Objective: Posterior fossa anomalies (PFAs) encompass a spectrum of central nervous system malformations affecting the cerebellum, brainstem, and surrounding cerebrospinal fluid spaces. This study evaluates the prenatal diagnosis, genetic findings, and pregnancy outcomes of PFAs in a tertiary care setting in India. Methods: A retrospective analysis was conducted on 35 cases of PFAs diagnosed via prenatal ultrasound and fetal MRI between January 2023 and May 2024. Anomalies were classified based on standard criteria, and genetic testing (karyotypte, chromosomal microarray analysis and whole exome sequencing) was offered. Pregnancy outcomes, including termination, live birth, and neonatal survival, were documented, with short-term neurodevelopmental follow-up conducted via telephonic inquiries. Results: The most common PFAs identified were Vermian Agenesis/Hypoplasia (VA/VH) and Cerebellar Hypoplasia (CH), each accounting for 25.71% of cases, followed by Dandy-Walker Malformation (20%). Isolated PFAs were observed in 37.14% of cases, while 62.85% had additional anomalies. Genetic testing was performed in 74.2% of cases, revealing variants in 5.71%. Karyotyping was performed in all tested cases and yielded normal results, while additional molecular testing with chromosomal microarray analysis (5 cases) and whole-exome sequencing (3 cases) detected clinically relevant variants in selected fetuses with posterior fossa anomalies. Among the 35 pregnancies, 65.71% opted for termination, facilitated by the Medical Termination of Pregnancy (MTP) Act, particularly for cases diagnosed beyond 24 weeks of gestation. Of the 9 live births, 2 neonates with vermian hypoplasia (5.71%) died within one month, while 6 (17.14%) had normal developmental milestones at 6 months including 6 babies with mega cisterna magna and one with an arachnoid cyst. One infant exhibited delayed milestones. Conclusion: PFAs present with diverse prognostic implications, necessitating detailed imaging, genetic evaluation, and individualized counseling. The MTP Amendment Act, played a crucial role in providing extended access to termination in pregnancies with severe PFAs and poor prognoses.

OBJECTIVE:To assess the emotional response and mental health of women undergoing second-trimester medical termination of pregnancy (MTP) for fetal anomalies. METHODS:This prospective observational study included 120 women undergoing MTP between 14 and 24 weeks gestation for fetal anomalies Emotional response and mental health were evaluated using the Impact of Event Scale-Revised (IES-R), Kessler Psychological Distress Scale (K10), Hospital Anxiety and Depression Scale (HADS), and Perinatal Grief Scale (PGS), administered before MTP and at 1 month post-procedure. Demographic, obstetric, and MTP-related data were collected using structured questionnaires and case records. RESULTS:At MTP, 50.8% of women reported acute stress reactions (IES-R), with 44.2% intrusion, 42.5% avoidance, and 41.7% hyperarousal. Psychological distress was observed in 55.8%, symptoms of anxiety in 65.8%, and depression in 59.2%, and grief response in 41.7% (active grief 58%, difficulty coping 40%, despair 38.3%). At 1 month, symptoms persisted in a subset: acute stress in 13.1%, psychological distress in 8.9%, symptoms of anxiety 30.4%, depression 35.2%, and grief in 84% women CONCLUSIONS: Second-trimester MTP exerts a substantial psychological impact, with persistent emotional difficulties in many women. The findings emphasize the need for systematic psychological support, ideally extending to couples.

Cardiovascular disease (CVD) is a leading and preventable cause of maternal mortality in low and middle-income countries (LMICs), yet most management guidelines rely on data from high-income countries. Robust, nationally representative data on pregnant women with heart disease (PWHD) are limited in India, underscoring the need for locally relevant evidence to guide clinical practice and policy. The National Pregnancy and Cardiac Disease Study in India (NPAC-India) is a multiphase national initiative, and this paper describes the protocol for Phase 1, a prospective multicenter observational study initiated at 56 sites across India. All consecutive pregnant women presenting for antenatal care with known or newly diagnosed cardiovascular diseases, including congenital or acquired structural heart disease, cardiac arrhythmia, ischemic heart disease, aortopathies, or pulmonary vascular disease, will be enrolled from July 2024. Clinical details related to antenatal, intranatal, and postnatal care will be systematically documented. All study participants will be followed up for 6 months after the end of their pregnancy. The primary outcome is a composite of maternal cardiac events during pregnancy and up to 6 weeks postpartum. The secondary outcomes cover obstetric and fetal parameters. The study will evaluate the predictive accuracy of widely used general and lesion-specific risk assessment tools in the Indian population and explore the development and validation of a population-specific risk stratification model. The NPAC-India study is expected to facilitate the development of evidence-based, locally tailored guidelines for managing heart disease in pregnancy, thereby reducing maternal and fetal risks in India. The generation of national data may strengthen clinical care, improve resource allocation, and inform public health policy.

