Impact of COVID-19 on psychosocial functioning of peripartum women: A qualitative study comprising focus group discussions and in-depth interviews

Objective

Peripartum is a period of profound hormonal changes in the body and COVID‐19 seems to have an additional impact on these women's psychosocial functioning. This calls for a need to address the psychosocial and behavioural impact of COVID‐19 on peripartum women's lives.

Methods

Three focus group discussions and ten in‐depth interviews were conducted. A format to guide discussions and interviews was made to bring uniformity across groups and participants. Participants were recruited through purposive sampling. In verbatim transcription was done, followed by thematic analysis to extract key conceptual themes.

Results

Fourteen pregnant and eleven postpartum women were included. The mean age was 28.5 years. Two major domains were identified: 1) the psychological domain including the categories of thoughts, emotions, and behaviour, and 2) the social domain comprising categories of relationships with family members and friends, perceived loss of social support, doctor‐patient relationship, and social determinants of health.

Conclusion

The pandemic has indeed affected the psychosocial functioning of peripartum women. The study results might prove to be helpful for clinicians and mental health specialists who can suggest and develop different coping strategies for peripartum women during this pandemic.

Management of the first patient with confirmed COVID-19 in pregnancy in India: From guidelines to frontlines

Successful pregnancy management in a patient with confirmed COVID‐19 requires a multidisciplinary team approach and facility preparedness, especially during the pandemic.

Family planning and abortion services in COVID 19 pandemic

Many routine and elective services have already been postponed or suspended by both Government and private setups in most parts of the world because of the unprecedented pandemic of COVID-19. Healthcare systems everywhere in the world are under pressure. Being a component of essential health services, family planning and abortion services should continue to cater the population in order to prevent the complications arising from unintended pregnancies and sudden rise in STIs. Due to airborne nature of transmission of the virus, it is advisable for all consultations relating to family planning services to be done remotely unless and until visit is absolutely necessary. Contraception initiation and continuation can be done by telemedicine in most individuals. Post partum contraception can be advised before discharge from hospital. In an individual planning for pregnancy, currently it is not advisable to discontinue contraceptive and plan for pregnancy as not much is known about the effect of the virus on foetal development. Also, pregnancy requires routine antenatal and peripartum care and complications arising from pregnancy may necessitate frequent hospital visits, exposing the individual to the risk of infection. Abortion services are time sensitive therefore should not be denied or delayed beyond legal limit. We need to change from real to virtual consultation to prevent the rise in unplanned pregnancies, sexually transmitted infections and unsafe abortions.

Weight Management Module for Perimenopausal Women: A Practical Guide for Gynecologists

Menopause has been identified as a high-risk stage for weight gain in a woman's lifecycle. Menopause-related weight gain is a consequence of low circulating estrogen levels due to progressive loss of ovarian function. Moreover, the changes in the hormonal milieu, chronological aging, decline in physical activity coupled with westernized dietary pattern, and recurrent emotional eating episodes associated with psychological distress also contribute to the increase in total body fat and waist circumference. Higher waist circumference is an independent risk factor for cardiovascular and metabolic disease in menopausal women. These obesity-related cardiometabolic risk factors and menopausal symptoms can be effectively managed by achieving clinically significant weight loss through lifestyle modification. Behavioral lifestyle intervention uses behavioral techniques for counseling corrective dietary and physical activity practices in achieving sustainable weight loss outcomes. Majority of menopausal women seek this counseling from gynecologist, especially in primary care settings due to nonavailability of multidisciplinary teams. Thus, the aim of the review is to understand the menopause-obesity link, associated risk factors, and its health-related burden in perimenopausal women to devise a practical women-centric weight management module based on lifestyle modification techniques to address the burden of menopausal obesity in regular gynecological practice.

Executive summary of evidence and consensus-based clinical practice guideline for management of obesity and overweight in postpartum women: An AIIMS-DST initiative

INTRODUCTION

Postpartum obesity is a public health concern. There is a need to counsel women about their postpartum weight management, accounting for various barriers they face. Limited literature in the Indian context underscored the need to develop the clinical practice guideline to be used by healthcare providers in Indian healthcare settings.

