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Objective: To compare efficacy of sublingual (S/L), oral and vaginal routes of misoprostol administration for cervical priming before suction evacuation (SE) under local anaesthesia. Methods: In a prospective randomised clinical trial, 200 women in the first trimester of pregnancy were randomised into four groups of 50 each. Patients in control group did not receive any medication before SE while other treatment groups received 400 microg of misoprostol three hours prior to SE either by sublingual/oral or by vaginal route. Main outcome measure was basal cervical dilatation while the secondary outcome measures were operative blood loss, time duration of surgery, patient satisfaction, pain perception and adverse effects. Results: Sublingual group had a higher dilatation (9.9 +/- 2.1 mm; P < 0.001) and lower time duration of surgery (3.6 +/- 1.0 min; P < 0.01) as compared to oral (8.2 +/- 2.6 mm, 4.9 +/- 1.7 min) or vaginal routes (7.6 +/- 2.6 mm, 5.2 +/- 1.8 min). Mean pain score of the sublingual group was significantly lower (2.4 + 1.3; P < 0.001) as compared to oral (3.4 +/- 1.3) or vaginal routes (3.6 +/- 1.2). Patient acceptability was higher for sublingual (53 of 150) and oral routes (62 of 150) as compared to vaginal (35 of 150) route. Conclusion: Sublingual route was significantly more effective than oral or vaginal administration of misoprostol for cervical dilatation. To the best of our knowledge, this is the first study to simultaneously compare the efficacy of sublingual, oral and vaginal routes of misoprostol for cervical priming before SE. [ABSTRACT FROM AUTHOR]

Objective: Risk of malformations in children of women with epilepsy -- 5 years data from prospective, control study. Methods: All pregnant women, including women during preconception, who attended our hospital during years 2002-2007 were screened for women with history of epilepsy (WWE) and were enrolled for prospective study after obtaining due consent. Pregnant women, including women during preconception, who had neither history of epilepsy nor taking any anti epileptic drug (AED), but matched for age, parity and period of gestation were enrolled as control group. All women were given 5 mg of folic acid daily after enrolment, if not taking already, Women were followed up every trimester till delivery and children were followed up to early neonatal period. Details of malformations were noted in both groups. Results: 2.75, 598 pregnant women, attending our hospital, were screened during years 2002-2007 for history of epilepsy or intake of AED. There were 530 pregnant women with epilepsy (0.2%) and 8 other women were taking AED for reasons other than epilepsy. 8 WWE were excluded from study because of severe co morbid conditions or induced abortion for personal reasons other than fetal status. 522 WWE and 474 controls were recruited in the study. Outcome was known in 424 WWE and 387 controls. There were 395 live births (93.5%) in WWE and 378 (97.7%) in control group. Congenital malformations were seen in 13 children of WWE (3.0%) and in 7 children of control group (1.8%) and the difference was not statistically significant (P value 0.249). There is no significant difference in the type of malformations between the groups. AED intake as mono therapy or no AED intake during pregnancy in WWE showed no significant difference in the risk of malformations in children of WWE (Odds ratio 1.20 and 95% C.I. 0.91-1.57). But, intake of AED as poly therapy increased the risk of malformations (10.4% Odds ratio 4.87 95% C.I. 1.36-17.41). Use of carbamazapine was not associated with any malformation in the present study. Conclusions: More than 90% women with epilepsy delivered normal children. Risk of malformations did not show any significant increase over controls. AED monotherapy did not increase risk of malformations. Long duration of epilepsy and Polytherapy with multiple AED significantly increased risk of malformations in WWE. Use of Carbamazepine did not result in any malformation in the present study. [ABSTRACT FROM AUTHOR]

