Evaluation of maternal plasma platelet activating factor acetylhydrolase activity and mRNA expression in pre-eclampsia: a case control study

Preeclampsia (PE) remains a leading cause of maternal morbidity and mortality all over the world. However, its aetiology and pathophysiology remain elusive. Platelet activating factor (PAF) is produced in response to oxidative stress and is a potent hypotensive agent. PAF acetylhydrolase (PAF-AH) inactivates PAF and is seen to decrease in normotensive women. The role of PAF-AH in preeclampsia has been in investigational literature, so far. The few studies done have shown a positive association of elevated levels of PAF-AH with preeclampsia. However, this marker has not been studied in the Indian population to-date and such studies are needed to elucidate the pathogenesis of this condition. Our study aimed to determine the PAF-AH activity by spectrophotometric assay in maternal plasma of 73 PE patients versus 73 normotensive controls and plasma PAF-AH mRNA expression to know the aberration of PAF-AH activity at the genetic level. Relative mRNA expression was calculated by Δ DCT method and a fold change was calculated by 2^-ΔDCT. We found that the mean plasma PAF-AH activity levels among cases was significantly higher than the normotensive controls. However, the mRNA expression of the PAF-AH gene was similar between the cases and controls, as well as between severe and non-severe preeclampsia (true fold change =1). To conclude, PAF-AH appears to be increased in women with preeclampsia and hence may contribute to pathophysiology and severity. However, a larger sample size will be required to reiterate this association. Recently, PAF-AH inhibitors such as Darapladib has been tested as a therapeutic option in atherosclerosis. After studying the role of PAF-AH in the pathogenesis of PE, PAF-AH inhibitors may be used as a therapeutic tool in the future in PE.IMPACT STATEMENTWhat is already known on this subject? Platelet activating factor (PAF) is produced in response to oxidative stress and is a potent hypotensive agent. PAF acetylhydrolase (PAF-AH) hydrolyses and inactivates PAF and is seen to decrease in normotensive women. The role of platelet activating factor-acetylhydrolase (PAF-AH) in preeclampsia has been investigational so far. Few studies done have shown a positive association of elevated levels of PAF-AH in preeclamptic women.What do the results of this study add? Our study aimed to determine the activity of PAF-AH in maternal plasma of PE patients versus normal pregnancy and plasma PAF-AH mRNA expression to know the aberration of PAF-AH activity at the level of the gene. We found that plasma PAF-AH activity among preeclamptics was significantly higher than in the controls with a possible role in early-onset preeclampsia (<32 weeks), in the Indian population. This marker has never been studied in this population earlier. The results of our study re-emphasised its role in the pathogenesis of preeclampsia.What are the implications of these findings for clinical practice and/or further research? Such studies are important to not only give us a greater understanding of the various pathways involved in this multifactorial dreaded condition, but can also offer us a marker for early identification of women at risk. Recently, PAF-AH inhibitors like Darapladib has been tested as a therapeutic option in atherosclerosis. After studying the role of PAF-AH in the pathogenesis of PE, PAF-AH inhibitors may be used as a therapeutic tool in the future in PE.

Development of vocational potential assessment tool and counseling module for persons with severe mental disorders

OBJECTIVE

To develop and validate the vocational potential assessment tool and counselling module for persons with severe mental disorders (SMD).

METHOD

The tool and the module were developed through review of existing assessment tools, individual interviews and focused group discussions with key stake holders- persons with SMD, caregivers, expert mental health professionals and employers. The developed tool and module were validated by experts.

RESULT

The process of tool and module development was conducted simultaneously and included 11 persons with SMD, 9 caregivers, 9 experts and 9 employers. A total of 38 themes were obtained through individual interviews and focused group discussions. The developed tool and module along with a scoring key were validated by 6 mental health experts.

CONCLUSION

The tool is easy to use and comprehensive, takes approximately 45 min to 1 h for assessment. The module provides a framework for vocational counselling. The scoring key provides a guideline for professionals during assessment.