METHODS

The guideline was formulated by following the standardised methodology proposed by the National Health and Medical Research Council. Various steps such as identification of the patient population, assembly of the guideline development groups, identification of the key clinical questions, guideline development methods, grading the quality of evidence and recommendations and guideline translation were carried out to develop and validate the clinical practice recommendations.

RESULTS

The evidence and consensus-based clinical practice guideline has been developed, providing recommendations for key topics of interest for first-line treatment of obesity (lifestyle-related management). Recommendations focus on screening and initiating discussion with overweight and obese postpartum women as well as those who had normal pre-pregnancy body mass index but have retained excessive weight in the postpartum period. Recommendations highlight the evaluation and management of dietary, physical activity and breastfeeding behaviour. Recommendations also account for behavioural modification techniques to improve adherence to the prescribed weight management advice. Duration and frequency of follow-ups as well as the advice to be disseminated have also been discussed in the recommendations.

CONCLUSION

The guideline provides clinical practice points that can be used by healthcare providers, postpartum women and policymakers for opportunistic screening and management of postpartum obesity.

Perinatal outcome in monochorionic twin pregnancies after selective fetal reduction using radiofrequency ablation

OBJECTIVE

To study the perinatal outcomes in women with complicated monochorionic twin pregnancies undergoing selective fetal reduction using radiofrequency ablation (RFA).

METHODS

This retrospective study included 44 patients with monochorionic twin pregnancies, between 14 and 28 weeks of pregnancy, who underwent RFA for selective fetal reduction. Perinatal and maternal outcomes and procedure-related complications were analyzed.

RESULTS

The procedure was technically successful in all 44 cases. Indications for selective fetal reduction included twin-to-twin transfusion syndrome (52.3%), twin reversed arterial perfusion (20.5%), twins discordant for anomaly (15.9%), and selective fetal growth restriction (11.4%). Median gestational age at procedure was 22^2/7  weeks (range 14-26^6/7 ). Live birth rate was 77.3% with three neonatal deaths; so overall survival was 70.5%. Median procedure-to-delivery interval was 12^3/7  weeks (range 2^4/7 -23). There were eight losses before 24 weeks of pregnancy, which included two co-twin deaths. Median gestational age at delivery was 35 weeks (interquartile range 32^1/7 -37 weeks). The preterm delivery rate was 66.7% (24/36) and preterm prelabor rupture of membranes (PPROM) occurred in 22.7% (10/44) of patients.

CONCLUSION

Selective fetal reduction using RFA is safe and effective in complicated monochorionic pregnancies. However, the rates of PPROM and preterm delivery remain high.

Redesigning routine antenatal care in low resource setting during COVID-19 pandemic

Obstetric population because of its unique and varying needs specific for different gestations justifies for distinctive considerations in times of pandemic like COVID-19. Healthcare facilities providing obstetric care need to develop contingency plans for minimizing antenatal visits to limit exposure of both healthy pregnant women and care providers from ill people. However, to mitigate any potential adverse effects of reduced antenatal visits, intelligent and smart use of evolving telemedicine capabilities can provide the continuum of care despite overwhelming burden due to pandemic. A collaborative work-model involving health workers in the community and the regional levels of health centres also has the potential to prevent the catastrophic collapse of obstetric care services during any pandemic like COVID-19.

Two-dimensional fetal biometry versus three-dimensional fractional thigh volume for ultrasonographic prediction of birthweight

OBJECTIVE

To develop and validate birthweight prediction models using fetal fractional thigh volume (TVol) in an Indian population, comparing them with existing prediction models developed for other ethnicities.

METHODS

A prospective observational study was conducted among 131 pregnant women (>36 weeks) attending a tertiary hospital in New Delhi, India, for prenatal care between December 1, 2014, and November 1, 2016. Participants were randomly divided into formulating (n=100) and validation (n=31) groups. Multiple regression analysis was performed to generate four models to predict birthweight using various combinations of two-dimensional (2D) ultrasonographic parameters and a three-dimensional (3D) ultrasonographic parameter (TVol). The best fit model was compared with previously published 2D and 3D models.

