Ascorbic Acid Concentration and Preterm Premature Rupture of Membranes

Introduction

Preterm premature rupture of membranes (PPROM) complicates 1–5 % of all pregnancies and is the major contributory factor for perinatal morbidity and mortality. Micronutrient deficiency (vitamin C) is associated with increased risk of PPROM. This study was conducted to establish the association between maternal plasma vitamin C concentration in women with PPROM and women without PPROM and to study the difference in maternal morbidity, neonatal morbidity, and mortality.

Methods

A prospective study was conducted where 40 women (20 in each study and control group) with singleton pregnancies between 28 and 37 weeks gestation were recruited. Women with anemia, diabetes, UTI, RTI, vaginal infection, bleeding, h/o PPROM in previous pregnancy, polyhydramnios, and smoker were excluded from the study. Maternal plasma vitamin C levels were measured.

Results

Ascorbic acid levels were low in women with PPROM 0.41 ± 0.08 versus 0.84 ± 0.19 mg/dl. There is a linear decline in plasma vitamin C levels as the pregnancy advances. Inverse relationship was observed between duration of rupture of membranes and vitamin C levels. There was a significant difference in maternal morbidity, neonatal morbidity, and mortality.

Conclusion

Ascorbic acid concentration was low in women with PPROM. Thus, vitamin C supplementation should be made mandatory along with iron and calcium to antenatal women to avoid the complications of PPROM.     

Perinatal Outcome in Idiopathic Polyhydramnios

Objectives

To study perinatal outcome in idiopathic polyhydramnios.

Methods

Case–control study was conducted in 500 pregnant women with idiopathic polyhydramnios (study group) and 500 normal pregnant women (control group) attending the outpatient department of SHKM Medical College, Haryana. Perinatal outcomes were recorded in both the groups.

Results

Out of 500 cases with idiopathic polyhydramnios, maximum cases were diagnosed between 28 and 36 weeks of pregnancy (84.6 %), and maximum presented with mild polyhydramnios (82 %). In the study and control groups, there were no statistically significant differences in preeclampsia and gestational hypertension (p = 0.445 and p = 0.230). In the study and control groups, 74.6 and 79.6 % women, respectively, had normal vaginal delivery (p = 0.250). The study group recorded much higher number of preterm deliveries than the control group (54 %) (p = 0.000). In the study group, 51.8 % women had maternal complications, while in the control group, 13.6 % women had obstetrical complications. The study group recorded higher perinatal mortality (10.4 %) than the control group.

Conclusions

Idiopathic polyhydramnios is associated with higher perinatal morbidity and mortality than normal pregnancy.     

Evaluation of Obstetric Near Miss and Maternal Deaths in a Tertiary Care Hospital in North India: Shifting Focus from Mortality to Morbidity

Objective

Near miss audit improves understanding of determinants of maternal morbidity and mortality and identifies areas of substandard care. It helps health professionals to revise obstetric policies and practices.

Methods

A retrospective review of obstetric case records was performed to assess frequency ad nature of maternal near miss (MNM) cases as per WHO criteria. For each case, primary obstetric complication leading to maternal morbidity was evaluated. Obstetric complications were analyzed to calculate prevalence ratio, case fatality ratio, and mortality index.

Results

There were 6,357 deliveries, 5,273 live births, 247 maternal deaths, and 633 MNM cases. As per WHO criteria for Near miss, shock, bilirubin >6 mg%, and use of vasoactive drugs were the commonest clinical, laboratory, and management parameters. Hemorrhage and hypertensive disorders of pregnancy were leading cause of MNM (45.7 and 24.2 %) and maternal deaths (28.7 and 21.5 %). Highest prevalence rate, case fatality ratio, and mortality index were found in hemorrhage (0.53), respiratory diseases (0.46), and liver disorders (51.9 %), respectively.

Conclusion

Developing countries carry a high burden of maternal mortality and morbidity which may be attributed to improper management of obstetric emergencies at referring hospitals, poor referral practices, and poor access/utilization of health care services.     

