Cesarean section for suspected fetal distress, continuous fetal heart monitoring and decision to delivery time.

OBJECTIVE: To find out the efficacy of continuous fetal heart monitoring by analyzing the cases of cesarean section for nonreassuring fetal heart in labor, detected by cardiotocography (CTG) and correlating these cases with perinatal outcome. To evaluate whether a 30 minute decision to delivery (D-D) interval for emergency cesarean section influences perinatal outcome. METHODS: This was a prospective observational study of 217 patients who underwent cesarean section at > or = 36 weeks for non-reassuring fetal heart in labor detected by CTG. The maternal demographic profile, specific types of abnormal fetal heart rate tracing and the decision to delivery time interval were noted. The adverse immediate neonatal outcomes in terms of Apgar score <7 at 5 minutes, umbilical cord thornH <7.10, neonates requiring immediate ventilation and NICU admissions were recorded. The correlation between non-reassuring fetal heart, decision to delivery interval and neonatal outcome were analyzed. RESULTS: Out of 3148 patients delivered at > or = 36 weeks, 217 (6.8%) patients underwent cesarean section during labor primarily for non-reassuring fetal heart. The most common fetal heart abnormality was persistent bradycardia in 106 (48.8%) cases followed by late deceleration in 38 (17.5%) cases and decreased beat to beat variability in 17 (7.8%) cases. In 33 (15.2%) babies the 5 minutes Apgar score was <7 out of which 13 (5.9%) babies had cord thornH <7.10. Thirty three (15.2%) babies required NICU admission for suspected birth asphyxia. Rest 184 (84.7%) neonates were born healthy and cared for by mother. Regarding decision to delivery interval of < or =30 minutes versus >30 minutes, there was no significant difference in the incidence of Apgar score <7 at 5 minutes, cord pH <7.10 and new born babies requiring immediate ventilation. But the need for admission to NICU in the group of D-D interval < or = 30 minutes was significantly higher compared to the other group where D-D interval was >30 minutes. CONCLUSION: Non-reassuring fetal heart rate detected by CTG did not correlate well with adverse neonatal outcome. There was no significant difference in immediate adverse neonatal outcome whether the D-D time interval was < or = 30 minutes or >30 minutes; contrary to this, NICU admission for suspected birth asphyxia in </= 30 minutes group was significantly higher.

Maternal antenatal profile and immediate neonatal outcome in VLBW and ELBW babies.

OBJECTIVE: To evaluate the antenatal profile of the mother and the immediate neonatal morbidity and mortality till discharge. METHODS: The study was a retrospective analysis of 92 patients of preterm labour who delivered babies weighing RESULTS: A total of 92 mothers in preterm labour at 26 to 34 weeks were admitted and subsequently delivered 70 VLBW babies (< 1500 gms) and 36 ELBW babies (< 1000 gms) including 8 pairs of twins and 3 triplets pregnancies. Majority of the patients (93.4%) were booked. Amongst the various high risk factors for preterm labour, anaemia during pregnancy (32.6%), bacterial vaginosis (26%), gestational hypertension (18.4%) and pervious history of preterm labour (18.4%) were common associations. Calcium channel blocker (Depin) tocolysis was effective in postponing labour from 48 hours to more than 2 weeks. The cesarean section rate was very high (67.3%) in our study. The commoner neonatal complications in both VLBW and ELBW babies were RDS, neonatal jaundice and sepsis. Features of IUGR were seen in both the groups (22.8% in VLBW and 22.2% in ELBW babies). The neonatal mortality rate till discharge was 15.7% in VLBW group and 33.3% in ELBW group. The morality rate was highest in 26 to 30 weeks gestation babies and in babies weighing < 800 gms. CONCLUSION: Antenatal profile of preterm labour in our series showed a number of high risk factors. The identification of common high risk factors is important for appropriate prenatal care. A better neonatal survival rate was possible due to timely intervention, appropriate management and NICU care facility available in our tertiary care centre.

Diploid partial mole with neonatal survival--a case report.

Partial mole is a gestational neoplastic disorder with a reported incidence of 0.005 - 0.01% of all pregnancies. The karyotype in such cases is usually triploid, baring a few exceptions. The diploid partial mole is an extremely rare entity with only few cases being documented in literature. The fetal outcome in such cases is usually poor. We describe a case of partial mole, which terminated at 28 weeks with a live diploid male fetus with good neonatal outcome. Follow-up showed no progression to malignant gestational trophoblastic disease.

Prenatal diagnosis of chromosomal abnormalities in women with high risk pregnancies.

BACKGROUND & OBJECTIVES: Prenatal diagnosis helps in averting the birth of infants with chromosomal abnormalities. Fluorescence in situ hybridization (FISH) has been introduced as a potentially powerful tool in clinical cytogenetics. Several studies have reported successful prenatal diagnosis of chromosomal abnormalities in high risk pregnancies using FISH, however there are no reported studies from an Indian set up. Prenatal diagnosis for the detection of chromosomal abnormalities was carried out by conventional cytogenetics in the present study in the foetuses of high risk pregnancies in women attending a tertiary care facility in north India. These cases were further analyzed using FISH, to test the efficiency and utility of this technique for prenatal detection of common aneuploidies. METHODS: A total of 82 women with high risk pregnancies (81 singleton, 1 twin) were included in the study. Prenatal diagnosis was performed in these women using conventional chromosomal analysis (CCA) and interphase or metaphase FISH on chorionic villus or amniotic fluid or cord blood samples. RESULTS: Chromosomal analysis was successful in 80 instances and uninformative in 2. Abnormal karyotypes were detected in five (6.09%) of these women. FISH was successful in all the subjects and the results were in conformity to the cytogenetic results. In the 2 women where cytogenetic analysis was uninformative, results were given on the basis of interphase FISH. INTERPRETATION & CONCLUSION: The study clearly demonstrates that prenatal diagnosis is useful in the detection of chromosomal abnormalities in foetuses of women with high risk pregnancies. FISH is a powerful sensitive molecular cytogenetic technique, through which specific chromosomal abnormalities can be diagnosed/identified rapidly and accurately and may be used as an adjunct to conventional cytogenetic analysis.