Objective: To assess the risk of abortions/stillbirths in women with epilepsy Methods: in a prospective, control study, pregnant women with epilepsy (WWE) and control group of pregnant women, who had neither history of epilepsy nor history of intake of antiepileptic drugs, but matched for age, parity and period of gestation were followed up till delivery to assess the risk of abortions/stillbirths. Women with severe comorbid conditions or women, who opted for medical termination of pregnancy for reasons unrelated to status of fetus were excluded from study. Results: 424 WWE and 387 controls were followed up till delivery. 29 WWE [6.8%] and 9 women in control group [2.3%] had abortion or stillbirth [P value 0.01]. Presence of generalized tonic clonic seizures during first trimester [14.7% vs 6.2% P value 0.05] and polytherapy with antiepileptic drugs [14.5% vs 5.4% P value 0.03] increased the risk of abortions/stillbirths in WWE. Use of antiepileptic drugs as monotherapy did not increase the risk of abortions or stillbirths in WWE. Conclusions: WWE had three times increased risk of abortions or stillbirths as compared to control group. Presence of generalized tonic clonic seizures during first trimester and use of polytherapy increased the risk in WWE, but antiepileptic drug use as monotherapy did not increase the risk of abortion or stillbirth in WWE. [ABSTRACT FROM AUTHOR]

Carbohydrate antigen 19-9 (CA 19-9) is a tumour marker found to be elevated in some ovarian tumours. We share our experience with a 55-year-old postmenopausal lady with unusually high CA19-9 levels arising from a benign mucinous cystadenoma of the ovary. The levels returned to normal eight weeks following staging laparotomy and a total abdominal hysterectomy with bilateral salpingo-oopherectomy. This report shows rare and significant elevation of CA 19-9 levels with benign mucinous cystadenomas of the ovary thus showing that women with unusually elevated tumour markers may actually harbour benign disease. The tumour markers should not be used to predict the malignant status of a tumour.

Background: Cyclooxygenase-2 (Cox-2) is frequently overexpressed in cervical carcinoma, but little is known about its altered serum concentration. Hence, this study evaluates clinical utility of cellular and serum level of Cox-2 enzyme in cervical cancer., Methods: The expression of Cox-2 was evaluated in cervical tissues and serum samples collected from normal controls (n = 100; n = 68), cervical intraepithelial neoplasia patients (CIN, n = 67; n = 12), and invasive squamous cell carcinoma patients (SCCs; n = 153; n = 127) by immunohistochemical and enzyme-linked immunosorbent assay (ELISA) analyses., Results: The significant cytoplasmic overexpression of Cox-2 was noted in 50.7% of CIN and 69.9% of SCCs as compared with normal (P = 0.0001). Serum level of Cox-2 was also found to be elevated both in CIN (median 4.35 ng/ml) and in SCCs (median 19.39 ng/ml) with respect to normal (median 0.44 ng/ml; P = 0.0001), respectively. The ROC analysis revealed the potential of serum Cox-2 over its cellular expression to distinguish CIN and SCCs from normal., Conclusion: Augmented Cox-2 activity is implicated in the pathogenesis of cervical cancer, and its serum level could serve a potential to distinguish this malignancy. Therefore, it is suggested that serum Cox-2 may be useful in monitoring the diagnosis and treatment outcome of patients., (© 2016 Wiley Periodicals, Inc.)

Objective: To assess the birth prevalence and pattern of congenital heart disease (CHD) using echocardiography in babies born in a community hospital of North India., Methods: A cross-sectional observational study conducted over a period of 3 years. Newborns born over a specific 8-h period of the day were recruited in the study. They underwent routine clinical examination and pulse oximetry, followed by screening echocardiography for diagnosing a CHD., Results: A total of 20,307 newborns were screened, among which 874 had abnormal echocardiograms; 687 had insignificant CHDs, 164 had significant CHDs, and 24 had other abnormal cardiac findings. The birth prevalence of significant CHDs was 8.07 per 1000 live births; 131 newborns had an acyanotic CHD (79.9%) and 33 a cyanotic CHD (20.1%). Ventricular septal defect (VSD) was the most common acyanotic CHD, present in 116 newborns, giving a prevalence of 5.7/1000 live births. Among the cyanotic CHD, transposition of great arteries was most common (prevalence 0.34/1000 live births)., Conclusion: The CHD birth prevalence in our study is similar to the reported worldwide birth prevalence. Acyanotic CHD (mostly VSD) is seen in about three-fourths of babies born with CHD. The more sinister cyanotic CHD is present in remaining 25%.