Sepsis in Obstetrics Score (SOS) utility and validation for triaging patients with obstetric sepsis in the emergency department: Evidence from a low income health care setting

BACKGROUND

Illness severity scores commonly used in critical care settings are not considered appropriate in obstetric practice as they do not account for pregnancy physiology. A new illness severity score called the 'Sepsis in Obstetrics Score' (SOS) was introduced by Albright et al. for triaging patients with sepsis in pregnancy in an emergency department setting.

OBJECTIVES

We aimed to determine whether this score could predict the need for critical care support using the presence of organ failure as the identification criteria. Severity and culture positivity in pregnancy-associated sepsis was also assessed.

MATERIALS AND METHODS

All pregnant, postabortal and postpartum women with suspected sepsis were enrolled (as per systemic inflammatory response syndrome criteria) were enrolled. Severe pregnancy-associated sepsis was defined as dysfunction of one or more organs due to sepsis. The severity of pregnancy-associated sepsis was graded according to the number of organ failures. A SOS cut off of 6 was taken for statistical analysis.

RESULTS

Out of 100 women with pregnancy-associated sepsis, 'severe sepsis' was present in 58%. When the SOS test performance was compared with the severity of pregnancy-associated sepsis, it had sensitivity of 68.9% and specificity of 80.9%, positive predictive value of 83% and negative predictive value 65% to predict severe sepsis. The area under curve for the SOS detecting severe pregnancy-associated sepsis was 0.810. SOS predicted organ failure in pregnancy-associated sepsis and this was statistically significant for all organs involved. Culture positivity did not correlate with the SOS in our study.

CONCLUSIONS

Sepsis in Obstetrics Score correlated well with organ failure in pregnancy-associated sepsis. It had a high positive predictive value (83%) for severe sepsis.

Are pregnant women also vulnerable to domestic violence? A community based enquiry for prevalence and predictors of domestic violence among pregnant women

Aim:

To generate local evidence to fill up the knowledge gap about the domestic violence faced by the antenatal females.

Objectives:

To screen for domestic violence in antenatal females. To explore association, if any, with socio-demographic and pregnancy related attributes among antenatal females of an urbanized village of Delhi.

Materials and Methods:

Socio demographic details and pregnancy related attributes and HITS (Hurt, Insult, Threaten, Scream) questionnaire for screening domestic violence was used on 165 pregnant females in a community based setting.

Results:

23% of pregnant women were screened positive for domestic violence. Physical hurt was present among 60% of victims of domestic violence. The predictors for domestic violence among pregnant women as derived from logistic regression were – educational status of head of the family/husband, substance abuse by husband and history of previous abortions.

Conclusion and Recommendations:

More emphasis should be given on well being of the pregnant women who are victims of domestic violence. The policy makers and program managers should integrate social welfare schemes with the RCH program and all levels of health care functionaries should be sensitized about dealing with victims of domestic violence. Laws should be implemented effectively against perpetrators of domestic violence and more importantly females should be made aware of such laws and should be motivated to report it to the legal authorities and not to take up violence for granted.

Umbilical Coiling Index Assessment During Routine Fetal Anatomic Survey: A Screening Tool for Fetuses at Risk

BACKGROUND

The umbilical cord is the lifeline of the foetus as it supplies water, nutrients, and oxygen. Protection of these blood vessels is needed and provided by Wharton's Jelly, amniotic fluid and the helical pattern, or coiling, of the umbilical cord vessels.

AIM

To establish the relationship between antenatal umbilical cord coiling index (aUCI) measured at 18-20 weeks along with level II USG and adverse perinatal outcomes.

METHODS

A cross-sectional study was conducted on 408 antenatal women, enrolled at the time of fetal anatomic survey, and their cord coiling index (aUCI) was measured, and its association with perinatal outcomes was observed. Umbilical coiling index was classified as Hypocoiled if UCI <10th percentile, hypercoiled >90th percentile, normocoiled between 10th and 90th percentile.

