OBJECTIVES:Currently, recommended high-dose oxytocin regimen for the prevention of postpartum hemorrhage (PPH) following cesarean delivery (CD) is associated with maternal side effects frequency of which is greater with a higher cumulative dose and rapid administration of oxytocin. Here, we evaluated the efficacy of single-dose intravenous oxytocin over 2-4 h (total = 10 units) with oxytocin maintenance infusion for 8-12 h (total = 30 units) in postoperative CD women for the prevention of PPH. METHODS:The current double-blinded randomized controlled trial was carried out in a tertiary care institute in Southern India. The primary outcome measures included the following: (a) the need for additional uterotonics to control PPH and (b) significant deterioration of vital signs as assessed by pulse rate and blood pressure in the postoperative period. The secondary outcome measures were as follows: (a) significant difference (≥10% between preoperative and postoperative packed cell volume) and (b) need for blood transfusion. RESULTS AND CONCLUSIONS:Two hundred and seventy-one women were randomized into Group A (oxytocin = 10 units; n = 135) and Group B (oxytocin = 30 units; n = 136). Both the groups were comparable with regard to demographic characteristics. There was no difference in any of primary or secondary outcome measures in the two groups. Thus, low-dose oxytocin regimen is as effective as high-dose oxytocin regimen in the prevention of PPH in postoperative CD women.

ABSTRACTObjectives(1) To investigate the association between term elective cesarean sections and neonatal respiratory morbidity and the importance of timing of the cesarean. (2) To assess the maternal morbidity when emergency lower segment cesarean section (LSCS) was required.ParticipantsAll women with singleton term (37—41 + 6 weeks) pregnancies and planned for elective cesarean section in Christian Medical College, Vellore, India.Outcome measuresThe primary outcome measures were neonatal morbidities such as transient tachypnea of newborn (TTN) and respiratory distress syndrome (RDS). The secondary outcome measures were emergency cesarean section and maternal morbidities such as scar dehiscence, urinary tract infection (UTI), endometritis, peritonitis, and hemoperitoneum in the mother.ResultsThe percentage of TTN in the infants in group I was 1.3% while there were none in group II. No infants were diagnosed to have RDS. Out of the 150 women who were planned for elective cesarean section, 55 women underwent emergency cesarean section. Among this, 19 (25.3%) of women were from group I as compared with 36 (48.0%) in group II. The difference in proportion between the two groups was –22.7 [95% confidence interval (CI): –37.7, –7.7], which was statistically significant (p < 0.01). The incidence of scar dehiscence, UTI, endometritis, and hemoperitoneum in the mothers of group II was marginally higher than that in the mothers of group I. There was one woman with peritonitis in group I while none was reported in the other group. All the maternal morbidities occurred to women who underwent emergency cesarean section. Out of the 19 women in group I and 36 women in group II who underwent emergency cesarean section, 1 (5.3%) and 6 (16.7%) women had morbidities.ConclusionWomen requiring elective cesarean section can safely be done between 37 and 39 weeks with no further significant increase in the rates of neonatal morbidity such as TTN and RDS.How to cite this articleRoy P, Jeyaseelan L, Ruby J, Garg R. Respiratory Morbidity in Term Infants delivered by Elective Cesarean Section at a Tertiary Care Hospital in India: A Randomized Controlled Trial. J South Asian Feder Obst Gynae 2017;9(4):312-317.

Caesarean delivery (CD) increases the risk of postpartum infection by 5 to 20 fold. Prevention of surgical site infection (SSI) is the goal of antibiotic prophylaxis. This study was carried out to assess the optimum timing for prophylactic antibiotic administration and to assess the amount of the antibiotic crossing the placental barrier.

