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• CASE REPORTS

Wilson’s Disease Diagnosed Postnatally Due to Neurological Manifestation

Pregnancy and its outcome in a rare case of combined protein c and protein s deficiency with severe adenomyosis case, spontaneous ohss in a young adolescent: a diagnostic dilemma, laparoscopic approach for recurrent huge vulval mass, pregnancy in a persistent vegetative state: a management dilemma. case report, literature review and ethical concerns.

Sujata Siwatch 1 • Minakshi Rohilla 1 • Apinderpreet Singh 2 • Chirag Ahuja 3 • Kajal Jain 4 • Vanita Jain 1

A woman who developed a persistent vegetative state in the late first trimester after an arterio-venous fistula (AVF) bleed in the brain presented at 12 weeks period of gestation. The difficult clinical and ethical management issues faced include whether to continue pregnancy, antenatal care and planning for delivery. Multidisciplinary team management along with a family centred approach helped in planning and continuing the pregnancy that resulted in a successful fetal outcome.

Keywords: Pregnancy • Persistent vegetative state • Coma • Ethical issues

Abbreviations:

AV arterio-venous ICH intracranial hemorrhage ECA external carotid artery ICA internal carotid artery MCA middle cerebral artery DSA digital subtraction angiography PVS persistent vegetative state

Inflammatory Myofibroblastic Tumour at Episiotomy Site: A Rare Case Report with Review of Literature

Meenal Bhati 1 • Meenakshi Gothwal 2 • Pratibha Singh 3 • Garima Yadav 2

An inflammatory myofibroblastic tumour (IMT) is a rare mesenchymal neoplasm which was earlier considered under the broad category of inflammatory pseudotumor. It can arise from various anatomic location, out of all lung is the most common site. In our case a 27 years old female presented in our OPD with a mass arising from the episiotomy scar site in the vagina. The histopathological examination showed spindle-shaped cells in fascicles with inflamed granulation tissue with dense mixed inflammation. Immunohistochemistry test showed immunoreactivity for Smooth muscle actin (SMA) and are focally immunoreactive for Bcl2 and Desmin, negative for CK, CD34 and S100 protein. We framed our diagnosis of an inflammatory myofibroblastic tumour of the episiotomy site. However, female genital tract IMT's are rare; to the best of our knowledge, there are no reported cases of IMT involving episiotomy site.

Pancreatitis in Pregnancy: Case Series for 5 Years

Chandrakala Magudapathi 1 • Sudha Shanthi 2 • R. Palanisamy 3

Background To study the course of pancreatitis in pregnant women and demonstrate that early diagnosis and conservative management leads to good maternal and perinatal outcome.

Methods: This article is a retrospective case series study. Six patients with acute pancreatitis during pregnancy were seen in a tertiary referral based obstetric practice at our department in the last 5 years. One of them had gallstones, one hyperlipidemia, one Diabetes and one miliary tuberculosis on ATT . Conservative treatment was instituted for pancreatitis. All of them were followed at least six weeks post-partum.

Results: There was no maternal mortality and perinatal mortality. Acute pancreatitis occurred in both primipara and multipara patients. Preterm labor was a complication in most of our cases complicated by acute pancreatitis. Most patients experienced relief from the pancreatitis soon after delivery. One patient underwent cesarean section due to fetal distress all the other 5 patients had vaginal delivery. One patient had Pseudopancreatic cyst and had a morbid postpartum period.

Conclusion: Pancreatitis is a rare event in pregnancy, approximately 3 in 10,000 pregnancies. It is most often acute and related to gallstones but nonbiliary causes should be sought because they are associated with worse outcomes. Although acute pancreatitis is a rare complication of pregnancy with 50% maternal and 70 % perinatal mortality early and appropriate treatment is of utmost importance to improve the outcome.

Ovarian Follicle: Twirling Microfilaria’s New Abode

Sachin Khanduri 1 · Namrata Nigam 2 · Mazhar Khan 1 · Anvisha Shukla 1 · Ekta Tyagi 1 · Tariq Ahmad Imam 1 · Shobha Khanduri 3

Filariasis is parasitic disease with significant morbidity and socio-economic implications. Its uncommon presentation in female genital organs and rarer presentation in ovarian follicles pose a major diagnostic problem even in endemic regions.As in recent times, there is increase in travel and immigration ,physicians need to be familiar with cases not only endemic to their region but to non endemic diseases as well.Herein ,we report a case of a 26 year old female patient who presented with chronic pelvic pain and polymenorrhoea. Transvaginal ultrasonography revealed microfilariae in ovarian follicular fluid which led to correct diagnosis. This case report sheds light on uncommon presentation of filariasis which needs to be considered for correct diagnosis in endemic as well as non-endemic regions.

Effective Management of Early Cervical Pregnancy with Bilateral Uterine Artery Embolization Followed by Immediate Evacuation and Curettage: A Case Report

Pregnancy in a rare case of intracranial rosai dorfman disease (rdd).

Shashikala Ksheerasagar 1,2 · N. Venkatesh 1 · Niti Raizada 1 · K. M. Prathima 1 · Ravindra B. Kamble 1 · K. Srinivas 1 · M. A. Suzi Jacklin 1 · B. A. Chandramouli 1

We report an extremely rare case of spontaneous pregnancy in a 38 year women following chemotherapy for Rosai-Dorfman Disease (Rosai-dorfman Disease). What made the case more interesting was the challenges that obstetric team faced managing the patient in the presence of co-morbidities like Gestational Diabetes Mellitus , anemia , sub clinical hypothyroidism , allergic bronchitis , progressive symptoms of Rosai-Dorfman Disease like diplopia and cerebellar ataxia

Granulosa Cell Tumor of the Ovary Accompanying with Ollier’s Disease: First Case of Contralateral Presentations

Amirmohsen Jalaeefar 1 · Mohammad Shirkhoda 1 · Amirsina Sharifi 2 · Mohsen Sfandbod 3

Objective: Granulosa cell tumor (GCT) is a rare entity of ovarian malignancies. Juvenile GCT is considered a malignant tumor with an indolent course and tendency toward late recurrence. However, the association of this tumor and multiple enchondromas has been reported.

Case Presentation: A 17-year-old female with abnormal uterine bleeding was referred to our center. Ultrasonographic evaluation revealed a mass with origin in right ovary. Patient was worked up to undergo salpingo-oophorectomy, she felt a dull pain in her left lower limb. X-ray imaging was indicative for Ollier’s disease at the distal part of femur and proximal part of tibia. Postoperative pathological review was compatible with juvenile granulosa tumor of the right ovary.

Conclusion: This case was the first of its kind that ovarian tumor was contralateral to the side involved by enchondromatosis.

Ogilvie Syndrome with Caecal Perforation After Caesarean Section

Osseous metaplasia of the vaginal vault: a case report, heterotopic quadruplet pregnancy after icsi conception.

Background : Heterotopic pregnancy (HP) is a condition characterized by the coexistence of multiple fetuses at two or more implantation sites. It occurs in 1% of pregnancies after assisted reproductive techniques (ART). Presence of triplet intrauterine pregnancy with ectopic gestational sac is one of the rarest forms of HP. Ectopic pregnancy is implanted in the ampullary segment of the fallopian tube in 80% of cases. Most of the patients present with acute abdominal symptoms due to rupture of the tube. Case Presentation This article reports a case of quadruplet heterotopic pregnancy after intracytoplasmic sperm injection (ICSI) with an ampullary ectopic pregnancy and intrauterine triplet pregnancies. The ruptured ampullary pregnancy was emergently managed by right salpingectomy. This was followed by embryo reduction at 12 ? 6 weeks and successful outcome of intrauterine twin pregnancy.

