Indian Journal of Obstetrics and Gynecology Research

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Online ISSN: 2394-2754

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Indian Journal of Obstetrics and Gynecology Research (IJOGR) open access, peer-reviewed quarterly journal publishing since 2014 and is published under auspices of the Innovative Education and Scientific Research Foundation (IESRF), aim to uplift researchers, scholars, academicians, and professionals in all academic and scientific disciplines. IESRF is dedicated to the transfer of technology and research by publishing scientific journals, research content, providing professional’s membership, more...


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Mishra, Chaudhari, Hol, and Shastri: Compare safety and efficacy of intramuscular progesterone versus vaginal progesterone in prevention of preterm labour


Introduction

Currently preterm labour is one of the most challenging problem faced by both obstetricians and perinatologists, as this episode in the course of woman’s pregnancy takes a heavy tool for perinatal mortality which accounts for approximately 50 -75%.1

The incidence of preterm labour is estimated to be 5-10% of all pregnancies, but there are some difference with different population and variable on socioeconomic status.2

Preterm birth (PTB) is the leading cause of perinatal mortality and morbidity in industrialized world. Approximately, 50% of all preterm births occur after 35 weeks gestation and almost all the mortality and morbidity of preterm birth occurs before this time. At 24 weeks of gestation, perinatal mortality is nearly 80% and 30 weeks of gestation mortality declines below 10%.3

Prematurity is a major cause of perinatal mortality and morbidity and it leads to greater risk for both short and long term complications which includes disability and impedinents in growth and mental development.4 Its contribution to overall perinatal mortality and morbidity is more than 50% of cases. About 40% of all preterm births occur before 34 weeks and 20% before 32 weeks. Majority of morbidity and mortality occurs among those who delivered before 34 weeks.5

Wide varieties of tocolytic agents are being advocated since decades for the prevention of Preterm labour6, 7 and also been tried for the management of threatened preterm labour8, 9 Above all, there are insufficient data on long term follow up for reliable conclusion about the effects on the baby of these tocolytic drugs. (RCOG Green top guidelines, 2011)10 Progesterone is essential for the maintenance and prolongation of pregnancy.11, 12 Delaying delivery reduces the rate of long term morbidity by facilitating maturity of vital organs, helps in optimum action of the administered glucocorticoids, helps in transfer to higher centre with NICU facilities. So different trials have been done to show the efficacy and safety of progesterone in prevention of recurrent preterm birth since 1960.13, 14

Progesterone can be administered via oral capsule, vaginal gel or suppository, or intramuscularly.15, 16 Oral administration has better patient compliance but there are variability in the plasma concentrations of the drug due to personal variation in gastric filling and enterohepatic circulation, also this route can be associated with side effects such as nausea, headache, sleepiness, etc.17, 18

The vaginal route results in higher local concentrations in uterus but its blood levels are low, while progesterone administered intramuscularly has optimal blood levels.19, 20 On 3rd February’ 2011 injectable form of 17α hydroxyl progesterone (Mekena) has been approved by FDA to reduce the risk of preterm labour before 37 weeks of gestation.21, 22

On February 3, 2011, the US Food and Drug Administration (FDA) approved the use of progesterone supplementation (hydroxyprogesterone caproate) during pregnancy to reduce the risk of recurrent preterm birth in women with a history of at least one prior spontaneous preterm delivery. This is the first time that the FDA has approved a medication for the prevention of preterm birth, and represents the first approval of a drug specifically for use in pregnancy in almost 15 years. This article reviews the evidence behind the use of progesterone for the prevention of preterm birth, and provide guidelines for the use of progesterone supplementation in clinical practise. The aim of this study was to compare between vaginal and intramuscular progesterone in the prevention of Preterm labour in women at high risk for preterm delivery.

Presently 17 hydroxyprogesterone caproate (intramuscular) is the only FDA approved product for the prevention of recurrent preterm birth, however recent studies suggest that vaginal progesterone may be used for this purpose, and may be even superior.

