Association of plasma Decorin levels and markers of glycocalyx disruption with adverse events in women with severe preeclampsia

Identifying preeclamptic women with an increased risk of severe maternal complications can aid in timely interventions to optimize pregnancy outcomes. Newer biomarkers such as Decorin and markers of endo glycocalyx disruption were assessed in earlier studies for its role in predicting preeclampsia, but their role in identifying those with adverse maternal outcomes is limited. This study aimed to evaluate the association of these biomarkers with adverse maternal outcomes in women with severe pre-eclampsia. Markers of glycocalyx disruption may be further explored for their role along with clinical features and other biomarkers in identifying women at higher risk of maternal complications.

Performance of microscopy compared to conventional PCR in identification of soil-transmitted helminth infections among antenatal women in a low-prevalence setting

PURPOSE

Traditional microscopy-based methods may provide inaccurate estimates of Soil transmitted helminth (STH) infections in mild intensity of infection. Therefore, we aimed to determine the prevalence of STH infections using molecular diagnostic methods and compare the diagnostic performance of microscopy with polymerase chain reaction (PCR) in stool samples collected from pregnant women in primary care settings in Puducherry, India.

METHODOLOGY

A singleplex PCR assay was developed to detect three species of STHs, namely Ascaris lumbricoides, Necator americanus, and Ancylostoma duodenale, by targeting the internal transcribed spacer regions (ITS1 and ITS2) of 5.8S rRNA. The PCR generated 420, 662, and 515 base pairs of DNA for the respective organisms. In addition to singleplex PCR, wet and concentration microscopy techniques were used. The results were expressed as percentages with 95% confidence intervals, and the diagnostic performance of microscopy was compared with PCR in terms of sensitivity, specificity, and positive, negative predictive values and kappa statistics.

RESULTS

Among the 650 pregnant women included, 48.8% were aged 25 years or less, 59% were primigravida, and half were from rural areas. The overall prevalence of any STH infection was higher in PCR compared to microscopy (8.9% vs. 7.2%). The prevalence of Ascaris lumbricoides was higher by microscopy (5.4% vs 2.6%), while the prevalence of Necator americanus was higher by PCR (6.3%) than by microscopy (1.8%). No species of Ancylostoma duodenale was detected. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of microscopy for detecting any STH infection was 22.4%, 94.3%, 27.7%, and 92.5%, respectively. The agreement between microscopy and PCR for the identification is as follows: for any STH infection, k ​= ​0.12, Ascaris k ​= ​0.16, and Necator k ​= ​0.20, respectively.

CONCLUSION

The prevalence of any STH infection identified by PCR was higher than microscopy, and the agreement between the two methods was poor.

Factors Associated with Perinatal Mortality in Adult Pregnant Women with Hypertensive Disorders: A Case-Control Study

Background

Hypertension complicates 5-10% of pregnancies and is a common cause of perinatal death. The perinatal mortality is estimated to be 3 to 5 times higher in hypertensive women compared to those without hypertension.

Methods

A hypertensive mother either with a stillbirth or if baby died within 7 days of life was included as a case. Once a case was recognized, the next two consecutive hypertensive mothers who delivered a live baby, who survived up to 7 days of life, were taken as controls. Fetuses with congenital malformations incompatible with life and multiple pregnancies were excluded from the study. One hundred and twelve women in cases and 224 women in controls were studied.

Results

Among 112 cases of perinatal death, 70% had died in utero before labor. Among the 33 fetuses alive, 50% were born still after labor and 50% died within 7 days of birth. We found that early onset hypertension (< 34 weeks) (p-< 0.001 (Chi2-23.819)), gestational age at termination of 28-32 weeks (OR 2.76), value of serum creatinine > 1.1 mg/dl (OR 10.1), abruption (OR 6.2) and birth weight < 1.5 kg was significantly associated with perinatal mortality (p-0.007, OR 5.7). Abnormal Doppler findings was a predictor of perinatal deaths.

Conclusion

Severely growth retarded fetuses in association with early onset severe preeclampsia are likely to die in utero and need vigilant monitoring antenatally. Abnormal umbilical artery Dopplers predict perinatal mortality. Caesarean section at the gestational age of ≥ 32 weeks and an estimated fetal weight of ≥ 1.2 kg in our hospital resulted in favorable outcome.

Comparison of Vaginal Birth Rate between Induction of Labour and Expectant Management at 40 Weeks in Women with a Previous Caesarean Section: A Pilot Randomized Controlled Trial

Background

The optimum time of labour induction among women with a previous caesarean without any pregnancy complication and eligible and willing for vaginal delivery is not specified. This study compares the vaginal birth rates between induction at 40 weeks and expectant management till 41 weeks.

Method

We conducted this parallel design nonblinded, randomized controlled trial in a tertiary care teaching institution in South India on women with a previous lower segment caesarean section eligible for a trial of labour with singleton foetus without any pregnancy complication at recruitment. We screened 1886 women. Sixty women underwent block (of 6 each) randomization into two groups of thirty each at 40 weeks. We induced the women in the intervention group at 40 weeks with oxytocin or a single 24-hour application of a Foley catheter followed by oxytocin infusion and amniotomy. The expectant group underwent maternal and foetal surveillance and induction at 41 weeks with the same protocol if not delivered by then. We compared the primary outcome of the proportion of vaginal birth rate with a chi-square test.

