July 2010 - AOGD

Volume 10 July 2010 Monthly Issue 3 

AOGD Bulletin 

M inimise 

aternal 

ortality 

Safe 

Mother 

Nation 

AOGD Secretariat 

Department of Obstetrics & Gynecology 

Room No. 112, Ward 1, Block A, First Floor, New Surgical Block, Lok Nayak Hospital & MAMC, New Delhi 

Tel.: 011-23232400 Ext. 4545, 4222 • E-mail : asmita.rathore@yahoo.com • website : www.aogd.org

AOGD Bulletin AOGD Bulletin AOGD Bulletin AOGD Bulletin AOGD Bulletin AOGD Bulletin AOGD Bulletin AOGD Bull AOGD Bulletin 

Editor 

Dr Vijay Zutshi 

9818319110 

Co-Editor 

Dr sarita s Kale 

9868392748 

Dr K agarwal 

9968604350 

Dr shaKun tyagi 

9013447287 

AOGD Bulletin 

Volume 10 July 2010 Monthly Issue 3 

AOGD Office BeArers 2010-11 

Patrons 

Dr anusuya Das 

9868511137 

Dr sn MuKerjee 

011-22523178 

Dr s Batra 

9968604338 

HosPitality sECrEtary 

Dr suDha prasaD 

9968604341 

Jt HosPitality sECrEtary 

Dr gauri ganDhi 

9968604344 

Dr MuMtaZ Khan 

9868392797 

Dr Deepti goswaMi 

9968604348 

PrEsidEnt 

Dr usha ManaKtala 

9968604339 

Joint sECrEtary 

Dr sangeeta gupta 

9968604349 

Dr DeVenDer 

9650520360 

Hon sECrEtary 

Dr asMita rathore 

9968604345 

WEb-Editor 

Dr ashoK KuMar 

9810261473 

Co-WEb Editor 

Dr latiKa sahu 

9968604400 

Dr renu tanwar 

9968604352 

Dr shiKha sharMa 

9868392747 

Ex-offiCio mEmbErs 

Dr. s prateeK Dr. renuKa sinha 

ExECutiVE mEmbErs 

ViCE-PrEsidEnt 

Dr reVa tripathi 

9968604340 

trEasurEr 

Dr y M Mala 

9968604347 

Joint trEasurEr 

Dr MaDhaVi gupta 

9968604351 

Dr ChanDan DuBey 

9871489719 

aCadEmiC sECrEtary 

Dr raKsha arora 

9968604342 

Jt aCadEmiC sECrEtary 

Dr sangeeta Bhasin 

9868392788 

Dr leena waDhwa 

Pub rElations sECrEtary 

Dr anjali teMpe 

9868604343 

Jt Pub rElations sECrEtary 

Dr poonaM sChDeVa 

9811515144 

Dr raChna sharMa 

9868830202 

Dr pushpa panDey 

Dr. a KuMar Dr. s Bhasin Col. B s Duggal 

Dr. s Bathla Dr. r Chitra Dr. s FoteDar 

Dr. i ganguli Dr. sangeeta gupta Dr. t gupta 

Dr. M gouri DeVi Dr. shiVlata gupta Dr. up jha 

Dr. s B Khanna Dr. s MaliK Dr. r Mehra 

Dr. a Kriplani Dr. s Mittal Dr. s salhan 

Dr. p singh Dr. s s triVeDi Dr. n B VaiD 

Contents 

• From the Editor’s Pen ..............................................................04 

• Secretary’s Message .................................................................05 

• Rational use of Oral Iron Therapy in Pregnancy ..............06 

• Journal Scan ..................................................................................11 

• Proceedings of the AOGD Clinical Meeting 

at Indraprastha Apollo Hospitals, Sarita Vihar, 

New Delhi on 25th June, 2010 ...............................................17 

• Next Clinical Meeting ...............................................................18 

• RCOG Green-top Guideline Summarized by 

RCOG- AICC, North Zone-Management 

of Monochorionic Twin Pregnancy ....................................19 

Disclaimer 

The advertisements in this bulletin are not a warranty, endorsement or approval of the products 

or services. The statements and opinions contained in the articles of the AOGD Bulletin are solely 

those of the individual authors and contributors, and do not necessarily reflect the opinions or 

recommendations of the publisher. The publisher disclaims responsibility of any injury to persons 

or property resulting from any ideas or products referred to in the articles or advertisements. 

Printed, Published & Edited by 

Dr Vijay Zutshi, Editor AOGD on behalf of Association of Obstetricians and Gynaecologists of Delhi. 

Published at AOGD Secretariat, Department of Obstetrics & Gynaecology, Maulana Azad Medical 

College, New Delhi 110 002, India, 

Tel.: 011-23232400 Ext. 4405. 

Printed at 

Process & Spot C-112/3, Naraina Industrial Area, Phase - 1, New Delhi 110 028 

3

AOGD BulletinA 

Bulletin 

4 

AOGD Bulletin AOGD Bulletin AOGD Bulletin AOGD Bulletin AOGD Bulletin AOGD Bulletin AOGD Bulletin 

Dear Friends, 

Despite the National programmes anemia is one of the leading indirect causes of maternal 

mortality in India. We all know iron supplements are available in various forms. How to 

choose the correct form for your patient, when to take, what to avoid with iron supplements 

has been beautifully highlighted in the review article by Dr. Goswami. If you recommend an 

iron supplement, consider the type of iron and pill, as well as the cost. The guidelines on the 

dilemma of managing monochorionic twin has been summarised for our members. Journal 

scan as usual gives you the abstracts of situations faced by all of us in day to day practice. 

Suggestions and contributions are invited from the members. 

Dr. Vijay Zutshi 

From the Editors Pen 

“Knowledge is of no value unless you put it into practice.” 

Anton Chekhov quotes (Russian playwright and master of the modern short story, 1860-1904) 

Dr. Bharti Minocha MD, FICMCH, FICOG 

Formerly Consultant, Associate Professor, Safdarjung Hospital & VMMC, New Delhi 

Presently Consultant at: 

Rockland Hospital 

Institutional Area 

Katwaria Sarai, New Delhi 

Tel.: 011-41222222, 41688756/765 Time: 9.00am-11.00am, Tue. - Sat. 

Aakash Hospital 

90/43, Malviya Nagar, New Delhi 

Tel.: 011-40504111 Time: 11:00am - 12:00am, Mon., Wed., Sat. 

Paras Hospital 

Sushant Lok 1, Gurgaon 

Tel.: 0124-4585555 Time: 5:00pm - 7:00pm, Tue., Thur., Fri. 

Appointment Requests 

Mob.: 9811473626 E-mail: minochab@yahoo.com


Dear Friends, 

Greetings from AOGD. 

Environment Day was celebrated on 5th of June. Significance of environment in women’s’ 

health is vital. Physical environment in terms of pollution free air, hygienic surroundings 

are generally important and family environment with focus on nutrition, status in family, 

access to healthcare have direct impact. We all should use this opportunity to sensitize 

ourselves and our clients regarding importance of healthy environment. 

Brief account of activities for month of June is given below. Many activities are planned 

for future apart from monthly clinical meeting. Please participate in them in large numbers. 

Your suggestions are valuable to us. 

Best regards 

Dr. Asmita Rathore 

Secretary’s Message 

Forthcoming Events 

1. “Symposium on Evidence to Action” for reducing maternal and neonatal morbidity and mortality on 17th-18th July, 2010 

at JLN Auditorium, AIIMS. Organized by Deptt of Obst. & Gynae., AIIMS in collaboration with MOHFW and WHO. 

2. Workshop on “Endoscopy Upadate 2010” on 18th July, 2010 at P.S.K., Laxminagar district centre, under aegis of AOGD & 

IFS, KJIVF & Laparoscopy Centre, Delhi. 

3. Next Clinical Monthly meeting of AOGD will be held on 30th July, 2010 at Army Hospital, New Delhi. 

4. Thirteenth Practical course & CME in Obstetrics & Gynaecology is being held from 6th to 8th August, 2010. for details 

contact Dr. Y. M. Mala, M.: 9968604347. 

5. National CME on Obstetrics & Gynecology Module 3 on 28-29th August, 2010 at AIIMS. For registration, please contact 

Dr. Neeta Singh, M.: 9868397311. 

6. 32nd Annual Conference of AOGD will be held on from 30th & 31st October, 2010 at Maulana Azad Medical College, N, D. 

7. Colposcopy Worskhop will be held on 31st July, 2010 at Sir Gangaram Hospital, New Delhi. For details contact: Dr Harsha 

Khullar, M.: 09414170555, Email: azadanita@rediffmail.com 

Thirteenth Practical Course & CME for Post Graduates from 6th - 8th Augest, 2010 at MAMC, New Delhi for details 

contact Dr. Y. M. Mala M.: 09968604347 or Dr. Madhavi M.: 09968604351 

Events Held 

1. IMA JANAKPURI GYNAE CLUB organised CME on 3rd June at Medico House Janakpuri under the aegis of AOGD. 

Dr Narender Malhotra & Dr Jaideep Malhotra delivered a talk on IUGR & CONGENITAL ANOMALIES. 

2. Live Workshop on Pelvic Surgery on 12th June, 2010 at Artemis Hospital, Gurgaon, Organized by Sunrise Keyhole 

Surgery Foundation & AOGD. 

