Anish Keepanasseril

A new objective scoring system for the prediction of successful induction of labour

A prospective study was done in 311 women undergoing induction of labour for the formulation of a new score, which will be more objective than the conventional Bishops score. Pre-induction cervical assessment was done by the transvaginal sonographic parameters followed by the digital examination. Labour induction was successful in 79.09%. A new score was formulated using the parameters having independent association and weighting of individual components was given according to its regression coefficients. A new score with a maximum value of 13 was proposed. The best cut-off point for the new score in receiver operating characteristics curve was six with a sensitivity of 95.5% and specificity of 84.6%. The new score was found to have a better area under the curve than the conventional score.

Maternal cardiovascular dysfunction in women with early onset preeclampsia and late onset preeclampsia: A cross-sectional study

OBJECTIVES To compare the cardiovascular changes associated with early onset (EOPE) and late onset (LOPE) subtypes of preeclampsia. METHODS A prospective matched cross-sectional study involving 50 women each with early and late onset subtypes of preeclampsia conducted in a tertiary hospital in South India. Cardiac function and remodelling were assessed by conventional 2D, M-mode and doppler echocardiography. RESULTS Women with EOPE had a significantly more altered left ventricular (LV) geometry, global LV diastolic dysfunction, impairment in myocardial contractility (40% vs. 24%) and a higher total vascular resistance index (863.0 vs 704.0 dynes/s/cm5/m2) compared to LOPE. Stroke volume index (55.3 vs. 62.2 ml/m2) and cardiac work index (520.7 vs. 584.9mmHg×L/min/m2) were higher in women with LOPE. However, the systolic function was found to be preserved in the LV in both the groups. CONCLUSIONS Women with EOPE have a more severe cardiac impairment than those with LOPE. The difference in the hemodynamic indices may provide a chance to tailor patient-specific treatment strategies to improve the pregnancy outcome as well as in early identification and initiation of preventive measures for those at risk of cardiovascular diseases later in life. KEY MESSAGE Adaptation of the heart in women with early onset subtype differs with that of late onset subtype of preeclampsia. Total vascular resistance is higher in early onset group compared to late onset group having a higher cardiac output. These differences in the hemodynamic indices may provide a chance to tailor patient-specific treatment strategies to improve the pregnancy outcome as well as in early identification and initiation of preventive measures for those at risk of cardiovascular diseases later in life.

Prophylactic magnesium sulphate in prevention of eclampsia in women with severe preeclampsia: randomised controlled trial (PIPES trial)

Abstract Optimum dose, route and duration of use of prophylactic magnesium sulphate in women with severe pre-eclampsia is still controversial. We compared the efficacy and safety of ‘low-dose Dhaka’ regime with ‘Loading dose only’ regime for seizure prophylaxis in severe preeclampsia using a randomised controlled trial in 402 women. The incidence of eclampsia in the ‘low-dose Dhaka’ regime group was 1.49% and that in the ‘Loading dose only regime’ was 2.98% (p = .321). In the low-dose Dhaka regime, injection site abscess and respiratory depression occurred in one woman each. Neonatal outcomes such as Apgar score at 5 minutes (5.0% vs. 8.05% p = .251) and perinatal mortality (20.4% vs. 21.9%, p = .724) were similar in both groups. Loading dose only regime may be considered an effective alternative regime for the prevention of eclampsia in women with severe preeclampsia. Impact statement What is already known on this subject: Efficacy of therapeutic short regime magnesium sulphate in eclampsia has already been reported. Data regarding prophylactic short regime in women with preeclampsia is sparse. What the results of this study add: We have shown that short regime of magnesium sulphate using only the loading dose in the prevention of seizure in preeclampsia is an effective alternative to the low-dose Dhaka regime. What the implications are of these findings for clinical practice and/or further research: The short regime is less resource-intensive. Further larger studies are needed to confirm the efficacy of this short regime and to establish its cost-effectiveness.

