This article introduces Suraksh, a mobile application that focuses on intensive intrapartum monitoring, shedding light on the novel concept of “distance monitoring”, incorporating the pressing need of the hour for complete digitalization. It aims to reduce the burden on under-resourced set-ups, improving the turn-over time, ensuring timely intervention and referrals along with strengthening our clinical database for retrospective and observational studies. It targets paperless documentation and patient care in the advent of the “new normal” of minimal contact in health care set-ups. While this application is in its pilot phase, it has shown promising compliance and acceptance at our tertiary center, Sri Ramachandra Institute of Higher Education and Research, amongst senior obstetricians, postgraduates, interns and nursing staff. We welcome and promote adoption and wider usage of this application across all tiers of obstetric care.

Background: Laparoscopic hysterectomy is a minimally invasive procedure with shorter operative time, decreased trauma, and less technical difficulty. However, the success of the procedure depends on various intrinsic and extrinsic factors. This study was done to evaluate the factors which influence the success of laparoscopic hysterectomy. Materials and methods: This retrospective record-based cross-sectional study was carried out among 100 participants who underwent laparoscopic hysterectomy for various indications in our tertiary care hospital. The demographic and clinical profiles of these participants were recorded. Particulars related to the success of the surgery including duration of surgery and hospital stay, infections, and other complications were recorded. Results: Our study showed that the duration of surgery and duration of hospital stay were significantly influenced by the parity. Multiparous women were more prone to longer duration of surgery and prolonged hospitalization. The observed difference was statistically significant (p < 0.05). Conclusion: It is essential to develop a scoring mechanism by which each case can be selected or rejected for laparoscopic hysterectomy considering various parameters. This may be carried out by further exploratory research on identifying the key factors which influence the success of the procedure.

Aim: • Evaluate the performance of first trimester combined screening (FTS) for Down's syndrome in singleton South Indian urban population. • Use local data to counsel our women and their families. Materials and methods: A retrospective study of singleton pregnancies who underwent the FTS from January 2013 to December 2015. Nuchal translucency scan and double marker were offered to all pregnant women who booked before 13 weeks 5 days gestational age. Pre- and posttest counseling were provided by consultants in obstetrics. Screen positive for Down's syndrome was taken as a posttest risk cut-off of 1:250 and/or NT >95th centile for gestation. The screen positives were offered a diagnostic test. Screen negatives were counseled about the low risk for Down's syndrome. The outcome of screening, diagnostic testing, and newborn phenotype and genotype were assessed. Results: Among 735 singleton pregnancies screened, 2 Down's syndrome fetuses were identified on diagnostic testing (among 13 screen positives). The detection rate with screening was 100%. There was a 1.5% false screen positive rate in singletons. There were no false-negatives during the study period. Conclusion: The NHS United Kingdom screening program targets a detection rate of 90% for a screen positive rate of 2% using a posttest risk cut-off 1 in 150 or NT >95th centile. First trimester Down's syndrome screening in this study of urban South Asian population had a 1.5% false-positive rate and 0% false-negative rate. The study analysis was based on a posttest risk cut-off of 1 in 250. All true screen positives had a risk cut-off of 1 in 150. Clinical significance: A risk cut-off of 1 in 150 appears to apply to our population when FTS is performed following the standards set by the fetal medicine foundation.

Aim: To estimate the optimal level of vaginal fluid creatinine to detect rupture of membranes (ROM). Materials and methods: A total of 300 pregnant women were recruited for the study. Group I consisted of 100 women with a diagnosis of ruptured amniotic membranes confirmed by sterile speculum examination. Group II consisted of 100 women in whom a diagnosis of ROM was suspected but not confirmed by speculum examination. Group III consisted of 100 pregnant women without any complaints taken as a control group. In all 300 women, vaginal fluid washing for creatinine sample was taken. The parameters (age, parity, gestational age at the time of sample collection, amniotic fluid index (AFI), and vaginal fluid creatinine) were compared with one-way analysis of variance (ANOVA) and ScheVe multiple comparison test. Receiver operating characteristic (ROC) curve analysis was used to establish an optimal cut-off concentration. Results: The optimal cut-off value of vaginal fluid creatinine to detect ROM arrived based on ROC curve analysis was ≥0.3 mg/dL. The mean vaginal fluid creatinine in group I was 1.097 mg/dL, in group II was 0.3 mg/dL, in group III was 0.068 mg/dL. This study demonstrates that vaginal fluid creatinine could accurately diagnose a ROM with a sensitivity, specificity, positive predictive value, and negative predictive value of 98.36, 100, 100, and 97.14%, respectively.