3. South Delhi Gynae Forum & SJH conducted CME on DUB on 24th June, 2010. 

4. AOGD Clinical meeting was held on 25th June, 2010 at Apollo Hospital. 

5. Part I MRCOG Course was held at RCOG NZ Centre, CR Park on 20th June, 2010. 

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REVIEW ARTICLE 

Rational use of Oral Iron Therapy in Pregnancy 

Dr Deepti Goswami, Professor, Obst. & Gynae., Maulana Azad Medical College, New Delhi 

BURDEN OF IRON DEFICIENCY ANEMIA _______ 

In a study of pregnant womne in urbam Delhi slums, it was 

found that 85.4% pregnant women had hemoglobin levels 

below 11.0 g/dl. The prevalence of mild (Hb level 10-10.9 

g/dl)), moderate (Hb level 7.0-9.9 g/dl) and severe anemia 

(Hb level 6.9 g/dl and below) was 30.4%,53.5% and 1.5%, 

respectively 1 . 

Iron metabolism is controlled by absorption rather than 

excretion 2 . 

Iron absorption 

• Occurs mostly in the duodenum and proximal jejunum. 

• Only 5 to 10 percent of dietary intake of iron gets 

absorbed. 

• The amount of elemental iron absorbed in the gut 

can vary significantly depending on several factors, 

including hemoglobin level and body iron stores. 

• In states of overload, absorption decreases. 

• Absorption can increase three- to fivefold in states 

of depletion. The decline in iron status that normally 

accompanies pregnancy results in an increase in the 

efficiency of absorption of dietary or supplemental iron. 

Dietary iron is available in two forms 

• Heme iron (meat) - its absorption is minimally affected 

by dietary factors. 

• Nonheme iron (plants, dairy foods)- requires acid 

digestion and its bioavailability varies depending on 

the concentration of enhancers (e.g., ascorbate, meat) 

and inhibitors (e.g., calcium, fiber, tea, coffee, wine) in 

the diet. 

Iron deficiency state 

• Iron stores are depleted before iron deficient 

erythropoiesis occurs. 

• Three years of a severely iron deficient diet (less than 

1-2 mg/d) or acute hemorrhage of two liters (0.4 mg 

elemental iron per ml whole blood) will both cause a 

complete loss of iron stores. 

• The loss of iron stores is reflected in the blood by a 

reduction in serum ferritin and reduced levels / of iron 

bound to transferrin. Serum ferritin levels


It has a pleasant taste and does not cause prominent 

gastrointestinal irritation. However most clinical 

studies have shown that it has variable and generally 

poor bioavailability. 

• Carbonyl iron is elemental iron, not an iron salt. It is 

a small particle preparation of highly purified metallic 

iron. Its rate of absorption depends on the production 

of gastric acid (which is required to make carbonyl 

iron soluble). Thus it enters the body much more 

gradually than other types of iron that can dissolve 

rapidly. Bioavailability is approximately 70% of 

a similar dose of ferrous sulfate. This slow rate of 

solubilization minimizes the toxicity of carbonyl 

iron. 

• Delayed release and enteric-coated iron 

preparations are better tolerated than the nonenteric 

coated tablets. However, they are less effective 

since they may contain less iron and their iron may not 

be released in the duodenum, where iron is absorbed. 

In fact, patients who have been treated unsuccessfully 

with enteric-coated and prolonged-release iron 

preparations may respond well to the administration 

of nonenteric-coated ferrous salts. 

b. Other ingredients in iron preparations 

Indian market is flooded with preparations containing iron, 

vitamins, minerals, and other micronutrients. 

Only preparations containing iron and folic acid (in appropriate 

amounts) are rational and recommended by the WHO. 

• Zinc salts act as competitors of iron absorption and 

thus decrease its absorption. 

• When present in an amount of 200mg or more, 

ascorbic acid (vitamin C) increases the absorption of 

medicinal iron by at least 30%. However, the increased 

uptake is associated with a significant increase in 

the incidence of side effects including destruction of 

the intestinal mucous membrane when put to over 

work. Therefore, the addition of ascorbic acid seems 

to have little advantage over increasing the amount 

of iron administered. (Goodman & Gilman, The 

Pharmacological Basis of Therapeutics, 11th edition) 

• Copper deficiency is extremely rare in human beings. 

• Oral treatment with pyridoxine is of benefit in 

correcting anemia associated with consumption of 

anti-tuberculosis drugs. 

• Haemoglobin per se is a poor source of elemental 

iron absorbed by the body. The source of haemoglobin 

is blood of animals killed in slaughter houses. No 

standard textbooks of medical sciences or medical 

journals mention the use of haemoglobin as a drug. 

Haemoglobin containing iron preparations are banned 

since year 2000. 

• Some preparations contain liver extract and even 

alcohol. Government notifications have banned 

combinations containing liver extract. 

c. Administering oral iron 3 

• Aim is to provide a daily dose of 150-200 mg of 

elemental iron. This would require prescribing one 

ferrous sulfate tablet 3 times daily. Since each tablet 

contains approximately 60 mg of elemental iron. 

Assuming that 10% of the iron is absorbed, the 

hemoglobin concentration may fully correct after 4 

weeks in patients with moderate, uncomplicated iron 

deficiency (about 500–800 mg of iron, enough for 500 

to 800 ml of packed red blood cells, or enough to raise 

the whole blood hemoglobin 2–3 g/dl). 

• Iron tablets are recommended between meals or at 

bedtime to avoid the alkalinizing effect of food and to 

take advantage of the peak gastric acid production late 

at night. 

• Although iron absorption occurs more readily when 

taken on an empty stomach, this increases the 

likelihood of stomach upset because of iron therapy. 

Increased patient adherence should be weighed against 

the inferior absorption. 

• Foods rich in tannates (e.g., tea) or phytates (e.g., 

bran, cereal), or medications that raise the gastric pH 

(e.g., antacids, proton pump inhibitors, histamine H2 

blockers) reduce absorption and should be avoided if 

possible. 

• Iron absorption can be increased by addition of citrus 

fruits. In contrast, tea inhibits iron absorption so one 

should wait 1-2 hours after the meal before drinking 

tea or alternatively, remove tea from their diet. 

• Absorption is also delayed with tetracyclines, milk, 

and phosphate-containing, carbonated beverages 

such as soft drinks. Even the calcium, phosphorus 

and magnesium salts contained in iron-containing 

multivitamin pills impair absorption of elemental 

iron. Hence multivitamin preparations should not be 

recommended as a sole therapy for iron deficient anemia. 

• The effect of calcium and milk is similar. When calcium 

carbonate is taken concurrently with ferrous 

sulphate; the iron absorption can be reduced by 

two-thirds. 

• Some persons have difficulty absorbing the iron 

because of poor dissolution of the coating. A liquid iron 

preparation would be a better choice for these patients. 

d. Side effects of oral iron and their management 

• Side effects of oral iron are directly related to the 

amount of elemental iron, administered. Hence side 

effects are much less with preparations which have 

much lower elemental iron content than anhydrous 

ferrous sulphate. 

• Laxatives, stool softeners, and adequate intake of 

liquids can alleviate the constipating effects of oral iron 

therapy. 

• If a patient is intolerant to the recommended dose of 

150-200mg of daily elemental iron, dose reductions 

are applied. Changes in iron salts (and hence elemental 

7


Bulletin 

8 


Table 1: Ferrous sulphate preparations (Elemental iron 37% in anhydrous/ dried ferrous sulphate, 20% in regular ferrous sulphate): 

S. No. Drug Pharma Co. Ferrous 

sulphate 

1. Conviron TR 

[cap] 

2. Elferri TR 

[cap] 

3. Fefol 

[spansule] 

4. Fefol-Z 

[spansule] 

Carbonyl iron 

5. Fesovit 

spansule 

[cap] 

6. J.P. tone TR 

[TR tab] 

Ranbaxy 

(Pharma) 

Swizera 

(ACE) 

Glaxo Smith 

Kline 

Glaxo Smith- 

Kline 

Glaxo Smith 

Kline 

Folic acid Vit B12 Other content Packing/ 

Price 

(Dried) 60mg 1.5 mg 15 µg Vit B6, Vit C 15’s 

(Rs. 55.35) 

(Dried) 60 mg 1.5 mg 15 µg Vit B6, Vit C 15’s 

(Rs.54) 

150 mg 0.5 mg x x 15’s (Rs. 

46.5) 

150 mg 0.5 mg x zinc 15’s 

(Rs.65.90) 

150 mg 1 mg 15 µg vit B6, 

nicotinamide 

30’s 

(Rs. 87.7) 

Jagsonpal (Dried) 150 mg 0.5 mg x zinc 1x15 

(Rs. 48) 

Table 2: Ferrous fumarate preparations (Elemental iron 33%): 

S. No. Drug Pharma 

Co. 

