Abstract
Background
Pelvic organ prolapse (pop) is a chronic disorder, often asymptomatic. There are several factors involved in the aetio-pathogenesis of POP. Perimenopausal women bear most of the burden of pop. Vaginal delivery is an established risk factor and clinical presentation may take years when women are symptomatic in menopausal age.
Method
A cross-sectional study was done for one year in a rural teaching hospital, where 150 pop women were included. Variables associated with both asymptomatic & symptomatic pop were analyzed. The mean, proportion, & simple logistic regression were used to analyze the data and p value < 0.05 was considered significant.
Results
The prevalence of pop was 4.8%. Associated socio-economic & obstetrical variables were age group of 41–50 years (82.7%), housewives (84%), multiparty (93.33%), lower economic conditions (86.7%), home deliveries (74.71%), and early resumption of work after delivery (61.3%). Bulging in the vagina (p < 0.001), & difficulties in micturition (p = 0.001) were significant symptoms. Among asymptomatic & symptomatic pop, difference in BMI (p = 0.042), education level (p = 0.001), menstrual history (p = 0.001) & place of delivery (p = 0.037) were significant. Different stages of pop were significantly associated with differences in age groups (p < 0.001), menstrual history (p < 0.001) & place of delivery (p = 0.039). Differences in the proportion of constipation were significant with anterior compartment defects (p < 0.001), whereas the association of chronic lung diseases was found significant (p = 0.028) in the case of apical compartment prolapse. Simple logistic regression of co-variants shows age can predict the severity of pop stages (OR 7.25; 95% CI 1.95–26.99).
Conclusion
All stages of pop were present mostly in the age group of 41–50 years rather than in the over 50 years age group. Menopause is associated with the severity of prolapse and is mostly symptomatic. Age can predict the severity of pop.
Keywords: Perimenopause, Menopause, Pelvic organ prolapse, Symptomatic and asymptomatic pop
Introduction
Pelvic organ prolapse (pop) is a chronic disorder, where herniation of the pelvic organs to or beyond the vaginal walls occurs. Several risk factors are associated with pop. The prevalence of pop is different in different countries. We lack the exact prevalence of pop as many women can not tell the presence of pop due to social reasons and many are asymptomatic [1]. Miedel and Colleagues recorded that age was an independent risk factor for symptomatic pop with an intact uterus and no history of prior pelvic surgery [2]. Quiroz and colleagues in a study found that in women aged 40 years or older, vaginal delivery increases the chances of prolapse than cesarean section [3].
Therefore the present study is undertaken to estimate prevalence and risk factors associated with pop in perimenopausal and menopausal women.
Material and Methods
A hospital-based cross-sectional study was done in a teaching hospital, in the Gynecology & Obstetrics department, for one year. Subjects were enrolled if they satisfy the following criteria:
- Inclusion criteria:
- Age > 40 years
- Vaginally parous women.
- Symptomatic prolapse.
- Asymptomatic prolapse presenting with other gynecological conditions.
- Exclusion criteria:
- Women ≤ 40 years of age.
- Pregnant women
- Previous history of cesarean birth.
- A prior history of pelvic surgery, hysterectomy, and vault prolapse.
- Women not willing to participate in the study or not giving consent.
There were a total of 163 perimenopausal and menopausal pop women, out of 3395 patients visiting the Gynecology department, only 150 fulfilled the study criteria. Detailed history & examination findings were recorded and relevant investigations were done. Examination for the different stages of pop was done by using the Pelvic Organ Prolapse Quantification (POP-Q) System and the different compartment defects were noted.
We defined as:
Symptomatic pop—Women were identified as symptomatic if they complained of any of the prolapse symptoms i.e., bulging in the vagina, difficulty in micturition, and difficulty in defecation.
Asymptomatic pop—Women were defined as asymptomatic when presented without the symptoms of pop, and presented with other gynecological conditions like AUB, endometriosis, amenorrhoea, vaginal discharge, contraception, etc.
The socio-economic status of the study subjects was determined using B G Prasad scale [4]. Categorization of Body Mass Index (BMI) in kg/m2 of the patients was done as per the WHO Asia Pacific Perspective for Asians WHO IOTF 2003 [5].
For statistical analysis, SPSS 21 version was used. Data had been summarized as mean and standard deviation for numerical variables and count & percentage for categorical variables. Pearson's chi-squared test was performed to see statistical relation. Simple logistic regression was used for further analysis of variables. A p value < 0.05 was considered to be statistically significant.