Background: Hypoglycemia is a major hindrance for optimal glycemic control in women with gestational diabetes mellitus (GDM) on insulin. In the present study, masked hypoglycemia (glucose <2.77mmol/L for >= 30 min) was estimated in pregnant women using a continuous glucose monitoring (CGM) system. Methods: Twenty pregnant women with GDM on insulin (cases) and 10 age-matched euglycemic pregnant women (controls) between 24 and 36 weeks gestation were recruited. Both groups performed self-monitoring of blood glucose (SMBG) and underwent CGM for 72 h to assess masked hypoglycemia. Masked hypoglycemic episodes were further stratified into two groups based on interstitial glucose (2.28-2.77 and <= 2.22 mmol/L). Results: Masked hypoglycemia was recorded in 35% (7/20) of cases and 40% (4/10) of controls using CGM, with an average of 1.28 and 1.25 episodes per subject, respectively. Time spent at glucose levels between 2.28 and 2.77 mmol/L did not differ between the two groups (mean 114 vs 90 min; P = 0.617), but cases spent a longer time with glucose <= 2.2 mmol/L. Babies born to women with GDM were significantly lighter than those born to controls (2860 vs 3290 g; P = 0.012). There was no significant difference in birth weight within the groups among babies born to women with or without hypoglycemia. Conclusion: Euglycemic pregnant women and those with GDM on insulin had masked hypoglycemia. Masked hypoglycemia was not associated with adverse maternal or fetal outcomes. Therefore, low glucose levels in the hypoglycemic range may represent a physiologic adaptation in pregnancy. This response is exaggerated in women with GDM on insulin.

ObjectivesTo identify the perinatal risk factors for early-onset Group B Streptococcus (EOGBS) sepsis in neonates after inception of a risk-based maternal intrapartum antibiotic prophylaxis strategy in 2004.DesignCase control study.MethodsAll newborn with early onset GBS sepsis (born between 2004 and 2013) were deemed to be "cases" and controls were selected in a 1:4 ratio.ResultsMore than three per vaginal (PV) examinations [odds ratio (OR) 8.57, 95% confidence interval (CI) 3.10-23.6] was a significant risk factors. Peripartum fever (OR 3.54, 95% CI 1.3-9.67), urinary tract infection (OR 2.88, 95% CI 1.08-7.63), meconium-stained amniotic fluid (MSAF) (OR 2.52, 95% CI 1.18-5.37) and caesarean section (OR 1.99, 95% CI 1.16-3.43) were also found to be associated with EOGBS sepsis.ConclusionMultiple vaginal examinations are the strongest risk factors for peripartum Group B Streptococcal (GBS) sepsis. The association of MSAF and caesarean section indicates that foetal distress is an early symptom of perinatal GBS infection.

Pregnant women with diabetes may have underlying beta cell dysfunction due to mutations/rare variants in genes associated with Maturity Onset Diabetes of the Young (MODY). MODY gene screening would reveal those women genetically predisposed and previously unrecognized with a monogenic form of diabetes for further clinical management, family screening and genetic counselling. However, there are minimal data available on MODY gene variants in pregnant women with diabetes from India. In this study, utilizing the Next generation sequencing (NGS) based protocol fifty subjects were screened for variants in a panel of thirteen MODY genes. Of these subjects 18% (9/50) were positive for definite or likely pathogenic or uncertain MODY variants. The majority of these variants was identified in subjects with autosomal dominant family history, of whom five were in women with pre-GDM and four with overt-GDM. The identified variants included one patient with HNF1A Ser3Cys, two PDX1 Glu224Lys, His94Gln, two NEUROD1 Glu59Gln, Phe318Ser, one INS Gly44Arg, one GCK, one ABCC8 Arg620Cys and one BLK Val418Met variants. In addition, three of the seven offspring screened were positive for the identified variant. These identified variants were further confirmed by Sanger sequencing. In conclusion, these findings in pregnant women with diabetes, imply that a proportion of GDM patients with autosomal dominant family history may have MODY. Further NGS based comprehensive studies with larger samples are required to confirm these finding