Result

Data from all sixty women were analyzed. Twenty (66.67%) in the induction compared to ten (33.33%) in the expectant group delivered vaginally. This difference was significant (RR 2.0, 95% CI: 1.13-3.52; P = 0.016). One woman in the expectant group had scar dehiscence.

Conclusion

Among women with a previous caesarean scar, labour induction at 40 weeks has a significantly higher vaginal birth rate than those managed expectantly till 41 weeks. More extensive trials are feasible and recommended. Trial Registry. The trial was prospectively registered with the clinical trial registry of India. This trial is registered with CTRI/2018/09/015719 (date of registration 14th September 2018).

Effect of the timing of insertion of postpartum intrauterine contraceptive device (PPIUCD) copper T380A on expulsion rates

Background & objectives

Postpartum intrauterine contraceptive device (PPIUCD) is well accepted and recommended for contraception. However, anxiety at the time of delivery may restrict the acceptance of a PPIUCD for its immediate insertion. So far there is limited evidence to conclude anything concrete on the association between the expulsion rates and the timing of insertion following a vaginal delivery. Thus, this study was undertaken to compare the expulsion rates in immediate and early insertions and their safety and complications.

Methods

This prospective comparative study was carried out over 17 months on women delivering vaginally in a tertiary care teaching hospital in South India. A copper device (CuT380A) was inserted using Kelly's placental forceps either within 10 min of placental delivery (immediate group, n=160) or between 10 min upto 48 h postpartum (early group, n=160). Ultrasound was done before discharge from the hospital. The expulsion rates and any other complications at six-week and three-month follow up were studied. Chi-square test was used to compare the difference in expulsion rates.

Results

The expulsion rate was five per cent in the immediate compared to 3.7 per cent in the early group (no significant difference). In ten cases, the device was found to be in the lower uterus upon ultrasound before discharge. These were repositioned. There was no case with perforation, irregular bleeding or infection up to the three-month follow up. Higher age, higher parity, lack of satisfaction and motivation to continue were predictors of expulsion.

Interpretation & conclusions

In the present study PPIUCD was found to be safe with overall expulsion in 4.3 per cent. It was marginally, though not significantly, higher in the immediate group.

Primary aldosteronism during pregnancy and eplerenone use – a case report

Primary aldosteronism is one of the important causes of secondary hypertension. However, pregnancy with primary aldosteronism is rare. Eplerenone is an aldosterone antagonist which is used in the treatment of primary aldosteronism. This is a case of successful pregnancy outcome in a young woman who was known to have primary aldosteronism and was on oral eplerenone from preconception. There are only five case reports on eplerenone use during pregnancy in the literature.

Adverse Neonatal Outcomes and Associated Antenatal Risk Factors - A Matched Case-Control Study from a Tertiary Care Hospital, South India

Introduction

The incidence of neonatal mortality has declined over the past few decades, but it remains a major concern. Identifying risk factors associated with adverse outcomes may help prevent and manage neonatal morbidity and mortality. The study aimed to explore the associated antenatal risk factors among pregnant women delivering in a tertiary care hospital in South India with adverse neonatal outcomes.

Material and Methods

This was a hospital-based, matched case-control study among pregnant women belonging to Puducherry and admitted for delivery. Cases were pregnant women who gave birth to adverse neonatal outcomes, while controls were pregnant women who gave birth to alive and healthy babies. Data was collected from various sources, primarily from medical records, and triangulated.

Results

Adverse neonatal outcomes were ten times more if pregnant women had placental complications and seven times more for intrauterine growth restriction noted during pregnancy. Pregnant women referred from peripheral care centers had 1.6 times more risk of adverse neonatal outcomes. Prior hospital admission during the present pregnancy had a protective effect in the final adjusted analysis.

Conclusion

Risk factors should be routinely monitored in all health centers. Women with high-risk pregnancies should be identified earlier, and appropriate care should be provided.

Comparison of respiratory distress syndrome amongst preterm twins (28-34 Weeks) born within and after two weeks of completion of single antenatal corticosteroid course: A bidirectional cohort study

BACKGROUND

The literature on neonatal outcomes in preterm twins delivered before 34 weeks but within and after 14 days of a single initial steroid course is limited.

MATERIAL AND METHODS

This bidirectional (226 prospective and 42 retrospectives) cohort study was performed at a tertiary care teaching hospital in South India. We compared the respiratory distress syndrome and neonatal death amongst preterm twins from 28 to 34 weeks born < 14 days (Group A, n=268) and after 14 days (Group B, n=268) of completion of a single course of antenatal steroids. We used multivariable regression analysis (log-binomial model) to adjust for confounding variables. We generated a propensity-matched score with probit regression to analyse outcomes (respiratory distress and neonatal deaths).

RESULTS

The two groups had significant differences in the distribution of birthweight, gestation period and mode of delivery. On adjusted analysis, the period of gestation below 33 weeks and weight below 1.5 kg had the maximum influence on respiratory and other morbidities, and weight less than 1 kg on neonatal death. [adjusted relative risk (ARR) 26.06, (95%CI=2.37-285.5), p=0.008]. On propensity scoring after matching all these variables, we found an [ARR of 2.0 (95% CI: 1.03-3.88), P=0.017] for neonatal death after 14 days of steroid injection. The ARR for respiratory distress syndrome was 1.13 in those born after 14 days of steroids, though it did not reach statistical significance.

