Maternal Near Miss-Experience At A Tertiary Care Teaching Hospital In Western India

Background:Pregnancy-related morbidity and mortality continue to have a huge impact on the lives of Indian women and their newborns. Any pregnant woman can develop life-threatening complications with little or no advance warning. All women need access to quality maternal health services that can detect and manage such complications1. Complications during pregnancy and childbirth remain a leading cause of death among women of reproductive age in India2. Each year in India, roughly 28 million women experience pregnancy and 26 million have a live birth. Of these estimated 67000 maternal and 10,00000 newborn deaths occur every year3. The maternal near-miss event was defined as “any acute obstetric complication that immediately threatens a woman’s survival but does not result in her death either by chance or because of hospital care she receives during pregnancy, labor or within 6 weeks of termination of pregnancy4.Maternal mortality data in practical terms is the tip of an iceberg while the maternal near-miss data is invisible and whic h is a very important tool to reduce maternal mortality.Material And Methods:This is a retrospective observational study carried out among 80 maternal near-miss cases who were admitted in obstetric ICU fulfilling criteria for identification for maternal near-miss cases as per Maternal Near Miss Review Operational Guideline (December 2014)in the Department of Obstetrics and Gynecology, in our tertiary care teaching hospital, between October 1, 2018, to October 31,2020.Patient fulfilling criteria for identification of near-miss cases as per Maternal Near miss Review Operational Guideline (December, 2014)Minimum 3 criteria were included in the study.Result:During the study period total of 18360 obstetric patients were admitted, out of which 80 patients ended up becoming maternal near-miss cases. Among them majority of patients were in age group of 18-25 years and occurrence was high in multipara women. In many patients more than one underlying disorder was present. Hemorrhage (67.5%) followed by a hypertensive disorder of pregnancy (30.0%) was the commonest presenting disorder in near-miss cases. In spite of being highly preventable, maternal sepsis (6.2%) also contributes to being a major cause of morbidity.In our study, 15% of near-miss cases had associated medical conditions. 5 % of cases (n=4) in the present study faced acute severe respiratory depression (ARDS) after getting infected with covid-19 infection. There was need for massive blood transfusions in 63.75 %, magnesium sulfate therapy in 17.25%, use of cardiotonic /vasopressor drugs in 10.0%, obstetric hysterectomy in 23.75 % of cases. More than one management modality was followed in many patients. All the near-miss cases were covered with broad spectrum antibiotic therapy. Total 21 near-miss cases (26.25%) were identified to have delays. Delay in the decision to seek care (Delay 1) occurred in 2.5% of women. Educational backwardness, ignorance of pregnancy itself, lack of regular antenatal care, and failure to give importance to warning signals may be the contributing factors. Delay in accessing adequate care (Delay 2) was identified in 7.5% of women. Conclusion: Hemorrhage, hypertensive disorders of pregnancy, abnormalities of labor, anemia, and sepsis are still major contributing factors for maternal near-miss cases. Anticipation, early diagnosis, and prompt treatment of maternal complications can reduce maternal morbidity and mortality. Sensitization of the population for proper utilization of available maternal health care facilities is very vital for reducing maternal near-miss cases.All the maternal near-miss cases are living le ssons, who de spite their misery show us our deficiencies.

Phacoemulsification with single-pass four-throw pupilloplasty and pre-Descemet's endothelial keratoplasty for management of cosmetic iris implant complication

Placement of an anterior chamber iris implant for cosmetic reasons has been associated with development of various complications. Even after the implant has been explanted from the eye, it leaves a trail of after effects that necessitate surgical management. We describe a technique that comprises of performing phacoemulsification with single-pass four-throw pupilloplasty and a pre-Descemet's endothelial keratoplasty procedure for this eye with cosmetic iris implant complication.

