Rekha Sachan

Acute renal failure in pregnancy: Tertiary centre experience from north Indian population

Background: Obstetrical acute renal failure ARF is now a rare entity in the developed countries but still a common occurrence in developing countries. Delay in the diagnosis and late referral is associated with increased mortality. This study aimed to evaluate the contributing factors responsible for pregnancy-related acute kidney failure, its relation with mortality and morbidity and outcome measures in these patients. Materials and Methods: Total 520 patients of ARF of various aetiology were admitted, out of these 60 (11.5%) patients were pregnancy-related acute renal failure. Results: ARF Acute renal failure occurred in 32 (53.3%) cases in early part of their pregnancy, whereas in 28 (46.7%) cases in later of the pregnancy. Thirty-two (53.3%) patients had not received any antenatal visit, and had home delivery, 20 (33.4%) patients had delivered in hospitals but without antenatal care and eight (13.3%) patients received antenatal care and delivered in the hospitals. Anuria was observed in 23 (38.3%) cases, remaining 37 (61.7%) cases presented with oliguria. Septicemia was present in 25 (41.7%), hypertensive disorder of pregnancy in 20 (33.3%), haemorrhage in eight (13.3%), abortion in 5 (8.3%), haemolysis elevated liver enzymes low platelets counts (HELLP) syndrome in one (1.67%) and disseminated intravascular coagulation in one (1.67%). (61.7%) patients were not dialyzed, 33 (55%) recovered normal renal function with conservative treatment. Complete recovery was observed in 45 (75%) patients, five (8.4%) patients developed irreversible renal failure. Maternal mortality was nine (15%) and foetal loss was 25 (41.7%). Conclusion: Pregnancy-related ARF is usually a consequence of obstetric complications; it carries very high morbidity and mortality.

correlation of serum neutrophil gelatinase- associated lipocalin with acute kidney injury in hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP) remain one of the largest single causes of maternal and fetal morbidity and mortality, accounting for 16.1% of maternal deaths in developed countries. The aim of the study was to evaluate acute kidney injury (AKI) in hypertensive disorders of pregnancy and to examine the correlation of serum neutrophil gelatinase-associated lipocalin (NGAL) with acute kidney injury. This prospective case control study was carried out over a period of 1 year. After written, informed consent and ethical clearance, 149 cases of hypertensive disorders of pregnancy were screened, and seven were lost to follow-up. Acute kidney injury was detected in 88 cases and acute renal failure in 30 cases of HDP. Thirty-one healthy pregnant nonhypertensive women were enrolled as controls. Quantitative measurement of serum NGAL levels was done by enzyme linked immunosorbent assay technique using a sandwich enzyme-linked immunosorbent assay kit. As per the Kidney Diseases Improving Global Outcomes International guidelines acute kidney injury network (AKIN), 50 cases (42.37%) of AKI stage I, 38 (32.2%) cases of AKI stage II, and 30 (25.42%) cases of renal failure were detected. Serum NGAL had a positive association with increasing proteinuria. It also had a positive correlation with systolic blood pressure (r∼0.36), diastolic blood pressure (r∼0.37), and serum creatinine (r∼0.4). NGAL was found to be significantly correlated with creatinine in the cases with the value of the correlation coefficient being 0.4. This direct correlation might be a consequence of endothelial dysfunction on which hypertension and proteinuria probably depends.

Genital tuberculosis with variable presentation: a series of three cases.

Tuberculosis (TB) is still frequently observed in third-world countries like Africa and Asia. Here we report three cases of genital TB with variable presentation. First case was a lady of reproductive age group who presented with polymenorrhagia and postcoital bleeding with unhealthy cervix. Histopathology of cervical tissue revealed tubercular cervicitis. Second and third cases presented with different complaints like discharge per vaginum, postcoital bleeding and pain in lower abdomen with growth over the cervix. Cervical biopsy was inconclusive of TB but endometrial tissue sampling for TB PCR was positive. This shows that newer diagnostic marker test can help us to detect secondary genital TB.

Outcomes in hypertensive disorders of pregnancy in the North Indian population.