Ferrous 

fumarate 

Apprx 

cost / tab 

Rs. 3.6 

Rs. 3.6 

Rs. 3 

Rs. 4.4 

Rs. 3 

Rs. 3.2 

Folic acid Vit B12 Other content Packing/ Price Approx cost 

/ tablet 

1. Autrin [cap] Wyeth 300mg 1.5 mg 15 µg x 30’s (Rs 36.60) Rs. 1.3 

2. Dumasules 

[cap] 

3. Elferri Z [cap] Swizera 

(ACE) 

Unimed 300mg 0.75 mg 7.5 µg vit C, Vit B1, Vit 

B, Niacinamide 

10’s (Rs. 11.56) Rs.1.1 

200mg 1.5mg 15 µg zinc 30’s (Rs. 35.65) Rs.1.1 

4. Hemsi [cap] Serum Intl 300 mg 1.5mg 5µg zinc, copper, 

manganese, 

lysine 

5. Globac Z [sg 

cap] 

6. Haem Up 

Gems [cap] 

7. Hembran plus 

[cap] 

Zydus 

Nutriva 

15’s (Rs. 31.50) Rs.2 

152 mg 1.5mg 15µg zinc 30’s (Rs 77.20) Rs.2.5 

Cadila 200mg 1.5mg x Copper, 

manganese 

30’s (Rs 67.07) Rs 2.2 

Brawn 300 mg 1.5mg 15µg vit C, vit B6 10’s (Rs. 20) Rs.2 

8. Hemsi [cap] Serum Intl 300 mg 1.5mg 5µg zinc, copper, 

manganese, 

lysine 

9. Livogen FC 

[captab] 

15’s (Rs. 31.50) Rs.2 

Merck 152 mg 1.5 mg x x 10’s (Rs 18.33) Rs.1.8 

10. Softeron [cap] Aristo 165mg 0.75 mg x Docusate sodium 15’s Rs. (17.20) Rs.1.1 

11. Vitcofol [cap] FDC 

(Select) 

12. Ziferrin TR 

[cap] 

300 mg 0.75 mg 7.5 µg zinc, vit B6 15’s (Rs 24.3) Rs.1.6 

Zydus cadila 200mg 1mg 10µg zinc 10’s (Rs. 20.44) Rs.2 

Table 3: Ferrous gluconate preparations (Elemental iron 12%): 

S. No. Drug Pharma Co. Ferrous 

gluconate 

1. J.P. tone 

[syr] 

2. Mulmin 

plus 

3. R.B.tone 

[cap] 

Jagsonpal 200 mg 

/10ml 

Folic acid Vit B12 Other content Packing/Price Approx cost / 

tablet 

x 2.5 µg Multivitamins, 

D-panthenol 

Juggat 50 mg 0.25 mg 5 µg Multivitamins, vit 

A,D,E,C 

Medley 

Nutrakare 

200 ml (Rs. 75) Rs 3.7/10ml 

10 (Rs. 40) Rs. 4 

259 mg 2.5 mg 2.5 mg zinc, calcium 15’s (Rs. 36) Rs. 2.4


Table 4: Ferrous glycine sulfate preparations (Elemental iron 23%): 

S. 

No. 

1. Fecontin-F 

[CR- tab] 

2. Fecontin-Z 

[CR- tab] 

3. Hemfer 

[cap] 

Drug Pharma 

Co. 

Modi 

Mundi 

Modi 

Mundi 

Ferrous glycine 

sulfate 

Folic acid Vit B12 Other 

content 

Packing/Price Approx cost / 

tablet 

100 mg 0.5 mg x x 120’s (Rs. 558.6) Rs. 4.6 

100 mg 0.5 mg x zinc 10’s (Rs. 62.9) Rs. 6.3 

Alkem 50 mg 0.5 mg 7.5 µg zinc, vit C 

75 mg 

Table 5: Ferric ammonium citrate (Elemental iron 18%): 


Co. 

1. Dexorange 

[cap] 

2. Dexorange 

[syr] 

Franco- 

Indian 

Franco- 

Indian 

3. Globac liq Zydus 

Alidac 

4. Haem Up 

liquid 

Ferric ammonium 

citrate 


content 

10’s (Rs. 22) Rs. 2.2 

Packing/ 

Price 

160 mg 0.5 mg 7.5 µg zinc 30’s (Rs. 

54.42) 

160 mg/15ml 0.5 mg 7.5 µg x 200 ml 

(Rs. 59.90) 

60 mg/15 ml 1 mg 12.5 µg zinc 200 ml (Rs. 

43.86) 

Cadila 160 mg /15ml 0.5 mg 7.5 µg copper, 

manganese 

Table 7: Iron (III) hydroxide polymaltose complex (iron 46%): 

S. No. Drug Pharma Co. Iron (III) hydroxide 

polymaltose 

1. Globac-PM 

[tab] 

Zydus 

(Alidac) 

2. Fegem [tab] Torrent 50 mg 100 

mg 


content 

200ml (Rs 

50.95) 

Packing/ 

Price 

100 mg 1.5 mg x x 10’s 

(Rs. 39.78) 

0.175 mg 

0.35 mg 

x x 10’s 

(Rs. 26.5) 10’s 

(Rs. 49) 

Approx cost / 

tablet 

Rs. 1.8 

Rs. 4.5/15 ml 

Rs. 3.3/15 ml 

Rs 3.75/ 15ml 

Approx cost/ 

tablet 

3. Femed [tab] Comed 100 mg 1 mg x x 10’s (Rs. 42) Rs. 4.2 

4. Fericip chew 

tab 

Cipla 100 mg 0.35 mg x x 10’s (Rs. 45) Rs. 4.5 

5. Ferium [cap] Emcure 100 mg 1 mg x x 10’s (Rs. 45) Rs. 4.5 

6. Ferose [cap] CFL 50 mg 0.35 mg x x 10’s (Rs. 42) Rs. 4.2 

7. Mumfer [chw 

tab] 

Table 8: Other iron preparations in the market: 


Co. 

1. Anofer Sun pharma Carbonyl 

iron 120 

mg 

Glenmark 100 mg 0.5 mg x 30’s 

(Rs.148.8) 

2. Safiron [cap] Khandelwal Carbonyl 

iron 100mg 

3. FeriumXT 

[cap] 

Emcure 

Schweiz 

Rs. 5 

Rs. 4 

Rs. 5 

Iron Folic acid Vit B12 Other content Packing/Price Approx cost 

/tablet 

Ferrous 

ascorbate 

100 mg 

iron per tablet) and formulations are commonly tried. 

One may also try dose reductions by lengthening the 

dose interval. This may permit iron-intolerant patients 

to continue oral therapy, and avoid parenteral therapy. 

However lowering the daily iron dose would require a 

longer duration of therapy. 

1.5mg 12µg Multivitamin, 

Sodium Docusate 

10’s 47 Rs 4.7 

1.5mg 10µg Zinc, selenium, vit E 3x10 (Rs. 400) Rs 13.3 

1.5 mg x x 10’s (Rs.72.95) Rs 7.3 

e. Response to therapy 

• Patients with iron deficient anemia should manifest a 

response to iron with reticulocytosis in three to seven 

days. 

• An increase in the hemoglobin level of 1 g per dl should 

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10 


occur every two to three weeks on iron therapy. 

• Theoretically, 500 mg of absorbed iron should produce 

500 cc of packed cells, or enough to raise the hemoglobin 

by about 2 g/dl. 

An insufficient response may be due to: 

• ongoing blood loss 

• malabsorption due to anatomical or inhibiting factors 

e.g. antacids or tea 

• incorrect diagnosis 

• noncompliance 

TR-timed release CR-controlled release 

• There are hundreds of products listed in drug formularies. 

In this article an effort has been made to include some of 

the marketed drugs in Delhi. 

• The prices are what are available on the website www. 

mims.com 

It is worthwhile to note that: 

• Similar names may have different iron preparations 

e.g.: 

FORTIS BLOOM IVF CENTRE 

Fortis La Femme Hospital, New Delhi 

• Globac PM (Iron (III) hydroxide polymaltose), Globac 

Z (ferrous fumarate) & Globac liq (ferric ammonium 

citrate). 

• Ferium (Iron (III) hydroxide polymaltose) & Ferium XT 

(Ferrous ascorbate) 

• Haem up gems (ferrous fumarate) & Haem Up liq 

(ferric ammonium citrate) 

• JP tone syrup (ferrous gluconate) & JP tone TR tablet 

(ferrous sulphate). 

• Different brands containing same iron preparation may 

contain different amount of iron, so when calculating 

the cost of daily therapy due consideration should be 

given to the amount of iron in the tablet and number 

of tablets required in a day. 

REFERENCES _______________________________ 

1. Killip S, Bennett JM, Chambers MD. Iron deficiency anemia. Am 

Fam Physician. 2007; 75:671-8. 

2. Mukherji J. Iron deficiency anemia in pregnancy. Rational Drug 

Bull. 2002; 12:2-5. 

3. Brise H, Hallberg L. Absorbability of different iron compounds. 

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Journal Scan 

Dr Shakun Tyagi, Dr Neha Singh, Dr Ayesha Arif, Dr Seema Beniwal 

WHAT MEASURED BLOOD LOSS TELLS US 

ABOUT POSTPARTUM BLEEDING: A SYSTEMATIC 

REVIEW. (BJOG 2010;117:788–800) ___________ 

Sloan NL, Durocher J, Aldrich T, Blum J, Winikoff B 

Objectives: Systematic review of measured postpartum 

blood loss with and without prophylactic uterotonics for 

prevention of postpartum hemorrhage (PPH). 

Methods: 29 studies with objective measurement of blood 

loss after delivery were evaluated. Most of the studies 

measured blood loss by placing a bedpan underneath the 

parturient woman. The collected blood was poured into a jar 

for volume measurement, and all soaked gauze pads were 

counted and weighed. A few studies used the fairly new 

blood collection sheet or delivery drape to calculate blood loss. 

Results: The distribution of average blood loss is similar 

with any prophylactic uterotonic, and is lower than without 

prophylaxis. Compared with no uterotonic, oxytocin and 

misoprostol have lower PPH (≥500 ml) and severe PPH 

(≥1000 ml) rates. Oxytocin has lower PPH and severe PPH 

rates than misoprostol. 