OBJECTIVE:Dichorionic triamniotic (DCTA) and monochorionic triamniotic (MCTA) triplet pregnancies are associated with significant maternal and fetal risks. Multifetal pregnancy reduction (MPR) or selective reduction (SR) may improve outcomes, but data specific to these complex chorionic configurations are limited. The aim of the present study was to evaluate fetal reduction strategies and pregnancy outcomes in DCTA and MCTA triplets. METHODS:This retrospective cohort study included 19 triplet pregnancies (14 DCTA, 5 MCTA) managed with MPR or SR at a tertiary care center in India between January 2021 and January 2025. Reductions were performed using intracardiac potassium chloride (KCl) or radiofrequency ablation (RFA), based on chorionicity and patient choice. Outcomes assessed included live birth, gestational age at delivery, and procedural complications. RESULTS:Of the 19 pregnancies, 10 were reduced to singletons and nine to twins (5 MCDA, 4 DCDA). The overall live birth rate was 89.47% (17/19), with 80% in singletons and 100% in twins. Preterm delivery occurred in 89.47% of pregnancies, with 15.78% delivering before 28 weeks. Premature rupture of membranes (PPROM) occurred in four cases (21.05%). Among DCTA pregnancies, RFA was associated with a 100% live birth rate and no extreme preterm births. Complications related to monochorionicity were observed in 31.57% of pregnancies before reduction. CONCLUSION:MPR and SR in DCTA and MCTA triplets are feasible and can yield favorable outcomes when tailored to chorionicity and gestational age. These findings add to existing evidence supporting early, tailored fetal reduction in high-order multiple pregnancies.

Background and aim Antenatal education and birth planning are essential components of respectful maternity care, improving childbirth experiences by preparing families for labor. Knowledge about prenatal exercises, birth companions, pain relief, delivery methods, and postpartum contraception empowers couples during childbirth and enhances the quality of care. Despite evidence supporting routine birth plans, our antenatal clinics lacked a formal policy for prenatal education. This study aimed to establish the practice of birth plan counseling from an existing rate of 0% and increase it to 50% within 10 months using the Point of Care Quality Improvement methodology. Methods Following baseline data collection and a fishbone analysis of existing deficits, five sequential Plan-Do-Study-Act cycles were implemented: (1) physician-led counseling and stakeholder training; (2) integration of paramedics and physiotherapists via video consultations; (3) transition of services to ultrasound rooms during COVID-19 outpatient closures; (4) implementation of trimester-wise room redistribution for group counseling; and (5) transfer of responsibilities to permanent family planning staff to ensure sustainability after resident graduation. Results Over the 10-month period, birth plan clinic attendance increased from a median of 0% to 50% and was sustained for an additional six months. Secondary outcomes also improved, including postpartum contraception adoption (from 28% to 54.25%), prenatal exercise participation (from 10% to 57%), and labor analgesia use (from 0% to 50%), although birth companion presence decreased from 40% to 29% because of pandemic-related social distancing mandates. Conclusions Systematic healthcare worker training and methodical staff utilization successfully established antenatal counseling practices. Implementing new healthcare practices requires a multistep approach with system-level changes, while routine monitoring ensures sustainability.

INTRODUCTION:Rh isoimmunization remains a major cause of haemolytic disease of the fetus and newborn, particularly when fetal anaemia develops early in gestation. Antenatal intravenous immunoglobulin (IVIG) has been proposed to improve fetal outcomes, but evidence remains limited, especially from low- and middle-income settings. METHODS:This study was conducted at a tertiary care centre in India and included pregnant women with severe anti-D isoimmunization managed between 2023 and 2025. Inclusion criteria were pregnant women, with a previous pregnancy complicated by hydrops with perinatal death and/or requirement of intrauterine transfusion (IUT) before 24 weeks. They received antenatal IVIG (1 g/Kg/week from 13 to 14 weeks for 4-6 doses) and were compared with cases managed without IVIG. Outcomes analysed included presence of fetal hydrops, the requirement for IUT and the total number of IUTs, gestational age at first IUT, gestational age at delivery, and pregnancy outcome (live birth, stillbirth, or abortion) and neonatal outcomes. RESULTS:Thirty-four pregnancies were included with17 managed with IVIG and 17 managed without IVIG based on the timing of referral. The incidence of fetal hydrops was significantly lower in the IVIG group (5.9% vs. 52.9%, p = 0.008), and preterm delivery occurred less frequently (70.5% vs. 100%, p = 0.04). The need for IUT, gestational age at first IUT, number of IUTs, gestational age at delivery, and birth weight were comparable between groups. Live birth rate and survival at discharge were higher in the IVIG group, though differences did not reach statistical significance. Infusion-related reactions occurred in 17.6% of IVIG-treated patients and were mild. CONCLUSION:Antenatal IVIG was associated with reduced fetal hydrops and preterm delivery in severe Rh isoimmunized pregnancies. However, these findings should be interpreted with caution as improved outcomes may also reflect earlier referral, surveillance, and intervention.

