A Rare Case of Spontaneous Bilateral Ruptured Tubal Ectopic Pregnancy Abstract Bilateral tubal ectopic pregnancy is very rare, spontaneous cases being exceptional. Here, the authors report a case of spontaneous bilateral tubal ectopic pregnancy of 10-weeks gestation diagnosed and managed at Bharatratna Dr. Babasaheb Ambedkar Municipal and General Hospital, Kandivali, Mumbai. A 29-year-old, G2P1L1 patient presented in the emergency department with 3-months amenorrhea, abdominal pain and vaginal bleeding. Urine pregnancy test was positive, and an emergency ultrasound done revealed bilateral tubal ectopic pregnancies of 10-weeks size with hemoperitoneum. Emergency exploration was done, and a right-sided ruptured ampullary ectopic pregnancy with a left-sided ruptured fimbrial ectopic pregnancy was found with hemoperitoneum. Bilateral salpingectomy was performed, and patient recovered well postoperatively.

Gross Hematuria in Pregnancy: An Enigma

Liver Tumor in Pregnancy

Comments on Manuscript: Interstitial and Cornual Ectopic Pregnancy: Conservative Surgical and Medical Management

Obstetric Complications of Donor Egg Conception Pregnancies Abstract Ovum donation (OD) pregnancies are becoming increasingly common. Obstetric complications with IVF pregnancies are well documented. However, until recently OD had not previously been investigated as a separate subtype of this. It could be postulated that there may be more complications with OD pregnancies as the embryo is immunologically different to the mother. The subsequent allograft reactions can cause problems with placental development and function leading to pathology. Initial studies investigating OD pregnancies were inadequate due to small sample size and inappropriate control groups. Studies specifically comparing to spontaneous pregnancies alone are not suitable when we already know that IVF in itself increases the risk to both mother and baby. Recent research has optimised the control group by using women undergoing IVF with autologous ovum. Ovum donation has now been shown to be an independent risk factor for hypertensive disease in pregnancy, post-partum haemorrhage and increased risk of caesarean section. Neonatal outcomes are less clear-cut, although there is some evidence to suggest there is increased risk of small for gestational age babies and preterm delivery. It is now clear that OD pregnancies are higher risk than IVF pregnancies with autologous ovum and they should be treated as such. Women with ovum donation pregnancies should have obstetric-led care, in a unit which has ready access to both blood transfusion and cell salvage. Future research should investigate how to reduce the risk of ovum donation to these women.

Validation of the Risk Score for Maternal Cardiac Complications in Women with Cardiac Disease in Pregnancy: A Retrospective Study Abstract Aim of the Study To validate the new cardiac risk scoring system, Sheela’s Cardiac Disease in Pregnancy (SHE-CDIP), in predicting the cardiac complications in women with cardiac disease in pregnancy. Materials and Methods The study was conducted at a tertiary care hospital in South India, over a period of 5 years from January 2010 to January 2015. Pregnant women with heart disease included in this study were 102, and data was collected from medical records. Risk Score was calculated at booking according to both the new scoring system (SHE-CDIP) and the standard CARPREG scoring system. The validation was done by assessing the ability of the new scoring system to predict maternal cardiac complications by comparing with the CARPREG scoring system. Statistical Methods The validation of the SHE-CDIP score was done against CARPREG score using cross tabulation between current cardiac risk score with CARPREG score. McNemar square test was done to compare the proportion between two scoring methods. Agreement between CARPREG and SHE-CDIP risk score was analyzed using Kappa statistics, and accuracy was reported. Results Comparing the two risk scores using Kappa statistics, accuracy and good agreement were noted (kappa = 0.70). Sensitivity of 83%, specificity of 88%, positive predictive value of 86% and negative predictive value of 84% for the SHE-CDIP scoring system were noted. Conclusion The new risk score (SHE-CDIP) would be useful to stratify the risk in Indian cohort of women with cardiac disease in pregnancy as it is population specific.

Can Seminal IL-8 Level Be Used as a Marker of Leukocytospermia and Does It Have Any Correlation with Semen Parameters in Infertile Couples? Abstract Objectives Infection of male genital tract leads to leukocytospermia which may have a detrimental effect on semen quality. This study was conducted to evaluate whether seminal IL-8 level can be used as a marker of leukocytospermia and does it have any correlation with semen parameters in infertile couples? Methods This cross-sectional study was conducted in an infertility clinic of a tertiary care hospital including 150 male partners of infertile couples who underwent semen analysis (WHO laboratory manual for the examination and processing of human semen, 5th edn, World Health Organization, Geneva, p 271, 2010), semen culture sensitivity and seminal IL-8 levels. Independent t-test, Mann–Whitney U test and Chi-square test were applied for analysis. Results Mean seminal plasma IL-8 level of patients with leukocytospermia was significantly higher than patients without leukocytospermia (1143.67 ± 887.03 vs. 267.174 ± 242.29, p value < 0.001). Strong positive correlation was found between seminal plasma IL-8 levels and pus cells in the semen (r = 0.950, p < 0.001); AUC for seminal plasma IL-8 was 0.985 (CI 0.972–0.988), and a cutoff value of 399 pg/ml was determined to diagnose leukocytospermia. This value had high sensitivity (91.8%), specificity (94.5%), positive predictive value (94.4%) and diagnostic accuracy (93.2%) for detecting leukocytospermia. Seminal IL-8 levels correlated negatively with sperm motility (r = − 0.29, p < 0.001) and morphology (r = − 0.230, p < 0.01). Conclusion Seminal plasma IL-8 levels were found to be almost five times higher in male partners with leukocytospermia than in non-leukocytospermia group, and it appears to be a promising tool to detect leukocytospermia. Seminal IL-8 level correlated negatively with semen parameters including sperm motility and morphology.