Comparison of USG guided modified rectus sheath block with intraperitoneal instillation with Inj Bupivacaine for postoperative pain relief in diagnostic laparoscopy

Background: Laparoscopic surgery is associated with considerable postoperative pain, though it is less compared to open surgery. Post laparoscopic pain results from phrenic nerve irritation caused by residual gas, stretching of the intraabdominal cavity and peritoneal inflammation. The Modified Rectus Sheath Block (MRSB) is fairly easy and reliable procedure when performed using ultrasound guidance so it is compared with the intraperitoneal instillation method by using Inj. Bupivacaine for postoperative analgesia in diagnostic laparoscopy. Aim of the study was to assess and compare the effect of the USG guided modified rectus sheath block (MRSB) with the intraperitoneal instillation using Inj. Bupivacaine in diagnostic laparoscopy. Material and methods: It was prospective randomized study. The Patients were randomly allocated in two groups. Group A were given USG guided rectus sheath block and Group B was given Patel V, Mehta K, Patel K, Parmar H. Comparison of USG guided modified rectus sheath block with intraperitoneal instillation with Inj. Bupivacaine for postoperative pain relief in diagnostic laparoscopy. IAIM, 2016; 3(1): 85-89. Page 86 intraperitoneal 25 mg Bupivacaine. Patients with obesity, local anesthetic agent allergy and emergency surgeries were excluded. Pain was assessed 1, 6, 10 and 24 hours postoperatively by visual analogue pain score. Results: Postoperative pain was assessed by visual analogue pain score (VAS) at every hour for 24 hours postoperatively. The VAS was significantly lower in Group A at 6 and 10 hours postoperatively. After 6 hours the median pain score was 3 in group A while it was 7 in group B. After 8 hourrs the median pain score was 2 in group A compared with 5 in group B and after 10 hours the median score were 2 and 5 in group A, group B respectively (p<.001 and <0.004 respectively). No significant difference noted in pain score at 1 hour and 24 hour post laparoscopy among the two groups. Conclusion: USG guided modified rectus sheath block (MRSB) provides prolonged post operative analgesia than intraperitoneal instillation in diagnostic laparoscopy.

Dietary Pattern of Schoolgoing Adolescents in Urban Baroda, India.

Diet plays a very important role in growth and development of adolescents, during which the development of healthy eating habits is of supreme importance. There is a dual burden of undernutrition and overnutrition in this age-group. The study assessed the food habits, food preferences, and dietary pattern of schoolgoing urban adolescents in Baroda, India. Both quantitative and qualitative methods were used in this study. A quantitative survey was carried out using a pre-tested self-administered structured questionnaire among 1,440 students from class 6 to 12 in 7 English medium and 23 Gujarati medium schools. Focus group discussions, 5 each with adolescent boys and girls, were held, along with 5 focus group discussions with teachers of Gujarati and English medium schools. Nearly 80% of adolescents had consumed regular food, like dal, rice, chapati, and vegetables, including green leafy vegetables. Nearly 50% of them had consumed chocolates, and about one-third consumed fast foods. Nearly 60% of adolescents had their breakfast daily while the remaining missed taking breakfast daily. Nearly one-third of adolescents were missing a meal once or twice a week. A large majority had consumed regular foods. However, more than half of them had consumed chocolates, soft drinks, and over one-third had taken fast foods.

A Case-control Study of Pelvic Inflammatory Disease and Its Association with Multiparity among Patients Attending SSG Hospital, Vadodara, Gujarat.

Objective: To know the association between pelvic inflammatory disease (PID) and multiparity. Study design: Case control study. Setting: Shree Sayaji General (SSG) Hospital, Government Medical College, Vadodara. Participants: Women attending Gynec Clinics and Curative Practice and General Practice (CPGP) OPD. Sample size: One hundred fifty cases and 150 controls. Statistical analysis: Chi-square test. Results: The odds ratio (OR) for PID with multiparity as risk factor was 0.69 with 95% confidence interval (CI) being 0.42-1.09. Among 143 cases multiparity was present in 63 cases (44.05), while in 150 controls it was in 80 (53.33%). The difference was not statistically significant (p = 0.141). But, the OR with untrained person as a risk factor for PID was 2.41 with 95% CI being 1.78-3.27. This suggests etiological fraction of 58.5% (CI 43.9-69.4%) among untrained persons. The delivery by untrained person was significantly higher in cases than in controls (p 0.00001). Conclusions: Present study did not show multiparity as risk factor but delivery conducted by untrained persons emerged as a risk factor.

