Santosh Joseph Benjamin

Pregnancy Outcome in Relation to Treatment of Murine Typhus and Scrub Typhus Infection: A Fever Cohort and a Case Series Analysis

Background There is a paucity of published reports on pregnancy outcome following scrub and murine typhus despite these infections being leading causes of undifferentiated fever in Asia. This study aimed to relate pregnancy outcome with treatment of typhus. Methodology/Principal Findings Data were analyzed from: i) pregnant women with a diagnosis of scrub and/or murine typhus from a fever cohort studies; ii) case series of published studies in PubMed using the search terms “scrub typhus” (ST), “murine typhus” (MT), “Orientia tsutsugamushi”, “Rickettsia tsutsugamushi”, “Rickettsia typhi”, “rickettsiae”, “typhus”, or “rickettsiosis”; and “pregnancy”, until February 2014 and iii) an unpublished case series. Fever clearance time (FCT) and pregnancy outcome (miscarriage and delivery) were compared to treatment. Poor neonatal outcome was a composite measure for pregnancies sustained to 28 weeks or more of gestation ending in stillbirth, preterm birth, or delivery of a growth restricted or low birth weight newborn. Results There were 26 women in the fever cohort. MT and ST were clinically indistinguishable apart from two ST patients with eschars. FCTs (median [range] hours) were 25 [16–42] for azithromycin (n = 5), 34 [20–53] for antimalarials (n = 5) and 92 [6–260] for other antibiotics/supportive therapy (n = 16). There were 36.4% (8/22) with a poor neonatal outcome. In 18 years, 97 pregnancies were collated, 82 with known outcomes, including two maternal deaths. Proportions of miscarriage 17.3% (14/81) and poor neonatal outcomes 41.8% (28/67) were high, increasing with longer FCTs (p = 0.050, linear trend). Use of azithromycin was not significantly associated with improved neonatal outcomes (p = 0.610) Conclusion The published ST and MT world literature amounts to less than 100 pregnancies due to under recognition and under diagnosis. Evidence supporting the most commonly used treatment, azithromycin, is weak. Collaborative, prospective clinical trials in pregnant women are urgently required to reduce the burden of adverse maternal and newborn outcomes and to determine the safety and efficacy of antimicrobial treatment.

Comparison of neonatal outcomes in women with gestational diabetes with moderate hyperglycaemia on metformin or glibenclamide--a randomised controlled trial.

Two oral hypoglycaemic agents, metformin and glibenclamide, have been compared with insulin in separate large randomised controlled trials and have been found to be as effective as insulin in gestational diabetes. However, very few trials have compared metformin with glibenclamide.

Anthropometric measurements as predictors of cephalopelvic disproportion

Objective. We assessed the efficacy of maternal anthropometric measurements and clinical estimates of fetal weight in isolation and in combination as predictors of cephalopelvic disproportion (CPD). Design. Prospective cohort study. Setting. Tertiary care teaching hospital, two affiliated hospitals with facilities for conducting cesarean delivery and seven affiliated primary care facilities with no operation theaters. Sample. Primigravidae over 37 weeks’ gestation attending these facilities during a 20‐month period with a singleton pregnancy in vertex presentation. Methods. Several anthropometric measurements were taken in 249 primigravidae. Fetal weight was estimated. Differences in these measurements between the vaginal delivery and CPD groups were analyzed. The validity of these measurements in predicting CPD was analyzed by plotting receiver operating characteristic curves and by logistic regression analysis. Main outcome measure. Mode of delivery. Results. Maternal height, foot size, inter‐trochanteric diameter and bis‐acromial diameter showed the highest positive predictive values for CPD. Combining some maternal measurements with estimates of fetal weight increased predictive values modestly, which are likely to be greater if the estimates of fetal weight are close to the actual birth weight. Based on multivariate analysis the risk factors for CPD in our population were foot length ≤23cm, inter‐trochanteric diameter ≤30cm and estimated fetal weight ≥3 000g. Conclusions. Maternal anthropometric measurements can predict CPD to some extent. Combining maternal measurements with clinical estimates of fetal weight only enhances the predictive value to a relatively modest degree (positive predictive value 24%).

Misoprostol versus Foley catheter insertion for induction of labor in pregnancies affected by fetal growth restriction.

To compare 25 μg of vaginal misoprostol with a Foley catheter for induction of labor (IOL) for fetal growth restriction.

