Lactate Dehydrogenase - A Biochemical Marker for the Prediction of Adverse Outcomes in Pre-Eclampsia

Hypertensive disorders are one of the leading causes of maternal mortality. Lactate dehydrogenase (LDH) is one of the markers to study the severity of pre-eclampsia. It is an intracellular enzyme which increases in pre-eclampsia due to cellular lysis. We wanted to assess the LDH levels in normal pregnant women and women with pre-eclampsia in antenatal period and study the role of LDH as a biochemical marker to predict adverse outcomes in pre-eclampsia. METHODSThis is a prospective observational study conducted between October 2016 and August 2018 at Sri Ramachandra Institute of Higher Education and Research. Antenatal women > 28 weeks were grouped as healthy normotensive women and those with pre-eclampsia and eclampsia. Antenatal women < 28 weeks, with pre-existing diabetes mellitus, renal disease, liver disease and epilepsy were excluded from the study. LDH levels were assessed. Both groups were followed up closely for new or worsening signs and symptoms of pre-eclampsia, till delivery and early postpartum period. LDH levels in both groups were broadly divided into 3 groups (< 600 IU / L, 600 - 800 IU / L, > 800 IU / L). Maternal and perinatal outcomes were studied in these groups. RESULTSAll normotensive antenatal women and 128 out of 147 (87 %) hypertensive antenatal women had a normal LDH value (< 600 IU / L). While the babies of 58.6 % of hypertensive antenatal women with normal LDH required NICU admission, babies of 68.4 % of those with elevated LDH required NICU admission (p value > 0.05). Hence, levels of LDH do not correlate with the severity of pre-eclampsia and neonatal outcome. Also, 47.4 % of hypertensive antenatal women with elevated LDH had HELLP syndrome; 10.5 % had disseminated intravascular coagulation and 63.2 % required ICU admission. P value was < 0.05. Therefore, increasing LDH level had a positive correlation with maternal complications like HELLP syndrome, disseminated intravascular coagulation and the need for ICU admission. CONCLUSIONSOur study showed no correlation between lactate dehydrogenase and the incidence of pre-eclampsia. LDH is a good biochemical marker to predict adverse maternal outcomes of pre-eclampsia but not neonatal outcome.

Pronóstico Perinatal en embarazadas de tercer trimestre recuperadas de infección por COVID-19 / Perinatal Prognosis in third trimester pregnant women recovered from COVID-19 infection

INTRODUCCIÓN Y OBJETIVOS: COVID-19 es una patología producida por el virus RNA SARS-CoV-2, declarada pandemia por la OMS en marzo de 2020. La literatura mundial describe mayor incidencia de parto prematuro y cesáreas en pacientes infectadas por COVID-19 principalmente de origen iatrogénico, sin embargo, existen escasos datos del pronóstico del embarazo al decidir diferir el parto hasta después del período infeccioso del virus. Este trabajo reporta un grupo de embarazadas diagnosticadas con COVID-19 en tercer trimestre donde se decidió no interrumpir el embarazo y diferir su parto hasta recuperación de la patología. MÉTODOS: Estudio observacional retrospectivo que analiza resultados materno-perinatales en 9 casos de mujeres infectadas por COVID, diagnosticadas posterior a las 33 semanas y cuyo parto se verificó después de recuperadas del COVID. RESULTADOS: Se observó un 77% de pacientes sintomáticas, 77% requirieron hospitalización, 33% por COVID, todas ingresaron a unidad de paciente crítico, sólo una requirió ventilación mecánica no invasiva. Dos cursaron con cetoacidosis normo-glicémica y dos con neumonía por COVID-19. Un 88% resultó en parto de término, sólo una paciente tuvo parto prematuro de causa obstétrica. La vía de parto fue un 67% vaginal y 33% por cesárea, todas por indicación obstétrica. La latencia al parto promedio fue de 17.3 días. Los puntajes de Apgar fueron todos mayor a 7 al minuto y 5 minutos. CONCLUSIÓN: Los resultados de esta serie sugieren que, en casos seleccionados, los partos posteriores al período infeccioso del COVID se asocian a buenos resultados materno-perinatales, sin embargo, resulta importante aumentar la casuística.

