Perimortem Caesarean Section : A Guideline-based Management of Maternal Cardiac Arrest

Maternal Cardiac Arrest is a rare event and Perimortem Caesarean Section (PMCS) has an established role in concurrence with maternal resuscitation to save the life of a dying mother as per various International Guidelines. Despite being a lifesaving procedure, this procedure has not yet gained acceptance amongst Obstetrician. Present case is first reported case of PMCS of this country where an out of Operation Theatre Perimortem Caesarean Section was performed with a positive maternal and foetal outcome.

Postpartum intrauterine contraceptive device: effect of antenatal versus postpartum counselling in acceptance of postpartum intrauterine contraceptive device

Background: The acceptance for PPIUCD in our country, especially in rural areas is very low despite all the efforts. Counselling during the antenatal visits may play a vital role in improving the acceptance of PPIUCD. Objective of this study was to assess the factors associated with the acceptability of immediate PPIUCD insertion in women; counselled during antenatal and postpartum period; according to their sociodemographic and obstetric characteristics, and future pregnancy desires.Methods: One-year prospective study carried out in the department of obstetrics and gynecology, S. S. Medical College Rewa, Madhya Pradesh, India. a total of 4850 women were counselled for PPIUCD insertion; 2540 during their antenatal visits, and 2310 during postpartum period who visited in study centre for first time and their follow up was done. Chi square tests were applied to compare proportions.Results: After antenatal counselling in 2540 women, (with multiple counselling sessions) about half of the women gave verbal acceptance for PPIUCD. However, during postpartum counselling in 2310 women, (where only single short session of counselling could be done) majority of the women declined (80.9%) for PPIUCD insertion with only about a fifth (19.1%) of the women giving verbal acceptance. Women who had antenatal counselling one third of them had PPIUCD insertion. In the postpartum counselling group, a meagre 15.1% women had PPIUCD insertion.Conclusions: Counselling during antenatal and postpartum period is the key to improve the awareness and acceptance of PPIUCD in our community. Multiple counselling sessions during antenatal visits make it easier for the women to slowly understand the process and accept PPIUCD as compared to the short counseling during postpartum period.

A comparative study to evaluate diagnostic accuracy and correlation between saline infusion sonography, hysterosalpingography and diagnostic hysterolaparoscopy in infertility

Background: Till date hysterosalpingography (HSG) remains the first-line method to detect tubal patency and to find out any uterine abnormalities in infertile female while diagnostic hysterolaparoscopy (DHL)  is considered to be the gold standard method, it is during last decades only that saline infusion sonography (SIS)/ sonohysterography (SHG) has emerged as an efficacious method of checking tubal patency and uterine anatomy as well. The present study aims to compare all three methods viz- SIS, HSG and DHL and to evaluate the correlation between these methods.Methods: 98 infertile females of age group 18-35 years with normal Hormonal profile without any male factor infertility, were prospectively selected from the outpatient department of obstetrics and gynecology, GMH Rewa, Madhya Pradesh over one year from 1st August 2016 to 31st July 2017.Results: Diagnostic accuracy (sensitivity and specificity) of SIS was found to be more than HSG for both tubal patency and uterine abnormalities detection. SIS has less numbers of false positive and false negative rates as compared to HSG. DHL was found to be much superior to both SIS and HSG, also detected additional findings in multiple sites like pelvis, tubes and the uterus on the same setting which were missed on SIS and HSG.Conclusions: SIS may replace HSG as a first step screening method for tubal patency detection, as it has more diagnostic accuracy than HSG and better correlation with DHL and has many advantages and minimal disadvantages as compared to HSG.

A randomized controlled study on expectant management of incomplete abortions caused by self medication

Background: Medical method of termination of pregnancy is a very effective method when used as per recommended regimen and under proper supervision. Self-administration of these drugs has become a very common practice these days, resulting in incomplete abortion because of improper use. Traditionally surgical curettage has been the preferred mode of treatment for these cases but is associated with very high complication rates. Expectant management of incomplete abortion has been recently adopted as a better method of management of incomplete abortions worldwide. Present study compares expectant management with surgical curettage in cases of incomplete abortions caused by self medication.Methods: It was one-year prospective randomized controlled study. Total of 220 patients were recruited for the study out of which 103 were randomized to undergo expectant management while 117 to undergo surgical curettage. Results were compared using chi square test..Results: Success rate of expectant and surgical management was found to be 82% and 95% respectively. Complication rate was found to be comparable in both the group while acceptability of expectant management was found to be much higher in expectant group. However, significantly more unplanned admissions and unplanned surgical curettage occurred after expectant management than surgical management.Conclusions: Expectant management is a safe and efficacious option in carefully selected cases. If used properly it can avoid complications associated with surgical management and therefore should be utilized whenever suitable.

