Shikha Rani

Risk factors for perinatal mortality due to asphyxia among emergency obstetric referrals in a tertiary hospital

ObjectivesTo evaluate the clinical, behavioral and health-care associated risk factors of intrapartum perinatal mortality (IPPM).DesignProspective cohort study.SettingLabor room and postnatal wards of a teaching hospital in North India.ParticipantsPregnant women were eligible for enrolment in the study if period of gestation at delivery was 35 weeks or more or baby weighed at least 2000 g at birth, index pregnancy was not booked in antenatal clinic of the study hospital and fetus was delivered within 24 h of admission in the hospital.MethodsInformation about antenatal care and events surrounding labor and delivery were retrieved from antenatal care records, referral notes, hospital clinical records and interview of mothers. Multivariate analysis was conducted using forward stepwise logistic regression analysis.Main Outcome MeasureIPPM was defined as asphyxiaspecific stillbirth or asphyxia-specific early neonatal death.ResultsAmong 248 emergency obstetric referrals during the study period, rate of IPPM was 8% (20/248, 18 fresh stillbirths and 2 asphyxia-specific neonatal deaths). District hospitals and community health-centers/first referral units contributed threefourths of all referrals. On logistic regression analysis significant risk factors for IPPM were presence of obstructed labor (OR: 23, 95% CI: 1.9–275.8), father engaged in unskilled labor (OR: 10, 95% CI: 1.3–77.7) and absence of urine examination during antenatal period (OR: 5.5, 95% CI: 1.8–16.3).ConclusionsLow socioeconomic status, inadequate antenatal care and poor intrapartum care due to unskilled birth attendance are risk factors of IPPM.

Prediction of perinatal outcome in preeclampsia using middle cerebral artery and umbilical artery pulsatility and resistance indices

ABSTRACT Objective: In preeclampsia, changes in fetal hemodynamics can be detected 2–3 weeks earlier than any changes in cardiotocogram. Thus, these Doppler changes can be used to predict perinatal outcome. The present study is planned to assess the accuracy of the middle cerebral artery to umbilical artery (UA) pulsatility index (PI) and resistance index (RI) in predicting adverse perinatal outcome in pregnancies complicated by preeclampsia. Methods: Total of 115 and 108 pregnant women were included in preeclampsia and control group, respectively. Weekly Doppler study was done in both groups starting from 30 weeks till 36 weeks or delivery, whichever is later. Results: Mean gestational age at delivery was 250 ± 13 and 273 ± 8 days, respectively, in preeclampsia and control group (p < 0.01). Thirty-four babies in preeclampsia group had been admitted to nursery; out of which three died (p < 0.01). On receiver operating characteristic analysis, MCA /UmA PI ratio and MCA /UmA RI ratio had sensitivity of 9% and 9.7% and specificity of 98% and 96.6%, respectively, for predicting adverse perinatal outcome. Conclusion: Doppler indices of MCA and Um A are significantly abnormal in preeclampsia. But on diagnostic statistical analysis they have good specificity but low sensitivity for detecting adverse perinatal outcome.

