Annamma Thomas

High folate and low vitamin B-12 intakes during pregnancy are associated with small-for-gestational age infants in South Indian women: a prospective observational cohort study

BACKGROUND Folic acid supplementation in those with a low vitamin B-12 intake or status may have adverse effects. These effects are unknown with regard to birth outcome in pregnant Indian women who are routinely supplemented with high doses of folic acid. OBJECTIVE The objective was to examine the association of unbalanced vitamin B-12 and total folate (folic acid supplement + dietary folate) intakes during pregnancy with outcomes in small-for-gestational-age (SGA) infants. DESIGN This was a prospective observational cohort study of 1838 pregnant women in South India. Low intake of dietary vitamin B-12 in the presence of high total folate intake was examined as the ratio of vitamin B-12 intake to total folate intake. RESULTS The inadequacy of vitamin B-12 intake (<1.2 μg/d) assessed by a food-frequency questionnaire in the first, second, and third trimesters of pregnancy was 25%, 11%, and 10%, respectively. Multivariate log binomial regression showed that low vitamin B-12 and folate intakes in the first trimester were independently associated with a higher risk of SGA. In a subgroup of women with high supplemental folic acid intakes in the second trimester, those with the lowest tertile of vitamin B-12:folate ratio had a higher risk of SGA outcome than did those in the highest tertile (adjusted RR: 2.73; 95% CI: 1.17, 6.37). A similar trend was observed in the analysis of blood micronutrient status in a random subset (n = 316) of the sample. CONCLUSIONS These findings suggest that, in addition to vitamin B-12 and folate deficiencies alone, there may be adverse birth outcomes associated with unbalanced vitamin B-12 and folate intakes or status during pregnancy. These findings have important implications for the antenatal B vitamin supplementation policy in India. This trial was registered at the Clinical Trial Registry of India as 2013/07/005342.

The effect of fish and ω-3 LCPUFA intake on low birth weight in Indian pregnant women

Background:Inadequate consumption of fish could be a risk factor for low birth weight (LBW). This study assessed fish intake and ω-3 LCPUFA intake and status for their association with LBW in a cohort of urban, south Indian pregnant women.Subjects/methods:In a prospective cohort study, data on maternal fish intake and ω-3 LCPUFA intake and status of 676 women were obtained at baseline (first trimester), the second and third trimesters of pregnancy. Infant birth weight was measured immediately following hospital delivery. The dropout rate was 7.6%.Results:Fifty-six percent of the study women consumed fish with low daily median intakes (3.4, 4.1 and 3.8 g day−1 at the three trimesters, respectively). Consequently, the median intakes of EPA and DHA during pregnancy were also low at 2.1 and 10.1 mg day−1, respectively. EPA and DHA intakes were associated with their status in erythrocyte membrane phospholipids during pregnancy (r=0.40 and 0.36, r=0.34 and 0.32 and r=0.37 and 0.41, at the three trimesters, respectively, all P<0.001). Women who did not eat fish during the third trimester had a significantly higher risk of LBW (OR: 2.49, P=0.019). Similarly, low EPA intake during the third trimester had an association with a higher risk of LBW (OR: 2.75, P=0.011).Conclusions:Among low fish-eating pregnant women, fish intake in the third trimester was closely associated with birth weight. Supplementation with ω-3 LCPUFA during pregnancy may have important implications for fetal development in India.

The effects of yoga in prevention of pregnancy complications in high-risk pregnancies: A randomized controlled trial

OBJECTIVE While previous studies have shown the potential effects of yoga in normal pregnancies, this randomized controlled trial investigated the effects of yoga in prevention of pregnancy complications in high-risk pregnancies for the first time. METHODS 68 high-risk pregnant women were recruited from two maternity hospitals in Bengaluru, India and were randomized into yoga and control groups. The yoga group (n=30) received standard care plus one-hour yoga sessions, three times a week, from the 12th to the 28th week of gestation. The control group (n=38) received standard care plus conventional antenatal exercises (walking) during the same period. RESULTS Significantly fewer pregnancy induced hypertension (PIH), preeclampsia, gestational diabetes (GDM) and intrauterine growth restriction (IUGR) cases were observed in the yoga group (p=0.018, 0.042, 0.049, 0.05 respectively). Significantly fewer Small for Gestational Age (SGA) babies and newborns with low APGAR scores (p=0.006) were born in the yoga group (p=0.033). CONCLUSION This first randomized study of yoga in high-risk pregnancy has shown that yoga can potentially be an effective therapy in reducing hypertensive related complications of pregnancy and improving fetal outcomes. Additional data is needed to confirm these results and better explain the mechanism of action of yoga in this important area.