Objective: Preterm labor (PL) is the onset of labor pains before 37 weeks and it eventually leads to preterm birth. Preterm birth accounts for 75% of perinatal mortality and more than half the long-term morbidity.¹ Various studies have been done on the ratios of blood cell subtypes like neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) to find out if they can be used as a predictor for diseases in which chronic low-grade inflammation is involved. Inflammation is one of the components in the initiation of PL, so markers of inflammation can be used as a potential predictor of PL. We aimed to study if any association exists between PL and the various blood cell subtypes like NLR, LMR, and PLR in a group of women who were hospitalized with the diagnosis of PL. Materials and methods: A total of 80 pregnant women were enrolled in the study. Forty cases who were admitted in the maternity ward with the diagnosis of PL and 40 gestational age-matched controls who came for routine antenatal care. The cases were further followed and divided into two groups according to gestational age at which they delivered, i.e., pregnant with PL who delivered <37 weeks and pregnant with PL who delivered at ≥37 weeks. The sociodemographic profile and the biochemical parameters of all the groups were compared. Results: The study showed that the neutrophils were significantly elevated in pregnant women with PL and lymphocytes reduced. However, the ratios like NLR, LMR, and PLR were not found to be significantly raised in pregnant women with PL when compared with control. Conclusion: Although we found a significant elevation of neutrophils and a significant reduction of lymphocytes in our study but to use these blood count parameters as a predictor of PL needs more validation. Further measurement of the ratio of subtypes of blood cells like NLR, LMR, and PLR was comparable in both cases and controls.

Introduction: Ureteral injuries have been recognized as a potential complication of gynecological surgical procedures since the inception of our discipline; incidence ranging from 0.5 to 1.5% and morbidity associated with it may be serious. Traditionally, most ureterovaginal fistulas have been repaired by ureteroneocystostomy. Open ureteral reimplantation is a potentially morbid surgical procedure. Endourological techniques are highly successful in treating posthysterectomy ureteral injuries. The objective of this presentation is to relate our experience and result with laparoscopic ureteral reimplantation. Materials and methods: Five patients with complaints of leakage of urine per vaginum postoperatively on day 12–24 (post-TLH) presented for treatment. After diagnosis, treatment of ureterovaginal fistula was performed completely laparoscopically. Laparoscopic ureteral reimplantation was done. Results: No major intraoperative or postoperative complications were encountered. The operating room time was 120 minutes (range 120–240 minutes). The average hospital stay was 4 days. Patients had a successful outcome defined as no evidence of radiographic obstruction and no clinical complaints of persistent renal colic or any other urinary symptoms. Conclusion: Our experience demonstrates that laparoscopic ureteral reimplantation is an effective minimally invasive treatment option for distal ureteral strictures.

Introduction: Intrahepatic cholestasis of pregnancy (ICP), also described as obstetric cholestasis is the second most common cause of icterus in pregnancy. Although not fully understood, proposed theories indicate it could be due to decreased bile flow through the liver and its poor excretion, leading to increased levels of colic and chenodeoxycholic acid. It is known to be associated with adverse maternal and fetal outcomes. Materials and methods: The data were collected by retrospective record review for the past 2 years and the information collected included obstetrical outcomes and complications in mothers with ICP admitted in a tertiary care hospital. Results: Among the 64 pregnant women admitted with ICP, 56.2% of women were booked pregnancies and 47 (73.4%) were in the age groups of 21–30 years. Most women presented with ICP at gestational ages of >37 weeks 51 (79.9%), with the onset of symptom around 33–36 weeks of gestation 21 (32.8%). Common complications encountered were severe preeclampsia and gestational diabetes mellitus 6 (9.3%). Among neonates, meconium-stained liquor (MSL) and low appearance pulse rate grimace activity respiration (APGAR) at 1 minute were common complications. Mothers with ICP were induced with PGE2 (dinoprostone) and 54.7% delivered vaginally. Pregnancies induced with PGE2 and PGE1 (misoprostol) had a higher chance of undergoing lower segment cesarean section (LSCS) 19 (29.6%). Conclusion: Mothers with ICP should be screened antenatally for preeclampsia. The delivery team should be prepared to manage meconium aspiration in the newborn, although most patients deliver vaginally. Key message: Newer modalities of treatment with better pregnancy outcomes in mothers with ICP.

