Arunima Chaudhuri

Fetomaternal outcome in obstructed labor in a peripheral tertiary care hospital

Background: Obstructed labor is the leading cause of hospitalization, comprising up to 39% of all obstetric patients in developing countries. It is the single most important cause of maternal death and is one of the three leading causes of perinatal mortality. Objectives: To study the different parameters of obstructed labor cases, like its frequency, etiology, management, and complications. This will help to formulate a positive strategy to prevent obstructed labor and its consequences. Materials and Methods: 313 patients admitted with features of obstructed labor were studied. By clinical examination, diagnosis of cephalopelvic disproportion, malposition, malpresentation, obstruction in birth canal, overdistended bladder, hematuria, rupture of uterus, and supermolding of fetal head was done. Screening for maternal exhaustion, dehydration, genital sepsis, pyrexia, rupture of uterus, postpartum hemorrhage, vesico-vaginal fistula, and shock was carried out. Deaths as a consequence of obstructed labor were noted. Diagnosis of asphyxiated or dead fetus or neonatal death was done. Mode of delivery and time interval between referral, admission, intervention done, and related feto-maternal outcome were noted. Statistical analysis was done using Epi Info software. Results: Majority of the patients (87.86%) were from low socioeconomic group, 88.82% were from rural areas, 16.16% were illiterate, and 27.79% were unbooked. The commonest cause of obstructed labor was cephalopelvic disproportion (55.59%). Other causes were malposition (23%), malpresentation (18.21%), fetal congenital abnormality (1.28%), myoma (0.32%), and non-dilatation of cervix (1.60%). The commonest mode of delivery was cesarean section (85.94%). Instrumental deliveries formed 9.58%. Destructive operation was done in 1.92% cases. Rupture uterus was seen in 8 (2.56%) cases, out of which hysterectomy was done in 5 cases and repair in 3 cases. The common maternal complications were sepsis [pyrexia 49.8%, urinary tract infection (UTI) 10.9%, wound infection 7.7%] and post-partum hemorrhage (PPH; 33.9%). Other complications were rupture uterus (2.56%), subinvolution (9.3%), shock (2.2%), bladder injury (1.9%), hysterectomy (1.6%), broad ligament hematoma (1.28%), maternal death (1.6%), vesico-vaginal fistula (VVF; 0.6%), and rectovaginal fistula (RVF; 0.3%). Perinatal mortality rate was 71/313 (22.68%), still birth rate was 57/313 (18.21%), and live birth rate was 256/313 (81.79%). Perinatal morbidity (in 198 cases) was most commonly due to birth asphyxia (29.68%), jaundice (16.80%), septicemia (14.84%), and meconium aspiration syndrome (9.77%). Incidence of PPH, still birth, perinatal mortality, and cesarean section was significantly higher among multiparous women. Conclusions: Cephalopelvic disproportion is the commonest cause of obstructed labor, and proper antenatal care, early diagnosis, and timely intervention may result in decrease in incidence of morbidity and mortality.

The potential role of short-term heart rate variability tests in identifying risk of hypertension in normotensive offspring of hypertensive parents

Background: Hypertension is one of the leading causes of cardiovascular death and is primarily silent as there is hardly any symptom before target organ damage. Heredity and autonomic nervous system play pivotal roles in pathogenesis of essential hypertension. Aims: To detect early cardiovascular autonomic changes by heart rate variability (HRV) before overt hypertension, among the offspring having family history of essential hypertension. Materials and Methods: 34 normotensive offspring aged 19-24 years with parental history of essential hypertension were included as study group and the control group included 32 age, sex, and body mass index (BMI) matched normotensive offspring having normotensive parents. Resting pulse, blood pressure, and short-term supine HRV was recorded initially followed by standing HRV. Results: A statistically significant increase in resting diastolic blood pressure in study group indicated increased sympathetic tone. Postural stress in the study group revealed a greater increase (P < 0.0001) in low frequency (LF) spectrum and simultaneous greater decrease (P < 0.0001) in high frequency (HF) band as compared to control group (P < 0.05). These findings indicate greater dysfunction in both autonomic branches associated with alterations in baroreflex function in the study group. Conclusions: Current study provides an evidence of early impairments in autonomic cardiovascular regulation in young adults having hereditary history of hypertension. Early lifestyle modification with sports activity may help in improving autonomic functions and thus decrease morbidity and mortality due to cardiovascular diseases.