RESULTS

The best fit model comprised biparietal diameter, head circumference, abdominal circumference, and TVol. This model had the lowest mean percentage error (0.624 ± 8.075) and the highest coefficient of determination (R² =0.660). It correctly predicted 70.2% and 91.6% of birthweights within 5% and 10% of actual weight, respectively. Compared with previous models, attributability for the 2D and 3D models was 0.65 and 0.55, respectively. Accuracy was -0.05 ± 1.007 and -2.54 ± 1.11, respectively.

CONCLUSION

Models that included TVol provided good prediction of birthweight in the target population.

The art of fetoscopy: a step toward minimally invasive fetal therapy

PURPOSE

To study the feasibility, learning curve, and safety of fetoscopy, so that fetal surgery can be confidently performed in ongoing pregnancies.

METHODS

Fetoscopy was performed at 12-20 weeks of gestation, in 12 women with fetal congenital malformations and/or for termination of pregnancy, under local anesthesia using fine fetoscopes ranging from 1 to 2-mm diameter. The fetal parts and placenta were examined for clarity of vision, identification, and anomalies.

RESULTS

Fetoscopy required great skill, patience, and extensive use of ultrasound for correct orientation. Visualization was better with endoscope of 2-mm diameter. Laser coagulation of placental vessels using diode laser system was possible in the last two cases. There were no major complications.

CONCLUSIONS

Fetal endoscopy is a feasible procedure, safe in experienced hands but has an appreciable learning curve.

Meta-analysis comparing diabetes in pregnancy study group India (DIPSI) vs the international association of the diabetes and pregnancy study groups (IADPSG) criteria for diagnosis of gestational diabetes among Indian population

Despite consensus on universal screening of women at 24-28 weeks for a diagnosis of gestational diabetes, controversy remains on an appropriate criterion. The study is aimed to find out the sensitivity and specificity of Diabetes in Pregnancy Study Group India (DIPSI) criteria compared to the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria for diagnosis of Gestational Diabetes Mellitus (GDM). A meta-analysis of studies comparing DIPSI as an index test to IADPSG as the reference test for diagnosing GDM was carried out. A total of 8 comparative studies were included. Pooled analysis showed a sensitivity of 0.44 [0.29 to 0.60] and specificity of 0.97 [0.94 to 0.98], which means the index test DIPSI will correctly identify only 44% of the subjects who have the disease (GDM positive) but it will also fail to identify 56% of the GDM positive subjects. Derek's funnel graph revealed fewerchances of publication bias. Though convenient, DIPSI criteria was not found to be sensitive enough for a diagnosis of GDM and missed an opportunity to improve pregnancy and subsequent long-term outcomes for a substantial number of women. Further studies should focus on comparing pregnancy outcomes for the two criteria, so that decision to adopt any criteria is more evidence-based.

Mifepristone Followed by Misoprostol or Ethacridine Lactate and Oxytocin for Second Trimester Abortion: A Randomized Trial

Objective

To compare two medical methods for second-trimester abortion, mifepristone followed by misoprostol versus mifepristone followed by ethacridine lactate and oxytocin for success rate, induction to abortion time and acceptability.

Materials and Methods

This is a randomized trial conducted from July 2014 to May 2016 and enrolled 120 women undergoing second trimester abortion (13-20 weeks). All patients received 200mg mifepristone orally and were randomized to receive further treatment after 36 hrs. Patients in Group M (n=60) received 400 microgram of misoprostol vaginally every 3 hours (maximum - 5 doses) and Group E (n=60) had extra-amniotic ethacridine lactate instillation followed by oxytocin infusion (max-100miu).

Results

Baseline demographic characteristics were comparable in both the groups. Success rate was 100% in group M and 98.3% in group E (p=0.31). Mean induction to abortion time was significantly shorter in group M than group E (8.2+2.3hours & 10.9+2.6 hours respectively; p=0.001). Majority of women reported side effects, 96.7% women in group M and 75% women in group E (p=0.001). Fall in hemoglobin after procedure was significantly higher in group M (0.70+0.33gram %) than group E (0.52+0.23 gram %) (p=0.001). Perception of intensity of pain was significantly more in group M but patient satisfaction in both groups was similar.