The American College of Obstetrics and Gynecology does not specify the optimal route of progesterone administration for the prevention of recurrent preterm birth. So it is our intention to compare vaginal and intramuscular progesterone to see if one is superior.

Aims and Objectives

Compare the safety and efficacy of intramuscular progesterone versus vaginal progesterone as maintenence therapy to prevent preterm labour in singleton pregnancy.

Inclusion criteria

All preterm patients (<37 weeks) visiting ANC OPD or admitted in labour room in spontaneous labour showing features of

  1. Singleton pregnancy.

  2. Live fetus

  3. Presence of one of the preterm delivery risk factors.

Exclusion criteria

All patients with

  1. Severe liver and renal disease.

  2. Multiple pregnancy.

  3. Major fetal anomaly, incompatible with survival.

  4. Pregnancies complicated with diabetes mellitus.

  5. Patient not giving consent.

Methods

It was a prospective randomize control study. All the cases with inclusion and exclusion criteria were selected during the study period. The subjects were randomized into two groups with group A received vaginal micronized progesteron and group B intramuscular 17a hydroxyprogesteron caproate. Total of 100 cases were included in this study.

All preterm pregnancy of more than 20 weeks were considered in this study. Initial nefidipine 10 mg, 4 tablets 15 min apart was given for tocolytic activity for 48 hours. Injection bethamethasone 12 mg I.M 2 doses in a duration of 24 hours apart is given for fetal lung maturity.

One group will receive weekly intramuscular hydroxyprogesteron (250 mg) injection while other group will receive daily micronized vaginal progesteron suppository (200mg).

Subsequently compare the safety and efficacy of intramuscular progesterone versus micronized progesterone as a maintenance therapy in preventing preterm labour and analyse maternal and fetal factors that consists of

Maternal factors

  1. Prolongation of pregnancy

  2. Rate of preterm delivery

  3. Gestational age at delivery

  4. Mode of delivery Normal versus LSCS

  5. Satisfaction of the participants

  6. Adverse effects of the drugs

Fetal factors

  1. Birth weight

  2. Mortality

  3. NICU admissions

  4. APGAR score

  5. Neonatal mortality or morbidity

  6. No of days of admission is evaluate

Patients are followed up on OPD basis at regular interval on antenatal visits, by thorough history taking, laboratory investigations, regular antenatal examination. Serial Ultrasonography to monitor gestation age and growth.

Statistical data analysis

The data on categorical variables is shown as n (% of cases) and the data on continuous variables is presented as Mean and Standard deviation (SD) across two study groups. The inter-group statistical comparison of distribution of categorical variables is tested using Chi-Square test or Fisher’s exact probability test. The inter-group statistical comparison of means of continuous variables is done using independent sample t test. The underlying normality assumption was tested before subjecting the study variables to t test. All results are shown in tabular as well as graphical format to visualize the statistically significant difference more clearly.

In the entire study, the p-values less than 0.05 are considered to be statistically significant. All the hypotheses were formulated using two tailed alternatives against each null hypothesis (hypothesis of no difference). The entire data is statistically analyzed using Statistical Package for Social Sciences (SPSS ver 22.0, IBM Corporation, USA) for MS Windows.

Results

Following section shows the detailed statistical analysis of the available data

50 cases studied in Group A, 7 (14.0%) had age between 18 – 20 years, 18 (36.0%) had age between 21 – 25 years, 17 (34.0%) had age between 26 – 30 years and 8 (16.0%) had age between 31 – 35 years. Of 50 cases studied in Group B, 7 (14.0%) had age between 18 – 20 years, 19 (38.0%) had age between 21 – 25 years, 16 (32.0%) had age between 26 – 30 years and 8 (16.0%) had age between 31 – 35 years. The age distribution of cases studied did not differ significantly between two study groups (P-value>0.05).

Figure 1

Inter-Group Age distribution of cases studied.

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Figure 2

Inter-Group distribution of parity of cases studied

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Of 50 cases studied in Group A, 25 (50.0%) are primigravida, 25 (50.0%) are multigravida. Of 50 cases studied in Group B, 23 (46.0%) are primigravida, 27 (54.0%) are multigravida. The distribution of parity of cases studied did not differ significantly between two study groups (P-value>0.05).

