high normal within the pregnant reference limit
(preferred approach) using the lowest possible dose
Antithyroid drugs can also be used to control of the drug [5]. Besides the fetal hypothyroidism risk
hyperthyroidism in women planning pregnancy or inflicted by maternal antithyroid drug therapy,
among those with newly discovered Graves’ disease untreated maternal hyperthyroidism may lead to
during pregnancy [5,8]. The antithyroid drugs transient central hypothyroidism in the fetus [5]. Fetal
methimezole ( and it’s prodrug carbimazole) is survelliance with serial ultrasound is required to

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Ashalata Bafna et. al. / Thyroid Dysfunction in Pregnancy – A Pandora’s Box
35

diagnose fetal thyroid dysfunction and follow fetal develop postpartum thyroiditis. In its classical form,
growth and wellbeing if a woman has uncontrolled postpartum thyroiditis manifests with an episode of
hyperthyroidism and/or positive TRAb during thyrotoxicosis followed by transient hypothyroidism
pregnancy. Levothyroxine and antithyroid drugs and subsequent euthyroidism but the clinical course
should not be used together, except in the rare cases varies [5,63]. The thyrotoxic phase generally does
of fetal hyperthyroidism. Administering both not require or respond to antityroid drugs but
concurrently leads to a relative increase in maternal symptomatic women may be treated with a low dose
fT4 levels leadingto increased requirements of of proprnanol. Treatment of the hypothyroid phase
antithyroid drugs, which in turn may lead to fetal of postpartum thyroiditis with levothyroxine depends
hypothyroidism [5]. Women with a history of Grave’s on the symptom severity, if a woman is breastfeeding,
disease or hyperthyroidism treated during pregnancy if she plans to conceive again in the near future and
are at higher risk of relapse during the postpartum her prefrence to receive treatment [5,63]. Treatment
period [5]. Moderate use of antithyroid drugs is safe for postpartum thyroiditis is usually transient, with
during lactation and has not been shown to affect discontinuation of treatment 6-12 months after the
thyroid hormone levels or the development of the initiation, unless the patient is pregnant,
infant. However, as a safety precaution, infants of breastfeeding or trying to become pregnant [5,63].
mothers taking antithyroid drug during lactation Postpartum thyroiditis can lead to permanent
need to be followed with thyroid function tests and hypothyroidism in over 50% of all women and annual
antithyroid drugs should be taken in divided does TSH tests are indicated to those with postpartum
immediately after feeding [5]. thyroiditis history [5,63].

Autoimmune Thyroiditis and Postpartum Thyroiditis Thyroid Nodules & Thyroid Cancer
Approximately 11–15 % of all fertile women have Thyroid size increases during pregnancy and
positive thyroid antibodies, either thyroid peroxidase pregnancy has been considered to be a risk factor for
antibodies (TPO-Abs)or thyroglobulin antibodies increasing growth of thyroid nodules [5]. However, it
(TG-Abs), which act as marker of silent autoimmune is still unclear that thyroid nodules are commonly
thyroiditis. Up to 20–40 % of all women with positive diagnosed in pregnant than in non-pregnant women,
thyroid antibodies develop hypothyroidism during although radionuclide scans are contraindicated in
pregnancy or immediately postpartum [53,54], and pregnancy [5]. Upon discovering the thyroid nodules
generally women with autoimmune thyroiditis have , a complete family and personal history and clinical
higher TSH concentrations at baseline [54]. Notably, examination, including thyroid function tests should
TPO-Ab and TG-Ab concentrations decrease as be performed [5,62]. Thyroid ultrasound is an accurate
pregnancy progresses [54], so false negative findings diagnostic tool that can be used in pregnancy to help
regarding thyroid autoimmunity are possible in late determine the features and growth of nodules. Fine-
gestation. needle aspiration biopsy is another safe procedure
Thyroid antibody positivity has been associated during pregnancy and pregnancy does not have an
with increase risk for miscarriages [55-58], perinatal effect on its diagnostic accuracy [5].
mortality [31], and preterm birth [57]. TPO-Ab Women diagnosed with differentiated with
positivity in euthyroid women is associated with differentiated thyroid cancer during pregnancy seem
placental abruptions [59], very early preterm delivery to have a similar prognosis if surgery is performed
[60],neonatal respiratory distress [60], and during or after pregnancy [5,62]. Therefore, surgery
externalising problems, for example, attention for differentiated thyroid cancer can generally be
problems and aggressive behaviour, in children [61]. delayed until after delivery , although sonographic
However most of these studies have evaluated thyroid monitoring over the course of pregnancy is indicated
function only once during pregnancy, so the effect of [5,62]. Thyroid hormone suppression therapy may
hypothyroidism as the underlying reason for these be considered for these patients, with goal of reducing
associations cannot be ruled out. TSH to 0.1-1.5 mU/l [5,62]. If surgery is required due
Postpartum thyroiditis is a new onset thyroid to thyroid cancer, the safest time to perform surgery is
dysfunction during the 12 months following in the second trimester [5,62]. Benign thyroid nodules
pregnancy in a previously euthyroid woman [5]. The do not generally require treatment during pregnancy,
risk of postpartum thyroiditis is higher in women unless compressive symptoms develop or if there is
with positive thyroid antibodies or other autoimmune rapid growth [5,62].
diseases . Up to 50% of all women with TPO-Ab or Women with thyroid cancer in remission on
TG-Ab positivity in first trimester of pregnancy suppressive thyroid hormone therapy should
Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Ashalata Bafna et. al. / Thyroid Dysfunction in Pregnancy – A Pandora’s Box
36

continue this treatment throughout pregnancy, as 10. Allan WC, Haddow JE, Palomaki GE et al. Maternal
subclinical hypothyroidism does not seem to affect thyroid deficiency and pregnancy complications:
pregnancy outcomes [5,31,32]. Thyroid cancer implications for population sceening. J Med. Screen.
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Thyroid function tests should be conductedevery 4-6 12. Benhadi N, Wiersinga WM, Reitsma JB, Vrijkotte
weeks in pregnancy to ensure that treatment goals TG, Bonsel GJ. Higher maternal TSH levels in
are met [5]. pregnancy are associated with increased risk for
miscarriage, fetal or neonatal death. Eur.
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Indian Journal of Obstetrics and Gynecology
39
Volume 4 Number 1, January - April 2016

Successfull Surgical Management of a Giant Condyloma Accuminata


in an Elderly Postmenopausal Woman

Amrita Singh*, Prasanta Kumar Nayak*, Subarna Mitra*, Sarita Agrawal*

Abstract may appear as pearly, filiform, fungating, or


plaque-like eruptions. They mainly occur in
the moist areas of the labia minora and
Condyloma accuminata (CA) is vaginal opening, but virtually, all genital
the overgrowth of epithelial tissue regions may be affected (fourchette, labia
of the anogenital area which occurs minora/majora, pubis, clitoris, urethral
due to the infection by human meatus, perineum, perianal region, anal
papilloma virus (HPV). Giant canal, introitus, vagina, and ectocervix). The
condyloma acuminata also called as prevalence of CA peaks in the early sexually
Buschke-Löwenstein tumour (BLT) active years. The age distribution of those
is a slow growing cauliflower-like treated for condylomata peaked in 20- to 39-
tumour, locally aggressive and years of age [3]. Although 90% of those who
destructive, with possible malignant contract HPV will not develop genital warts,
transformation. It is a disease those infected can still transmit the virus [4].
transmitted by sexual intercourse Little is known about the prevalence and
and affects both women and men. persistence of HPV in older women. Lesions
We are reporting an interesting case are commonly multiple (multicentric) and
of giant condyloma accuminata in a multifocal, affecting the perianal, vaginal,
multiparous, 70 year old lady, who and cervical regions concurrently. Treatment
presented with one year history of options include drugs like podophyllin and
rapidly growing vulval mass, 5 fluorouracil or by surgical excision.
associated with malodorus vaginal Surgical treatments have the highest primary
discharge, pruritus, pain and clearance rates with initial cure rates up to
difficulty in walking. The tumor 60–90%. They include surgical excision,
measured 10cm x 8cm and was electrosurgery and laser therapy. Formal
successfully excised with lotus petal surgery under anaesthesia is convenient for
skin grafting. the removal of bulky and extensive warts.
Keywords: Condyloma But the healing of the skin defect occurring
Accuminata; Human Papilloma due to excision of the giant condylomata is
Virus; Lotus Petal Skin Grafting. very slow and often require skin grafting.
We report a case of 70 year old lady with
a giant Condyloma acuminata of vulva, who
Introduction
was successfully treated with ipsilateral
vulvectomy and reconstruction of the defect
Department of Obstetrics by lotus petal skin grafting. This is an
Condyloma acuminatum or
– Gynaecology, All India
India Institute of Medical genital warts refer to benign interesting case because of its rare
Sciences, Raipur, India. proliferative epidermal or mucosal presentation in a 70 year old
lesions attributed mostly to HPV postmenopausal woman and successful
type 6 or 11 but co-infections with treatment of the wide defect in the skin by
Prasanta Kumar Nayak,
Assistant Professor, high-risk HPV types are frequent [1]. lotus petal skin grafting
Department of Obstetrics Giant condylomas are an
and Gynaecology, All India exceedingly rare condition with an Case Report
India Institute of Medical
estimated incidence of 0.1% in the
Sciences, Raipur,
Chhattisgarh, India-492099. general population [2]. CA are soft,
E-mail: raised masses, with smooth, A 70 year old multiparous lady, presented
drprasant79@gmail.com verrucous, or lobulated surface that to the gynecology clinic with a history of
©Red
IndianFlower
JournalPublication Pvtand
of Obstetrics LtdGynecology / Volume 4 Number 1 / January - April 2016
Amrita Singh et. al. / Successfull Surgical Management of a Giant Condyloma Accuminata
40
in an Elderly Postmenopausal Woman