The Relationship of Pregnancy-Associated Plasma Protein A and Human Chorionic Gonadotropin with Adverse Pregnancy Outcomes: A Prospective Study Abstract Purpose This prospective study investigated the relationship between pregnancy-associated plasma protein A (PAPP-A) and human chorionic gonadotropin (hCG) and adverse pregnancy outcomes in the Iranian population. Materials Overall, 994 singleton pregnant mothers of 18–35-year old were referred for first-trimester screening tests, including PAPP-A and β-hCG, at the age of 6 days and 11–13 weeks, and were followed until the end of their pregnancy. The adverse pregnancy outcomes, PAPP-A, and β-hCG serum levels were recorded and analyzed. The sensitivity and specificity of the test were measured by calculating the area under the curve of receiver operating characteristic curve (ROC). Results The mean serum level of PAPP-A and β-hCG was 1.10 ± 0.69 and 1.09 ± 0.8 MoM, respectively. Pregnancy-associated plasma protein A, regardless of its percentile, showed a significant relationship with the incidence of preeclampsia, preterm birth, and fetal low birth weight (p < 0.001 for each). However, the relationship between PAPP-A and abortion was not significant (p > 0.05). According to ROC, the results indicated that PAPP-A had a significant relationship with the incidence of preeclampsia, preterm birth, and fetal low birth weight (p < 0.001). However, β-hCG levels showed no significant relationship with adverse pregnancy outcomes. Conclusions The result of this study revealed that lower level of PAPP-A and β-hCG could be a predictive factor in preterm labor. Also, this study indicated that PAPP-A measurements could be a screening test for adverse pregnancy outcomes, such as preeclampsia, low birth weight and preterm labor.

Effect of Melatonin on Blood Loss After Cesarean Section: A Prospective Randomized Double-Blind Trial Abstract Background and Objectives The similarities between the melatonin and oxytocin signaling could lead to increased contractility of myometrium. We designed this randomized double-blind, placebo-controlled trial to evaluate the efficacy of melatonin in reduction of blood loss during and after the lower segment cesarean section. Methods One hundred and twenty patients who had been scheduled for cesarean section under spinal anesthesia were enrolled in the study. We randomly allocated them to one of the three following groups to receive either melatonin 3 mg (M3), melatonin 6 mg (M6), or placebo (P) sublingually 20 min before the surgery. The hemoglobin levels before and 12 h after surgery, the mean weight of the materials used in the operation time, the need for additional oxytocic therapy, and the incidence of adverse effects were probed and recorded. Results There was a significant difference between the group M6 and both M3 and P in the mean weight of the materials (p = .024 and .041, respectively) and between M6 and P groups in terms of mean decrease in hemoglobin during 12 h after cesarean section (p = .029). Conclusion Using 6 mg melatonin, sublingually, as a premedication in patients undergoing cesarean section with spinal anesthesia could statistically reduce the amount of blood loss after the lower segment cesarean section, although it may not be clinically meaningful. Registration number: ACTRN12612000117819 and ClinicalTrials.gov Identifier: NCT01572805

Assessment of a Combination of Clinical Maneuvers in Evaluation of Post-Laparoscopic Pain: A Randomized Clinical Trial Abstract Background To assess the efficacy of the combined maneuvers in evaluation of post-laparoscopic pain. Material and Methods A randomized controlled study was conducted. Sixty-four women were included in the study and were randomly divided into two groups. Intervention group received combined maneuvers such as intraperitoneal normal saline infusion, pulmonary recruitment maneuver and local bupivacaine instillation at port sites after laparoscopic surgery. Control group received routine care. Main Outcome Measures Upper abdominal pain, shoulder pain and incision site pain were noted in both groups at 3, 6, 12, 24 and 48 h postoperatively. Results The median interquartile range (in centiles) of upper abdominal pain score 3, 6 and 12 h postoperatively in the intervention group was 1.0 (0.25–1.0), 1.0 (0.0–1.0) and 0.50 (0.0–1.0), and in the control group, the values were 2.0 (2.0–1.0), 2.0 (2.0–1.0) and 1.0 (0–1.0) at 3, 6 and 12 h, respectively (p < 0.000). The median interquartile range of shoulder pain score 3, 6 and 12 h postoperatively in the intervention group was 0.0 (0.0–1.0), 0.0 (0.0–0.75) and 0.0 (0.0–1.0), and in the control group, the values were 1.0 (0.0–2.0), 1.0 (0.0–1.75) and 1.0 (0–1.0) at 3, 6, and 12 h. The upper abdominal pain and shoulder pain relief was significantly more in the intervention group than in the control group in the first 12 h of surgery. Conclusion Combined maneuvers could significantly reduce post-laparoscopic upper abdominal and shoulder pain. Clinical Trial CTRI Registration Number-CTRI/2017/07/0089, web address of CTRI—http://ctri.nic.in