Shakun Tyagi

Screening for gestational diabetes mellitus: A prospective study in a tertiary care institution of North India

Aim:  The aim of this study was to determine the relevance of universal screening for gestational diabetes mellitus (GDM) in the patients attending the antenatal clinic of a tertiary institute of North India.

Comparison of scar thickness measurements using trans-vaginal sonography and MRI in cases of pregnancy with previous caesarean section. Do they correlate with actual scar thickness?

The aim of this study was to evaluate scar thickness in cases of pregnancy with previous caesarean section, by trans-vaginal sonography (TVS) and magnetic resonance imaging (MRI), and to correlate precision of radiologically-measured scar thickness with actual measurement of scar thickness. A total of 35 pregnant patients with previous caesarean section planned for elective caesarean section, were evaluated prospectively. Their scar thickness was measured by TVS and MRI on the day of elective repeat caesarean section. These measurements were correlated with each other and with scar thickness measured during elective repeat caesarean section by using a caliper. The correlation coefficients between scar thickness measured by TVS and MRI with peroperative evaluation with a caliper, were +0.72 and +0.59, respectively. The study concluded that as MRI is a costlier modality and TVS has better correlation coefficient with actual scar thickness, TVS can be considered to be the better modality for antenatal scar thickness measurement.

Comparison of rapid bedside tests for phosphorylated insulin-like growth factor-binding protein 1 and fetal fibronectin to predict preterm birth.

To compare the accuracy of rapid bedside tests for phosphorylated insulin‐like growth factor‐binding protein 1 (phIGFBP‐1) and fetal fibronectin (fFN) to predict preterm delivery among women with threatened preterm labor.

Maternal and fetal outcomes in pregnant women with Takayasu aortoarteritis: Does optimally timed intervention in women with renal artery involvement improve pregnancy outcome?

OBJECTIVE Takayasu aortoarteritis (TA) is common in the Southeast Asian and Indian subcontinent regions with a female-to-male ratio of 8:1. Age at diagnosis is < 30 years in 90% of the cases. Because the disease is common in women of child-bearing age, management of pregnancy in these patients becomes an important issue. The purpose of this study is to evaluate the maternal and fetal outcomes in pregnancies with TA and also to evaluate whether early intervention for renal artery involvement is associated with improved outcomes. MATERIALS AND METHODS We collected data of 12 patients with 18 pregnancies prospectively from 2006 to 2012. The patients were divided into three groups and their outcomes were noted: (1) without renal artery involvement; (2) with renal artery involvement without intervention; and (3) with renal artery involvement for which intervention has been done. RESULTS Body mass index of patients was between 18.5 kg/m(2) and 23.2 kg/m(2). Renal artery involvement and hypertension were seen in four patients. One patient had percutaneous transluminal balloon angioplasty and another had renal artery stenting. In patients without renal artery involvement, gestational hypertension was seen in 50%, pre-eclampsia in 10%, abortion in 10%, and intrauterine growth restriction (IUGR) in 40% of pregnancies. In patients with renal artery involvement without intervention, gestational hypertension was seen in 90%, pre-eclampsia in 20%, abortion in 60%, preterm in 20%, IUGR in 20%, fetal demise in 20%, and neonatal death in 20% of pregnancies. In patients with renal artery involvement for which intervention has been carried out, gestational hypertension was seen in 66%, and abortion and IUGR were seen in 33% of pregnancies. CONCLUSION Patients with renovascular involvement without intervention are at high risk of having maternal and fetal complications. Early intervention prior to conception in these women is recommended to prevent pregnancy complications.

Varied presentation of uterine arteriovenous malformations and their management by uterine artery embolisation

Uterine arteriovenous malformations are rare lesions which have a varied presentation that may range from the patient being asymptomatic to varying degrees of menorrhagia. It can be diagnosed by Doppler sonography but a strong index of suspicion is necessary. Management of this condition depends on presentation and available resources. In asymptomatic patients, we can leave the patients on regular follow-up as many lesions regress spontaneously. In patients with excessive haemorrhage not responding to embolisation or when facilities of embolisation are not available, hysterectomy needs to be done. Uterine artery embolisation should be considered the optimum treatment, as it has a high success rate coupled with few complications and also has fertility-preserving potential. Clinical follow-up usually suffices but sonography may occasionally be required.

Facility‐based review of 296 maternal deaths at a tertiary centre in India: Could they be prevented?

The aim of this study was to identify causes of maternal mortality at the facility and to assess the standard of care, deficiencies in health services and preventability of these deaths using facility‐based maternal death reviews.