Preeclampsia and Reactive Oxygen Species

Main biological role of oxygen in aerobic animals is as a free electron acceptor in the electron transport chain in mitochondria where it participates in the oxidative phosphorylation to generate ATP molecules and in the process, is reduced to water molecules. Incomplete reduction of oxygen produces a series of molecules called reactive oxygen species (ROS). Examples include hydroxyl, superoxide and hydrogen peroxide. Some of these molecules have an unpaired electron in the outer shell and act as free radicals. ROS have a definite role in cell biology including signaling, regulation of nitric oxide production, oxidative burst for phagocytic functioning, oxygen level sensing and cell apoptosis. ROS level in body is kept in check by presence of enzymatic and non-enzymatic antioxidant defense mechanisms. When these mechanisms are overwhelmed because of excess production of ROS or deficient antioxidant components or both, this oxidantantioxidant balance is disturbed. Present in excess, ROS can damage different cell components like cell membrane lipids, amino acids and nucleic acids. Neonates, especially those born preterm are prone to oxidant damage due to deficient antioxidant mechanisms and increased exposure to oxygen during resuscitation and respiratory morbidities. Free radical damage to tissues plays an important role in the pathogenesis of periventricular leukomalacia, bronchopulmonary dysplasia and necrotizing enterocolitis. Exposure to 100% oxygen even for a short duration at the time of birth is associated with oxidative stress at 4 wk of age and, in comparison to resuscitation with room air is associated with worse neurological outcome [1]. In this issue of the journal, Bhardwaj et al. report higher levels of markers of oxidative stress in maternal and cord blood in women with pregnancies complicated by preeclampsia [2]. Increased oxidant levels in preeclampsia have been reported previously in maternal blood, placenta, cord blood and neonatal blood [3–6]. Further, these alterations have been associated with evidence of DNA damage in cord blood [7]. Going further, Bhardwaj et al. also report association between lower maternal anti-oxidant status and worse motor outcomes at 1 y of age. Although, babies born to women with preeclampsia were of lower gestation and birth weight and were more likely to suffer from major neonatal morbidities which themselves increase the risk of adverse neurological outcome, the study findings merit further attention. The findings need to be confirmed in a larger study in which gestation at birth, the major determinant of the antioxidant status of neonates is matched in the group of women with and without preeclampsia. In view of mounting evidence of association between preeclampsia and increased oxidative stress, one may deduce that antioxidant administration may prevent preeclampsia or prevent oxidative damage to fetal brain and other organs in women with established preeclampsia. However, large clinical trials with antioxidants have shown no change in incidence of preeclampsia or related morbidities and rather increase in risk of birth of a low birth weight neonate [8, 9]. An animal model study has reported that inhibition of ROS activity leads to decreased placental angiogenesis, suppressed fetal growth, and worsened maternal survival [10]. Evidently, the relationship between preeclampsia and ROS is not a simply causative and ROS-mediated signaling has a positive role in placental growth in women with preeclampsia. In this interplay, does the fetus with a susceptible antioxidant mechanism suffer from collateral damage? * Deepak Chawla drdeepakchawla@gmail.com

Improving quality of care during childbirth in primary health centres: a stepped-wedge cluster-randomised trial in India

Background Low/middle-income countries need a large-scale improvement in the quality of care (QoC) around the time of childbirth in order to reduce high maternal, fetal and neonatal mortality. However, there is a paucity of scalable models. Methods We conducted a stepped-wedge cluster-randomised trial in 15 primary health centres (PHC) of the state of Haryana in India to test the effectiveness of a multipronged quality management strategy comprising capacity building of providers, periodic assessments of the PHCs to identify quality gaps and undertaking improvement activities for closure of the gaps. The 21-month duration of the study was divided into seven periods (steps) of 3  months each. Starting from the second period, a set of randomly selected three PHCs (cluster) crossed over to the intervention arm for rest of the period of the study. The primary outcomes included the number of women approaching the PHCs for childbirth and 12 directly observed essential practices related to the childbirth. Outcomes were adjusted with random effect for cluster (PHC) and fixed effect for ‘months of intervention’. Results The intervention strategy led to increase in the number of women approaching PHCs for childbirth (26 vs 21 women per PHC-month, adjusted incidence rate ratio: 1.22; 95% CI 1.17 to 1.28). Of the 12 practices, 6 improved modestly, 2 remained near universal during both intervention and control periods, 3 did not change and 1 worsened. There was no evidence of change in mortality with a majority of deaths occurring either during referral transport or at the referral facilities. Conclusion A multipronged quality management strategy enhanced utilisation of services and modestly improved key practices around the time of childbirth in PHCs in India. Trial registration number CTRI/2016/05/006963.

Vulvar myiasis following suction and evacuation for incomplete abortion

Myiasis is caused by fly larva capable of penetrating healthy or necrotic tissue, usually in tropical and subtropical countries. The involvement of an exposed area is common; however it may very rarely involve the genital region. We present a rare case of vulvar myiasis which occurred after suction and evacuation performed for incomplete abortion.

Clinical outcome of abdominal sacrocolpopexy

Introduction: Vaginal vault prolapse is one of the distressing conditions which occur after hysterectomy. This is due to the weakness or detachment of sacrouterine cardinal ligament complex from the vaginal cuff. Till now, the most accepted procedure for this condition is sacrocolpopexy. Materials and Methods: We present a cohort of patients who underwent abdominal sacrocolpopexy (ASC) from April 2009 to August 2013. These patients were followed till April 2014 and were evaluated for subjective and objective outcomes following ASC. Results: One patient had intraoperative hemorrhage and postoperative hematoma formation. One patient had vault abscess which was managed conservatively. Hundred percent success rate was noted at 1 year. Long-term patient satisfaction score was 85 (70-90).