Outcome of Gestational Diabetes Mellitus from a Tertiary Referral Center in South India: A Case–Control Study

Background

Carbohydrate intolerance is the most common metabolic complication of pregnancy. Gestational diabetes mellitus (GDM) poses numerous problems for both mother and fetus. The objective of this study was to compare the maternal and perinatal outcome between women with gestational diabetes mellitus and non-diabetic women.

Study Design

A case–control study with 286 cases and 292 age-matched controls was conducted for a period of 11 months (August 2007–June 2008) in Sree Avittom Thirunal Hospital, Thiruvananthapuram, India.

Materials and Methods

Universal screening was applied by means of glucose challenge test (GCT) using 50 g of glucose. If GCT >130 mg%, the patients were subjected to oral glucose tolerance test with 100 g of glucose. National Diabetes Data Group criteria was taken to assign patients to study group. These women were further followed up and the maternal and perinatal outcomes were assessed.

Statistical Analysis

Univariate analysis was done by means of t test, Odd’s ratio, Chi-square test, and Fisher Exact test. P < 0.05 was taken as significant.

Results

The frequency of induction of labor was significantly higher than spontaneous labor (OR = 1.84, P = 0.001). 40.1 % GDM mothers and 35.8 % of non-diabetic mothers were delivered by Cesarean section. Premature rupture of membranes (PROM) was the most common complication of labor (OR = 1.66, P = 0.04). Babies of diabetic mothers had a positive trend toward prematurity (OR = 2.3, P = 0.007). Hypoglycemia was the most common neonatal complication (OR = 11.97, P < 0.001) and nine babies of diabetic mothers were macrosomic (OR = 5.2, P = 0.02).

Conclusions

Maternal morbidities and neonatal complications such as neonatal hypoglycemia, macrosomia, and prematurity were significantly higher in GDM.     

Risk Assessment at 11–14-Week Antenatal Visit: A Tertiary Referral Center Experience from South India

Background

Present study carried out in a tertiary referral hospital in South India attempts to determine the predictive value of integrated screening at 11–14-week antenatal visit.

Objectives

To determine the detection rate of fetal abnormalities at 11–14 weeks and also to predict the placental dysfunction disorders based on early integrated evaluation.

Method

Integrated screening performed on 440 women between 11 and 14 weeks, including detailed maternal history [medical history, bad obstetric history (BOH)], body mass index (BMI), mean arterial pressure (MAP), detailed ultrasound and maternal serum biochemistry as part of combined first-trimester screening for aneuploidy.

Results

There were two proven Down’s syndrome foetuses; both detected with combined screening test. There were 12 fetuses with major anomalies, out of whom 7 (58.3%) detected in 11–14-week scan. Among 440, 114 pregnancies (25.9%) developed complications in pregnancy, including 33 (7.5%) gestational hypertension, 8 (1.8%) pre-eclampsia, 41 (9.38%) SGA, 13 (2.9%) abortions, 22 (5%) indicated and 9 (2.04%) spontaneous preterm deliveries, 38 (8.63%) GDM and 3 (0.6%) stillbirth/IUD. Among the risk factors, age >35 years, BMI >23 kg/m², BOH, MAP >105 mmHg and PAPP-A <0.5 MoM correlated well with adverse outcome. Using early integrated screening, 78.9% of obstetric complications could be predicted although 306 (69.5%) were labeled high risk, among whom 90 (29.4%) developed adverse pregnancy outcomes.

Conclusions

Majority of fetal abnormalities can be detected, and majority adverse pregnancy outcomes can be predicted at 11–14-week antenatal visit, although this study shows high screen positivity and low specificity in a tertiary referral unit.

     

Prevention of Parent to Child Transmission of HIV (PPTCT): An Effort of 4 Years in a Tertiary Centre

Objective

The aim of this study was to see the fetomaternal outcome of pregnancy in HIV positive mother.

Methods

This study was conducted in the department of OBGYN Medical College Kolkata from 1st January 2004 to 31st December 2007, a period of 4 years since the establishment of PPTCT centre in our institution. All the pregnant women attending the antenatal clinic for consultation and those coming directly to labour room for delivery (unbooked cases) were counseled for HIV testing, informed consent was obtained and blood samples collected for HIV testing. Babies of HIV positive women delivered were followed up to 18 months for testing.

