(a) (i) Describe the clinical features and diagnostic workup of a suspected case of peritonitis. (ii) Enumerate the principles of…

(a) Peritonitis

Clinical Features and Diagnostic Workup Peritonitis, an inflammation of the peritoneal cavity, manifests clinically with severe, localized or generalized abdominal pain exacerbated by movement. On physical examination, classical signs of an acute abdomen include localized or generalized muscular guarding, board-like rigidity, marked rebound tenderness (Blumberg sign), and a silent abdomen due to paralytic ileus. Systemic features include high-grade fever with chills, tachycardia, tachypnea, hypotension, oliguria, and toxic facies (facies Hippocratica).

Diagnostic workup proceeds systematically:

1. Laboratory Investigations: Complete blood count reveals marked polymorphonuclear leukocytosis; serum electrolytes, blood urea, and creatinine assess renal function and dehydration; serum amylase and lipase rule out acute pancreatitis; arterial blood gas (ABG) evaluates metabolic acidosis and tissue perfusion.
2. Diagnostic Paracentesis: Ascitic fluid analysis reveals an absolute neutrophil count >250 cells/mm³ (diagnostic of spontaneous bacterial peritonitis), elevated protein, elevated LDH, positive Gram stain, and bacterial culture. High fluid amylase or bilirubin indicates hollow viscus or biliary perforation.
3. Imaging Modalities: An erect chest X-ray demonstrates free air under the right dome of the diaphragm (pneumoperitoneum) in gastrointestinal perforation. Ultrasonography (USG) identifies free fluid, collections, and pelvic pathology. Contrast-enhanced computed tomography (CECT) of the abdomen is the definitive modality to localize the exact site of perforation, mesenteric ischemia, or intra-abdominal abscesses.

Principles of Management

1. Emergency Resuscitation: Nil per os (NPO), placement of a wide-bore nasogastric tube for bowel decompression, and urinary catheterization to monitor hourly urine output.
2. Hemodynamic and Sepsis Management: Rapid restoration of intravascular volume using balanced crystalloids guided by the Surviving Sepsis Campaign bundle.
3. Antimicrobial Therapy: Immediate administration of empirical, broad-spectrum intravenous antibiotics covering aerobic Gram-negative bacilli, Gram-positive cocci, and anaerobes (e.g., third-generation cephalosporin or piperacillin-tazobactam plus metronidazole).
4. Surgical Source Control: Emergency laparotomy or laparoscopy to identify and correct the underlying pathology (perforation repair, appendectomy, or bowel resection), thorough peritoneal lavage with warm normal saline, and placement of dependent drains.
5. Postoperative Care: Nutritional support (early enteral where feasible, or parenteral), analgesia, deep vein thrombosis prophylaxis, and intensive organ support in cases of septic shock.

Important Complications

1. Septic shock and Multi-Organ Dysfunction Syndrome (MODS).
2. Localized intra-abdominal, subphrenic, or pelvic abscesses.
3. Enterocutaneous and anastomotic fistulae.
4. Early or late adhesive intestinal obstruction.
5. Wound dehiscence, burst abdomen, and death.

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(b) Anaemia Mukt Bharat (AMB) Programme

The Anaemia Mukt Bharat strategy follows a comprehensive 6x6x6 framework to accelerate the reduction of anemia prevalence across India.

Interventions and Specific Measures

1. Prophylactic Iron-Folic Acid (IFA) Supplementation: Age-specific dispensing of IFA syrup/tablets (bi-weekly IFA syrup for infants; weekly pink tablets for children; weekly blue tablets for adolescents; daily red IFA tablets during pregnancy and lactation).
2. Periodic Deworming: Biannual administration of Albendazole (400 mg) linked to National Deworming Day (NDD) platforms.
3. Intensified Behaviour-Change Communication (BCC): Promotion of infant and young child feeding (IYCF) practices, delayed cord clamping for at least 3 minutes, and dietary diversity focusing on iron and Vitamin C-rich foods.
4. Testing and Digital Point-of-Care Treatment: Deployment of digital invasive hemoglobinometers at Ayushman Arogya Mandirs for real-time testing and stratified clinical management (mild/moderate/severe).
5. Mandatory Food Fortification: Inclusion of double-fortified salt (iron and iodine) and fortified rice in public schemes such as ICDS and PM-POSHAN.
6. Targeting Non-Nutritional Causes: Diagnosis and management of endemic causes like malaria, fluorosis, and hemoglobinopathies (sickle cell disease, thalassemia).

Target Population Groups

1. Children aged 6–59 months.
2. Children aged 5–9 years.
3. Adolescents aged 10–19 years (school-going and out-of-school).
4. Non-pregnant, non-lactating women of reproductive age (15–49 years).
5. Pregnant women.
6. Lactating mothers (0–6 months postpartum).

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(c) Infertility and Assisted Reproductive Technology

Definition and Tubal Factor Investigation Infertility is defined as a disease of the reproductive system characterized by the failure to achieve a clinical pregnancy after 12 months or more of regular, unprotected sexual intercourse in women under 35 years of age (or after 6 months in women aged 35 years and older).

Tubal pathology accounts for approximately 25–35% of female infertility. Its investigation involves:

1. Hysterosalpingography (HSG): A fluoroscopic procedure performed during the early follicular phase (days 7–10) using radiopaque contrast. It evaluates tubal patency, detects cornual or distal tubal blockages, and identifies hydrosalpinx or tubal mucosal architecture.
2. Hysterosalpingo-Contrast Sonography (HyCoSy) / Saline Infusion Sonography (SIS): Transvaginal ultrasound with intrauterine saline or echogenic contrast injection, avoiding radiation and assessing both uterine cavity and tubal spillage.
3. Laparoscopic Chromopertubation: The gold standard diagnostic and therapeutic investigation. Under general anesthesia, dilute methylene blue dye is injected transcervically, and its free spill from the fimbrial ends is directly visualized. It simultaneously diagnoses and allows treatment of peritubal adhesions, endometriosis, and pelvic pathology.
4. Hysteroscopy: Often combined with laparoscopy to evaluate the tubal ostia and correct proximal tubal occlusion via selective tubal cannulation.

Enumeration of Assisted Reproductive Technology (ART) Procedures

1. Intrauterine Insemination (IUI): Controlled ovarian stimulation followed by placement of processed, washed motile spermatozoa directly into the uterine cavity.
2. In Vitro Fertilization and Embryo Transfer (IVF-ET): Oocyte retrieval followed by extracorporeal fertilization in culture dishes and transfer of resultant embryos into the uterus.
3. Intracytoplasmic Sperm Injection (ICSI): Direct micromanipulation involving the mechanical injection of a single spermatozoon into the cytoplasm of a mature metaphase-II oocyte.
4. Gamete Intrafallopian Transfer (GIFT) and Zygote Intrafallopian Transfer (ZIFT): Laparoscopic transfer of unfertilized gametes or early zygotes directly into the fallopian tubes.
5. Surgical Sperm Retrieval: Techniques for azoospermic males, including Percutaneous Epididymal Sperm Aspiration (PESA), Testicular Sperm Aspiration (TESA), and Microdissection Testicular Sperm Extraction (Micro-TESE).
6. Cryopreservation and Vitrification: Ultra-rapid freezing of gametes (oocytes, sperm) and embryos for future transfer cycles.
7. Pre-implantation Genetic Testing (PGT): Genetic profiling of blastocyst biopsies via PGT-A (aneuploidy) and PGT-M (monogenic disorders) prior to embryo transfer.