Hemoglobin status in pregnant women for diagnosis of anemia, assessment of severity and its socio-demographic determinants in rural area of Kanpur district, Uttar Pradesh, India

Background: Anaemia is one of the most common nutritional deficiency disorders affecting the pregnant women in the developing countries. In India anaemia in pregnancy is a major health issue with adverse maternal and foetal outcome. Nutritional anaemia in pregnant women continues to be a cause of concern despite the fact that this problem is largely preventable and easily treatable. Objectives was to determine the prevalence and severity of anaemia in the pregnant women.Methods: Around 350 pregnant women in different trimesters of pregnancy were enrolled coming for the 1st time in outpatient department of Obstetrics and Gynaecology, in Rama Medical College Hospital and Research Centre, Kanpur from Janurary 2016 to December 2016. Information regarding age, age at marriage, age at 1st pregnancy, parity, Interval between previous and index pregnancy, no of abortions, educational status, dietary habits, Type of family, Socioeconomic status was collected in pre-designed structured schedule after taking written consent from pregnant women attending out-patient department. Haemoglobin estimation was done by auto analyser and anaemia was graded according to WHO criterion. Statistical analysis was done by percentages and proportions.Results: A high prevalence of anaemia, (87.71%) was observed in pregnant women. The current study shows (24.7%) cases of mild anaemia, (54.5%) cases of moderate anaemia, and (7.9%) of severe anaemia.Conclusions: A very high prevalence of anaemia in pregnancy needs awareness about late marriage, birth spacing, one or two child norm, antenatal care, green leafy vegetable in diet, mandatory regular supply of iron folic acid (IFA) tablets to adolescent and pregnant women along with correction of other nutritional deficiencies.

Efficacy of conventional pharmacotherapy of syndromic management of STIs: a two year cross-sectional prospective study

Background: Syndromic management has been the centre for treating STIs in a resource constraint facility since its introduction by WHO and CDC more than a decade back. Recently there has been lots of debate on its empirical use in an era of antibiotics resistance and ever-changing varieties of microorganisms causing these infections. Present study evaluated the efficacy of pharmacotherapy of syndromic management measured by symptomatic improvement in females presenting with STIs.Methods: It was a two year cross-sectional prospective study including all the females of STI syndromes, attending Gynecology OPD of Sanjay Gandhi Memorial Hospital and results were assessed in pharmacology department, Gajra Raja medical college Gwalior from Jan 2015 to December 2016.Results: During the study period total of 24,556 patients attended the Gynecology OPD out of which 8562 patients presented with different STI syndromes. Lower abdomen pain with vaginal discharge was the most common symptom while Ulcerative lesions were the least common complaint. Maximum recurrence was seen in patients of vaginal discharge and itching followed by PID syndrome which responded to second line of drugs.Conclusions: Syndromic Management of STIs is an old approach to deal with a very common gynecological problem and needs to be reviewed in an era of wide spread antibiotics resistance.

A one year case control study on oxytocin use in labor and its effect on maternal: fetal outcomes

Background: Oxytocin is a drug commonly administered drug to a pregnant lady during labor, nowadays even without an indication, in the hope that the progress of labor can be improved and the need for cesarean delivery may be reduced. This study emphasizes the need for using safeguards like use of checklists before starting oxytocin augmentation, therefore ensuring its rational use to minimize maternal and neonatal complications when augmenting labor with oxytocin, including rigorous indications, use of minimal useful dose and careful efficacy evaluation.Methods: This is a retrospective, Case-Control, descriptive and analytical study. Study population included women delivering in labor room of Gandhi Memorial Hospital associated with Shyam Shah Medical College, Rewa, from July 2015 to June 2016, then after data were compiled and assessed in department of pharmacology G.R. Medical College, Gwalior.Results: Results show that the use of oxytocin in labor stimulation can be detrimental to both the mother and the newborn, since they indicate that the use of oxytocin is associated with increased cesarean section rates both in primiparous and multiparous. Furthermore, it was also observed, a significant association between stimulation with oxytocin and low Apgar scores at 1 and 5 minutes both, of the newborns.Conclusions: Therefore, it may conclude that stimulation with oxytocin should not be used without any indication, but only in very specific cases, in which its use is particularly necessary. These results provide to health professionals a better understanding of the effects of the use of oxytocin during labor, which can be useful for decision-making in clinical practice.