Maternal and Perinatal Outcome During Expectant Management of Severe Pre-Eclampsia Between 24 and 34?Weeks of Gestation

Objective

To determine the maternal and perinatal outcome after expectant management of severe pre-eclampsia between 24 and 34 weeks of gestation.

Method

The maternal and fetal status was monitored by an intensive, non-invasive method among 94 women with severe pre-eclampsia between 24 and 34 weeks of gestation who were scheduled for expectant management in the OICU at a tertiary care center. Pregnancy prolongation and maternal and perinatal morbidity and mortality were analyzed by the Student ‘t’ test and the Mann–Whitney U test.

Results

The days of pregnancy prolongation and perinatal mortality were significantly higher among those managed at <30 weeks. Increasing gestational age correlated with a reduction of RDS. Maternal morbidities were significantly higher among those managed at <28 weeks. But, there was no maternal mortality.

Conclusion

Expectant management of severe pre-eclampsia at 30–34 weeks in a tertiary care center of a developing country is associated with good perinatal outcome and risk reduction for the mother.     

Successful Pregnancy Outcome Following Conservative Management of Morbidly Adherent Placenta

Objective

To determine the prevalence and impact of placental malaria on maternal and fetal outcome.

Design

Cross sectional observational.

Setting

The Department of Obstetrics of Government NSCB Medical College Hospital, Jabalpur (Madhya Pradesh).

Population

Five hundred parturient women with fever or history of fever during the present pregnancy.

Method(s)

Subjects were tested for peripheral and placental malaria by thick and thin smear examination. Maternal and perinatal outcome correlated with malaria results.

Results(s)

The mean age of the studied subjects was 24.5 ± 2.6 years, 60.6 % were primigravida, 87.2 % had unsatisfactory antenatal care. 89.2 % were not using effective malaria prevention measures. Peripheral smear positivity for malaria was detected in 1.8 % subjects and placental malaria positivity in 2.2 % subjects. The mean Hb was lower in malaric subjects (χ² = 14.47, p < 0.05). Maternal mortality and prematurity was significantly higher in malaria +ve subjects (p < 0.001). The mean birth weight in malaria +ve subjects was significantly less (p < 0.001). Poor 5 min APGAR (p < 0.0001) and perinatal mortality (p < 0.05) was significantly more common in malaria +ve subjects.

Conclusion(s)

Malaria, particularly placental infestation with malarial parasites significantly increases maternal and perinatal morbidity and mortality.     

Safety and Efficacy of Oral Mifepristone in Pre-induction Cervical Ripening and Induction of Labour in Prolonged Pregnancy

Objective(S)

To study the safety and efficacy of oral mifepristone in pre-induction cervical ripening and induction of labour in prolonged pregnancy.

Method(S)

This is a single blind randomized control trial. 100 women with prolonged pregnancy beyond 40 weeks and Bishop score <6 were recruited, and randomly allocated into two groups. Women who received Tab. Mifepristone 200 mg orally were assigned in Study Group (n = 50) and who received placebo orally were assigned in Control Group (n = 50) At the end of 24 h, change in the Bishop’s score was assessed and Tab. Misoprostol 25 μg was administered intravaginally every 4 h, maximum 6 doses for induction/augmentation of labour. Analysis regarding safety and efficacy of the drug was done with regards to maternal and perinatal outcome.

Result(S)

Among 100 subjects, 50 received mifepristone and 50 received placebo. Mean induction to delivery interval was 1,907 ± 368.4 min for Study Group versus 2,079 ± 231.6 min for Control Group. The improvement in mean Bishop score was 5.0408 ± 1.90 for Study Group compared with 3.26 ± 1.15 was for Control Group after 24 h. Mean dose of misoprostol in Study Group was 40 ± 27.2, while the same in Control Group was 52 ± 19.46. Eight (16 %) women in Study Group and two (4 %) women in Control Group delivered vaginally within 24 h without any need of augmentation. There were 6 (12 %) cesareans and 2 (4 %) instrumental deliveries in Study Group and 8 (16 %) cesareans and 5 (10 %) instrumental deliveries in the Control Group. There was no statistically significant difference in perinatal outcomes between two groups.