Anthropometry and body composition of south Indian babies at birth

OBJECTIVES To assess the consequences on body composition of increasing birth weight in Indian babies in relation to reported values in Western babies, and to assess the relationship between maternal and neonatal anthropometry and body composition. DESIGN Prospective observational study. SETTING Bangalore City, India. SUBJECTS A total of 712 women were recruited at 12.5+/-3.1 weeks of gestation (mean+/-standard deviation, SD) and followed up until delivery; 14.5% were lost to follow-up. Maternal body weight, height, mid upper-arm circumference and skinfold thicknesses were measured at recruitment. Weight and body composition of the baby (skinfold thicknesses, mid upper-arm circumference, derived arm fat index and arm muscle index; AFI and AMI, respectively) were measured at birth in hospital. RESULTS The mean+/-SD birth weight of all newborns was 2.80+/-0.44 kg. Birth weight was significantly related to the triceps and subscapular skinfold thickness of the baby. In a small number of babies with large birth weight for gestational age, there was a relatively higher normalised AFI relative to AMI than for babies with lower or appropriate birth weight for gestational age. Maternal height and fat-free mass were significantly associated with the babys length at birth. CONCLUSIONS Skinfold thicknesses in Indian babies were similar to those reported in a Western population with comparable birth weights, and the relationship of AFI to birth weight appeared to be steeper in Indian babies. Thus, measures to increase birth weight in Indian babies should take into account possible adverse consequences on body composition. There were no significant relationships between maternal anthropometry and body composition at birth on multivariate analysis, except for sum of the babys skinfold thicknesses and maternal fat-free mass (P<0.02).

Uterine rupture in a primigravida with misoprostol used for induction of labour

A 19 year old primigravid woman was booked for antenatal care at 11 weeks of gestation. Her past medical history was not significant. She had regular antenatal care until 32 weeks of gestation. Her booking investigations were normal except for a haemoglobin concentration of 9.6 g/dL. The anaemia was due to iron deficiency. Oral haematinics were prescribed. She did not attend the antenatal clinic for the next seven weeks. At 39 weeks of gestation she was seen again. She had oedema of the ankles, her blood pressure was 160/100 mmHg and she was very pale. She was admitted to the maternity unit. Her plasma uric acid concentration was increased, but her platelet count and her liver function tests were normal. Her haemoglobin concentration was 7.6 g/dL. An ultrasound scan estimated the fetal weight to be 2.6 kg, and the volume of the amniotic fluid was normal. A cardiotocogram showed a reactive trace. The presentation was cephalic, the head being at the brim of the pelvis. The cervix was anterior, uneffaced, and closed. Her height was 14.5 cm and her weight 58 kg. In view of her pregnancy-induced hypertension at 39 weeks of gestation, induction of labour was performed. Because of her unfavourable cervix, we used misoprostol. At 1400 h the first dose of 50 Ag of misoprostol was inserted into the posterior fornix. From 1400 to 2200 h the condition of the woman was assessed at regular intervals. Her blood pressure was 140/90 to 160/100 mmHg, and her uterus was relaxed. At 2200 h a vaginal examination was carried out. The cervix was 2 cm dilated, uneffaced and anterior. The head was 3 cm above the ischial spines. A second dose of 50 Ag of misoprostol was inserted into the posterior fornix. An hour later, uterine contractions lasting for 10 to 15 seconds at intervals of 5 to 8 minutes were recorded. Her labour progressed until 0330 h, when the fetal heart rate tracing showed decelerations to 110 beats per min. Vaginal examination showed that the cervix was 3 cm dilated, partly effaced, with a bag of forewaters. The head was 1 cm above the ischial spines. Artificial rupture of membranes was done and thick meconium-stained amniotic fluid was drained. The woman started having strong uterine contractions and a sensation of bearing down. In view of the thick meconium-stained amniotic fluid and the abnormalities of the fetal heart rate, she was taken to the operating theatre for a caesarean section. Just before her caesarean section, the cervix was 8 cm dilated, the presentation was vertex, the position was right occipito-transverse and the head was 1 cm above the ischial spines. The fetal heart rate was 80–100 beats per minute. On opening the abdomen, a tear of the uterus 15 cm long was found, from the right corner of the uterus to the right lateral fornix. A lower segment caesarean section was performed and the tear in the right lateral wall of the uterus was repaired. The woman’s post-operative course was uneventful, and she was discharged on her 12th post-operative day.