RESULTS

408 antenatal women were enrolled for the study. Mean aUCI was 0.43 ± 0.30 (normocoiled group), 0.18 ± 0.4 (hypocoiled), and 0.53 ± 0.05 (hypercoiled group). The average gestational age at delivery in hypocoiled group was 36.8 ± 2.34 weeks, and it was shorter than 38.3 ± 1.82 weeks of the normocoiled group and 38.9 ± 1.72 weeks of the hypercoiled group. Mean birth weight observed was 2055 ± 744 (hypocoiled group), 3049 ± 564 (hypercoiled), and 3102 ± 564 (normocoiled) p < 0.001. Preterm births 52 (59%) and low birth weight 76 (69%) were significantly associated with hypocoiling.

CONCLUSION

Abnormal umbilical cord coiling index, detected at the fetal ultrasound anatomic survey in the second trimester (18-20 weeks), can be used potentially as a screening or as a predictive tool for adverse antenatal or perinatal events.

Pregnancy-Associated Plasma Protein A Levels in Late First Trimester Pregnancies with Small-for-Gestational Age Neonates: A Prospective Case-Control Study

OBJECTIVE

We aimed to investigate the association of pregnancy associated plasma protein A (PAPP-A) levels in late first trimester with small for gestational age (SGA) neonates and adverse pregnancy outcomes in a low-income setting.

METHODS

The inclusion criteria were late first trimester (11-13 + 6 weeks) women with singleton and non-anomalous pregnancy. Enrolled participants were sampled for PAPP-A and prospectively followed up for delivery outcome and antenatal complications. A multiple of median (MoM) was calculated and statistically compared between groups.

RESULTS

Out of total 284 subjects, 14.54% delivered SGA babies and formed cases (Group A), 66.5% delivered appropriate for gestational age (AGA) neonates with uneventful antenatal period (controls, Group B), and 19.3% were AGA group with adverse pregnancy complications (Group C). The late first trimester median PAPP-A MoM was significantly lower (0.61) in Group A compared to Group B (1.47). Using receiver operating characteristic (ROC) curve for PAPP-A MoM, optimal cutoff value was found at 0.45 MoM, with positive predictive value of 56.2%, specificity of 92.6% and sensitivity of 45%. The median interquartile range (IQR) of PAPP-A MoM value in Group C in comparison with Group B was significantly lower except for abruption. At PAPP-A MoM cutoff value <1, <0.8, <0.6 and <0.4, the odds ratio for adverse pregnancy outcome was 8.30, 7.29, 10.97 and 10.60, respectively, indicating an inverse relationship.

CONCLUSION

With 0.45 MoM cutoff of PAPP-A, the detection rate, specificity and positive predictive value for SGA were 45, 92.6 and 56.2%, respectively. As PAPP-A MoM values decreased, the odds ratio of having adverse pregnancy outcomes increased.

Intestinal GIST masquerading as an ovarian mass: Diagnosed on FNAC

The preoperative diagnosis of metastatic intestinal gastrointestinal stromal tumors (GIST) on cytology can be quite difficult at times. The present case characterizes the cytomorphological and immunocytochemical features of GIST, emphasizing the utility of fine-needle aspiration cytology (FNAC) in the evaluation of spindle cell tumors of gastrointestinal tract. An accurate and early diagnosis of GIST affects the treatment, primarily allowing the use of tyrosine kinase inhibitors in unresectable or metastatic cases. Presence of highly cellular fragments of spindle-to-oval cells with variable degree of pleomorphism, atypia, and necrosis supplemented by immunocytochemistry can render a cytological diagnosis of GIST in dilemmatic clinical situations. Our case highlights the diagnostic role of FNAC in the evaluation of a pelvic mass, which was clinicoradiologically misdiagnosed as ovarian carcinoma.