Conclusion(S)

Mifepristone had a modest effect on cervical ripening when given 24 h prior to labour induction and appearing to reduce need for misoprostol compared with placebo.     

Risk Factors for Macrosomia

Objective

To identify risk factors for macrosomic babies.

Methods

This cross-sectional analytical study was carried out in the University Teaching Hospital and the Central Hospital of Yaoundé (Cameroon) from October 1st, 2012 to March 31st, 2013. Women who gave birth to ≥4,000 or 3,000–3,499 g babies were recruited. Variables recorded were fetal sex and birth weight, gestational age, maternal age, parity, mother’s body mass index (BMI), weight gain during pregnancy, previous macrosomia, and father’s BMI. Fisher exact test and student t-test were used for comparison. Level of significance was P < 0.05.

Results

Main risk factors for macrosomia are delivery of a previous macrosomic baby (OR 13.1), maternal weight gain ≥16 kg (OR 10.2), parity ≥3 (OR 4.8), father’s BMI ≥30 (OR 3.7), male sex (OR 2.2), and post-term (OR 1.9).

Conclusion

Father’s obesity should be added among the known risk factors for macrosomia.     

Perinatal outcomes for transfer of blastocysts vitrified and warmed in defined solutions with recombinant human albumin: 374 babies born after 898 embryo transfers

Purpose

To assess the efficacy of a novel, defined vitrification procedure using recombinant human albumin (rHA) for cryopreservation of human blastocysts. Design: Retrospective study. Setting: Private IVF clinic. Patients: 1,496 patients received vitrified/warmed embryo transfer (ET).

Methods

Surplus blastocysts, and blastocysts from patients undergoing elective embryo cryopreservation, were vitrified/warmed using Cryotop carriers in homemade solutions containing either human serum albumin (HSA) or rHA. Main Outcome Measures: Clinical and neonatal outcomes regarding the vitrified/warmed ET procedures.

Results

The HSA and rHA groups had a total of 1,163 and 898 vitrified/warmed cycles, respectively. Embryo survival rates (98.7 % vs. 98.9 %, respectively) and the number of embryos transferred (1.08 ± 0.01 vs. 1.06 ± 0.01, respectively) were similar in the HSA and rHA groups. Clinical pregnancy rates/ET were higher (P < 0.05) in the rHA group (56.0 %) than in the HSA group (51.5 %). The HSA and rHA groups had similar live delivery rates/pregnancy (72.2 % vs. 72.3 %, respectively) and perinatal outcomes, including birth weight (2,988 ± 28 vs. 3,046 ± 26 g, respectively). Birth defects occurred in 0.9 % and 1.6 % of neonates in the HSA and rHA groups, respectively.

Conclusions

rHA effectively replaced HSA for human embryo vitrification procedures, and yielded high rates of pregnancy and live births after vitrified/warmed ET. This new approach will support the development of defined ART systems, which will eliminate the variation and risks associated with the use of blood-derived products.     

A New Maneuver for Prevention of Postpartum Haemorrhage

Background

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. Many methods have been developed to decrease its rate. The aim of this study was to evaluate the applicability of a new non-pharmacologic maneuver in decreasing its rate.

Methods

This case series study was conducted in one center in Cairo, Egypt, from January-2010 to June-2013. 400 pregnant women, aged 18 years or more and candidate for normal labor, were enrolled to this study. High risk subjects for PPH were excluded. After placental delivery, the new maneuver was done by sustained traction of the anterior and posterior lips of the cervix by two ovum forceps for duration of 90 s. The amount of blood loss was estimated by standardized visual estimation after removal of the forceps. All subjects were followed up for 6 h.

Results

The rate of PPH, defined as more than 500 ml, was eight cases (2 %) with 95 % CI (0.63–3.37 %). The rate of PPH was not affected by parity, gestational age, episiotomy, or the presence of tears. PPH is more in cases with anemia (p 0.032). It occurred in all cases with uterine atony (p < 0.001). The range of estimated blood loss was 550–600 ml in cases with PPH and 150–450 ml in cases without PPH. Severe PPH more than 1,000 ml did not occur.