Conclusion

Both methods are comparable for success rate, induction interval was more for ethacridine lactate compared to misoprostol.

Aortic isthmus Doppler in normal and small-for-gestational-age fetuses and its association with prediction of adverse perinatal outcome

OBJECTIVE

To establish reference ranges for aortic isthmus Doppler indices in appropriate-for-gestational-age (AGA) fetusesand to evaluate its association with perinatal outcome in small-for-gestational-age (SGA) fetuses.

METHODS

Prospective cohort observational study in which 30 pregnant women with SGA fetuses and 60 women with AGA fetuses were recruited from the prenatal clinic of the hospital. The AGA group was eventually followed from 24 weeks by 4-weekly Doppler assessment, and the SGA group was examined as per institutional protocol. We analyzed the data using STATA version 14.0 statistical software. Continuous variables were examined for normality assumption using the Kolmogorov-Smirnov test. To develop a nomogram for appropriate gestational age, we adopted a mixed linear model analysis. For each of the variables Ao pulsatility index (PI), Ao peak systolic velocity (PSV), Ao systolic nadir (Ns), and Ao isthmic systolic index (ISI) mean predicted values, 3rd centile and 97th centile were calculated based on the parameter estimation of mixed model. Observed data for each of the variables in the SGA group were plotted in the nomogram developed for the AGA group to show the trend of SGA data in comparison to AGA data.

RESULTS

The total number of observations made on 60 AGA and 30 SGA fetuses were 240 and 67, respectively. Nomograms for the 3rd and 97th centiles were derived for Ao PI, Ao PSV, Ao Ns, and Ao ISI. Mean Ao PI values were significantly higher in SGA group (2.37 vs 2.22; P < .05); mean Ao PSV was significantly lower in the SGA group (67.1 vs 76.3; P < .05), but mean Ao Ns and mean Ao ISI values were significantly higher in the SGA group (-5.24 vs 2.0 and -0.04 vs -0.01; P < .05).

CONCLUSIONS

Aortic Doppler assessment seems to provide beneficial information for monitoring small fetuses. Ao PI and Ao ISI, which were raised in fetuses with SGA, can be used in prognosis.

Reducing the waiting time to initiation of infertility treatment at a tertiary care centre in India

Background

In a low-resource and high-volume setting, it is often felt that patient care cannot be improved within the limitations of existing infrastructure and resources. However, the use of a systematic problem-solving method can bring about significant improvement even in these settings.

Aim

To decrease the mean waiting time from first visit to initiation of infertility treatment by 70% within 4 weeks (1–30 June 2019) for patients coming to the gynaecological outpatient department (OPD).

Methods

We constructed a multidisciplinary quality improvement team consisting of an academic consultant, a senior resident physician, a junior resident physician and a nurse to address the problem of long waiting times to initiation of fertility treatment. We collected baseline data from 10 consecutive women presenting to gynaecological OPD with complaints of infertility by calculating the time between their first visit to the facility and the day of performance of hysterosalpingography (HSG). The average waiting time was found to be 6 months and 25 days (mean=6.85 months; 3.5–10 months). The team used process flow diagrams and fishbone analysis to identify various causes of these long waiting times. The main reason for the delay in starting infertility treatment was that the date for HSG was given only after seeing the endometrial aspiration report (ie, after ruling out endometrial tuberculosis as there is a risk of dissemination of tuberculosis during HSG). Also, HSG was done only once a week during a short 2-hour slot in the fluoroscopy room.

Results

After the implementation of change ideas, there was significant reduction in the waiting period to starting treatment in patients with infertility. After the first change idea, the average waiting period seen in 10 consecutive patients with infertility reduced to 3.25 months, that is, by 51.8% from baseline within a 2-week interval, and there is shift in the run chart diagram. After the second change idea, the waiting time reduced to 2 months, that is, by 70%, seen in the next 10 consecutive patients with infertility within the next 2 weeks’ time. The results were sustained to the average waiting time of 2 months for 6 months without any additional resources.

Conclusion

With a well-organised and conducted quality improvement project and team efforts, the required changes can be brought about in an established conventional healthcare delivery system and improvements can be sustained over a long period of time.