CONCLUSION

On propensity scoring, the steroid-delivery interval more than 14 days was associated with a significantly increased risk (ARR of 2) of neonatal death.

Malakoplakia of Endometrium with Osseous Metaplasia on Evaluation of Postmenopausal Leukorrhea: A Rare Case Report

Malakoplakia is a chronic xanthogranulomatous condition that affects the genitourinary tract reported earlier as urinary granulomas and pelvic masses. We report a different clinical manifestation of malakoplakia presenting as postmenopausal pyometra. A 64-year-old postmenopausal female presented with foul-smelling vaginal discharge with a past history of induced abortion, followed by dilatation and evacuation. On examination, abdomen was soft, vaginal examination revealed pus discharge, parous size uterus with free fornices, and pap smear ruled out malignancy. Ultrasonography revealed linear, echogenic structures in the endometrial cavity suspicious of bony spicules with fluid around. Hysteroscopy revealed congested endometrium with multiple pieces of shredded bone-like structures that were removed followed by curettage. Histopathological examination was suggestive of malakoplakia with osseous metaplasia. Retained bony spicules can cause chronic granulomatous inflammation that may become symptomatic postmenopause due to absent cyclical shedding. This is the first reported case of malakoplakia of uterus following retained bony spicules.

'I was scared I will end up in another abortion': a mixed-methods study assessing the impact of COVID-19 pandemic and lockdown on the antenatal care of pregnant women in Puducherry, South India

BACKGROUND

As a mitigation measure for COVID-19 pandemic, lockdown was implemented in India for a period of 2 months (24 March-31 May 2020). Disruption in antenatal care (ANC) provisions during lockdown is expected due to diversion of public health facilities on pandemic.

OBJECTIVE

To assess the proportion of pregnant women who had not completed the ideal number of antenatal visits, availability of iron-folic acid (IFA) supplements and challenges in availing health services during the period of lockdown.

METHODS

A concurrent mixed-methods study was conducted among pregnant women in Puducherry, India. Information on obstetric characteristics and details regarding antenatal visits were collected through telephonic interviews. In-depth interviews were conducted to understand the perceived challenges in availing health services during the lockdown period.

RESULTS

Out of 150 pregnant women, 62 [41.3%; 95% confidence interval (CI) 33.6-49.3] did not complete the ideal number of visits and 61 (40.7%, 95% CI 32.7-49.0) developed health problems. Out of 44 women who received medical care for health problems, 11 (25%) used teleconsultation. Of all the women, 13 (8.7%, 95% CI 4.9-14.0) had not taken the IFA supplements as prescribed by the health provider. Economic hardship, restricted mobility, lack of information about the health system changes and psychological stress due to the fear of COVID were the challenges in accessing care.

CONCLUSIONS

Two out of five pregnant women did not complete the ideal number of visits and developed health problems during the lockdown period.

Pelvic organ prolapse in a woman with previous mitrofanoff operation: Management of a case

Mitrofanoff operation or vesico-appendicostmy is a continent conduit operation performed for intractable incontinence. The long-term complications reported in the literature are related to the stoma. Pelvic organ prolapse among women who have undergone this surgery is not reported earlier. A woman of 27 years of age presented with uterovaginal prolapse. She had sustained bladder neck transection following a road traffic accident at 16 years of age. The same was primarily repaired but incontinence had remained. Many standard operations for incontinence were performed. Finally, Mitrofanoff operation was carried out 9 years back because of persisting intractable incontinence. She got married and had two uneventful vaginal deliveries 5 and 2 years back. There was supravaginal elongation of the cervix with a rectocele. After counseling Fothergills operation with laparoscopic ligation was performed. The challenges and details of the management of the case are highlighted.

Risk stratification for venous thrombosis in post-partum women in a tertiary care setup in south India

Background & objectives

The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines for thromboprophylaxis among post-partum women are recommended across Asia. This study was aimed to find the proportion of post-partum women eligible for thromboprophylaxis based on the RCOG guidelines and how many actually received it in a tertiary care health facility in south India.

Methods

This cross-sectional study was carried out on 1652 consecutive women who delivered in the setup of tertiary care. Risk stratification for venous thrombosis was done as per the RCOG guidelines. The number of women who received thromboprophylaxis was also noted.

Results

Among the 1652 women studied, three [0.18%; 95% confidence interval (CI): 0.06-0.53] were in the high-risk, 598 (36.2%; 95% CI: 33.9-38.6) in the intermediate and 254 (15.4%; 95% CI: 13.7-17.2) in the low-risk category for thrombosis. All the three women in the high-risk and only two women in the intermediate-risk category actually received thromboprophylaxis with heparin.

Interpretation & conclusions

It was seen that the number of women needing prophylaxis in our setup, as per the RCOG guidelines, was as high as 601 (36.4%), but only five (0.8%) received it.

Experiences and Felt Needs of Women During Childbirth in a Tertiary Care Center: a Hospital-Based Cross-Sectional Descriptive Study

BACKGROUND

Childbirth experience is unique to every woman. Negative experience is detrimental to both mother and child. This study was undertaken to understand the positive and negative experience and felt need of women undergoing labor and the factors affecting them.