Conclusion

This pilot study introduced a novel maneuver that can be helpful in decreasing the rate of PPH and reducing the amount of postpartum blood loss. Further RCT is recommended to investigate it.     

KAP Studies Among Indian Antenatal Women: Can We Reduce the Incidence of Anemia?

Aim

To study the knowledge, attitude, and practices of antenatal women regarding nutrition and drug compliance in a maternal and child health center in Navi Mumbai.

Material and Methods

This study was carried out on 250 pregnant females visiting a maternal and child health center over a period of 4 months from November 2012 to February 2013. Women attending the antenatal OPD were asked to fill a questionnaire regarding anemia so as to test their knowledge, attitudes, and practices pertaining to anemia and role of their diet.

Observation

The observations were analyzed. This study reflects the ignorance and lack of education among the majority of child-bearing women of low socioeconomic class.

Conclusion

Educating antenatal women about the importance of diet and implementing this into practice will help in the prevention of anemia. It is also seen that drug compliance for iron and folic acid (free supply) has significantly improved, not only because of the cost factor but also due to the reinforcement of knowledge by the staff so as to achieve the minimum WHO target hemoglobin of 10.5 g% in all mothers.

Electronic supplementary material

The online version of this article (doi:10.1007/s13224-014-0618-0) contains supplementary material, which is available to authorized users.     

Pregnancy in Women Aged 35 Years and Above: A Prospective Observational Study

Abstract

Pregnancy is affected by maternal age from conception till delivery. Various studies have been conducted globally to study this effect; few in developing countries. Maternal age is increasing in developing countries as well, so we have conducted this study.

Method

This was a prospective observational study consisting of 1,263 women booked at Jehangir hospital during a period of 2 years, fulfilling inclusion criteria and consenting for the study. They were divided into two groups; women aged 35 years and above and women less than 35 years of age. Pregnancy outcomes were studied in terms of antepartum, intrapartum and postpartum complications. Neonatal outcomes were studied in terms of birth weight and NICU admissions. Data was analyzed statistically using statistical package for social sciences version 17, by applying Chi square test and Fisher exact test. A p value below 0.05 was considered significant.

Results

Women aged 35 years and above constituted 9.63 % of the total study population. Most were multigravidae. Rate of assisted conception was significantly higher among women aged 35 years and above; early pregnancy loss was also high in this group. Pre-eclampsia and abruption were significantly higher among them. Neonatal outcomes were comparable.

Conclusion

Women with advanced maternal age are at higher risk of complications from conception till delivery and should be provided close supervision for better pregnancy outcome.     

Morbidly Adherent Placenta: A Critical Review

Objective

To evaluate the demographic profile, high risk factors, fetomaternal outcome and management options in morbidly adherent placenta (MAP).

Study Design

Retrospective analysis.

Methodology

Review of 20 case records of women with MAP during year 2001–2006.

Results

The mean age and parity of the women was 27.7 ± 4.2 years and 2.5 respectively. 70 % women had previous uterine scar, and similar number had placenta previa. 60 % women presented with antepartum hemorrhage and 20 % with retained placenta. 85 % women underwent hysterectomy with 5 % requiring internal iliac artery ligation, another 5 % partial cystectomy and 15 % bladder repair. Blood loss was between one and nine litres requiring an average of six units whole blood and 4 units FFP. There were six (30 %) maternal deaths. 55 % of the newborns were preterm and the perinatal mortality was 33.3 %.

Conclusion

Cesarean section and placenta previa are significant risk factors. MAP is associated with high fetomaternal morbidity and mortality.     

Risk Factors Associated with the Malignant Changes of Symptomatic and Asymptomatic Endometrial Polyps in Premenopausal Women

Objective

This study aimed to evaluate the prevalence of premalignant and malignant lesions of symptomatic and asymptomatic endometrial polyps among premenopausal women and to verify whether different clinical parameters, and polyp volume and number are associated with a more precise estimate of malignancy.