Objective: To evaluate the use of pulse oximetry as a screening tool for detecting major congenital heart defects (CHDs) in Indian newborns., Design: Cross-sectional observational study., Patients: In a community hospital of north India, babies born during a specific 8 h period of the day were recruited over a period of 3 years. Newborns with incomplete documentation were excluded., Intervention: Routine clinical examination, pulse oximetry and bedside echocardiography., Outcome Measures: Any abnormalities in clinical examination and pulse oximetry were recorded. CHDs were diagnosed using bedside echocardiography. Accuracy of pulse oximetry, clinical examination and their combination for detecting major CHDs was calculated., Results: Among the 19 009 newborns screened, 70 had major CHDs at birth (44 serious, 26 critical). Pulse oximetry detected 39 major (sensitivity 55.7%, 95% CI 44.1% to 66.8%; specificity 68.3%, 67.6% to 68.9%) and 22 critical CHDs (sensitivity 84.6%, 66.5% to 93.9%; specificity 68.3%, 67.6% to 68.9%). Addition of pulse oximetry to clinical examination significantly improved sensitivity for major CHDs (35.7% (25.5% to 47.4%) to 75.7% (64.5% to 85.3%), p<0.01) and critical CHDs (11.5% (4.0% to 29.0%) to 84.6% (66.5% to 93.9%), p<0.01)., Conclusions: Pulse oximetry is a sensitive screening tool for detecting major CHDs in Indian newborns. It adds significant value to the current practice of using clinical examination as a sole screening tool for detecting major CHDs. However, specificity of pulse oximetry was much lower in our study. Possible reasons for low specificity could be non-repetition of pulse oximetry in newborns with initial lower saturations, high prevalence of infections and respiratory issues in our cohort and use of non-motion tolerant oximeter., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Spontaneous umbilical endometriosis occurring in absence of any previous abdominal or uterine surgery is extremely atypical. Its association with umbilical hernia is very rare and hernia getting spontaneously resolved has not been reported in literature so far. Here we report a case of a patient with spontaneous umbilical endometriosis associated with umbilical hernia which led to spontaneous hernia reduction. This was also associated with multiple uterine fibromyoma and bilateral ovarian endometrioma which were simultaneously treated by total abdominal hysterectomy with bilateral salpingo-oopherectomy along with surgical excision of the endometriotic tissue and repair of the abdominal wall defect. To the best of our knowledge, this is the first described case of spontaneous umbilical hernia reduction due to development of endometriosis.

Problem: To determine the role of inactivated GSK3β with respect to Wnt/β-catenin pathway activation in HPV-16/18-associated cervical cancer., Method of Study: The expression of active (pGSK3β-Try(216)), inactive (pGSK3β-Ser(9)), and c-Myc as well as HPV-16/18 infection was analyzed in cervical intra-epithelial neoplasia (CIN), squamous cell carcinoma (SCCs) and normal by immunohistochemistry and multiplex PCR. The proteins level was also compared with β-catenin and APC expression., Results: The dramatic decrease of pGSK3β-Try(216) expression but ectopic overexpression of pGSK3β-Ser(9) and c-Myc was observed both in CIN and SCCs samples compared to normal tissues. 57/67 CIN and 132/153 SCCs showed HPV-16 infection, while 3/67 CIN and 4/153 SCCs were harbored with HPV-18 infection. Both the proteins were significantly upregulated in HPV-16 infected cases (P = 0.0001; P = 0.001) and also positively correlated with nuclear β-catenin (P = 0.0001; P = 0.0001)., Conclusion: The process of generation of HPV-16-associated cervical tumorigenesis is synergized with GSK3β inactivation and overactivation of Wnt/β-catenin pathway., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The aim of this study is to compare the effectiveness of 100 mg versus 200 mg mifepristone along with misoprostol for medical abortion in gestation upto 56 days. This is a prospective controlled study. Eighty women seeking medical abortion with a gestation up to 56 days were included in the study. The women were randomly allotted into two groups. They received 100 mg/200 mg mifepristone on day 1 followed by 800 mcg misoprostol two days later. Women who had not aborted completely by day 14, received a repeat dose of 400 mcg misoprostol and were evaluated on day 21 for completeness of the procedure. Five women in both the groups had incomplete abortion by day 14 (12.5%), while one woman in the test group had to undergo dilatation and evacuation on day 3 due to excessive bleeding. By repeating a second dose of misoprostol, all of them aborted completely and the complete abortion rates were markedly improved from 85% and 87.5% in the test and the control group, respectively to 97.5% and 100%, respectively. It may be concluded that 100 mg mifepristone is as effective as 200 mg and appears to be the lowest effective dose for medical abortion.

