Seema Mehrotra

Background Hypertensive disorders in pregnancy are responsible for 14% of maternal deaths. Maternal mortality is not only due to medical disorder but also due to underlying social–cultural factors lead to delays in getting timely and appropriate intervention. This study aimed to analyse three delays, to identify socio-cultural, demographic and accessibility factors that contributed to maternal deaths due to hypertension in pregnancy. Method It was a prospective observational study. Verbal autopsy was done for each maternal death that occurred due to hypertensive disorder. The “3 delay model” concept was used in collection and analysis of data for each maternal death. The Chi-square test (χ²) and multivariable logistic regression model were used to accomplish the study objectives. Results Out of 326 maternal deaths, 52 deaths were due to hypertensive disorders. Pulmonary oedema, eclamptic encephalopathy, sepsis and cerebrovascular accident were the major causes of maternal mortality. In thirty-nine (75%) type I delay was the most significant contributor of maternal death. Twenty-four (46.15%) and 14 (26.9%) had Type II/III delay. The reasons for level I delay were failure to recognize the danger signs, delay in decision-making, no ANC registration, Type II delay being lack of timely transport facility, type III delay being lack of adequate monitoring, delay in initiating treatment and substandard care in hospital were observed. Conclusions Socio-cultural and demographic factors significantly contribute to the direct or indirect medical cause of maternal death. Analysing these factors provide deep insight into the maternal death and will provide useful information for guiding the policy makers to take corrective actions and direct their programmes and policies such as strengthening referral networking, widespread coverage of healthcare facility and raising awareness of danger signs of pregnancy by reaching at grass root levels.

Aims and objectives Ultrasound has an important role in in pregnancy complicated by hyperglycaemia. This study is to assess the association between third trimester ultrasound parameters and adverse outcomes in hyperglycaemic pregnant women & neonates. Methodology A prospective observational study including 166 hyperglycemic pregnant women (39–preexisting; 127-GDM) Ultrasound was done between 34 weeks gestation and beyond to note parameters i.e. FW centile, AC centile, CPR ratio, AFI. All were followed till delivery; adverse outcomes noted (C-section done for fetal distress, arterial cord blood ph < 7.1, 5 min APGAR < 7, admission to neonatal unit, neonatal hypoglycemia, perinatal death). Composite adverse outcomes were determined by having any 2/7 above-described outcomes. Ultrasound parameters were then correlated with composite adverse outcomes and correlation was determined. Results Out of 166; in 66 pregnancies composite adverse neonatal outcomes were present. Women with HIP having > 90th centile of estimated fetal weight have 3.52 times higher chances [OR 3.52 & 95% CI (1.55–7.97)] of having CAO compared to rest of the women. Statistically, a significant association was found for Composite Adverse Outcomes and deranged AFI (p value < 0.018). Women with HIP having Polyhydramnios have 3.13 times higher odds [OR 3.13 & 95% CI (1.08–8.94)] of having CAO compared to rest of the women. Further, Women with HIP having cerebroplacental insufficiency i.e. CPR < 1 have 4.2 times higher odds [OR 4.200 (CI 1.825–9.668)] of having CAO compared to rest of the women with HIP i.e. women having CPR > 1. Conclusion In women with hyperglycemia, third trimester USG parameters have an important role in predicting adverse outcomes beyond the impact of maternal predictors. The best combination of USG parameters detecting Composite Adverse Outcomes was EFW < 10th centile and CPR < 1 (OR 14.61). So third trimester sonographic parameters appears to be promising tool to preplan deliveries that should be conducted in tertiary care centres to reduce perinatal morbidity and mortality.

Obstetric acute kidney injury (AKI) is a serious unsolved global health-care problem and is a significant contributor to the overall burden of AKI resulting in devastating maternal and foetal outcomes. We studied the characteristics of obstetric AKI and the factors related to its unfavourable outcome. A total of 110 patients developed AKI among 10,138 admission giving a frequency of 1.08%. The commonest risk factor was pre-eclampsia followed by haemorrhage and sepsis. Complete recovery of renal function occurred in 40.9%. However, 9.1% were left with end-stage renal disease. AKI due to sepsis, delayed referral and deranged renal function on admission was associated with unfavourable outcome. AKI in pregnancy merits special attention because it involves risk to two lives, mother and foetus. Early identification of risk factors coupled with timely and efficient management will result in reducing obstetric AKI and associated maternal morbidity and mortality

Background Gestational diabetes mellitus (GDM) is associated with various maternal and perinatal morbidities. Serum ferritin is a major storage protein of iron and also acts as acute phase reactant which is increased in inflammatory conditions. GDM is a state of insulin resistance and associated with inflammation. The aim of this study was to find the correlation between serum ferritin and development of GDM. Objectives To determine the serum ferritin concentration in nonanemic pregnant women and its correlation with subsequent development of GDM. Methodology In this prospective observational study, 302 nonanemic pregnant women with singleton gestation between 14 and 20 weeks, attending antenatal OPD, were enrolled. Serum ferritin was measured at the time of enrolment, and they were followed till 24–28 weeks of gestation and subjected to blood glucose test by DIPSI method. A total of 92 women had blood glucose level ≥ 140 mg/dl and were labeled as GDM, and 210 pregnant women with blood glucose level < 140 mg/dl were labeled as non-GDM. Result Mean serum ferritin level of women with GDM (56.44 ± 19.19 ng/ml) was found to be higher as compared to non-GDM (27.62 ± 12.11 ng/ml), and this difference was found to be statistically significant (p < 0.001). The cutoff value of serum ferritin > 37.55 ng/ml was found to be 85.9% sensitive and 81.9% specific. Conclusion We can infer that serum ferritin is associated with development of GDM. Based on the findings of the current study, serum ferritin level can be used a predictive marker for the development of GDM.