progressive growth of a vulval tumour, associated which oral thyroxine was prescribed along with oral
with itching, contact bleeding, malodorous discharge iron.CT scan findings of abdomen and pelvis was
and burning sensation during micturition. The normal and did not reveal any features of invasion of
swelling was so huge that she had difficulty in the tumour to the surrounding tissue. Later on the
walking. She was treated by some local physician histopathology report confirmed the diagnosis of
with some topical medication. condyloma accuminata. She was planned for simple
Examination revealed that she had a huge vulvectomy after normalization of hemoglobin and
cauliflower like vulval growth with malodorous thyroid hormone levels.
discharge from the lesion which confused with vulval The whole of the growth was excised along with
malignancy (Fig.1). The growth had covered the entire the entire right vulva. The smaller satellite lesions on
right labia from clitoris to posterior fourchette, the left vulva were excised and the base was electro-
measuring about 10cm x 8cm. Small satellite lesions cauterised. The defect in the right hemi vulval skin
of size 1 cm to 2 cms was noted on left labia also. Left was covered with lotus petal shaped gluteal skin flap.
side inguinal node was palpable with size 1cm x 1cm The skin grafting was accomplished by rotating the
and was mobile. Cervix and vagina was normal in lotus petal shaped skin flap keeping its base intact to
appearance. Biopsy was taken from the growth and maintain the vascularity.
sent for histopathology. Her post operative period was uneventful. The
Her vital parameters were within normal range wound was completely healed by the end of third
and all the routine blood investigation findings were post-operative week. The histopathology result did
also normal except haemoglobin level which was 8 not show any evidence of malignancy.and the
gm%. She was also found to have hypothyroid for surgical margin was free

Fig. 1: Preoperative picture showing giant condyloma

Fig. 2: Itraoperative picture showing complete removal of Fig. 3: Intraoperative picture showing repair of skin defect due
condyloma with right hemivulvectomy to vulvectomy with lotus petal skin graft from gluteal area

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Amrita Singh et. al. / Successfull Surgical Management of a Giant Condyloma Accuminata
41
in an Elderly Postmenopausal Woman

in our case.
Now a days giant CA is not found in urban and
affluent families. It is more seen among lower socio
economic groups of rural areas as in our case. In this
case the time taken for wound healing was three
weeks which can be due to the poor personal hygiene
and low immunity attributed to her old age. There
was no recurrence of the disease till six months
following her surgery.

Conclusion

Fig. 4: Postoperative picture after completion of surgery Giant CA is still seen in low resource countries
like India, due to late presentation. Although
commonly found among reproductive age group
Discussion women, it should be kept in the differential diagnosis
of any exophytic vulval growth in postmenopausal
women. Proper surgical excision with adequate
CA is a benign disease caused by HPV that is margin and cauterization of base are essential for the
sexually transmitted and that can cause malignant successful treatment
transformation. Giant CA is a rarely seen form which
develops by the overgrowth of condyloma
acuminatum and has a high risk of malignant References
transformation [4]. Giant CA was first described by
Buschke and Löwensteinin [5]. This condition is
described as large exophytic cauliflower-like lesion 1. Aubin, J.L. Pretet, A.C. Jacquard, M. Saunier, X.
affecting the anogenital skin surface due to infection Carcopino, F. Jaroud, P. Pradat, B. Soubeyrand, Y.
Leocmach, C. Mougin, D. Riethmuller .Human
by HPV [6]. HPV transmission occurs due to
papillomavirus genotype distribution in external
homosexuality, bad genital hygiene, chronic genital acuminata condylomata: a Large French National
infections, and polygamy. About 90% of genital warts Study (EDiTH IV) Clin. Infect. Dis. 2008; 47: pp. 610–615.
are caused by HPV 6 and 11 [7]. Giant CA caused by
2. A. Geusau, G. Heinz-Peer, B. Volc-Platzer, G. Stingl,
HPV-16 has also been reported [8]. Usual age of and R. Kirnbauer, “Regression of deeply infiltrating
presentation is reproductive years with a peak giant condyloma (Buscheke-Lowenstein Tumor)
between 20 -39 years as it is described earlier but our following long-term intralesional interferon alfa
patient was a very elderly postmenopausal lady. therapy,” Archives of Dermatology. 2000; 136(6):
CA can be treated with medical therapy or surgical pp. 707–710.
intervention. Surgical excision has the lowest 3. Fleischer AB Jr1, Parrish CA, Glenn R, Feldman SR
recurrence rate. Medical therapy with Podophyllin Condylomata acuminata (genital warts): patient
salts, Imiquimod ,Trichloroacetic acid (TCA) solution demographics and treating physicians. Sex Transm
Dis. 2001 Nov; 28(11): 643-7.
(80–90%) and five-flourouracil have all been used
with varied results [9]. Podophyllin is still considered 4. Q. D. Chu, M. P. Vezeridis, N. P. Libbey, and H. J.
one of the best medical therapies. The reported effect Wanebo, “Giant condyloma acuminatum (Buschke-
of podophyllin is to block the mitosis, with spindle L¨owenstein tumor) of the anorectal and perianal
regions: analysis of 42 cases,” Diseases of the Colon
destruction [10]. Size of the growth is the major
and Rectum, 1994; 37(9): 950–957.
impediment to medical treatment. Wide excision with
histopathological margins control is the best surgical 5. Niazy F, Rostami K, Motabar AR. Giant Condyloma
Acuminatum of Vulva Frustrating Treatment
choice in the treatment of giant CA. Due to the high
Challenge. World J Plast Surg. 2015; 4(2): 159-162.
frequency of local recurrence, complete surgical
excision is the current treatment of choice for them as 6. Buschke A, LöwensteinL (1932) Über die Beziehungen
topical preparations and chemotherapy are generally von spitzen Kondylomenzu Karzinomen des Penis.
Deutsche Medizinische Wochenschrift-DMW. 58:
considered ineffective [11]. Putting a skin graft helps
809-810.
in early healing of the larger skin defect. Various types
of skin graft techniques can be followed including 7. Smith JS, Lindsay L, Hoots B, et al. Human papilloma
that of lotus petal skin graft technique as it was done virus type distribution in invasive cervical cancer

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Amrita Singh et. al. / Successfull Surgical Management of a Giant Condyloma Accuminata
42
in an Elderly Postmenopausal Woman

and high-grade cervical lesions: a metaanalysis actinic keratoses, basal cell carcinoma and other skin
update. Int J Cancer. 2007; 121: 621–32. lesions. Drugs. 2007; 67: 2187-2210.
8. Bhageerathy PS, Cecilia M, Sebastian A, 10. Tan XJ, Wu M, Lang JH, Giant condyloma acuminatum
Raghavendran A, Abraham P, Thomas A et al. of the vulva. IntJ Infect Dis. 2010; 14: e455-456
Human papilloma virus-16 causing giant condyloma 11. Balik E, Eren T, Bugra D. A surgical approach to
acuminate. J Surg Case Rep. 2014 Jan; 2014(1): rjt126 anogenital Buschke Loewenstein tumors (giant
9. Wagstaff AJ, Perry CM, Topical imiquimod: A review condyloma acuminata). Acta Chir Belg. 2009; 109:
of its use in the management of anogenital warts, 612-16.

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Indian Journal of Obstetrics and Gynecology
43
Volume 4 Number 1, January - April 2016

Live Birth in an Unruptured Non-Communicating


Rudimentary Horn

Savita Rani Singhal*, Susheela Chaudhary**, Anjali Gupta*

Abstract reports are there in the literature of successful


pregnancy outcome in non communicating
uterine horn3,4,5. We report a case of successful
Pregnancy in a rudimentary horn pregnancy outcome at 34 weeks in a non
of uterus is a form of ectopic communicating rudimentary horn which
pregnancy. Clinical manifestations was diagnosed at laparotomy.
will depend upon the development
of rudimentary horn. Viable
pregnancy in non-communicating Case Report
rudimentary horn is very rare, as
more than 80% cases of rudimentary
horn pregnancy present in second A 22 years old, unbooked, gravida three
trimester with rupture of the horn para one with no live child and one abortion,
and is life threatening. Early presented with 34 weeks of gestation with
diagnosis of rudimentary pregnancy severe preeclampsia. The general condition
is required to avoid such of the woman was good, per abdomen
complication. Sometimes, even examination revealed 28 weeks size
modern ultrasonography scan asymmetrically enlarged uterus more on left
cannot confirm the diagnosis of side with breech presentation. The liquor was
rudimentary horn pregnancy. We less and the uterus was full of the fetus.
report a case of successful Ultrasound showed a single live fetus,
pregnancy outcome at 34 weeks in a presenting as breech, corresponding to 32 ±
non communicating rudimentary 3 weeks of the gestation, with absent liquor,
horn. baby weight of 1300 ± 100 gms and
bicornuate uterus. On detailed history, it was
Keywords: Pregnancy; found that she attained menarche at the age
Ultrasonography; Rudimentary of 15 years and was married since four and
Horn. half years. She had normal menstrual cycles
with history of moderate dysmenorrhoea on
Introduction first day of cycle for which she took off and
on analgesics. Three years back, she had
preterm vaginal delivery at seven months of
Incidence of mullerian gestation conducted at home and the baby
abnormality is 3-4% and pregnancy expired after one day due to prematurity.
in rudimentary horn accounts for 1: After the first delivery she started having
*Professor **Assistant 1,00,000 to 1: 1,40,000 pregnancies pain in lower abdomen for which she
Professor, Department of [1]. Pregnancy in a rudimentary horn consulted general practitioner and got her
Obstetrics and Gynecology, ultrasonography done which showed
Pt B D Sharma Post
of a unicornuate uterus is a form of
Graduate Institute of ectopic pregnancy and results from bicornuate uterus with right horn measuring
Medical Sciences, Rohtak, trans peritoneal migration of sperm 55mmx34mm and left horn 35mmx26mm
Haryana, 124001, India. or zygote. In more than 80% cases with single cervix. Hysterosalpingography
rupture of horn occurs in second showed single spindle shaped uterine cavity
Savita Rani Singhal
14/8FM, Medical Campus trimester and patient presents as on right side with single fallopian tube and
Rohtak, 124001. acute abdomen with haemoperit- with free peritoneal spill. Magnetic
Haryana, India oneum [2]. Very few pregnancies resonance imaging showed two separate
E-mail: endometrial cavities, left horn smaller than
reach viability and are difficult to
savita06@gmail.com
diagnose antenatally. Solitary case the right with single cervix and both the
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JournalPublication Pvtand
of Obstetrics LtdGynecology / Volume 4 Number 1 / January - April 2016
Savita Rani Singhal et. al. / Live Birth in an Unruptured Non-Communicating Rudimentary Horn
44