Results
Table 1 shows 84% of the women were housewives with daily household activities and 10.7% of women were involved in heavy work which includes farmers and laborers. In the present study, 86.7% of the patients belonged to the lower class followed by 13.3% from the lower middle class. In the present study, 42.7% of the patients were obese, 40% of patients had normal BMI and 17.3% were overweight. Among the study population, 52 patients (34.7%) had a history of four or more childbirth followed by 50 (33.3%) of them with three childbirth, 38 (25.3%) of two childbirth, and 10 (6.7%) of single childbirth. Out of 150 patients, 92 (61.3%) patients had a history of early resumption of work. 112 (74.7%) women had a history of home delivery whereas only 38 (25.3%) had a history of hospital delivery.
Table 1.
Distribution of POP women according to sociodemographic characteristics
| Variables | Frequency (N = 150) | Percentage (%) |
|---|---|---|
| Occupation | ||
| House wife | 126 | 84 |
| Heavy worker | 16 | 10.7 |
| Light worker | 8 | 5.3 |
| Socio-economic condition | ||
| Lower middle class | 20 | 13.3 |
| Lower class | 130 | 86.7 |
| Age category | ||
| 41–50 Years | 124 | 82.7 |
| > 50 Years | 26 | 17.3 |
| BMI category in Kg/m2 | ||
| Normal (18.5–22.9) | 60 | 40 |
| Overweight (23–24.9) | 26 | 17.3 |
| Obese (≥ 25) | 64 | 42.7 |
| Parity | ||
| One | 10 | 6.7 |
| Two | 38 | 25.3 |
| Three | 50 | 33.3 |
| Four or more | 52 | 34.7 |
| Resumption of work | ||
| Early (< 42 days) | 92 | 61.3 |
| Late (≥ 42 days) | 58 | 38.7 |
| Place of delivery | ||
| Hospital | 38 | 25.3 |
| Home | 112 | 74.7 |
Table 2 shows, while comparing the symptoms with different stages of pop, it was found that bulging in the vagina and difficulty in micturition was significantly related to stages of pop and difficulty in defecation was not significant with stages of POP.
Table 2.
Symptoms in relation to different stages of POP
| Symptoms | Stage category | p value | ||
|---|---|---|---|---|
| I (n = 83) | II (n = 39) | III + IV (n = 28) | ||
| Bulging in the vagina | ||||
| Absent | 65 (78.3%) | 5 (12.8%) | 4 (14.3%) | < 0.001 |
| Present | 18 (21.7%) | 34 (87.2%) | 24 (85.7%) | |
| Difficulty in micturition | ||||
| Absent | 67 (80.7%) | 23 (59%) | 13 (46.4%) | 0.001 |
| Present | 16 (19.3%) | 16 (41%) | 15 (53.6%) | |
| Difficulty in defecation | ||||
| Absent | 58 (69.9%) | 28 (71.8%) | 18 (64.3%) | 0.795 |
| Present | 25 (30.1%) | 11 (28.2%) | 10 (35.7%) | |
Tables 2 and 4 show the analysis of early-stage I, II pop with advanced stages III &IV pop in relation to symptoms and variables for a better clinical point of view.
Table 4.
Variables in relation to different stages of POP
| Variables | Stage I (n = 83) |
Stage II (n = 39) |
Stage III + IV (n = 28) |
p value |
|---|---|---|---|---|
| Socio-economic condition | ||||
| Lower middle class | 11 (13.3%) | 5 (12.8%) | 4 (14.3%) | 0.984 |
| Lower class | 72 (86.7%) | 34 (87.2%) | 24 (85.7%) | |
| Menstrual history | ||||
| Premenopause | 54 (65.1%) | 8 (20.5%) | 12 (42.9%) | < 0.001 |
| Menopause | 29 (34.9%) | 31 (79.5%) | 16 (57.1%) | |
| Place of delivery | ||||
| Hospital | 26 (31.3%) | 10 (25.6%) | 2 (7.1%) | 0.039 |
| Home | 57 (68.7%) | 29 (74.4%) | 26 (92.9%) | |
| Age group | ||||
| 41–50 years | 81 (97.6%) | 27 (69.2%) | 16 (57.1%) | < 0.001 |
| > 50 years | 2 (2.4%) | 12 (30.8%) | 12 (42.9%) | |
| Occupation | ||||
| House wife | 74 (89.2%) | 28 (71.8%) | 24 (85.7%) | 0.066 |
| Heavy worker | 5 (6%) | 9 (23.1%) | 2 (7.1%) | |
| Light worker | 4 (4.8%) | 2 (5.1%) | 2 (7.1%) | |
| BMI category | ||||
| Normal weight | 35 (42.2%) | 17 (43.6%) | 8 (28.6%) | 0.228 |
| Over weight | 18 (21.7%) | 4 (10.3%) | 4 (14.3%) | |
| Obese | 30 (36.1%) | 18 (46.2) | 16 (57.1%) | |
In Table 3, differences in the proportion of asymptomatic and symptomatic pop are found to be significantly related to the differences in the BMI category, educational qualifications, menstrual history, and place of delivery. However, no statistical significance has been found regarding socio-economic condition, resumption of work & parity.