Matched cohort study of external cephalic version in women with previous cesarean delivery

To evaluate the efficacy and safety of external cephalic version (ECV) among women with previous cesarean delivery.

Clinical and imaging profile of patients with new-onset seizures & a presumptive diagnosis of eclampsia – A prospective observational study

OBJECTIVE To study the clinical and imaging profile of patients with new-onset seizures with a presumptive diagnosis of eclampsia. METHODS This was a cross-sectional study, conducted in a tertiary teaching hospital, on pregnant women presenting with new onset seizures with presumptive diagnosis of eclampsia excluding those with pre-existing neurological conditions. Demographic details, medical and obstetric examination findings were noted. All women underwent neuroimaging within 5 days of onset seizures. RESULTS Presumptive diagnosis of eclampsia was made in 0.7% (n = 186) of women delivering during the time period. Most women (55.4%) presented with seizures in the antenatal period. Neuroimaging is performed in 130 cases and it was found to be abnormal in 45.4% of women (59/130). Most common associated neurological condition was Posterior Reversible Encephalopathy Syndrome in 20% (n = 26) followed by Cerebral Venosus Sinus Thrombosis in 10% (n = 14). All six women with primary intracerebral haemorrhage succumbed to the disease. CONCLUSION New-onset seizures may be the initial presentation of uncommon and unpredictable complication of pregnancy with serious maternal/ fetal morbidity and mortality. Neuroimaging will help in these patients to avoid the delay or misdiagnosis, resulting in early initiation of specific treatment which will help to improve and optimize outcomes.

386. Care of pregnant women with prosthetic heart valves: Still a formidable challenge in low to middle income countries?

Introduction Patients with mechanical heart valves require lifelong anticoagulation and pregnancy being a pro-thrombotic state poses additional risk of thromboembolic complications. In pregnancy, anticoagulation regimes using Coumadin derivatives or various heparins offers advantage over each other remains inconclusive. Especially in low to middle income countries cost of medication/monitoring and compliance remains a major challenge. We report a single center experience of managing pregnancy in women with prosthetic heart valve from South India. Methods We collected demographic, medical and obstetric details of pregnant women with prosthetic heart valve admitted to a regional tertiary center catering to rural population of South-eastern India from Jan 2011 to March 2018. Outcomes assessed were maternal complications such as maternal mortality, prosthetic valve thrombosis, and perinatal complications such as miscarriages or rates of congenital malformation. Data was expressed as mean with standard deviation or frequency with percentages as appropriate. Results We collected data of 73 pregnancies in 59 women with prosthetic heart valve during the time period. Majority of the women (84%) had valve replacement in mitral position and were replaced with ttk Chitra (titling disc) valve (80%). Five women developed thrombotic complication; three while on unfractionated heparin and two on warfarin therapy. Among three women with prosthetic valve thrombosis, two underwent thrombolysis while one succumbed to the disease. Two third of women were on warfarin therapy in first trimester. One fetus was diagnosed with warfarin-embryopathy and 4 had miscarriages. Cesarean section rates were 16.4%. Hemorrhagic complications occurred in six women in the postpartum period; four of them were on heparin. Conclusion Pregnancy in women with prosthetic mechanical heart valves can lead to life-threatening complications. Anticoagulation regimes should take into consideration fetal risk concerns, cost or treatment/ monitoring which will ensure a better compliance especially in low to middle income countries.