ovaries were normal. She did not undergo any further caesarean section was planned. Per operatively, the
treatment. Two years back, she had spontaneous uterus was asymmetrically enlarged with two well
abortion at two and half months of gestation, not defined uterine horns, with one larger than the other
followed by the curettage. During the present due to pregnancy. Vertical incision was given over
pregnancy, she did not have any antenatal checkup. the pregnant horn of the uterus as lower segment was
After admission to the hospital, the pateint was not formed (Figure-1) and a baby weighing 1.25 kg
started on tablet labetalol and investigated for was delivered. On inspecting the uterine cavity, no
preeclampsia. Hypertension persisted even after communication with the other horn was found which
medical treatment and termination of pregnancy was was confirmed by dye test. The rudimentary horn was
decided. On per vaginum examination there was attached to the normal uterus by about 2.5 cm broad
single cervix which was uneffaced, admitting tip of stalk and it was excised (Figure-2). Unicornuate
finger, no fetal part felt within reach of finger and the uterus left appeared to be normal (Figure-3). Post
uterine horn which was communicating the cervix operative period was uneventful. The patient was
seemed to be non pregnant. Diagnosis of pregnancy discharged seven days after surgery in satisfactory
in non communicating horn was suspected and condition.

Fig. 1: Bicornuate uterus after cesarean section


Fig. 3: Uterus after excision of rudimentary Horn

Discussion

Unicornuate uterus with a rudimentary horn is a


rare type of uterine malformation and results from an
arrest in the development of the mullerian ducts with
inappropriate fusion on contralateral side. In 83% to
90% of cases, there is no direct communication between
the horn and the functional portion of the uterus and
fertilization is thought to occur via transperitoneal
migration of the sperm or conceptus [5].
Clinical manifestation is different in
communicating and non communicating
rudimentary horn pregnancy. In communicating
rudimentary horn, chances of live fetuses are more.
Patient may present with pain abdomen, bleeding
per vaginum, malpresentation and sometimes
diagnosed at time of termination of pregnancy as a
retained placenta. Non communicating rudimentary
horn present in second trimester in 80% cases due to
rupture of gravid horn as an acute emergency with
Fig. 2: Excised Rudimentary horn evidence of haemoperitoneum. In 20% cases, it may

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Savita Rani Singhal et. al. / Live Birth in an Unruptured Non-Communicating Rudimentary Horn
45

present late when musculature is well developed to Conclusion


accommodate growing fetus, and the patient complains
of frequent pain abdomen and is associated with preterm
labor, intra-uterine growth retardation, oligohydramnios, If diagnosis of rudimentary horn is made in non
pre-eclampsia and malpresentation [2]. pregnant stage, it should be excised before patient
becomes pregnant to avoid life threatening
To prevent serious complications due to rupture of complications of pregnancy in rudimentary horn. If
horn early diagnosis is important and only 8% patient presents during pregnancy, early diagnosis
rudimentary horn pregnancies are diagnosed before before the serious symptoms of uterine rupture appear
symptoms appear. Diagnosis of uterine malformation is important. High degree of suspicion is required for
may be done by hysterosalpingography, early diagnosis and it should be suspected in a patient
hysteroscopy, ultrasonography, laproscopy. MRI and who presents with asymmetrical enlarged uterus with
ultrasonography are not very satisfactory because the continuous pain abdomen, malpresentation,
enlarging horn with a thinning of myometrium can olignydraamnios or growth restriction.
obscure anatomic structures [6].
Laprotomy is the standard mode of treatment in
non-communicating rudimentary horn pregnancy References
and usual procedure is removal of baby followed by
excision of rudimentary horn along with fallopian 1. Johansen K. pregnancy in a rudimentary horn
tube of that side to prevent future recurrence of ectopic pregnancy. Obstet Gynecol. 1983; 16: 565-7.
pregnancy, as was done in present case. There are few
2. Nahum GG. Rudimentary Uterine horn
case reports of the live pregnancy in non communicating
pregnancy:The 20th century worldwide experience
uterine horn [3,4,5]. As now the nursery facilities are of 558 cases. J Reprod Med. 2002; 47: 151-63.
increasing the live babies are delivered even at a gestation
3. Acmaz G, Tayyar A, Oner G, Tayyar M. Live birth in
lower than 28 weeks and incidence of live pregnancy in
an unruptured communicating rudimentary horn
rudimentary horn may rise in future. pregnancy at 32 weeks; case report. Med J Bakirkay.
In our case exact diagnosis of rudimentary horn 2008; 4(4): 170-2.
pregnancy was not made prior to laprotomy though 4. Goel P, Saha Pk, Mehra R, Huria A. Unruptured
the case was diagnosed as bicornuate uterus in non postdated pregnancy with a live foetus in a
pregnant state. Decision for laprotomy was taken as noncommunicating rudimentary horn. Ind J Med Sci.
clinically the pregnancy was suspected in non 2007; 61(1): 23-7.
communicating horn. Had the patient undergone the 5. Shin JN, Kim HJ, A case of live birth in a non
excision of the horn in non pregnant stage this communicating rudimentary horn pregnancy. J
laparotomy might have been avoided. So once the Obstet Gynecol Res. 2005; 31: 329-31.
diagnosis of rudimentary horn is made in non pregnant 6. Sutkin G, Jazayeri A. Diagnosis of a rudimentary
stage, it should be excised before patient becomes uterine horn in pregnancy. J Ultrasound Med. 2003;
pregnant to avoid life threatening complications. 22; 985-8.

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
46

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Indian Journal of Obstetrics and Gynecology
47
Volume 4 Number 1, January - April 2016

Puerperal Rupture Uterus in A Primigravida: A Rare Case

Ananya Das

Abstract According to the patient the duration of


labour was almost ten hours and the baby
cried after birth. She was absolutely normal
Rupture uterus is a dreaded till eight days back, when she suddenly
obstetric complication. It is a very developed pain abdomen following lifting
rare event in an unscarred uterus of of a heavy bucket. Gradually her pain
a primigravida. We present a case of increased and she got admitted in a local
rupture uterus in a primigravida hospital. She was referred subsequently to
diagnosed late in puerperium. She our hospital after two days. On admission
was managed conservatively she was found to be very pale but her vitals
without the need of any laparotomy. were stable. On per abdominal examination,
Such case is yet not reported in a soft, non tender mass of 28 weeks size was
literature. Primigravidas are not found in the hypogastrium. On per vaginal
immune to rupture uterus and many examination, uterus could not be accessed
a times it can be treated without any separately from the lump. At the time of
surgical intervention. admission her hemoglobin was 7.6 gm%,
Keywords: Rupture Uterus; platelet count 5 lakh/cumm and total
Primigravida; Puerperium. leukocyte count was 13,800/cumm.
Emergency ultrasonography showed
rupture of uterus in the posterior fundal
Introduction region with collected blood clot without
hemoperitoneum. The patient was under
close monitoring and her vitals remained
Traditionally, the primigravid
stable. Conservative treatment was done with
uterus has been considered almost
antibiotics and anti-inflammatory drugs. The
immune to spontaneous rupture.
lump gradually decreased to 14 weeks size
Uterine rupture in an unscarred
after two weeks of treatment. Repeat
primigravid uterus is a rare event,
sonography showed a normal uterus with
Assistant Professor, the estimated occurrence being one
no blood clot or hematoma after another 2
Department of Obstetrics & in 8000-15000 deliveries [1].
Gynaecology, North Eastern
weeks. She was then discharged home with
Moreover such rupture diagnosed
Indira Gandhi Regional iron supplements and also advised follow
late in puerperium has not been
Institute of Health & up after 2 weeks.
Medical Sciences reported in literature yet. Herein we
NEIGRIHMS), present a case report of a lady with
Mawdiangdiang, Shillong- ruptured uterus which was Discussion
793018, Meghalaya, India. diagnosed one month after childbirth
and treated conservatively.
Ananya Das, Assistant Rupture of the uterus usually presents as
Professor, Department of
Obstetrics & Gynaecology, an acute life-threatening condition with
North Eastern Indira Case Report symptoms and signs that makes diagnosis
Gandhi Regional Institute relatively easy particularly when there is
of Health & Medical history of obstructed labour and other risk
Sciences (NEIGRIHMS), An 18 years old lady attended
Mawdiangdiang, Shillong- factors. The main risk factor is a scarred
793018, Meghalaya, India.
casualty with pain abdomen since uterus, usually secondary to a previous
E-mail: eight days. She had a history of home cesarean delivery. Besides cesarean section,
mailmedrananyadas@ delivery one month back by a inappropriate prostaglandin and oxytocin
rediffmail.com traditional birth attendant. usage, previous instrumental abortion,
©Red
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JournalPublication Pvtand
of Obstetrics LtdGynecology / Volume 4 Number 1 / January - April 2016
Ananya Das / Puerperal Rupture Uterus in A Primigravida: A Rare Case
48