Placental histopathological findings in preterm/term and early/late onset small for gestation age: Are they significant?

We undertook a prospective comparison of placental histopathological findings in preterm versus term and early onset versus late onset small for gestation age (SGA) to find more information on the etiological aspects of this disorder. A total of 130 women with nonanomalous SGA were allocated into preterm (n = 60); term (n = 70); early onset (n = 9) and late onset (n = 121) groups. The blinded intergroup placental histopathology comparison was performed both qualitatively (type of lesion) and quantitatively (number of the lesion). All SGA placentae showed varying number of maternal underperfusion (MUP), fetal under perfusion, inflammatory, and others lesions. There was a slight higher percentage of placenta having MUP in preterm and early onset SGA. Perivillous fibrin deposition was peculiar for placenta of preterm SGA (P = 0.043). Both preterm and early onset SGA had a higher number of placental lesions, but there was no statistical difference either in type or number of the placental lesion in any of the examined groups.

Long-term treatment of phenylketonuria with a new medical food containing large neutral amino acids

BACKGROUND/OBJECTIVES

Phenylketonuria (PKU) is an autosomal recessive disease caused by deficient activity of phenylalanine hydroxylase. A low phenylalanine (Phe) diet is used to treat PKU. The diet is very restrictive, and dietary adherence tends to decrease as patients get older. Methods to improve dietary adherence and blood Phe control are continuously under investigation.

SUBJECTS/METHODS

A new formula Phe-neutral amino acid (PheLNAA) has been tested in this study with the purpose of improving the compliance and lowering blood phenylalanine. The formula has been tested for nitrogen balance, and it is nutritionally complete. It is fortified with more nutritional additives that can be deficient in the PKU diet, such as B12, Biotin, DHA, Lutein and increased levels of large neutral amino acids to help lower blood Phe. The new formula has been tested on 12 patients with a loading test of 4 weeks.

RESULTS

Fifty-eight percent of patients had a significant decline in blood Phe concentration from baseline throughout the study. The PheLNAA was well tolerated with excellent compliance and without illnesses during the study.

CONCLUSIONS

In conclusion, the new formula is suitable for life-long treatment of PKU, and it offers the PKU clinic a new choice for treatment.

A Ten Year Audit of Maternal Mortality: Millennium Development Still a Distant Goal

OBJECTIVE

To assess various causes of maternal mortality over a ten year period.

DESIGN

Retrospective audit of hospital case records.

SETTING

Tertiary care hospital.

POPULATION

Pregnant women who expired in the premises of GTB Hospital.

MATERIALS AND METHODS

A retrospective audit of case records of maternal deaths was conducted for a ten year period (January 2005 to December 2014).

RESULTS

There were a total of 647 maternal deaths out of 1,16,641 live births. Sixty-eight percent (n = 445) of women were aged 21-30 years, while 10.5% (n = 68) were <20 years of age. The most common direct causes of maternal mortality were preeclampsia/eclampsia in 24.4% (n = 158), obstetric hemorrhage in 19.1% (n = 124) and puerperal sepsis in 14.5% (n = 94). With regards to indirect causes, anemia accounted for 15.3% (n = 99) mortality. There was only 1 (0.1%) mortality because of HIV/AIDS. Other notable causes of maternal mortality were infective hepatitis in 7.1% (n = 46). Tuberculosis, that is a disease of tropical countries, accounted for 3.0% (n = 20) of the total deaths.

CONCLUSION

High maternal mortality in GTB hospital can be due to it being a tertiary hospital with referrals from all neighbouring states. Accessible antenatal care can help prevent these maternal deaths. Female education can be of immense help in dealing with the problem and improving the utilization of public health facilities.