Objective: The present study was aimed to investigate the importance of Pin1 expression in Squamous Cell Carcinoma (SCC) of cervix and to assess its level with β-catenin and APC to understand the possible involvement of Pin1 in the regulation of these proteins and subsequent activation of Wnt/β-catenin signaling., Materials and Methods: Expression of Pin1, β-catenin and APC was examined in 153 SCC patients by immunohistochemistry and revalidated by western blotting., Results: Of the 153 SCC analyzed, Pin1 was overexpressed in 73 (47.71%) cases. Loss of membranous β-catenin was noticed in 117 (76.47%) SCCs, whereas 66/153 (43.13%) and 93/153 (60.78%) cases showed its distinct cytoplasmic as well as nuclear accumulation respectively. Down regulation/loss of APC was observed in 69 (45.09%) cases, suggesting the activation of Wnt/β-catenin pathway in SCCs. Pin1 showed the significant association with nuclear β-catenin (r=.349, p<0.0001) and cytoplasmic loss of APC (r=-.287, p<0.0001). Both Pin1 as well as nuclear β-catenin were found to be associated with tumor stage (p=0.004, p=0.031) and tumor size (p=0.022, p=0.003). The Pin1 overexpression showed the significant association with disease free survival (p=0.002) but not with overall survival (p=0.421) of SCC patients., Conclusion: Current results explore the expressional relationship between Pin1, β-catenin and APC suggesting that Pin1 regulates the activation of Wnt/β-catenin pathway in SCCs via modulating the interaction between β-catenin and APC. Furthermore, the significant association of Pin1 and β-catenin with tumor variables underscores the clinical utility of these proteins in cervical cancer.

Background: Maternal position affects spinal block characteristics. We investigated the effect of lateral, modified lateral and sitting position for spinal anesthesia with 2 mL hyperbaric bupivacaine 0.5% on spinal block characteristics in this prospective, randomized study., Methods: Seventy-five ASA physical status I parturients were randomly allocated to the left lateral to supine-wedged, modified lateral to supine-wedged with a10°head-up tilt or the sitting to supine-wedged position for induction of spinal anesthesia for Cesarean delivery. Neural block was assessed by pin prick and modified Bromage scale. Data were analyzed using ANOVA, Chi-square test and Wilcoxon rank sum test, where appropriate. P<0.05 was considered significant., Results: Onset time (mean ± SD) for sensory block to T5 dermatome for the lateral, modified lateral and sitting groups was 6.8 ± 2.7, 13.6 ± 6.2 and 9.7 ± 5.5 min, respectively; P<0.001. The median (interquartile range) maximum dermatomal level was significantly lower in the modified lateral group (T5[T3-T5]) compared with the lateral (T3[T2-T4]) and sitting (T3[T3-T4]) groups, respectively; P=0.022 and P=0.030, respectively. Three women in the modified lateral group required general anesthesia compared with none in the other groups; P= 0.044. Apgar scores and cord blood pH, PO2 and PCO2 were similar between groups., Conclusion: The modified lateral position with 10 mg of hyperbaric bupivacaine was associated with a slower onset and a lower maximum sensory block necessitating higher requirement for conversion to general anesthesia. It did not offer any advantage over lateral and sitting positions for induction of spinal anesthesia for elective Cesarean delivery and cannot be recommended.