vacuum extraction delivery, and vigorous fundal reported. The rupture in the primigravid unscarred
pressure are the other risk factors for uterine rupture uterus presented very unusually after 1 month of
[1, 2]. Chisara et al reports a case of rupture uterus in home delivery and could be successfully managed
a primigravida secondary to abdominal manipulation conservatively. Being primigravida and in late
by a traditional birth attendant, similar to that in our puerperium cannot exclude the diagnosis of rupture
case[3]. These cases are usually diagnosed uterus. Also laparotomy is not always the answer to
intrapartum or shortly after delivery and managed such kind of a rupture uterus.
with immediate repair of the ruptured site or subtotal
hysterectomy. Few cases of rupture discovered in the
postpartum period are described in the literature. References
There is a reported case of rupture uterus in Vaginal
Birth After Caesarean diagnosed two days after 1. Pan HS, Huang LW, Hwang JL, Lee CY, Tsai YL,
delivery[4]. Hruska et al described a patient who Cheng WC. Uterine rupture in an unscarred uterus
presented to the Outpatient Obstetric Clinic with after application of fundal pressure. J Reprod Med.
worsening left lower quadrant abdominal pain 4 2002; 47: 1044–1046.
days postpartum of an uncomplicated vaginal 2. Wang PH, Yuan CC, Chao HT, Yang MJ, Ng HT.
delivery involving low dose oxytocin stimulation. Posterior uterine wall rupture during labour. Hum
She underwent hysterectomy due to defect in the Reprod. 2000; 15: 1198–1199.
lower uterine wall [5]. In our case, the patient 3. Chisara C Umezurike, Paul A Feyi- Waboso.
presented very unusually after one month of Ruptured uterus in a primigravida, secondary to
uneventful vaginal delivery. She was a primigravida abdominal manipulation by a traditional birth
with unscarred uterus and no other known risk attendant: a case report. Tropical Journal of Obstetrics
factors of rupture uterus. Since she was and Gynaecology. 2005; 22(1): 83-84.
hemodynamically stable inspite of a low hemoglobin 4. Guiheneuf A, Cabaret AS, Grall JY. A case of uterine
concentration, we could successfully treat her with rupture described in the postpartum period. J
conservative management alone. Gynecol Obstet Biol Reprod (Paris). 2008 Apr; 37
(2): 197-9.
5. Hruska KM, Coughlin BF, Coggins AA, Wiczyk HP.
Conclusion MRI diagnosis of spontaneous uterine rupture of an
unscarred uterus. Emerg Radiol. 2006; 12: 186-188.
This case of rupture uterus is first of its kind ever

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Indian Journal of Obstetrics and Gynecology
49
Volume 4 Number 1, January - April 2016

Fetal Gastroschisis: A Differential Diagnosis of


Uterine Perforation

Savita Rani Singhal*, Suresh Kumar Singhal**, Ankita Agarwal*

Abstract developing countries. Hence, a number of


patients with fetal, abdominal wall defects
are diagnosed only after the delivery. Uterine
Gastroschisis is type of an perforation is an uncommon but potentially
abdominal wall defects, can be serious complication of evacuation of
diagnosed in antenatal period with retained products of conception or
the help of an ultrasonic scan. termination of pregnancy. The usual
However, routine ultrasonic presentation of uterine rupture is
scanning of all gravida is not hemorrhage, shock, distension and pain
possible due to lack of adequate abdomen [2]. In developing countries,
facilities in some health centers in especially in India it is not uncommon to see
developing countries. Hence, a the patients presenting with gut loops lying
number of patients with fetal, in vagina or outside vagina in cases of
abdominal wall defects are abortions being managed by unskilled
diagnosed only after the delivery In persons [3]. If one sees intestines coming out
developing countries, especially in in the vagina, the first possibility which is
India it is not uncommon to see the thought is of either the uterine perforation or
patients presenting with gut loops rupture uterus. We report a rare case in which
lying in vagina or outside vagina in gastrochisis was confused with uterine
cases of abortions being managed by rupture, due to presence of intestines in the
unskilled persons. If one sees vagina of the mother.
intestines coming out in the vagina,
the first possibility which is thought
is of either the uterine perforation or Case Report
rupture uterus. We report a rare case
in which gastrochisis was confused
with uterine rupture, due to presence A 30 years old unbooked woman gravida
of intestines in the vagina of the four para two with two live children with 24
mother. weeks of pregnancy presented with pains
abdomen and leaking per vaginum for two
Keywords: Gastroschisis; Bowel hours was referred to tertiary care center with
Loops; Uterine Perforation. the diagnosis of uterine perforation. The
patient and her attendants were very anxious
Introduction due to diagnosis of perforation uterus. She
*Professor **Senior
belonged to poor socioeconomic status and
Professor, Department of
Obstetrics and Gynaecology, worked at brick kiln and had no antenatal
Junior Resident, Department Gastroschisis is type of an check up or ultrasound prior this visit. The
of Anesthesia, Pt BD abdominal wall defects, in which is patient had stable vitals. Abdominal
Sharma, Post Graduate
on right side of normally inserted examination revealed 20-22 weeks size, non
Institute of Medical
cord and free-floating bowel loops
Sciences, Rohtak, Haryana, tense, non tender uterus, with well
India. are present [1]. Abdominal wall maintained contour, the fetal parts were
defects can be diagnosed in palpable. There was pack in the vagina, same
Savita Rani Singhal,
antenatal period with the help of an removed and on removing the pack;
H No. 14/ 8 FM, Medical
Campus, Rohtak–124001, ultrasonic scan. However, routine congested and edematous intestinal loops
Haryana (India). ultrasonic scanning of all gravida is were seen hanging out of vagina. On Vaginal
E-mail: not possible due to lack of adequate examination, the cervix was four cm dilated,
savita06@gmail.com
facilities in some health centers in fully effaced, gut loops were coming out
©Red
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JournalPublication Pvtand
of Obstetrics LtdGynecology / Volume 4 Number 1 / January - April 2016
Savita Rani Singhal et. al. / Fetal Gastroschisis: A Differential Diagnosis of Uterine Perforation
50

through cervix and fetal parts were felt. Urine was were confused with the maternal intestines and the
clear with adequate output. As the size of the intestines diagnosis of uterine perforation was made. Treating
was not of adult size, and clinically perforation of obstetrician never thought of the presence of
uterus was ruled out, provisional diagnosis of congenital anomaly (Gastroscisis) in fetus, as this is
ruptured Gastroschisis/Omphalocele was made. a rare anomaly, and moreover this type of atypical
Augmentation was done with oxytocin and a dead presentation is not reported in literature. In this
male baby weighing 700 gms was delivered and had patient, if a scan was done before 20 weeks of
no complications, the uterus was found to be intact. gestation, gastroschisis might have been diagnosed,
Baby was grossly malformed, bowel loops coming she would have undergone MTP and undue referral
out through a paraumblical defect on right side of and anxiety to the patient and attendants might have
umblical cord which was not covered by a membrane. been avoided.
Intestine was thickened, edematous and dark red.
Anal opening was absent, right lower limb was
hypoplastic, left lower limb was deformed (Figure-1). Conclusion
The patient did not give consent for autopsy.
In developing and underdeveloped countries,
where still the antenatal anomaly scan is not available
to all the mothers, obstetricians should be aware of
anterior abdominal wall defects and their
presentation as intestines lying in vagina or at
introitus, so that unnecessary referral and undue
anxiety on the part of patient and treating doctors
can be avoided.

References

1. Curry JI, McKinney P, Thornton JG, Stringer MD.


Fig. 1: Fetus with gastroschisis and other anomalies The aetiology of gastroschisis. BJOG. 2000;107 (11):
1339-46.
Discussion
2. Koshiba A, Koshiba H, Noguchi T, Iwasaku K,
Kitawaki J. Uterine perforation with omentum
incarceration after dilatation and evacuation/
The incidence of gastroschisis is 1/4000-6000
curettage: magnetic resonance imaging findings.
births, prenatal ultrasonography is very important Arch Gynecol Obstet. 2012 Mar; 285(3): 887-90.
for the detection of abdominal wall defects [4].
3. Mabula JB, Chalya PL, McHembe MD, Kihunrwa A,
Antenatal diagnosis can be made by prenatal
Massinde A, Chandika AB, et al. Bowel perforation
sonography and elevated maternal serum AFP levels. secondary to illegally induced abortion: a tertiary
Prenatal ultrasonography is very important for the hospital experience in Tanzania. World J Emerg Surg.
detection, identification, and follow-up of abdominal 2012 Sep 1; 7(1): 29.
wall defects. Gastroschisis is usually detected in the
4. Holland AJ, Walker K, Badawi N; Gastroschisis: an
second trimester by anomaly scan and by trans update. Pediatr Surg Int. 2010 Sep; 26(9): 871-8. Epub
vaginal sonography, it can be diagnosed as early as 2010 Aug 5.
12 weeks and has 70-72% detection rates [5]. If one
5. Bonilla-Musoles F, Machado LE, Bailão LA, Osborne
sees intestines coming out in the vagina, the first NG, Raga F. Abdominal wall defects: two- versus
possibility which is thought is of the uterine three-dimensional ultrasonographic diagnosis. J
perforation. In the present case the fetal intestines Ultrasound Med. 2001; 20(4): 379-89.