Background: The surgical transversus abdominis plane (TAP) block is an established technique for postoperative analgesia following abdominal surgery. However, it has not been practiced frequently by obstetricians. This work was done to study the efficacy of the surgical TAP block after cesarean delivery (CD). Materials and methods: The study included 100 women undergoing CD in MVJ Medical College and Research Hospital, Hoskote, Bengaluru, Karnataka. The operating obstetrician performed a surgical TAP block for 50 participants in the “Study” group. Twenty milliliters of 0.25% bupivacaine was injected in the transversus abdominis neurofascial plane, on either side. Another 50 participants were included in the “Control” group. Postoperatively, visual analog scores (VAS) for pain were monitored for 24 hours. Whenever the patient demanded rescue analgesia or VAS was recorded as 4 or more, rescue analgesia was administered with intravenous injection tramadol 50 mg. The time of the first rescue analgesia and the total dose of rescue analgesics required in the first 24 hours were recorded. The patients in the “Control” group routinely received intravenous injection tramadol 50 mg, 8th hourly for pain relief. Results: The difference in the mean VAS score at all time intervals between the two groups was statistically significant (p < 0.05). The mean time to first rescue analgesia in the “Study” group and “Control” group was 11.7 ± 7.344 and 2.1 ± 1.125 hours, respectively, and the total tramadol consumption was 50 ± 28.571 and 180 ± 26.726 mg, respectively. This difference was statistically highly significant (p < 0.001). Conclusion: Surgical TAP block is an important adjunct in the multimodal pain management strategy and should be practiced more often in obstetric practice.

Aim: The primary objective of this consensus document is to develop evidence-based consensus recommendations on the use of the levonorgestrel-releasing intrauterine system (LNG-IUS) for contraception in the Indian setting. Background: The unintended pregnancy rate in India is among the highest in the world. Current contraceptive options for women in India include combined or progesterone-only contraceptive pills, vaginal ring, depot medroxyprogesterone acetate, copper intrauterine devices, LNG-IUS, and implants. However, currently, there are no India-specific guidelines/recommendations on the use of LNG-IUS in women. Therefore, an expert panel meeting was convened to arrive at practical recommendations for clinicians on the appropriate use of LNG-IUS. Review results: The panel comprising 15 obstetrics and gynecology experts from India discussed appropriate patient profiles for LNG-IUS and available evidence for the general population and women with comorbidities. The panel thoroughly reviewed the existing literature on contraception and put forth definitive recommendations to be followed on the use of LNG-IUS in the Indian setting. Consensus-based clinical recommendations were developed to serve as a reference for clinicians, regarding the use of LNG-IUS in the general population and women with comorbidities. Conclusion: The use of the LNG-IUS in selected population can ensure contraception and also enhance treatment outcomes. The consensus recommendations given in this document can guide clinicians toward the same in Indian settings. Clinical significance: The LNG-IUS, while being effective for contraception, offers several advantages in terms of reversibility, reduced pelvic infections, etc. Clinicians should carefully select the specific patient profiles/subgroups who would benefit from the use of LNG-IUS.

The thin endometrium is an important cause of failure of cycle cancellations in in vitro fertilization (IVF). Several modalities like estrogen, low-dose aspirin, heparin, vaginal sildenafil, pentoxifylline, and granulocyte-colony stimulating factor (G-CSF) intrauterine perfusion have been tried and studied in patients with a thin endometrium. We discuss platelet-rich plasma (PRP) administration by intrauterine infusion as a novel approach in these patients. We reviewed and analyzed all important and relevant articles including case series, pilot studies, and case reports published from January 2000 to December 2020. Studies pertaining to other uses of PRP were not included. We found that intrauterine infusion of PRP can significantly increase the endometrial thickness and improve the pregnancy rates in infertile patients with thin endometrium <6 mm.