INTRODUCTION AND OBJECTIVES: COVID-19 is a pathology produced by the RNA virus SARS-CoV-2, declared a pandemic by the WHO in March of 2020. The world literature describes more preterm birth and caesarean section in pregnant women infected by COVID-19, principally by medical indication, but it has not been described in depth what happens when we differ delivery after the infectious period. This report reviews a subgroup of patients who were diagnosed with COVID-19 in the third trimester and decided to differ birth until they recovered from the disease. METHODS: Retrospective observational study that analyzes maternal and perinatal outcome of 9 women who were diagnosed with COVID-19 after the 33 weeks of pregnancy, decided to differ delivery and had their birth recovered from the disease. RESULTS: We observed 77% of patients symptomatic, 77% required hospitalization, 33% because of COVID, all admited to critical patient care, only one required non invasive mechanical ventilation. 2 patients suffered normoglycemic ketoacidosis, 2 had COVID-19 pneumonia. An 88% resulted in term birth, only 1 was prematurely interrupted by obstetric cause. 66% patients had vaginal delivery and 33.3% caesarean section, all by obstetric cause. The average latency to birth was 17.3 days. Apgar scores were all more than 7 at minute 1 and 5. CONCLUSION: The results of this series suggest that in selected cases where the clinical characteristics allow it, to differ interruption of pregnancy until after the infectious period can associate to good outcomes of maternal and neonatal morbimortality, however, it's fundamental to continue research.

Changing trends in the indication of caesarean delivery in multigravida- experience from a referral center in Eastern India: a prospective study

Background: Caesarean delivery is one of the commonly performed surgical procedures in obstetrics in today's practice. The objective of this study was to estimate the overall incidence and indications of primary caesarean delivery among multiparous women and to study the immediate maternal and perinatal outcome.Methods: It was a prospective observational study done in Sikkim Manipal Institute of Medical Science, Sikkim, India. It included all pregnant women after 28 weeks of gestation who had normal vaginal delivery in previous pregnancy but underwent caesarean delivery during current pregnancy (n=120) from January 2016 to December 2016. Authors collected data using a pro forma. Relevant history including demographic details, relevant clinical, laboratory and radiological examination, indication for caesarean delivery, details of delivery and neonate, and duration of hospital stay were noted. Data was described using descriptive data like mean and percentages.Results: Out of 1646 deliveries conducted, 49% were by caesarean section. It included 7.29% primary caesarean delivery in multigravida.  Majority of women (27%) were in the age group 25-29. Maternal request was the commonest indication for caesarean delivery (21.66%). Atonic PPH was the commonest intraoperative complication (2.5%). Surgical site infection was the commonest post-operative morbidity (3.33%). There were 51 perinatal morbidity and 2 perinatal mortality. There was no maternal mortality.Conclusions: Caesarean section rates in this study was higher than WHO recommendation (15% versus 49.69%). This shift in trend can be attributed to higher number of maternal request for caesarean delivery which can be avoided by good analgesic facility and good counselling.

Chronic rheumatic heart disease and congenital heart disease complicating pregnancy: a study of the cardiac events, the maternal and perinatal outcome during 2011-2013 at tertiary care centre