METHODOLOGY

This cross-sectional descriptive quantitative study was conducted among women who delivered in JIPMER and consented to participate through a questionnaire that captured four areas of childbirth experience. The study was carried out before the LaQshya guidelines were implemented.

RESULTS

Three hundred and seventy women completed the study. The mean age of women in this study was 24.5 years and 60% were primipara. Five women (1.3%) experienced physical abuse. Another 47 (12.7%) experienced disrespect in the form of scolding/insult/discrimination or nonconsented care. Three-fourths of the women wanted a relative (majority preferred their mother) with them, and 54% wanted a prayer hall in the labor room. On univariate analysis, no significant determinant was found for negative experience constituting disrespect and abuse. Complete pain relief as a need was found to be significantly higher (X2 = 11.0783, p < 0.004) in women of lower parity. The women educated beyond scholastic level felt that information given about delivery is inadequate when compared to participants who were illiterate or had primary education only.

CONCLUSIONS

In our hospital 12.7% women undergoing labor experienced disrespectful behavior and 1.3% experienced physical abuse. Need for prayer hall, complete pain relief and presence of relative was felt by more than half of the participants. We did not find any specific factor influencing the negative experience.

The diagnostic dilemma of a pregnant woman presenting with an isolated sixth nerve palsy: A case report

Pregnant women presenting with isolated cranial palsies are uncommon. Isolated sixth nerve (abducens nerve) palsy can occur for a variety of reasons and neuroimaging is often performed to identify an underlying cause. We report a case of a woman in her third pregnancy with preeclampsia who presented with an isolated sixth nerve palsy. The diagnosis of aseptic cavernous sinus thrombosis was made and she subsequently made a full recovery.

Decreased maternal serum adiponectin and increased insulin-like growth factor-1 levels along with increased placental glucose transporter-1 expression in gestational diabetes mellitus: Possible role in fetal overgrowth

INTRODUCTION

The placental glucose transporter - 1 (GLUT-1) is involved in the transplacental glucose transport to the fetus. GLUT-1 expressions are increased in diabetic pregnancies and associated with altered fetal growth. However, the factors regulating the GLUT-1 expressions are largely unknown. We hypothesised that maternal adipokines and insulin-like growth factor-1 (IGF1) modulate the placental expressions of GLUT-1 through the activation of insulin/IGF-1 signalling which may contribute to a fetal overgrowth in GDM.

METHODS

Maternal blood, cord blood and placental samples were collected from GDM and control pregnant women (CPW). The biochemical parameters, IGF1, adipokines, and high sensitive C- reactive protein were measured. We analysed the placental expressions of GLUT-1 and proteins related to insulin/IGF-1 signalling - insulin receptor -β, insulin receptor substrate - 1, phosphatidylinositol-3-kinase p110α, phospho Akt-1, phospho extracellular signal-regulated kinase 1/2, and nuclear factor-κB p65 in GDM and CPW.

RESULTS

Increased maternal IGF-1 and decreased adiponectin levels were found in the GDM women. Maternal IGF-1 levels were positively correlated, whereas adiponectin levels were negatively correlated with the birth weight of GDM newborns. Increased phosphorylation of Akt and ERK 1/2 was found in the placenta of GDM women. Placental expressions of GLUT-1 were significantly higher in the GDM women and positively correlated to the maternal IGF-1 levels in the GDM group.

DISCUSSION

Decreased maternal adiponectin and increased IGF-1 levels might have caused increased GLUT-1 expression via the increased activation of insulin/IGF-1 signalling in the placenta of GDM women which might have influenced the fetal growth.

Cystic Uterine Endosalpingiosis in a Patient with Carcinoma Endometrium

Endosalpingiosis is a benign condition characterized by the presence of tubal-type epithelial cells outside the Fallopian tube. It may rarely involve the uterus and present as a cystic or tumor-like mass. We report an unusual case of cystic uterine endosalpingiosis in a postmenopausal female with carcinoma endometrium. Preoperative and intraoperative diagnosis of this condition is challenging. Awareness about this condition in clinicians may help in preventing misdiagnosis and overtreatment.

Increased hepcidin levels in preeclampsia: a protective mechanism against iron overload mediated oxidative stress?

Background: Pregnancy is a metabolic state which demands increased iron bioavailability. While in preeclampsia, due to the placental vascular events there is an iron surplus environment along with inflammation and placental hypoxia. Routinely in India iron is supplemented to all pregnant women irrespective of their general physical condition. Hepcidin a regulator of iron metabolism protects the cells from iron mediated cytotoxicity.Objective: To find out whether hepcidin gets induced as a protective mechanism in preeclampsia patients in order to combat the environment of iron overload, oxidative stress, and endothelial dysfunction.Methods: A cross-sectional study with follow up was carried out in a South Indian Tamil population. Forty healthy pregnant women and forty preeclampsia patients in the gestational age 32 ± 4 weeks were recruited (n = 80). Biochemical analysis to assess the serum levels of the following were carried out (1) indices of iron homeostasis - serum iron, ferritin, transferrin, hepcidin, (2) endothelial dysfunction -serum assymetric dimethyl arginine (ADMA) (3) oxidative stress - Malon di aldehyde (MDA) and ferric reducing ability of plasma (FRAP). Kolmogorov-Smirnov test, Mann-Whitney U test, Spearman's correlation, linear regression and ROC^AUC analysis were performed to understand their relationship with each other.Results: Levels of serum iron, ferritin, transferrin saturation, hepcidin, and MDA/FRAP ratio were elevated significantly in preeclampsia patients compared to controls, while serum transferrin levels were significantly decreased in them. Hepcidin levels showed a significant positive correlation with serum ADMA, and MDA/FRAP. Serum hepcidin, transferrin saturationand MDA/FRAP ratio is useful in differentiating pre-eclampsia patients from healthy pregnant women.Conclusion: Iron supplementation in preeclampsia patients might have led to a state of iron overload, which might have caused oxidative stress and endothelial dysfunction in preeclampsia patients. The rise in hepcidin levels in this scenario may be viewed as a protective mechanism to combat the iron overload mediated cytotoxicity.