A Rare Case of Adenoma Malignum: Preparing for the Unforeseen

Gayathri Dinesh Kamath 1 • Aditi Bhatt 1 • Veena Ramaswamy 1

Gonadal Vein Graft for Maintaining Renal Circulation After a Complication During Para-Aortic Nodal Dissection: A Case Report

Pesona Grace Lucksom 1 • Jaydip Bhaumik 1 • Gautam Biswas 2 • Sujoy Gupta 3 • Basumita Chakraborti 1

A 39 year old female underwent staging laparotomy for carcinoma endometrium. During para aortic node dissection the left renal vein (LRV) was accidentally injured. The patency of the LRV after rent repair was not adequate for functioning of the left kidney. Nepherectomy was considered but plans for saving the kidney was discussed by the joint team of surgeons. The venous blood of the left kidney was diverted through an anastomosis of the left gonadal vein with the venacava. Patency of the anastomosis was checked and was found to be adequate for keeping the left kidney functional. Doppler of the renal veins done on post-operative day three was normal and she was fit for discharge on day four.

Benign Ovarian Edema Masquerading as Malignancy: A Case Report

Shalini Singh 1 • Kameswari Surampudi 1 • Meenakshi Swain 2

Solid ovarian masses in young age can pose significant diagnostic and therapeutic challenges to the clinician. A young 16 year old girl presented with irregular cycles, pain abdomen and reportedly bulky ovaries with calcifications. Examination was unremarkable. Ultrasound scan revealed bilateral complex ovarian masses suggestive of neoplasm. MRI confirmed a solid right ovarian mass with normal left ovary. Tumour markers were normal. Option of frozen section followed by complete surgery if malignant or two stage procedure including staging laparotomy and if necessary a second surgery were discussed. Parents opted for the latter. At midline laparotomy, free fluid from abdomen was sent for cytology. Right ovary was irregular and enlarged measuring 10 x 8 cm with unruptured white capsule and no torsion. Left ovary was normal. Right salpingo-oophorectomy with omental and peritoneal biopsies were performed. Cytology was benign and histopathology showed massive ovarian edema which was a surprise and relief. Massive ovarian edema is a unique condition with tumour like enlargement of the ovary mimicking neoplasm on imaging leading to overtreatment of patients. Knowledge of this condition allows for fertility sparing procedures.

Maternal Near-Miss: A Perimortem Caesarean Section Resulting in a Remarkable Foetomaternal Recovery in a Rural Tertiary Care Centre in Eastern India

Leiomyoma of urinary bladder in middle-aged female.

Bhushan Dodia 1 • Abhay Mahajan 1 • Dhruti Amlani 1 • Sandeep Bathe 1

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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

PRENATAL OBSTETRICS

Perinatal depression and mortality (March 2024)

Perinatal depression is associated with an increased risk of death. An analysis of a national register from Sweden compared outcomes among individuals with and without a diagnosis of depression during pregnancy or postpartum, matched by age and year of delivery [ 1 ]. After controlling for potential confounding factors, all-cause mortality was greater in those with perinatal depression over 18 years of follow-up; the increased risk was largely driven by suicide. These results confirm previous data on the risks of perinatal depression and support our practice of screening for depression during pregnancy and postpartum. Services to ensure follow-up for diagnosis and treatment should accompany screening efforts. (See "Unipolar major depression during pregnancy: Epidemiology, clinical features, assessment, and diagnosis", section on 'All cause' .)

Noninsulin antidiabetic medications and pregnancy (February 2024)

Noninsulin antidiabetic medications such as glucagon-like peptide 1 (GLP-1) agonists, sodium-glucose cotransporter 2 (SGLT-2) inhibitors, and dipeptidyl peptidase 4 (DPP-4) inhibitors are commonly used in nonpregnant individuals but avoided in pregnancy because of lack of safety data in humans and harms observed in animal studies. However, in a multinational population-based cohort study including nearly 2000 individuals with preconception/first trimester exposure to these medications, the frequency of congenital anomalies was not increased compared with insulin [ 2 ]. A limitation of the study is that it did not adjust for potential differences in A1C, diabetes severity, or diabetes duration, which could obscure true effects on risk for congenital anomalies. We continue to avoid use of GLP-1 agonists, SGLT-2 inhibitors, and DPP-4 inhibitors in females planning to conceive and in pregnancy. (See "Pregestational (preexisting) diabetes: Preconception counseling, evaluation, and management", section on 'Patients on preconception noninsulin antihyperglycemic agents' .)

Updates to the United States perinatal HIV clinical guidelines (February 2024)

The United States Department of Health and Human Services has released updates to the perinatal HIV clinical guidelines [ 3 ]. Ritonavir-boosted darunavir is now a preferred agent only for treatment-naïve pregnant individuals who have used cabotegravir-based pre-exposure prophylaxis, because of the concern for integrase inhibitor-resistant mutations; for other pregnant individuals, it is now an alternative rather than preferred agent. Additionally, bictegravir, which was previously not recommended for initial therapy in pregnant individuals, is now an alternative agent based on new pharmacokinetic data that support its use during pregnancy. Our approach to treating HIV during pregnancy is consistent with these updated guidelines. (See "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings", section on 'Selecting the third drug' .)

Combined use of metformin and insulin for treating diabetes in pregnancy (February 2024)

In patients with type 2 diabetes, insulin is the mainstay for managing hyperglycemia in pregnancy. The addition of metformin improves maternal glucose control and reduces the chances of a large for gestational age newborn, but a prior randomized trial reported an increased risk for birth of a small for gestational age (SGA) infant. A recent randomized trial comparing use of insulin alone with insulin plus metformin in nearly 800 adult pregnant patients with either preexisting type 2 diabetes or diabetes diagnosed in early pregnancy confirmed the previously reported benefits but found that both treatment groups had low and similar rates of SGA [ 4 ]. The discordancy in SGA risk needs to be explored further, as metformin cotreatment would be undesirable if this risk is real. (See "Pregestational (preexisting) diabetes mellitus: Antenatal glycemic control", section on 'Metformin' .)

Fetoplacental GDF15 linked to nausea and vomiting of pregnancy (February 2024)

Almost all pregnant people experience nausea with or without vomiting in early pregnancy; however, the pathogenesis of the disorder has been unclear. Previous studies have shown that GDF15 is expressed in a wide variety of cells, with the highest expression in placental trophoblast, and that its protein (GDF15) appears to regulate appetite. A recent study confirmed the fetoplacental unit as a major source of GDF15 and also found that higher GDF15 levels correlated with more severe nausea and vomiting of pregnancy [ 5 ]. In the future, drugs targeting the production or action of GDF15 are a potential novel pathway for treating nausea and vomiting of pregnancy, if safety and efficacy are established. (See "Nausea and vomiting of pregnancy: Clinical findings and evaluation", section on 'Pathogenesis' .)

Use of cerebroplacental ratio at term does not reduce perinatal mortality (February 2024)

Cerebral blood flow may increase in chronically hypoxemic fetuses to compensate for the decrease in available oxygen and can be assessed by the cerebroplacental ratio (CPR; middle cerebral artery pulsatility index divided by the umbilical artery pulsatility index). However, increasing evidence indicates that use of the CPR does not reduce perinatal mortality in low-risk pregnancies. In a randomized trial comparing fetal growth assessment plus revealed versus concealed CPR in over 11,000 low-risk pregnancies at term, knowledge of CPR combined with a recommendation for delivery if the CPR was <5th percentile did not reduce perinatal mortality compared with usual care (concealed group) [ 6 ]. We do not perform umbilical artery Doppler surveillance, including the CPR, in low-risk pregnancies. (See "Doppler ultrasound of the umbilical artery for fetal surveillance in singleton pregnancies", section on 'Low-risk and unselected pregnancies' .)