Pheochromocytoma in pregnancy is rare (1 in 50,000 full term pregnancies). Recognition of the condition is central to improving outcome (maternal and foetal mortality is reduced from 58% and 56%, respectively to 2% and 11-15%, respectively). An antenatal patient in third trimester diagnosed as pheochromocytoma has been described. Diagnosis of pheochromocytoma was confirmed by urinary VMA levels and demonstration of right adrenal mass on ultrasound. A multidisciplinary approach was used and the patient received antihypertensives for 10 days. Vaginal delivery was conducted under epidural analgesia and the patient was kept under close surveillance. She delivered a healthy baby girl weighing 2.5 kg. The intrapartum and the postpartum period were uneventful. Adrenalectomy was done at 6 weeks postpartum. Using multidisciplinary approach and individualised management decreases both maternal and foetal morbidity and mortality. Selected multigravidae cases and those with previous history of short uncomplicated labour, may be considered for vaginal delivery under epidural analgesia and with back up facilities available to manage hypertensive crisis.

Cervical cancer is one of the most common gynecological malignancies that causes a serious health problem worldwide. The aim of the present study was to analyze the association of p53 codon72 (arginine/proline) polymorphism (rs1042522) and Murine Double Minute 2 (MDM2) SNP309 T/G (rs2279744) with the advancement of cervical cancer by using polymerase chain reaction-restriction fragment length polymorphism method followed by direct sequencing. The frequencies of GG genotype at 309 position in the second promoter (P2) of MDM2 and Arginine in codon72 of p53 were found to be 3.5 (odds ratio [OR]=3.51; 95% confidence interval [CI]=1.93-6.4; p<0.0001) and 5 (OR=4.978; 95% CI=2.7-9.2; p<0.0001) fold higher, respectively, in cases than in the control. On gene-gene interactions between MDM2 and p53 polymorphisms, the frequency of MDM2 G/G and p53 Arg/Arg together was found to be 6.5-fold higher in cervical cancer patients compared with healthy controls (OR=6.497; 95% CI=2.987-14.13; p<0.0001). We found an association of p53 codon72 arginine and MDM2 SNP309 GG genotype with different clinical and histological grades, human papillomavirus (HPV) infection, and age at the time of diagnosis of cervical cancer. In conclusion, Arginine at codon72 of p53 and GG genotype at 309 in P2 of MDM2 together reveal a direct proportionality with the tumor grade of cervical cancer along with HPV infection in postmenopausal women.

Chlamydial infection of the lower genital tract usually spreads to the upper genital tract and is then responsible for more serious consequences, such as infertility, ectopic pregnancy, pelvic pain, and pelvic inflammatory disease. Genital infection with Chlamydia trachomatis and the resulting cytokine response largely determines the outcome of infection and disease. To date, studies showing comparative effects of azithromycin and doxycycline treatment for C. trachomatis infection in women with reproductive sequelae like infertility and their effect on immune molecules like cytokines are lacking. Hence, our objective was to study the effect of azithromycin and doxycycline in vitro on cytokines in cells from C. trachomatis-positive fertile and infertile women as well as their efficacy in C. trachomatis infection. Fertile and infertile women with primary and recurrent C. trachomatis infection attending the gynecology outpatient department of Safdarjung Hospital, New Delhi, India, were enrolled. Enzyme-linked immunosorbent assay and real-time reverse transcription-polymerase chain reaction was performed for evaluating cytokines in cells stimulated with chlamydial elementary bodies (EBs) in the presence and absence of antibiotics (azithromycin and doxycycline). C. trachomatis-infected women were also followed up to assess the efficacy of azithromycin and doxycycline. We observed inhibition of cytokines (interleukin [IL]-1beta (β), IL-6, IL-8, IL-10, and tumor necrosis factor-alpha) in the presence of azithromycin in EB-stimulated cells from both fertile and infertile women with primary and recurrent C. trachomatis infection. However, in presence of doxycycline, inhibition of cytokines (IL-1β and IL-6) was only observed in stimulated cells from fertile women with primary C. trachomatis infection. The clinical efficacy of azithromycin was also better than doxycycline in recurrent C. trachomatis infection in women with complications such as infertility. Overall, this study suggests that azithromycin treatment with broader immunomodulatory effects may be preferable to doxycycline for the treatment of recurrent C. trachomatis infection associated with infertility.