Placental Accumulation of Triacylglycerols in Gestational Diabetes Mellitus and Its Association with Altered Fetal Growth are Related to the Differential Expressions of Proteins of Lipid Metabolism

INTRODUCTION

Gestational diabetes mellitus (GDM) exhibit altered placental lipid metabolism. The molecular basis of this altered metabolism is not clear. Altered placental expression of proteins of lipogenesis and fatty acid oxidation may be involved in the placental accumulation of triacylglycerols (TG). The present study was aimed at investigating the differential expressions of placental proteins related to lipid metabolism among GDM women in comparison with control pregnant women (CPW) and to correlate them with maternal and fetal lipid parameters as well as altered fetal growth.

MATERIALS AND METHODS

Maternal blood, cord blood, and placental samples were collected from GDM and CPW. The biochemical parameters, glucose, lipid profile and free fatty acids (FFA) were measured. The placental TG content was measured. Differential placental expressions of proteins; phosphatidylinositol-3-kinase (PI3K) p85α, PI3K p110α,liver X receptor alpha (LXRα), sterol regulatory element binding protein1(SREBP1), fatty acid synthase (FAS), stearyl CoA desaturase1 (SCD1), lipoprotein lipase (LPL),Peroxisome proliferator-activated receptor (PPAR)α and PPARγ were analysed by western blotting and immunohistochemistry.

RESULTS

Placental protein expressions of PI3K p110α, LXRα, FAS, SCD1, and LPL were found to be significantly higher, whereas PPARα and PPARγ were lower in GDM women compared with CPW. The placental TG content and cord plasma FFA were increased in GDM women compared with CPW. The placental TG content positively correlated with Ponderal index of GDM new-borns.

CONCLUSION

Differential expressions of placental proteins related to lipid metabolism in GDM might have led to placental TG accumulation. This might have contributed to the fetal overgrowth in GDM.

Recurrent leiomyoma of the vulva mimicking peripheral nerve sheath tumour

Leiomyoma, a benign monoclonal tumour, is very rarely found in extrauterine sites, especially in the vulval region. Histopathology of the soft tissue tumours affecting this region is similar and immunohistochemistry (IHC) may be essential to confirm the diagnosis. We report a case of a 63-year-old postmenopausal woman who presented with a recurrent vulval mass involving the clitoris and left labia majora with suspected urethral involvement. Although the wedge biopsy was reported as peripheral nerve sheath tumour, staining with smooth muscle actin clinched the diagnosis of leiomyoma, highlighting the importance of IHC for diagnosis.

Diagnostic ability of hepcidin in predicting fetal outcome in preeclampsia

Background: Low birth weight and prematurity are the major contributors to neonatal mortality and morbidity. Preeclampsia which is associated with both maternal and fetal mortality and morbidity is a major contributor to such poor fetal outcomes. Hepcidin an acute phase peptide hormone gets elevated in conditions of iron overload, inflammation, infections, and cytotoxicity. Hepcidin levels can get elevated in pregnancies with such pathologies which invariably will be having a poor fetal outcome.Objective: To study the role of hepcidin as a diagnostic marker in predicting a poor fetal outcome.Materials and methods: A cross-sectional study with follow up was carried out in a South Indian Tamil population. Forty healthy pregnant women and forty preeclampsia patients were recruited between the gestational age of 34 ± 4 weeks and followed up till delivery. Serum levels of hepcidin were analyzed for all the participants and comparisons were done between preeclampsia and healthy pregnancies as well as between pregnancies with good and poor fetal outcomes. Fetal outcome variables such as birth weight, gestational age at the time of delivery and NICU admission status of the newborn were collected during the follow-up period. ROC curves were constructed to determine the ability of maternal serum hepcidin levels in predicting poor fetal outcomes with good sensitivity, specificity and likelihood ratios.Results: Maternal hepcidin levels were found to be significantly elevated in preeclampsia patients (p < .001) as well as in mothers with the poor fetal outcome (p < .001). On ROC curve analysis, AUC were 0.686, 0.788, 0.749 and LR + were 2.18, 2.44, 2.14, respectively for predicting low birth weight, preterm delivery and NICU admission status of the newborn. Hepcidin was able to predict the overall poor fetal outcome in our preeclampsia patients above a cut off level of 615 pg/mlConclusion: Above a cut off level of 615 pg/ml and at the gestational age of 34 ± 4 weeks, maternal hepcidin levels were able to predict poor fetal outcomes such as low birth weight, preterm delivery, and NICU admission.