Background: Objective of this study was to assess the prevalence of chronic rheumatic heart disease and congenital heart disease complicating pregnancy, study the maternal and perinatal outcome, and indications for termination of pregnancy.Methods: Preconception counseling, antenatal care by pregnancy heart team as per protocol. One 2nd gravida (G2A1) with 26 weeks gestation, underwent mitral valve replacement during 26th week gestation i/v/o infective endocarditis associated with severe mitral regurgitation.Results: Authors had CRHD: CHD = 29:21, out of 50 cases, the ratio was 1.3:1 in this study. Atrial septal defect (ASD) was the predominant lesion in this study -29% ASD alone and 9% associated with pulmonary artery hypertension. Eisenmenger's syndrome, was associated with ASD in three and VSD in two. Corrected lesions were 24%. In the rheumatic heart disease, mitral stenosis was the predominant lesion and PBMV was done in four (13.7%) cases. In CRHD cases, surgically corrected by prosthetic heart valve were -11 (37.9%). In CRHD total corrected cases, by prosthetic heart valve and percutaneous balloon mitral valvotomy (PBMV) account for 51.7%. One patient had PBMV procedure during 5th month of present pregnancy i/v/o severe mitral stenosis with mitral valve area -0.8 cm2 and another patient had PBMV during her first pregnancy. In this study 42% were in NYHA class I. 14% were in NYHA class IV. CHF was seen in 10%. Termination of pregnancy was necessary in 6 with CHD and 5 with CRHD. There were 39 deliveries with one set of twins. All the babies were alive. Maternal mortality was confirmed in one case with Eisenmenger’s syndrome + HELLP syndrome. Live birth rate was higher in cases with NYHA class I/II than in those with NYHA class III/IV (82.8% versus 66.60%).Conclusions: Management by a pregnancy heart team as per guidelines would reduce mortality.

Placenta previa: risk factors, feto-maternal outcome and complications

Background: Placenta previa is defined as placenta that is implanted somewhere in the lower uterine segment either over or very near the internal cervical os. Placenta previa and coexistent accrete syndromes contribute substantively to maternal and perinatal morbidity and mortality.Methods: All This is a retrospective study of 88 cases of placenta previa, which were admitted under department of obstetrics and gynecology in our institute during July 2017 to June 2019. All patients of placenta previa with gestational age > 28 weeks up to full term were included in the study. All cases were confirmed by ultrasound examination. Outcome measures prevalence of placenta previa, maternal and neonatal outcomes, and case fatality rate.Results: The total number of deliveries performed during the study period was 16330, of them, 88 cases were placenta previa. Thus, the prevalence of PP was 0.53%. Multiparity was one of the etiological factors in 84.09%, whereas previous LSCS was 47.73%, previous H/O D and E was 14.73%, previous H/O placenta previa was 7.95%. Obstetric hysterectomy was done in 7 (7.95%) patients out of 88 patients. 92.04% of patients delivered with cesarean section and 7.95% patients delivered with normal vaginal delivery. 22 (26.50%) babies out of 83 live born were admitted in NICU.Conclusions: Advancing maternal age, multiparity, prior cesarean section, and prior abortions are independent risk factors for placenta previa. Placenta previa remains a risk factor for adverse maternal and perinatal outcome. The detection of placenta previa should encourage a careful evaluation with timely delivery to reduce the associated maternal and perinatal complications. Measures to reduce the primary caesarean section rate should be adopted.

Comparative study on usefulness of modified WHO Partograph in management of labour at one of the rural teaching institutes of Gujarat, India

Background: Modified WHO Partograph is a simple, inexpensive pre-printed form on which labour observation are recorded. It generally comprises three sections of information: maternal condition, fetal condition and labor progress. To study on usefulness of Modified WHO Partograph in management of labour of low risk women, this indirectly improved maternal and perinatal outcome.Methods: In this study the progress of labour of 150 women with uncomplicated full term pregnancies with cephalic presentation in active labour was studied using modified WHO partograph. 150 historical matched controls comprising of low risk women who delivered without the use of partograph were identified from the labour register and their course of labour studied. The hospital records were studied to obtain the demographic variables. Maternal and perinatal outcome was analyzed for both cases and controls.Results: The emergency cesarean section rate was reduced from 38.7% in controls to 24.7% in cases and both are significant statistically. None of the cases had labour beyond 16 hours, thus indicating significant reduction in prolonged labour. Neonatal intensive care admissions decreased from 18.6% in controls to 6% in cases indicating an improved maternal and neonatal outcome.Conclusions: Modified WHO Partograph work as “early alarming warning system” which help in detecting delayed progress of labour which improves maternal as well as perinatal outcome.