Results

The no. of women detected positive were 28, 53, 69 and 98 (total 248) in the consecutive years. Therefore the seroprevalence of HIV was 0.41, 0.63, 0.67 and 0.76% in 2004, 2005, 2006 and 2007 respectively. Out of 248 women who were detected positive in the 3 years, only 103 (41.53%) delivered in our institution. 32 (12.90%) underwent MTP. But unfortunately 113 (i.e. 248 − (103 + 32) = 113) were lost to follow up during antenatal care. Out of the 95 live births, only 46 babies have been tested so far out of which only one is reactive, 45 are non reactive.

Conclusion

The main obstacle we faced was in following up the mother and the baby. To achieve a high success rate, PPTCT programmes must have well-trained, supportive staff who take great care to ensure confidentiality. They must be backed up by effective HIV testing and counseling programmes and by good quality HIV/AIDS education, which is essential to eliminate myths and misunderstandings among pregnant women, and to counter stigma and discrimination in the wider community.     

Prediction of Preterm Birth in Multiple Pregnancies: Development of a Multivariable Model Including Cervical Length Measurement at 16 to 21 Weeks’ Gestation

ObjectiveTo develop a multivariable prognostic model for the risk of preterm delivery in women with multiple pregnancy that includes cervical length measurement at 16 to 21 weeks’ gestation and other variables.MethodsWe used data from a previous randomized trial. We assessed the association between maternal and pregnancy characteristics including cervical length measurement at 16 to 21 weeks’ gestation and time to delivery using multivariable Cox regression modelling. Performance of the final model was assessed for the outcomes of preterm and very preterm delivery using calibration and discrimination measures.ResultsWe studied 507 women, of whom 270 (53%) delivered < 37 weeks (preterm) and 66 (13%) < 32 weeks (very preterm). Women with cervical length < 30 mm delivered more often preterm (hazard ratio 1.9; 95% CI 0.7 to 4.8). Other independently contributing predictors were previous preterm delivery, monochorionicity, smoking, educational level, and triplet pregnancy. Prediction models for preterm and very preterm delivery had a c-index of 0.68 (95% CI 0.63 to 0.72) and 0.68 (95% CI 0.62 to 0.75), respectively, and showed good calibration.ConclusionIn women with a multiple pregnancy, the risk of preterm delivery can be assessed with a multivariable model incorporating cervical length and other predictors.     

Preconception care: advancing from ‘important to do and can be done’ to ‘is being done and is making a difference’

There is a growing evidence base for preconception care - – the provision of biomedical, behavioral and social interventions to women and couples before conception occurs. Firstly, there is evidence that health problems, problem behaviours and individual and environmental risks contribute to poor maternal and child health outcomes. Secondly, there are biomedical, behavioural and social interventions that when delivered before conception occurs, effectively address many of these health problems, problem behaviours and risk factors. And thirdly, there is emerging experience of how to deliver these interventions in low and middle income countries (LMIC).The preconception care interventions delivered and whom they are delivered to, will need to be tailored to local realities. The package of preconception care interventions delivered in a particular setting will depend on the local epidemiology, the interventions already being delivered, and the resources in place to deliver additional interventions. Although a range of population groups could benefit from preconception care, prioritization based on need and feasibility will be needed.There are both potential benefits and risks associated with preconception care. Preconception care could result in large health and social benefits in LMIC. It could also be misused to limit the autonomy of women and reinforce the notion that the focus of all efforts to improve the health of girls and women should be at improving maternal and child health outcomes rather than at improving the health of girls and women as individuals in their own right.There are challenges in delivering preconception care. While the potential benefits of preconception care programmes could be substantial, extending the traditional Maternal and Child Health package will be both a logistic and financial challenge.We need to help countries set and achieve pragmatic and meaningful short term goals. While our long-term goal for preconception care should be for a full package of health and social interventions to be delivered to all women and couples of reproductive age everywhere, our short-term goals must be pragmatic. This is because countries that need preconception care most are the ones least likely to be able to afford them and deliver them. If we want these countries to take on the additional challenge of providing preconception care while they struggle to increase the coverage of prenatal care, skilled care at birth etc., we must help them identify and deliver a small number of effective interventions based on epidemiology and feasibility.     

Women’s empowerment and experiences of mistreatment during childbirth in facilities in Lucknow,India: results from a cross-sectional study

Background

Recent evidence has found widespread reports of women experiencing abuse, neglect, discrimination, and poor interpersonal care during childbirth around the globe. Empowerment may be a protective mechanism for women against facility mistreatment during childbirth. The majority of previous research on mistreatment during childbirth has been qualitative in nature.

Methods

In this analysis, we use quantitative data from 392 women who recently gave birth in a facility in the slums of Lucknow, India, to explore whether measures of women’s empowerment are associated with their experiences of mistreatment at their last childbirth. We use the Gender Equitable Men (GEM) scale to measure women’s views of gender equality.