Factors determining the occurrence of unwanted pregnancies.

BACKGROUND: We aimed to identify the factors involved in the occurrence of unwanted pregnancy in women seeking medical termination of pregnancy, and to describe their contraceptive practices. METHODS: A descriptive interview-based study of 402 women seeking abortion was done. Information was gathered regarding demographic variables, contraceptive practices and reasons for the unwanted pregnancy. RESULTS: All the women in our sample were married and multiparous. The husband's unwillingness for contraception and the improper use of condoms was responsible for one-third of all unwanted pregnancies. Lactation was believed to be a protection against pregnancy by 11.3% of women while 6.3% were unaware of any contraceptive method. CONCLUSION: We believe that focusing on these areas in public health programmes will help to decrease the number of unwanted pregnancies.

Prenatal diagnosis and assessment of fetal malformations by ultrasonography in India.

A multicentre study to assess the status of prenatal diagnosis of fetal malformation in India was conducted. Questionnaires were sent to the teaching hospitals and to centres in the private sector involved with ultrasonography in all the four zones. Data were obtained from 13 centres. Basic level I scans were performed on all pregnant women in 64% centres, whereas level II or targeted scans were performed as routine in 42% centres. Obstetricians performed level II scans in only 35% of cases while rest were performed by radiologists. Malformations of the central nervous system were commonest, accounting for 35-69% of all malformations, followed by genitourinary and gastrointestinal malformations. Malformations of the cardiovascular system were detected in 9.3% as abnormal four chamber view and outlet tract abnormalities, subsequently confirmed on fetal echocardiography. Invasive prenatal diagnosis by fetal blood sampling, chorion villus sampling and amniocentesis for chromosomal analysis of malformed fetuses was performed at 40% centres. At the All India Institute of Medical Sciences, approximately 11,042 ultrasound scans were performed by obstetricians as routine in all pregnant women. A total of 543 malformations were detected accounting for a 4.9% incidence of structural anomalies. A total of 98 cardiovascular malformations were detected in high and low risk pregnant women on fetal echocardiography. No database or registry exists in India to give an actual insight into the problem of congenital malformation and their prenatal diagnosis. It is important to train obstetricians in level I and II ultrasonography, to recognise centres and institutions at national and regional level, and to integrate a network of diagnostic testing. Close liaison between geneticists, radiologists, pediatric surgeons, pediatricians and obstetricians is a must for prenatal diagnosis and management of fetal malformations.

Ultrasonographic normogram of fetal kidney circumference and fetal abdominal circumference ratio for early prenatal diagnosis.

Serial ultrasound scans were done in 300 fetuses between 16 to 24 weeks of gestation to establish the normogram of fetal kidney circumference (FKC) and fetal abdominal circumference (FAC) ratio (FKC/FAC). Of 300 fetuses, 150 fetuses were in the high risk group for fetal malformation and 150 patients were in the control group. The value of FKC/FAC varied from 0.27 to 0.30 from 16 to 24 weeks of gestation. No statistical difference was observed in the value of FKC/FAC in high risk and low risk (control) cases (p > 0.05). The value of FKC/FAC greater than or equal to 0.5 at 20 weeks or more was pathological for enlarged kidney. In 4 cases of multicystic kidney, the value of FKC/FAC ranged from 0.50 to 0.52 which was approximately 6SD above the normal mean ratio for that period of gestation.

Ultrasonographic fetal nomograms of anterior ventricular hemisphere ratio (AVHR) and posterior ventricular hemisphere ratio (PVHR) for early prenatal diagnosis of hydrocephalus.

Serial ultrasound scans were done in 150 fetuses between 14th to 22nd week of gestation to establish the nomograms of anterior ventricular hemisphere ratio (AVHR) and posterior ventricular hemisphere ratio (PVHR). Of 150 fetuses, 100 were in the high risk group for neural tube defect and 50 were in the control group. The study indicates that the value of AVHR decreases from 0.62 to 0.50 and PVHR from 0.60 to 0.50 between 14th to 22nd week of gestation. No statistical difference was observed in the values of AVHR and PVHR in high risk and low risk (control) cases (p > .001). The value of AVHR or PVHR greater than 0.5 after 18 weeks of gestation or more was considered pathological for hydrocephalus. In 2, out of 3 cases of hydrocephalus detected in our series, the value of AVHR and PVHR was 0.7 at 20 weeks and in the third case it was 0.6 at 18 weeks. All of these values were 3 SD above the normal for the period of gestation.

Nomograms of fetal nuchal fold thickness for early detection of Down syndrome.

A prospective study was undertaken in North India to find the normative data on the nuchal fold thickness of randomly selected 150 fetuses between 16-22nd week of gestation. The data revealed that the width of nuchal fold thickness ranged between 2-5 mm. The mean for 16-18, > 18-20, and > 20-22 week's gestation was 2.6 +/- 0.2, 3.8 +/- 0.9, and 4.0 +/- 0.8 mm respectively. In one fetus nuchal fold thickness was 6mm at 18 weeks (> 2SD above the normal value) and thus Down Syndrome was suspected. This was later confirmed by amniocentesis and karyotyping.