Table 3.
Variables in asymptomatic and symptomatic pop
| Variables | Asymptomatic pop (n = 64) |
Symptomatic pop (n = 86) |
p value |
|---|---|---|---|
| Education qualification | |||
| Illiterate | 34 (53.1%) | 68 (79.1%) | 0.001 |
| Primary | 12 (18.8%) | 12 (14%) | |
| Upper primary and higher | 18 (28.1%) | 6 (7%) | |
| Socio-economic condition | |||
| Lower middle class | 10 (15.6%) | 10 (11.6%) | 0.479 |
| Lower class | 54 (84.4%) | 76 (88.4%) | |
| BMI Category (kg/m2) | |||
| Normal weight | 32 (50%) | 28 (32.6%) | 0.042 |
| Over weight | 12 (18.8%) | 14 (16.3%) | |
| Obese | 20 (31.3%) | 44 (51.2%) | |
| Menstrual history | |||
| Premenopause | 42 (65.6%) | 32 (37.2%) | 0.001 |
| Menopause | 22 (34.4%) | 54 (62.8%) | |
| Resumption of work | |||
| Early | 44 (68.8%) | 48 (55.8%) | 0.128 |
| Late | 20 (31.3%) | 38 (44.2%) | |
| Parity | |||
| One | 6 (9.4%) | 4 (4.7%) | 0.121 |
| Two | 20 (31.3%) | 18 (20.9%) | |
| Three | 22 (34.4%) | 28 (32.6%) | |
| Four and more | 16 (25%) | 36 (41.9%) | |
| Place of delivery | |||
| Hospital | 22 (34.4%) | 16 (18.6%) | 0.037 |
| Home | 42 (65.6%) | 70 (81.4%) | |
In Table 4, differences in the stage categories are significantly related to the difference in the age group, menstrual history, and place of delivery. However, no significant relationship has been found between stage categories and differences in the BMI categories, occupations, and socio-economic conditions.
Table 5 shows further analysis with simple logistic regression where the severity of pop is more likely associated with age group and the strength of association was significant (OR 7.25; 95% CI 1.95–26.99).
Table 5.
Simple logistic regression and p value of co-variants with dependable variables
| Co-variants | Early pop (stage I + II) vs advance pop (stage III + IV) | ||
|---|---|---|---|
| Odds ratio | 95% C.Ia | p value | |
| Socio-economic condition | 1.099 | 0.300–4.029 | 1.00 |
| Age group | 7.257 | 1.951–26.994 | < 0.001 |
| Resumption of work | 1.513 | 0.606–3.777 | 0.669 |
| Place of delivery | 3.692 | 0.769–17.715 | 0.015 |
| Menstrual history | 0.472 | 0.141–1.584 | 0.531 |
aCI Confidence Interval
Table 6 shows the association of variables with different compartment defects. Among the study subjects, 44 of them had constipation and 14 had chronic lung diseases in the present study. Differences in the proportion of menstrual history, age group, and constipation were significant with the anterior compartment defect, whereas the place of delivery and BMI were significant in the posterior compartment defect. In apical compartment defect, differences in the proportion of menstrual history, place of delivery, age group, occupation, and chronic lung diseases were significant.
Table 6.