Availability and Distribution of Emergency Obstetric Care Services in Karnataka State, South India: Access and Equity Considerations

Background As part of efforts to reduce maternal deaths in Karnataka state, India, there has been a concerted effort to increase institutional deliveries. However, little is known about the quality of care in these healthcare facilities. We investigated the availability and distribution of emergency obstetric care (EmOC) services in eight northern districts of Karnataka state in south India. Methods & Findings We undertook a cross-sectional study of 444 government and 422 private health facilities, functional 24-hours-a-day 7-days-a-week. EmOC availability and distribution were evaluated for 8 districts and 42 taluks (sub-districts) during the year 2010, based on a combination of self-reporting, record review and direct observation. Overall, the availability of EmOC services at the sub-state level [EmOC = 5.9/500,000; comprehensive EmOC (CEmOC) = 4.5/500,000 and basic EmOC (BEmOC) = 1.4/500,000] was seen to meet the benchmark. These services however were largely located in the private sector (90% of CEmOC and 70% of BemOC facilities). Thirty six percent of private facilities and six percent of government facilities were EmOC centres. Although half of eight districts had a sufficient number of EmOC facilities and all eight districts had a sufficient number of CEmOC facilities, only two-fifths of the 42 taluks had a sufficient number of EmOC facilities. With the private facilities being largely located in select towns only, the ‘non-headquarter’ taluks and ‘backward’ taluks suffered from a marked lack of coverage of these services. Spatial mapping further helped identify the clustering of a large number of contiguous taluks without adequate government EmOC facilities in northeastern Karnataka. Conclusions In conclusion, disaggregating information on emergency obstetric care service availability at district and subdistrict levels is critical for health policy and planning in the Indian setting. Reducing maternal deaths will require greater attention by the government in addressing inequities in the distribution of emergency obstetric care services.

Effects of Yoga on Utero-Fetal-Placental Circulation in High-Risk Pregnancy: A Randomized Controlled Trial

Introduction. Impaired placentation and inadequate trophoblast invasion have been associated with the etiology of many pregnancy complications and have been correlated with the first trimester uterine artery resistance. Previous studies have shown the benefits of yoga in improving pregnancy outcomes and those of yogic visualization in revitalizing the human tissues. Methods. 59 high-risk pregnant women were randomized into yoga (n = 27) and control (n = 32) groups. The yoga group received standard care plus yoga sessions (1 hour/day, 3 times/week), from 12th to 28th week of gestation. The control group received standard care plus conventional antenatal exercises (walking). Measurements were assessed at 12th, 20th, and 28th weeks of gestation. Results. RM-ANOVA showed significantly higher values in the yoga group (28th week) for biparietal diameter (P = 0.001), head circumference (P = 0.002), femur length (P = 0.005), and estimated fetal weight (P = 0.019). The resistance index in the right uterine artery (P = 0.01), umbilical artery (P = 0.011), and fetal middle cerebral artery (P = 0.048) showed significantly lower impedance in the yoga group. Conclusion. The results of this first randomized study of yoga in high-risk pregnancy suggest that guided yogic practices and visualization can improve the intrauterine fetal growth and the utero-fetal-placental circulation.

Assessment of facility readiness and provider preparedness for dealing with postpartum haemorrhage and pre-eclampsia/eclampsia in public and private health facilities of northern Karnataka, India: a cross-sectional study