Conclusion: Oxytocin is superior to misoprostol in 

hospitals. Although oxytocin is superior, misoprostol 

substantially lowers PPH and severe PPH. A sound 

assessment of the relative merits of the two drugs is needed 

in rural areas, where most PPH deaths occur. 

RISK OF UTERINE RUPTURE ASSOCIATED WITH 

AN INTERDELIVERY INTERVAL BETWEEN 18 AND 

24 MONTHS (OBSTETRICS & GYNECOLOGY, MAY 

2010;115,( 5): 1003-6) _______________________ 

Bujol E, Gauthier R 

Objective: To estimate the association between interdelivery 

interval and uterine rupture in women with a 

previous cesarean delivery 

Methods: Secondary analysis was performed in a 

retrospective cohort study of women who underwent a trial 

of labor after undergoing a previous cesarean delivery. Only 

singleton pregnancies with a trial of labor at term were 

included. The rates of uterine rupture were compared among 

women with interdelivery intervals 24 months or longer 

(controls), 18–24 months, and fewer than 18 months. The 

student t test and multivariable logistic regression analysis 

were conducted. A P value of less than .05 was considered 

significant. 

Results: Of the 1,768 women analyzed, 1,323 (74.8%) 

had an interdelivery interval of 24 months or longer, 257 

(14.5%) had an interval between 18 and 24 months, and 188 

(10.6%) had an interval of less than 18 months. The rate of 

successful VBAC (70%, 74%, and 73%, respectively; P=0.28) 

not different across the three groups. After adjustment for 

confounding variables, an interdelivery interval less than 18 

months was associated with a significant increase of uterine 

rupture (odds ratio [OR], 3.0; 95% confidence interval [CI], 

1.3–7.2), whereas an interdelivery interval between 18 and 

24 months was not (OR, 1.1; 95% CI, 0.4 –3.2) 

Conclusion: The risk of uterine rupture was significantly 

higher in women with an interdelivery interval less than 18 

months than in women with an interval of 24 months or 

longer, but not in women with an interval between 18 and 

23 months. An interdelivery interval less than 18 months 

was an independent and an important factor associated 

with uterine scar defect, after adjustment for a uterine 

scar thickness less than 2.3 mm and a previous single-layer 

closure of the uterus. 

PROGESTOGEN TREATMENT OPTIONS FOR 

EARLY ENDOMETRIAL CANCER (BR J OBSTET 

GYNAECOL 2010;117:879–84) ________________ 

Cade TJ, Quinn MA, Rome RM, Neeshama D 

Objective: Analysis of cancer-free outcome and fertility 

potential with progestogen therapy for early endometrial 

cancer. 

Methods: Sixteen patients receiving progestogen therapy 

for stage-1 grade-1 endometrial cancer were retrospectively 

reviewed and their response to treatment, duration of 

response and fertility outcome in a specialist gynaecological 

oncology unit at a tertiary hospital was evaluated. 

Results: Of the 16 patients, four received an oral 

progestogen, three received levonorgestrel-releasing 

intrauterine system (Mirena), and nine received both forms 

of treatment. Response to therapy was assessed by disease 

regression on serial endometrial curettage. Ten patients 

(63%) responded to treatment, with a median time to 

response of 5.5 months. Six patients did not respond, but 

they were either early in treatment or opted for surgical 

management before the average time of response. No 

patient who responded had a later recurrence. The mean 

follow-up time was 27 months (range 3–134 months), 

with no patient deaths. Three patients had successful 

pregnancies. 

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Conclusions: Progestogen therapy appears to be a realistic 

treatment option in selected patients in the closely 

supervised environment of a specialist gynecological 

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on 18th July 2010, Sunday 10am to 2pm 

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MD, FICOG, FIAMS 

HOD, Dept. of Gynae- Oncology 

Former HOD, Safdarjung Hospital 

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Live Pelvic Surgery Workshop jointly organized by Sunrise Keyhole Surgery Foundation and AOGD 

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13


Proceedings of the AOGD Clinical Meeting at Indraprastha 

Apollo Hospitals, Sarita Vihar, New Delhi on 25th June, 2010 

UTERINE ARTERIOVENOUS MALFORMATIONS- 

REPORT OF TWO CASES _____________________ 

SB Khanna, Harsh Rastogi, Kiranbala Dash, Saba 

Uterine AV malformation is a rare cause of uterine bleeding. 

Clinical presentation varies from no signs over various 

degrees of menorrhagia to massive life -threatening vaginal 

bleeding. Clinical findings in such cases are unreliable and 

uterine curettage is not therapeutic and even aggravates 

at times. Therefore high index of clinical suspension is 

required to diagnose this condition. With availability of 

newer diagnostic modalities like Doppler flow USG, MRI & 

Pelvic angiography it has become easier to diagnose such 

cases. Two cases of uterine arteriovenous malformation are 

being presented. 

Case - 1: Mrs. U.S a 30years old P1A2 presented with 

complaints of continuous bleeding P/V for 3 months 

not responding to hemostats & estrogen progesterone 

combinations. She also had D&C done one month back 

(HPE: proliferative endometrium). On examination she 

had moderate pallor. Pelvic examination revealed a normal 

sized uterus. Her haemoglobin was 7gm/dl. Her USG Pelvis 

reaveled a 7.3cm x 4cm with hypoechoic area in posterior 

myometrium with internal vascularity. On color flow florid 

colour pattern with mosaic aliasing color flow was seen 

which was continuing with Right adnexal vessels and right 

uterine artery. She was admitted, transfused with one 

unit of packed red cells. After discussing all possibilities of 

treatment with the patient she wanted to conserve uterus 

for fertility. Her pelvic angiography revealed high flow AVM 

in right posterior part of body & fundus fed by both uterine 

arteries and right ovarian artery. 

Case-2: Mrs. H. a 45year old female P0A4 presented with 

pain in lower abdomen and irregular periods with heavy 

bleeding for 5-6 years. Her cycles were of 4-5/30-60 days but 

very heavy. She had 4 spontaneous early pregnancy losses 

followed by D&E each time. On examination uterus was of 

16 week size, soft and pulsations were felt in both fornices. 

She also had blood transfusion twice. Her USG abdomen 

revealed a bulky uterus with markedly tortuous and dilated 

vessels in myometrium and B/L adnexa suggestive of 

uterine arteriovenous malformation. MRI pelvis revealed a 

bulky uterus with multiple tortous flow voids seen involving 

uterus, b/L adnexal region, perivesical region in pelvic 

cavity with large venous pouch noted in left adnexal region. 

Left ovarian artery also appeared dilated and tortuous. B/L 

uterines appeared tortuous dilated. Pelvic angiogram was 

suggestive of fistulous communication noted on the left 

side fed by branches of left ovarian artery and draining 

into pelvic veins. Fistulous side was noted near the inferior 

aspect of left SI joints. Multiple fistulous communications 

noted from both uterine arteries and draining into pelvic 

veins. Both these cases were managed successfully with 

uterine artery embolization. 

A RARE CASE OF VAGINAL OBSTRUCTION 

ASSOCIATED WITH MENSTRUAL PROBLEM AND 

IN FERTILITY _______________________________ 

Sushma Sinha, Jyoti Gupta 

Introduction 

Birth trauma, chemical vaginitis, carcinoma and 

radiotherapy are known to cause vaginal stenosis, leading 

to difficult sexual intercourse or scanty periods. Rarely, 

vaginal obstruction may be due to postmenopausal atrophy, 

endometriosis, or vaginitis, leading to scarring or adhesions. 

We report a rare case of vaginal obstruction associated with 

menstrual problem and infertility. 

Case Report 

A 26 year old nullipara, married for 4 years presented 

with inability to conceive and cyclical spotting for 2 years 

along with pain lower abdomen off and on specially during 

spotting. Abdomen was soft and non-tender. Per speculum, 

no projecting cervix was visualized. A small pit was seen at 

vault with a spot of blood and the pit could not be negotiated. 

Per vaginum, pelvis felt empty. Per rectum, a doubtful 

boggy mass was felt anterior to rectum. All investigations 

pertaining to infertility were normal. USG pelvis revealed 

a normal size uterus with short cervix. Vagina could not be 

clearly differentiated from fluid in anterior and posterior 

fornix. MRI revealed a well defined peripherally enhancing 

collection in posterior fornix and vagina with normal uterus 

and cervix. Laparoscopy was done. Uterus was normal 

size. No evidence of infection or endometriosis seen. No 

significant collection was seen in pouch of douglous. Bulge 

seen in posterior fornix. Speculum examination under 

anaesthesia revealed vault like appearance. Colpotomy 

was done and cream coloured pus was drained both from 

anterior and posterior forniceal sites. Pus was sent for AFB 

culture, PCR aerobic and anaerobic culture Aerobic culture 

revealed coagulase negative staphylococcus. Patient was 

sent home on antibiotics. On follow up 3 months later, 

she was relived of pain. Menstrual pattern was same. On 

speculum examination, vault was still closed and no orifice 

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18 


was seen. On EUA, Small opening at vault seen. No pus or 

blood seen. A lacrimal probe guided dissection was done 

around the opening at vault. Cervix was seen and held with 

vulsellum. A circumferential incision was given over cervix 

and vaginal wall stitched circumferentially over cervix. After 

2 months, cycles were regular without pain. Intercourse has 

not resumed. Speculum examination revealed a healthy 

looking cervix. Uterus was normal sized, mobile, nontender 

with free fornices, on vaginal examination. 