Figure 3

Inter-Group comparison of mean gestational age at which drug was administered

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The mean ± SD of gestational age at which the drug was administered among the cases studied in Group A and Group B was 30.28 ± 2.21 weeks and 30.31 ± 2.19 weeks respectively.

Distribution of mean gestational age at which the drug was administered among the cases studied did not differ significantly between two study groups (P-value>0.05).

Figure 4

Inter-Group distribution of gestational age at the time of delivery

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Of 50 cases studied in Group A, 12 (24.0%) had gestational age less than 37 weeks, 32 (64.0%) had gestational age between 37 – 40 weeks and 6 (12.0%) had gestational age more than 40 weeks.

Of 50 cases studied in Group B, 8 (16.0%) had gestational age less than 37 weeks, 37 (74.0%) had gestational age between 37 – 40 weeks and 5 (10.0%) had gestational age more than 40 weeks.

Distribution of gestational age at the time of delivery among the cases studied did not differ significantly between two study groups (P-value>0.05).

Figure 5

Inter-Group distribution of mode of delivery

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Of 50 cases studied in Group A, 40 (80.0%) had normal delivery and 10 (20.0%) had LSCS delivery.

Of 50 cases studied in Group B, 42 (84.0%) had normal delivery and 8 (16.0%) had LSCS delivery.

Distribution of mode of delivery among the cases studied did not differ significantly between two study groups (P-value>0.05).

Figure 6

Inter-Group distribution of incidence of adverse effect of the drug

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Of 50 cases studied in Group A, 14 (28.0%) had adverse effect and 36 (72.0%) did not have any adverse effect of the drug.

Of 50 cases studied in Group B, 12 (24.0%) had adverse effect and 38 (76.0%) did not have any adverse effect of the drug.

Distribution of incidence of adverse effect of the drug among the cases studied did not differ significantly between two study groups (P-value>0.05).

Figure 7

Inter-Group distribution of birthweight

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Of 50 babies born in Group A, 11 (22.0%) had birthweight less than 2500 gm, 37 (74.0%) had birthweight between 2500 – 3500 gm and 2 (4.0%) had birthweight more than 3500 gm.

Of 50 babies born in Group B, 7 (14.0%) had birthweight less than 2500 gm, 43 (86.0%) had birthweight between 2500 – 3500 gm and none had birthweight more than 3500 gm.

Distribution of birthweight did not differ significantly between two study groups (P-value>0.05).

Figure 8

Inter-Group distribution of incidence of NICU admission

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Of 50 babies born in Group A, 8 (16.0%) required NICU admission and 42 (84.0%) did not require NICU admission.

Of 50 babies born in Group B, 6 (12.0%) required NICU admission and 44 (88.0%) did not require NICU admission.

Figure 9

Inter-Group distribution of APGAR Score

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Of 50 babies born in Group A, 7 (14.0%) had abnormal APGAR score and 43 (86.0%) had normal APGAR score.

Of 50 babies born in Group B, 2 (4.0%) had abnormal APGAR score and 48 (96.0%) had normal APGAR score.

Of 50 babies born in Group A, 8 (16.0%) required mechanical ventilation and 42 (84.0%) did not require mechanical ventilation.

Of 50 babies born in Group B, 6 (12.0%) required mechanical ventilation and 44 (88.0%) did not require mechanical ventilation.

Figure 10

Inter-Group distribution of incidence of neonatal mortality

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Of 50 babies born in Group A, 2 (4.0%) expired and 48 (96.0%) survived. Of 50 babies born in Group B, 1 (2.0%) expired and 49 (98.0%) survived.

Discussion

In our study there is no significant difference between vaginal and intramuscular progesterone groups regarding baseline characteristics like maternal age, parity, gestational age at admission, cervical dilatation, and risk factors.