Introduction Although Cesarean delivery (CD) is the most common surgical procedure employed by the Obstetrician, vaginal delivery is the generally preferred mode of delivery by most women. But, sometimes while awaiting vaginal delivery, due to various factors mentioned below, the fetal head gets impacted during the second stage of labour. The impacted fetal head is then delivered by one of several described methods which could give rise to increased maternal and neonatal morbidity. This could lead to failed instrumental delivery with its attendant morbidity as well. The fetal head is said to be impacted when the station of the fetal head is below the Ischial spines on vaginal examination and the head cannot be easily delivered. The exact incidence of impacted fetal head is unknown. It usually occurs as a consequence of a prolonged second stage of labor, use of epidural anesthesia in labor and mal-position of the fetal head could contribute to impaction as well. Impacted fetal head results in difficult and potentially traumatic disengagement of the deeply wedged head during CD. The maneuvers commonly used to disengage the wedged head include, pushing (bimanual or by an assistant) the head through the vagina or alternatively, pulling the infant's feet through the uterine incision. Extracting a deeply impacted head at CD is a real challenge and associated with several maternal and neonatal complications like trauma to the fetus, increased risk of infection, uterine incision extension, and excess blood loss. Some of the maneuvers that have been tried are the following: 1. Pushing the wedged fetal head from below by an assistant (push method). 2. Making a low vertical uterine incision and extracting the infant by the feet and legs 3. Pushing the head from below with a device called Fetal Disimpacting System 4. Extracting the head first with a Murless head extractor (a method that has been practiced since 1948) 5. Bimanual version of the push method with one hand of the surgeon in the vagina and the other hand in the uterus 6. Patwardhan method (disimpaction of the fetal shoulders first followed by delivery of the baby) 7. Reverse breech extraction (Pull method). This (pull method) technically means grasping the fetal feet through an incision made high in the overstretched lower uterine segment and performing a semi-version to deliver. Pushing the fetal head from below through the vagina by an assistant is the most used technique. The most recently favored method is the reverse breech extraction (pull method). These two techniques are the most used methods in our institution for the delivery of the impacted fetal head. Three known major complications associated with the push technique are extensions of the uterine incision and post operative endometritis and surgical site infections (SSI). The objective of this study was to compare neonatal and maternal outcomes associated with “push” versus “pull” methods for delivery of the impacted fetal head at CD.

Background: Birth weight centile curves are commonly used as a screening tool and to assess the position of a newborn on a given reference distribution. Birth weight of twins are known to be less than those of comparable singletons and twin-specific birth weight centile curves are recommended for use. In this study, we aim to construct gestational age specific birth weight centile curves for twins born in south India.Methods: The study was conducted at the Christian Medical College, Vellore, south India. The birth records of all consecutive pregnancies resulting in twin births between 1991 and 2005 were reviewed. Only live twin births between 24 and 42 weeks of gestation were included. Birth weight centiles for gestational age were obtained using the methodology of generalized additive models for location, scale and shape (GAMLSS). Centiles curves were obtained separately for monochorionic and dichorionic twins.Results: Of 1530 twin pregnancies delivered during the study period (1991-2005), 1304 were included in the analysis. The median gestational age at birth was 36 weeks (1st quartile 34, 3rd quartile 38 weeks). Smoothed percentile curves for birth weight by gestational age increased progressively till 38 weeks and levels off thereafter. Compared with dichorionic twins, monochorionic twins had lower birth weight for gestational age from after 27 weeks.Conclusions: We provide centile values of birth weight at 24 to 42 completed weeks of gestation for twins born in south India. These charts could be used both in routine clinical assessments and epidemiological studies.

Background: Hypertensive disorders of pregnancy remain a leading cause of maternal and perinatal morbidity and mortality. The aim of this study was to find out whether immediate induction of labour in women with singleton pregnancy complicated by mild gestational hypertension at term reduced maternal and neonatal morbidity, mortality and expenditure when compared to conservative management without increasing instrumental delivery and caesarean section rates. Methods: This was a randomized controlled trial to compare immediate induction of labour to conservative management for mild gestational hypertension in women between 18-35 years of age with singleton pregnancy with mild gestational hypertension at 37-39.5 weeks without any other complications. Eligible patients presenting to the obstetric outpatient department or labour room of Christian Medical College, Vellore with gestational hypertension were randomized (49 patients in the induction arm and 51 patients in the conservative arm) and followed up. The maternal and neonatal outcomes in both groups were compared. Results: There was no maternal mortality in both the groups. There was increased incidence of composite maternal morbidity (pre-eclampsia, eclampsia, HELLP syndrome, pulmonary oedema, renal failure, thromboembolic disease, abruption, need for ICU care and major postpartum haemorrhage) in the conservative arm when compared to induction arm (14 versus 8), though not statistically significant (p 0.23).There was no significant difference in the caesarean section rates between the two groups (p 0.313 and 0.306 respectively) despite the much favorable Bishop score in the conservative group (p 0.054). There was no significant difference in neonatal morbidity and mortality. A slight increase by about 600 rupees in the median total cost was found with conservative management when compared to induction group. Conclusions: The study did not show a statistically significant difference in maternal mortality, composite maternal morbidity, neonatal mortality and morbidity as well as treatment cost between immediate induction of labour and conservative management for mild gestational hypertension at term.