Clinical evaluation of severe anemia in pregnancy with special reference to macrocytic anemia

Aims:  Anemia in pregnancy has been almost synonymous with iron‐deficiency anemia but there appears to be a changing trend with emerging evidence of macrocytic anemia. The aim of this study was to evaluate the clinical profile of patients having severe anemia in pregnancy.

Can Preterm Labour Be Predicted in Low Risk Pregnancies? Role of Clinical, Sonographic, and Biochemical Markers

Background and Objectives. This is a prospective nested cohort study conducted over a period of 3 years. 2644 women were recruited, out of which final analysis was done for 1884 women. Methods. Cervicovaginal and blood samples were collected for all recruited women. Out of these, 137 women who delivered before 35 weeks were treated as cases and equal number of matched controls were chosen. Analysis of samples for serum G-CSF, AFP, ferritin, and cervicovaginal interleukin-6 and IGFBP-1 was done. Results. Poor orodental hygiene, which can be a social marker, was significantly more common in women who delivered preterm (P = 0.008). Serum alkaline phosphatase and serum ferritin were found to be significantly associated with preterm deliveries. The 90th percentile value of these parameters was considered as cut-off as there is no specific cut-off. Conclusions. Our study did not prove usefulness of any predictive marker. Serum ferritin and alkaline phosphatase were found to have correlation but their values are affected in many conditions and need to be elucidated with caution. Larger studies are needed for predicting preterm labour in asymptomatic women.

Metformin in gestational diabetes mellitus

The primary goal of therapy for gestational diabetes mellitus (GDM) is to achieve euglycaemia and thus decrease adverse perinatal outcomes. The proportion of patients who require pharmacotherapy to achieve this end result is dependent on diagnostic criteria used. However, with current low diagnostic thresholds, the proportion requiring pharmacotherapy is lesser than in the past where insulin has been the gold standard treatment for GDM when dietary and lifestyle measures have failed. Theoretically, insulin sensitizers should have been the ideal agent in the treatment of GDM, but foetal concerns have outweighed practical utility till the recent past. Oral hypoglycaemic agents are cost-effective, patient-friendly, potentially compliance-enhancing and also more physiological, given that insulin resistance is likely to be the main pathogenetic mechanism in GDM1. Metformin has been in use since decades for patients of type II DM and also for many years now in insulin-resistant polycystic ovarian syndrome (PCOS) patients2. However, its use in pregnancy has been limited.

Evaluation of 75 g glucose load in non-fasting state [Diabetes in Pregnancy Study group of India (DIPSI) criteria] as a diagnostic test for gestational diabetes mellitus

Background & objectives: There is no consensus regarding optimal standard for diagnosis of gestational diabetes mellitus (GDM). In this study, use of 75 g glucose load in non-fasting state [Diabetes in Pregnancy Study Group of India (DIPSI) criteria] as a diagnostic test for GDM in pregnant women was compared with different oral glucose tolerance tests (OGTTs). Methods: This prospective study included 936 pregnant women, who underwent plasma glucose evaluation two hours after the challenge of 75 g glucose load irrespective of the timing of last meal (DIPSI criteria for GDM). After three days, standard 75 g OGTT was done in all women irrespective of previous plasma glucose value. Accuracy of the first result was compared to OGTT using cut-offs as per the World Health Organization (WHO) and International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria for the diagnosis of GDM. Results: Of the total 936 pregnant women, 73 (7.8%) patients had plasma glucose value ≥140 mg/dl when measured two hours after glucose load. When comparing with the WHO and IADPSG criteria, the sensitivity values were 65.1 and 74.1 per cent, respectively, and the corresponding specificity values were 96.3 and 96.9 per cent, respectively. On comparing with the WHO OGTT, only 41 of the 73 (56.2%) were true positives, whereas when IADPSG criteria were used, true positives were 46 (63%). False negative cases were also present when classified by the WHO and IADPSG criteria though in lesser numbers than false positives. The positive predictive values (PPVs) for the WHO and IADPSG criteria were 56.1 and 63 per cent, respectively, and their corresponding negative predictive values were 97.7 and 97.9 per cent, respectively. Interpretation & conclusions: Our findings showed that when 75 g glucose load in non-fasting state was used as a diagnostic test for GDM, almost one quarter of patients with GDM escaped diagnosis as sensitivity values were low. On the other hand, some GDM cases were falsely labelled as normal as this test did not account for cases of fasting hyperglycaemia. In addition, comparison with other OGTTs showed low PPVs. Hence, use of DIPSI criteria for diagnosing GDM must be reconsidered till further validation.