Body Mass Index (BMI) and Self-Perception of Weight and Height among school going adolescents in urban Vadodara, India.

Background: Weight comments are commonly received by adolescents, but the accuracy of the comments and their effects on weight misperception are unclear. Aims & Objective: To know the perceptions of adolescents about their health status, body image, height and weight and then to compare it with their actual (Body Mass Index) BMI status. Material and Methods: This was Cross sectional study and Qualitative survey carried out using a self-administered semi-structured questionnaire among 1440 (748 girls and 692 boys) students from classes 6-12 in 7 English medium and 23 Gujarati medium schools. Five focus group discussions were held each with adolescent boys and girls from both Gujarati and English medium schools. Results: Regarding their perception about their health status, nearly 65% of the boys and girls felt that they were healthy. While their perception about the appropriateness of their height and weight, nearly half of the boys and girls felt that they had appropriate height and weight, One-fourth of them perceived themselves to be underweight, while another fourth thought that they were obese. When adolescents’ perception of the appropriateness of height and weight was compared with their actual BMI, it was found that, 10 to 15% of them were underweight or undernourished while 25 to 30% of them were overweight or obese. Among those, having normal BMI, 59% of boys and 62% of girls felt that their height and weight was normal. Conclusion: There has been a need for addressing physical growth, particularly; height and weight need to be explained more scientifically and in depth.

Oral Zinc Supplementation for Reducing Mortality in Probable Neonatal Sepsis: A Double Blind Randomized Placebo Controlled Trial.

Objective: To study the role of Zinc in the treatment of neonatal sepsis. Design: Double blind, randomized, placebo controlled trial. Setting: Tertiary Care Hospital. Participants: 614 neonates with probable neonatal sepsis. Intervention: The drug group (n=307) received 1mg/kg/day of elemental zinc, and placebo group (n=307) received the placebo, in addition to antibiotic therapy and supportive care, till the final outcome (discharge/death). Outcome Measures: Decrease in mortality rates (primary outcome), duration of hospital stay and need of higher lines of antibiotic therapy (secondary outcomes) were tested. Results: Baseline characteristics of the two groups were similar. No statistically significant differences between drug and placebo group were found in mortality rate (9.77% vs 7.81 %; P=0.393), mean duration of hospital stay (142.85±69.41 hrs, vs. 147.99±73.13 hrs; P=0.841), and requirement of higher lines of antibiotic therapy (13.35% vs 12.05%, P=0.628) after supplementation. Conclusions: This study does not report decrease in mortality rates, duration of hospital stay and requirement of higher lines of antibiotic therapy following zinc supplementation in neonatal sepsis.

Sonographic Measurement of Renal Size in Normal Indian Children.

Objectives: To determine the renal size in normal Indian children by sonography. Settings: Pediatric teaching hospital, Mumbai, India. Duration: 1.5 years. Design: Cross-sectional observational study. Participants: 1000 normal Indian children aged 1 month - 12 years. Methods: Sonographic assessment of renal size (length, width and thickness) was performed using Philips real time mechanical sector scanner of 3.5-5 MHz frequency with electronic caliper. The mean renal dimensions and volume were calculated for each age group with ± 2SD. The renal length and calculated renal volume were correlated with somatic parameters like age, weight, height and body surface area. Regression equations were derived for each pair of dependent and independent variables. Results: No statistical difference was found in renal size between sexes and between right and left kidney. A strong correlation was seen between renal size with various somatic parameters, the best correlation was between renal size length and body height (coefficient of correlation=0.9). Conclusion: This study provides values of renal length (mean ± 2SD) in normal Indian children. Renal length can be easily calculated by derived linear regression equation.

Prevalence of dental fluorosis & dental caries in association with high levels of drinking water fluoride content in a district of Gujarat, India.