A prospective, double blind randomised controlled trial on efficacy of laparoscopic uterosacral nerve ablation as an alternative of pharmacotherapy in treatment of chronic pelvic pain

Background: Chronic Pelvic Pain (CPP) is one of the commonest symptomatology in gynaecologist’s outpatient clinics. CPP has a profound impact on a woman's health and quality of life, including an economic impact through loss of working hours. Treatment for chronic pelvic pain is often unsatisfactory. Present study compares Laparoscopic Uterosacral Nerve Ablation (LUNA) with laparoscopy without pelvic denervation in patients presenting with chronic pelvic pain to our outpatient clinic.Methods: It was a Randomised Controlled Trial Study. After considering inclusion and exclusion criteria, 120 patients were selected, out of which 60 (Group I) had undergone diagnostic laparoscopy and 60 (Group II) had undergone diagnostic laparoscopy with LUNA.Results: The overall success rate for group I and group II were 80%, 78.3% and 66.6% versus 85%, 81.6%, and 83.3% at 3, 6, and 12 months, respectively. However, on subgroup analysis it was found that in patients suffering from Congestive Dysmenorrhoea, there was a significant difference in success rate of both the groups.Conclusions: It was found in present study that there was a benefit for patients with dysmenorrheal, further research in this area is desirable to reach towards a discrete conclusion regarding the benefits of LUNA in patients of CPP.

IL-10 down-regulates the expression of survival associated gene hspX of Mycobacterium tuberculosis in murine macrophage

Abstract Mycobacterium tuberculosis (MTB) adopts a special survival strategy to overcome the killing mechanism(s) of host immune system. Amongst the many known factors, small heat shock protein 16.3 (sHSP16.3) of MTB encoded by gene hspX has been reported to be critical for the survival of MTB. In the present study, the effect of recombinant murine interferon-gamma (rmIFN-γ) and recombinant murine interleukin-10 (rmIL-10) on the expression of gene hspX of MTB in murine macrophage RAW264.7 has been investigated. By real-time RT-PCR, it was observed that three increasing concentrations (5, 25 and 50 ng/ml) of rmIFN-γ significantly up-regulated the expression of hspX whereas similar concentrations of rmIL-10 (5, 25 and 50 ng/ml) significantly down-regulated the hspX expression. This effect was not only dependent on the concentration of the stimulus but this was time-dependent as well. A contrasting pattern of hspX expression was observed against combinations of two different concentrations of rmIFN-γ and rmIL-10. The study results suggest that rIL-10 mediated down-regulation of hspX expression, in the presence of low concentration of rIFN-γ, could be used as an important strategy to decrease the dormancy of MTB in its host and thus making MTB susceptible to the standard anti-mycobacterial therapy used for treating tuberculosis. However, as these are only preliminary results in the murine cell line model, this hypothesis needs to be first validated in human cell lines and subsequently in animal models mimicking the latent infection using clinical isolates of MTB before considering the development of modified regimens for humans.

Vitamin C, total polyphenols and antioxidant activity in raw, domestically processed and industrially processed Indian Chenopodium quinoa seeds.

Total antioxidant activity, Vitamin C and total polyphenols were determined for the first time in Indian Chenopodium quinoa seeds. The raw seeds were subjected to domestic processing method by soaking and germination to see the effect on antioxidant activity, Vitamin C and total polyphenols as compared to the industrially processed seeds. Antioxidant activities were determined by DPPH and FRAP method. Total phenolic content and flavonoid was determined colorimetrically and vitamin C by N- bromosuccinimide (NBS) method. The results show that domestically processed seeds have higher vitamin C, total phenolic content (TPC), total flavonoid content (TFC) and antioxidant activity as compared to the raw and industrially processed seeds. Antioxidant activity was found significantly correlated to the total phenolic content in raw, domestically processed and industrially processed seeds. The results suggest use of domestic processing of quinoa seeds to retain nutrient value and also infer dietary importance of Indian Chenopodium quinoa.