Low- versus high-dose calcium supplements and risk of preeclampsia (January 2024)

In populations with low baseline dietary calcium intake, the World Health Organization recommends 1500 to 2000 mg/day calcium supplementation for pregnant individuals to reduce their risk of developing preeclampsia. However, a recent randomized trial that evaluated low (500 mg) versus high (1500 mg) calcium supplementation in over 20,000 nulliparous pregnant people residing in two countries with low dietary calcium intake found low and similar rates of preeclampsia in both groups [ 7 ]. These findings suggest that a 500 mg supplement is sufficient for preeclampsia prophylaxis in these populations. For pregnant adults in the United States, we prescribe 1000 mg/day calcium supplementation, which is the recommended daily allowance to support maternal calcium demands without bone resorption. (See "Preeclampsia: Prevention", section on 'Calcium supplementation' .)

Respectful maternity care (January 2024)

Respectful maternity care is variably defined but broadly involves both absence of disrespectful conduct and promotion of respectful conduct toward pregnant individuals. A systematic review found that validated tools to measure respectful maternity care were available, but the optimal tool was unclear and high quality studies were lacking on the effectiveness of respectful maternity care for improving any maternal or infant health outcome [ 8 ]. Respectful maternal care is a basic human right, but how to best implement and monitor it and assess outcomes requires further study. (See "Prenatal care: Initial assessment", section on 'Effectiveness' .)

Outcome of a multifaceted intervention in patients with a prior cesarean birth (January 2024)

Patients with a pregnancy after a previous cesarean birth must choose between a trial of labor (TOLAC) and a planned repeat cesarean. The optimal care of such patients is unclear. In a multicenter, cluster-randomized trial including over 20,000 patients with one prior cesarean birth, a multifaceted intervention (patient decision support, use of a calculator to assess chances of a vaginal birth after cesarean [VBAC], sonographic measurement of myometrial thickness, clinician training in best intrapartum practices during TOLAC) reduced perinatal and major maternal morbidity composite outcomes compared with usual care [ 9 ]. VBAC and uterine rupture rates were similar for both groups. Further study is needed to identify the most useful component(s) of the intervention for reducing morbidity. (See "Choosing the route of delivery after cesarean birth", section on 'Person-centered decision-making model' .)

Serial amnioinfusions for bilateral renal agenesis (January 2024)

Bilateral renal agenesis (BRA) is incompatible with extrauterine life because prolonged oligohydramnios results in pulmonary hypoplasia, leading to postnatal respiratory failure. A prospective study (RAFT) assessed use of serial amnioinfusions to treat 18 cases of BRA diagnosed at <26 weeks of gestation [ 10 ]. Of the 17 live births, 14 survived ≥14 days and had placement of dialysis access, but only 6 survived to hospital discharge. Of the 4 children alive at 9 to 24 months of age, 3 had experienced a stroke and none had undergone transplant. These findings show that serial amnioinfusions for BRA mitigates pulmonary hypoplasia and increases short-term survival and access to dialysis; however, long-term outcome remains poor with no survival to transplantation. Serial amnioinfusions remain investigational and should be offered only as institutional review board-approved research. (See "Renal agenesis: Prenatal diagnosis", section on 'Investigative role of therapeutic amnioinfusion' .)

Prenatal genetic testing for monogenic diabetes due to glucokinase deficiency (December 2023)

In pregnant individuals with monogenic diabetes due to glucokinase (GCK) deficiency, management depends on the fetal genotype. If the fetus inherits the maternal GCK variant, maternal hyperglycemia will not cause fetal hyperinsulinemia and excessive growth, and maternal hyperglycemia does not require treatment. However, if the fetus does not inherit the pathogenic variant, maternal insulin therapy is indicated to prevent excessive fetal growth. Fetal ultrasound has been used to predict fetal genotype but has limited diagnostic utility. In a cohort of 38 pregnant individuals with GCK deficiency, fetal genetic testing using cell-free DNA in maternal blood had higher sensitivity (100 versus 53 percent) and specificity (96 versus 61 percent) for prenatal diagnosis of GCK deficiency compared with ultrasound measurement of fetal abdominal circumference [ 11 ]. When available, noninvasive prenatal genotyping should be used to guide management of GCK deficiency during pregnancy. (See "Classification of diabetes mellitus and genetic diabetic syndromes", section on 'Glucokinase' .)

Early metformin treatment of gestational diabetes mellitus (November 2023)

Usual initial gestational diabetes mellitus (GDM) care (ie, medical nutritional therapy, exercise) may result in a few weeks of hyperglycemia before a need for pharmacotherapy is established. In a randomized trial evaluating whether initiating metformin at the time of GDM diagnosis regardless of glycemic control improves clinical outcomes compared with usual care, the metformin group had a lower rate of insulin initiation and favorable trends in mean fasting glucose, gestational weight gain, and excessive fetal growth, but more births <2500 grams [ 12 ]. Rates of preeclampsia, neonatal intensive care unit admission, and neonatal hypoglycemia were similar for both groups. Given these mixed results, we recommend not initiating metformin at the time of GDM diagnosis except in a research setting. (See "Gestational diabetes mellitus: Glucose management and maternal prognosis", section on 'Does early metformin initiation improve glycemic control and reduce need for insulin?' .)

Automated insulin delivery in pregnant patients with type 1 diabetes (October 2023)

Hybrid closed-loop insulin therapy is associated with improved glucose control in nonpregnant adults and in children, but little information is available in pregnant people. In the first randomized trial in this population, hybrid closed-loop insulin delivery beginning at 11 weeks gestation improved glycemic control compared with standard insulin therapy in 124 patients with type 1 diabetes, without increasing their risk of severe hypoglycemia [ 13 ]. The system allowed customization of glycemic targets appropriate to pregnancy, in contrast to other commercially available systems in the United States. Additional study is needed to confirm these findings, evaluate the effects on obstetric and neonatal outcomes, and identify optimal candidates. (See "Pregestational (preexisting) diabetes mellitus: Antenatal glycemic control", section on 'Continuous subcutaneous insulin infusion (insulin pump)' .)

Valacyclovir for prevention of congenital cytomegalovirus infection (October 2023)

Emerging evidence suggests that maternal administration of valacyclovir for primary cytomegalovirus (CMV) infection substantially reduces the risk of congenital CMV infection, especially if begun prior to 14 weeks of gestation and within 8 weeks of the maternal infection. In a 2023 individual patient data meta-analysis (one randomized trial, two observational studies), maternal valacyclovir administration upon diagnosis of periconception or first-trimester primary CMV infection was associated with a 66 percent reduction in congenital CMV (11 versus 25 percent) [ 14 ]. We suggest high-dose oral valacyclovir (8g per day) for patients with a primary CMV infection in early pregnancy after a comprehensive discussion of the potential benefits and risks (eg, 2 percent risk of reversible maternal kidney failure). (See "Cytomegalovirus infection in pregnancy", section on 'Antiviral medication' .)

Respiratory syncytial virus vaccination in pregnancy (April 2023, Modified October 2023)

Respiratory syncytial virus (RSV) is a major cause of morbidity and mortality in infants. In October 2023, the United States Centers for Disease Control and Prevention, along with guidelines from other expert groups, endorsed RSV vaccination of pregnant individuals to reduce severe RSV infections in their infants [ 15-18 ]. Nirsevimab , a monoclonal antibody that can be given to infants postnatally to reduce the risk of severe RSV, has also been recently approved and endorsed by expert guidance panels. In settings where nirsevimab is not available, we suggest vaccination of pregnant individuals between 32 0/6 and 36 6/7 weeks of gestation in September through January (in the northern hemisphere) with inactivated nonadjuvanted recombinant RSV vaccine (RSVPreF; Abrysvo). In settings where both maternal vaccination and nirsevimab are available, the optimal preventive strategy remains uncertain, and, in most cases, it will not be possible to use both. For such patients, both options should be discussed and shared decision-making undertaken. (See "Immunizations during pregnancy", section on 'Choosing the optimal strategy' .)