KEY MESSAGE

Preeclampsia/eclampsia and obstetric hemorrhage have been the main causes of maternal mortality for ages. Regular antenatal visits and the judicious training of grassroot level workers to pick-up complications early on in the pregnancy can be an effective way to deal the morbidity and mortality associated with these problems. The Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakaram (JSSK) in India are pioneer steps in this direction.

Value of "Three Dimensional Multidetector CT Hysterosalpingography" in Infertile Patients with Non-Contributory Hysterosalpingography: A Prospective Study

BACKGROUND

Infertility is a common health problem requiring imaging to delineate the anatomical causes in women. Three dimensional multi-detector computed tomography hysterosalpingography (3D-MDCT-HSG) offers an easy workup for uterine, tubal and peritoneal factors.

METHODS

To present the spectrum of uterine, tubal and peritoneal factors on 3D-MDCT-HSG and determine its diagnostic accuracy for female factor infertility, a prospective study was conducted on 25 infertile women with non-diagnostic HSG from November 2012 to March 2014. Sixty four slice MDCT acquired the scan during pre-ovulatory phase by contrast instillation into uterine cavity. A blinded reviewer interpreted the 3D-MDCT-HSG and results were compared with final diagnosis made on hystero-laproscopy in 22 patients. Diagnostic accuracy of 3D-MDCT-HSG for various factors was expressed as sensitivity, specificity, positive and negative predictive value.

RESULTS

MDCT-HSG demonstrated definite findings in 96% of patients having non-diagnostic HSG. In this study, tubal, uterine and peritoneal abnormalities were present in 68.75%, 56% and 32% of cases, respectively. 48 tubes in 25 patients were evaluated of which 22 tubes were blocked constituting the commonest finding present in 15 (60%) patients. The sensitivity, specificity, positive predictive value and negative predictive value for uterine factors was 83.33%, 100%, 100% and 96.84%, respectively, for tubal factors 93.55%, 94.68%, 85.29% and 96.83%, respectively and for peritoneal factors 62.5%, 92%, 71.43% and 88.46%, respectively. Mean effective radiation dose was 1.76±0.18 mSv in MDCT-HSG.

CONCLUSION

3D-MDCT-HSG can detect various factors responsible for female infertility especially tubal and uterine; in cases where HSG fails to clearly delineate the pathology.

Evaluation of Dehydroepiandrosterone Supplementation on Diminished Ovarian Reserve: A Randomized, Double-Blinded, Placebo-Controlled Study

INTRODUCTION

We conducted a randomized, double-blinded, placebo-controlled study, to evaluate the effect of dehydroepiandrosterone (DHEA), on diminished ovarian reserve (DOR).

MATERIALS AND METHODS

Twenty patients with DOR received DHEA (oral 25 mg three times a day). Post-supplementation 12 weeks, D2/3 age-specific follicle-stimulating hormone (FSH), anti-mullerian hormone (AMH) levels, and antral follicle count (AFC), were repeated to evaluate response. Spontaneous pregnancy rates and regularization of menstrual cycles were also studied as secondary outcome.

RESULTS

Predominant risk factors were age >35 years (28 %) and poor responders to ovarian stimulation (23 %). There was significant improvement of AMH levels (1.15 ± 1.49 vs. 1.53 ± 1.62) found before and after supplementation in the DHEA group. When the AMH values between DHEA and placebo group were compared, pre- and post-supplementation, no significant difference was found. There was decrease in FSH levels and increase in AFC value post-supplementation in both DHEA and placebo groups which was not statically significant. DHEA supplementation benefited clinically, as evidenced by the improvement in the menstrual abnormality spontaneous conception in two cases each.

CONCLUSIONS

A significant improvement in AMH levels pre- and post-supplementation of DHEA was noted. The same was not seen for FSH and AFC values.

To Evaluate the Efficacy of Combination Antioxidant Therapy on Oxidative Stress Parameters in Seminal Plasma in the Male Infertility

INTRODUCTION

Infertility is defined as inability to conceive after 1 year of unprotected intercourse and it affects 7% of male population and 8-10% of couples. According to estimates WHO, 13-19 million couples in India are infertile. Oxidative stress is the causative factor in 25% of infertile males.