Relationship of gender and lipid profile with cardiac parasympathetic reactivity

Background: Lower heart rate variability has been proven to be associated with a greater risk for developing hypertension among normotensive men, and hypertension is one of the major risk factor of coronary heart disease. Hormonal factors in premenopausal women may cause variance in heart rate variability and impact lipid profile. Objectives: The study was designed to evaluate the relationship of gender and lipid profile with cardiac parasympathetic reactivity. Materials and Methods: Sixty premenopausal and 60 postmenopausal women along with 60 young and 60 elderly, age and body mass index (BMI) matched men without any apparent illness were selected. Cardiac parasympathetic reactivity during Valsalva maneuver, deep breath test, and 30:15 R–R interval ratios were studied and lipid profile analyzed. Results: Lipid profile showed significant increase in values of total cholesterol, low density lipoprotein (LDL), triglyceride, and significant decrease in high density lipoprotein (HDL) values in younger males when compared with premenopausal females and no difference in these parameters were noticed when comparison was done between elderly males and females. Deep breath test and 30:15 R–R interval ratios showed significant decrease in values in younger males when compared with age matched premenopausal females. Total cholesterol, triglyceride, LDL were negatively correlated with parasympathetic function tests; whereas HDL was positively correlated with parasympathetic function tests. Conclusion: Sex hormone levels may alter the autonomic nervous system response and lipid metabolismand lipids play an important role in modulation of autonomic functions.

A study of autonomic functions and obesity in postmenopausal women

Background: Easy accessibility to Medicare and better living conditions has increased life expectancy in recent years. There are over 60 million postmenopausal women above 55 years in India. Obesity, physical inactivity, and altered estrogen metabolism play an integrated role in contributing to the disease risk profile of postmenopausal women. These same risk factors also affect modulation of the autonomic nervous system. A study was undertaken to test the hypothesis whether there is indeed an alteration in autonomic functions in obese postmenopausal women. Materials and Methods: 60 postmenopausal women without any gross systemic disease whose body mass index and waist/hip ratio were recorded. Subjects were divided into two groups of 36 Non-Obese and 24 Obese. The two groups were well matched for age and menopausal duration. The physical as well as physiological parameters like valsalva ratio, heart rate variation with deep breath test, heart rate response to postural change (30:15 R-R interval ratio), orthostatic tolerance test, and isometric handgrip test were recorded. Results: Results of valsalva ratio, deep breath test, and 30:15 R-R interval ratios and isometric handgrip test were significantly decreased and orthostatic tolerance values were significantly increased in Obese subjects. Conclusion: Findings show decreased sympathovagal activity with obesity in postmenopausal women.

Management of displaced supracondylar fracture of the humerus in children

Background: There have been controversies regarding the ideal method of treatment of displaced supracondylar fractures of the humerus in children. Aims: The aim was to treat displaced supracondylar fractures of the humerus in children by conservative method and if results are not acceptable then by operative method and evolve a management protocol which will provide minimum complications with available facilities. Materials and Methods: This prospective study was conducted in a tertiary care hospital in a time span of 1-year. Ninety patients with Gartland′s Type II and Type III fractures were initially subjected to closed manipulative reduction, of which acceptable reduction could be achieved only in 27 patients. Sixty-three patients who had unacceptable results were subjected to operative treatment. The final results of the treatment were assessed using the criteria of Flynn et al. Results: Among the Gartland′s Type II fracture patients, acceptable reduction was achieved in 9 patients. Among Type III fracture, acceptable reduction was achieved in 18 patients (25%). The conservative treatment yielded excellent results for 9 patient and good for 9 patients. Of the 63 patients subjected to operative treatment, 15 patients had excellent result (23.81%), 24 good (38. 10%), 15 fair (23.81%), and 9 poor (14.29%). Satisfactory result was achieved in 39 patients (61.90%). Conclusion: Closed reduction in case of supracondylar displaced fracture of the humerus in children still remains an option in a developing country. It may be, followed by closed operating techniques when results are not acceptable as this delay does not affect functional outcome.