Background The birth weight and gestational age at birth are two important variables that define neonatal morbidity and mortality. In developed countries, chronic maternal diseases like hypertension, diabetes mellitus, renal disease or collagen vascular disease is the most common cause of intrauterine growth restriction (IUGR). Maternal nutrition, pregnancy induced hypertension, chronic maternal infections, and other infections such as cytomegalovirus, parvovirus, rubella and malaria are the other causes of IUGR. The present study examines the secular trend of Small for Gestational Age (SGA) over 15 years and risk factors for SGA from a referral hospital in India. Methods Data from 1996 to 2010 was obtained from the labour room register. A rotational sampling scheme was used i.e. 12 months of the year were divided into 4 quarters. Taking into consideration all deliveries that met the inclusion criteria, babies whose birth weights were less than 10 th percentile of the cut off values specific for gestational ages, were categorized as SGA. Only deliveries of live births that occurred between 22 and 42 weeks of pregnancy were considered in this study. Besides bivariate analyses, multivariable logistic regression analysis was done. Nagelkerke R 2 statistics and Hosmer and Lemeshow chi-square statistics were used as goodness of fit statistics. Results Based on the data from 36,674 deliveries, the incidence of SGA was 11.4% in 1996 and 8.4% in 2010. Women who had multiple pregnancies had the higher odds of having SGA babies, 2.8 (2.3-3.3) times. The women with hypertensive disease had 1.8 (1.5-1.9) times higher odds of having SGA. Underweight women had 1.7 (1.3 - 2.1) times and anaemic mothers had 1.29 (1.01 - 1.6) times higher odds. The mothers who had cardiac disease were 1.4 (1.01 - 2.0) times at higher odds for SGA. In teenage pregnancies, the odds of SGA was 1.3 (1.1 - 1.5) times higher than mothers in the age group 20 to 35 years. Conclusions There is a significant reduction in the incidence of SGA by 26% over 15 years. The women with the above modifiable risk factors need to be identified early and provided with health education on optimal birth weight.

Background: With an aim to reduce the rates of repeat cesarean section in women with a previous scar, prediction of scar rupture or dehiscence is important. If we could predict the risk of rupture by measuring the scar thickness closer to term, we could pursue a trial of scar safely. Aims: To evaluate the use of ultrasound measured thickness of lower uterine segment as one of the predictors of scar rupture or dehiscence in labour and establish a cut off beyond which trial of labour can be attempted safely. Methodology: 187 randomly selected pregnant women with history of one previous cesarean section in the past who satisfied the inclusion criteria, attending the outpatient clinic over a period of six months, at a tertiary level teaching institution in southern India were selected and counseled to undergo a transvaginal measurement of the scar region. These women were then followed up until delivery and the outcome of trial of scar, successful vaginal delivery, rupture or dehiscence of uterus was analysed in relation to the scar thickness and various other contributing factors. Results: 187 women with history of previous cesarean section, attending the outpatient clinic were randomly chosen to undergo trans vaginal scan at term. 52 underwent elective cesarean section and 135 went through trial of scar. The median cut-off of the lower uterine segment in this study population of 135 was 2.4 mm. The sensitivity was 90.9%, specificity was 43.5%, positive predictive value was 12.5%, and negative predictive value was 98.3% at this cut-off for scar rupture or dehiscence. Conclusions: The lower uterine scar thickness could be a useful tool to predict scar rupture. This could aid in making decisions regarding induction of labour with oxytocin in women with previous cesarean section.

