Pregnancy with Eisenmenger Syndrome: A Challenge to Obstetrician

Eisenmenger syndrome is defined as the development of pulmonary hypertension in response to a left-to-right cardiac shunt with consequent bidirectional or reversal (right-to-left) of shunt flow. Maternal mortality in the presence of Eisenmenger syndrome is reported to be 30-50%. If the patient continues her pregnancy against advice, a well-coordinated multidisciplinary team approach is advocated. Here, we report a case of pregnancy with Eisenmenger syndrome and its successful outcome.

Antihypercholesterolaemic influence of dietary tender cluster beans (Cyamopsis tetragonoloba) in cholesterol fed rats.

Background & objectives: Cluster beans (Cyamopsis tetragonoloba) are rich source of soluble fibre content and are known for their cholesterol lowering effect. The beneficial anti-hypercholesterolaemic effect of whole dietary cluster beans as a source of dietary fibre was evaluated in high cholesterol diet induced hypercholesterolaemia in experimental rats. Methods: Male Wistar rats (90-95 g) divided in six groups of 10 rats each were used. Freeze dried tender cluster beans were included at 12.5 and 25 per cent levels in the diet of animals maintained for 8 wk either on high (0.5%) cholesterol diet or basal control diet. Results: Significant anti-hypercholesterolaemic effect was seen in cluster bean fed animals, the decrease in serum cholesterol being particularly in the LDL associated fraction. There was also a beneficial increase in HDL associated cholesterol fraction. Hepatic lipid profile showed a significant decrease in both cholesterol and triglycerides as a result of feeding tender cluster beans along with high cholesterol diet. Interpretation & Conclusions: The present experimental results showed the beneficial hypocholesterolaemic and hypolipidimic influences dietary tender cluster beans in atherogenic situation. Studies in human need to be done to confirm the results.

The impact of VKORC1-1639 G>A polymorphism on the maintenance dose of oral anticoagulants for thromboembolic prophylaxis in North India: A pilot study.

BACKGROUND: The dose requirements for oral anticoagulants in thromboembolic events are influenced by promoter polymorphism in the VKORC1 gene. However, limited data are available on the influence of the polymorphism in various Indian populations. The present study aimed at determining the relationship between the VKORC1-1639 G>A genotypes and maintenance doses of oral anticoagulants for therapeutically stable INR values in patients taking Acitrom after valve replacement surgery. MATERIALS AND METHODS: Fifty patients from the northern Indian region were genotyped for VKORC1-1639 G>A by polymerase chain reaction and restriction fragment length polymorphism. Means of the weight-normalized daily Acitrom dose were calculated for every patient. RESULTS AND DISCUSSION: The VKORC1 1639G>A minor allele frequency in the study population (n = 50) was found to be 22%. The patients with a wild type genotype required the maximum drug dose as suggested for full functionality of the enzyme. Heterozygous patients were found to have an intermediate drug dose and the patients with a variant homozygous genotype had the minimum maintenance drug dose requirement. These findings are in concurrence with the effect of the promoter polymorphism on vitamin K epoxide reductase activity.1639G>A minor allele frequency in the study population (n = 50) was found to be 22%. The patients with a wild type genotype required the maximum drug dose as suggested for full functionality of the enzyme. Heterozygous patients were found to have an intermediate drug dose and the patients with a variant homozygous genotype had the minimum maintenance drug dose requirement. These findings are in concurrence with the effect of the promoter polymorphism on vitamin K epoxide reductase activity. CONCLUSION: The VKORC1-1639 G>A status can be indicative of establishing the therapeutic dose of oral anticoagulants in Indian patients.

The challenge of grandmultiparity in obstetric practice.

INTRODUCTION: Traditionally grandmultiparity has been considered to be an obstetric hazard both to the mother and foetus. Compounding factors are low socioeconomic status, poor female literacy and social deprivation. In developed populations with improved and optimal obstetric services, parity per se is no longer considered a significant risk for adverse obstetric and perinatal outcome. OBJECTIVES: To compare the obstetric and perinatal outcome between grandmultiparas and second gravidas with previous one delivery as well as analyse certain socio demographic features in the two groups. METHODOLOGY: Case records from Maternity Hospital, Kathmandu, an inner city tertiary care centre were retrospectively studied. 106 cases of grandmultiparous patients were compared with 110 cases of second gravidas who had previously delivered once which was taken as the control group. Biosocial features as well as obstetric and perinatal outcome were analyzed. RESULTS: Rural residents comprised 60.4% of the grandmultiparous group versus 27.7% of the control group. A predominance of early marriage as well as an older age profile was noted in the grandmultipara. ANC attendance was documented to be much lower among grandmultipara with 26.4% having absolutely no antenatal care. A higher frequency of hypertensive disorders in pregnancy, preterm birth, anaemia, malpresentations, multiple pregnancy and premature rupture of membranes, postpartum haemorrhage and retained placenta was noted in the grandmultipara which also had a slightly higher caesarean delivery rate. The salient adverse perinatal outcome was found to be intrauterine foetal death, preterm birth and neonatal sepsis. CONCLUSION: In our set up, grandmultiparity continues to challenge our obstetric practice with its associated increased likelihood of maternal and perinatal complications. Concerted effort should be directed to reducing high parity in the community through effective family planning initiatives and specialized antepartum and intrapartum supervision of this group should be available.