Background & objectives: Endemic fluorosis resulting from high fluoride concentration in groundwater is a major public health problem in India. This study was carried out to measure and compare the prevalence of dental fluorosis and dental caries in the population residing in high and normal level of fluoride in their drinking water in Vadodara district, Gujarat, India. Methods: A cross-sectional study was conducted in Vadodara district, six of the 261 villages with high fluoride level and five of 1490 with normal fluoride level in drinking water were selected. The data collection was made by house-to-house visits twice during the study period. Results: The dental fluorosis prevalence in high fluoride area was 59.31 per cent while in normal fluoride area it was 39.21 per cent. The prevalence of dental caries in high fluoride area was 39.53 per cent and in normal fluoride area was 48.21 per cent with CI 6.16 to 11.18. Dental fluorosis prevalence was more among males as compared to females. Highest prevalence of dental fluorosis was seen in 12-24 yr age group. Interpretation & conclusions: The risk of dental fluorosis was higher in the areas showing more fluoride content in drinking water and to a lesser degree of dental caries in the same area. High fluoride content is a risk factor for dental fluorosis and problem of dental fluorosis increased with passage of time suggesting that the fluoride content in the water has perhaps increased over time. Longitudinal studies should be conducted to confirm the findings.

Gallbladder Mucosal Changes Associated with Chronic Cholecystitis and Their Relationship with Carcinoma Gallbladder.

384 cholecystectomy specimens were examined during a period of one year from Oct 2005 to Oct 2006, in the department of Pathology, ASCOMS, Sidhra. Jammu, for studying the histological patterns of chronic cholecystitis, the frequency of associated mucosal changes, the age related incidence and the relationship of carcinoma with various mucosal changes. Majority of patients presented in the fourth decade of life. The youngest patient was 16 years and the oldest 78 years of age. Acute and chronic inflammatory lesions were associated with ulceration in 13.02%, mucosal hyperplasia in 25.26% and antral metaplasia in 53.40%. Intestinal metaplasia constituted 9.11%, cholesterolosis was seen in 12.25%, dysplasia in 3.64% and neoplasia in 0.78% of cases. All the cases of carcinoma were associated with gallstones. Histological continuity between epithelial changes was seen in 35 cases. 8 cases had continuity of antral metaplasia, intestinal metaplasia and dysplasia. 2 cases showed continuity of intestinal metaplasia with dysplasia and carcinoma and 1 case showed continuity of dysplasia with carcinoma.It is inferred that antral metaplasia, intestinal metaplasia, dysplasia and carcinoma have an inter-relationship. There is a significant higher incidence of carcinoma gallbladder in patients who harbor gallstones for longer period. Histopathological examination is thus important in every case of cholecystectomy for identifying metaplasia, dysplasia and carcinoma.

Management of steroid resistant nephrotic syndrome.

JUSTIFICATION: There is a lack of evidence based guidelines for management of children with steroid resistant nephrotic syndrome (SRNS). PROCESS: Experts of the Indian Society of Pediatric Nephrology were involved in a two-stage process, the Delphi method followed by a structured face to face meeting, to formulate guidelines, based on current practices and available evidence, on management of these children. Agreement of at least 80% participants formed an opinion. OBJECTIVES: To develop specific, realistic, evidence based criteria for management of children with idiopathic SRNS. RECOMMENDATIONS: The Expert Group emphasized that while all patients with SRNS should initially be referred to a pediatric nephrologist for evaluation, the subsequent care might be collaborative involving the primary pediatrician and the nephrologist. Following the diagnosis of SRNS (lack of remission despite treatment with prednisolone at 2 mg/kg/day for 4 weeks), all patients (with initial or late resistance) should undergo a renal biopsy, before instituting specific treatment. Patients with idiopathic SRNS secondary to minimal change disease or focal segmental glomerulosclerosis should receive similar therapy. Effective regimens include treatment with calcineurin inhibitors (tacrolimus, cyclosporine), intra-venous cyclophosphamide or a combination of pulse corticosteroids with oral cyclophosphamide, and tapering doses of alternate day corticosteroids. Supportive management comprises of, when indicated, therapy with angiotensin converting enzyme inhibitors and statins. It is expected that these guidelines shall enable standardization of care for patients with SRNS in the country.

Diagnosis of multiple myeloma by demonstration of M protein in bone marrow aspirate by agar gel electrophoresis: a case report.

A number of laboratory tests are used to confirm the diagnosis of multiple myeloma, including M protein in the serum. Since M protein in the serum originate from tumour cells in the bone marrow before circulating in the serum, demonstration of M protein in bone marrow aspirate can be added to the batteries of diagnostic parameters.