Methods

One hundred and fifty women aged 29–52 years and with certain diagnosis of endometrial polyp were enrolled in a prospective observational study. The recruited patients underwent hysteroscopic polypectomy based on saline infusion sonohysterography and diagnostic hysteroscopy. Pathologic report was the main outcome.

Results

Among women with endometrial polyps, 62 % had asymptomatic polyps. The prevalence of premalignant and malignant polyps comprised 4.6 % of cases (3.3 % hyperplasia with atypia and 1.3 % carcinomatous polyps). The presence of abnormal uterine bleeding was not a predictor of premalignant and malignant changes in the polyp. On logistic regression analysis, the premalignant and malignant lesions were influenced by polycystic ovary syndrome (p < 0.001; OR 4.61; CI 1.9–27), polyp volume >10 ml (p < 0.001; OR 5.83; CI 4.31–9.17), and multiple polyps (p = 0. 01; OR 2.05; CI 1.09–3.76). Notably, the odds ratio of polyp volume >10 ml was 5.83. This additional risk confirms the importance of polyp volume in the detection of malignant transformation rather than associating bleeding in premenopausal women.

Conclusion

Polycystic ovary syndrome, polyp volume greater than 10 ml, and increased polyp number represent the markers of risk for premalignant and malignant transformation of endometrial polyps in premenopausal women. Nonetheless, the majority of polyps are asymptomatic, and the risk of malignancy is very low. Therefore, for women with polyp volume ≤10 ml and no risk factors, a more expectant approach may be warranted in order to reduce surgical risks and costs.     

Risk of Malignancy Index (RMI) in Evaluation of Adnexal Mass

Background

The discrimination between benign and malignant adnexal masses is central to decisions regarding clinical management and surgical planning in such patients.

Purpose of Study

To determine if the RMI (RMI 2) can distinguish between benign and malignant adnexal masses.

Methods

A prospective cohort study was conducted of 58 women with an adnexal mass referred to a teaching hospital for diagnosis and management.

Results

RMI > 200 had a sensitivity of 70.5 % (95 % CI 46.87–86.72), a specificity of 87.8 % (95 % CI 74.46–94.68), a positive predictive value of 70.5%, and negative predictive value of 87.8 %. ROC showed that cut off value of 25 achieved a sensitivity and specificity of 82.35 and 43.9 %, respectively, and a cut off value of 1,000 gave a sensitivity and specificity of 58.81 and 97.56 %, respectively. The association between RMI and disease status was not statistically significant for mucinous tumors.

Conclusion

RMI is a reliable tool in differentiating benign from malignant adnexal masses. It is simple, easy to use and cost effective. However it’s predictive accuracy was less for mucinous as compared to serous epithelial ovarian cancers. The study is limited by its small sample size.     

Pregnancy Complicated by Maternal Heart Disease: A Review of 281 Women

Objectives

To study maternal heart disease in an Indian setting for: (1) different etiological factors, (2) different types of lesions, and (3) maternal and perinatal outcome.

Methods

281 women with heart disease who delivered ≥28 weeks of gestation at different teaching institutions (tertiary care centres) in India were studied.

Results

Rheumatic heart disease (n = 195; 69.4 %) with isolated mitral stenosis (n = 75; 26.7 %) were the commonest. Septal defect (n = 27; 9.6 %) was the predominant lesion among the congenital heart disease (n = 60; 21.3 %) patients, whereas in the miscellaneous group (n = 26; 9.2 %), ischemic heart disease (n = 10; 3.6 %) was the leading cause. Multiple cardiac lesions were also diagnosed in 100 (35.58 %) women. In 87 (31 %) women, diagnosis was made first time in labor. Majority n = 131, (46.6 %) had spontaneous vaginal delivery and few (n = 9; 3.3 %) required induction of labor. Cardiac complications were noted in 72 women (25.6 %). There were three (1.06 %) maternal deaths and perinatal mortality was 4 % (n = 11).