Objective: Infections significantly contribute to maternal mortality. There is a perceived change in the spectrum of such infections. This study aims to estimate the contribution of various types of infections to maternal mortality.Material and Methods: We retrospectively reviewed records of maternal death cases that took place between 2003 and 2012 in the Christian Medical College, Vellore, India. The International Classification of Diseases-Maternal Mortality was used to classify the causes of deaths and World Health Organization near-miss criteria were used to identify organ dysfunction that occurred before death. Infections during pregnancy were divided into three groups, i.e., pregnancy-related infections, pregnancy-unrelated infections, and nosocomial infections.Results: In this study, 32.53% of maternal deaths were because of some type of infection as the primary cause. The contribution of pregnancy-related infections was comparable with that of pregnancy-unrelated infections (16.03% vs. 16.50%). Metritis with pelvic cellulitis, septic abortions, tuberculosis, malaria, scrub typhus, and H1N1 influenza (influenza A virus subtype) were among the most commonly encountered causes of maternal death due to infections. Another 7.07% of cases developed severe systemic infection during the course of illness as nosocomial infection. A significant majority of mothers were below 30 years of age, were primiparae, had advanced gestational age, and had operative delivery. Cardiovascular and respiratory system dysfunctions were the most common organ dysfunctions encountered.Conclusion: The contribution of pregnancy-unrelated infections to maternal deaths is significant. Control of these diverse community-acquired infections holds the key to a reduction in maternal mortality along with the promotion of clean birthing practices. Nosocomial infections should not be underestimated as a contributor to maternal mortality.

BACKGROUND: Chorionic villus sampling (CVS) is an invasive diagnostic procedure done in early pregnancy to obtain cells for the prenatal diagnosis of chromosomal and genetic defects.AIMS: To study the indications, results and complications of pregnancies following transabdominal chorionic villus sampling (CVS).STUDY DESIGN AND SETTINGS: This is a retrospective analytical study on women who had undergone transabdominal CVS in a single unit at the Obstetrics and Gynaecology department, Christian Medical College, Vellore from January 2012 to December 2014.MATERIAL AND METHODS: All pregnant women who underwent CVS for various indications during the specified period were included in the study. The clinical details of the women were retrieved from the hospital database regarding age, domicile, obstetric history, family history, gestation age, indication and outcome of procedure.RESULTS: Total 67 women had undergone transabdominal CVS during the study period. Out of 67 procedures, tissue retrieval was possible in 64 (95.52%) cases. Out of 64 samples, 2 (2.98%) were contaminated. Most of the procedures were done between 11-13 weeks gestation. The most common indication for doing the procedure was for chromosomal disorders (39%). Forty six women (74.19%) had normal results and 16 (25.80%) had abnormal results. Of those with abnormal results, 9 (14.51%) fetuses were affected including 3 with chromosomal abnormalities whereas 7 (11.29%) had carrier state. Majority of abnormal results were found when indication for the procedure was previous affected child. No woman had vaginal bleeding, leaking or pregnancy loss within 3 weeks of procedure.CONCLUSION: Transabdominal CVS is a safe and reliable outpatient procedure for prenatal diagnosis in early pregnancy and should be considered as procedure of choice. CVS is beneficial in providing early prenatal diagnosis and offering further options of management if pregnancy is affected. In experienced hands miscarriage rate following the procedure is very low.