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Indian Journal of Obstetrics and Gynecology
51
Volume 4 Number 1, January - April 2016

Pseudomyxoma Peritonei or Jelly Belly – Varied Presentations

Joylene D. Almeida*, Ganesh Bongale**, Sujaya V. Rao***

Abstract interesting and varied presentations of PMP


( pseudomyxomaperitonei ) that were seen
over a period of three years in a tertiary
Pseudomyxomaperitonei is a rare institute and their management.
gynaecological condition characterised
by mucinous ascites. It has been
described as the presence of Case Series
gelatinous ascites and implants that
involve the peritoneal surfaces and
omentum. Though essentially Case 1
associated with mucinous A 55 year old postmenopausal lady ,
cystadenomas of the appendix and presented with abdominal bloating and
the ovaries , the proliferative nature distension since two months , that kept
and gross mucinous ascites progressively increasing. She did not have
associated with PMP demand the any associated bowel or bladder difficulties
need for an optimal debulking and also did not show any features of fever ,
surgery. Newer modalities of jaundice or breathlessness. She was
treatment for PMP are still being tachyapneic on examination and other vitals
studied, intra peritoneal were normal. It was noted that she had a
chemotherapy has been found to be vague yet large palpable abdominal mass
the most useful after debulking extending from the pelvis to both the iliac
surgery, to prevent recurrence. fossa. The borders of the abdominopelvic
Keywords: Pseudomyxoma mass could not be differentiated. The uterus
Peritonei; Jelly Belly; Mucinous and bilateral adnexa felt unusually normal
Ovarian Tumours. in position and consistency.
Her haematological work up was normal
Introduction and tumour marker was as follows : CA 125
: 43.6 IU
An ultrasound and CT revealed bilateral
Pseudomyxomaperitoneiis a rare
cystic masses right side 11cm x 17 cm and
gynaecological condition which was
left side 11 x 9 cm with multiple septations ,
first described by Werth, as the
*Assistant Professor and displacing the bowel on both sides. Mild
Consultant, **Department presence of gelatinous ascites and
omental thickening was noted and an
of Obstetrics and implants that involve the peritoneal
impression of a malignant cysic ovarian mass
Gynaecology, Department surfaces and omentum. 1 In the
of Pathology, Father Muller was made.
western world the average incidence
Medical College,
is 1 to 2 million per year. Mucinous The RMI ( risk of malignancy scoring ) for
Mangalore.
tumours of the ovary can very often the patient was 392.4. This suggested moderate
present as pseudomyxomaperitonei risk of malignancy , intermediate chances of
Joylene Diana DAlmeida survival and the need for intervention of an
Assistant Professor and
and these tumours are often labelled
Consultant, Department of as mucinous low malignant oncosurgoen with the gynaecologist.
Obstetrics and Gynaecology potential ( LMP ) tumours. It is also The patient was posted for a staging
Father Muller Medical associated with mucinous cysts of
college hospital, Mangalore, laparotomy. Intra operatively the abdominal
Karnataka-575002.
the appendix and rarely with cavity was distended with mucin. On further
E-mail: malignant cystadenomas. examination bilateral ovaries were enlarged
joylene16@yahoo.com and cystic of about 11cm x 9 cm masses and
This case report deals with four

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of Obstetrics LtdGynecology / Volume 4 Number 1 / January - April 2016
Joylene D. Almeida et. al. / Pseudomyxoma Peritonei or Jelly Belly – Varied Presentations
52

m uc in w a s fo u nd o ve r t he a p pe nd i x a n d Post operative course of the patient was uneventful


omentum. A total abdominal hysterectomy with and histopathology confirmed the diagnosis of a
bilateral salphingo ophorectomy was done. In mucinous cystadenoma.This case of PMP was
addition an appendicectomy and infracolic associated with a benign ovarian neoplasm.
omentectomy was done.

Case 2
A 48 year old male patient presented with
abdominal distention since 1 yrassociated with vague
abdominal pain . He had a significant past historypf
undergoing surgery for mucinous cystadenoma of
appendix with PMP 11yrs prior. When he was
examined he was found to have multiple , firm masses
in epigastrium , right iliac fossa and hypogastrium.
A CT scan revealed the following: CT scan- Multiple
cystic masses with septations involving the mesentry,
omentum, lesser sac and perigasrtium indenting the
gastric wall and scalloping the body and the tail of the
Fig. 1: Mucin found in the abdominal cavity
pancreas. Exploratory laparotomy, suboptimal
debulking of the mucin and a right hemicolectomy was
done. Nodular mucoid cysts were found in the colon
and mucoid cystic lesions in the hepatic flexure.

Fig. 4: Specimen of Hemicolectomy with mucin and nodular


mucoid cysts

Fig. 2: Mucin stained bowel and appendix

Fig. 5: Histology showing fibrosis in the bowel wall with mucin


deposits

Postoperatively , the patient recovered well. The


histology confirmed the benign nature of the disease.
In this casepseudomyxomaperitonei was
Fig. 3: Specimen of Uterus, bilateral ovarian masses and omentum associated with mucinous cysts of the colon.
Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Joylene D. Almeida et. al. / Pseudomyxoma Peritonei or Jelly Belly – Varied Presentations
53

Case 3
A 68 year old postmenopausal lady presented with
progressivedistention of abdomen since 3 weeks. He
also had a past history of pseudomyxomaperitonei
and was operated 3 yrs back for the same. When
examined he appeared to have gross ascites and a
fluid thrill could be elicited.
An ultrasound of the abdomen gave the following
impression: Gross ascites with fluid collection causing
scalloping of the diaphragmatic surface of the liver.
On followup a CT Scan was done and it showed
gross ascites with omentalthickening and also fluid
collection along the diaphragmatic surface causing
scalloping. Following these reports a provisional
diagnosis of Pseudomyxomaperitoneiwas made. Fig. 8: Magnified view: Mucin globules

Case 4
A 69 year old male presented to the ER with pain
abdomen and fever since 3 days. On examination he
had diffuse abdominally tenderness and a clinical
impression of acute colitis was made. He had a past
history of diabetes mellitus. A CT scan of the abdomen
showed multiple pockets of free intraperitoneal air
and peripherally enhancing pelvic collection with
air-fluid levels with ascites.
Patient was prepared for an emergency laparotomy.
Intra operatively,multiple peritoneal, omental
mucinous deposits over the bowel. There was also
thick purulent fluid collection and it was found
Fig. 6: Fluid collection along the diaphragmatic surface causing
scalloping dilated appendix with perforation. A
resectionanastamosis of tumor with segment of ileum
Folllowing investigations the patient underwent a was done.TheCytokeratin profile showed a positivity
laparotomy. Further a total abdominal hysterectomy of CK 20.
,omentectomy and debulking of mucin was done.
Histopathology showed diffuse areas of fibrosis and Post operative histopathology confirmed the
mucin filled globules in the omentum. diagnosis of pseudomyxomaperitonei.

Cytokeratin profile showed negativity for CK-7. In this case PMP was associated with mucinous
which is a marker for ovarian tumors. In this case adenoma of the appendix, that presented with
PMP was associated with mucinous omental perforation.
deposits and benign ovarian tumours.

Fig. 7: Omental thickening with mucin. Fig. 9: Peritoneal deposits of mucin

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Joylene D. Almeida et. al. / Pseudomyxoma Peritonei or Jelly Belly – Varied Presentations
54

abdominal surfaces that absorb peritoneal fluid (such


as the greater omentum and the undersurfaceof the
diaphragm) are coated by these tumor cells. These
tumour cells do not invade visceral tissue but only
extensive proliferate on the surface. This leads to gross
ascites in PMP and minimal visceral invasion. Some
authors also suggest mucinous metaplasia in the
peritoneal mesothelium to be a cause [4].
The most common presenting symptom ofPMP is
abdominal distension that progresses rapidly over a
short duration. Other symptoms could be of
abdominal pain, fever, vomiting, anorexia and weight
loss. All four cases in our series presented with
abdominal distension. Its median age of onset has
been noted to be 55 years and the male to female ratio
of occurrence of pseudomyxomaperitonei is 7:3.
We noted that two of our cases were in
Fig. 10: Perforated appendix postmenopausal women and two were in males above
the age of 40.
An exploratory laparotomy is the only key to a
diagnosis and confirmation of PMP. However this
condition should be suspected in patients when
radiologically there is evidence of distended abdomen
with air fluid levels, displacing the bowel or scalloping
the diaphragm are seen and the patient is stable. No
laboratory tests have found to be diagnostic though
CT scan can be of great help in clinching the diagnosis.
As the disease progresses rapidly , a good number
of patients present with emergency obstructive
symptoms and require an emergency debulking
surgery.
The mainstay of treatment for pseudomyxoma
peritonei remains cytoreductive surgery, removing the
primary disease, ie, oophorectomy and/ or total
abdominal hysterectomy, followed by removal of
Fig. 11: Histology showing mucn deposits beneath the epithelium
mucinous nodules from the omentum and peritoneal
Discussion surfaces. Appendectomy must be done and submitted
for through sampling by microscopic analysis [2].
Newer modalities of therapy include laser
Pseudomyxomaperitonei means false mucinous cauterisation of peritoneal implants, peritoneal
tumor of the peritoneum. It is most commonly applied stripping, adjuvant mucolytic agents like dextran
to a slowly progressive disease process characterized sulphate, photodynamic therapy and radiotherapy.
by copious amounts of mucus that, over time, fills the These however have not been proven to be of great
peritoneal cavity. Associated tumors are not use and are still in the phase of research [5].
considered biologically aggressive because it does not
invade or metastasize, although it is a deadly process.2 Cisplatin-based regimens have become the
standard of treatment in cases of ovarian epithelial
Psuedomyxomaperitonei is most commonly neoplasms and researchers have reported using
associated with benign, borderline or malignant single cisplatin or cisplatinum-based regimens to
mucinous tumors of the ovary and appendix and treat pseudomyxoma. However the efficacy of these
rarely with mucinous tumors of the urachus, bowel, modalities in preventing recurrence is questionable.
pancreas and common bile duct. 3 Two of our patients underwent revision surgery after
The etiopathogenesis is explained by the “ being diagnosed previously with PMP and were
redistribution phenomenon” which suggests that cases of recurrence.