Results

We find that women who had more equitable views about the role of women were less likely to report experiencing mistreatment during childbirth. These findings suggest that dimensions of women’s empowerment related to social norms about women’s value and role are associated with experiences of mistreatment during childbirth.

Conclusions

This expands our understanding of empowerment and women’s health, and also suggests that the GEM scale can be used to measure certain domains of empowerment from a women’s perspective in this setting.

     

‘Removed from humanity’: a qualitative analysis of attitudes toward abortion providers in anti-abortion individuals in Canada

Objective: The present study explores the content of abortion provider stigma.

Background: Abortion stigma extends beyond women who have abortions to abortion providers. Previous analyses of anti-abortion bills and rhetoric have revealed stereotypes of abortion providers as dangerous and less trustworthy than other health professionals.

Methods: We present a thematic analysis of one-on-one interviews about attitudes toward abortion providers with Canadian individuals (N = 21) holding an anti-abortion stance.

Results: We found participants held two kinds of beliefs about abortion providers: (1) providers are agentic and intentional actors and (2) providers are non-agentic victims of a larger system. While the former subtype of provider was viewed with hostility and disgust, the latter was viewed with pity, with participants suggesting that restriction of abortion would be beneficial for provider well-being.

Conclusion: We document a new component of abortion provider stigma: the belief that abortion providers are harmed by abortion and that they are to be pitied for this. This ‘abortion harms providers’ attitude parallels recent anti-abortion arguments that abortion harms women. These stigmatising attitudes both construct the provider as untrustworthy and unable to properly care for women.     

Tensions and conflicts in ‘choice’: Womens’ experiences of freebirthing in the UK

Backgroundthe concept of choice is a central tenet of modern maternity care. However, in reality women’s choice of birth is constrained by a paucity of resources and dominant medical and risk adverse discourses. In this paper we add to this debate through highlighting the tensions and conflicts that women faced when enacting a freebirthing choice.Methodssecondary analysis of data collected to explore why women choose to freebirth in the UK was undertaken. Ten women were recruited from diverse areas of the UK via invitations on freebirthing websites. Women provided a narrative and/or participated in an in-depth interview. A thematic analysis approach was used.Findingswe present three key themes. First ‘violation of rights’ highlights the conflicts women faced from maternity care systems who were unaware of women’s legal rights to freebirth, conflating this choice with issues of child protection. ‘Tactical planning’ describes some of the strategies women used in their attempts to achieve the birth they desired and to circumnavigate any interference or reprisals. The third theme, ‘unfit to be a mother’ describes distressing accounts of women who were reported to social services.Conclusion and implications for practicewomen who choose to freebirth face opposition and conflict from maternity providers, and often negative and distressing repercussions through statutory referrals. These insights raise important implications for raising awareness among health professionals about women’s legal rights. They also emphasise a need to develop guidelines and care pathways that accurately and sensitively support the midwives professional scope of practice and women’s choices for birth.     

Diagnosis and management of henoch-sch?nlein purpura in pregnancy: a review of the literature

Introduction

Henoch-Sch?nlein Purpura (HSP) is an IgA-mediated hypersensitivity vasculitis uncommon in adults and rarely described in pregnancy. So far, only 20 cases have been described in pregnancy in the worldwide literature. Although prognosis for this condition is reported as excellent, most studies are based on the paediatric population. Henoch-Sch?nlein Purpura is known to be more severe in adults, and women with a history of HSP have an increased risk of complications during pregnancy. Diagnosis and management of HSP in adults is based on limited evidence, with little data regarding the obstetric population.

Material and methods

Review of data cited in current published cases.

Conclusion

We review the obstetric cases reported so far and discuss diagnostic matters and current management strategies.     

Ectopic Pregnancy in the Era of Medical Abortion: Are We Ready for It? Spectrum of Sonographic Findings and Our Experience in a Tertiary Care Service Hospital of India

Aim

The aim of this study was to share our experience of clinical presentation and ultrasonographic findings in cases of ectopic pregnancy especially in the context of usage of unsupervised medical abortifacients.

Settings and Design

This is prospective study conducted over a period of 1 year extending from August 01, 2009 to July 31, 2010 in a tertiary care Armed Forces Hospital of India.

Materials and Methods

Clinically and or sonologically suspected cases of ectopic pregnancy formed the study group. Detailed clinical, menstrual, and treatment history was obtained for each patient. Ultrasonography (USG) was done with multifrequency convex (2.5–6 MHz) followed by transvaginal (6–10 MHz) probes. Operative findings were noted and recorded in each case.