Mesenchymal stem cells (MSCs) possess immunomodulatory properties that can be harnessed for treating acute graft-versus-host disease (aGVHD). In this study, we compared bone marrow (BM) and Wharton's jelly (WJ)-derived MSCs and investigated how hypoxia preconditioning (1% O2, 24 h) influences their immunoregulatory function. Using direct co-cultures with activated peripheral blood mononuclear cells from aGVHD patients, we evaluated T cell proliferation, Treg induction, macrophage polarization, mitochondrial transfer, and MSC apoptosis. Hypoxia-preconditioned WJ-MSCs (WJ-MSCsHYP) more effectively suppressed T cell proliferation, enhanced Treg differentiation, promoted M2 macrophage polarization, and improved T cell metabolic balance via mitochondrial transfer. These effects were primarily driven by apoptosis and occurred independently of efferocytosis. Our findings highlight tissue-specific mechanisms underlying MSCs' immunoregulation and reveal that hypoxia enhances the therapeutic potential of WJ-MSCs. This work provides mechanistic insight into MSCs-based interventions and supports WJ-MSCsHYP as a promising cell source for immunomodulatory therapy in inflammatory disorders such as aGVHD.

Placental dysfunction contributes substantially to adverse perinatal outcomes, yet current antenatal monitoring tools provide limited direct assessment of placental physiology. We used an optimised time-domain near-infrared spectroscopy (TD-NIRS) system (MAESTROS II) to measure placental oxygenation (PltO2) and metabolism across gestation and describe expected physiological behaviour and provide preliminary reference data in healthy pregnancies. In this prospective observational study, 113 women with low-risk singleton pregnancies underwent 30-minute TD-NIRS monitoring sessions. Placental position and depth were assessed by ultrasound, and skin pigmentation by Fitzpatrick scale. PltO2, changes in cytochrome-c-oxidase oxidation state (oxCCO), and the phase relationship between a haemodynamic oxygen-related signal (haemoglobin difference, HbD) and oxCCO were analysed. Mean PltO2 was 50.4% (±6.6%) with no significant gestational change. Placental depth, location, and skin tone did not significantly affect measurements. Wavelet analysis demonstrated predominantly out-of-phase HbD-oxCCO relationships, suggesting independent metabolic regulation. These findings provide reference data and support the potential clinical utility of monitoring placental function using optical measurements of oxygenation and metabolism.

Early-onset fetal growth restriction (FGR) may result from genetic abnormalities, uteroplacental insufficiency, or constitutional smallness, with differentiation often difficult in the absence of maternal hypertension or abnormal genetic findings. The sFlt-1/PlGF ratio has emerged as a potential marker of placental dysfunction. This single-center case series evaluated the clinical utility of the sFlt-1/PlGF ratio in pregnancies with early-onset FGR. Maternal characteristics, hypertensive disorders, and perinatal outcomes were analyzed. All patients had elevated sFlt-1/PlGF ratios (129.31–817.39). One patient had chronic hypertension, four developed gestational hypertension at least two weeks after FGR diagnosis, and four remained normotensive. Four pregnancies resulted in intrauterine demise. Among five live births, one neonate died, two required ongoing neonatal intensive care, and two were discharged after prolonged NICU stays. Elevated ratios were associated with placental insufficiency and adverse perinatal outcomes. The sFlt-1/PlGF ratio may help identify uteroplacental dysfunction in early-onset FGR and reduce reliance on costly genetic testing when aneuploidy screening is normal. Larger studies are needed to defi ne thresholds, optimal timing,and clinical utility.