Discussion 

Case of vaginal stenosis are largely seen in old women 

resulting from carcinoma or radiotherapy. In younger 

women, causes are largely pertaining to trauma or pelvic 

surgery. Such a case of vaginal obstruction is a rare 

observation in literature. Infectious and anatomical 

etiologies have good prognosis in infertile patients provided 

the treatment is prompt and adequate. 

CHALLENGES IN DISCORDANT TWIN 

PREGNANCIES _______________________________ 

Sohani Verma, Anita Kaul, Chinmayee Ratha 

The prevalence of multifetal pregnancies continues to rise all 

over the world. Despite the improved standards of antenatal 

care and diagnostics, at times we are still faced with some 

rather tricky clinical scenarios. Severe discordance among 

both fetuses in terms of either a structural or genetic 

abnormality or a severe growth restriction leading to 

imminent or actual intrauterine demise of one of the twins, 

is one of the greatest challenges in the management of twin 

pregnancy. Such discordance is certainly much more lethal 

in fortunately less prevalent monochorionic pregnancies, 

However, even in more common dichorionic diamniotic 

(DCDA) twin pregnancies, one may have to face these 

problems with significant medical and ethical dilemmas. 

We are presenting here two such cases to highlight these 

challenges. 

Case 1: The first case is about a DCDA twin pregnancy 

with one fetus anencephalic and the other normal cotwin. 

Unfortunately the anencephaly was detected only 

at 26 weeks of gestation due to delayed attendance for 

antenatal care. Since the option of selective feticide was 

not plausible at that gestation, a conservative approach 

was opted for. However the sac with the anencephalic twin 

developed severe polyhydramnios and caused maternal 

respiratory distress. After detailed counselling of the 

couple about the maternal and fetal risks, they opted for 

amnioreduction with the aim to reduce maternal distress. 

She was given prophylactic antenatal corticosteroids and 

about 2 litres of amniotic fluid was aspirated from the 

sac of the anencephalic twin. The mother felt relieved. 

The amniodrainage was repeated after three weeks due to 

recurrence of maternal respiratory distress. The normal 

twin developed signs of intrauterine growth restriction. 

The pregnancy continued till 34 weeks when she set into 

preterm labour. She had an uneventful vaginal delivery on 

14.06.2010 with no immediate postpartum complications. 

The normal twin weighed 1.3kg, female, required minimal 

neonatal resuscitation and is presently doing well in the nursery. 

This case highlights the merits of conservative approach in 

the interest of the normal co-twin. Had the case presented 

earlier, selective feticide could be considered. 

Case 2: A 29 year old female with history of for unexplained 

primary infertility of 4 years duration and several failed 

ovarian stimulation (OS) cycles outside, was treated with 

OS +IUI. She conceived with a triplet pregnancy. Multifetal 

pregnancy reduction was performed at 8 weeks gestation 

and she continued with DCDA twin pregnancy normally 

till 22 weeks gestation. Further course of pregnancy was 

complicated by obstetric cholestasis, threatened preterm 

labour at 29 weeks, mild PIH and severe intrauterine 

growth restriction (IUGR) of twin II. Pregnancy was closely 

monitored by serial ultrasounds with colour Doppler 

studies. Despite being aware of the imminent death of twin 

II, a conscious informed decision was taken by the parents to 

continue the pregnancy in the interest of the comparatively 

healthier twin I. Twin II suffered intrauterine demise at 31 

weeks gestation. Pregnancy continued for further 12 days, 

when due to non-reassuring CTG, reduced fetal movements 

and moderate IUGR on ultrasound of the surviving twin, 

an elective LSCS was performed at 33 weeks gestation. 

Both mother and female baby (birth weight 1.9 kg, Apgar 

9/1,9/5) are healthy at the follow ups at 3 and 6 months. 

This case highlights the turbulent course of post infertility 

treatment multiple gestation. Apart from the medical 

problems it also addresses the difficult and controversial 

ethical and emotional decision making challenges faced by 

the parents as well as the Obstetric team. 

A multidisciplinary approach in a tertiary level centre with 

counselling and sufficient neonatal support is essential for 

optimizing the outcome in twin pregnancies with single 

fetus demise. 

Next Clinical Meeting 

Date: 30th July, 2010, Time: 04.00 – 05.00pm 

Venue: Army Hospital, New Delhi 

Topics 

1. Pregnancy with acute pulmonary edema 3. Embryo reduction 

2. Two cases of ipsilateral absence of tube and ovary 4. A case of Intersex state


RCOG Green-top Guideline Summarized by RCOG-AICC, North Zone 

Management of Monochorionic Twin Pregnancy 

Compiled by Dr Neema Sharma MD, MRCOG and Dr Nirmala Agarwal MD, FRCOG 

The particular challenges of monochorionic (MC) 

pregnancies arise from the vascular placental anastomoses 

that are almost universal and connect the umbilical 

circulations of both twins: twin–twin transfusion syndrome 

(TTTS), the consequences to the co-twin of fetal death and 

the management of discordant malformations. In addition, 

monochorionic, monoamniotic (MCMA) pregnancies 

(1% of twin pregnancies) carry a very high risk of cord 

entanglement. 

Diagnosis of monochorionic twin pregnancy 

All women with a twin pregnancy should be offered an 

ultrasound examination at 10–13 weeks of gestation to 

assess viability, chorionicity, major congenital malformation 

and nuchal translucency. (Grade B recommendation) 

If there is uncertainty about the diagnosis of chorionicity, 

a photographic record of the ultrasound appearance of the 

membrane attachment to the placenta should be retained 

in the case notes and a second opinion should be sought. [√] 

Chorionicity is better assessed by ultrasound before 14 

weeks than after 14 weeks. (Grade C recommendation) 

Ultrasound diagnosis was based on demonstration of the 

‘lambda’ or ‘twin peak’ sign (dichorionic) (DC)or ‘T-sign’ 

(monochorionic) at the membrane–placenta interface 1 . 

(Evidence level 2+) 

The diagnosis of TTTS is based on ultrasound criteria: 

• the presence of a single placental mass 

• concordant gender 

• oligohydramnios with maximum vertical pocket [MVP] 

less than 2 cm in one sac and polyhydramnios in other 

sac (MVP ≥ 8 cm) (some would say ≥ 8 cm at ≤ 20 weeks 

and ≥ 10 cm over 20 weeks) 

• discordant bladder appearances – severe TTTS 

• haemodynamic and cardiac compromise – severe TTTS 

What is the Outcome of MC compared to dichorionic 

(DC) twin pregnancies ? 

Clinicians and women should be aware that MC twin 

pregnancies have higher fetal loss rates than DC twin 

pregnancies, mainly due to second trimester loss and, 

overall, may have a propensity to excess neurodevelopmental 

morbidity. (Grade C recommendation) 

A prospective Scandinavian study of 495 pregnancies 

diagnosed before 15 weeks found fetal loss at less than 24 

weeks of gestation to be 14.2% MC compared with 2.6% DC 

(P < 0.05) 2 . (Evidence Level 2+) 

Sebire and colleagues have suggested that the main risk 

of fetal death in MC pregnancies is before 24 weeks of 

gestation and after this time the rate of perinatal loss is 

only slightly higher in MC than DC pregnancies (4.9% 

versus 2.8%, respectively) 3 . 

Ultrasound scanning 

Nuchal translucency measurements should be offered 

to women with MC pregnancies who wish to have fetal 

aneuploidy screening. [√] 

All MC twins should have a detailed ultrasound scan which 

includes extended views of the fetal heart. 

(Grade B recommendation) 

A fetal echocardiographic assessment should be considered 

in the assessment of severe TTTS. 

(Grade D recommendation) 

Fetal ultrasound assessment should take place every 2–3 

weeks in uncomplicated MC pregnancies from 16 weeks. [√] 

After 24 weeks, when first presentation of TTTS is 

uncommon, the main purpose is to detect fetal growth 

restriction, which may be concordant or discordant. 

Grading/staging system for severity of TTTS 

Women with monochorionic twin pregnancies should 

be asked to report sudden increases in abdominal size or 

breathlessness, as this may be a manifestation of TTTS. [√] 

How useful are grading systems for severity of TTTS in 

establishing prognosis? 

The Quintero system of staging TTTS (Table 1) has 

some prognostic value but the course of the condition 

is unpredictable and may involve improvement or rapid 

deterioration. 

The Quintero classification system 4 

i. There is a discrepancy in amniotic fluid volume with 

oligohydramnios of a maximum vertical pocket (MVP) 

≤ 2 cm in one sac and polyhydramnios in other sac 

(MVP ≥ 8 cm). The bladder of the donor twin is visible 

and Doppler studies are normal 

ii. The bladder of the donor twin is not visible (during 

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length of examination, usually around 1 hour) but 

Doppler studies are not critically abnormal 

iii. Doppler studies are critically abnormal in either twin 

and are characterised as abnormal or reversed enddiastolic 

velocities in the umbilical artery, reverse flow 

in the Ductus venosus or pulsatile umbilical venous 

flow 

iv. Ascites, pericardial or pleural effusion, scalp oedema 

or overt hydrops present 

v. One or both babies are dead. 

What is (are) the Optimal treatment(s) of TTTS and 

their outcomes? 

Twin–twin transfusion syndrome should be managed 

in conjunction with regional fetal medicine centres with 

recourse to specialist expertise. [√] 

Severe twin–twin transfusion syndrome presenting before 

26 weeks of gestation should be treated by laser ablation 

rather than by amnioreduction or septostomy. 