AIM

To study the efficacy of antioxidant therapy on oxidative stress parameters in seminal plasma of infertile male.

MATERIALS AND METHODS

Forty patients of male infertility were enrolled in study after two abnormal semen analyses reports at 2-3 weeks interval, of oligozoospermia and/or asthenozoospermia, as per WHO guide line 1999. First semen sample was collected at a time of enrollment of study and second semen sample was collected three months after combined antioxidant therapy. Semen samples from the infertile male (the second confirmatory sample of oligoasthenozoospermia) were taken and after liquefaction semen sample were utilized for various analyses, 0.5 ml of sample for standard semen analysis, 1.2 ml sample for separation of seminal plasma to evaluate Oxidative stress (OS) parameters like Malondialdehyde (MDA), Protein Carbonyl (PC) and antioxidant capacity by Glutathione (GSH). We followed the patient for three months after completion of the treatment.

RESULTS

Semen parameters - Out of 40 patients recruited in the study group 7 patients had only oligospermia (1 to 20 million/ml) and 31 patients had oligoasthenozoospermia (motility range 0-50%) and 2 patients had oligoasthenoteratozoospermia. There was no patient with asthenospermia alone as abnormal semen parameters. After the three months treatment with combined antioxidants the semen parameters like count (mean SD = -1.70±1.44) and motility (mean +SD= -9.56±9.05) were significantly increased (p-value=0.000). Oxidative Stress Assessment - The level of MDA which is a marker of oxidative stress was significantly lower after the three months therapy of antioxidants (p-value=0.002) whereas another marker which is denoted by PC was also lower after the treatment but not statistically significant (p-value=0.584). The level of antioxidants GSH also significantly increased after the treatment (p-value=0.000). After the treatment out of 40, five patients conceived (16.7%).

CONCLUSION

As we have seen through this study antioxidant dramatically reduced the oxidative stress markers and enhancing the antioxidant enzymes. They should be used on routine basis in case of male infertility.

Spontaneous rupture of pyometra manifesting as an acute abdomen: a case report

Spontaneous perforation of pyometra is a rare entity with a reported incidence in the range of 0.01-0.05%. The clinical picture is similar to peritonitis arising from intestinal perforation and commonly the correct diagnosis is only made perioperatively. We report a case in an elderly postmenopausal woman presenting with an acute abdomen.

Pyoderma gangrenosum following a routine caesarean section: Pseudo-infection in a caesarean wound

A 22-year-old booked primigravida underwent lower segment caesarean section for breech presentation. She developed signs and symptoms of wound infection by the fourth postoperative day. This was initially managed with antibiotics and wound dressing, but debridement was later undertaken after consulting surgeons. This resulted in an alarming worsening of the wound with sudden and fast increase in its size along with systemic symptoms. Wound biopsy established the diagnosis of pyoderma gangrenosum. The patient's management included oral medication with prednisolone, cyclosporin and dapsone and wound care. There was a dramatic response to this treatment. The wound completely healed by the eighth postoperative month. The oral medications were tapered off slowly and stopped by that time.