According to Meis et al and coinvestigator23 study, women randomized to 17 hydroxycaproate prophylaxis had a significant reduced risk of preterm birth at all gestational ages .Moreover infants born to group treated with 17 hydroxycaproate (250 mg) has less perinatal morbidity and mortality.

In a present study efficacy findings showed that in case of Intramuscular progestron group out of total 100 cases studied (24.0%) had gestational age less than <37 weeks, 3 (64.0%) between 37–40 weeks and (12.0%) more than >40 weeks.

According to Fonseca et al. and coinvestigator19 study, women randomized to progesterone prophylaxis had a significantly reduced risk of recurrent preterm labour at all gestational ages.

In a present study in the case of vaginal progesterone group (16.0%) had gestational age less than <37 weeks, (74.0%) between 37–40 weeks and (10.0%) more than >40 weeks. These results confirmed that progesterone therapy have acceptable efficacy in the prevention of preterm labor Distribution of mean gestational age at which the drug was administered among the cases studied was 30.28 ± 2.21 weeks and 30.31 ± 2.19 weeks respectively which did not differ significantly between two study groups (P-value>0.05).

Our results indicates that the frequency of preterm delivery and mean gestational age at delivery were not statistically different between the vaginal progesterone and intramuscular progesterone group. This indicated that these two modes of administering progesterone had essentially the same efficacy in preventing preterm delivery.

Out of total 100 cases studied total (28.0%) had adverse effect in intramuscular progesterone group and (24.0%) in vaginal progesterone group. Incidence of adverse effect of the drug among the cases studied did not differ significantly between two study groups (P-value>0.05). According to the result Vaginal progesterone has more of local minor side effects like vaginal discharge, itching, pruritis, irritation, yeast infection. Side effect of synthetic injectable progesterone are also mild and restricted to injection site, like pain, swelling, itching, bruising and systemic side effects like nausea, vomiting, pain abdomen, diarrhea, bloating, headache

The studies of Khandelwal et al., Hassan et al. and O’Brien et al. indicated that the rate of adverse effects of vaginal progesterone was similar to that of the placebo.24 Maher et al. showed that the rate of side effects in women treated with vaginal progesterone was lower than in the case of intramuscular progesterone, i.e., 7.5% as opposed to 14.1%.25

Therefore, this study concluded that the use of vaginal progesterone was safer than the use of intramuscular progesterone.

In this study, in addition to comparing the efficacy and safety of vaginal progesterone and intramuscular progesterone in the prevention of preterm delivery, we assessed their effects on some infant outcomes. Based on the results, the birth weights of the two intramuscular progesterone versus vaginal progesterone group was 2784.2 ± 490.7 gm and 2813.9 ± 363.3 gm respectively. Distribution of mean birth weight did not differ significantly between the two study groups (P-value>0.05) confirmed the positive effects of progesterone on increasing infants’ weights at birth.

Abd El Hameed24 studied three groups, i.e vaginal progesterone, intramuscular progesterone, and control groups, and confirmed the positive effect of both vaginal progesterone and intramuscular progesterone on birth weight . In this study, similar to our results, the birth weight of newborns of the vaginal progesterone and intramuscular progesterone groups was not significantly different.

Out of total 100 babies born in intramuscular progesterone group (16.0%) required NICU admission and in vaginal progesterone group (12.0%) and 14.0% had abnormal APGAR score in intramuscular progesterone Group and 4.0% in vaginal progesterone group. Out of that 4 babies in intramuscular group and 3 babies in vaginal progesterone group needs mechanical ventilation.

Distribution of incidence of abnormal APGAR score did not differ significantly between two study groups (P-value>0.05) which shows positive effects of progesterone on reducing admissions to NICU and reducing perinatal mortality and morbidity.

De-Franco et al. confirmed the positive effects of progesterone on reducing admissions to the NICU.26 The studies of Edwards et al. Conde -Agudelo et al., Abd El Hameed, Hassan et al. and Berghella, et al. confirmed the positive effects of progesterone on reducing perinatal mortality and morbidity.27, 28, 29, 24

In a present study Neonatal mortality are seen in (4.0%) of babies in intramuscular progesterone group and in (2.0%) of the patient with vaginal progesterone group. Distribution of incidence of mortality did not differ significantly between two study groups (P-value>0.05). This confirmed the positive effect of progesterone on reducing neonatal mortality.