Results

In the study period, a total of 1958 pregnant patients were admitted and treated, which included 1690 deliveries and 268 abortions. Based on USG findings, 16 cases (0.8 %) of ectopic pregnancy were diagnosed. While four patients were treated medically (with methotrexate), 12 cases underwent surgery. Out of 16 cases, 10 cases were suspected clinically as ectopic pregnancy. Features suggestive of menorrhagia, threatened abortion, and pelvic inflammatory disease were present in five, three, and three cases, respectively. History of intake of medical abortifacients (MA) (mifepristone followed by misoprostol) was present in 07 (43.75 %) cases. On USG, commonest abnormality was a complex adnexal mass seen in 12 (75 %) cases. Gestational sac with definite embryo within and surrounding echogenic rim was seen in five cases. Live ectopic pregnancy was diagnosed in two (12.5 %) cases. Endometrial thickness was less than 10 mm in all cases who had taken MA. Pseudo gestation sac was seen in 02 (12.5 %) cases. Significant hemoperitoneum was present in 10 out of 12 cases operated. Organized hematoma in pelvis masking the presence of adnexal mass was noted in three cases.

Conclusion

Over-the-counter availability, failure to strictly follow the guidelines, unsupervised usage of MA along with atypical clinical history have increased diagnostic dilemma in ectopic pregnancy. Sonographic findings are frequently atypical in such cases. Ectopic pregnancy may remain under-diagnosed with potentially serious consequences in patients who have taken MA without prior confirmation of intrauterine gestation.     

Management of Turner’s syndrome in adult life: case-series and systematic review

Objective: To assess the symptoms and outcomes of clinical management in adult patients with Turner’s Syndrome. Design: Retrospective case-series and systematic review of the literature. Setting: Gynaecological Endocrinology Unit in a teaching hospital. Patients: Patients followed in the Gynaecological Endocrinology Unit. Interventions: Review of medical records and a computer search via several databases to identify journals relevant to the subject were performed. Main outcome measures: Final height, weight, previous treatments with growth hormone, cardiac or renal malformations, metabolic profile, and additional treatment for osteoporosis. Results: Thirty-one patients were analysed. Differences in final height were found between groups with monosomy and other karyotypes. Four patients bore congenital cardiac malformations, and six, renal congenital malformations. Nine patients had a previous diagnosis of hypercholesterolemia. The most abnormal hepatic parameter was GGT, with fifteen patients having values over the normality limit. Ten patients were receiving treatment for osteopenia or osteoporosis. Conclusions: This case-series provides recommendations for the management of adult patients with Turner’s syndrome and insight into the different medical complaints of this syndrome. A link between karyotypes and clinical features suggests a novel hypothesis to explain the different phenotypes and clinical abnormalities of these patients.     

Trends in births at and beyond term: evidence of a change?

OBJECTIVE: To examine trends in the distribution of births at and beyond term in New South Wales and in particular, to determine whether any changes are associated with changes in the obstetric practices of induction and elective caesarean section. DESIGN: Cross-sectional analytic study. SETTING: New South Wales, Australia. POPULATION: All 540,162 women delivering a singleton cephalic-presenting infant of gestational age > or = 37 weeks from 1 January 1990 to 31 December 1996. METHODS: Data were obtained from the New South Wales midwives data collection, a population-based surveillance system covering all births in New South Wales. The data were analysed to examine changes over time and associations between gestational age, maternal factors and onset of labour. MAIN OUTCOME MEASURES: Induction of labour and elective caesarean section rates. RESULTS: From 1990 to 1996 there was a significant decrease in births reported as 40 weeks of gestation, from 35,670 (46.3%) to 30,651 (40.3%). These declines were offset by significant increases in births at 38 and 39 weeks. Births > or = 42 weeks declined from 3321 (4.6%) to 2132 (2.8%). The decline in prolonged pregnancies was associated with increasing induction rates at 41 weeks. The re-distribution of some births from 40 to 38-39 weeks was associated with increasing rates of elective caesarean sections and induction at 38 and 39 weeks, and increasing maternal age. CONCLUSIONS: Clinicians appear to be implementing the recommendations of randomised controlled trials to offer induction after 41 weeks of gestation. However the trend of performing elective caesarean sections at earlier gestational ages may be unnecessarily putting some infants at increased risk of respiratory morbidity.     

Trends in births at and beyond term: evidence of a change?