Effects of exercise training on correlation of VO 2 max and anthropometric parameters, physical fitness index in young adult Indian males

Background: The lack of physical activity and sedentary lifestyles in the young generation have been a matter of concern in recent days, and about 3.3% of all deaths can be attributed to physical inactivity. Aims: To assess the effects of an exercise program on correlation of VO 2 max and anthropometric parameters, Physical Fitness Index (PFI). Materials and Methods: This pilot project was carried in a time span of 2 years in a tertiary care hospital on 100 young adult male subjects. Untrained Group comprised of 100 healthy young adult males. History was recorded followed by anthropometry and clinical examination. Body mass index (BMI) was calculated. Resting pulse rate, blood pressure, heart rate variations during deep breathing, VO 2 max, PFI were measured. These subjects were given training of aerobic exercises for a time span of 1 year. After completion of 1 year of training, all parameters were re-evaluated. Results: BMI, pulse rate and blood pressure, were significantly lower in trained individuals. Heart rate variations during deep breathing, VO 2 max, PFI were significantly increased following training. A good negative correlation was seen between BMI and VO 2 max amongst the untrained subjects (Pearson coefficient of −0.673), which was statistically significant at P < 0.0001. However, the correlation between VO 2 max and BMI amongst the trained subjects was a weak negative correlation (Pearson′s correlation coefficient of −0.202. The correlation between VO 2 max and pulse amongst the trained subjects also showed a negative correlation with a Pearson′s correlation coefficient of −0.271. The correlation between VO 2 max and PFI amongst the trained subjects was strong with a Pearson′s correlation coefficient of 0.792. Conclusions: Regular exercise training decrease resting pulse rate, blood pressure and increase VO 2 max, heart rate variations during deep breathing, PFI. These positive physiological outcomes of exercise and training have important implications in the prevention of cardiovascular diseases and needs to be popularized among younger generations.

Comparative study of treatment of fracture shaft femur by intramedullary interlocking nails through piriform fossa entry and tip of the greater trochanter entry approach

Background: Several techniques and tools are available for achieving fracture reduction during antegrade intramedullary nailing of femur fractures. Aims: To compare results of femoral shaft fracture treatment with nailing through the greater trochanter to nailing through the piriformis fossa (PF). Materials and Methods: The present pilot project was conducted in a time span of 1-year. The patients admitted with femoral diaphyseal fractures were alternately selected for antegrade nailing through PF group and greater trochanter entry (GTE group) approach. Total number of patient in each group was 15 (n = 15). Results: Complications of nailing: PE group - 6.7% infection, 20% malunion, 20% delayed union, 20% restriction of hip range of motion (ROM), 6.7% restriction of knee ROM, 13.3% limb length discrepancy, 13.3% hardware prominence. GTE group - 13.3% malunion, 13.3% delayed union, 33.3% Restriction of hip ROM, 6.7% restriction of knee ROM, 20% limb length discrepancy, 26.7% hardware prominence. Radiological union time in PE was 12-15 weeks in 5 patients, 16-19 weeks in 8 patients, 20-23 weeks in 1 and >24 weeks in 1 patient. Radiological union time in GTE was 12-15 weeks in 4 patients, 16-19 weeks in 9 patients, 20-23 weeks in 2 patients. Need for dynamization was 20% in the PE group and 13.3% in GTE group. Thoresen′s scoring system showed no significant difference between the two groups. Conclusion: Femoral nailing through the greater trochanter with specifically designed nails and with attention to specific techniques for such insertion should be considered a rational alternative to femoral nailing through the PF with the benefit of reduced requirement for fluoroscopy and decreased operative time.

Comparative study of fixation of proximal tibial fractures by nonlocking buttress versus locking compression plate

Background: Management of tibial plate fracture represents a challenging problem in developing countries. Aims: To compare the results of treatment of tibial plateau fractures with conventional nonlocking buttress plates (BP group) and locking compression plates (LCPs). Materials and Methods: The study was conducted on 30 patients with intra-articular closed fractures of the proximal tibia who were alternately assigned to two different treatment protocol, conventional nonlocking BP group or locking plates (LP group). Results : Schatzker Type II fracture was found to be the commonest fracture type with 13 patients. Only lateral plating was done in 24 patients, and dual plating was done in 6 patients. In 8 patients, corticocancellous bone graft were used. On follow-up complications like superficial skin necrosis (two cases), infection (two cases), varus collapse (three cases) developed. Sixty percent in LCP group, 66.6% in buttress group fractures clinically united in the time period of 7-9 weeks and 73.3% in LCP group and 80% in buttress group radiological union occurred in a period of 12-15 weeks. The results were graded in accordance with Poul S. Rasmussen′s grading system. During the follow-up, 73.3% in LCP group and 66.6% in buttress group had no pain after clinical union. 66.6% patients in LCP group and 73.3% in buttress group could perform normal walking. About 86.6%in each group had no lack of extension. Nine patients (60%) in LCP group and 10 patients (66.6%) had flexion of up to at least 140°. About 86.6% in LCP group and 80% in buttress group had a stable joint in extension. Conclusion: Considering its high cost, LP group should only be used, where it is more advantageous than conventional plate.