Analysis of various criteria for identification of severe acute maternal morbidity in a rural tertiary health care centre: A prospective one year study.

Background: Maternal mortality has been the indicator of measurement of maternal health. Over the last decade, identification of severe acute maternal morbidity (SAMM) has emerged as a compliment or alternative to investigation of maternal deaths. A review of causes of SAMM will help to find out the potential problems which in turn will enable women to get the treatment on time. Recent researches have suggested that proper identification of SAMM cases can prove to be a better method to monitor the quality and effectiveness of obstetric care than mortality alone. Although there have been many criteria which have been introduced from time to time to identify these cases, because of vast variation of different level of facilities, these criteria cannot be applied across the regions. WHO has recently come up with certain set of criteria which could be more applicable to low resource settings. Aims & Objective: Present study tried to identify SAMM cases through various criteria and compared the applicability of them in our setup which is resource poor setting catering mainly to a huge rural population. Materials and Methods: It is a prospective study done over a period of one year, from September 2012 to August 2013. All severely morbid pregnant women or who had delivered or aborted within 42days were included. Initial identification of these cases was done on the basis of general criteria and later on other criteria were applied according to the primary obstetric event, clinical features, Lab findings or management provided. A comparison was done amongst all criteria and their individual applicability was checked as per the facility available in our set up. Results: During the study period total 7819 women delivered in the hospital out of which 6498 delivered vaginally and 1321 delivered through caesarian section. Total live births during this period were 5219. The present study found an incidence of severe maternal morbidity/near miss ranging from 5.56 to 40 per 1000 live births. Among 244 women suspected to be SAMM/MNM, 179(73%) met Waterstone’s criteria, 48(20%) met Mantel’s Criteria and 63(26%) met WHO criteria, 20% women met Mantel and Waterstone’s criteria both while 17% met all three criteria. Conclusion: The study of SAMM cases and their identification through suitable criteria can contribute to know its magnitude, as well as to identify most frequent characteristics and clinical conditions which will help to recognize the problems in antenatal services, peripheral health care facilities and referral system. The criteria which are available now cannot be applied uniformly, and need to be tailored to identify more specific criteria according to infrastructure of a particular setting in order to utilize resources effectively.

Whole cell & culture filtrate proteins from prevalent genotypes of Mycobacterium tuberculosis provoke better antibody & T cell response than laboratory strain H37Rv.

Background & objectives: The immune responses to different antigens of Mycobacterium tuberculosis H37Rv vary from patient to patient with tuberculosis (TB). Therefore, significant difference might be documented between the H37Rv with long histories of passages and recent clinical isolates of M. tuberculosis. In the present study, immune response of TB patients and healthy controls against 39 clinical M. tuberculosis isolates was correlated with laboratory strain H37Rv. Methods: The antibody response was studied coating whole cell extracts and culture filtrate proteins of M. tuberculosis isolates and laboratory strain H37Rv by enzyme linked immunosorbent assay (ELISA). Lymphoproliferation was studied by incorporation of tritiated thymidine and cytokines (IFN-γ and IL-4) by using commercially available kits. Results: Sero-reactivity to whole cell extract (WCE) of 11 clinical isolates was higher with pooled serum and individual's serum from tuberculosis patients showed significant reactivity (P<0.05) to ten of these isolates using ELISA. Of the WCE of 39 clinical isolates, 10 were found to be potent inducer of lymphoproliferation as well as cytokine secretion (P<0.05) in peripheral blood mononuclear cells from PPD+ healthy controls. Six culture filtrate proteins (CFPs) from these selected clinical isolates were also better inducers of antibody and T-cell response. Interpretation & conclusion: Overall, our results revealed that the clinical isolates belonging to prevalent genotypes; CAS1_Del (ST-26), East African-Indian (ST-11) and Beijing family (ST-1) induced better antibody and T cell responses compared to H37Rv laboratory strain. Further studies need to be done to purify and identify the dominant protein (s) using whole cell extract and culture filtrates from these immunologically relevant clinical M. tuberculosis isolates, which will be worthwhile to find out pathogenic factors, potential diagnostic markers and protective molecules for tuberculosis.