B-Lynch brace suture simple surgical technique for managing post-partum haemorrhage - report of three cases.

Post-partum haemorrhage is a major contributor to maternal morbidity and mortality. Numerous medical and surgical therapies have been used but none has been uniformly successful. Three cases which were managed successfully with brace suture following failure of medical management for post-partum haemorrhage are being presented. The ease and usefulness of this procedure as a life saving measure, its relative safety and its capacity for preserving the uterus and thus fertility is high lighted.

Comprehensive abortion care service at Kathmandu Medical College--an experience.

INTRODUCTION: His Majesty's Government amended the Nepal Criminal Code (Muluki Ain)--for Liberalising abortion law in the month of Chaitra 2058 (March 2002) and Royal Assent was given on 10th Asoj 2059 (27th September 2002). Accordingly Comprehensive Abortion Care (CAC) Services was initiated in the country. Kathmandu Medical College after enlisting with Ministry of Health started this service from June 2004. OBJECTIVE: This study was carried out to know--1. Reasons for undergoing CAC service. 2. The complications after the CAC services. 3. The various contraceptive methods adopted by the client following CAC. METHODOLOGY: Hospital based prospective study was carried out in Department of Obstetrics & Gynaecology at KMCTH from the period July 2004 to April 2005. Total 160 patients who asked for CAC were enrolled in the study. Counselling, history taking and general examination and per vaginal examination was carried out at the visit. CAC was performed with premedication with Doxycycline 100 mg and Ibuprofen 400 mg half an hour before the procedure. Paracervical block was also given with 1% xylocaine. MVA was performed as described in standard techniques. Patient was discharged after 1-2 hours of observation and with contraception opted by the clients. RESULTS: Main reason for performing CAC was unwanted pregnancy in 66.75%. Complication following CAC was 1.25%. Post CAC contraception was adopted by 93%. Most preferred method was Inj. Depoprovera CONCLUSION: The reason for CAC service asked by the patients was unwanted pregnancy. CAC service performed had minimal complication and also gave the opportunity for contraception.

Pattern of dermatoses in diabetics.

Two hundred diabetics comprising of 125 males and 75 females were studied for the presence of cutaneous lesions and type of infective organism, if any, in them. 70.2% of patients with uncontrolled diabetes mellitus showed some form of cutaneous involvement while only 51% of the patients with controlled diabetes had it. Infections with bacterial (16%) and fungal (10.5%) agents were the most common manifestation. Among bacterial infections, Staph. aureus was the most frequent causative agent in 65.6% cases. Pruritus was present in 4.5% of cases only.

Immunochemical studies in Wilson's disease.

The present study deals with a total of 28 cases of Wilson's disease, 50 normal individuals alongwith siblings and parents of eight cases. Male predominance (18 out of 28 cases), a median age of 11 years and universal presence of Kayser-Fleischer (K. F.) ring marked the cardinal features. Furthermore, 11 patients had hepatic-neural presentation while two had only the K. F. Ring without clinical abnormality. Single Radial Immunodiffusion (SRID) as the absolute quantitative procedure revealed a profound deficiency of ceruloplasmin with the levels ranging anywhere between 0.5 mg/dI to 23 mg/dI amongst the patients of Wilson's disease. The data from siblings and parents also revealed deficiency in 15 out of 23 serum samples when subjected to disc electrophoresis-benzidine screening procedure.

Effect of microinjections of 5-hydroxytryptamine and adrenaline in central grey on pain responsiveness during acute food deprivation in conscious rats.

To study the effects of microinjections of 5 hydroxytryptamine and adrenaline in central grey on pain responsiveness during acute food deprivation, experiments were conducted in nine male rats. Microinjections of 5 HT (10 micrograms/microliter) and adrenaline (10 micrograms/microliter) were given in central grey before and at the end of 6, 12, 18 and 24 hr food deprivation and the effects on pain threshold, cardiorespiratory parameters and body temperature were noted. Observations showed that 5 HT increased the pain threshold (antinociception) significantly (P < 0.05) with no change in cardiorespiratory response and body temperature, adrenaline did not alter pain threshold with no change in cardiorespiratory response and body temperature. The observations suggest the possible existence of two types of monoaminergic receptors or pathways in the central grey.

Immunochemical studies in multiple myeloma.