Background The cerebroplacental ratio (CPR) is emerging as a predictor for adverse perinatal outcome in term pregnancies. Earlier, it has shown a role in small for gestational age (SGA) pregnancies, but a proportion of appropriate for gestational age foetuses (AGA) despite of good size have impaired growth velocity and are thereby at risk of adverse outcome. CPR has implication for assessment of well being of SGA and AGA foetuses close to term. Objective To investigate the association between foetal CPR and adverse perinatal outcome in uncomplicated term AGA pregnancies. Methods This was a prospective observational study done in Department of Obstetric and Gynaecology, King George Medical University, Lucknow, over a period of one year. Women > 37 week singleton pregnancy with no known risk factor who had Doppler USG done within a week of delivery were included. CPR was calculated by dividing the Doppler indices of middle cerebral artery (MCA) by umbilical artery (MCA PI/UA PI). CPR < 1 was taken as abnormal. These patients were followed up till delivery to look for various perinatal outcomes. Results Out of 127 low-risk AGA pregnancies who went for USG colour Doppler scan, 117 patients who met our inclusion criteria were analysed; out of 117 patients 23(i.e. 19.65 %) were having CPR < 1 and 94 patients (i.e. 80.34%) were having CPR>1. Among 23 patients with CPR < 1, 22 (91.30%) had adverse outcome as compared to only 20.21% patients with CPR > 1, and this is found to be statistically significant (p < 0.001). Conclusion Our study found CPR measure to be a very promising tool for optimising the identification of at risk foetus in low-risk AGA pregnancies.

Leiomyomas are the most common benign smooth muscle tumors of the uterus. The incidence during pregnancy ranges between 1.6 to 10%. The management of fibroids encountered during caesarean section poses a therapeutic dilemma. We present a case of giant anterior wall lower segment leiomyoma complicating term pregnancy which posed a great surgical challenge. Myomectomy was performed before delivering the baby by lower segment caesarean section by locating the tumor free area using preoperative ultrasound. The tumor mass weighed 3kg. This case highlights the preoperative use of ultrasound in emergency caesarean section to avoid classical caesarean section and to prevent fetal mortality and morbidity by avoiding time consuming caesarean myomectomy before the delivery of the baby.

Introduction: To analyze the relationship between first trimester uric acid levels and risk of development of gestational diabetes mellitus (GDM). Method: A total of 300 pregnant women up to 14 weeks of pregnancy were enrolled in this study. After obtaining their demographic data and clinical assessment blood sample for serum uric acid was taken. Women were subsequently followed till term. All women were subjected to blood sugar screening one hour after 50 gm glucose and glucose tolerance test if screening was < 200mg/dl. GDM was diagnosed by 3 hours glucose tolerance test using Carpenter and Coustan criteria or by one hour screening value > 200 mg /dl. Results: GDM complicated 2.66% (8/300) of the pregnancies. All the women with serum uric acid > 5 mg/dl (n=6) had deranged blood sugar screening and out of this 5 developed GDM. Conclusion: The study demonstrates a striking association between first trimester uric acid and risk of developing GDM. First trimester uric acid level may be used as predictor for development of GDM.

This study was undertaken to compare the effect of oxytocin and human chorionic gonadotrophin (hCG) on ovulation and conception. A total of 100 women with anovulatory infertility were allocated into two equal groups to take clomiphene citrate plus hCG or clomiphene citrate plus oxytocin. The size and number of follicles by transvaginal sonography determined the administration of hCG or oxytocin. The serum progesterone concentration was measured to provide evidence for ovulation. The ovulation and pregnancy rate of the two groups were compared. There was no significant difference between the groups with respect to mean number of follicles, mean follicular size and rate of ovulation in three cycles. The rate of pregnancy was higher in the oxytocin group compared with the hCG group (12% vs 4%) but it failed to reach statistical difference (p = 0.140). Mild pain was the only side-effect observed in the two groups. Oxytocin was found to be a viable alternative to hCG for triggering ovulation in infertile patients.

Herein, we present a case of tubal choriocarcinoma which was diagnosed initially as chronic ectopic pregnancy. During laparotomy we noticed a haemorrhagic friable mass in the left flank, adherent to the bowel. Left-sided salpingoopherectomy was performed. Serum β HCG (human chorionic gonadotropin) levels performed in the postoperative period were elevated. Histopathology demonstrated choriocarcinoma. She was given six cycles of chemotherapy (etoposide, methotrexate, actinomycin D-cyclophosphamide, vincristine/oncovine (EMA-CO) regime) and monitored by serial β HCG estimation. This case highlights the importance of undertaking histopathological examination of the tubal tissue in every patient who presents with ectopic pregnancy. This important diagnostic test prevents the potential of missing this rare and highly malignant disease which is otherwise curable in most instances.