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Joylene D. Almeida et. al. / Pseudomyxoma Peritonei or Jelly Belly – Varied Presentations
55

Intra peritoneal chemotherapy is a popular method Newer methods to tackle its recurrence are still being
used in the treatment of PMP. Though varying amount researched.
of success in preventing recurrence has been noted, it
has a large number of side effects like abdominal pain,
seizure, neutropenia and thrombocytopenia. References
Patients with ovarian tumors of low malignant
potential have a significantly better prognosis than 1. Werth R. Pseudomyxomaperitonei. Arch Gynakol.
patients with adenocarcinoma. The overall 5- and 1884; 24: 100-18.
10- year survival rates for patients with borderline 2. ThanasakSueblinvong et al. Thai Journal of Obstetrics
tumors are 85-90% and 75-80% [6,7]. and Gynaecology June 2003; 15: 123-128.
3. Jones DH. Pseudomyxomaperitonei. Br J ClinPract.
1965; 19: 675-9.
Conclusion
4. Sandenbergh HA, Woodruff JD. Histogenesis of
pseudomyxomaperitonei. Review of 9 cases.
Pseudomyxomaperitonei or jelly belly is a rare ObstetGynecol. 1977; 49: 339-45.
gynaecological condition and there is a lot of debate 5. Mann WJ, Wagner J, Chumas J, Chalas E. The
revolving around its origin and optimum treatment. management of pseudomyxomaperitonei. Cancer.
It is commonly associated with benign mucinous 1990; 66: 1636- 40.
cystadenoma of the ovary and intestine. Though 6. Kaern J, Trope CG, Abeler VM. A retrospective study
essentillay benign, it can be associated with of 370 borderline tumors of the ovary treated at the
malignancy and the aggressive nature of spread Norwegian Radium Hospital from 1970 to 1982. A
makes it a condition to watch out for. review of clinicopathologic features and treatment
modalities. Cancer. 1993; 71: 1810-20.
An optimal debulking procedure done by skilled
surgical expertisecould be the key to preventing 7. Rice LW, Berkowitz RS, Mark SD, Yavner DL, Lage
JM. Epithelial ovarian tumors of borderline
recurrence in PMP. Post operative intra peritoneal
malignancy. GynecolOncol. 1990; 39: 195-8.
chemotherapy is a recommended treatment option.

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
56

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Indian Journal of Obstetrics and Gynecology
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Volume 4 Number 1, January - April 2016

Digoxin Therapy for Fetal Supraventricular Tachycardia


Diagnosed at 29 Weeks Gestation

Nitisha Lath*, Savita Bansal**, Pratibha Singh***

Abstract clinically important entity is- either an


automatic focus, provoking atrial
contractions ata rate faster than the sino-
Fetal Supraventricular tachycardia atrial node or the re-entry mechanism in
(SVT), though rare, is the most which there is a circular electrical current
commonly encountered clinically running between a fast conducting assessor
significant tachycardia in the fetus. pathway, the ventricle, atrioventricular node
When SVT is sustained, congestive and atria in either direction.
heart failure and fetal hydrops may Supraventricular tachycardiamay bepart of
ensue, due to both systolic and a cardiac malformation such as Ebstein’s
diastolic dysfunction. Sonographic anomaly but in majority it is found to bethe
diagnosis is usually incidental sole pathology. The usual cardiac contraction
during the second or third trimester. rate in SVT is 220-280 bpm, but faster rates
Treatment goals are cardioversion to than this have been described.5 When such
sinus rhythm and reversal of cardiac rates are sustained, diastole is shortened
dysfunction [1]. Digoxin has been significantly, thus decreasing the atrial and
successfully used to treat fetal SVT, ventricular filling time and increasing
when therapy with digoxin fails systemic venous volume load and central
alternative therapies may be used venous pressure [6]. This is accompanied by
with equivocal results [2]. There is reversible systolic dysfunction. Insufficient blood
no clear consensus regarding the supply through coronary arteries to the
best drug-treatment regimens for myocardium during diastole causes relative
fetal SVT. Digoxin has been ischaemia and may cause myopathy. Cardiac
recommended as first-line therapy in dilatation impairs contractility according to
cases of SVT with cardiac failure, but Starling’s law and dilatation of annulus fibrosus
recent evidence suggests that the causes atrio-ventricular valve regurgitation.
transplacental passage may be These changes has been referred to as
impaired in the presence of hydrops ‘tachycardia induced cardiomyopathy’ [7]. The
[3]. Other agents such as flecainide and resulting heart failure presents as fetal hydrops.
sotalol have been tried as first-line Diagnosis is generally incidental in second or
agents but with adverse events [4]. third trimester.
We here describe a case of fetal The treatment goal is to break the vicious
*Senior Resident, supraventricular tachycardia cycle by slowing the heart rate and
***Additional Professor, without hydrops diagnosed
Department of Obstetrics
synchronising atrial and ventricular
antenatally at 29 weeks of contractions. This can be achieved by blocking
and Gynaecology, All India
Institute of Medical gestationand managed with oral automacity of ectopic rapidly pacing focus and
Sciences, Jodhpur. digoxin. blocking fast conduction via the assessor
**Consultant, Soni Manipal
Hospital, Jaipur.
pathway. Successful treatment leads to sinus
rhythm, disappearance of hydrops and reversal
Introduction
Pratibha Singh of cardiac dysfunction and ultimate to birth of a
Addl Prof, Department of alive fetus.
Obstetrics & Gynecology,
AIIMS jodhpur. Basni Supraventricular tachycardia
Industrial Area, Phase-2, (SVT) is a commonly encountered, Case Report
Jodhpur, Rajasthan 342005. clinically significant sustained
E-mail:
tachycardiain the fetus. The basic
drpratibha69@hotmail.com
underlying mechanism for this A 25 Year old 3rd gravida with previous
©Red
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JournalPublication Pvtand
of Obstetrics LtdGynecology / Volume 4 Number 1 / January - April 2016
Nitisha Lath et. al. / Digoxin Therapy for Fetal Supraventricular Tachycardia Diagnosed at 29 Weeks Gestation
58

one term delivery and one abortion at 29 weeks had a full term normal delivery, gave birth to a female
gestation came for routine antenatal check-up and child, who is 5 year old without any cardiovascular
was found to have fetal tachycardia, with heart beats complication.
of 220 bpm; which was confirmed by sonography in On admission fetal heart rate was 220 bpm by
M mode. Antenatal period was apparently fetal doppler. Fetal Echo showed a structurally
uncomplicated till 29 weeks, and was on regular normal heart with a fetal heart rate of 228 bpm on M
antenatal visits. There was no maternal or family mode, and a 1:1 atrioventricular conduction with
history of cardiac disease and patient had no fever, mild right atrial and right ventricular dilatation and
anaemia, intake of any drug or excessive caffeine reversal in ductus venosus (Fig 1-4).
intake or thyrotoxicosis. In her first pregnancy, she Maternal baseline 2 D Echo and ECG, serum

Fig. 1: M-mode showing FHR 228 BPM with 1:1 A-V conduction

Fig. 2: Mild right ventricular dilatation

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Nitisha Lath et. al. / Digoxin Therapy for Fetal Supraventricular Tachycardia Diagnosed at 29 Weeks Gestation
59

Fig. 3: Structurally normal heart

Fig. 4: Reversal in ductus venosus

electrolytes and thyroid profile were done after emergency caesarean section at 39 weeks for foetal
cardiologist consultation. All the maternalparameters distress (Bradycardia with late decelerations on
were found to be in normal limits, so she was started CTG)(Fig.5 ) and delivered a male baby of 3.5 kg,
on oral digoxin with a dose of 0.25 mg BD. Resolution cried immediately after birth with an APGAR score
of tachyarrhythmia was achieved in 72 hours and of 7 and 9 at 1 and 5 minutes. Neonatal Echo was
fetal heart rate reduced to 152 bpm. This dose of 0.25 done which showed structurally normal heart with
mg digoxin BD was continued for a week. Normal no episode of SVT. Neonatal heart rate remained
sinus rhythm of fetus was achieved between 130 between 130 to 150 bpm.
to 150 bpm and there was no recurrence of After a period of neonatal cardiac monitoring the
tachyarrythmia. Dose of digoxin was then reduced mother and her baby was discharged on 5th day in
to 0.25 mg every 24 hours andpatient was kept on stable condition. The neonate on follow up was
fetal surveillance with weekly follow up with no healthy 28 days after birth without recurrence of
recurrence of SVT till delivery. She underwent an arrhythmia.
Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Nitisha Lath et. al. / Digoxin Therapy for Fetal Supraventricular Tachycardia Diagnosed at 29 Weeks Gestation
60

Fig. 5: CTG showing baseline FHR 150 bpm followed by bradycardia and late decelerations

Discussion tract” limb occurs outside the atrioventricular node.