Increased placental expressions of nuclear factor erythroid 2-related factor 2 and antioxidant enzymes in gestational diabetes: Protective mechanisms against the placental oxidative stress?

OBJECTIVE

Gestational diabetes mellitus is associated with increased oxidative stress. Oxidative stress may contribute to the risk for pregnancy pathologies associated with gestational diabetes mellitus. In this study we investigated the expression of placental nuclear factor erythroid 2-related factor 2 (Nrf2) and antioxidant enzymes of gestational diabetes mellitus and healthy pregnant women and correlated them with the maternal and cord plasma as well as placental tissue oxidative stress parameters.

STUDY DESIGN

A cross sectional study was carried out in a South Indian Tamil population. Forty healthy pregnant women and forty gestational diabetes mellitus patients in the gestational age of 32 ± 4weeks were recruited. Maternal plasma, cord plasma and placental oxidative stress parameters were measured. Placental expression of Nrf2, phospho Nrf2, catalase and superoxide dismutase 1(SOD1) were analyzed by western blotting and immunohistochemistry.

RESULTS

Placental expression of Nrf2, catalase and SOD1 were found to be significantly higher in gestational diabetes mellitus. The maternal plasma, cord plasma and placental tissue oxidative stress parameters, total antioxidant status (TAS) levels were significantly lower; whereas MDA (malondialdehyde) and MDA/TAS levels were significantly higher in gestational diabetes mellitus. Placental Nrf2 expression correlated positively with the placental catalase expression and negatively with placental TAS levels in both groups.

CONCLUSION

Maternal, fetal and placental oxidative stress was observed in gestational diabetes mellitus. The gestational diabetic placenta had an increased Nrf2 protein expression. The activated placental Nrf2/ antioxidant response element (ARE) pathway might have led to an increased expression of antioxidant enzymes SOD1 and catalase. This may be viewed as a protective mechanism in placenta from the further onslaught of oxidative stress.

Adipokine levels and their association with insulin resistance and fetal outcomes among the newborns of Indian gestational diabetic mothers

OBJECTIVES

To investigate the cord blood levels of adipokine and to assess their association with the fetal insulin resistance and fetal outcomes in newborns of gestational diabetic women (GDM). Methods: This cross-sectional study was performed in 40 GDM women and 40 healthy pregnant women (HPW) in the Department of Obstetrics and Gynecology at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) hospital in Puducherry, India, during the period from May 2016 to December 2017. Cord blood samples were collected at delivery from GDM and HPW groups. Cord plasma biochemical parameters such as insulin, C-peptide, adiponectin, leptin, resistin, and visfatin concentrations were measured. Leptin/adiponectin ratio (L/A), homeostasis model assessment of insulin resistance (HOMA2-IR), insulin sensitivity (HOMA2-%S) and beta cell function (HOMA2-%B) were calculated. The pregnancy outcomes such as birth weight (BW), Ponderal index and Apgar scores of the baby were measured. Results: The BW and Ponderal index of the baby were found to be significantly higher in GDM newborns compared to HPW newborns. Cord plasma insulin, C-peptide, HOMA2 -IR, visfatin, leptin, and L/A ratio were significantly higher whereas adiponectin level was lower in GDM compared to HPW. A significant positive correlation was observed between L/A ratio and fetal HOMA2-IR. Conclusion: Altered adipokine levels with increased L/A ratio was observed among the new-borns of Indian gestational diabetic mothers. There was an association between increased L/A ratio, insulin resistance and increased Ponderal index among the new-borns.

Management of vulvar lymphedema of filarial origin in a pregnant woman and its outcome: A case report

Lymphedema of filarial origin affecting the vulva is extremely rare. It is a dilemma if seen in a pregnant woman as there are no guidelines regarding excision and the mode of delivery. With the World Health Organization-driven global program to eradicate filaria, it is unfortunate to see such cases. We report of a woman who had massive lymphedema of both the labia majora following filarial infection with a small secondary ulcer. She presented to our outpatient department in early pregnancy. After detailed counseling with the couple, a decision was taken for excision. The same was carried out. The wound healed well but the lymphedema recurred after 6 weeks. She was thereafter managed symptomatically. Pregnancy advanced without any complication. Her intrapartum management for a successful vaginal delivery is outlined in the report.

Sertoliform Endometrioid Carcinoma of Ovary Presenting as Abdominal Wall Abscess

Sertoliform endometrioid carcinoma (SEC) is a rare epithelial ovarian cancer which may be mistaken for sex cord tumour on microscopy. Immunohistochemistry and extensive sampling of tumour to look for areas of conventional endometrioid carcinoma are important to confirm the diagnosis of SEC. We report a case of SEC of ovary in a postmenopausal lady who presented to us with abdominal wall abscess in epigastric region.

Continuous wound infiltration of bupivacaine at two different anatomical planes for caesarean analgesia - A randomised clinical trial

Background and Aims:

Continuous wound infiltration of local anaesthetics provide postoperative analgesia by peripheral nociceptors blockade.The placement of wound infiltration catheter in the optimal anatomical plane of surgical wound may play a significant role in reducing postoperative pain depends on the surgical procedure. We hypothesised that preperitoneal infusion of local anaesthetics will reduce the postoperative opioid consumption as compared to subcutaneous infusion following cesarean section.