Objectives. Anemia is a major public health problem throughout the world which assumes prominence in pregnant mothers. Patients with severe anemia continue to present themselves at term or in labor. This study was conducted to compare the improvements in hematological parameters of patients receiving partial exchange blood transfusion and transfusion of packed cells without exchange. Methods. One hundred and twenty-five severely anemic antenatal mothers were admitted from outpatient service. Partial exchange transfusion was given to sixty-six patients while fifty-nine received transfusion of packed cells with frusemide cover. Results. The two groups were comparable in terms of age, height, weight, religion, diet, education, occupation of self and husband, and income. Hemoglobin level in Group 1 was comparatively less than Group 2 at prelevel (5.2 ± 1.5 versus 6.6 ± 2.3, P = 0.001) and postlevel (7.2 ± 1.5 versus 8.6 ± 1.8, P = 0.001), respectively, but there was no significant difference between the two modes of transfusion (2.09 ± 1.6 versus 2.01 ± 1.5, P = 0.78). Conclusion. The study produced an equally significant improvement in hematological parameters in partial exchange and packed cell transfusion. Platelet counts were significantly less in partial exchange as compared with packed cell transfusion.

Problem: To study the innate immune response -TLR2 TLR 4 and iNOS expression in female genital Chlamydia trachomatis infection., Method: TLR 2, TLR 4, and iNOS expression was evaluated by real-time PCR in C. trachomatis-infected asymptomatic, mucopurulent cervicitis (MPC), and fertility disorders (FD) women. Expression of TLR signaling pathway genes was checked in vivo in C. trachomatis-infected cervical monocytes. Further, inos gene expression and nitric oxide release was assessed in vitro in THP-1 cell line upon chlamydial infection., Results: TLR2, TLR4, and iNOS expression was significantly (P < 0.05) higher in C. trachomatis-positive women with FD, MPC, and asymptomatic women, respectively, than in control. Chlamydial infection significantly upregulates CD86, TLR4, MyD88, IRAK2, nF-κB, IL-1,β and IL-12 genes. Expression of iNOS gene was found to be significantly (P < 0.05) high 12 hrs post-infection., Conclusions: Chlamydia trachomatis stimulates innate immune cells by activation of TLR2/TLR 4. Overall data indicate that recognition by TLR4 helps in initiation of immune response while recognition by TLR2 leads to secretion of inflammatory cytokines while iNOS-induced nitric oxide production helps in clearing Chlamydia. These results are first to provide initial insights into how innate immune response operates in human cervical monocytes upon chlamydial infection., (© 2011 John Wiley & Sons A/S.)

We investigated the expression of methyl transferase G9a and methylated histone H3-K9 in fresh human decidual/endometrial tissue of 12 normal early pregnancies and 15 unexplained recurrent spontaneous abortions (URSA). The samples were obtained through dilatation and curettage and collected as per strict inclusion-exclusion criteria. The tissue was subjected to immunohistochemical analysis (IHC), western blotting (WB) and RT-PCR analysis. The results demonstrated methyl transferase G9a to have a lower expression in abortions when compared with that in normal pregnancy (P < 0.05). The sensitivity of RT-PCR, IHC and WB were respectively 66.67, 75 and 71.43%, while specificity of the same were 66.67, 60 and 78.92%, respectively. Methylated histone H3-K9 was significantly lower (P < 0.0001) in URSA tissues than in controls. This study suggests that methylation may cause URSA and indicates the need for further work to explore the role of methylation in URSA and its possible prevention through locally acting methylating/demethylating agents.