Introduction: Hypertensive disorders complicating pregnancy seriously endanger the safety of the mother and fetus during pregnancy. Very few studies have explored hypertensive disorders of pregnancy in India, even though this disease has been associated with adverse maternal and perinatal outcomes. This study aimed to analyze the disease pattern and risk factors associated with the disorder and assess the maternal and fetal outcomes in cases of hypertensive disorders of pregnancy. Subjects and methods: This case-control study was carried out over 1 year from 2011 to 2012 at the Department of Obstetrics and Gynecology, King George’s Medical University, Lucknow, Uttar Pradesh, India. A total of 149 patients were enrolled in the study. As seven were lost to follow-up, analysis was carried out on 142 cases. Patients were further classified according to the National High Blood Pressure Education Program Working Group (2000) as having mild preeclampsia (65 cases), severe preeclampsia (32 cases), or eclampsia (45 cases). Thirty-one healthy pregnant non-hypertensive women were enrolled into the study as controls. Results: The most common manifestation was edema, seen in 90% of cases. Proteinuria was also relatively common, 26.76% of patients with proteinuria of ≥300 mg/24 hours, 47.88% with proteinuria of ≥2 g/24 hours, and 25.35% with a urinary protein excretion of 3–5 g/24 hours. Central nervous system involvement was observed in 42.2% of cases, elevated bilirubin levels in 47.0%, visual symptoms in 6.4%, vaginal bleeding in 11.3%, and HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome was reported in 2.80%. Maternal deaths occurred in 2.8% of cases, all of which were from the eclampsia group. Stillbirths occurred in 16.9% of cases, and overall neonatal death observed in 4.23% of cases. Conclusion: Women with hypertensive disorders of pregnancy were more prone to adverse maternal and fetal outcomes than normotensive pregnant women, but we observed a decreasing trend in the present study compared with that reported in other studies, which might be due to the increased number of hospital deliveries that occurred in our study.

Ischemic Stroke in Young due to Combined Protein C and S Deficiency

WHO defines stroke as an event caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue [1]. Globally, stroke is the third commonest cause of mortality [2] and the fourth leading cause of disease burden [3]. Ischemic stroke is the most common cerebrovascular disease, most often due to atherothrombotic diseases and uncommonly by disorders of hypercoagulation. Disorders of coagulation leading to thrombotic disorders are approximately 1% of all ischemic strokes and 4-8% of young strokes. Similarly combined deficiency of protein C and S can lead to hypercoagulable state and rarely present as cerebrovascular accident. We describe here a rare case of 27 year old male who presented with right middle cerebral artery territory infarct due to combined protein C and S deficiency.

Diagnostic and prognostic significance of serum soluble endoglin levels in preeclampsia and eclampsia

Background: Preeclampsia is a multisystem disorder of unknown etiology that affects 4–5% of all pregnancies. The aim of the study was to evaluate the diagnostic accuracy of serum soluble endoglin (sEng) in preeclampsia and eclampsia and also to evaluate its prognostic significance. Materials and Methods: This prospective case–control study carried out over a period of 1 year in the Department of Obstetrics and Gynaecology, King George Medical University, Lucknow. After written informed consent and ethical clearance, total 90 subjects were enrolled. Among them, 30 subjects of eclampsia, 15 of nonsevere preeclampsia, 15 of severe preeclampsia served as cases, and 30 healthy pregnant normotensive women served as controls. Levels were estimated by enzyme-linked immunosorbent assay technique in both cases and controls. Results: Mean level was highest in eclampsia group (14.96 ± 1.96 ng/mL) and lowest in controls (2.08 ± 0.56 ng/mL). At cut-off value of sEng levels of ≥6.26 ng/mL, it was found to be 100% sensitive and 100% specific for the diagnosis of preeclampsia (area under curve =1) at 95% confidence interval. sEng levels were strongly correlated with systolic (r = 0.928) and diastolic blood pressure (r = 0.916), serum lactate dehydrogenase (r = 0.791) and serum uric acid (r = 0.722). All four maternal deaths were reported within eclampsia group, in whom the mean sEng level was significantly higher (17.84 ± 0.22) as compared to other subjects (9.50 ± 5.80). Conclusion: sEng is a novel marker for diagnosis of preeclampsia, and it can also be used as a prognostic marker to predict the severity of preeclampsia.