Maternal and perinatal outcome in patients of preeclampsia with and without HELLP syndrome

Background: Preeclampsia is seen in about 5-10% of all pregnancies and HELLP Syndrome occurs in 6-12% of these patients. Both are known to increase maternal and perinatal morbidity. The study aims to provide a comprehensive view of these myriad outcomes in the mother and neonate both, in each of the groups. It also compares the incidence of such outcomes in mother and child, in preeclampsia only and in those complicated by HELLP syndrome.Methods: This prospective, observational, comparative study was conducted at a tertiary referral centre. 55 patients with preeclampsia were compared with 55 patients with HELLP syndrome. The relevant clinical features, laboratory investigations and the maternal and perinatal outcomes along with the incidence were studied and results analyzed.Results: Significant differences were observed in laboratory parameters and duration of ICU stay in patients with preeclampsia and patients with HELLP syndrome. Incidence of maternal complications and need for blood transfusion was greater in HELLP syndrome. Only marginal differences were observed in birth weight, NICU admission rates and neonatal mortality rates.Conclusions: HELLP syndrome is associated with increased maternal morbidity and mortality as compared to preeclampsia. Neonatal outcomes appear to be influenced; only marginally, by HELLP syndrome, nevertheless, their incidence is more than in preeclampsia. Aggressive treatment for pregnant women appears to decrease the maternal mortality rate.

A study to evaluate serum 25-hydroxy vitamin D3 and calcium levels in maternal and cord blood and their effect on pregnancy outcome

Background: To determine the prevalence of vitamin D deficiency among pregnant mothers and their neonates and to study the effect of vitamin D deficiency on maternal and perinatal outcome.Methods: This prospective cohort study conducted in a teaching hospital included 223 pregnant mothers and their offspring born in 2017. Detailed history was taken to ascertain the causes of vitamin D deficiency.   vitamin D3 and calcium levels were estimated in maternal and cord blood samples. To study the association between the vitamin D status and the various maternal and neonatal parameters.Results: 91.9 % of women were house wives involved in indoor activities. Pre-eclampsia and GDM were seen in 4.5% of cases each. 5.41% were obese and 84%  were of medium complexion,  and 8% were  dark. 93.7% were non- vegetarians,  and fish, egg and milk consumption was adequate in 61.3% , 64% and 71% respectively. Only 5.40% of women had adequate exposure to sunlight.  The mean birth weight was 3.08± 0.36 Kg. and 14 babies were admitted to NICU for neonatal asphyxia.77.40% had deficient levels of vitamin D  <20 ng/ml. Only four pregnant mothers (1.8%) had sufficient levels vitamin D. There was no statistically significant association between vitamin D deficiency and various maternal and neonatal parameters.Conclusions: This study has shown that the prevalence of vitamin D deficiency among south Indian pregnant mothers and their newborn is very high and the ways to improve the vitamin D status among pregnant mothers should be looked at.

Proteína plasmática A asociada al embarazo y fracción β de gonadotrofina coriónica humana en pacientes con resultados materno y perinatal adverso: informe preliminar / Plasma protein associated with pregnancy and β fraction human chorionic gonadotropin results in patients with adverse maternal and perinatal: preliminary report

