A Critical Assessment of Stillbirths at a Tertiary Care Hospital

Background: Globally in 2015, 2.6 million stillbirths occurred with estimated stillbirth rate (SBR) of 18.4/1000 births. India is the world capital of stillbirth accounting for 22.6% of world’s stillbirths. Objectives: The objective of the study is to study the demographic profile of women experiencing stillbirth, to understand the risk factors for stillbirth in low resource settings, and to find the etiology of stillbirth so as to facilitate designing of a stillbirth prevention strategy. Methods: This was a cross?sectional observational study done at a tertiary care hospital of Delhi from June 2017 to December 2019. All babies delivered after 20 weeks of gestation showing no sign of life after birth were considered stillborn. Prestructured proforma was filled for each case and data were analyzed. Results: A total of 50,461 births took place during the study period, out of which 1824 were stillborn, making SBR of 36.15/1000 births of our institution. Most of the women belonged to age group 21–25 years and more than 50% of women were illiterate. Twenty?nine percent of women were completely unbooked, 48% were referred from other centers and 23% were registered at our hospital. Placental causes accounted for 22%, hypertension for 23%, and labor complications for 9% of cases while in 22% cases, cause could not be found. Conclusion: Stillbirth remains a neglected issue. A significant proportion of stillbirths are preventable by adequate antenatal care. Notification of stillbirths will give us the exact figures and realization of the seriousness of the problem which will help us work towards the solutions.

Evaluation of cervical and anal intraepithelial neoplasia in women attending a sexually transmitted infection clinic.

Background: The incidence of anal and cervical cancers and their precursors have increased in the past decades. Women with HIV and sexually transmitted infections are at a higher risk. Cervical human papilloma virus infection may serve as a reservoir and source of anal infection or vice versa. A higher incidence of anal cytological abnormality has been observed in patients with abnormal cervical cytology. Objectives: This cross sectional study was designed to estimate the prevalence and associations of anal and cervical cytological abnormalities in a cohort of sexually active women using Papanicolaou smears. Methods: We conducted a single centre study of 35 consecutive HIV positive and 40 HIV negative women attending the sexually transmitted infection clinic. Cervical and anal specimens were obtained for cytology after a detailed history and examination. Chi square test and coeffi cient of correlation were used for comparison. Results: Cervical dysplasia was observed in 22.6% (17.3% low-grade squamous intraepithelial lesion and 5.3% high grade squamous intraepithelial lesion) and anal dysplasia in 8% study subjects (6.7% low-grade squamous intraepithelial lesion and 1.3% high grade squamous intraepithelial lesion); no association was observed with HIV infection. A higher number of patients with cervical dysplasia (29.4%) were found to have concomitant anal dysplasia (P = 0.002). History of anal intercourse was reported in all patients with anal dysplasia and was higher (P < 0.037) in patients with cervical dysplasia. Limitations: The limitations included a small sample size, lack of correlation with histological fi ndings and bias due to STI clinic-based recruitment of the study population. Conclusion: Cytology may be used to screen for cervical and anal dysplasia in women irrespective of HIV status. Women with cervical dysplasia may be preferentially screened for anal dysplasia and vice versa. Anal intercourse may be a risk factor for anal and cervical dysplasia.

Association of organochlorine pesticides with the mRNA expression of tumour necrosis factor-alpha (TNF-α) & cyclooxygenase-2 (COX-2) genes in idiopathic preterm birth.

Background & objectives: Preterm birth (PTB) is an important cause of prenatal death, neonatal morbidity and mortality and adult illness. Increased inflammation occurs in normal parturition, and inflammatory cytokines and oxidative stress are found to be higher in PTB cases. The present study was planned to investigate the association of organochlorine pesticides (OCPs) with mRNA expression of inflammatory pathway genes such as tumour necrosis factor-alpha (TNF-α) and cyclooxygenase-2 (COX-2) in preterm delivery (PTD) cases. Methods: Maternal blood samples of PTD (n=30) cases and equal number of term delivery (n=30) were collected at the time of labour. Women occupationally exposed to OCPs and other high risk factors such as anaemia, hypertension, bacterial vaginosis, renal and heart disease, diabetes, etc. were excluded. The OCP levels were estimated by gas chromatography, and mRNA expressions of TNF-α and COX-2 genes were analysed using real-time PCR (qPCR). Results: Significantly higher levels of β-HCH (beta-hexachlorocyclohexane, 95% CI=2.08-4.633, P=0.001), p’p’-DDE (para, para-dichlorodiphenyldichloroethylene, 95% CI=0.546-2.551, P=0.003), and o’p’-DDD (ortho, para-dichlorodiphenyldichloroethane, 95% CI=0.004-0.690, P=0.047) were observed in maternal blood of PTB cases as compared to term delivery. The mRNA expressions of COX-2 and TNF-α genes were 3.13 and 2.31 folds higher in PTB cases in comparison to term delivery. Linear positive correlations were observed between period of gestation (POG) and ΔCt of COX-2 and TNF-α genes. Interpretation & conclusions: Environmental factors such as OCPs may be associated with inflammatory events showing gene-environment interaction in PTB cases. Evaluating the molecular control of inflammation along with gene environment interaction may be used as a model to explore the aetiology of idiopathic PTB cases and may be considered for the prognosis of adverse reproductive outcomes.