Transvaginal sonographic assessment of cervix in prediction of admission to delivery interval in preterm premature rupture of membranes

Abstract Objective: To assess the usefulness of cervical parameters measured by transvaginal sonography, that is, cervical length and posterior cervical angle, in predicting the admission to delivery interval in women with preterm rupture of membranes. Methods: This prospective study was conducted in a tertiary care centre in South India. Women with preterm premature rupture of membranes at 28–34 weeks, confirmed clinically, not in labour and presenting within 24 hours to hospital were included. We evaluated the relationship between latency interval and transvaginal sonographic parameters (cervical length and posterior cervical angle), parity, age, Amniotic Fluid Index (AFI), total leucocyte count at admission using Cox proportional hazards model. Results: Mean time interval between the membrane rupture and delivery was 96.9 h. Majority of the women (63.8% (n = 51)) delivered within 48 hours. Transvaginal sonographic cervical length was not shown to be associated with latency interval (p = .559), whereas. Posterior cervical angle was shown to be significantly associated with the interval (hazard ratio 1.03, 95%CI: 1.01–1.06; p = .003) Conclusions: Posterior cervical angle assessment using transvaginal sonography is an useful tool in the assessing the latency interval in women with preterm premature rupture of membranes (PPROM). This could help in counselling and planning timely referral to centres with neonatal facilities.

Antenatal risk factors associated with need of postpartum antihypertensives in women with preeclampsia in South India: Case control study

OBJECTIVES To investigate the antepartum risk factors associated with the need for antihypertensive medication in the postpartum period in women with pre-eclampsia. METHODOLOGY Matched retrospective case control study was done in a tertiary center in south India between January 2016 and June 2016. We compared 100 preeclamptic women requiring antihypertensive medication in the postpartum period at discharge with 100 preeclamptic women who were not on antihypertensive medication at discharge, matched for age and parity at a ratio 1:1. Demographic data, maternal medical conditions, and delivery data were abstracted from maternal charts. Risk factors were evaluated using conditional logistic regression. RESULTS Gestational age at delivery was comparable in both groups (34.3vs. 35.6weeks, p=0.220). Cesarean section rates were higher in the cases compared to controls (53% vs. 32%, p=0.004). After adjusting for age and parity women who had eclampsia, required prophylactic magnesium sulphate therapy and high peak antenatal systolic blood pressure were associated with postpartum antihypertensives. Using multivariate conditional logistic regression, mean systolic blood pressure (OR=1.03, 95% CI 1.00-1.07), development of eclampsia (OR=6.43, 95% CI 1.03-39.91) and need of prophylactic magnesium sulphate (OR=5.02, 95% CI 2.02-12.47) were found to be associated with the need of postpartum antihypertensives. CONCLUSIONS In women with preeclampsia, development of eclampsia, use of prophylactic magnesium sulphate and high peak antenatal systolic blood pressure are more likely to require antihypertensives in postpartum period.

Wilson disease presenting during pregnancy: A diagnostic and therapeutic dilemma:

Wilson’s disease is an autosomal recessive genetic disorder affecting copper transport leading to hepatic and/or neuropsychiatric manifestations. Changes in pregnancy can mimic certain clinical features of chronic liver disease such as spider naevi, and constraints for the use of various investigation for diagnosis pose a challenge to physicians. A high index of suspicion, multi-disciplinary team approach, use of correct non-invasive testing including viral serology, autoantibodies and copper studies and ultrasonography help to diagnose most of the pre-existing, de novo or pregnancy-specific hepatological conditions. We report a case of Wilson’s disease diagnosed during pregnancy and discuss the challenges in diagnosis and treatment in pregnancy.

Pregnancy in women with Klippel-Trenaunay syndrome: Report of three pregnancies in a single patient and review of literature

Klippel-Trenaunay syndrome is characterised by vascular abnormality which increases the risk of thromboembolism and haemorrhage. Physiological changes in pregnancy pose an increased risk to these complications. Being an uncommon disorder, there is limited literature about the management of women with pregnancy and Klippel-Trenaunay syndrome. We report in detail two of three pregnancies in a woman with Klippel-Trenaunay syndrome who had repeated episodes of haematochezia leading to anaemia, managed with Argon laser Photo-Coagulation in pregnancy and also reviewed the complications and the management of pregnant women with Klippel-Trenaunay syndrome.