Neutrophil gelatinase-associated lipocalin as a biomarker of disease progression in patients with chronic kidney disease

Chronic kidney disease (CKD) is associated with early mortality, decreased quality of life and increased health care expenditures. The aim of this study was to determine whether or not urinary NGAL (uNGAL) level is associated with renal damage and kidney disease progression in patients with CKD and to evaluate the predictive value of uNGAL in progression of CKD. Totally, 91 cases of CKD stage II, III, IV, and 50 age-matched healthy controls were enrolled. The follow-up end-point was 18 months; end-point of the study was progression to an estimated glomerular filtration rate (eGFR) of <15 ml/min and/or CKD stage V. Forty-five cases (49.4%) were progressors and 46 were nonprogressors. uNGAL levels were significantly higher in CKD subjects as compared to healthy controls (log 1.09 ± 0.22 μg/ml in controls versus log 1.22 ± 2.08 μg/ml in stage II, log 3.34 ± 2.74 μg/ml in stage III and log 3.70 ± 0.18 μg/ml in stage IV). Univariate Cox proportional hazards model showed that only eGFR (hazard ratio [HR]: 0.95; 95% confidence interval [CI]: 0.93–0.96; P < 0.001) and uNGAL (HR: 1.11; 95% CI: 1.01–1.20; P < 0.001) were significantly associated with end-point of CKD stage V, but multiple Cox proportional regression model showed significant association of uNGAL (HR: 1.11; 95% CI: 1.01–1.20; P < 0.001) and eGFR (HR: 0.962, 95% CI: 0.95–0.98; P < 0.001) with end-point of CKD stage V. This suggests that uNGAL would not be a simple surrogate index of baseline eGFR, but a marker of CKD progression beyond the information provided by eGFR estimation.

Complete axial torsion of pregnant uterus with leiomyoma.

Uterine torsion is defined as a rotation of the uterus of more than 45° along its long axis. It is a rare complication during pregnancy; a common cause of torsion can be uterine myoma. Here we describe the case of a 27-year-old G2P1+0 woman at 15 weeks 3 day pregnancy, who presented to our outpatient department as a case of acute abdomen, in a state of shock. Clinical findings did not correlate with investigation. On lapratomy she was diagnosed as a case of complete axial torsion of pregnant uterus with fundal myoma with massive abruption. Early diagnosis and timely intervention would help in improving both maternal and fetal outcome.

Correlation of serum neutrophil gelatinase associated lipocalin with disease severity in hypertensive disorders of pregnancy

Background: Vascular endothelial dysfunction is considered central to the pathogenesis of hypertensive disorders of pregnancy (HDP). Serum level of neutrophil gelatinase-associated lipocalin (NGAL) is closely related to endothelial injury. The aim of this study was to examine the correlation of serum NGAL with disease severity in HDP. Materials and Methods: This prospective case-control study was carried out for one year. After informed consent, ethical clearance, total 1,850 pregnant women were screened. Analysis was performed on 142 cases of HDP and 31 healthy controls. Quantitative measurement of serum NGAL levels was done by the enzyme linked immunosorbent assay (ELISA) technique, by using sandwich ELISA kit. Results: Mean serum NGAL value in patients with oliguria was significantly higher when compared with non-oliguric patients (P < 0.001). Serum NGAL had a positive correlation with systolic blood pressure (r ~ 0.5973), diastolic blood pressure (r ~ 0.6195), blood urea (r ~ 0.4392), serum creatinine (r ~ 0.6112), serum uric acid (r ~ 0.3878). Sensitivity and specificity of serum NGAL using a cut-off value of 545 pg/ml, for the diagnosis of HDP, was 97.89% and 93.55% respectively, using 95% confidence interval. Conclusion: Between the two groups, we found that serum NGAL had a positive correlation with disease severity and better sensitivity and specificity in the evaluation of HDP.

Schwannoma of the brachial plexus: a rare cause of monoparesis

Schwannomas, also referred as neurilemmomas, are benign, encapsulated perineural tumour of neuroectdermal derivative that originate from the schwan cells of the neural sheath of motor and sensory peripheral nerves. About 25% of schwannomas occur in the head and neck region,1 usually involving cranial nerves and sympathetic chain; however, brachial plexus schwannomas are uncommon, occurring in 0.3–0.4/100 000 person per year.2–4 Their malignant potential is low, they can be locally destructive if allowed to progress. Primary tumours of the brachial plexus are unusual. Patients commonly seek medical attention because of pain and loss of function of the affected part of the body. We report a case of schwannoma arising from left brachial plexus and presented as monoparesis of left upper limb. A young …