INTRAPARTUM AND POSTPARTUM OBSTETRICS

Intrauterine postpartum hemorrhage control devices for managing postpartum hemorrhage (February 2024)

Intrauterine balloon tamponade and vacuum-induced uterine compression are the most common devices used for intrauterine postpartum hemorrhage (PPH) control in patients with atony, but it is unclear which device is superior as few comparative studies have been performed. In a retrospective study including nearly 380 patients with PPH, quantitative blood loss after placement, rate of blood transfusion, and discharge hematocrit were similar for both devices [ 19 ]. Based on these and other data, in the setting of ongoing uterine bleeding, rapid use of one of these devices is likely to be more important than the choice of device when both devices are available. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device", section on 'Choice of method' .)

Labor epidural analgesia and risk of emergency delivery (December 2023)

It is well established that contemporary neuraxial labor analgesia does not increase the overall risk of cesarean or instrument-assisted vaginal delivery. However, a new retrospective database study of over 600,000 deliveries in the Netherlands reported that epidural labor analgesia was associated with an increased risk of emergency delivery (cesarean or instrument-assisted vaginal) compared with alternative analgesia (13 versus 7 percent) [ 20 ]. Because of potential confounders and lack of detail on epidural and obstetric management, we consider these data insufficient to avoid neuraxial analgesia or change the practice of early labor epidural placement to reduce the potential need for general anesthesia in patients at high risk for cesarean delivery. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Effects on the progress and outcome of labor' .)

Delayed cord clamping in preterm births (December 2023)

Increasing evidence supports delaying cord clamping in preterm births. In an individual participant data meta-analysis of randomized trials of delayed versus immediate cord clamping at births <37 weeks (over 3200 infants), delaying cord clamping for >30 seconds reduced infant death before discharge (6 versus 8 percent) [ 21 ]. In a companion network meta-analysis evaluating the optimal duration of delay, a long delay (≥120 seconds) significantly reduced death before discharge compared with immediate clamping; reductions also occurred with delays of 15 to <120 seconds but were not statistically significant [ 22 ]. For preterm births that do not require resuscitation, we recommend delayed rather than immediate cord clamping. We delay cord clamping for at least 30 to 60 seconds as approximately 75 percent of blood available for placenta-to-fetus transfusion is transfused in the first minute after birth. (See "Labor and delivery: Management of the normal third stage after vaginal birth", section on 'Preterm infants' .)

Vacuum-induced intrauterine tamponade for postpartum hemorrhage (November 2023)

Intrauterine tamponade (with a balloon, packing, or vacuum) may be used to manage patients with postpartum hemorrhage (PPH) resulting from uterine atony that is not controlled by uterotonic medications and uterine massage. However, outcome data regarding vacuum-induced tamponade are limited. A study of data from a postmarketing registry of over 500 patients with PPH and isolated atony treated with vacuum-induced tamponade reported that the device controlled bleeding without treatment escalation or bleeding recurrence in 88 percent following cesarean birth and 96 percent following vaginal birth, typically within five minutes [ 23 ]. These data are consistent with previously published outcomes. Given its efficacy and ease of use, vacuum-induced tamponade is an important option for managing PPH in centers where this device is available. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device", section on 'Vacuum-induced tamponade' .)

Risk of pregnancy-associated venous and arterial thrombosis in sickle cell disease (November 2023)

Sickle cell disease (SCD) and pregnancy both confer an increased risk of venous thromboembolism (VTE), but the magnitude of the risk is unclear. In a new administrative claims data study involving >6000 people with SCD and >17,000 age- and race-matched controls who were followed for one year postpartum, the risk of VTE was 11.3 percent in the patients with SCD, versus 1.2 percent in controls [ 24 ]. Arterial thromboembolism was also increased (5.2 percent, versus 0.6 percent in controls). This study emphasizes the value of postpartum VTE prophylaxis in people with SCD and the need for vigilance in evaluating suggestive symptoms. (See "Sickle cell disease: Obstetric considerations", section on 'Maternal risks' .)

Racial disparities in anemia during pregnancy (October 2023)

A new study has found that racial disparities in anemia during pregnancy persist and may be increasing. This analysis involved nearly four million births in the state of California from 2011 to 2020 [ 25 ]. Antepartum anemia was most common in Black individuals (22 percent), followed by Pacific Islanders (18 percent), Native American and Alaska Native peoples (14 percent), multiracial individuals (14 percent), Hispanic individuals (13 percent), Asian individuals (11 percent), and White individuals (10 percent). Antepartum anemia is associated with an increase in severe maternal morbidity. The reasons for disparities are multifactorial. (See "Anemia in pregnancy", section on 'Racial disparities' .)

Intrapartum magnesium sulfate before preterm birth and cerebral palsy (October 2023)

Magnesium sulfate is typically administered to pregnant women with impending preterm birth <32 weeks of gestation to decrease the incidence and severity of cerebral palsy in offspring. However, the recent MAGENTA trial comparing the effects of magnesium sulfate versus placebo administered before impending preterm birth between 30 and 34 weeks of gestation found that it did not prevent cerebral palsy among surviving infants [ 26 ]. These findings do not change our current practice because the trial used a single 4 g bolus of magnesium sulfate alone, whereas we also provide an ongoing 1 g/hour infusion until delivery and do not use the medication after 32 weeks; the trial was likely underpowered to find a significant difference. (See "Neuroprotective effects of in utero exposure to magnesium sulfate", section on 'Lower and upper gestational age' .)

OFFICE GYNECOLOGY

Infertility and autism spectrum disorder (December 2023)

Patients with infertility often ask about the impact of the disorder and its treatment on risk of autism spectrum disorder (ASD) in offspring. In a large population-based cohort study comparing ASD risk among children whose parents had subfertility (an infertility consultation without treatment), infertility treatment, or neither (unassisted conception), children in the subfertility and infertility treatment groups had a small increased risk of ASD compared with unassisted conception but the absolute risk was low (2.5 to 2.7 per 1000 person-years versus 1.9 per 1000 person-years with unassisted conception) [ 27 ]. The increased risk was similar in the subfertile and infertility treatment groups, suggesting that infertility treatment was not a major risk factor. Obstetrical and neonatal factors (eg, preterm birth) appeared to mediate a sizeable proportion of the increased risk for ASD. (See "Assisted reproductive technology: Infant and child outcomes", section on 'Confounders' .)

Macular changes related to pentosan polysulfate sodium (November 2023)

Macular eye disease has been reported in patients who have taken pentosan polysulfate sodium (PPS), which is used for the treatment of interstitial cystitis. In a prospective cohort study of 26 eyes with PPS maculopathy and >3000 g cumulative PPS exposure, progression of macular changes continued 13 to 30 months after drug cessation [ 28 ]. Median visual acuity decreased slightly; most patients reported progression of symptoms, including difficulty in low-light environments and blurry vision. These results indicate that PPS maculopathy progresses despite drug discontinuation, underscoring the importance of regular screening for maculopathy in patients with current or prior PPS exposure. (See "Interstitial cystitis/bladder pain syndrome: Management", section on 'Pentosan polysulfate sodium as alternative' .)

Vaginal laser therapy not effective for genitourinary syndrome of menopause (November 2023)

Laser devices, including the fractional microablative CO 2 laser, have been marketed for treatment of patients with genitourinary syndrome of menopause (GSM), but data regarding their safety and efficacy are limited. In a randomized trial including nearly 50 postmenopausal patients with GSM, treatment with CO 2 laser did not improve symptom severity compared with sham therapy [ 29 ]. Change in vaginal histology, which is a common surrogate determinant of treatment success, was similar in both groups at six months postprocedure. In addition, histologic features associated with a hypoestrogenic state correlated poorly with the severity of vaginal symptoms. Although the trial had limitations, these findings are consistent with other data and support our practice of not using laser treatment for patients with GSM. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Laser or radiofrequency devices' .)