BackgroundThe maternal mortality ratio in India has been declining over the past decade, but remains unacceptably high at 212 per 100,000 live births. Postpartum haemorrhage (PPH) and pre- eclampsia/eclampsia contribute to 40% of all maternal deaths. We assessed facility readiness and provider preparedness to deal with these two maternal complications in public and private health facilities of northern Karnataka state, south India.MethodsWe undertook a cross-sectional study of 131 primary health centres (PHCs) and 148 higher referral facilities (74 public and 74 private) in eight districts of the region. Facility infrastructure and providers’ knowledge related to screening and management of complications were assessed using facility checklists and test cases, respectively. We also attempted an audit of case sheets to assess provider practice in the management of complications. Chi square tests were used for comparing proportions.Results84.5% and 62.9% of all facilities had atleast one doctor and three nurses, respectively; only 13% of higher facilities had specialists. Magnesium sulphate, the drug of choice to control convulsions in eclampsia was available in 18% of PHCs, 48% of higher public facilities and 70% of private facilities. In response to the test case on eclampsia, 54.1% and 65.1% of providers would administer anti-hypertensives and magnesium sulphate, respectively; 24% would administer oxygen and only 18% would monitor for magnesium sulphate toxicity. For the test case on PPH, only 37.7% of the providers would assess for uterine tone, and 40% correctly defined early PPH. Specialists were better informed than the other cadres, and the differences were statistically significant. We experienced generally poor response rates for audits due to non-availability and non-maintenance of case sheets.ConclusionsAddressing gaps in facility readiness and provider competencies for emergency obstetric care, alongside improving coverage of institutional deliveries, is critical to improve maternal outcomes. It is necessary to strengthen providers’ clinical and problem solving skills through capacity building initiatives beyond pre-service training, such as through onsite mentoring and supportive supervision programs. This should be backed by a health systems response to streamline staffing and supply chains in order to improve the quality of emergency obstetric care.

In vivo arginine production and nitric oxide synthesis in pregnant Indian women with normal and low body mass indices

Background/Objectives:Nitric oxide (NO) has been proposed as a mediator of vascular expansion during pregnancy. Inability to increase NO synthesis and/or production of its precursor, arginine, may be a contributor to pregnancy-induced hypertension or preeclampsia. Because maternal weight is associated with blood pressure and risk of preeclampsia during pregnancy, it may also influence arginine and/or NO production. The purpose of this study was to determine the in vivo arginine production and NO synthesis rate in pregnant women with normal (n=10) and low (n=10) body mass indices (BMIs).Subjects/Methods:Arginine flux and NO synthesis rate were measured in the postabsorptive state with constant infusions of 15N2-arginine and 13C,2H4-citrulline. Plasma concentrations of arginine and NO metabolites were also measured. Kinetic parameters were correlated to maternal variables, gestational age, birth weight and blood pressure.Results:Endogenous arginine flux was significantly faster in the low-BMI compared with normal-BMI women in the first trimester (63.1±3.4 vs 50.2±2.0 μmol/kg per h, P<0.01), but not in the second. Plasma NO concentration was higher (44.7±5.3 vs 30.4±1.9 μmol/l, P=0.03) and its rate of synthesis trended faster in the low-BMI compared with normal-BMI group in the second trimester. Maternal weight and BMI were negatively correlated with arginine flux in both trimesters and NO synthesis in the second trimester.Conclusions:These findings suggest, but do not prove, that maternal BMI may be a factor in the ability to produce NO during pregnancy and may be one way by which BMI influences blood pressure during pregnancy.

Whole body methionine kinetics, transmethylation, transulfuration and remethylation during pregnancy

BACKGROUND & AIMS There is evidence from a study of pregnant American women that methionine transmethylation (TM) and remethylation (RM) rates increases and transulfuration (TS) decreases as pregnancy progresses from trimester 1 to 3. To determine whether pregnant Indian women can make this adaptation successfully, methionine kinetics, TS, TM, and RM were measured in Indian women in early and late pregnancy. METHODS Measurements were made in the postabsorptive and fed states in the 1st and 3rd trimesters of pregnancy by infusing 1-(13)C,(2)H3-methionine in 24 women, 12 with low (≤150 pmol L(-1)) and 12 with normal (≥200 pmol L(-1)) vitamin B12 status at recruitment. RESULTS From trimester 1 to 3, except RM which decreased significantly, there was no change in any weight-specific methionine kinetic parameter. When expressed per whole body, methionine flux from protein breakdown increased significantly from trimester 1 to 3 in the fed and postabsorptive states. Flux to protein synthesis also increased significantly in the fed state. Rates of TM, TS and RM did not change, regardless of vitamin B12 status at recruitment. Protein and methionine intakes correlated with TM and RM rates and the change in RM from trimester 1 to 3 correlated with the change in dietary protein intake. CONCLUSION These results suggest that methionine flux and its utilization for protein synthesis increases in Indian women as pregnancy progresses from trimester 1 to 3. TM and RM rates do not increase however, possibly because of inadequate protein intake and not because of vitamin B12 deficiency at trimester 1.