Electrocardiographic changes in patients of postcerebrovascular accident in rural population of Eastern India

Background: Disorders of the central nervous system cause a wide array of cardiovascular disorders. Aims: The present study was conducted to study the pattern of electrocardiogram (ECG) changes associated with acute stroke in recovery phase among patients without cardiovascular diseases in a rural population of a developing country. Materials and Methods: The present study was conducted in a tertiary care hospital of eastern India in a time span of 1 year. Study group consisted of hundred postcerebrovascular accident (CVA) patients during recovery stage and age and gender matched hundred subjects with no history of CVA or cardiac dysfunction in present or past were chosen as control. Results: Average heart rate of controls was 76.58 ± 6.31 per min and in stroke it was 69.74 ± 12.03 per min. The P value was significant (<0.01). Axis, P-R interval, ST segment, Q-Tc intervals were significantly worse in patients suffering from stroke as compared to normal. Average heart rate of ischemic stroke patients was 71.36 ± 12.17 per min and in the haemorrhagic stroke was 65.12 ± 10.52 per min. The P value was significant (0.02FNx01 < 0.05). There was no significant difference in other ECG parameters among the two groups of stroke patients. Conclusion: The major ECG abnormalities are S-T segment depression, prolonged corrected Q-T interval and abnormalities in heart rate and rhythm following CVA and are nearly identical in ischemic and haemorrhagic CVA. The patients of acute CVA in developing countries need to be treated with proper follow-up considering the neurological as well as cardiological complications.

Role of magnesium sulfate in prolonging the analgesic effect of spinal bupivacaine for cesarean section in severe preeclamptics

Background: Magnesium sulfate, N-methyl-d-aspartate receptor antagonist, has both analgesic and sedative properties. Aim: The aim was to evaluate the analgesic efficacy of perioperative intravenous (i.v) magnesium sulfate in severe preeclamptic patients scheduled for cesarean section under spinal anesthesia. Subjects and Methods: A double blind prospective randomized controlled study was designed conducted on 80 patients randomly allocated into two equal groups (n = 40) to receive either bupivacaine heavy intrathecally - Group B (control group) or bupivacaine heavy intrathecally along with i.v magnesium sulfate - Group BM (study group). Magnesium sulfate 40 mg/kg diluted in 100 ml of normal saline was administered over 15 min about 30 min prior to surgery followed by continuous infusion at the rate of 10 mg/kg/h for the next 24 h while the other group received similar volume of normal saline in the same manner. Intraoperatively, patients were monitored for hemodynamic perturbations, respiratory rate, urine output, Apgar score, uterine tonicity, and any other adverse effects. Postoperatively, duration of analgesia, number of rescue analgesics, signs of any magnesium toxicity, and incidence of postpartum eclampsia in the first 24 h were recorded. Data were analyzed using SPSS version 16. Results: At different time intervals, patients in Group BM had less pain than Group B when compared on visual analog scale. Patients in Group BM were significantly more sedated as compared to Group B patients. None of the patients demonstrated bradycardia, hypotensive episodes, hypoxia, or hypoventilation in the postoperative period in the recovery room. There was no significant respiratory depression, Apgar score was comparable, and uterine tonicity was adequate in both the groups. Postoperatively, time required for first analgesic dose was significantly more in Group BM 270 (35.1) min than Group B 223 (31.4) min. There was a significant decrease in total rescue analgesic requirement in Group BM 2.5 (0.4) compared to Group B 3.6 (0.4). Incidence of postpartum eclampsia in study group (one patient) was less than the control group (four patients). Conclusion: Preoperative i.v magnesium sulfate, in severe preeclampsia not only reduces the probability of developing peripartum eclampsia, but also significantly prolongs the duration of analgesia and reduces postoperative analgesic consumption without any significant side effects.