Aim: Successful management of acute liver failure in a case of dengue infection in postpartum patient by a multidisciplinary approach. Background: Dengue fever is a viral infection transmitted by the bite of Aedes aegypti mosquito. It is a major public health problem in developing countries like India. Symptomatology of dengue ranges from mild self-limiting illness to fulminant liver failure. Hepatic dysfunction is a known complication in dengue fever that ranges from mild to moderate elevation of serum transaminases to catastrophic fulminant liver failure. Acute liver failure is a rare complication of dengue infection with high mortality rate. Case description: We report here a case of 19-year-old female who was referred to our center for management of primary postpartum hemorrhage with acute febrile illness. Laboratory investigations revealed anemia, thrombocytopenia, and positive dengue NS1 antigen test. The patient was managed in the critical care unit for pulmonary edema, acute kidney injury, and deranged coagulation profile secondary to hepatic dysfunction. Postpartum hemorrhage was another challenge tackled conservatively. The spectrum of liver involvement varied from a modest rise in transaminases in the early phase and culminating finally in acute hepatic failure by the end of 2 weeks. Multiple blood and blood products were transfused during her 1 month stay in intensive care. There was no perinatal transmission. A multidisciplinary approach involving obstetricians, intensivists, and gastroenterologists resulted in successful recovery of the patient from acute liver failure. Conclusion: Clinicians should have a high index of suspicion for dengue fever in endemic areas in a case of acute febrile illness with/without the classical signs and symptoms of dengue fever. Pregnancy poses a special challenge for the obstetrician as delivery during this period can have devastating complications. A multidisciplinary approach with cautious fluid management is advisable in patients with severe dengue infection. Postpartum hemorrhage can be one of the life-threatening complications due to thrombocytopenia and deranged coagulation profile. Acute liver failure is a rare complication but can develop in patients with severe hepatitis. Clinical significance: Dengue infection in pregnancy can mimic other causes of thrombocytopenia like HELLP syndrome, megaloblastic anemia, and gestational thrombocytopenia; hence, a detailed evaluation is warranted in pregnant women presenting with acute febrile illness with thrombocytopenia. Liver involvement in dengue infection can have devastating consequences leading to severe hepatitis and acute liver failure.

Background: Struma ovarii is a rare ovarian neoplasm, which contains thyroid tissue. It accounts for less than 5% of ovarian teratomas. These are mostly benign, occurring between 40 years and 60 years of age. Clinical and radiological features are inconclusive and mostly it is diagnosed by histopathology. About 5–8% cases have hyperthyroidism. Cystic struma ovarii is very rare with only 25 cases reported till now. It creates confusion in diagnosis, as even in histopathology, the cells are mostly like those resembling other cystic ovarian tumors with minimal thyroid follicles. Case description: A 20-year-old girl came with complaints of abdominal discomfort and difficulty in squatting and lying supine. Clinically, a 28-week-size cystic tumor was palpated. Ultrasound showed features of a cystic benign tumor. Tumor markers were normal. Laparoscopic cystectomy was done. Histopathology showed cystic struma ovarii. At 6-month follow-up, the patient has been doing well. Conclusion: Cystic struma ovarii is a rare diagnosis. Clinical, biochemical, and radiological features do not help. A careful and keen pathological examination is necessary so that thyroid follicles are not left while viewing. There is no clear consensus on follow-up of these patients, but benign tumors usually do not need extensive follow-up. Clinical significance: It is a rare tumor and a good histopathological diagnosis is needed. Cystic tumors should be carefully examined. A proper correlation between clinical, biochemical, radiological, intraoperative, and histopathological findings may help us to consider this diagnosis when we get similar cases.