Role of newer methods of diagnosing genital tuberculosis in infertile women

Genital tuberculosis is an important under-diagnosed factor of infertility. A vast majority of cases are asymptomatic and diagnosing them will help in treating such patients. We conducted a retrospective study in a tertiary care hospital of Delhi with an aim to compare different methods i.e., histopathological examination (HPE), acid-fast bacilli (AFB) smears, Lowenstein-Jensen (LJ) culture, BACTEC culture and polymerase chain reaction deoxyribonucleic acid (PCR-DNA) for diagnosing endometrial tuberculosis in infertile women. The data from 546 samples of endometrial biopsy histopathology, AFB smears and LJ culture was collected and then analyzed. Of these, HPE for tuberculosis was positive in 13, LJ culture in 10, AFB smear was positive in one case. BACTEC and PCR-DNA were feasible for 90 patients and PCR-DNA was positive in 20 and BACTEC in eight patients. Out of 20 patients with PCR positive results, 15 were only PCR positive and were subjected to hyster-laparoscopy and five had evidence of tuberculosis. Thus, none of the available tests can pick up all cases of genital tuberculosis, but conventional methods i.e., histopathology and LJ culture still has an important role in the diagnosis of endometrial tuberculosis in government setups where BACTEC and PCR are not performed routinely due to lack of resources.

Fallopian tube herniation: an unusual complication of surgical drain

Background. Surgical drains have been used since time immemorial, but their use is not without complications. By presenting this case we aim to describe an uncommon complication of herniation of fallopian tube following the simple procedure of surgical drain removal. Case Presentation. This case describes a 23-year G2P1L1 who underwent an emergency cesarean section for obstructed labor with intraperitoneal drain insertion. The patient had an uneventful postoperative period, drain was removed on day 4, and she was discharged. She presented on day 8 with the complaint of soakage of drain site dressing. On examination an edematous, tubular structure with early sign of necrosis was seen coming out of drain site and a provisional diagnosis of appendix herniation was made. On emergency laparotomy fallopian tube was seen coming out through the drain site and salphingectomy was done. Conclusion. Drains are not a substitute for good surgical technique. Although herniation of intestine, omentum, appendix, gall bladder, and ovary have been reported, we could not find any case of fallopian tube herniation in the literature searched by us.

Invasive Escherichia coli vaccines expressing Brucella melitensis outer membrane proteins 31 or 16 or periplasmic protein BP26 confer protection in mice challenged with B. melitensis

Because of the serious economic and medical consequences of brucellosis, efforts are to prevent infection of domestic animals through vaccines. Many disadvantages are associated with the current Brucella melitensis Rev.1 vaccine prompting development of alternative vaccines and delivery. Escherichia coli (DH5α) was engineered to express a plasmid containing the inv gene from Yersinia pseudotuberculosis and the hly gene from Listeria monocytogenes. These recombinant invasive E. coli expressing B. melitensis outer membrane proteins (Omp31 or 16) or the periplasmic protein BP26 were evaluated for protection of mice against virulent B. melitensis. Importantly, these invasive E. coli vaccines induced significant protection against B. melitensis challenged mice. Invasive E. coli may be an ideal vaccine platform with natural adjuvant properties for application against B. melitensis since the E. coli delivery system is non-pathogenic and can deliver antigens to antigen-presenting cells promoting cellular immune responses.

Effect of Helicobacter pylori eradication therapy in iron deficiency anaemia of pregnancy - a pilot study

BACKGROUND & OBJECTIVES

Despite routine iron supplementation and promotion of diet modification, iron deficiency anaemia (IDA) remains widely prevalent in our antenatal population. Recent studies in pediatric population have highlighted the role of Helicobacter pylori infection in IDA. This study was undertaken to study the effect of eradication therapy in H. pylori infected pregnant women with IDA.

METHODS

Randomized placebo-controlled double blind clinical trial was done on 40 antenatal women between 14-30 wk gestation, with mild to moderate IDA and having H. pylori infection, as detected by stool antigen test. These women were randomly divided into group I (n=20): H. pylori treatment group (amoxicillin, clarithromycin, omeprazole for 2 wk) and group II (n=20): placebo group. Both groups received therapeutic doses of iron and folic acid. Outcome measures were improvement in haematological parameters and serum iron profile after 6 wk of oral iron therapy.

