Krishna Agarwal

Treatment and Prevention of Rh Isoimmunization

Rhesus (Rh) isoimmunization is an important clinical entity in India and other developing countries, which is responsible for fetal anemia and hydrops fetalis, and if not treated, it can result in intrauterine fetal demise. Rh isoimmunization is responsible for severe jaundice in neonates, which can be severe enough to cause kernicterus with debilitating consequences, if not treated adequately. It can be prevented with simple measures and treated if recognized in time.

Obstetric outcome in women with hepatitis C virus infection and thyroid dysfunction.

Objectives. To determine the incidence of thyroid abnormality in pregnant women with hepatitis C virus (HCV) infection and evaluate pregnancy outcomes with respect to thyroid function status. Design. Prospective cohort study. Setting. Tertiary care hospital. Population. Pregnant women with HCV infection. Methods. Seventy‐eight HCV positive women had radioimmunoassay thyroid function tests. All were followed until delivery. Pregnancy outcomes were compared in women with and without subclinical hypothyroidism. Main outcome measures. Maternal and perinatal outcomes. Results. Of 78 anti‐HCV antibody positive pregnant women, 13 (16.7%) had abnormal thyroid‐stimulating hormone (TSH) (>5 mIU/L; hypothyroid group) and the remaining 65 (83.3%) had normal TSH values (euthyroid group). None had abnormal free T4 levels. None showed evidence of fetal distress in labor or fetal asphyxia. In the hypothyroid group, 23% compared to 6.2% in euthyroid group underwent cesarean section (p = 0.07). The incidence of preterm delivery (7.7% vs. 24.6%; p = 0.28), mean gestation at delivery (38.2±1.8 vs. 37.5±1.8 weeks, p = 0.19), and birthweight (2,687±430 g vs. 2,846±379 g, p = 0.18) was comparable. Neonatal nursery admissions were comparable. Conclusion. The presence of subclinical hypothyroidism in pregnant women with HCV infection does not adversely affect short‐term pregnancy outcomes.

Safety of Delayed Umbilical Cord Clamping in Preterm Neonates Less than 34 weeks Gestation

To the Editor: Delayed cord clamping (DCC) is recommended in infants born at or above 34 wk; however, there is a concern about its safety in babies born at less than 34 wk [1–3]. We conducted a study with a primary objective of comparing the rates of hyperbilirubinemia and polycythemia during initial 7 d in infants born at less than 34 wk of gestation who were randomized to either DCC by 120 s or early cord clamping (ECC) within less than 30 s. Hundred pregnant womenwere randomly subjected to DCC or ECC at the time of birth in a tertiary referral hospital setting. Blood samples of the newborns were taken at 48 h and 7 d for hematocrit measurements. Serum bilirubin levels were estimated once the infants had clinically significant jaundice or at 72 h. Mean hematocrit at 48 h was 56.0 ± 2.5% in DCC as compared to 45.5 ± 2.0% in ECC and at 72 h, hematocrit was 51.6 ± 2.3% in DCC as compared to 42.1 ± 1.6% in ECC. Mean hematocrit at 48 h and 7 d was significantly higher in the DCC group as compared to the ECC group (p < 0.001), suggesting that DCC helps to increase placental transfusion in preterm infants. None of the babies in either group had polycythemia (hematocrit ≥65%). Mean total serum bilirubin level at 72 h of birth was 6.6 ± 1.2 mg/dl in DCC group and 8.7 ± 1.6 mg/dl in ECC group. There was no increased risk of hyperbilirubinemia in the DCC group. None of the babies in DCC group and one baby in EEC group had required phototherapy. In our study, delaying umbilical cord clamping up to 120 s after birth as compared to early cord clamping (within 30 s of birth), in infants born at less 34wk of gestation does not increase the risk of polycythemia, hyperbilirubenemia and need for phototherapy during initial 7 d of life. DCC is also found to be significantly effective in increasing the hematocrit at 48 h and at 7 d of life as compared to ECC with no significant difference in length of NICU and hospital stay between the two groups.

Visual Inspection Methods for Cervical Cancer Prevention

Cervical cancer is the most common cancer in Indian women, accounting for about 1,320,000 new cases each year and 73,000 deaths per year. It has a long preinvasive stage and so screening strategies are effective in decreasing the morbidity and mortality associated with cervical malignancy. Visual screening methods are important screening modalities for low resource countries as they require minimum infrastructure and manpower. These methods can also be used to facilitate “see and treat” protocols especially in populations with poor compliance.

Unusual Rhesus Antibodies as a Cause for Fetal Isoimmunisation

Hemolytic disease of the newborn due to Rh isoimmunisation in a Rhesus D (Rh-D) negative mother with an Rh-D positive fetus is a well recognised entity. Although antibody to Rh-D antigen (anti-D antibody) was once the major cause of hemolytic disease of the fetus and newborn (HDFN), widespread adoption of antenatal and postnatal prophylactic anti-D immunoglobulin administration has resulted in a marked decrease in the prevalence of allo-immunisation due to the Rh-D antigen during pregnancy. However, at the same time, the maternal allo-immunisation to other red cell Rhesus antigens became more evident as a cause for HDFN, since no prophylactic immunoglobulins are available to prevent the formation of these antibodies. The authors report a case of a pregnant woman with AB negative blood group and positive indirect Coombs test (ICT) with rising middle cerebral artery peak systolic velocity (MCA-PSV) on follow up visits. Fetus required intrauterine transfusion. Fetal cord blood sampling revealed the fetus to be B negative and the direct Coombs test (DCT) was positive. On further testing, maternal serum was found to be positive for anti-D, anti-C and anti-G antibodies. Postnatally, the baby required double volume exchange transfusion. The authors highlight the importance of irregular antibody screening for women with obstetric history suggestive of HDNF. This could help in diagnosis and successful treatment of the affected fetus.

Pregnancy at 65, risks and complications

A 65-year-old postmenopausal pregnant woman was referred with antepartum hemorrhage at 29 weeks of gestation. Postadmission diagnosed with chronic hypertension, gestational diabetes mellitus, valvular heart disease, and placenta previa. Her pregnancy was terminated by cesarean delivery at 32 weeks as she had a bout of bleeding per vaginum. Most of the placenta was adherent with no plane of cleavage; therefore, cesarean hysterectomy was performed. Baby birth weight was 1650 g and was shifted to nursery for observation and mother needed Intensive Care Unit care postcesarean. On the 15th day, both healthy mother and baby were discharged. Although pregnancy is possible in postmenopausal women with hormone support but the incidence of complications remain very high. It raises a need for developing well-laid guidelines for performing in vitro fertilization in older age group women.