Conclusion

In this study, rheumatic heart disease in pregnancy is still predominant though acquired cardiac lesions are rising. In rheumatic heart disease, mitral valve involvement was the commonest and multiple valve lesions were a major observation. Most common obstetric complication was small for gestation baby. Maternal morbidities in the unbooked women are high and congestive cardiac failure was the major cardiac complication.     

Emergency Peripartum Hysterectomy: A 13-Year Review at a Tertiary Center in Kuwait

Objective

To determine the incidence, indications, risk factors, and complications of emergency peripartum hysterectomy (EPH) and to evaluate total versus subtotal hysterectomy for EPH.

Materials and Methods

This is a retrospective case series involving thorough examination of the files of all women who had EPH between January 2000 and December 2012 in the department of Obstetrics and Gynecology, Al-Jahra hospital, Kuwait after taking approval from the ethics committee. Incidence, indications, risk factors, type of hysterectomy, and complications of EPH were obtained from patient files.

Results

There were 63,337 deliveries of which 70.3 % were vaginal deliveries, and 29.6 % were by cesarean section (CS). Sixty-eight women underwent EPH representing an overall incidence of 1 case per 1,000 deliveries. The indications for EPH included abnormal placentation (77.4 %), uterine atony (14.5 %), and uterine rupture (8.1 %). There was one maternal death. Maternal morbidity occurred in 25 (40.3 %) women. The most common complications were mild to severe coagulopathy (19.35 %) and injury to the urinary tract (17.74 %). Injury to the ureter was avoided by placing ureteric stents preoperatively. Our population was significant in having higher rate of CS deliveries (91.9 %), women with prior CS (83.87 %), and high parity (mean 5.8).

Conclusion

Abnormal placentation was the most common indication to perform EPH. The relative risk of EPH was 27 for CS deliveries as compared to vaginal deliveries. There was no significant difference between subtotal versus total hysterectomy with respect to age, parity, previous CS, operative time, blood transfusion, and intra and post operative complications.     

Maternal Mortality and Its Causes in a Tertiary Center

Objectives

To study the maternal mortality and the complications leading to maternal death.

Methods

A retrospective study of hospital records and death summaries of all maternal deaths over the period from January 2000 to August 2009 was carried out.

Results

There were a total of 80 maternal deaths out of 88,443 live births giving maternal mortality rate (MMR) of 90.45 per 100,000 live births. Unbooked and late referral accounted for 77.5 % of maternal deaths. The majority of the deaths was in 30–40-year age group and around term. Hemorrhage was the commonest cause of death (52.5 %), followed by sepsis (13.75 %) and pregnancy-induced hypertension including eclampsia (10 %).

Conclusions

Hemorrhage, sepsis, and pregnancy-induced hypertension including eclampsia were found to be the direct major causes of death. Anemia and cardiac disease were other indirect causes of deaths.     

Trends in Maternal Mortality and Impact of Janani Suraksha Yojana (JSY) on Maternal Mortality Ratio in a Tertiary Referral Hospital

Objective

To analyse the impact of Janani Suraksha Yojana (JSY) on Maternal Mortality Ratio (MMR).

Design

Retrospective analysis of maternal mortality.

Methods

Analysis of all maternal deaths between January 2001 and December 2009.

Results and Discussion

The total number of deliveries has been steadily rising from 1,685 in 2001 to 3,957 in 2009. The MMR doubled from 1,500/100,000 live births in 2001 to 3,000/100,000 live births in 2006, then declined to 2,464/100,000 live births in 2009. Implementation of the various maternity benefit schemes has had no significant impact on the profile of dying mothers—admission-to-death interval. Deaths due to anemia and eclampsia have significantly increased (P < 0.05), whereas due to sepsis (P < 0.001) and hemorrhage (P < 0.05), deaths have significantly decreased. Almost 96 % of dying subjects received inadequate antenatal care. However, significantly less number (P < 0.001) of women are delivering at home.

Conclusions

There is a need to stress the importance of good antenatal care in reducing MMR.