In this study, we also assessed the satisfaction of the pregnant women with the drug they received in terms of convenience of use. The findings showed that 100% of participants had a satisfaction level of moderate or better. Also, satisfaction scores were not significantly different between the two groups that were studied. In this regard, Khandelwal et al. in their study in 2012 found that vaginal progesterone was acceptable to women due to its ease of use. 30

Conclusion

Preterm birth remains a significant problem in obstetric care, affecting women and babies world-wide. There are considerable health consequences for infants born preterm, as well as economic consequences for the health care system, individuals, and their families.

Based on our results, we can conclude that progesterone therapy had acceptable efficacy in the prevention of preterm labor in terms of prolongation of delivery and by increasing gestational age at delivery. Both Vaginal progesterone and intramuscular progesterone can be equally useful in the prevention of preterm delivery. Our study indicated that both the two modes of administering progesterone had essentially the same efficacy and safety in preventing preterm delivery with lesser side effects. Present study also indicates positive effect of progestron in decreasing neonatal morbidity and mortality as it had a positive impact on NICU stay, APGAR score, birth weight as the ultimate purpose of interventions designed to prevent preterm delivery is the improvement of infant outcomes. We also assessed the satisfaction of the pregnant women with the drug they received in terms of convenience of use. The findings showed that 100% of participants had a satisfaction level of moderate or better.

Source of Funding

No funding sources.

Conflict of Interest

None declared.

Ethical Approval

The study was approved by the Institutional Ethics Committee.

Acknowledgments

Authors would like to thanks institutional head, head of department of obstetrics and gynecology and all colleagues from department of obstetrics and gynecology Smt. Kashibai Navale Medical College and General Hospital for providing help and support for the project.

References

1 

S Dasgupta OG Mukherjee K Buckshee Preterm labourImmunlogical basis of pathophysiology1st edition199847

2 

RL Goldenberg JF Culhane JD Iams R Romero Epidemiology and causes of preterm birthLancet20173717584

3 

BA Magowan M Bain E Juszczak K McInneny Neonatal mortality amongst Scottish preterm singleton birthsBr J Obstet Gynaecol19981059100510

4 

Lluis Cabeno Rouna (Spain) and European Association of Perinatal Medicines-Study group on “Preterm BirthArch Perinat Med20161342935

5 

PD Gluckman MA Hanson Living with the past: evolution, development, and patterns of diseaseScience2014305569117336

6 

Maternity - Tocolytic Agents for Threatened Preterm Labour before 34 Weeks Gestation Document Number PD2011_025 NSW policy directive Revhttps://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2020_009.pdf

7 

ME Hannah Search for best tocolytic for preterm labourLancet2014356699700

8 

DM Hars TF Tinperlate PR Kirkpatrick RW Klein TW Zollinger AM Gollchopwshi Tocolytics therapy,-a metaanalysis and decision analysisObstet Gynecol2009113358594

9 

TC Tan K Devendra LK Tan HK Tan Tocolytic treatment for management of preterm labour:a systematic reviewSingapore Med J20064753616

10 

Tocolytics for women in preterm labourhttps://www.slideshare.net/elnashar/tocolysis-37621163

11 

E Grazzini G Guillon B Mouillac HH Zingg Laboratory of Molecular Endocrinology, Royal Victoria Hospital Research Institute, McGill University, Montreal, Quebec, Canada; Unite INSERM U469, Centre de Pharmacologie-Endocrinologie, Montpellier, France.) Inhibition of oxytocin receptor functions by direct binding of progesterone. Nature 1998

12 

RE Garfield MS Dannan EE Daniel Gap junction formation in myometrium controlled by estrogen, progesterone & prostaglandinAm J physiol1980238819