Objective To examine trends in the distribution of births at and beyond term in New South Wales and in particular, to determine whether any changes are associated with changes in the obstetric practices of induction and elective caesarean section.
Design Cross-sectional analytic study.
Setting New South Wales, Australia.
Population All 540,162 women delivering a singleton cephalic-presenting infant of gestational age ≥ 37 weeks from 1 January 1990 to 31 December 1996.
Methods Data were obtained from the New South Wales midwives data collection, a population-based surveillance system covering all births in New South Wales. The data were analysed to examine changes over time and associations between gestational age, maternal factors and onset of labour.
Main outcome measures Induction of labour and elective caesarean section rates.
Results From 1990 to 1996 there was a significant decrease in births reported as 40 weeks of gestation, from 35,670 (46.3%) to 30,651 (40.3%). These declines were offset by significant increases in births at 38 and 39 weeks. Births ≥ 42 weeks declined from 3321 (4.6%) to 2132 (2.8%). The decline in prolonged pregnancies was associated with increasing induction rates at 41 weeks. The re-distribution of some births from 40 to 38–39 weeks was associated with increasing rates of elective caesarean sections and induction at 38 and 39 weeks, and increasing maternal age.
Conclusions Clinicians appear to be implementing the recommendations of randomised controlled trials to offer induction after 41 weeks of gestation. However the trend of performing elective caesarean sections at earlier gestational ages may be unnecessarily putting some infants at increased risk of respiratory morbidity.     

‘And they kill me,only because I am a girl’…a review of sex-selective abortions in South Asia

The low social status of women and the preference for sons determine a high rate of sex-selective abortion or, more specifically, female feticide, in South Asian countries. Although each of them, irrespective of its abortion policy, strictly condemns sex-selective abortion, data suggest high rates of such procedures in India, Nepal, China and Bangladesh. This paper reviews the current situation of sex-selective abortion, the laws related to it and the factors contributing to its occurrence within these countries. Based on this review, it is concluded that sex selective abortion is a public health issue as it contributes to high maternal mortality. Abortion policies of South Asian countries vary greatly and this influences the frequency of reporting of cases. Several socio-economic factors are responsible for sex-selective abortion including gender discriminating cultural practices, irrational national population policies and unethical use of technology. Wide social change promoting women's status in society should be instituted whereby women are offered more opportunities for better health, education and economic participation through gender sensitive policies and programmes. A self-regulation of the practices in the medical profession and among communities must be achieved through behavioural change campaigns.     

Evidence-based medicine and the role of the private sector in assisted reproduction: a response to Dr Fishel’s commentary ‘Evidenced-based medicine and the role of the National Health Service in assisted reproduction’

We respond to Dr Fishel’s commentary on evidenced-based medicine in assisted reproduction and the role of the UK’s National Health Service. We agree that proper randomised clinical trials are not easy to set up or execute. Recruitment is also challenging but requires that all personnel involved in the study, clinicians, embryologists and nurses, agree with its aims and buy in to the need for an answer. Those who believe fervently in the method under scrutiny prior to the availability of robust evidence are likely to undermine the success of any trial. New technologies are not necessarily better technologies. Neither is the supposed ‘logic’ of a treatment nor anecdotal clinical experience a substitute for evidence properly gained and fairly demonstrated. Dr Fishel would agree that the first obligation of healthcare professionals, whether they are in the public or private sector, is not to do harm to their patients. Adopting new interventions without rigorous assessment of the potential for harm flies in the face of this basic principle.     

‘Primary gingival and later primary vulval carcinomas arising in lichen planus: report of a case and clinical suggestions for diagnosis of a neglected disease’

Abstract

Lichen planus (LP) is a chronic immune-mediated dermatosis mainly affecting skin, oral, and genital mucosa. The heterogeneous clinical presentation, spectrum of symptoms depending on subtype and overlap with other vulval and cutaneous disorders can lead to challenging in diagnosis. We report an unusual case of vulval SCC arising within a patient with initial oral mucosal lichen planus who later developed lichen planus of the vulva. Discussion of this case is important as it typifies the difficulties in diagnosis of vulvo-vaginal disorders and potential complications. Evidence is available that lichen planus may be potentially precancerous condition and is associated with SCC development. This case may confirm an inherent oncologic potential of the disease. All efforts must be made by specialists involved in the management of this disease to obtain an early diagnosis, ensure proper treatment and adequate follow up. This highlights the need to perform vulval examination in patients with symptoms or with a history muco-cutaneous LP and if necessary consider referral to specialist center for biopsy and management.