Audit of management of pregnant women with positive VDRL tests.

BACKGROUND: Syphilis is a preventable cause of foetal loss and congenital disease. Although the VDRL test is an integral part of routine antenatal care in India, little is known about the disease burden in pregnancy in India. Therefore, we carried out a study to determine the prevalence of VDRL positivity and syphilis among pregnant women in Vellore and to audit the management and outcome of VDRL-positive pregnancies. METHODS: A retrospective review of case records. RESULTS: Only 0.98% of pregnant women were positive by the VDRL test. However, foetal loss occurred in 16 (32%) of the 50 seropositive women; 15 of these did not receive antenatal care. Seventeen of the 34 seropositive multiparous women had had previous foetal losses. Only 16 women had received penicillin. CONCLUSION: Although the seroprevalence of syphilis in pregnancy is low, it is an unrecognized cause of foetal loss in Vellore. An audit of the testing and management of VDRL positivity in pregnancy provides valuable information on the quality of antenatal care in an area.

Prenatal diagnosis of beta-thalassaemia mutations using the reverse dot blot technique.

BACKGROUND: Beta-thalassaemia is the most common genetic disorder among Indians and a number of mutations causing this disease have been reported. Since effective treatment of thalassaemia major is complicated and very expensive, prenatal diagnosis has become an important option for those at risk of having an affected foetus. We report the use of a rapid hybridization method called 'reverse dot blot' for detection of specific mutations of the beta-globin gene. METHODS: DNA was obtained from a 12-week-old foetus by chorionic villus sampling and was amplified using specific primers by the polymerase chain reaction and analysed by the reverse dot blot test. Results were available within 36 hours after sampling. RESULT: The father and mother were found to be heterozygous for codon 15 (G-A) mutation of the beta-globin gene. The foetus was normal. CONCLUSION: Reverse dot blot is a rapid and reliable technique for mutation detection in the beta-globin gene and can be useful for antenatal diagnosis.

Birthweight standards for south Indian babies.

OBJECTIVE: To obtain birthweight standards for south Indian babies. DESIGN: Prospective cohort study. SETTING: A tertiary care hospital in south India. PATIENTS AND METHODS: Data from 11, 641 singleton live births between 1991 and 1994 were used to calculate smoothed gestation specific birthweight centiles for four categories based on sex of the infant and birth order. Smoothed gestation specific birthweight centiles were also calculated for all births between 37-41 weeks without adjustments for sex of infant or birth order. Data for births between 37 and 41 weeks were reanalysed using non-adjusted birthweight centiles and birthweight centiles adjusted for sex and birth order to determine misclassification of data. Multiple regression analysis was used to determine the influence of various variables on birthweight. RESULTS: Factors influencing birthweight were gestation at birth, sex of infant, birth order and maternal height. A quadratic equation including these variables and the square of the gestational age explained 18% of variation in birthweight. Female infants were on the average 113 g (95% CI 26-200 g) lighter than male infants. Later born babies were on the average 130 g (95% CI 40-220 g) heavier than first born babies. Therefore significant misclassification of infants occurred when non-adjusted birthweight centiles were used. Babies born to women whose heights were outside the interquartile range (150-158 cm) were 81 g lighter or heavier than those born to women within this range. CONCLUSIONS: Birthweight centiles for gestation when used should be adjusted for birth order, sex of infant and maternal height.

The normal preterm foetal heart rate pattern.

A longitudinal study was carried out on 38 women with low risk pregnancies. These women had cardiotocography at 27-28 wk initially, at fortnightly intervals thereafter until 36 wk and at weekly intervals thereafter until delivery. All cardiotocographs were analyzed by one investigator who was not aware of the individual clinical situation. Of the 232 cardiotocographs, 12 (0.5%) of poor quality were excluded from analyses. The mean base-line heart rate decreased from 142.5 (SD 6.03) beats per min at 27-30 wk to 138.2 (SD 7.4) at term. Analysis of variance for repeated measures showed that the decrease in foetal heart rate with gestation was statistically significant (P < 0.001). The number of accelerations increased with gestation (P = 0.002). There were no significant changes in variability and decelerations with increasing gestation.

Colposcopy in women with a normal Papanicolaou smear.

BACKGROUND. Colposcopy is usually done when the Papanicolaou smear is abnormal so that the necessity for cone biopsy is reduced. However, there is often a strong clinical suspicion of cervical neoplasia even though the smear is normal and this problem of the false negative Papanicolaou smear has not, we feel, been adequately addressed. We, therefore, examined the usefulness of colposcopy in detecting cervical neoplasia in women in whom the Papanicolaou smear was normal. METHODS. A cross-sectional design was used which included 80 patients in whom cervical neoplasia was suspected and who had undergone colposcopy in one gynaecology unit at the Christian Medical College Hospital, Vellore. The Papanicolaou smear result of these patients was then related to their diagnosis on colposcopy. RESULTS. The Papanicolaou smears were normal in 56 patients and abnormal in 24. In the normal Papanicolaou smear group there were 18 women with grade I cervical intra-epithelial neoplasia and 3 with grade II lesions. In the abnormal smear group there were 8 women with grade I cervical intra-epithelial neoplasia, 9 with grade II cervical intra-epithelial neoplasia and 1 had microinvasive carcinoma. Patients with abnormal Papanicolaou smears had a relative risk of 7.8 (95% CI 2.4 to 25.8) of having a lesion more advanced than grade I cervical intra-epithelial neoplasia compared with those in whom cervical neoplasia was only suspected clinically. CONCLUSION. When the clinician suspects cervical neoplasia but the Papanicolaou smear is negative, colposcopy reveals at least grade II cervical intra-epithelial neoplasia in 5% of patients. Such patients, therefore, need to be followed up closely or else have a colposcopy and directed biopsy.