Use of vaginal estrogen in breast cancer patients taking aromatase inhibitors (October 2023)

Use of vaginal estrogen to manage symptoms of genitourinary syndrome of menopause (GSM) may be harmful in patients with breast cancer on aromatase inhibitors (AIs). In a subgroup analysis of a claims-based analysis, vaginal estrogen therapy was associated with a higher rate of breast cancer recurrence in patients taking versus not taking an AI [ 30 ]. Time to recurrence in the AI group was approximately 140 days. While this study had many limitations, these data support our general practice of avoiding vaginal estrogen for the management of GSM in most patients with breast cancer taking AIs. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Patients with breast cancer' .)

GYNECOLOGIC SURGERY

Risk of unplanned hysterectomy at time of myomectomy (February 2024)

Myomectomy is an option for patients with bothersome fibroid symptoms (eg, bleeding, bulk); however, data are limited regarding the risk of unplanned hysterectomy at the time of myomectomy. In a retrospective study of the American College of Surgeons' National Surgical Quality Improvement Program database from 2010 to 2021 including over 13,000 patients undergoing myomectomy, the risk of unplanned hysterectomy was higher in those undergoing laparoscopic myomectomy compared with an open abdominal or hysteroscopic approach (7.1, 3.2, and 1.9 percent respectively) [ 31 ]. While much lower risks have been reported (<0.4 percent), and expert surgeons at high-volume centers may have fewer conversions to hysterectomy, this study highlights the importance of discussing the risk of unplanned hysterectomy during the informed consent process. (See "Uterine fibroids (leiomyomas): Laparoscopic myomectomy and other laparoscopic treatments", section on 'Unplanned hysterectomy' and "Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure", section on 'Unplanned hysterectomy' and "Uterine fibroids (leiomyomas): Hysteroscopic myomectomy", section on 'Unplanned hysterectomy' .)

Risk of subsequent hysterectomy after endometrial ablation (January 2024)

Endometrial ablation is an alternative to hysterectomy in selected premenopausal patients with heavy menstrual bleeding. Most ablations are performed using a non-resectoscopic technique; however, the long-term efficacy of this approach is unclear. In a meta-analysis of 53 studies including over 48,000 patients managed with non-resectoscopic endometrial ablation (NREA), the rates of subsequent hysterectomy were 4 percent at 12 months, 8 to 12 percent at 18 to 60 months, and 21 percent at 120 months [ 32 ]. Hysterectomy rates were similar for the different NREA devices (eg, thermal balloon, microwave, radiofrequency). These findings are useful for counseling patients about the long-term risk for hysterectomy after NREA. (See "Endometrial ablation: Non-resectoscopic techniques", section on 'Efficacy' .)

Pregnancy and childbirth after urinary incontinence surgery (January 2024)

Patients with stress urinary incontinence (SUI) have historically been advised to delay midurethral sling (MUS) surgery until after childbearing because of concerns for worsening SUI symptoms following delivery. In a meta-analysis of patients with MUS surgery who were followed for a mean of nearly 10 years, similar low SUI recurrence and reoperation rates were reported for the 381 patients with and the 860 patients without subsequent childbirth [ 33 ]. Birth route did not affect the findings. Although the total number of recurrences and reoperations was small, this study adds to the body of evidence suggesting that subsequent childbirth does not worsen SUI outcomes for patients who have undergone MUS. (See "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Subsequent pregnancy' .)

GYNECOLOGIC ONCOLOGY

Types of hysterectomy in patients with stage IB1 cervical cancer (March 2024)

Patients with stage IB1 cervical cancer (ie, >5 mm depth of stromal invasion and ≤2 cm in greatest dimension) are typically treated with radical hysterectomy; however, less extensive surgery is being evaluated. In a randomized trial including over 640 patients with stage IB1 cervical cancer, radical hysterectomy and simple hysterectomy plus lymph node assessment resulted in similar rates of recurrence at three years (2.2 and 2.5 percent, respectively) [ 34 ]. Although the study has limitations, including a short follow-up period, simple hysterectomy with lymph node assessment may be an acceptable alternative to radical hysterectomy in patients with IB1 cervical cancer. (See "Management of early-stage cervical cancer", section on 'Type of surgery' .)

Increasing incidence of cervical and uterine corpus cancer in the United States (February 2024)

In January 2024, the American Cancer Society published their annual report of cancer statistics in the United States [ 35 ]. Notable trends in regard to gynecologic cancers include a 1.7 percent increase in the annual incidence of cervical cancer from 2012 to 2019 in individuals aged 30 to 44 years, after decades of decline. Cancer of the uterine corpus (all ages) continued to increase by approximately 1 percent annually and was the only cancer in the report in which survival decreased. These and other data emphasize the continued importance of both early detection and prevention (eg, for cervical cancer: human papillomavirus vaccination and screening for precursor lesions; for endometrial cancer: achieving and maintaining a normal body mass index). (See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis", section on 'Incidence and mortality' and "Endometrial carcinoma: Epidemiology, risk factors, and prevention", section on 'Epidemiology' and "Endometrial carcinoma: Clinical features, diagnosis, prognosis, and screening", section on 'Prognosis' .)

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Obstetric Medicine provides the reader with 55 cases of different clinical presentations in obstetric medicine. Each case is presented with a background to the subject area, a summary of the history, and examination findings, and relevant investigation results. This is followed by several questions on clinically important aspects of the case with answers and detailed discussion, particularly of the differential management options. Each topic is mapped on to both the curriculum for physicians undertaking obstetric medicine, and for obstetric trainees studying for membership exams, the Advance Training Skills Module in maternal medicine, and speciality training in maternal and fetal medicine. Providing an ideal self-assessment tool, this new title is of interest to all doctors working in obstetrics, midwives, physicians who may encounter pregnant women in their clinical practice, and students revising for exams.

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A reflection on current obstetrics and gynaecology research in India

Juan f. pacheco-páramo.

1. Bogota, Colombia

Jon Cornwall

2. University of Otago, Dunedin, New Zealand

Introduction

Obstetrics and gynaecology, including topics such as contraception, antenatal care, and maternal and neonatal health, are an important part of medical practice. In recent years there have been many studies examining aspects of this healthcare sector in India. This editorial examines some of the recently published research from this field, and country, with the aim of highlighting the existence and variety of the investigations that have been published on this topic. It is hoped that the review of these works will allow researchers and clinicians in all countries to reflect on the value of parochial research that can focus healthcare intervention on areas that necessitate further promotion or examination.

Contraception

Attitudes and knowledge of both Indian medical staff and the general public to contraception have been reported in recent years. Rahaman and colleagues 1 concluded in their study of attitudes among Indian nursing staff that knowledge of Emergency Contraception (EC) appears to be inadequate, reflecting other research from different countries around the world. One hundred and thirty-one nursing staff participated in the survey, although 19 nurses (14 per cent) had never heard of EC and were thus excluded from the study. Research on adolescent Indian girls’ knowledge about contraception has also been shown to be poor;2 even though overall knowledge about contraceptive method was only 40.76 per cent, only 65.4 per cent were interested in acquiring further knowledge while the remainder had the belief that this type of education will increase adverse sexual practice. In other studies about contraceptive practices in India, Prateek and Saurabh 3 found that there is a great difference between the knowledge and actual use of contraceptives in married women in reproductive age: 52.4 per cent of women knew about contraceptive practices, but only 32.2 per cent of them were using any contraceptive method. Jain and Muralidhar 4 concluded that the preferred contraceptive practice is female sterilisation. In regard to the practice of sterilisation, Srividya and Kumar 5 performed a crosssectional study on 399 women prior to tubectomy and found that most women (73.9 per cent) had not previously used any kind of contraception.