Methods:

This was a randomised, double-blinded clinical trial. Fifty-two pregnant women who underwent lower segment caesarean section by Pfannensteil incision, under spinal anaesthesia, were randomised to group 'subcutaneous’ and group ’preperitoneal’. A wound infiltration catheter was placed in the subcutaneous or preperitoneal plane, depending on their randomisation at the end of the surgery. Bupivacaine of 0.25% at 5 mL/h was infused for the next 48 h. Pain was assessed using numerical rating scale at 1, 2, 3, 4, 5, 6, 12, 24, 36 and 48 h after surgery. Cumulative postoperative consumption and adverse effects of morphine and complications of the procedure were looked for.

Results:

Cumulative 48-h morphine consumption showed no statistical significance between the preperitoneal group (15.96 ± 7.69 mg) and subcutaneous group (21.26 ± 11.03 mg); P = 0.058. Pain score was comparable. Independent T-test and Mann–Whitney test were the statistical tests used for continuous and categorical data, respectively.

Conclusion:

Postoperative cumulative morphine consumption and pain scores are comparable when bupivacaine is infused continuously through wound infiltration catheter either in the preperitoneal or subcutaneous layer following Caesarean delivery.

Effect of Antenatal Steroids on Respiratory Morbidity of Late Preterm Newborns: A Randomized Controlled Trial

OBJECTIVE

The objective of this article was to study the effect of antenatal dexamethasone on the respiratory morbidity of late preterm newborns.

STUDY DESIGN

A randomized controlled trial, conducted in Obstetrics and Gynecology Department in collaboration with Neonatology department at JIPMER, India. In total, 155 women were studied in each group. Intention to treat analysis and per protocol analysis were done.

RESULTS

Overall 31 (10%) newborns were admitted to intensive care unit. The composite respiratory morbidity (defined as respiratory distress syndrome and/or transient tachypnea of newborn) was observed in 64 (41.6%) infants in the study and 56 (36.2%) infants in the control group. On multivariable-adjusted analysis, use of steroids was not found to be associated with decrease in composite respiratory morbidity [adjusted relative risk 0.91 (95% confidence interval: 0.7-1.2)].

CONCLUSIONS

Antenatal dexamethasone does not reduce the composite respiratory morbidity of babies born vaginally or by emergency cesarean to women with late preterm labor.

Management of aortic aneurysm presenting during pregnancy: A case report

Aortic aneurysm in pregnancy is associated with higher risk of complications due to the stress induced by the physiologic changes in pregnancy. Many of the reports are concentrated on those with catastrophic outcomes or who underwent surgical repair during pregnancy/puerperium. We report a case of aortic aneurysm, who presented during the second trimester and had a successful pregnancy outcome, and discuss the various issues concerning the management during pregnancy.

Malignant Peripheral Nerve Sheath Tumor of the Pelvic Retroperitoneum Misdiagnosed as Carcinoma Ovary

A 52-year-old postmenopausal female was found to have a large solid cystic adnexal mass, compressing the right ureter, and was suspected to have carcinoma ovary. However, it turned out to be a retroperitoneal neurogenic tumor. Malignant peripheral nerve sheath tumors (MPNST) may have cystic areas and may be misdiagnosed as ovarian tumors. Treatment of MPNST involves complete surgical excision of the tumor with a wide margin.

Tobacco use, exposure to second-hand smoke among pregnant women and their association with birth weight: A retrospective cohort study

Background:

There is paucity of studies on prevalence of SHS among pregnant women and its association with low birth weight (LBW).

Objectives:

The study was designed to determine the proportion of tobacco use, exposure to second hand smoke among pregnant women and their association with LBW.

Materials and Methods:

A Retrospective cohort study was conducted from March–June 2017 among 1043 pregnant women admitted for delivery in the Department of Obstetrics and Gynecology, JIPMER. Socio-demographic and obstetric characteristics, tobacco use and exposure to SHS during pregnancy were assessed by interviews. Birth weight of the baby was also extracted. Data was analysed using STATA v12. Univariate analysis was used to assess the association of socio-demographic, obstetric characteristics and exposure to SHS with LBW.

Results:

Out of 1043 pregnant women, the mean age was 25 (±3.9) years. More than half (57.4%) of women were primigravida. The proportion of women exposed to SHS during pregnancy was 69.9% (95% CI: 67.0-72.6) among which 24% of the women belonged to family, where family members were smokers. Only four had ever used tobacco in the past. However, none used any form of tobacco during pregnancy. LBW was present in 21.4% of the babies. There was no association between exposure to SHS and LBW [PR:0.98 (95% CI:0.71-1.35)].

Conclusion:

The study shows that there was no significant association between the SHS exposure of pregnant women and low birth weight.

Fetal inflammatory response syndrome (FIRS) and outcome of preterm neonates - a prospective analytical study

OBJECTIVES

To estimate the incidence of fetal inflammatory response syndrome (FIRS) in preterm neonates and correlate it with immediate and one-year neurodevelopmental outcome.