This pathway directly connects the atria and ventricle
and is known as Wolff-Parkinson-White Syndrome.
Fetal tachycardia was first recognised in 1930 by The third mechanism of SVT is automatic atrial
Hyman et al, which is a condition occurring in tachycardia resulting from discreet pacemaker within
approximately 0.4-0.6% of all pregnancies.8 Fetal the atrium outside the sinoatrial node. Atrial flutter
supraventricular tachycardia is a rare but most and fibrillation results from “circular
commonly encountered fetal cardiac arrhythmia in pathway”within the atria themselves ruled out in an
pregnancy that may be associated with adverse indirect fashion.
perinatal outcome. Excessive caffeine, smoking,
drugs, fetal cardiac malformation, and extracardiac There is no proper guidelines regarding start of
malformations like diaphragmatic hernia may therapy and mode of application, so management
must be individualised [3]. Digoxin is widely accepted
contribute to frequent fetal premature atrial
as anti arrhythmic drug of choice in non-hydropic
contractions which may progress to unrelenting
fetus [9]. Digoxin is cardiac glycoside that partially
tachyarrhythmia.
blocks conduction through atrioventricular node [10].
There are three forms of abnormal conduction It terminates “circular movement”within re-entrant
defects which may lead to supraventricular circuits by prolonging the refractory phases that the
tachycardia. First is atrioventricular nodal re-entrant aberrant wave of excitation reaches depolarised
tachycardia. Extrasystole generates an electric tissue. Recent studies show a high fetal mortality rate
waveform of depolarisation which arrives at the AV of 27% to 50% without treatment as compared to 5%
node. “Fast tract” within the AV node is refractory to to 10 % when anti arrhythmic was administered [11].
arriving wave while the “slow tract” depolarises Second line medication as sotalol, depresses AV nodal
again. At precise time the “fast tract” in AV node conduction, produce an increase in duration of action
become repolarised and accepts the waveform from potential and lengthen the effective and absolute
“slow tract” and depolarizes in retrograde fashion, refractory period [12].
re-entering the atrial tissue. Depolarisation occurs Potential pro-arrhythmic action of sotalol remain
through the fastest conduction pathway available, a source of concern and excludes it as a drug of first
and so this “circular movement” predominates over choice in uncomplicated SVT. In case of severe
the slower impulses generated by sinoatrial node. hydrops and poor cardiac function, due to its negative
Second is atrioventricular re-entrant tachycardia, ionotropic effect , the drug should always be
same “circular movement” is established, but “fast administered in association with digoxin. Flecainide,

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Nitisha Lath et. al. / Digoxin Therapy for Fetal Supraventricular Tachycardia Diagnosed at 29 Weeks Gestation
61

another anti-arrhythmic which depresses conduction 2. Lisa M Jones,Sara H Garmel. Successful digoxin
throughout myocardium and prolongs the refractory therapy for fetal supraventricular tachycardia.
period is mainly used in fetal SVT complicated by obstetrics and gynaecology. 2001; 98: 921-23.
hydrops. Amiodarone which prolongs repolarisation 3. Strasburger JF. Fetal arrhythmias. Progr Pediatr
has gained popularity. However adverse effects are Cardiol. 2000; 11: 1-17.
of concern (mainly neonatal hypothyroidism) and 4. Jaeggi ET, Nii M. Fetal brady- and tachyarrhythmias:
hence should be used as second line therapy [13]. New and accepted diagnostic and treatment
methods. Semin Fetal Neonatal Med 2005;10:504-14.
The management depends upon the age of
gestation and presence of hydropic features. In non 5. Lingman G, Ohrlander S, Ohlin P. Intrauterine
hydropic foetus with fetal lung maturity (>34 weeks digoxin treatment of fetal paroxysmal tachycardia.
gestation) delivery with evaluation of neonate can be Case report. Br J ObstetGynaecol. 1980.
considered. Combination drug therapy reduces the 6. Gembruch U, Krapp M, Baumann P. Changes of
dose, increases effectiveness and decreases side effect venous blood flow velocity waveforms in fetuses
in hydropic infant. Maternal administered oral drug with supraventricular tachycardia. Ultrasound Obstet
Gynecol. 1995; 5: 394–399.
therapy crosses transplacentally to the foetus and has
anti arrhythmic action. Oral digoxin avoids the need 7. Krapp M, Gembruch U, Baumann P. Venous blood
of therapeutic drug-level monitoring, which is flow pattern suggesting tachycardia-induced
required in intravenous therapy. Direct fetal therapy ‘cardiomyopathy’ in the Fetus. Ultrasound obstet
gynecol. 1997; 10: 32-40.
should only be usedin cases of tachycardia
complicated with hydrops resistant to transplacental 8. Rana Y.S.,Sodhi B, Kochar SPS, Arora D. Successful
multidrug therapy. digoxin therapy of fetalsupraventricular tachycardia.
South Asian Federation of Obstetrics and
The optimal duration of treatment of prenatally Gynaecology. Jan-Apr 2009; 1(1): 44-46.
diagnosed supraventricular tachycardia remains
9. Simpson JM, Sharland GK. Fetal tachycardias:
undetermined. Most reported cases treatment was management and outcome of 127 consecutive cases.
continued until birth, newborns are treated with beta Heart. 1998; 79: 576–581.
blocker if SVT recurs early after birth or is easily
10. Goodman DJ, Rossen RM, Cannom DS, Rider AK,
inducible during transesophageal electrophysiologic Harrison DC. Effect of digoxin on atrioventricular
study [4]. conduction. Studies in patients with and without cardiac
Postnatal recurrence of arrhythmia has been autonomic innervation. Circulation1. 975; 51: 251–256.
described in approximately 50% of neonates [14]. 11. Strasburg JF, Cheulkar B, Wichman HJ. Perinatal
Some favour prophylactic continuation of drug during arrhythmias: diagnosis and management. Clin
first 6-12 months of life to prevent recurrence [15]. In Perinatol. 2007; 34: 627-52.
10-20% of cases, SVT will persist beyond first year of 12. V Samuel Rajadurai, Samuel Menahem. Fetal
life [14]. arrhythmias: a 3-year experience. Australian and
New Zeland Journal of Obstetrics and Gynaecology.
Timely diagnosis, ruling out other cardiac and non
2008; 32: 28-31.
cardiac problems by appropriate investigations; and
timely and correct therapynot only saves the fetus 13. Pradhan M, Manisha,singh r. Amiodarone in
but also gives a good prognosis to these fetuses treatment of supraventricular tachycardia. Fetal
Drug Ther. 2006; 21: 72-76.
14. Hansmann M, Gembruch U, Bald R, Manz M, Redel
References DA. Fetal tachyarrhythmias: transplacental and
direct treatment of the fetus – a report of 60 cases.
Ultrasound Obstet Gynecol. 1991; 1: 162-170.
1. Merriman JB, Gonzalez JM, Rychik J. Can sotalol
15. Simpson J. Fetal arrhythmia. In Textbook of fetal
and digoxin therapy for fetal supraventricular
cardiology,Allan L, Hornberger L, Sharland G (eds).
tachycardia and hydrops be successful? J Reprod med.
Greenwich Medical Media:London. 2000; 423-451.
2008; 53(5): 357-59.

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
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image can be reduced by decreasing the actual height 8) Source(s) of support in the form of grants,
and width of the images (keep up to 400 pixels or 3 equipment, drugs, or all of these;
inches). All image formats (jpeg, tiff, gif, bmp, png,
9) Acknowledgement, if any; and
eps etc.) are acceptable; jpeg is most suitable.
l0) If the manuscript was presented as part at a
Legends: Legends for the figures/images should
meeting, the organization, place, and exact date
be included at the end of the article file.
on which it was read.
If the manuscript is submitted online, the
contributors’ form and copyright transfer form has
to be submitted in original with the signatures of Abstract Page
all the contributors within two weeks from The second page should carry the full title of the
submission. Hard copies of the images (3 sets), for manuscript and an abstract (of no more than 150
articles submitted online, should be sent to the words for case reports, brief reports and 250 words
journal office at the time of submission of a revised for original articles). The abstract should be
ma nuscript. Editorial office: Re d Flower structured and state the Context (Background), Aims,
Publication Pvt. Ltd., 48/41-42, DSIDC, Pocket-II, Settings and Design, Methods and Materials,
Mayur Vihar Phase-I, Delhi – 110 091, India, Statistical analysis used, Results and Conclusions.
Phone: 91-11-22754205, 45796900, Fax: 91-11- Below the abstract should provide 3 to 10 keywords.

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Guidelines for Authors
64

Introduction mechanisms, clinical research). Do not repeat in


State the background of the study and purpose of detail data or other material given in the Introduction
the study and summarize the rationale for the study or the Results section.
or observation.
References
Methods List references in alphabetical order. Each listed
The methods section should include only reference should be cited in text (not in alphabetic
information that was available at the time the plan order), and each text citation should be listed in the
or protocol for the study was written such as study References section. Identify references in text, tables,
approach, design, type of sample, sample size, and legends by Arabic numerals in square bracket
sampling technique, setting of the study, description (e.g. [10]). Please refer to ICMJE Guidelines
of data collection tools and methods; all information (http://www.nlm.nih.gov/bsd/uniform_
obtained during the conduct of the study belongs in requirements.html) for more examples.
the Results section.
Reports of randomized clinical trials should be Standard journal article
based on the CONSORT Statement (http://www. [1] Flink H, Tegelberg Å, Thörn M, Lagerlöf F. Effect
consort-statement. org). When reporting experiments of oral iron supplementation on unstimulated
on human subjects, indicate whether the procedures salivary flow rate: A randomized, double-blind,
followed were in accordance with the ethical placebo-controlled trial. J Oral Pathol Med 2006; 35:
standards of the responsible committee on human 540-7.
experimentation (institutional or regional) and with
the Helsinki Declaration of 1975, as revised in 2000 [2] Twetman S, Axelsson S, Dahlgren H, Holm AK,
(available at http://www.wma.net/e/policy/l 7- Källestål C, Lagerlöf F, et al. Caries-preventive effect
c_e.html). of fluoride toothpaste: A systematic review. Acta
Odontol Scand 2003; 61: 347-55.