Relationship of variables with different compartment defect in pelvic organ prolapse
| Variables | Anterior wall defect | Apical defect | Posterior wall defect | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Absent (n = 22) | Present (n = 128) | p value | Absent (n = 74) | Present (n = 76) | p value | Absent (n = 36) | Present (n = 114) | p value | |
| Socio-economic condition | |||||||||
| Lower middle class | 5 | 15 | 0.161 | 11 | 9 | 0.586 | 4 | 16 | 0.653 |
| Lower class | 17 | 113 | 63 | 67 | 32 | 98 | |||
| Menstrual history | |||||||||
| Premenopause | 17 | 57 | 0.005 | 44 | 30 | 0.014 | 17 | 57 | 0.771 |
| Menopause | 5 | 71 | 30 | 46 | 19 | 57 | |||
| Place of delivery | |||||||||
| Hospital | 4 | 34 | 0.404 | 25 | 13 | 0.019 | 14 | 24 | 0.032 |
| Home | 18 | 94 | 49 | 63 | 22 | 90 | |||
| Age group | |||||||||
| 41–50 years | 22 | 102 | 0.020 | 71 | 53 | < 0.001 | 32 | 92 | 0.258 |
| > 50 years | 0 | 26 | 3 | 23 | 4 | 22 | |||
| Occupation | |||||||||
| House wife | 18 | 108 | 0.685 | 70 | 56 | 0.002 | 33 | 93 | 0.212 |
| Heavy workers | 2 | 14 | 2 | 14 | 1 | 15 | |||
| Light workers | 2 | 6 | 2 | 6 | 2 | 6 | |||
| BMI | |||||||||
| Normal | 12 | 48 | 0.053 | 35 | 25 | 0.187 | 21 | 39 | 0.013 |
| Over weight | 0 | 26 | 12 | 14 | 7 | 19 | |||
| Obese | 10 | 54 | 27 | 37 | 8 | 56 | |||
| Chronic lung diseases | |||||||||
| Absent | 19 | 117 | 0.453 | 71 | 65 | 0.028 | 32 | 104 | 0.674 |
| Present | 3 | 11 | 3 | 11 | 4 | 10 | |||
| Constipation | |||||||||
| Absent | 7 | 99 | < 0.001 | 49 | 57 | 0.237 | 29 | 77 | 0.135 |
| Present | 15 | 29 | 25 | 19 | 7 | 37 | |||
Discussion
In our population study, the prevalence of asymptomatic and symptomatic pop is the proportion of 2:3. The prevalence varies in different regions due to multiple socio-cultural facts. In our study, the prevalence of pop was 4.8%. In Chandigarh, India prevalence of pelvic organ prolapse is 7.6% [6]. A Study made at the Government Rajaji Hospital, Madurai, Tamilnadu, India reported a prevalence of 1.6% prolapse in gynecological cases [1]. In the USA, 2.9% of women reported symptoms of prolapse as per the National Health and Nutrition Examination Survey [7]. As per symptoms, the prevalence of POP was much lower (3–6%) than the prevalence identified after the examination (41–50%) [8].
The majority of women were housewives aged between 41-50 years and belonged to the low socio-economic group in the present study. The mean age was 46.96 ± 5.899 years, ranging from 41 to 65 years. The modal age group was 41 to 50 years (82.7%) followed by more than 50 years (17.3%). Mean parity was 3.07 ± 1.139 and mean BMI was 24.112 ± 3.41 kg/m2 in this study. Demographic and obstetrical variables found in different studies in pop, also support our study findings. Gumanga et al., reported mean age of 45.9 ± 15.1 years [9]. In a study done by Dhama et al., mean age of POP was 47 years, whereas in a study done at Bahir Dar, North West Ethiopia the mean age was found to be 43 + 12 years [10, 11]. In the present study, 84% of the study population were housewives with daily household activities, but they were engaged in daily lifting or carriage of water, farm produce, firewood, and traded goods. These activities can increase the risk for POP or worsen existing POP. It is also found that 10.7% of the patients were involved in heavy work, the majority of them being farmers and laborers which involved lifting heavy weights and prolonged sitting in squatting position in their routine work, which would have contributed to the prolapse. In a case–control study by Asresie et al., it was found that 75% of the cases had a history of lifting heavy objects [11]. In another study done by Masenga G. G. et al., it was found that women who carried out heavy work for five hours or more daily had almost five times increased risk of severe POP [12].
In the present study, majority of the patients belonged to the low socio-economic class (86.7%) followed by the lower middle class (13.3%), as per the modified B. G. Prasad scale [4]. In a study done by Sumathi N. et al., the majority (99%) of the patients belonged to the low socio-economic class [1].