Background Placental dysfunction remains a leading cause of stillbirth and neonatal morbidity, yet current monitoring tools provide only indirect and intermittent measures of fetoplacental wellbeing. Near infrared spectroscopy (NIRS) offers noninvasive, continuous monitoring of tissue oxygenation and metabolism. Objectives To develop a wearable NIRS system for placental monitoring (FetalSenseM v1 or FSM v1), investigate optical markers of placental oxygenation and metabolism in a population at high risk of adverse pregnancy outcomes such as stillbirth, and to apply machine learning analysis to develop a model for pregnancy outcome prediction. Study design In this prospective observational study, women with high-risk singleton pregnancies underwent antenatal placental NIRS monitoring for over 40 minutes. FSM v1 incorporates dual source detector separations and multiwavelength light sources to derive absolute placental oxygen saturation (PltO2) and relative cytochrome c oxidase (oxCCO) changes. FSM was placed on the abdominal wall following an ultrasound scan locating the placental position. Monte Carlo simulations were performed to estimate placental sensitivity, and a minimum placental sensitivity (MPS) threshold (>5%) defined a physiologically refined subcohort. Outcomes were classified using the In Utero nearmiss criteria for stillbirth. Machine learning (ML) analysis evaluated 11 classifiers using nested stratified 5 to 4 cross validation (5 outer folds for performance estimation and 4 inner folds for hyperparameter tuning). Results Seventy monitoring sessions from 58 participants were completed across gestational ages (25+2 to 41+1 weeks gestation); 33 recordings from 30 participants met MPS criteria. In the full cohort, mean PltO2 was 49.8% and was not related to gestational age or poor outcome based on near miss stillbirth criteria. In the MPS sub-cohort, higher PltO2 was observed in severe fetal growth restriction (FGR) and lower PltO2 in gestational diabetes (both p=0.04). Hemodynamic-metabolic coupling (HbD:oxCCO semblance) was increased in severe FGR (p=0.0002). The best performing ML model (SVM) achieved a balanced accuracy of 78%, a recall (sensitivity) of 72% and a specificity of 84% under 5 to 4 nested cross-validation using the top 50 features. Feature importance analysis identified oxCCO-derived and haemodynamicmetabolic coupling features as dominant predictors, whereas static PltO& was nondiscriminatory. Conclusion We describe the first wearable NIRS device to provide simultaneous non-invasive placental haemodynamic and metabolic monitoring. While static oxygenation indices lacked predictive value, ML analysis applied to dynamic NIRS features yielded accurate pregnancy outcome prediction, with metabolic signals emerging as key drivers. These findings support further development of wearable placental NIRS integrated with advanced analytics for antenatal surveillance. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The authors were supported by the Wellcome Trust (219610/Z/19/Z), Wellcome Leap as part of the In Utero programme, Wellcome / EPSRC Centre for Interventional and Surgical Sciences (WEISS), and National Institute for Health Research University College London Hospitals Biomedical Research Centre. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics Committee of East of England - Essex Research Ethics Committee gave ethical permission for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the author

Background:Mesenchymal stem cell-based therapy faces challenges that have driven interest in MSCs-derived culture-conditioned media (CCM) as a cell-free alternative. Our study aims to optimize the dose and collection timing of CCM to enhance its therapeutic efficacy in aGVHD, while also standardizing co-culture conditions for CD3+ T-cell interaction with CCM. Material and methods:Human MSCs were isolated from BM and WJ and subsequently preconditioned under hypoxic conditions (1 % O2) for 24 h in a tri-gas incubator. Culture-conditioned media (CCM) were collected from both naive (MSCs) and hypoxia-preconditioned MSCs (MSCsHYP) at 24, 48, and 72 h and filtered using a 0.2 μm membrane filter. CD3+ T-cell were isolated from PBMNCs derived from aGVHD patients. These T-cell were co-cultured at varying densities (2∗106, 5∗106, and 10∗106 cells/ml) with different concentrations of CCM (25 %, 50 %, and 100 %), and cell proliferation was assessed using the MTS assay. Furthermore, CD3+ T-cell proliferation and activation status were evaluated in a 2D co-culture model of CD3+ T-cell and CCM using flow cytometry. Results:Our findings revealed that CCM collected at 48 h, at a 50 % concentration, exerted the most pronounced inhibitory effect on CD3+ T-cell proliferation, particularly at a density of 5∗106 cells/ml, irrespective of the MSCs source. Hypoxia preconditioning significantly enhanced the immunomodulatory effects, with WJ-MSCsHYP-CCM demonstrating superior efficacy in suppressing T-cell proliferation, increasing the CD4+/CD8+ T-cell ratio, and reducing CD4+ T-cell activation compared to BM-MSCsHYP-CCM. Conclusion:These results emphasize the critical role of optimizing CCM collection timing and concentration to maximize therapeutic potential. Our study paves the way for the development of standardized, scalable, and effective cell-free therapies for aGVHD.