Aim: To discuss the effect of pregnancy in sickle cell disease (SCD) patients and its associated complications. Background: Sickle cell disease is the most common inherited disorder worldwide and in certain regions of India with varying clinical severity and potentially serious complications. Sickle cell disease can magnify complications during pregnancy and in turn negatively influence the pregnancy outcomes. The physiological adaptations during pregnancy that occur in the circulatory, hematologic, renal, and pulmonary systems can overburden organs that already have chronic injuries secondary to SCD, thus increasing the rate of obstetric complications like miscarriage, anemia, preeclampsia, worsening of vaso-occlusive crisis, and acute chest syndromes. Case description: A 23-year-old Indian primigravida patient, known case of SCD with anemia and splenic infarct with h/o multiple blood transfusions. The patient presented at 12 weeks with intrauterine fetal demise and was medically aborted. The post-abortion patient was posted for splenectomy as she had episodes of hemolytic jaundice. Post-splenectomy patient further developed bowel obstruction and thrombus formation in the infrarenal part of inferior vena cava (IVC). She was again operated and for obstruction and the band was removed. For thrombi, patient was given low molecular weight heparin (LMWH). The patient was finally discharged on tb. hydroxyurea and other antibiotics. Conclusion: The higher rate of complications occurs in women with sickle cell crisis exaggerated by underlying factors such as long-term anemia and pregnancy increases the risk further. Thus, a multidisciplinary approach with regular follow-up of SCD patients since the time of preconceptional time is important to avoid pregnancy-related complications and also for a better pregnancy outcome. Clinical significance: The physiological changes of pregnancy like increased blood volume, increased metabolic demand, increased blood viscosity, and hypercoagulability get aggravated in SCD patients leading to increased incidence of complications. Prepregnancy anemia and other complications of a mother can further affect the outcome, thus preconceptional counseling is a crucial part of management.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an autosomal dominant arteriopathy, caused by mutations in a gene called Notch3 on long arm of chromosome 19. It is very rare in pregnancy. This case report is presented to create awareness regarding investigating patients presenting with such illness for a better perinatal outcome.

Deep vein thrombosis (DVT) and venous thromboembolism are major health problems and are leading causes of maternal morbidity and mortality. Recurrent pregnancy loss either early or late is a serious problem and has both psychological and physical impacts. Thrombophilia is one of the most important causes of DVT as well as recurrent pregnancy loss as it worsens the physiological hypercoagulable case which exists in pregnancy. Homocysteinemia is rare but an important cause of DVT and recurrent pregnancy loss. Serum homocysteine levels in pregnancy have been linked to preeclampsia, recurrent abortions, and low birth weight. Diagnosis of this condition is missed on a routine basis due to extremely less frequency of the evaluation of serum homocysteine levels. Here, we report a case of hyperhomocysteinemia as an underlying cause of bad obstetric history and DVT which are a few of the classic presentations of the entity seen in the single patient. The condition was diagnosed by a multidisciplinary approach.

Background: A collision tumor is the coexistence of two distinct tumors without any histological intermixing in the same organ or tissue. Though these types of tumors are often seen in various organs, their occurrence in the ovary is rare. Case description: Here, we have reported a case series of three collision tumors—serous cystadenoma with mature cystic teratoma, mucinous cystadenoma with benign cystic teratoma, and a case of serous cystadenofibroma with mature cystic teratoma. Clinical significance: It is important to identify collision tumors and also document all their components for optimal treatment.

Aim: To study the outcome in COVID-19-positive pregnancies. Materials and methods: Data collected and analyzed retrospectively from COVID-19-positive pregnant women admitted to our hospital between April and September 2020. Results: 78.85% of women below 30 years of age, 60.57% multigravidae, 53.71% above 37 weeks of gestation. 76.85% no comorbidities, 73.42% no history of travel/contact with COVID-19 cases. 84.57% asymptomatic, two had a severe acute respiratory infection (SARI), requiring intensive care. 74.57% diagnosed using reverse transcriptase-polymerase chain reaction (RT-PCR). 91.42% turned negative within 6–10 days. The SARI patients required intensive care unit (ICU) care, one expired. 81.42% discharged between 8 days and 14 days of admission, returned for delivery at term. 83.42% required no medication. 96.28% had normal investigation reports. 83.14% of patients discharged, 16.57% required emergency obstetric intervention. Cesarean section rate 52.28%, the previous cesarean section most common indication (43.16%). Two babies were stillborn. 99.20%, Apgar > 7 at 5 minutes. Two required resuscitations. Nine required neonatal intensive care unit (NICU) admission. Two hundred and seven babies isolated from their mother, four turned positive. Forty-four were roomed in with mothers, 30 turned positive. One hundred and sixty-seven were breastfed, included 34 positive babies. Affected babies were asymptomatic. Conclusion: COVID-19 runs a milder course in pregnancy, possibly due to altered immune status. However, severe cases can deteriorate rapidly. There is evidence of community spread. COVID-19 seemed to increase cesarean rates. Neonatal transmission appeared higher following vaginal deliveries, rooming-in, and breastfeeding. Clinical significance: There is a dearth of adequate data to formulate guidelines about COVID-19-positive pregnancies despite numerous studies. We hope that our findings make a humble addition to ongoing research and provide further impetus to the global fight against this pandemic.