Results
Article in supplement or special issue
Present your results in logical sequence in the text,
tables, and illustrations, giving the main or most [3] Fleischer W, Reimer K. Povidone iodine antisepsis.
important findings first. Do not repeat in the text all State of the art. Dermatology 1997; 195 Suppl 2: 3-9.
the data in the tables or illustrations; emphasize or
summarize only important observations. Extra or
Corporate (collective) author
supplementary materials and technical details can
be placed in an appendix where it will be accessible [4] American Academy of Periodontology. Sonic
but will not interrupt the flow of the text; alternatively, and ultrasonic scalers in periodontics. J Periodontol
it can be published only in the electronic version of 2000; 71: 1792-801.
the journal.
Unpublished article
Discussion [5] Garoushi S, Lassila LV, Tezvergil A, Vallittu
Include summary of key findings (primary PK. Static and fatigue compression test for particulate
outcome measures, secondary outcome measures, filler composite resin with fiber-reinforced composite
results as they relate to a prior hypothesis); Strengths substructure. Dent Mater 2006.
and limitations of the study (study question, study
design, data collection, analysis and interpretation);
Personal author(s)
Interpretation and implications in the context of the
totality of evidence (is there a systematic review to [6] Hosmer D, Lemeshow S. Applied logistic
refer to, if not, could one be reasonably done here regression, 2nd edn. New York: Wiley-Interscience; 2000.
and now?, What this study adds to the available
evidence, effects on patient care and health policy,
Chapter in book
possible mechanisms)? Controversies raised by this
study; and Future research directions (for this [7] Nauntofte B, Tenovuo J, Lagerlöf F. Secretion and
particular research collaboration, underlying composition of saliva. In: Fejerskov O, Kidd EAM,
Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Guidelines for Authors
65

editors. Dental caries: The disease and its clinical Type or print out legends (maximum 40 words,
management. Oxford: Blackwell Munksgaard; 2003. p. 7-27. excluding the credit line) for illustrations using
double spacing, with Arabic numerals
corresponding to the illustrations.
No author given
[8] World Health Organization. Oral health
surveys - basic methods, 4th edn. Geneva: World Sending a revised manuscript
Health Organization; 1997. While submitting a revised manuscript,
contributors are requested to include, along with
single copy of the final revised manuscript, a
Reference from electronic media photocopy of the revised manuscript with the
[9] National Statistics Online—Trends in suicide changes underlined in red and copy of the comments
by method in England and Wales, 1979-2001. with the point to point clarification to each comment.
www.statistics.gov.uk/downloads/theme_health/ The manuscript number should be written on each
HSQ 20.pdf (accessed Jan 24, 2005): 7-18. Only of these documents. If the manuscript is submitted
verified references against the original documents online, the contributors’ form and copyright transfer
should be cited. Authors are responsible for the form has to be submitted in original with the
accuracy and completeness of their references and signatures of all the contributors within two weeks
for correct text citation. The number of reference of submission. Hard copies of images should be sent
should be kept limited to 20 in case of major to the office of the journal. There is no need to send
communications and 10 for short communications. printed manuscript for articles submitted online.
More information about other reference types is
available at www.nlm.nih.gov/bsd/uniform_ Reprints
requirements.html, but observes some minor
deviations (no full stop after journal title, no issue or Journal provides no free printed reprints, however
date after volume, etc). a author copy is sent to the main author and
additional copies are available on payment (ask to
the journal office).
Tables
Tables should be self-explanatory and should not Copyrights
duplicate textual material.
The whole of the literary matter in the journal is
Tables with more than 10 columns and 25 rows copyright and cannot be reproduced without the
are not acceptable. written permission.
Table numbers should be in Arabic numerals,
consecutively in the order of their first citation in the
text and supply a brief title for each. Declaration

Explain in footnotes all non-standard A declaration should be submitted stating that the
abbreviations that are used in each table. manuscript represents valid work and that neither
this manuscript nor one with substantially similar
For footnotes use the following symbols, in this content under the present authorship has been
sequence: *, ¶, †, ‡‡, published or is being considered for publication
elsewhere and the authorship of this article will not
be contested by any one whose name (s) is/are not
Illustrations (Figures)
listed here, and that the order of authorship as placed
Graphics files are welcome if supplied as Tiff, EPS, in the manuscript is final and accepted by the co-
or PowerPoint files of minimum 1200x1600 pixel size. authors. Declarations should be signed by all the
The minimum line weight for line art is 0.5 point for authors in the order in which they are mentioned in
optimal printing. the original manuscript. Matters appearing in the
When possible, please place symbol legends below Journal are covered by copyright but no objection
the figure instead of to the side. will be made to their reproduction provided
permission is obtained from the Editor prior to
Original color figures can be printed in color at
publication and due acknowledgment of the source
the editor’s and publisher’s discretion provided the
is made.
author agrees to pay.

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
Guidelines for Authors
66

Abbreviations • Abbreviations spelt out in full for the first time.


Standard abbreviations should be used and be Numerals from 1 to l0 spelt out
spelt out when first used in the text. Abbreviations • Numerals at the beginning of the sentence spelt
should not be used in the title or abstract. out

Checklist Tables and figures


• Manuscript Title • No repetition of data in tables and graphs and
• Covering letter: Signed by all contributors in text.

• Previous publication/ presentations mentioned, • Actual numbers from which graphs drawn,
Source of funding mentioned provided.

• Conflicts of interest disclosed • Figures necessary and of good quality (color)


• Table and figure numbers in Arabic letters (not
Roman).
Authors
• Labels pasted on back of the photographs (no
• Middle name initials provided. names written)
• Author for correspondence, with e-mail address • Figure legends provided (not more than 40
provided. words)
• Number of contributors restricted as per the • Patients’ privacy maintained, (if not permission
instructions. taken)
• Identity not revealed in paper except title page • Credit note for borrowed figures/tables provided
(e.g.name of the institute in Methods, citing
previous study as ‘our study’) • Manuscript provided on a CDROM (with double
spacing)

Presentation and Format


Submitting the Manuscript
• Double spacing
• Is the journal editor’s contact information
• Margins 2.5 cm from all four sides current?
• Title page contains all the desired information. • Is the cover letter included with the manuscript?
Running title provided (not more than 50 Does the letter:
characters)
1. Include the author’s postal address, e-mail
• Abstract page contains the full title of the address, telephone number, and fax number for
manuscript future correspondence?
• Abstract provided: Structured abstract provided 2. State that the manuscript is original, not
for an original article. previously published, and not under concurrent
• Key words provided (three or more) consideration elsewhere?
• Introduction of 75-100 words 3. Inform the journal editor of the existence of any
similar published manuscripts written by the
• Headings in title case (not ALL CAPITALS).
author?
References cited in square brackets
4. Mention any supplemental material you are
• References according to the journal’s instructions
submitting for the online version of your article.
Contributors’ Form (to be modified as applicable
Language and grammar and one signed copy attached with the
manuscript)
• Uniformly American English

Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016
67
Revised Rates for 2016 (Institutional)
Title Frequency Rate (Rs): India Rate ($):ROW
Dermatology International 2 5000 500
Gastroenterology International 2 5500 550
Indian Journal of Agriculture Business 2 5000 500
Indian Journal of Anatomy 3 8000 800
Indian Journal of Ancient Medicine and Yoga 4 7500 750
Indian Journal of Anesthesia and Analgesia 3 7000 700
Indian Journal of Anthropology 2 12000 1200
Indian Journal of Biology 2 4000 400
Indian Journal of Cancer Education and Research 2 8500 850
Indian Journal of Communicable Diseases 2 8000 800
Indian Journal of Dental Education 4 4500 450
Indian Journal of Forensic Medicine and Pathology 4 15500 1550
Indian Journal of Forensic Odontology 2 4500 450
Indian Journal of Genetics and Molecular Research 2 6500 650
Indian Journal of Law and Human Behavior 2 5500 550
Indian Journal of Library and Information Science 3 9000 900
Indian Journal of Maternal-Fetal & Neonatal Medicine 2 9000 900
Indian Journal of Medical & Health Sciences 2 6500 650
Indian Journal of Obstetrics and Gynecology 3 7000 700
Indian Journal of Pathology: Research and Practice 3 11500 1150
Indian Journal of Plant and Soil 2 5500 550
Indian Journal of Preventive Medicine 2 6500 650
International Journal of Food, Nutrition & Dietetics 3 5000 500
International Journal of History 2 6500 650
International Journal of Neurology and Neurosurgery 2 10000 1000
International Journal of Political Science 2 5500 550
International Journal of Practical Nursing 3 5000 500
International Physiology 2 7000 700
Journal of Animal Feed Science and Technology 2 4100 410
Journal of Cardiovascular Medicine and Surgery 2 9100 910
Journal of Forensic Chemistry and Toxicology 2 9000 900
Journal of Microbiology and Related Research 2 8000 800
Journal of Orthopaedic Education 2 5000 500
Journal of Pharmaceutical and Medicinal Chemistry 2 16000 1600
Journal of Practical Biochemistry and Biophysics 2 5500 550
Journal of Social Welfare and Management 3 7500 750
New Indian Journal of Surgery 3 7100 710
Ophthalmology and Allied Sciences 2 5500 550
Otolaryngology International 2 5000 500
Pediatric Education and Research 3 7000 700
Physiotherapy and Occupational Therapy Journal 4 8500 850
Urology, Nephrology and Andrology International 2 7000 700

SUPER SPECIALITY JOURNALS

Indian Journal of Emergency Medicine 2 12000 1200


Indian Journal of Surgical Nursing 3 5000 500
Indian Journal of Trauma & Emergency Pediatrics 3 9000 900
International Journal of Pediatric Nursing 3 5000 500
Journal of Community and Public Health Nurisng 2 5000 500
Journal of Geriatric Nursing 2 5000 500
Journal of Medical Images and Case Reports 2 5000 500
Journal of Nurse Midwifery and Maternal Health 3 5000 500
Journal of Organ Transplantation 2 25900 2590
Journal of Psychiatric Nursing 3 5000 500
Psychiatry and Mental Health 2 7500 750

OPEN ACCESS JOURNALS

Global Research in Engineering 5000 500


Global Research in Food and Nutrition 5000 500
Global Research in Library and Information Science 5000 500
Global Research in Medical Sciences 5000 500
Global Research in Space Science 5000 500
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Indian Journal of Obstetrics and Gynecology / Volume 4 Number 1 / January - April 2016