The study deals with a total of 72 patients with Plasma cell dyscrasias (PCD) selected on the basis of atypical plasmacytosis in the bone marrow aspirate and radiological evidence of osteolytic lesions. Males(48) outnumbered the females (24). Pathological fracture and paraplegia was the commonest presenting symptom encountered in 38 patients. Electrophoresis of serum for 'M' band and Immunoelectrophoretic analysis of the serum revealed IgG myeloma in 40 patients followed by, IgA myeloma(13), Light chain disease (12) and other variants in remaining seven cases. The urinary Bence Jones proteins were detected in a total of 34 cases and was frequently encountered with IgA myeloma (7 out of 13) compared with IgG myeloma (13 out of 40) when analysed in Disc electrophoresis. Kappa light chain was observed in 21 cases and lambda counterpart in nine cases without any clinical significance. One case of solitary myeloma terminated in characteristic multicentric multiple myelomatosis within a span of six months in the sequential follow up study. We recommend the triangular approach to diagnosis of paraproteinemia with a special emphasis on immunoelectrophoresis for typing multiple myeloma and allied disorders along with disc electrophoresis for the demonstration of urinary Bence Jones protein in the routine set up.

Analysis of immunoglobulin deficiency cases: a five year study.

A total of 734 serum specimens from various clinical disorders along with 100 control samples from healthy subjects were processed for estimation of serum IgG, IgA and IgM employing single radial immunodiffusion procedure. Immunoglobulin deficiency, either selective or combined was noted in 31 males and 24 females in all age groups. Of the 55 cases encountered it was secondary immunoglobulin deficiency which was seen on a larger scale and encountered in patients with Multiple myeloma (16 out of 32) followed by Leprosy (14 out of 250), Lymphoma (5 out of 43), Malaria (4 out of 137), Burns (4 out of 52), Rheumatoid arthritis (2 out of 69) and non lymphoreticular malignancies (1 out of 41) in decreasing order of frequency. Primary immunoglobulin deficiency was observed in nine cases comprising of six belonging to Idiopathic late onset immunoglobulin deficiency, two of dysgammaglobulineamia and a solitary case of Ataxia telangiectasia. Panimmunoglobulin deficiency was observed in six cases, 11 had a dual deficiency while 38 showed deficiency of an isolated class with selective IgA deficiency in 20 cases. Furthermore, one patient each had total absence of IgG or IgA while IgM was not detectable in seven patients. A high suspicion index along with a regular rapport between the clinician and the laboratory personnel is necessary in the diagnostic set up of immunoglobulin deficiency states.

Determination of proteins secreted by growing rat decidual cells in vitro.

Proteins secreted by rat decidual cells while growing in culture medium were monitored on gel electrophoresis. It was done by assuming that outgrowing cells in vitro mimic differentiated endometrial stromal tissue in vivo following attachment of embryo. The decidual cells were obtained from implantation swellings of day 10 pregnant rats, maintained in serum free medium and the cell dependent protein profile was analysed after 48 hr on single dimensional polyacrylamide gel electrophoresis (SDS-PAGE). The proteins identified were in molecular weight range of 29, 43 and 66 kDa respectively. The result indicated involvement of the differentiated stromal cells in secreting these low molecular weight proteins.

Sequential study of IgG antibody response in immunized rabbit and development of immunization protocol for raising monospecific antibody.

The present study was planned to develop an immunization protocol to decide the bleeding modalities for harvesting anti IgG antibody from the immunized rabbit. A fourteen dose immunization protocol (four primary and ten boosters) of the purified human IgG spread over the one calendar year was executed. The antibody titre estimated by Reverse Single Radial Immunodiffusion displayed a six-phased pattern. The titre following the initial immunization ranged between nil to 1.02, characteristic of the primary response while the titres after 7th and 8th boosters (phase V) ranged between 0.5 to 3.87 consistent with secondary response. Phase II, III, IV had moderately elevated titres. The antibody titre amongst the six phases reached to its peak generally by the 12th day after the last dose of protocol and it took about 60 days to reach to its basal level. Administration of antigen with the higher levels of residual antibody did not produce high titre antibody and is probably ascribed to elimination of antigen through an immunecomplex mechanism. Based on the data we recommend that 15 batches. (3 per phase, phase I to phase V) with a total yield of 100 to 120 ml of serum can be procured from one immunised animal over the span of one calendar year and that should make the programme cost effective.

Reverse single radial immunodiffusion for estimation of titre of anti IgG antibody.

Reverse Single Radial Immunodiffusion (SRID) for estimating titre of anti IgG antisera is reported. Unlike the conventional radial immunodiffusion, the antigen (IgG) is held immobile in the gel while the antibody (Anti IgG) diffuses radially from the well (7 microliters) and the diameter of the resulting immuneprecipitates after immunodiffusion at 4 degrees C for 24 hr, represents a linear correlation with the antibody titre. The procedure was standardised by an extensive trial and error employing different concentrations of human IgG in the gel (60-240 micrograms) against varying dilutions of the standard antibody (titre: 3.8 mg/ml). The best results were obtained at 80 micrograms of IgG in the gel. The locally raised rabbit anti IgG antisera displayed a distinctive titre pattern under optimised conditions. Technical reproducibility, high-sensitivity threshold (0.25 mg/ml), simultaneous visual scrutiny of several antibody batches at a glance and ability to assess the shelf life of the stored antisera are its distinct assets.