Pregnancy in women with complete heart block (CHB) poses a substantial challenge. We share our experience of managing pregnancies in patients with CHB. In this case series, outcome of 12 pregnancies in 10 women with PPM is studied. The presentation, need for pacemaker, and cardiac intervention were noted in patients with CHB. Mode of delivery, obstetric complications, and neonatal outcomes were compared with 24 low-risk pregnancies. Data analysis was carried out using SPSS software. Syncope was presenting symptoms in seven (70

OBJECTIVE:To analyze maternal and perinatal outcomes in women with rheumatic valvular heart disease and to evaluate the predictive factors for adverse cardiac outcomes in this cohort. METHODS:A retrospective analysis was performed of pregnant women with rheumatic heart disease (RHD) who delivered at a tertiary care referral hospital over a 5-year period from 2018 to 2023. RESULTS:A total of 118 pregnant women with RHD were encountered during the study period. The mitral valve was most commonly affected (75/118; 62.7%), 79/118 (66.9%) underwent cardiac interventions, and 39/118 (33%) were on anticoagulation medication. Deterioration in New York Heart Association (NYHA) functional class was noted in 36/118 (30.5%) of these women prenatally, and cardiac failure developed in 18/118 (15.3%). New-onset arrhythmia occurred in 6/118 (5.1%), which was managed medically. Mean gestational age at delivery was 36.73 ± 2.53 weeks, with a cesarean delivery rate of 68/118 (57.6%). Among fetal and neonatal outcomes, average birth weight was 2390.46 ± 574.46 g, with 38/118 (32.2%) being preterm and 61/118 (52.5%) being low birth weight. Key predictors of poor cardiac outcomes included more than one affected valve and a poor NYHA functional class (more than II) at admission. Patients with mechanical heart valves faced higher risks from anticoagulation. CONCLUSION:Pregnancy in women with RHD is associated with adverse maternal cardiac, obstetrical, and neonatal outcomes. More than one affected heart valve and a poor NYHA functional class were found to be strong predictors of adverse cardiac outcomes during pregnancy. A specialized cardio-obstetric team is crucial for enhancing pregnancy outcomes.

INTRODUCTIONMultiple Endocrine Neoplasia (MEN) 2A is an autosomal dominant syndrome characterized by medullary thyroid carcinoma (MTC), pheochromocytoma (PCC) and parathyroid tumors.[1-4] Caused by germ-line mutation in the RET proto-oncogene located on chromosome 10, MEN-2A is a subtype of the MEN-2 syndrome and is the more commonly encountered clinical variant (accounting for 75% cases) as opposed to MEN-2B.[5,6] Almost 90% afflicted individuals manifest with MTC while PCC and parathyroid tumors are noted in upto 40-50% and 20-30% cases respectively. As the disease may present with polyglandular involvement, screening of other endocrine organs is imperative once any single organ involvement is detected. Current literature on diagnosis and management of MEN-2A syndrome in pregnancy is scant and largely comprises case series or case reports. Most patients were incidentally detected to have hypertension during routine antenatal screening and found to have an underlying pheochromocytoma. The limitations imposed by pregnancy both in terms of restricted imaging options due to radiation exposure to the fetus and restricted period of surgical intervention in the second trimester makes the management of this situation challenging in most cases. We share our experience of a young woman with MEN 2A syndrome who became pregnant immediately post adrenalectomy for pheochromocytoma and had to undergo surgery for medullary thyroid carcinoma in second trimester during a nationwide lockdown due to the ongoing COVID pandemic. The case highlights the various challenges we faced in patient management, surgical intervention, post-operative care and follow up amidst travel restrictions during the lockdown along with how these challenges were overcome through multidisciplinary teamwork, teleconsultation services and shared decision making with the patient which led us to a successful outcome in a difficult clinical scenario, in such challenging times.