Obesity was significantly associated with POP as reported by Giri A et al. in a systematic review and meta-analysis of observational studies [13]. In the present study, 42.7% of patients were found to be obese followed by normal weight (40%) and overweight (17.3%), as per the Asia Pacific Perspective for Asians (WHO IOTF 2003) [5]. In a study by Pooja et al., the majority (59.97%) of patients had BMI < 24.9 kg/m2 and 40.41% of patients had BMI ≥ 25 kg/m2 [14]. In a prospective observational cohort study, stage II pop was found in 56.9℅ women after first vaginal birth [15]. The majority had a history of multiple births at home and early resumption of work after delivery in the present study. In our study, only vaginally delivered women have been included and the proportion of POP has been found increasing with parity. POP was found to be more prevalent among multiparous women (93.3%, 140/150) as compared to primipara (6.7%, 10/150) which is similar to the result seen in the study done by Sumathi N. et al., where 94% of women who had delivered 2 or more children had POP [1]. In a retrospective study, by Peker N et al., it was found that the number of deliveries is associated with the development of pop who gave birth by vaginal route at home [16]. In the present study, only 25.3% of all POP women had a history of delivery in hospital, and the majority (74.7%) of them delivered at home. In a study done at Bahir Dar, North West Ethiopia, it was found that the majority (83.3%) of the patients had a history of last birth at home [11].
Difficulty in defecation was the most common symptom associated with stage I prolapse, whereas vaginal bulging predominates in stage II & higher stages of prolapse. Difficulties in micturition followed an increasing trend of distribution with increasing stages of prolapse. Stress urinary incontinence was found in 6.66% (10/150) pop women in the present study. Differences in vaginal bulging & difficulties in micturition were highly significant in relation to different stages of prolapse in the present study. Dhama et al., reported something coming out of the vagina was the most consistent symptom found in 84% of patients [10]. In a study done by Pooja et al., they found that the most common symptom was something coming out per vaginum ( 97.87%) followed by disturbances in micturition found in 93.62% of women [14].
Out of 150 pop women, 86 (57.3%) were symptomatic and 64 (42.7%) were asymptomatic, but they were presented with other gynecological symptoms. Clinical presentation may vary in patients according to their priorities & concern. Pelvic floor-related symptoms do not predict the anatomic location of the prolapse in women with mild to moderate prolapse [17]. Distribution of variables in an asymptomatic pop group, in terms of socio-economic conditions, resumption of work after delivery, and place of delivery followed a similar trend of distribution, among subgroups, with symptomatic pop in the present study. Most of them had normal body weight and are pre-menopausal in the asymptomatic pop group, whereas obesity and menopause were common in symptomatic pop women. Obesity seems to be a risk factor for symptoms of prolapse [18]. Forceps delivery and a BMI over 25 were associated with higher POP, observed in a study by Glazener et al. [19].
In the present study, 50.7% (76/150) of the patients were menopausal and 49.3% (74/150) were pre-menopausal. In a study done by Burrows et al., 75% were menopausal and 25% were pre-menopausal [20]. However, a contrasting result was found in another study with the majority (62.5%) of patients being pre-menopausal and 37.5% being menopausal [9]. In our study, Stage I pop was found mostly in pre-menopausal women, whereas in menopausal women stage ll, lll& lV were common. Hence it can be inferred that menopause is associated with advance or higher stages of prolapse and it is highly significant in the present study. The proportion of all of the stages of prolapse was more among in the 41–50 years age group than in the over 50 years age group and the difference was highly significant in the present study indicating that disease is developing following vaginal delivery and pop can be identified at an early age. In a study done by Masenga G.G et al., the prevalence of the POP, stage was found to increase with advancing age [12]. However, Gyhagen et al., in their study showed that age is not a risk factor for symptomatic POP [21]. If POP is described by validated pelvic organ prolapse quantification examination alone, 30 to 65% of women will have Stage II prolapse, who are presenting for routine gynecological care [22].
Home delivery carries a risk in all stages of prolapse, whether it is symptomatic or asymptomatic as found in the present study. Differences in place of delivery were statistically significant in relation to differences in stage category prolapse and also in symptomatic vs asymptomatic group as shown in tables no-3 &4. These all indicated that hospital delivery under supervision may decrease the prevalence of pop in future. In the present study, out of 150 pop more than half of the patients (83, 55.3%) had stage l pop, followed by stage II (39, 26%), stage III (24, 16%), and stage IV (4, 2.7%) pop. Almost similar results and trends were found in a study done by Quiroz et al. [3] On the contrary, Dhama et al., in their observational study showed POP in stage 1 was 0% followed by 16% in stage 2, and 49% and 35% in stage 3, 4, respectively [10]. These differences in the result may be due to the inclusion of asymptomatic patients in the present study, which consisted of the majority (74.70%, 62/83) among the total stage I pop. Incidence of pop doubles with each decade in women aged between 20–59 years [23]. An increase in incidence may be due to age-related physiological changes, degenerative processes, and hypoestrogenism. Age is also known to be associated with the prevalence and severity of all pelvic floor disorders.