(Grade A recommendation) 

In a Cochrane review, for laser ablation versus 

amnioreduction, there were fewer deaths of both babies 

(RR 0.33, 95%CI 0.16–0,67), fewer neonatal deaths (RR 

0.29, 95% CI 0.14–0.61, adjusted for clustering) and fewer 

perinatal deaths (RR 0.59, 95% CI 0.40–0.87, adjusted for 

clustering). More babies were alive without neurological 

abnormality at 6 months of age after laser ablation (RR 

1.66, 95% CI1.17–2.35, adjusted for clustering). Long-term 

outcomes are awaited 5 . (Evidence level 1+) 

Some women request termination of pregnancy when 

severe TTTS is diagnosed and this should be discussed as 

an option. (Evidence level 3) 

What is the optimal timing and method of delivery for 

otherwise uncomplicated MC pregnancies ? 

It is appropriate to aim for vaginal birth of monochorionic 

twins unless there are accepted, specific clinical indications 

for caesarean section, such as twin one lying breech or 

previous caesarean section. [√] 

Delivery should be planned for 36–37 weeks of gestation, 

unless there is an indication to deliver earlier. [√] 

For uncomplicated MCDC pregnancies (without TTTS 

or fetal growth restriction), there may be a higher risk 

of unexplained fetal demise despite intensive fetal 

surveillance. The management of multiple pregnancies in 

general is controversial, as are the timing of induction and 

the proposed mode of delivery. 

An RCOG Study Group 6 suggested that, in DC twin 

pregnancies, discussion should take place as to the mode 

of delivery and intrapartum management at 34–36 weeks. 

Delivery should be planned at 37–38 weeks. In MC twin 

pregnancies, discussion should take place as to the mode 

of delivery and intrapartum management at 32–34 weeks. 

Delivery should be planned at 36–37 weeks. 

What are the consequences for the surviving twin 

after fetal death of the co-twin in a MC twin pregnancy 

and what is optimal clinical managment ? 

After the single fetal death in a monochorionic pregnancy, 

the risk to the surviving twin of death or neurological 

abnormality is of the order of 12% and 18%, respectively. 

Clinicians should be aware that the risks are much higher 

than in dichorionic pregnancies and that management of 

such pregnancies is complex. (Grade B recommendation) 

Damage to MC twins after the death of a co-twin is now 

thought to be caused by acute haemodynamic changes 

around the time of death, with the survivor essentially 

haemorrhaging part of its circulating volume into the 

circulation of the dying twin. This may cause transient or 

persistent hypotension and low perfusion,leading to the 

risk of ischaemic organ damage, notably but not exclusively, 

to the brain. 

Clinical management is complex and is best overseen by 

fetal medicine experts with the knowledge and experience to 

advise about the advantages and disadvantages of different 

approaches. Rapid delivery is usually unwise, unless there 

are significant cardiotocographic abnormalities or evidence 

of anaemia in the survivor, as evidenced by abnormal middle 

cerebral artery Doppler waveforms or if fetal death occurs 

late in pregnancy. Detailed counselling is essential and 

should be recorded in the case records. Serious compromise 

in the surviving fetus may be anticipated and this should 

be discussed with parents, including the significant risk of 

long-term morbidity. Evidence of fetal compromise (such 

as abnormal cardiotocography) could represent continuing 

damage to the brain and other organs, as well as already 

existing damage. A conservative policy is often appropriate, 

with brain imaging planned by 4 weeks to establish (if the 

baby has survived) whether serious cerebral morbidity 

has occurred. The appearances of such manifestations on 

ultrasound examination of the fetal central nervous system 

are variable and may take up to 4 weeks to occur. Fetal 

magnetic resonance imaging provides earlier and more 

detailed information about brain lesions in the surviving 

fetus than does ultrasound and its use is recommended. 

(Evidence level 3) 

In such circumstances, termination of pregnancy would 

then be an option. The gestational age at the time of 

diagnosis will have an important influence on management 

options. The views of the parent or parents will be critical. 

REFERENCE ________________________________ 

1. Sepulveda W, Sebire NJ, Hughes K, Odibo A, Nicolaides KH. 

The lambda sign at 10–14 weeks of gestation as a predictor of 

chorionicity in twin pregnancies. Ultrasound Obstet Gynecol 

1996;7:421–3. 

2. Sperling L. Detection of chromosomal abnormalities, congenital


abnormalities and transfusion syndrome in twins. Ultrasound 

Obstet Gynecol 2007;29:517–26. 

3. Sebire NJ, Snijders RJ, Hughes K, Sepulveda W, Nicolaides KH. 

The hidden mortality of monochorionic twin pregnancies. Br J 

Obstet Gynaecol 1997;104:1203–7. 

4. Quintero RA, Morales WJ, Allen MH, Bornick PW, Johnson PK, 

Kruger M. Staging of twin-twin transfusion syndrome. J Perinatol 

1999;19:550–5. 

5. Roberts D, Neilson JP, Kilby MD, Gates S. Interventions for the 

treatment of twin-twin transfusion syndrome. Cochrane Database 

Sys Rev 2008;CD002073. 

6. Consensus views arising from the 50th Study Group: Multiple 

Pregnancy. In: Kilby M, Baker P, Critchley H, Field D, editors. 

Multiple pregnancy. London: RCOG Press; 2006. p. 283–6. 

GRADES OF RECOMMENDATIONS ____________ 

A - At least one meta-analysis, systematic reviews or 

randomised controlled trial rated as 1++ and directly 

applicable to the target population; or A systematic review 

of randomised controlled trials or a body of evidence 

consisting principally of studies rated as 1+, directly 

applicable to the target population and demonstrating 

overall consistency of results 

B - A body of evidence including studies rated as 2++ directly 


overall consistency of results; or Extrapolated evidence 

from studies rated as 1++ or 1+ 

C - A body of evidence including studies rated as 2+ directly 


overall consistency of results; or Extrapolated evidence 

from studies rated as 2++ 

D - Evidence level 3 or 4; or Extrapolated evidence from 

studies rated as 2+ 

[√] Good practice point - Recommended best practice based 

on the clinical experience of the guideline development group 

CLASSIFICATION OF EVIDENCE LEVELS _______ 

1++ High-quality meta-analyses, systematic reviews of 

randomised controlled trials or randomised controlled 

trials with a very low risk of bias 

1+ Well-conducted meta-analyses, systematic reviews of 

randomised controlled trials or randomised controlled 

trials with a low risk of bias 

1- Meta-analyses, systematic reviews of randomised 

controlled trials or randomised controlled trials with a high 

risk of bias 

2++ High-quality systematic reviews of case–control or 

cohort studies or high quality case–control or cohort 

studies with a very low risk of confounding, bias or chance 

and a high probability that the relationship is causal 

2+ Well-conducted case–control or cohort studies with 

a low risk of confounding, bias or chance and a moderate 

probability that the relationship is causal 

2- Case–control or cohort studies with a high risk of 

confounding, bias or chance and a significant risk that the 

relationship is not causal 

3 Non-analytical studies; e.g. case reports, case series 

4 Expert opinion 

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(An ISO 9001:2008 CERTIFIED DIAGNOSTIC CENTRE) 

• MRI 1.5 TESLA (SIEMENS) 

• USG with Obstetrics color Doppler 

• LAB collection centre 

Disclaimer ‘ The RCOG takes no responsibility for the 

accuracy of the summary or any consequences that follows 

by following the summary Guidelines’. View full guideline on 

www.rcog.org.uk/womens-health/clinical-guideline 

*One of the few centres equipped with dedicated breast coil for MRI mammography 

with added advantage of: 

No radiation 

No compressive pain 

Can be done for young patients also 

Dr Sanjay Srivastava, M.B.B.S, D.M.R.D., D.N.B. 

Sr Consultant Radiologist 

1,2,3, Purvanchal Plaza, Pocket–B, Market, Mayur Vihar, Phase-2, Delhi 110 091 

Tel.: 011-22779009, 9811157069, 9811892896 

On Panel: CGHS, ESI, BSES 

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Website: www.aiccrcognzindia.com 

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RCOG-NZ India Advanced Laparoscopy & Hysteroscopy Workshop 

Dates: 26th & 27th July 2010 Venue: Max Hospital Saket 

Organising Chairperson: Dr. U.P. Jha 

Organising Secretaries & Contact Persons: Dr. Anjila Aneja, Dr. Meena Naik 

Invited National Faculty: Dr. Shailesh Puntambekar, Dr. Praveen Patel 

Day 1 Monday, 26th July, 2010 

Lectures 

09:00 - 09:10 am Laparoscopic ergonomy and port placement- Dr. U.P.Jha 

09:10 - 09:20 am Avoiding laparoscopic complications- Dr. Anjila Aneja 

09:20 - 09:30 am Avoiding complications with electrocautery and energy sources 

- Dr. Meena Naik 

Video Sessions - Unedited & edited videos 

09:30 - 11:30 am Management of Endometriosis 

Management of endometriomas, Dissection of obliterated 

pouch of Douglas, Excision of rectovaginal septum, Ureteric & 

etroperitoneal dissection in endometriosis, Repeat surgery 

in endometriosis, Uteroscacral nerve ablation. 