Serial assessment of biochemical parameters of red cell preparations to evaluate safety for neonatal transfusions.

Background & Objectives: Neonatologists often prefer fresh blood (<7 days) for neonatal transfusions. The main concerns for stored RBCs are ex vivo storage lesions that undermine red cell functions and may affect metabolic status of neonatal recipients. This study was designed to evaluate serial in vitro changes of biochemical parameters in different RBC preparations during storage to consider for neonatal transfusions even after storage beyond one week. Methods: Twenty five units each of whole blood (CPDA-1 RBC, SAGM RBC) were selected for serial biochemical parameter assessment after each fulfilled the quality criteria (volume and haematocrit). These units were tested serially for supernatant potassium, pH, lactate, haemoglobin, glucose and red cell 2,3 diphosphoglycerate (2,3 DPG) up to 21 days of storage. Results: Within each group of RBC, rise in mean concentration of potassium, lactate and plasma haemoglobin from day 1 to 21 of storage was significant in CPDA-1 RBC having the highest levels at day 21. From day 3 to 21, SAGM RBC had higher mean pH value than CPDA-1 RBC though this difference was not statistically significant. SAGM RBC had highest mean glucose concentration during storage than other two types of red cell preparations (P<0.005). Within each group, fall in mean 2,3 DPG concentration from day 1 to 7 was significant (P<0.05). A positive correlation existed between mean plasma potassium and haemoglobin in all three types of red cells (r=0.726, 0.419, 0.605 for CPDA-1 RBC, SAGM RBC and whole blood respectively, P<0.005). Interpretation & Conclusions: All the three red cell preparations tested revealed biochemical changes within acceptable limits of safety till 21 days of storage. CPDA-1 RBCs had the highest degree of these changes.

A simple and rapid method of sample preparation from culture filtrate of M. tuberculosis for two-dimensional gel electrophoresis

Sample preparation for Two-dimensional gel electrophoresis (2DE) is tedious and not sufficient to provide a comparative profile of secreted proteins for various strains of M. tuberculosis. High lipid content in mycobacteria limits the use of common methods as it can hinder the 2DE run. This study highlights the significance of SDS-TCA procedure over common used methods for the preparation of sample from culture filtrate as well as other proteinaceous fluids.

Transfusion related acute lung injury.

Transfusion related acute lung injury (TRALI) is an uncommon but potentially fatal adverse reaction to transfusion of plasma containing blood components. We describe a case of 10-year-old male child with aplastic anemia, platelet count of 7800/΅l, B positive blood group who developed fever (39.2΀C), difficulty in breathing and cyanosis within 2 hrs after transfusion of a random platelet concentrate. Despite the best resuscitative efforts, the child died within next 24 hrs. The present case highlights the fact that TRALI should be kept as a differential diagnosis in all patients developing acute respiratory discomfort within 6 hrs of transfusion. Without a 'gold standard' the diagnosis of TRALI relies on a high index of suspicion and on excluding other types of transfusion reactions. Notification to transfusion services is crucial to ensure that a proper investigation is carried out and at-risk donor and recipients can be identified, and risk reduction measures can be adopted.

Functional characterization of the phospholipase C activity of Rv3487c and its localization on the cell wall of Mycobacterium tuberculosis.

Mycobacterium tuberculosis survives and persists for prolonged periods within its host in an asymptomatic,latent state and can reactivate years later if the host's immune system weakens. The dormant bacilli synthesize and accumulate triacylglycerol, reputed to be an energy source during latency. Among the phospholipases, phospholipase C plays an important role in the pathogenesis. Mutations in a known phospholipase C, plcC, of M.tuberculosis attenuate its growth during the late phase of infection in mice. Hydrolysis of phospholipids by phospholipase C generates diacylglycerol, a well-known signalling molecule that participates in the activation of extracellular signal-regulated kinases (ERK) through protein kinase C leading to macrophage activation. In the present study, we show that M.tuberculosis possesses an additional cell wall-associated protein, Rv3487c, with phospholipase C activity. The recombinant Rv3487c hydrolyses the substrate phosphatidylcholine and generates diacylglycerol by removing the phosphocholine. Furthermore, Rv3487c is expressed during infection as it exhibits significant humoral immunoreactivity with sera from children with tuberculosis, but not with that from adult patients.