Random plasma glucose and the glucose challenge test in pregnancy.

BACKGROUND. The oral glucose tolerance test for detecting women with gestational diabetes is too complicated and prolonged for routine use. Similar and less time consuming screening tests have been proposed including random plasma glucose estimation and the glucose challenge test (blood glucose estimation one hour after a 50 g glucose load). However, in practice, correct timing of the blood sample, which is of critical importance in the interpretation of the results of these tests, is difficult to ensure. This study was designed to evaluate these two screening tests in identifying women with abnormal glucose tolerance in pregnancy. METHODS. One hundred and eleven consecutive pregnant women at risk for gestational diabetes and 121 consecutive pregnant women with no risk factors had random plasma glucose estimation followed by the 50 g glucose challenge test at 26 to 30 weeks of gestation. A 100 g 3 hour oral glucose tolerance test was done within two weeks of the screening tests. The sensitivity and specificity of screening tests in predicting abnormal glucose tolerance were calculated. RESULTS. Seven (6.3%) women in the high risk group and four (3.3%) in the low risk group had gestational diabetes, while 11 (9.9%) and 8 (6.6%) had impaired glucose tolerance. Random plasma glucose level of 90 mg/dl or greater had a sensitivity of 63% and specificity of 66% in predicting abnormal glucose tolerance, while a threshold level of 115 mg/dl for the glucose challenge test yielded a sensitivity of 63% and a specificity of 55%. CONCLUSIONS. Neither random plasma glucose estimation nor the glucose challenge test is a useful screening procedure for abnormal glucose tolerance in pregnancy.

Prevalence of genital mycoplasma & ureaplasma infections in pregnancy & their effect on pregnancy outcome.

A cohort of 200 women with singleton pregnancies attending the antenatal clinic, were studied to determine the prevalence of genital mycoplasma and ureaplasma infections in pregnant women and the effect of infection on pregnancy outcome. Vaginal and endocervical swabs were taken at 26-30 wk and again at 36-38 wk of pregnancy and cultured for mycoplasma and ureaplasma. Forty (20%, 95% CI 14.5-25.6%) women were found to be infected with arginine metabolising mycoplasmas and 79 (39.5%, 95% CI 32.7-46.3%) with ureaplasma at either site or either time. The mean +/- SD birth weight of infants born to women infected with mycoplasma alone was 2879 +/- 471 g while that of infants born to women infected with ureaplasma alone was 2964 +/- 412 g. Mean +/- SD birthweight of infants born to women infected with both organisms was 2969 +/- 389 g while that of infants born to uninfected women was 2919 +/- 432 g. These differences were not statistically significant. The median gestation at delivery was 39 wk in the cohort; the differences among the groups were minor and statistically not significant. Thus, although genital mycoplasma/ureaplasma infections were frequent, no association was observed between infection and pregnancy outcome.

Influence of exposure to tobacco smoke on serum alpha fetoprotein levels of women in midtrimester pregnancy.

The influence of exposure to tobacco smoke on maternal serum alpha-fetoprotein (AFP) levels at 16 wk gestation was examined. Urinary cotinine levels were used to quantify exposure to tobacco smoke. Significantly higher levels of maternal serum AFP were found in 101 women who had more than 1.0 microgram cotinine/mg urinary creatinine compared with 180 women whose urinary cotinine levels were below this level [(mean +/- SD) 1.23 +/- 0.64 and 1.06 +/- 0.54 respectively; 95 per cent CI of difference of means 0.01-0.31; P < 0.05]. There was a mild albeit statistically significant correlation between urinary cotinine levels and maternal serum AFB (r 0.099; P < 0.05). However, the difference in maternal serum AFP levels between the two groups was not found to be significant, when adjustments for maternal body mass index were made.

Candida antibodies in amniotic fluid.

Amniotic fluid samples were tested for specific immunoglobulins against Candida albicans by indirect immunofluorescence. Nineteen of the 23 samples tested contained specific IgA while specific IgG antibodies were detected in only seven samples (P less than 0.01). None of the samples contained specific anticandidal IgM (P less than 0.001). These 23 samples and a further 30 amniotic fluid samples were tested for Candida mannan antigen by latex agglutination. Mannan was not detected in any of the samples tested. It is concluded that anticandidal IgA in amniotic fluid is naturally occurring.