Objective. Screening for disease using a smartphone camera is an emerging tool for conditions such as jaundice and anaemia, which are associated with a colour change (yellowing in jaundice; pallor in anaemia) of the external tissues. Based on this, we aimed to test a technique to non-invasively screen for anaemia in a population highly affected by anaemia: pregnant women in India. In this group, anaemia can have severe health consequences for both the mother and child. Approach. Over 3 years of data collection, in 486 pregnant women in India, we attempted to replicate a previously successful smartphone imaging technique to screen for anaemia. Using smartphone images of the eye and eyelid, we compared two techniques (white balancing and ambient subtraction) to control for variation in ambient lighting, and then extracted 'redness' features from images, which we used as features to predict anaemia via statistical modelling. Main results. We found that we were not able to predict anaemia with enough accuracy to be clinically useful, at 89.6% sensitivity and 26.1% specificity. We consider the hypothesis that this may be due to pigmentation on the sclera and palpebral conjunctiva. Visual judgement showed that pigmentation on the sclera, which may affect the measured colour, is more prevalent in pregnant women in India than in preschool aged children in Ghana (a population previously studied in this context). When participants with subjectively judged visible scleral pigmentation are removed, ability to screen for anaemia using the smartphone images slightly improves (93.1% sensitivity, 28.6% specificity). Significance. These findings provide evidence to reinforce that applying smartphone imaging techniques to understudied populations in the real world requires caution-a promising result in one group may not necessarily transfer to another demographic.

To evaluate the performance of WHO and INTERGROWTH-21 (IG-21) fetal growth charts in the Indian population. A total of 250 pregnant women were recruited in this prospective observational pilot study carried out at a tertiary care hospital, New Delhi, India. Women underwent ultrasound scans for fetal biometry twice during their pregnancy, at 24–26 weeks and 34–36 weeks gestation. Measured values were plotted on WHO and INTERGROWTH-21 fetal growth charts. The 10th, 50th, and 90th centiles of fetal biometry were calculated for the study population, and prepared study charts were compared to the two growth charts for respective centiles. There was an agreement for both WHO and IG-21 charts with all the centiles of study charts for HC in both the 2nd and 3rd trimesters. However, the WHO chart had an agreement with the study charts for FL at all centiles but IG-21 underestimated FL in both trimesters. WHO chart was in agreement with the study population for BPD at 10th and 50th centiles only and IG-21 overestimated BPD at all centiles in both trimesters. For AC, both WHO and IG-21 charts have an agreement with study charts at the 10th and 50th centile at all gestations. However, for the 90th centile, IG-21 underestimates AC and the WHO chart agrees with the study population in 2nd trimester only. For EFW in the 2nd trimester, both WHO and IG-21 charts agreed to the study charts at all centiles but in the 3rd trimester WHO chart overestimates and IG-21 underestimates the study population for the 10th and 50th centiles. According to this pilot study, neither WHO nor IG-21 charts are a good fit for the Indian population, and locally developed fetal growth charts are needed.

OBJECTIVE:To evaluate ERAS protocol with multimodal analgesia incorporating transverse abdominis plane(TAP) block compared to routine postoperative care for pain control in women undergoing elective caesarean delivery. METHODS:This randomized study was conducted after ethical approval and CTRI registration (2020/10/028652). Total 140 women scheduled for elective caesarean were randomised into two groups. ERAS protocol was implemented in Group-1(n=70), and routine practice was followed in Group-2(n=70). Multimodal analgesia included TAP block after skin closure and intravenous paracetamol at shifting to recovery, followed by oral drugs as per analgesic clock. Outcomes were Pain Numerical Rating Scale(NRS) at rest and on movement at 6, 12, 24, 48 hours and at readiness for discharge, and need for rescue analgesics. RESULTS:NRS was significantly less in group-1 at all time points at rest and movement. Mean±SD NRS at rest was 30.57±1.52 vs. 64.71±1.52 at 6 hours, 28.14±1.39 vs. 56.57±1.39 at 12 hours in group-1 vs. group-2 respectively; (P=0.001). NRS on mobilisation was 37.71±1.57 vs. 74.00±1.57 and 36.42±1.46 vs. 65.28±1.46 at 6 and 12 hours respectively, (P=0.001). Patients needing rescue analgesia were 30 % vs. 87.1 % within 6 hours(65 % reduction), in 24.3 % vs. 77.1 % between 6-12 hours, 4.3 % vs. 40 % between 12-24 hours in group-1 and 2 respectively; with no requirement after 48 hours in either group. The mean Likert score for satisfaction was 4.4±0.60 and 3.4±0.78 in group-1 and group-2, respectively, p<0.001. CONCLUSION:ERAS protocol incorporating TAP block was effective in reducing postoperative pain, with 65 % reduction in requirement of rescue analgesia within six hours.