Correlation of antioxidants and fitness levels in undergraduate medical students.

Fitness is the ability of the organism to maintain the various internal equilibriums as closely as possible to the resting state during strenuous exercise and to restore promptly after exercise. The aim of the present study was to evaluate the fitness and correlate it with anti-oxidant levels of 50 male medical students in the age group of 18 to 25 years. Fitness was assessed by Harvard Step Test. The antioxidant status was assessed by Vitamin C and Vitamin E levels in the blood. Three groups were formed on the basis of fitness score. The mean values of fitness scores were 95.33 +/- 7.66, 68.5 +/- 9.22 and 37 +/- 10.9, in-group A, B and C, respectively. Between the three groups, Vitamin E values were significantly different but not the Vitamin C levels. Thus, it is concluded that Vitamin E levels influence the fitness state of an individual.

Effect of vitamin E supplementation on antioxidant enzymes and lipid peroxidation in myocardial infarction patients

Oxidative stress is increased in patients with myocardial infarction [MI] owing to increase in free radical production. Alteration in the levels of antioxidant enzymes in these patients are a consequence of either increased production of free radicals or depletion of endogenous antioxidants. It is believed that vitamin E supplementation reduces MI by scavenging free radicals and by ameliorating enzyme activity. However, the outcomes of clinical trials with vitamin E in MI prevention have been mixed. The present study was therefore, undertaken to assess the status of antioxidant markers: superoxide dismutases [SOD], ceruloplasmin, and lipid peroxidation i.e., malondialdehyde [MDA] levels in the blood samples of MI patients and to investigate the effect of vitamin E supplementation in ameliorating the levels of antioxidant enzymes and malondialdehyde in Ml subjects. 120 Ml patients 30 to 65 years of age were taken for the study and 72 healthy individuals served as controls. In vitro vitamin E supplementation study in the blood samples of the respective MI subjects was performed. Vitamin E supplementation brought about an improved antioxidant status with significantly raised, SOD levels [22.4%, p<0.05] and simultaneously depleted MDA levels [32.58%, p<0.001]. Ceruloplasmin levels however, remained unaltered [p<0.1]. These findings further support the preventive and helpful role of vitamin E supplementation in reducing oxidative stress levels in MI patients

Feasibility of pre-operative autologous blood donation in Indian patients with elective orthopaedic surgery.

BACKGROUND & OBJECTIVES: Pre-operative autologous blood donation (PABD) in elective orthopaedic surgeries is a well known procedure in the West. We initiated this programme at a tertiary care hospital in north India to study its feasibility in Indian patients. METHODS: In a prospective case-control study, 144 patients undergoing primary total hip or knee replacement, inter-vertebral discectomy, mal-union and non-union reconstruction were educated and motivated to pre-donate. Patients fulfilling the inclusion criteria and making autologous donation formed the PABD group (n=22). Patients eligible for PABD, but unwilling to participate; age, sex, pre-operative haemoglobin and operative procedure matched acted as controls (n=27). Unit(s) collected was processed like an allogeneic unit. Unit(s) found reactive for infectious markers or not utilized was discarded. Mean blood losses, transfusion trigger, allogeneic exposure and wastage between the two groups were compared. RESULTS: Of the 144 patients motivated, 40 per cent of the eligible subjects pre-deposited. The main motivational factor was fear of getting infection from someone's blood. Cardiac events and anaemia prevented 61.8 per cent patients to participate. Of the 50 units ordered, autologous units with a mean of 1.4 units/patient contributed 62 per cent. For total hip and total knee replacement (THR and TKR), autologous units met 76.2 and 80 per cent respectively of the total blood requirement. A significant decrease in the allogeneic exposure was observed between PABD and control group (18.2 vs 66.7%); 32.3 per cent of the autologous units were discarded. INTERPRETATION & CONCLUSION: Comprehensive PABD programme may be an effective method for reducing the need for allogeneic transfusion in patients undergoing joint replacement surgeries in our country, where transfusion transmitted infections due to high percentage of replacement donations and lack of sensitive assays for testing are still a cause for concern.