13 

L Levine Habitual abortion: a controlled study of progestational therapyWest J Surg Obstet Gynecol196472306

14 

E Papiernik Double blind study of an agent to prevent preterm delivery among women at increased riskEdition Schering, Serie IV197065880

15 

JW Johnson KL Austin GS Jones Efficacy of 17alpha-hydroxyprogesterone caproate in the prevention of premature laborN Engl J Med197529367580

16 

JC Hauth LC Gilstrap AL Brekken JM Hauth The effect of 17 alpha hydroxyprogesterone caproate on pregnancy outcome in an active-duty military populationAm J Obstet Gynecol198314618790

17 

M Yemeni R Borenstein E Dreazen Z Apelman BM Mogilner I Kessler Prevention of premature labor by 17 alpha-hydroxyprogesterone caproateAm J Obstet Gynecol19851515747

18 

MJ Keirse Progestogen administration in pregnancy may prevent preterm deliveryBr J Obstet Gynaecol19909714954

19 

EB DaFonseca RE Bittar MH Carvalho M Zugaib Prophylactic administration of progesterone by vaginal suppository to reduce the incidence of spontaneous preterm birth in women at increased risk: a randomized placebo-controlled double-blind studyAm J Obstet Gynecol200318841924

20 

PJ Meis M Klebanoff E Thom P Mitchell Prevention of recurrent preterm delivery by 17-alpha hydroxyprogesterone caproateN Engl J Med2003348237985

21 

EB Fonseca E Celik M Parra M Singh KH Nicolaides Progesterone and the risk of preterm birth among women with a short cervixN Engl J Med20073574629

22 

DJ Rouse SN Caritis AM Peaceman A Sciscione EA Thom CY Spong A trial of 17 alpha-hydroxyprogesterone caproate to prevent prematurity in twinsN Engl J Med2007357545461

23 

PJ Meis M Klebanoff E Thom National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Prevention of recurrent preterm delivery by 17 alphahydroxyprogesterone caproateN Engl J Med2003348237985

24 

SS Hassan R Romero D Vidyadhari S Fusey JK Baxter M Khandelwal Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trialUltrasound Obstet Gynecol20113811831

25 

MA Maher A Abdelaziz M Ellaithy MF Bazeed Prevention of preterm birth: a randomized trial of vaginal compared with intramuscular progesteroneActa Obstet Gynecol Scand201392221522

26 

EA Defranco JM O’brien CD Adair DF Lewis DR Hall S Fusey Vaginal progesterone is associated with a decrease in risk for early preterm birth and improved neonatal outcome in women with a short cervix: a secondary analysis from a randomized, double-blind, placebo-controlled trialUltrasound Obstet Gynecol2007305697705

27 

DR Velez Edwards FE Likis JC Andrews AL Woodworth RN Jerome CJ Fonnesbeck Progestogens for preterm birth prevention: a systematic review and meta-analysis by drug routeArch Gynecol Obstet20132876105966

28 

A Conde-Agudelo R Romero K Nicolaides T Chaiworapongsa JM O’brien E Cetingoz Vaginal progesterone vs. cervical cerclage for the prevention of preterm birth in women with a sonographic short cervix, previous preterm birth, and singleton gestation: a systematic review and indirect comparison metaanalysisAm J Obstet Gynecol201320814210.1016/j.ajog.2012.10.877

29 

V Berghella D Figueroa J M Szychowski J Owen G D Hankins J D Iams 17-alpha hydroxyprogesterone caproate for the prevention of preterm birth in women with prior preterm birth and a short cervical lengthAm J Obstet Gynecol20102024351

30 

M Khandelwal Vaginal progesterone in risk reduction of preterm birth in women with short cervix in the midtrimester of pregnancyInt J Womens Health201244819010.2147/IJWH.S28944



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© This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article type

Original Article


Article page

541-547


Authors Details

Aparajita Mishra, Shilpa Chaudhari*, Kishor Hol, Shraddha Shastri


Article History

Received : 15-06-2021

Accepted : 04-08-2021

Available online : 26-11-2021


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