Bowel adhesiolysis, Unusual sites of endometriosis 

11:45 - 01:00 pm Advanced Hysteroscopy 

Myomectomy, Septal resection, Asherman’s syndrome, 

Tubal cannulation, Use of Versascope & Versapoint 

01:30 - 03:30 pm Laparoscopic Myomectomy 

Subserous fibroids, Cervical fibroids, Intramural fibroids, 

Large fibroids, Intracorporeal suturing, LAM – Laparoscopic 

assisted myomectomy, Vaginal removal of fibroids & vaginal 

suturing 

03:30 - 04:30 pm Laparoscopy in Infertility 

Laparoscopic salpingostomy/fimbrioplasty, Laparoscopic 

tubal anastomosis, Restoring tubo - ovarian relationship 

Free Videos Session 

04:30 - 05:30 pm Competitive video presentations 

Day 2 Tuesday, 27th July, 2010 

Video Sessions (edited & unedited) 

08:30 - 10:30 am Laparoscopic management of adnexal masses 

Ovarian dermoid cysts, Multicystic ovarian lesions, Large ovarian 

masses, Suspicious adnexal masses, Solid ovarian tumours 

10:45 - 12:30 pm Laparoscopic hysterectomy TLH, LAVH 

Hysterectomy for large uterus, Hysterectomy for severe 

endometriosis, NDVH 

01:00 - 04:00 pm Laparoscopic Onco Surgery 

Laparoscopic surgery for endometrial cancer, Radical 

hysterectomy for carcinoma cervix, Laparoscopic pelvic 

lymphadenectomy, Laparoscopic para-aortic lymphadenectomy 

Laparoscpic omentectomy 

04:00 - 05 :00 pm Pelvic floor repair 

Vault suspension, Anterior & posterior compartment repair 

Repair of nulliparous prolapse 

Royal College of Obstetricians & 

Gynaecologists North Zone India 

(A Registered Society Under the Registrar of Societies) 

RCOG Office & Centre for Activities: B-235, CR Park, New Delhi 

Forthcoming Activities in 2010 under aegis of AOGD 

RCOG-NZ India Advanced Obstetric Skills Course 

Date: 25th July, 2010 

Venue: RCOG-NZ Office & Centre, B-235, Chitranjan Park, New Delhi 

Workshop Convenors: Dr. Urvashi P Jha, Dr. Sanjeev Sharma (UK) 

Workshop Coordinators & Contact Persons: Dr. Anjila Aneja, Dr. Jayasree Sundar 

Overview: This hands on training course will be of great value to postgraduates 

and practicing obstetricians. Expert faculty will give hands-on training on 

various techniques. 

Course Programme - Training module stations & groups: 

• Management of pregnant patient with fits 

• Management of massive obstetric hemorrhage 

• Shoulder dystocia 

• Twins and breech delivery 

• Post partum collapse 

• CTG and its clinical implications 

• Partogram and management of labour 

Limited seats only 

Registration Fee: Rs. 700/- (For PG students Rs. 500/-) 

Free Video Session 

04:30 - 05:00 pm Competitive video presentation 


Registration Fee: Rs. 1500/- (For PG students Rs. 700/-) 

The Complete RCOG-NZ MRCOG Part 1 Revision Course 

Date: 23rd-25th July, 2010 

Venue: RCOGNZ Centre, CR Park(Basement), New Delhi 

Course Organiser & Contact Persons: Dr Neema Sharma, Dr Mamta Mishra 

Overview: Three day refresher course in basic sciences relevant to MRCOG, 12 

important tips to clear the exam, EMQ & MCQ practice tests 

Course Fee: Rs. 5,000/- 

The Complete RCOG Franchised MRCOG Part 2 Revision Course 

(Written and OSCE) New Delhi, India 

Date: 28th-30th July, 2010 

Course Organiser & Contact Persons: Dr Saritha S. Kale, Dr Jayasree Sundar 

Overview: The course reflects the current MRCOG Part 2 examination and 

will be conducted by experienced consultants from the Royal College of 

Obstetricians and Gynaecologists. The emphasis will be on key topics. 

Candidates will have the opportunity to experience ALL the current formats of 

testing, namely: MCQ, EMQ, SAQ and OSCE. 

Success Rate : 75% in Sept. 2009 exams. 

Course Convenors: Dr David Redford (UK) & Dr A. Hollingworth (UK) 

Course Organiser: Dr Sanjeev Sharma (UK) 

The course will be limited to 20 candidates. 

The intensive nature of this course reflects the fact that it is specifically designed 

for examination candidates requiring revision only - it is not a teaching course. 

There will be 10 OSCE stations. 

Programme 

Day 1 

08:15 am Registration 

08:30 am Introduction Mr Sanjeev Sharma 

08:45 am Extended Matching Questions-Lecture Mr Sanjeev Sharma 

09:00 am EMQ’s Test 

09:30 am MCQ’s Lecture Mr Sanjeev Sharma 

09:45 am MCQ’s Test 

10:30 am Clinical Governance and Mr Sanjeev Sharma 

the NHS health system 

11:00 am Uro - Gynaecology Dr Sonu Agarwal 

11:40 am Foetal Medicine Dr Anita Kaul 

12:10 pm SAQ’s Lecture Mr Sanjeev Sharma 

12:10 pm SAQ’s 1 & 2 Test Mr Sanjeev Sharma 

13:00 pm LUNCH and briefing to local examiners Mr Sanjeev Sharma 

13:30 pm OSCE Lecture Mr Sanjeev Sharma 

13:30 pm Prioritization Dr Neema, Dr Jayasree 

14:30 pm Demonstration OSCE’s 

15:30 pm Role Play 1.Good Role, 2.Bad Role 

17:00 pm OSCE Discussion General Discussion/Feedback 

Home Work- SAQ’S 3,4,5,6 

Day 2 

08:15 am Feedback-MCQs and EMQs Mr Sanjeev Sharma 

09:30 am Risk management in obstetrics Mr Sanjeev Sharma 

and gynaecology with sample questions 

10:00 am Audit with practice audits Mr Sanjeev Sharma 

11:45 am Feedback- SAQs 1-2 Mr Sanjeev Sharma 

12:15 pm Screening in the UK-Antenatal and cervical Dr Jayasree/Dr Sarita 

12:45 pm MCQ Test 

13:15 pm LUNCH and briefing to local examiners 

14:00 pm OSCE All Examiners 

16:30 pm Discussion & feedback with candidates 

Home work SAQ’s 7 & 8 

Day 3 

08:30 am Feedback–SAQ’s 3,4,5 & 6 Mr Sanjeev Sharma


09:00 am NHS Assisted conception, MDT Mr Sanjeev Sharma 

09:45 am MCQ’s Test Mr Sanjeev Sharma 

10:30 am Critical Appraisal with practice Dr Sarita Kale 

11:30 am Feedback SAQ’s 7 & 8 Mr Sanjeev Sharma 

12:00 pm Feedback MCQ & General discussion Mr Sanjeev Sharma 

13:00 pm Briefing to local examiners Mr Sanjeev Sharma 

13:30 pm OSCE All Examiners 

16:00 pm Discussion/Feedback with candidates 

Course Fee: Rs. 15,000/- 

RCOG-UK Certified & Franchised 

Basic Practical Skills Course in Obstetrics & Gynaecology 

Organised by North Zone India 

Dates: 31th July & 1st August, 2010 

Venue: Ethicon Institute of Surgical Education, Kirtinagar, New Delhi 

Course Conveners: Dr. Urvashi P Jha, Dr Sanjeev Sharma (UK) 

Course co-ordinators & Contact Persons: Dr. Jasmine Chawla, Dr. Mamta Dagar 

Course Contents: Hands on Franchise Course for Trainees & Practising 

Gynaecologists Certified by RCOG London on the following topics with one 

to one interaction 

Principles of Safe & Effective Surgery Principles of Gynae Examination 

Knotting & Suturing Episiotomy repair 

Tissue Handling Mx of normal & breech delivery 

Handling Instruments Fetal blood sampling 

Surgical Documentation Ventouse & forceps delivery 

Anatomy of Pelvic Floor Caesarean section 

Management of Massive Obstetric Management of shoulder dystocia 

Haemorrhage Principles of safe endoscopy 

Endoscopic Equipment Principles of haemostasis & dissection 

Principles of Electro Surgery Evacuation of uterus 


Course Fee: Rs. 5,000/- (for manual £ 36 additional and optional) 

RCOG-NZ India Annual Conference 

(All India Co-ordinating Committee-Royal College of Obstetricians & Gynaecologists UK) 

Conference Theme: 

“Changing Clinical Practice in Changing Times” 

Date: Saturday, 4th September, 2010 

Time: 08.00 am - 05.00 pm 

Venue: Indraprastha Apollo Hospitals, Auditorium, Sarita Vihar, New Delhi 110076 

Organizing Chairperson: Dr Urvashi Prasad Jha 

Organizing Secretaries: Dr Sohani Verma, Dr. Sarita S. Kale, Dr Anita Kaul 

Invited International Faculty 

Dr Richard Charles (Rick) Warren (UK), Dr Theresa Freeman Wang (UK) 

Others to be announced soon 

Planned Topics 

One Stop Clinics, Day Care Major Gynae Surgeries, Managing HPV Positive 

Women, Interventional Radiology in Obs & Gynae, Ambulatory Obstetrics, 

Changing trends in HRT and Menopause, Fertility preservation in Gynaecology, 

Changing pattern in Prolapse Management, The 12 Week Fetal Clinic, Minimal 

Invasive Perinatal Autopsy, Contraception in Changing Times, Caesarean 

Sections-Changing Indications and technique, Predicting Preterm Labour, 

Peripartum Mental Health Issues, Challenges of Obesity in Obs & Gynae, The 

Latest Trend- Revirgination and Cosmetic Surgery of the Female Genitalia 

• Those registering only for the “Ultrasound Workshop” on 5th September, 

may send their registration request and cheque in favour of “Delhi 

Ultrasound Update” payable at New Delhi to Dr Kuldeep Singh, Secretary- 

IFUMB, D-80, East of Kailash, New Delhi 110065 

For details and registration form log on to: www.aiccrcognzindia.com 

Mailing Address: Dr. Sohani Verma, IVF Unit, 1st Floor, Gate No. 6, Indraprastha 

Apollo Hospitals, Sarita Vihar, New Delhi 110 076 

Email: sohaniverma@hotmail.com, shamsundersaritha@gmail.com, 

anitagkaul@gmail.com, Tel.: 011-29872146/99, M.: 09810116623 

Inauguration of 

RCOG-NZ Centre, CR Park, New Delhi 

on Saturday, 4th September, 2010 at 7pm 

by Mr Richard Charles (Rick) Warren 

Honorary Secretary, RCOG (London) 

All RCOG-NZ Courses & CMEs are being conducted in association with 

AOGD. Last date of registration 20th July, 2010. PG students must 

enclose certificate form HOD. To register for any of the courses, please 

download the Registration Form from: www.aiccrcognzindia.com. 