Treatment of neonatal candidiasis with liposomal amphotericin B(L-AMP-LRC-1): phase II study.

A liposomal amphotericin B preparation (L-AMP-LRC-1) has been developed and tested successfully in adults by us. This preparation was administered to 23 neonates with candidiasis in an open phase II study. All the 14 assessable patients responded completely to the L-AMP-LRC-1 therapy given at 1 mg/kg for 28 days. Compared to AmBisome, another liposomal formulation of amphotericin B, L-AMP-LRC-1 was effective at lower dose in neonatal candidiasis. Thus L-AMP-LRC-1 appears to be an effective and low cost drug for the treatment of candidiasis.

Dual kidney transplantation--a solution for less than ideal brain dead donors.

For renal transplantation, an elderly cadaver donor is often rejected because of the relatively poor long-term graft survival. Considering that a number of potential recipients are waiting for a renal transplant, dual kidney transplantation would be a more appropriate approach in this situation. We report one such case with a successful outcome.

Dialysis therapy in children.

Acute dialysis can be life saving for children suffering from acute emergencies due to acute renal failure, poisoning or inborn errors of metabolism causing severe organic acidaemia and hyperammonaemia. Chronic dialysis is life sustaining for children with chronic renal failure or end stage renal disease till renal transplantation is performed. The basic principles, indications, procedures, equipment, complications of acute and chronic dialysis in children are same as in adults. Dialysis can be performed in children at any age from newborn to adolescent period. In newborn, infants and preschool children (0-5 years age) haemodialysis is difficult due to technical problems associated with vascular access and haemodynamic instability. Peritoneal dialysis is simple, efficient, easy to perform, does not require highly sophisticated equipment or personnel and with low complication rate. For successful dialysis appropriate sizes of catheters, tubings, dialysers, small volume dialysate bags, etc, are required. These are now available in our country, although the cost of peritoneal dialysis fluid and catheters, etc, is 2-3 times higher than equipment for haemodialysis. Hence, continuous ambulatory peritoneal dialysis for chronic renal failure/end stage renal disease has not taken off yet in India. A team of experts including specially trained paediatric nephrologists, urologists, nurses, dieticians, technicians and social workers are needed to organise dialysis programme for children with end stage renal disease. Acute peritoneal dialysis should be made available in each paediatric department offering emergency services to children.

Bilateral renal angiomyolipomas in association with end stage renal disease without features of tuberous sclerosis.

We report a case of end stage renal disease in association with bilateral renal angiomyolipomas (RAML). There were no features suggestive of tubercous sclerosis (TS). Renal angiomyolipomas were detected incidentally, patient being asymptomatic for the same. She is being evaluated for live related kidney transplant.

Severe acute renal failure in malaria.

BACKGROUND: We have noticed a recent rise in the incidence and severity of acute renal failure (ARF) in malaria. AIM: To study the incidence, severity and outcome of ARF in malaria. SETTING and DESIGN: It is a retrospective analysis of data of one year from a tertiary medical centre in a metropolitan city. MATERIALS AND METHODS: Patients with ARF and smear positive malaria were evaluated. STATISTICAL ANALYSIS: Results were expressed as mean, range and standard deviation. RESULTS: Out of 402 detected smear positive malaria, 24 had ARF. Eighteen were of the age group 21-40 years. Plasmodium falciparum (PF) was detected in 16, Plasmodium vivax in three, and mixed infection in five. Non-oliguric ARF was seen in 14. Eighteen showed severe ARF (Serum creatinine >5 mg%). Twenty-two patients needed dialysis. Prolonged ARF lasting for 2-6 weeks was seen in eight. Seventeen patients recovered completely, while seven showed fatal combination of disseminated intravascular coagulation (DIC), acute respiratory distress syndrome (ARDS), severe ARF and PF malaria. No response was seen to chloroquine and artesunate given alone and twenty patients required quinine. CONCLUSION: ARF necessitating dialysis was seen in 92% of patients with ARF in malaria. PF infection, severe ARF, DIC and ARDS were poor prognostic factors. Resistance was noted to both chloroquine and artesunate.