Scrub typhus continues to be a threat in pregnancy

Scrub typhus, a zoonosis, caused byOrientia tsutsugamushi is a widely prevalent disease in the Asia–Pacific region. It is transmitted by the bite of the larval trombiculid mite. The clinical features are similar in pregnant and nonpregnant women and include high fever with chills, myalgia, and headache. The eschar is a 5 to 20-mm necrotic lesion on the skin at the site of the vector bite. It is present in 60% of scrub typhus patients and, if present, is pathognomonic for the disease [1]. Scrub typhus can lead to various complications such as pneumonia, acute respiratory distress syndrome, myocarditis, liver failure, acute renal failure, encephalitis, and shock. Opinion varies on the effects of scrub typhus in pregnancy. The aim of the present study was to evaluate the effect and outcome of scrub typhus infection in pregnancy. The medical records of 46 pregnant women with scrub typhus treated at the Christian Medical College, Vellore, India, between January 1, 2011, and December 31, 2012, were reviewed. Patients who had fever at least one day before deliverywere included. Data for four patients were not available and these patients were excluded. The retrospective nature of the study rendered it exempt from informed consent and IRB approval. The patients’ serum was tested for IgM antibodies to Orientia tsutsugamushi using the Scrub Typhus Detect IgM ELISA System (Inbios International Inc, Seattle, WA, USA). The test was performed according to the manufacturer’s instructions and a positive result was identified as an optical density of greater than or equal to 0.5. All 42 pregnant patients included in the study were IgM ELISA positive for scrub typhus. A total of 28 (67%) patients delivered live healthy fetuses, while 14 (33%) patients had pregnancy loss. Of the 6 (14%) patients in the first trimester, 4 (67%) had a spontaneous abortion. Among 16 (38%) patients in the second trimester, 6 (38%) experienced pregnancy loss. Of the 20 (48%) patients in the third trimester, 4 (20%) had an intrauterine death. There was one maternal death due to the infection. In the general population the standard rates of pregnancy loss across all trimesters, in the first trimester, and in the early and late second trimester are 10%−20% [2], 12%–24% [3], and 1%−5% and 0.3% [2], respectively. In the third trimester the background occurrence of stillbirth is 1%−3% [4]. During the study period, there were an average of 1128 pregnant patients per month, with a live birth rate of 97.2% and a pregnancy loss rate of 2.8%. Therefore, pregnancy loss in patients infected with scrub typhus is significantly higher in this setting (33% vs 2.8%; P b 0.001). The hospital is a tertiary care and referral center and the mode of delivery was similar in both groups: 30.5% lower section cesarean delivery rate in the general population compared with 32.7% in patients with scrub typhus. Regarding the associated risk factors, two patients were hepatitis B surface-antigen positive: onehad a live birth and onehad a spontaneous abortion. Three patients had hepatitis E infection: one had a live fetus and two had fetal loss. All patients were younger than 35 years (range, 20−33 years; mean 24.3 years). None of the patients had any associated medical risk factors such as diabetes or hypertension. We could not find any relation between parity and fetal loss. None of the patients had a background of recurrent pregnancy loss or poor obstetric history. All of the patients had fever greater than or equal to 38.3 °C and 15 (36%) patients had an eschar. Among the 14 patients with pregnancy loss, 8 (57%) had an eschar. IgM ELISA is a reliable test for sero-diagnosis of scrub typhus. The optical density value of IgM ELISA for these patients was between 0.656 and 3.336, with a mean of 2.624. Only two of the 42 patients had an optical density value of less than or equal to 1.5. In our experience, optical density of greater than or equal to 1.5 has a very high specificity for scrub typhus. In conclusion, scrub typhus infection in pregnancy carries a high risk of fetal loss. The risk is highest in the first trimester and decreases with advancing gestational age. However, this correlation needs further evaluation in large prospective studies.

A randomised controlled trial comparing 30 mL and 80 mL in Foley catheter for induction of labour after previous Caesarean section

Inducing labour with a Foley balloon catheter rather than using oxytocin or prostaglandins is considered to be less risky if the uterus is scarred.1 It is not known if more fluid in the balloon is more effective without being more dangerous. Volumes of 80 mL and 30 mL were compared in 154 eligible women. Mode of delivery, duration of labour and delivery within 24 h were similar in both groups. However, the second group required oxytocin more frequently. Though more scar dehiscences occurred in the first group, the difference was not significant.

Umbilical Cord Haematoma Causing Still Birth- A Case Report

Still birth continues to be one of the many challenges that an obstetrician has to face. Still births that occur in the antenatal period are more difficult to explain than that which occurs intrapartum. The latter is most often due to intrapartum asphyxia, medical complications or infections; however a cause for antenatal still birth is difficult to ascertain. A thorough examination of the case along with necessary investigations might not necessarily reveal any cause and this leads to considerable anxiety for both the mother and the treating obstetrician. In the investigation of a case of still birth a detailed examination of the placenta and cord has to be emphasised as a considerable number of still births that are thought to be unexplained may be attributable to placental or cord pathologies. Here we present one such case where an umbilical cord haematoma resulted in intrauterine foetal death.

A randomised double-blind placebo-controlled trial comparing stepwise oral misoprostol with vaginal misoprostol for induction of labour.

A comparison of induction of labour (IOL) using three doses of 25 µg vaginal misoprostol inserted at intervals of 4 h or more with a stepwise oral regime starting with 50 µg followed by two doses of 100 µg was studied in a double-blind placebo-controlled trial in a tertiary centre in South India. Primary outcome was vaginal delivery in 24 h. Significantly more women in the first group required oxytocin augmentation and a third dose of the drug than women in the second group. Uterine tachysystole and other maternal and neonatal complications were similar. Thus it is concluded that women induced with oral, as compared to vaginal misoprostol are more likely to labour without oxytocin.

Early diagnosis of a large vesical calculus complicating pregnancy.

Vesical calculus-complicating pregnancy is rare. This is a case report of a large vesical calculus-complicating pregnancy. The early diagnosis and appropriate surgical management of the large vesical calculus prevented complications like recurrent urinary tract infections and obstructed labor. It enabled the mother to have an uneventful vaginal delivery.

A retrospective study of the prevalence and outcomes of syphilis in pregnancy in a 5‐year period

To determine the prevalence of syphilis in pregnancy and to assess the effect of syphilis on maternal and perinatal outcomes.