Teenage pregnancy

In an investigation of teenage pregnancy in India, Parasuramalu et al. 6 reported that most teenage mothers seen in primary health centres were married before the legal age of 18 years. In a four month hospital-based cohort study, Banerjee et al. 7 found that 24.2 per cent of pregnancies correspond to teenage pregnancies, and that this group had a greater prevalence of anaemia, preterm delivery and low birth weight than the control group (women of 20-24 years old).

Infant delivery

Unnikrishnan and colleagues 8 reported on Caesarean section (CS) rates in coastal South India. Their paper begins with the observation that there is a rising rate of CS in modern obstetric practice, and goes on to report a CS rate of 23.3 per cent for 2009 as compared to 20.2 per cent in 2005 with the major indication for this being previous CS. The authors considered this a vicious cycle that can only be stopped by reviewing the indications for CS. The reports of increasing rates of CS have also been described in other publications: reports indicate a trend in recent years for an increase from 10 per cent in the year 2000 to 15-25 per cent in 2006 outside India in Malaysia, 9 while Kambo et al. 10 described the rates for CS in India ranging from 24.4 per cent in medical colleges and teaching hospitals to 47 per cent in private sector hospitals. Saha et al. 11 compared deliveries in 2007 with those in 2008 under a new strategy protocol for CS in a tertiary facility care centre, finding an incidence in the retrospective group of 29 per cent and in the prospective group of 18.4 per cent, providing a possible solution to halt the increasing CS prevalence, and determining a necessity to undertake further multicentric clinical trials to examine possible interventions for the increasing trend in CS.

Maternal health

In India, anaemia is the second most common cause of maternal death, accounting for 20 per cent of total maternal deaths. Ezzati et al. 12 established the prevalence of iron deficency anaemia between 33-89 per cent and the National Family Health Survey (2005-2006) and reported the incidence of anaemia in pregnancy in India is 54.6 per cent in urban centres and 59 per cent in rural areas. One particular study aimed to determine the prevalence of anaemia and to explore factors associated with anaemia in one rural Indian pregnant population from Maharashtra, 13 finding that of the 310 subjects who were enrolled, 232 (74.8 per cent) were found to be anaemic. The majority (50.9 per cent) demonstrated moderate anaemia while mild and severe anaemia were recorded in 70 (30.2 per cent) and 44 (18.9 per cent) respectively. A highly significant association was found with the mother‘s age, educational and socio-economic status, religion, parity and body mass index. As normocytic hypochromic and microcytic hypochromic blood pictures were predominant in this study, it indicates deficient iron intake/absorption irrespective of age, type of family, caste, religion or number of children as the prevalence was equally high in all groups in this population. A very high prevalence of anaemia (74.8 per cent) early in pregnancy is an indicator of the failure of national and the WHO is facilitating programmes to address this problem.

Anaemia during pregnancy can be alleviated, however, by iron supplementation - though until recently there was a paucity of up-to-date research investigating the level of adherence for such supplementation in distinct Indian populations. Bilimale et al. 14 examined the adherence to iron supplementation during pregnancy in a rural population. Remarkably all aspects of the diet were considered inadequate in the study population. Forty to fifty per cent of women remained anaemic throughout the study regardless of the study group to which they had been allocated in the randomised trial. Interestingly, those who received the simple intervention of being observed taking their medication were more likely to be compliant with iron supplementation.

The management of patients with common complications of pregnancy received attention from Roy et al. 15 in their review of treatment with magnesium sulphate compared to phenytoin in eclampsia. In a randomised trial 80 women with eclampsia were randomised to receive either magnesium sulphate or phenytoin. The time taken for return to consciousness was significantly earlier and patients delivered sooner in the phenytoin group compared to those in the magnesium sulphate group, suggesting that phenytoin is better than magnesium sulphate in the bedturnover rate of eclampsia patients from the labour room eclampsia-turret to the post-partum ward. The authors conclude that in low and middle income countries, where there is a high incidence of eclampsia and labour rooms are overflowing with such critical patients, the concept of having earlier delivery, decreased number of Caesarean deliveries, increased bed turn-over (from the eclampsia turret to the labour ward), and lower cost of therapy with phenytoin appear to have practical implications. According to Arora et al. 16 pre-eclampsia and eclampsia are present in 4.6 per cent of all deliveries, with a neonatal mortality rate of 43 per 1000 live births in India. A retrospective study from Guin et al. 17 analysed all maternal deaths between January 2001 and December 2009, dividing data in two phases: before and after the implementation of the Janani Suraksha Yojana, which is a financial incentive to all women delivering in government hospitals. The first phase ran from 2001 to 2005 and the second phase between 2006 and 2009. In the first phase, eclampsia and pre-eclampsia were responsible for 31.4 per cent of the 172 maternal deaths, and in the second phase both accounted for 41.3 per cent of the 341 maternal deaths. Further to this research, and in an attempt to provide information on a suitable intervention for eclampsia, Chaturvedi et al. 18 examined the availability and use of magnesium sulphate for the treatment of eclampsia in the public health system in Maharashtra, India. They found that private care providers used magnesium sulphate in eclampsia, while the public care providers did not routinely use of it because of a fear of complications.

Infectious diseases in antenatal care has also been examined and reported on. Once such study aimed to investigate the incidence of infectious disease was the focus of a report from rural Maharashtra. 19 Kwatra et al. 19 reported a retrospective analysis of data on the utilisation of Integrated Counselling and Training Centre (ICTC) services by pregnant women at a tertiary care hospital. From over 12,000 pregnant women attending the antenatal clinic, 10,491 (82.5 per cent) accepted pre-test counselling and HIV testing. One hundred and forty-five women were found to be seropositive with a seroprevalence rate of 1.4 per cent; 11 per cent did not come for collection of the laboratory report and missed the post-test counselling. Most of the seropositive women were from rural areas, had low socioeconomic status, did not have a formal education, and were unaware of their serostatus and their husband’s risk behaviour. Less than one in three women were using some form of contraception. After registration, the majority of seropositive women (89.7 per cent) attended the antenatal clinic regularly; 11 per cent opted for pregnancy termination; 76 per cent delivered vaginally and 12 per cent underwent CS. A further 86 per cent of women and 80 per cent of newborns received Nevirapine prophylaxis; postnatal follow-up of babies was very limited. Results indicated that HIV seroprevalence among the pregnant population is declining steadily, and the authors were encouraged that a growing proportion of women are attending the facilities of ICTC centres. Other research has found that the seroprevalence of HIV was 0.41, 0.63, 0.67 and 0.76 per cent in 2004, 2005, 2006 and 2007 respectively in a tertiary care centre. 20

Rare pregnancy

Rare obstetric cases have also been topical in the research literature in recent years. Case reports on the rare and potentially life-threatening ovarian pregnancy were reported by Roy and Sinha Babu. 21 This form of pregnancy is a rare event constituting one to three per cent of all ectopic pregnancies, with primary ovarian pregnancy having a better outcome than secondary ovarian or tubal ectopic pregnancy. This study reinforced the position that a high index of suspicion is required for diagnosis to avoid a crisis situation in the ward or operation theatre. Two cases of ovarian pregnancy – one primary and one secondary – were reported as having occurred in the same patient within a six-month period. The authors concluded that unlike tubal ectopic and secondary ovarian pregnancies, patients with primary ovarian pregnancy are likely to experience success in future intra-uterine conception and negligible risk.