Predictors and outcome of obstetric admissions to intensive care unit: A comparative study.

This descriptive observational study was carried out in Guru Teg Bahadur Hospital to identify predictors and outcome of obstetric admission to Intensive Care Unit (ICU). Ninety consecutive pregnant patients or those up to 42 days of termination of pregnancy admitted to ICU from October 2010 to December 2011 were enrolled as study subjects with selection of a suitable comparison group. Qualitative statistics of both groups were compared using Pearson's Chi-square test and Fisher's exact test. Odds ratio was calculated for significant factors. Low socioeconomic status, duration of complaints more than 12 h, delay at intermediary facility, and peripartum hysterectomy increased probability of admission to ICU. High incidence of obstetric admissions to ICU as compared to other countries stresses on need for separate obstetric ICU. Availability of high dependency unit can decrease preload to ICU by 5%. Patients with hemorrhagic disorders and those undergoing peripartum hysterectomy need more intensive care.

Effect of Helicobacter pylori eradication therapy in iron deficiency anaemia of pregnancy – A pilot study.

Background & objectives: Despite routine iron supplementation and promotion of diet modification, iron deficiency anaemia (IDA) remains widely prevalent in our antenatal population. Recent studies in pediatric population have highlighted the role of Helicobacter pylori infection in IDA. This study was undertaken to study the effect of eradication therapy in H. pylori infected pregnant women with IDA. Methods: Randomized placebo-controlled double blind clinical trial was done on 40 antenatal women between 14-30 wk gestation, with mild to moderate IDA and having H. pylori infection, as detected by stool antigen test. These women were randomly divided into group I (n=20): H. pylori treatment group (amoxicillin, clarithromycin, omeprazole for 2 wk) and group II (n=20): placebo group. Both groups received therapeutic doses of iron and folic acid. Outcome measures were improvement in haematological parameters and serum iron profile after 6 wk of oral iron therapy. Results: The prevalence of iron deficiency in pregnant women with mild to moderate anaemia was 39.8 per cent (95% CI 35.7, 44.3); and 62.5 per cent (95% CI 52, 73) of these pregnant women with IDA were infected with H. pylori. After 6 wk of therapeutic oral iron and folic acid supplementation, the rise in haemoglobin, packed cell volume, serum iron and percentage transferrin saturation was significantly (P<0.05) higher in the group given H. pylori eradication therapy as compared to the placebo group. Interpretation & conclusions: Our results showed a high occurrence of H. pylori infection in pregnant women with IDA. Eradication therapy resulted in significantly better response to oral iron supplementation among H. pylori infected pregnant women with IDA.

Dilantin as anticonvulsant in eclampsia.

Sixty-six cases of eclampsia amongst 9178 deliveries were managed from July, 1997 to December, 1998 in the department of obstetrics and gynaecology at UCMS & GTB Hospital, Delhi. The aim was to evaluate the changing trends in patients of eclampsia and to assess the efficacy of dilantin in its treatment. The incidence recorded was 1 in 139 deliveries (0.7%). Majority (90.91%) were unsupervised in antenatal period and 68.18% were primigravidae. Eclampsia developed at < 28 weeks of pregnancy in 3.03% of patients. All the patients had hypertension and proteinuria at the time of admission and 51.52% showed hypertensive changes on fundus examination. While single anticonvulsant therapy in the form of dilantin was used to manage 57.57% of patients, 13.64% required intubation and positive pressure ventilation. Fit recurrence on treatment was noticed in 40.91% of patients. Lower segment caesarean section was conducted in 18.18% of patients. Three maternal deaths (4.56%) attributed to ventricular tachycardia, aspiration and intracerebral haemorrhage were recorded. Morbidity was frequent in the form of status eclampticus (n = 5), postpartum psychosis (n = 5), retinal detachment (n = 1), coagulation abnormality (n = 11). The perinatal mortality rate was 30.43%. The study concludes that eclampsia is still rampant in India and despite better medical facilities, maternal and perinatal mortality remains high. The efficacy of dilantin as anti-eclamptic needs to be reviewed.