RESULTS

The prevalence of iron deficiency in pregnant women with mild to moderate anaemia was 39.8 per cent (95% CI 35.7, 44.3); and 62.5 per cent (95% CI 52, 73) of these pregnant women with IDA were infected with H. pylori. After 6 wk of therapeutic oral iron and folic acid supplementation, the rise in haemoglobin, packed cell volume, serum iron and percentage transferrin saturation was significantly (P<0.05) higher in the group given H. pylori eradication therapy as compared to the placebo group.

INTERPRETATION & CONCLUSIONS

Our results showed a high occurrence of H. pylori infection in pregnant women with IDA. Eradication therapy resulted in significantly better response to oral iron supplementation among H. pylori infected pregnant women with IDA.

Pregnancy concomitant with metastatic adult granulosa cell tumor

INTRODUCTION

Metastatic adult granulosa cell tumor of the ovary is rarely encountered with pregnancy.

CASE REPORT AND RESULTS

Primigravida (26 years) presented at 20 weeks of gestation with acute abdomen and clinical evidence of supraclavicular lymphadenopathy and ascites. She was diagnosed of adult granulosa cell tumor (AGCT) of the right ovary following right salpingoophrectomy done 1 month prior to conception. Fine needle aspiration cytology of supraclavicular lymph node, revealed it to be a metastatic AGCT. Chemotherapy was given antepartum and she delivered a healthy preterm baby at 30 weeks. Subsequently, she had optimal debulking surgery following 6 cycles of cisplatin-based chemotherapy. Baby at 10 months of age was with normal milestones.

CONCLUSIONS

The case is an unusual presentation of metastatic adult granulosa cell tumor at child bearing age. Although rapidly progressing, successful prolongation of pregnancy till 30 weeks of gestation was possible with the judicious use of chemotherapy. Fetal and maternal outcomes were favorable.

Longitudinal vaginal septum 'obstructive variety'--a challenge for gynaecologist

The cases which have been presented here have varied presentations but all the three patients in the series had acyclical abdominal pain. Since the uterus is functional there is collection of blood in the pouch formed due to the vaginal septum. This is a potential site for infection and could result in foul smelling discharge. Failure of fusion of lower ends of mullerian ducts that form vagina results in longitudinal vaginal septum. The septum may be partial or complete. The clinical syndrome of double uterus with vaginal obstruction (unilateral, partial or complete) and ipsilateral renal agenesis (same as of the side of obstruction) is rare. This combination is suggestive of embryologic arrest occuring at 8 weeks of pregnancy that simultaneausly affected the mullerian and metanephric ducts.

Bilirubin oxidation provoked by nitric oxide radicals predicts the progression of acute cardiac allograft rejection

Bilirubin, a strong intrinsic antioxidant, quenches free radicals produced under inflammatory conditions. The oxidized bilirubin metabolites, i.e. biopyrrins, are immediately excreted into urine and can indicate the intensity of oxidation in vivo. Our preliminary studies suggested the involvement of reactive nitrogen species (RNS) in generation of biopyrrins. However, little is known about biological significance of bilirubin oxidation by RNS. Here, we analyzed the correlation between bilirubin oxidation and nitric oxide (NO) radicals during rat acute cardiac allograft rejection. In allograft recipients, urinary biopyrrins steeply increased on day 3 prior to the increase in myocardial tissue damage marker, serum troponin-T. In contrast, no significant changes in urinary biopyrrins were evident in recipients of isografts or cyclosporine-A treated allografts. Urinary nitrotyrosine, a marker of oxidation by NO radicals also increased on day 3, while administration of a NO synthase inhibitor, N(G)-monomethyl-L-arginine apparently diminished the elevation of urinary biopyrrins as well as nitrotyrosine. Immunohistochemistry revealed enhanced local expression of heme oxygenase-1, biopyrrins and nitrotyrosine in allografts in accordance with the cellular infiltrates, suggesting that changes in urinary biopyrrins reflect the bilirubin oxidation in grafts undergoing rejection. These results indicate that locally evoked bilirubin oxidation by NO radicals can predict the progression of rejection.