Other types of pregnancy have also come under scrutiny. A prospective study by Mahji et al. 22 analysed 180 cases of ectopic pregnancy between 2002-2004, and during this period the incidence of this pathology was one in 161 (0.6 per cent). The risk factors for ectopic pregnancy include infections (pelvic inflammatory disease, Chlamydia trachomatis ), tubal surgery, smoking, induced conception cycle and endometriosis. The incidence is higher in women who had received ovulation induction. 23

Neonatal health

Bhardwaj and colleagues reported on a rare case of neonatal varicella, 24 where the mother had skin lesions at the time of delivery and the neonate contracted the disease during the perinatal period and developed clinical disease on day five post-partum. Specific anti-viral therapy was given to the mother and the baby and the recovery was uneventful. Neonatal varicella can be a consequence of maternal varicella during the last three weeks of pregnancy, and if it occurs near term or soon after delivery can be potentially fatal. 25 In an investigation to determine rates of neonatal varicella incidence in India, Tarang and Anupam 26 reported one case of neonatal varicella from 44 neonates with vesicobullous lesions in Departments of Dermatology and Paediatrics in the Muzaffarnagar Medical College and Hospital between 2008-2009. Although the incidence of this disease is seemingly low, these cases do serve to remind clinicians of its presence in India.

Deformities at birth have also received attention in research publications. Pandy et al. 27 described a case of abdominothoracopagus twins with single heart. The male twins were delivered in the 15th week of gestation following the desire of the parents to terminate pregnancy. This case was considered of particular interest because of the rarity of the abdomino-thoracopagus male twins with a single heart. Other cases include reports from Asaranti et al. 28 who described an autopsy of conjoined twins who shared heart, liver and part of digestive system, and the report of Fishman et al. 29 who describe the separation of thoracopagus conjoined twins with a single heart, and Gerlis et al. 30 who made a review of 36 pairs of conjoined twins, one being a case of single heart.

Conclusions

Research on the topic of obstetric and gynaecology practice in India is seemingly in good health. Recent investigations demonstrate a wide range of topics that include research into contraception attitudes and the importance of antenatal care to rare obstetric cases. Maternal morbidity and mortality, data on Caesarean section prevalence, the prevalence of neonatal disease, adherence of treatment in the case of anaemia, and the treatment in eclampsia are also prevalent. Perhaps of interest and importance is that investigations include both rural and urban populations, providing a balanced perspective from which to explore trends in obstetric and gynaecological care and intervention in India. Given the recent volume of such articles, it is perhaps worth considering how this research can be used to facilitate change in the medical practice in India to affects health outcomes. By reflecting on this, and perhaps taking the results of the research back to the populations of interest, the research will become truly translational - from bedside, to bench top, to bedside once more - and provide the ability for India to facilitate ongoing improvements in obstetric and gynaecological healthcare in India.

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John Cornwall is the Deputy Editor of the AMJ.

Please cite this paper as: Pachecho-Paramo JF, Cornwall J. A reflection on current obstetrics and gynaecology research in India. AMJ 2013, 6, 12, 708-712. http//dx.doi.org/10.4066/AMJ.2013.1953

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Case Files: High-Risk Obstetrics

Author(s): Eugene C. Toy; Edward R. Yeomans; Linda Fonseca; Joseph M. Ernest

• 1 Physiologic Adaptation to Pregnancy
• 2 First-Trimester Screening
• 3 Second-Trimester Serum Screening
• 4 Vaginal Breech Delivery
• 5 VBAC—The "Approach to Counseling and Management"
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Working arrangements for locum doctors pose significant patient safety challenges, finds study

by British Medical Journal

Working arrangements for locum doctors pose significant patient safety challenges for the NHS in England, although there are opportunities to be grasped too, finds qualitative research involving a broad spectrum of health professionals, published online in the journal BMJ Quality & Safety .

NHS leaders need to rethink how these professionals are engaged, supported, and used, while health care organizations and locums themselves need to reflect on whether their practices provide a collective approach to patient safety and quality of care , conclude the researchers.

Locum doctors are a vital resource that enable health care organizations to deliver care by flexing capacity and covering staffing gaps, and the need for them is expected to increase given the projected increase in the NHS vacancy rate, say the researchers.

But despite longstanding concerns among policymakers, health care providers, professional associations, and professional regulators about the implications of locum working for quality and safety as well as cost, there is limited good quality empirical research to substantiate these concerns, they add.

In a bid to build on the evidence base , the researchers looked at how locum working arrangements might impact quality and safety and the implications of locum working for patients, locums, and health service organizations in primary and secondary care in the NHS in England.

They carried out semi structured interviews and focus groups with 130 people between March 2021 and April 2022. Participants included locums, patients, permanently employed doctors, nurses, and other health care professionals with governance and recruitment responsibilities for locums across NHS primary and secondary health care organizations in England.

The responses were divided into common themes, the first of which was familiarity with an organization and its patients and staff, which was seen as essential to delivering safe care.

Locums described how they often worked in unfamiliar environments, sometimes with minimal induction and varying levels of support. Unfamiliarity, lack of access to, or other restrictions on computer systems, policies, procedures and buildings meant that they weren't always able to do their job safely, productively, or effectively, they said.

The balance and stability of services reliant on locums were perceived to be at risk of destabilization and lacking leadership for quality improvement.

Locums were less likely to be involved in team and organizational development. They recognized that having "an NHS run by locums" was detrimental to quality and safety, and departments that were disproportionately dependent on them were often perceived to lack clinical leadership and direction which meant that quality improvement was slower or less likely to happen.

And the discrimination and exclusion experienced by locums were detrimental to morale, retention, and patient outcomes.

Most locums described negative behaviors and attitudes from staff and some patients, which affected their involvement, inclusion, and experiences in organizations. Negative perceptions of competency and safety meant that locums were often stigmatized, with ethnicity and gender further worsening discrimination.

Locums were viewed as practicing defensive medicine as a result of their perceived increased vulnerability and low levels of support. And locums recognized that they were likely to be scapegoated if things went wrong; some described being more likely to practice defensively as a result.

Locums also felt they were more vulnerable to criticisms of their clinical competence and disempowered to make decisions. Other staff felt that some locums were simply avoiding work and evaded responsibility for patients by pushing work onto others or into the future.

Clinical governance arrangements often didn't adequately cover locum doctors. Responsibility for involving them in performance feedback, supervision, educational opportunities, appraisal, and quality improvement was unclear.

While some organizations included locums in their governance activities, others regarded locum work as transactional–where the locum was there merely to provide a finite service. Where complaints arose, the doctor had often moved on and was unaware of the concerns.

"Our findings provide some profound and concerning insights for patient safety and quality of care. The ways in which locums were recruited, inducted, deployed and integrated, and supported by organizations undoubtedly affected quality and safety," write the researchers.

"Our findings indicate that regardless of their level of experience, it was unlikely that locum doctors would be able to function optimally in unfamiliar environments; and organizations who had poor supportive infrastructure and governance mechanisms for locums were less likely to deliver high-quality safe services," they add.

"Our findings are a call to action for organizations to take stock of how they engage, support and work with locums, and ask both locums and organizations to reflect on whether their practices support a collective approach to patient safety and quality of care," they conclude.

In a linked editorial, Professor Richard Lilford of the University of Birmingham, comments that the evidence presented by the study "suggests that locum doctor arrangements are unkind and unfair, and potentially harmful to patient safety," and that "the life of the locum is a difficult and lonely one"

He suggests some potential solutions, based on the premise that locum services are essential. "There nevertheless seems to be a good case for bearing down on the market and strongly encouraging all posts to be filled with non-locum staff—less money spent on locum doctors with more money for the substantive posts."

"Inspection processes could monitor the use of medical locums and nudge hospital managers to model their workforce requirements to find the optimal balance between substantive and temporary posts," he adds.