MATERIALS AND METHODS

This prospective observational analytical study, in preterm neonates with gestational age between 26 and 34 weeks was conducted from May 2014 to December 2015 in a tertiary care hospital in South India. FIRS was defined as the presence of either elevated levels of interleukin-6 (IL-6) in cord blood ≥11 pg/ml and/or the placental histopathology showing evidence of fetal inflammatory response. One hundred and twenty neonates were recruited. During delivery 2 ml cord blood for interleukin-6 and placenta were collected and stored appropriately. Based on presence/absence of FIRS (IL-6 in cord blood ≥11 pg/ml and or features of placental fetal inflammation), neonates were grouped into two groups. The neonatal and maternal characteristics between two groups were compared. The short-term outcome parameters during NICU stay and neurodevelopmental outcome at one year of corrected age was compared between groups.

RESULTS

Among the 120 infants studied, 19 expired. Out of 101 babies discharged, 87 were followed up till corrected 1 year of age. On examination of placenta and cord blood, 50 neonates had evidence of FIRS (41.6%). So there were 50 neonates in FIRS and 70 in NO-FIRS group. The mean gestational age, birth weight, and gender distribution were comparable between the two groups. Mortality [OR: 2.44 (CI: 1.14-5.26)] and early hypotension [OR: 2.13 (CI: 1.1-4.2)] were significantly higher in the FIRS group. The neurodevelopmental assessment at corrected age of 1 year showed that infants with FIRS had lower mean motor developmental quotient by developmental assessment scale for Indian infants (DASII) [87.6 ± 9.15 versus 93.07 ± 9.3, p < .04].

CONCLUSIONS

FIRS has a significant role on survival and neurodevelopmental outcome of preterm infants.

Virilization in a Postmenopausal Female Due to Androgen Secreting Ovarian Dermoid Cyst

Virilizing ovarian dermoid cysts are very rare. The source of androgen in these cysts may be tumors such as Sertoli–Leydig cell tumor or Leydig cell hyperplasia. A 52-year-old postmenopausal female with virilization was found to have an ovarian dermoid cyst on ultrasound. Her serum testosterone levels were elevated. Leydig cell hyperplasia within the dermoid cyst was found to be the source of androgen in this patient.

Chronic non-healing sinus manifesting in episiotomy scar: hidden fistula-in-ano

A non-healing sinus manifesting in an episiotomy scar after it has healed is rare. We report one such woman. There were no underlying risk factors like third- or fourth-degree tear or inflammatory bowel disease. In spite of previous attempted exploration the problem had persisted. Examination of the case under anaesthesia revealed it to be a low fistula-in-ano. The methodical evaluation and management of the case is detailed. Fistulectomy completely cured the patient. Most of these patients present to obstetricians and gynaecologists. Awareness and a high index of suspicion of communication with the anorectal canal are important. A team approach with the colorectal surgeon would help in better preoperative counselling, planned evaluation and definitive procedure to completely cure the patient.

Can treatment for polycystic ovarian disease induce ovarian tumour? A case report

Polycystic ovarian disease in adolescents is not uncommon. Usually underlying ovarian tumours can cause hirsutism and ovulation. A 15-year-old girl presented with infrequent cycles and hirsutism. Her baseline evaluation ruled out ovarian tumour and other endocrinological problems. She was treated with insulin sensitizers and hormone treatment. After more than a year of treatment she developed a large ovarian tumour which turned out to be a juvenile granulose cell tumour at laparotomy a year after treatment with insulin sensitizers. The authors recommend continued surveillance of ovaries of adolescent girls undergoing treatment for polycystic ovarian disease to monitor for formation of ovarian tumours.

Undiagnosed xiphopagus twins: a perinatal malady

Conjoined twins are a very rare entity. It is associated with poor survival rate in the presence of vital organ sharing. The entity can be diagnosed as early as the first trimester. A conjoined twin diagnosed late in labor is a malady with high perinatal mortality and maternal morbidity. We present one such case of xiphopagus twins. The management of a case diagnosed late in labor can be very challenging. Such obstetric challenges can be avoided by a meticulous early scan with a high index of suspicion, especially in the absence of separating membrane while scanning multiple pregnancies.

Urological injuries during hysterectomies: A 6-year review

AIM

Urological injuries that occur during hysterectomy are a rare but important cause of morbidity. An understanding of the risk factors can help us to reduce their incidence and studying their management and outcome could help us to evolve optimal management strategies. The aim of the present study was to examine the incidence of urological injuries that occur during hysterectomy and to determine the risk factors, management and outcome of such injuries.

METHODS

A retrospective analysis of cases of urological injuries sustained during hysterectomies carried out from June 1996 until May 2002, at our institution. The chi-squared test was applied for statistical analysis.

RESULTS

The overall incidence of urological injuries was 0.40% (0.28% bladder and 0.12% ureteral). No ureteral injuries occurred during vaginal surgery. The incidence of bladder injury was significantly higher in non-descent vaginal hysterectomies compared with abdominal hysterectomies or vaginal hysterectomies for genital prolapse (P<0.05). Hysterectomy for ovarian malignancies had a significantly higher risk for bladder injuries compared with other indications. Bladder injuries detected during vaginal hysterectomies could be managed through the vaginal route. All the repairs healed successfully.

CONCLUSIONS

Non-descent vaginal hysterectomy and hysterectomy for ovarian malignancies have a higher risk of bladder injury. Urological injuries during hysterectomy are uncommon. Early detection and appropriate management ensure successful healing and minimal long-term sequelae.