Diabetes in Pregnancy Study Group India (DIPSI) and WHO (1999) diagnostic criteria for GDM: A meta-analysis

BACKGROUND AND AIMS

The diagnosis of Gestational diabetes mellitus (GDM) is challenging and controversial due to the heterogeneity or lack of consensus regarding the screening and diagnostic criteria for GDM.

METHODS

A meta-analysis of studies comparing Diabetes in Pregnancy Study Group India (DIPSI) and WHO 1999 for diagnosing GDM was carried out.

RESULTS

A total of 6 comparative studies were included. Pooled analysis showed sensitivity and specificity as 0.79 (95% CI: 0.53 to 0.92) and 0.97 (95% CI: 0.94 to 0.98) respectively.

CONCLUSION

Based on the results of the meta-analysis, DIPSI showed higher specificity when compared to WHO 1999, hence may be used to rule in disease in probable GDM cases. However, the results should be interpreted more cautiously and carefully since only a few studies were included.

Exploring the safety and diagnostic utility of amniocentesis after 24 weeks of gestation: a retrospective analysis

OBJECTIVES

This study aims to describe the indications, complications, yield, and safety of amniocentesis beyond 24 weeks for prenatal diagnostic procedures along with the associated maternal and fetal outcomes.

METHODS

A retrospective analysis was conducted on 60 pregnant women (with 61 fetuses) who underwent amniocentesis at or beyond 24 weeks from March 2021 to June 2023 at a tertiary care referral center. Data was collected from medical records and individual patient followups. Descriptive data was collected on patient demographics, amniocentesis indications, and the test results. The other outcomes analyzed were the procedure-related complications and pregnancy outcomes.

RESULTS

The mean gestational age at time of the procedure was 254/7 (241/7-331/7). The most common indication for late amniocentesis was abnormal sonographic findings (44/61, 72.13 %), with structural anomalies being the commonest (21/61, 34.44 %). There were no complications related to the procedure. Of the 60 women, 88.3 % (53/60) continued their pregnancies, while 11.66 % (7/60) opted for termination of pregnancy, and two patients had intrauterine fetal demise (2/61, 3.27 %). Genetic testing revealed abnormalities in 6.55 % (4/61) of cases. Of the 51 pregnancies, 39 delivered vaginally (76.47 %; 39/51) and 12 (23.52 %; 12/51) required caesarean sections. There were five neonatal and infant deaths due to heart defects (2), metabolic syndrome, congenital diaphragmatic hernia, and non-immune hydrops, respectively.

CONCLUSIONS

Amniocentesis, done at a later gestation, is a safe and an effective tool for prenatal diagnosis and provides an opportunity to make a genetic diagnosis and further counseling.

Use of 'Printed Investigation Sheet' as Checklist in Admitted Antenatal Patients: A Quality Improvement Initiative

Background

The study was conducted to establish use of printed investigation sheets as checklists for timely workup and clinical evaluation of antenatal women with medical diseases; admitted in maternity ward, by third day of their hospital admission. This was aimed to standardize care, avoid repeated blood sampling of patients, avoid delay in starting the treatment and help teams perform optimally by systematic use of quality improvement (QI) tools.

Methods

The present study was conducted in the Department of Obstetrics and Gynaecology at a tertiary care teaching hospital using point-of-care quality improvement methodology systematically. A QI team was made who formulated an aim statement, conducted a root-cause analysis, performed plan-do-study-act (PDSA) cycles. The outcome was measured as complete clinical evaluation of antenatal women with anaemia, hypertension, and/or diabetes by third day of admission in the maternity ward.

Results

The baseline data showed that median percentage of patients with complete clinical evaluation was only 29.2%. After a root-cause analysis with fishbone tool, three PDSA cycles were conducted to achieve the target of 80%. After the third PDSA cycle, complete clinical evaluation in anaemia, hypertension, diabetes showed an improving trend with a median of 75%.

Conclusion

Adopting simple principles of quality improvement, initiating use of printed investigation sheets as checklist can streamline and expedite clinical evaluation of antenatal patients with medical problems so as to avoid unnecessary delay in initiating the management in busy maternity wards.