"Because locums find it hard to adapt to different procedures and protocols, organizations could be incentivized to standardize," he suggests. A bespoke induction when locums join a clinical service and awareness raising among other staff of the sorts of issues locums face could help to tackle the isolation and discrimination they face, he says.

Routine structured feedback to locum agencies and feedback from the doctors themselves about the organizations and teams in which they work could also prove invaluable learning points for all concerned and enhance patient safety , he adds.

But change won't happen by itself, he acknowledges. "I recommend that, in England and beyond, design groups should be formed including policymakers, service managers, local agency managers and public contributors to develop a set of workable solutions for subsequent piloting, careful evaluation, and later implementation," he writes.

The study findings "should not be simply curated among the voluminous safety literature. [They] should be considered as a call to action by senior policy makers ," he advocates.

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Arizona Supreme Court revives 1864 abortion ban. What to know about the ruling

Abortions are illegal in nearly all circumstances under a pre-statehood law the Arizona Supreme Court upheld Tuesday.

The abortion ban was put in place under Arizona law in 1864. The state Court of Appeals, however, issued an injunction against the 160-year-old ban when the U.S. Supreme Court issued its historic Roe v. Wade decision in 1973.

When the Dobbs v. Jackson Women's Health Organization ruling came in June 2022 and removed the Roe protections, conservative activists in Arizona petitioned the courts to remove the injunction against the ban.

Here's what we know about the latest abortion ruling in Arizona.

Who are they? 2 justices who upheld Arizona's 1864 abortion ban are up for reelection

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When is abortion legal under law?

The pre-statehood law indicates abortions are allowed when necessary to save the life of the mother.

When would an abortion be necessary to save the life of a mother?

The ban doesn't include specific criteria to help providers determine when an abortion is legally allowable, said Jennifer Piatt, co-director of the Center for Public Health Law and Policy at Arizona State University's Sandra Day O’Connor College of Law.

That raises legal questions and could make it difficult for doctors to parse out when a medical emergency is so severe that they can perform an abortion without fearing retribution.

"There's no specific definition. The 15-week ban had very specific definitions of what constituted emergency circumstances," she said. "Working that out and figuring out the contours and limitations of that is also going to be this brand-new, big legal question for folks to have to tangle with."

Arizona Supreme Court: Abortion set to be illegal in nearly all circumstances

What about medication abortion?

The law bans all abortions except when necessary to save the mother's life. The ban includes medication abortions, which are a two-drug combination recommended for use up to 10 weeks of pregnancy. Medication abortions are also often known as abortion pills.

Arizona  has a law  that says a "manufacturer, supplier or physician or any other person is prohibited from providing an abortion-inducing drug via courier, delivery or mail service," though the law doesn't say anything about whether it's legal for a person to receive the drugs in the mail.

As a result, some Arizonans could end up turning to obtaining abortion pills from suppliers outside the state or the country.

Plan C,  a U.S.-based information campaign about medication abortions, says that while abortion pills are prescription medications in the U.S., it is possible to get them from some places without a prescription. Plan C is referring patients to a free, confidential Repro Legal Helpline at 844-868-2812.

When does the 1864 abortion law take effect in Arizona?

The territorial ban could take effect as soon as roughly 60 days from now to much further down the road, depending on how the parties to the lawsuit respond to the Arizona Supreme Court’s decision. That's according to Jared Keenan, legal director of the ACLU of Arizona, which was not a party in the case that led to today’s decision.

The Supreme Court stayed enforcement of the territorial ban for 14 calendar days from Tuesday. Plus, the parties in a separate lawsuit had agreed with former Arizona Attorney General Mark Brnovich that should the territorial ban take effect, the state could not enforce it for an additional 45 days, Keenan said.

So, under that reasoning, the earliest possible enforcement date is roughly 60 days away.

But if the parties raise additional challenges to the territorial ban at the trial court level in the next two weeks, they also can ask the trial court to stay the state Supreme Court’s opinion, Keenan said.

Keenan said a potential stay by the trial court could remain in place until the case is resolved. That could be months in the future − possibly after the November election, when a measure protecting abortion access may be on the ballot.

If passed, that constitutional amendment would take effect in early December, after the general election votes are canvassed.

Arizona politics: What Arizona leaders and lawmakers are saying about abortion ban

What are the punishments for abortions?

The pre-statehood law  requires two to five years in prison for anyone aiding an abortion, except if the procedure is necessary to save the life of the mother.

Could a woman be prosecuted for seeking an abortion?

The text of the pre-statehood law notes that it could apply to any person who "provides, supplies or administers to a pregnant woman, or procures such woman to take any medicine, drugs or substance, or uses or employs any instrument or other means whatever, with intent thereby to procure the miscarriage of such woman, unless it is necessary to save her life."

Jennifer Piatt of the Sandra Day O'Connor College of Law said that leaves open the possibility that a woman could be prosecuted under the law for seeking an abortion. She said the question is "subject to ongoing litigation."

"We didn't have this law in place, so there wasn't any reason to sort of tear out those nitty-gritty pieces of it. Now that it's in place, there's going to be that legal argument available. The language is broad enough, I think, in the statute, that it's possible."

She noted a law from the same era requiring at least a year in prison for a woman seeking an abortion was repealed in 2021 . That could create legal arguments around legislative intent that would indicate the pre-statehood law upheld Tuesday doesn't apply to anyone who receives an abortion.

"We just don't know," she said. "So I think it's possible that could be litigated."

How will the Arizona abortion ban be enforced?

Enforcement of the law is stayed for 14 days under the state Supreme Court's ruling. Beyond that, it's unclear just how, or if, the law will be enforced.

Democratic Gov. Katie Hobbs issued an executive order last year giving all power to enforce abortion laws to the state attorney general.

The current attorney general, Democrat Kris Mayes, has vowed not to enforce any abortion bans. But her decision and Hobbs' order could be challenged by one of the state's county attorneys.

What does 'prospectively enforced' mean?

The Arizona high court ruling indicated the ban can be only "prospectively enforced."

Because the law is "prospectively enforced," said the Sandra Day O'Connor College of Law's Piatt, attorneys wouldn't be able to prosecute any previous abortions or abortions that could occur in the time before the ruling would take effect.

How could an abortion ban affect maternal mortality in Arizona?

Abortion bans have a harmful effect on maternal mortality, studies and health experts say.

"Pregnant people in states where abortion is already banned are nearly three times as likely to die in pregnancy, childbirth or soon after delivery," said Dr. Jill Gibson, chief medical officer for Planned Parenthood Arizona.

"Arizona's maternal mortality rate has tragically quadrupled over the last 20 years. And today, the Arizona Supreme Court has made a decision that we know from data will directly cause the maternal mortality rate in Arizona to become even more unacceptable and tragic."

An abortion ban also could reduce the number of medical students and recent graduates who will want to do their obstetrics/gynecology training in the state, health policy expert Swapna Reddy said. And based on what has happened in other states with abortion bans, there could be a chilling effect on finding providers, including pharmacists, nurses and support staff in the field of reproductive health care in general.

"That's a problem for our larger society and it disproportionately affects folks in rural areas and it disproportionately affects areas that already have maternal care shortages," said Reddy, who is a clinical associate professor at Arizona State University's College of Health Solutions. She said her opinions are personal and do not represent the university.

"In the United States, we have the worst maternal mortality stats of any developed nation , and Arizona already has maternal mortality issues, so it's something I think we really need to be conscious of."

Where is abortion illegal in the United States?

Abortion is banned in the following states, according to CNN's abortion law tracker :

• Mississippi
• North Dakota
• South Dakota
• West Virginia

These states have bans in place making abortions illegal depending on how far along the pregnancy is:

• North Carolina
• South Carolina