Simple logistic regression and p value of the co-variants show there is a relationship between age and different stages of prolapse (OR 7.25; 95% CI 1.95–26.99), which was highly significant as shown in table no 5. Place of delivery and resumption of work have a risk effect on the severity of pop stages.
Table 6 shows variables associated with anterior, posterior, and apical compartment defects in the present study. In the present study, anterior vaginal wall prolapse was found in the majority (128/150, 85.3%) followed by posterior vaginal wall prolapse (114/150, 76%) and apical prolapse (76/150, 50.7%). Combined, all compartment defects were found to be present in 44% (66/150) of the women. Home deliveries were mostly associated with apical defect (63/76, 82.89%) and posterior compartment defect (90/114, 78.94%) and the differences in the proportion of place of delivery were significant. Akter F et al., in a cross-sectional survey, found that COPD and constipation were positively associated with pop which has the potential to be modified [24]. In the present study, chronic lung diseases with cough were associated with all three compartment defects, and differences in the proportion of chronic lung diseases were found to be significant (p = 0.028) in the apical compartment prolapse. In the present study, constipation was mostly associated with posterior compartment defects (37/114, 32.45%) than apical (19/76, 25%) or anterior defects (29/128, 22.65%), and differences in the proportion of constipation were significant with anterior compartment defects (p < 0.001). Ellerkmann RM et al., in a study, found that women with pop experience symptoms that do not necessarily correlate with compartment-specific defects [25]. Genetic factors vary from race, ethnicity, family history, advanced molecular biology, and genes associated with pop as noted in an article by Weintraub et al. [26]. In our single-center hospital-based, limited period study, it is difficult to pinpoint the association of genetics in pop. Economically weak and illiterate women constitute the bulk of the patient flow in the present study. However, the distribution of pop among people of different religions follows the population distribution in this area.
Limitations of the study-a different study design, where all hospital delivered women in the community will be included, which may further highlight the strength of the relationship between predictors and outcome.
In conclusion, symptomatic or asymptomatic pop is common following vaginal delivery in menopausal and perimenopausal women. All stages of pop were present mostly in 41–50 years age than over 50 years age. Age can predict the severity of pop. Menopause is associated with the severity of prolapse and in most cases were symptomatic. Anterior vaginal wall prolapse was the most common followed by the posterior vaginal wall prolapse in the present study. Hence there is a scope for early detection of pop which will improve patient care service.
Dr. Md. Kamaluddin Ansari
is currently working as RMO, in the Department of Obstetrics and Gynecology at North Bengal Medical College and Hospital, Sushrutanagar, Darjeeling, West Bengal after passing MS in OBG from Midnapore Medical College and Hospital, Midnapore. His field of interest is Urogynecology and menopausal problems. He has published one article in index journal and presented a paper in the BOGS CME Kolkata West Bengal.
Authors contributions
MD KA &SK-design, data collection, analysis, interpretation of data and drafting of the article. PPS: conception, design, acquisition of data, analysis and revise critically for intellectual content of the article and final approval of the version.
Funding
No funding source.
Declarations
Conflict of interest
None declared regarding financial, personal, political, intellectual, or religious interests.
Ethical Approval
This study on human participants was approved by the institutional ethics committee and has been performed in accordance with the ethical standard as laid down in the Helsinki Declaration. This article does not contain any studies with animals performed by any of the authors.
Informed Consent
Patients written, informed consent for the study was taken before enrollment.
Footnotes
Md. Kamaluddin Ansari, M.B.B.S, M.S, RMO is an Department of Obstetrics and Gynecology, North Bengal Medical College and Hospital, Sushrutanagar, Darjeeling, West Bengal, India; Partha Pratim Sharma, M.B.B.S, M.D, Associate Professor is an Department of Obstetrics and Gynecology, Midnapore Medical College and Hospital, Paschim Midnapore, West Bengal, 721101, India; Sharmin Khan, M.B.B.S, M.D, Senior Resident, Department of Pharmacology, MidnaporeMedical College and Hospital, Paschim Midnapore, West Bengal, India.
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Contributor Information
Md. Kamaluddin Ansari, Email: Kamal.kamal2603@gmail.com.
Partha Pratim Sharma, Email: Parthap_sharma@yahoo.co.in.
Sharmin Khan, Email: Khan.sharmin.sharmin@gmail.com.
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