Payments to be made by cheque/demand draft (only) in favour of “CME- 

NZ-RCOG2007 Plus”. Please post the form & the cheque/demand draft 

to Dr. Saritha Shamsunder Kale, Hon Secretary RCOG-NZ India, E-99, 

Ansari Nagar (East), AIIMS Campus, New Delhi 110029, India 

Contacts 

Dr Sarita Shamsunder Kale 

shamsundersaritha@gmail.com 

M: 09868392748 

Dr Sohani Verma 

sohaniverma@hotmail.com 

M: 09810116623 

Dr. Jasmine Chawla 

drjasminechawla@gmail.com 

M: 09310009321 

Dr Mamta Mishra 

shreeja11@yahoo.co.in 

M: 09868078855 

Dr Kuldeep Singh 

singhdrkuldeep@rediffmail.com 

ifumbdelhichapter@gmail.com 

M: 09811196613 

Dr Mala Arora 

narindermala@gmail.com 

M: 09818676801 

Dr Anjila Aneja 

anjilaaneja@yahoo.co.in 

M: 09810059519 

Dr Anita Kaul 

anitagkaul@gmail.com 

M: 09811100511 

Dr Payal Singhal 

payal_sgh@yahoo.co.in 

M: 09312277293 

Dr Neema Sharma 

nimavijay@yahoo.co.in 

M: 09582500310 

Dr Meena Naik 

m.naik1971@yahoo.com 

M: 09818258503 

Dr Jayasree Sundar 

jayasreesundar@yahoo.co.in 

M: 09810297461 

Dr Mamta Dagar 

mamtadagar2004@yahoo.co.in 

M: 09811437782 

RCOG-NZ, India Pre-conference Workshop 

Annual Hands-On Colposcopy Course 

(Under Aegis of INDIAN SOCIETY OF COLPOSCOPY & CERVICAL PATHOLOGY) 

Approved by International Federation of Cervical Pathology & Colposcopy (IFCPC) 

Date: 2nd & 3rd September, 2010 

Venue: Day-1- RCOGNZ Center, CR Park, New Delhi 

Day-2- Max Super Specialty Hospital, Saket, New Delhi 

Course Convenors: Dr. Urvashi P Jha, Dr. Vijay Zutshi 

Course Coordinators: Dr. Sarita Shamsunder Kale, Dr. Meena Naik 

Invited International Faculty: Dr Theresa Freeman Wang(London, UK) 


RCOG-NZ India Post Conference Workshops 

Post Conference Workshop I-Ultrasound Workshop 

In association with International Federation of Ultrasound in Medicine & Biology (Delhi Chapter) 

Theme: Woman’s Imaging- Meeting The Needs of the Modern Woman 

Date: Sunday, 5th September, 2010 

Venue: Indraprastha Apollo Hospitals, Sarita Vihar New Delhi 110076 

Organizing Secretaries: Dr Kuldeep Singh, Dr Anita Kaul 

Post Conference Workshop II- Life Skills for Doctors 

Date: Sunday, 5th September, 2010 

Venue: RCOG- NZ Center, B-235, CR Park, New Delhi 

Organizing Secretary & Contact Person: Dr Mala Arora 

This workshop aims to develop the necessary Life Skills required by Practising 

Gynecologists to cope with the demands of their profession. Emphasis will be on: 

Self Awareness - Identifying ones strengths and weaknesses, Problem 

Solving, Decision Making, Critical Thinking, Creative Thinking, Effective 

Communication, Doctor Patient Relationships, Coping with Emotions, Stress 

Management 

Post Confrence Workshop III- Certified AICC RCOG-NZ 

Practical Training Course for OT Staff 

(Doctors, Nurses & Technicians) 

(Open, Vaginal & Minimal Access Gynae Surgeries) 

Essential for effective functioning & maintenance of OT 

Dates: 5th September 2010 

Venue: Max Hospital, 1 Press Enclave Road, Saket) 

Organizing Chairperson: Dr. U. P.Jha 

Organizing Secretaries & Contact Persons: Dr. Anjila Aneja, Dr. Jayasree 

Sundar, Dr. Payal Singhal, Dr. Meena Naik 

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26 

Team Gynae 

Dr Sonia Malik 

Dr Kavita Katoch 

Dr Vinita Sherwal 

Dr.Vandana Bhatia 

Anaesthesia 

Dr Avtar Krishan 

Embryology 

Dr Ved Prakash 


Facilities 

IUI,IVF, ICSI, Oocyte & Embryo, Donation, Surrogacy 

Semen Banking Embryo freezing, Fetal Reduction, Interventional Ultrasound 

LOCATION-1 

Holy Angels Hospital 

1st Floor, Community Centre, Basant Lok 

Vasant Vihar, New Delhi-110057 

Tel.: 65416928, 26153635, 26141229, 26143411 

Email:southendr@rediffmail.com 

Specialty Clinics: 

Infertility 

Recurrent pregnancy loss 

Andrology 

Sexual Medicine 

Immunology 

LOCATION-2 

PARAS Hospital 

PARAS Southend Fertility & IVF Centre 

C-1Block, Phase 1, Sushant Lok, Sector 43, Gurgaon 

Tel.: 01244585555

Name: _______________________________________________________________________________________ 

Address for Correspondence: ____________________________________________________________________ 

_______________________________________________________________________________________________ 

Telephone Numbers: 

Residence STD Code ________________________ Tel. No. ________________________________________ 

Clinical/Hospital STD Code ________________________ Tel. No. ________________________________________ 

Mobile _________________________________________ Fax. No. ________________________________________ 

E-mail: _______________________________________________________________________________________ 

Tittle of free paper / poster (if appricable): ________________________________________________________ 

Registration Fee 

32 nd Annual Conference of AOGD 

30th-31st October, 2010 

Auditorium, Maulana Azad Medical College, New Delhi 

REGISTRATION FORM 

Conference Registration Details 

Delegate Members Non- members Postgraduates* 

Before 30.09.10 1800/- 2000/- 1500/- 

Till 15.10.10 2500/- 3000/- 2000/- 

After 15.10.10 (Spot) 3500/- 4000/- 2500/- 

Cancellation Charges 

Before 30th August, 2010 25% 

After 30th August, 2010 75% 

After 30th September, 2010 No Refund 

Spot Registration does not guarantee a Conference Kit 

Payment Details 

Cheque / DDs payable at Delhi drawn in favour of “AOGD Conference 2010” 

Cash Amount __________________ Cheque/ Demand Draft No. __________________ Dt. _____________ 

Amount __________________________________________ Drawn on bank _______________________________ 

________________________________________________ Signature ___________________________________ 

*Post graduates should attach a certificate from HOD. 

Send Completed Registraction Form along with cheque to: 

Dr. Asmita M. Rathore, Organizing Secretary 

AOGD Secretariat, Deptt. of Obstetrics & Gynaecology 

Room No. 112, Ward 1, Block A, First Floor, New Surgical Blcok 

Lok Nayak Hospital (Opp. Delhi Gate), Jawaharlal Nehru Marg, New Delhi 110 002 

Tel.: 011-23232400 Ext.: 4545 

Abstract Form at the back of this page

AOGD Conference - 2010 

Abstract Form 

Type of Presentation: Oral Poster Competition Paper 

Topic of paper / poster: ................................................................................................................................................................... 

Theme 

Minimizing Maternal Mortality Endometrium and it’s related problems Miscellaneous 

Name: …………………………….......................................………………………….......………………..…............……........……… 

Mailing Address: …………………………….................................................................................................................................... 

................................................................………………………….......................................…………...……....................…........… 

Telephone (R): ………………............................... (O): ………………............................... (M):………….....……........................... 

Fax: .................................................................................. Email: ................................................................................................. 

Registration Fee Details: DD / Cheque / Receipt No. .................................................................................................................... 

Title: .............................................................................................................................................................................................. 

Rules for paper submission : 

1. Free Papers : Presenting author’s name to be first and underlined. Structured abstract (with a soft copy in a CD) not more than 250 words along with 

Abstract Form to reach AOGD Secretariat by 30th Sept., 2010. 

2. Competition Paper : Abstract form with full text & CD in 4 copies should reach AOGD Secretariat by 15th Sept., 2010. 

The competition paper should not carry the name of institution and co-authors. 

Only best 8 papers will be selected for presentation in oral session. 

Structured Abstract with title: 

Type your abstract of 250 words in this box and e-mail to asmita.rathore@yahoo.com.

July 2010 - AOGD

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