Foetal cardiac rhabdomyomas are the most common prenatally diagnosed cardiac tumours. They are known for their association with the tuberous sclerosis complex. We describe a case of an isolated cardiac rhabdomyoma which was picked up on a routine obstetrical ultrasound. Cardiac rhabdomyomas are known for their association with tuberous sclerosis complex, an autosomal dominant multisystemic disorder. Therefore when diagnosed antenatally, attempt should be made to look for other stigmata associated with this complex. We describe the case of an isolated fetal cardiac rhabdomyoma diagnosed on routine antenatal scan, done at 34 weeks’ gestation. The tumor had an uneventful course in the prenatal period. At birth, the diagnosis of cardiac rhabdomyoma was confirmed. There were, however, no other stigmata of tuberous sclerosis in the neonate. The parents and others in the family were screened for presence of tuberous sclerosis and were found to be negative. The neonate had no evidence of hemodynamic compromise at birth, hence was kept under expectant observation for tumor regression. Serial evaluation of the tumor using echocardiography , showed no increase in the size at three and six months of life ,with no deterioration of the cardiovascular status. CASE REPORT A 23 year old, primigravida was referred to our tertiary care hospital at 34 weeks’ gestation, following a routine obstetrical ultrasound done elsewhere, which revealed a solid tumour in the foetal heart. She had no known antenatal risk factors. Ultrasound done here, at the time of evaluation, showed no evidence of intra uterine growth restriction. Four chamber view of the foetal heart revealed a homogenously echogenic, solid mass, measuring one by one cm, arising from interventricular septum and abutting into the left ventricle. There was no evidence of pericardial effusion. The findings were consistent with that of cardiac rhabdomyoma. Umbilical artery Doppler studies were normal. There were no other gross anomalies on survey of foetal anatomy. Foetal Echocardiography cnfirmed the presence of rhabdomyoma, away from the outflow and inflow tracts. The patient was counselled regarding the possibility of tuberous sclerosis in the foetus. Parents and their first degree relatives were screened for the presence of tuberous sclerosis with history and clinical examination and were found to be negative. Foetal growth was monitored closely. Serial ultrasounds were done to look for onset of foetal growth restriction, size of the tumour and development of hydrops. The size of the tumour remained same till delivery and afterwards. Labour was induced at 40 weeks’ gestation and she delivered a healthy male baby, weighing 2.7 kgs, by LSCS. Thorough physical and radiological examination of the neonate, however, did not reveal any other stigmata of tuberous sclerosis. There was no increase in the size of the tumour on neonatal echo done on third day and six months of life. The infant continues to be in regular follow up at our hospital. DISCUSSION The incidence of congenital cardiac tumours is 1-2 :10,000, and 90% of them are benign.1 Of these, rhabdomyomas are the most commonly diagnosed in utero, followed by teratomas and fibromas. The reported prevalence is 0.25% in Isolated Fetal Cardiac Rhabdomyoma: A Case Report 2 of 3 autopsies and 0.08% among the live born. 1,2 Rhabdomyomas are hamartomas derived from embryonal myoblasts. They may be solitary or multiple. Interventricular septum is the most common site of origin. The prognosis of tumours detected prenatally is favourable, with most of them regressing spontaneously after birth. The risk of foetal demise is 4-6%.3 Poor prognostic indicators include inflow or outflow tract obstruction, leading to hydrops; atrioventricular valve dysfunction, leading to valvular incompetence and presence of dysrrythmias. Cardiac rhabdomyomas are known for their association with tuberous sclerosis complex, an autosomal dominant multisystemic disorder. The risk of association is 30-50% , in case of a solitary tumour, and 70% with multiple lesions.4.When a cardiac rhabdomyoma is diagnosed prenatally, attempt to look for other features of this complex, should be made . Standard obstetrical management is appropriate for uncomplicated cases. Delivery in a tertiary care centre with paediatric cardiology and surgery facilities is recommended. After delivery, in the absence of haemodynamic compromise, expectant management is advised. Regular follow up with serial echocardiograms is the mainstay of management. Figure 1 Obstetrical ultrasound depicting the transverse view of fetal thorax, at the level of the heart. The arrow mark showing the cardiac rhabdomyoma, which appears like a solid, homogeneously echogenic mass Figure 2 Fetal echocardiography confirming the diagnosis of cardiac rhabdomyoma, seen arising from the interventricular septum References 1. McAllister H Jr. Primary tumors of the heart and pericardium. Pathol Annu 1979; 14:325-55 2. Dennis MA, Appareti K, Manco –Johnson ML et al. The echocardiographic diagnosis of multiple fetal cardiac tumors. J Ultrasound Med 1985;4:327-329 3. Bader RS, Chitayat D, Kelly E, Ryan G, Smallhorn JF, Toi A et al. Fetal Rhabdomyoma: Prenatal Diagnosis , Clinical outcome, and Incidence of associated Tuberous Sclerosis Complex. Journal of Pediatrics , November 2003:620-4. 4. Crawford DC, Garrett C, Tynan M, Neville BG, Allan LD. Cardiac rhabdomyomata as a marker for antenatal detection of tuberous sclerosis. J Med Genet 1983; 20:303-4. Isolated Fetal Cardiac Rhabdomyoma: A Case Report 3 of 3 Author Information Manisha Madhai Beck, MD Associate Professor, Department of Obstetrics and Gynecology, Christian Medical College and Hospital Tamil Nadu, India beckmanisha@yahoo.com Jacob Jose, MD, DM (Cardio), FACC, FCCP, FIAE Professor and Head, Department of Cardiology, Christian Medical College and Hospital Tamil Nadu, India Ruby Jose, MD, DGO Professor and Unit Head, Department of Obstetrics and Gynecology, Christian Medical College and Hospital Tamil Nadu, India

Objective: Preceding the use of World Health Organization (WHO) near-miss approach in our institute for the surveillance of Severe Maternal Outcome (SMO), we pilot-tested the tool on maternal death cases that took place over the last 10 years in order to establish its feasibility and usefulness at the institutional level.Material and Methods: This was a retrospective review of maternal deaths in Christian Medical College Vellore, India, over a decade. Cases were recorded and analyzed using the WHO near-miss tool. The International Classification of Diseases, 10th Revision was used to define and classify maternal mortality.Results: There were 98,139 total births and 212 recorded maternal deaths. Direct causes of mortality constituted 46.96% of total maternal deaths, indirect causes constituted 51.40%, and unknown cases constituted 1.9%. Nonobstetrical cause (48.11%) is the single largest group. Infections (19.8%) other than puerperal sepsis remain an important group, with pulmonary tuberculosis, scrub typhus, and malaria being the leading ones. According to the WHO near-miss criteria, cardiovascular and respiratory dysfunctions are the most frequent organ dysfunctions. Incidence of coagulation dysfunction is seen highest in obstetrical hemorrhage (64%). All women who died had at least one organ dysfunction; 90.54% mothers had two-and 38.52% had four-or more organ involvement.Conclusion: The screening questions of the WHO near-miss tool are particularly instrumental in obtaining a comprehensive assessment of the problem beyond the International Classification of Diseases-Maternal Mortality and establish the need for laboratory-based identification of organ dysfunctions and prompt availability of critical care facilities. The process indicators, on the other hand, inquire about the basic interventions that are more or less widely practiced and therefore give no added information at the institutional level.

Fibroids are benign (non-cancerous) growths on the uterus.There is an overall incidence of 20% in women more than 30yrs of age.The incidence of cervical fibroids is much lower at 1-2%.An unmarried girl presented with complaints of difficulty in passing urine, lower abdominal pain and spasmodic dysmenorrhea for 4 months.Per abdomen there was a firm, non-tender midline mass arising from the pelvis corresponding to 20 weeks size gravid uterus with restricted mobility.Cervix could not be felt.Ultrasonographic examination showed 10.2x10.7 cm fibroid in the posterior wall with no adnexal pathology and bilateral mild hydronephrosis.On laparotomy, the uterus was found to be sitting like a lantern on the dome of St. Paul's Cathedral.A 25x18 cm pseudo central cervical fibroid, partly intramural, partly sub mucous was seen to arise from the posterior cervico isthmic region.Myomectomy was performed successfully.Central cervical fibroid expands the cervix equally in all directions and the uterus is elevated on top of the large tumor.Diagnosis is by ultrasonogram and HSG.Management in cervical fibroid of supravaginal portion is hysterectomy if fertility is not desired and myomectomy if the patient is young and fertility is desired, as in our case.

Germ cell tumours (GCTs) of the ovary are rare, comprising approximately 20% of all ovarian tumors with the malignant variant accounting for less than 5% of all ovarian neoplasms.Malignant mixed germ cell tumours are rarer still with dysgerminoma & yolk sac tumour being the most common components with three component variants being categorised in the rarest of rare varieties.Bilateral dysgerminomas occur in 15% of germ cell neoplasms but rarely present with premature ovarian failure.We present the case of an adolescent girl with a short history of abdominal pain and distension with amenorrhoea for a year.Clinical and radio ogical examination revealed a pelvic/adnexal mass with elevation of tumour markers and she had to undergo a staging laparotomy with bilateral salpingo-oophorectomy.Histopatholgy examination was reported as malignant mixed germ cell tumour of left ovary, predominantly with immature teratoma and minor components of yolk-sac tumour and dysgerminoma and right ovary with dysgerminoma.In view of mixed germ cell disease, she was planned for adjuvant chemotherapy.