Objetivo: Evaluar el comportamiento de marcadores bioquímicos: proteína plasmática asociada al embarazo (PAPP-A) y fracción β de la hormona gonadotrofina coriónica (β hCG) con resultado materno y perinatal adverso en el Hospital “Dr. Adolfo Prince Lara”. Métodos: Estudio prospectivo, comparativo en 35 gestantes con embarazos simples entre las 11 y 13 semanas + 6 días y resultado del embarazo conocido. Se realizó tamizaje combinado: traslucencia nucal, hueso nasal, ductus venoso, longitud craneocaudal y marcadores bioquímicos (PAPP-A y β -hCG). Se determinó la concentración de PAPP-A y β -hCG y sus resultados se expresaron en MoM. Variables cuantitativas fueron expresadas en media y desviación estándar (DE), cualitativas en porcentajes y se compararon estas variables entre el grupo de gestantes con resultado materno perinatal normal (RMPN) y adverso (RMPA) con la prueba U de Mann-Whitney. Resultados: 71 % tuvieron un RMPN y 29 % RMPA. No se encontraron diferencias entre los grupos respecto a edad materna, peso materno, IMC, paridad, presión arterial. La PAPP-A expresado en MoM presentan un valor más alto en las embarazadas que tuvieron un RMPA (1,07 vs 1,43) siendo estadísticamente significativo, los valores de β-HCG tuvieron valores más altos (0,60 vs 0,76) entre el grupo con RMPA en relación al grupo con RMPN sin llegar a la significancia estadística. Conclusión: Valores de la MoM PAPP-A difieren en las embarazadas con RMPA de aquellas con resultado normal, pero con valores mayores en las primeras, contrario a lo encontrado en la mayoría de las publicaciones estudiadas, iguales hallazgos con la β-hCG. Se debe profundizar en estos estudios para verificar los resultados encontrados.

Objective: To evaluate the behavior of biochemical markers PAPP-A and β hCG with adverse pregnancy and perinatal outcomes. Methods: Prospective, comparative study in 35 pregnant women with singleton pregnancies between 11 and 13 weeks + 6 days and outcome of pregnancy known. Nuchal translucency, nasal bone, ductus venosus, rump length and biochemical markers (PAPP-A and β-hCG) combined screening was performed. The concentration of PAPP-A and β-hCG was determined and the results were expressed in MoM. Quantitative variables were expressed as mean and standard deviation (SD), and these percentages qualitative variables between the group of pregnant women with a normal perinatal maternal outcome (NPMO) and adverse (AMPO) with the U Mann-Whitney test were compared. Setting: Hospital “Dr. Adolfo Prince Lara”. Results: 71 % had a NPMO and 29 % had an AMPO. No differences between the groups in respect of maternal age, maternal weight, BMI, parity, blood pressure were found. PAPP-A MoM have expressed a higher value in pregnant having an AMPO (1.07 vs 1.43) were statistically significant, the values of β-HCG had higher values (0.60 vs 0.76) between the group with AMPO relative to NMPO group without reaching statistical significance. Conclusion: MoM values of PAPP-A differ in pregnant with AMPO than in those with normal results, but with higher values in the first opposite to that found in most of the studied publications, the same findings with β-hCG. Thus, it should look into these studies to verify the results found.

Acute fatty liver of pregnancy complicating acute respiratory distress syndrome: A case report with survival of mother and child / 대한산부인과학회지

We report our experience with the diagnostic, clinical and biochemical findings, complications and maternal-perinatal outcome in a case of acute fatty liver of pregnancy. A 31-year-old multipara presented herself at 35 weeks' gestation with general malaise, gastroesophageal reflux, jaundice, hepatorenal dysfunction and disseminated intravascular coagulation. An abdominal ultrasound revealed a mild fatty liver. A tentative diagnosis of acute fatty liver of pregnancy was made, and immediately a healthy male infant weighing 2330 gm was delivered by emergency cesarean section. On 1, 2 and 6 days after delivery, oliguria, acute respiratory distress syndrome and pancreatitis developed, respectively. Abnormal levels of AST/ALT, creatinine, fibrinogen, PT/PTT and platelet recovered to normal ranges 7-10 days after delivery. Serum amylase and lipase became normal 24 days after delivery with conservative treatment. Ventilator care for acute respiratory distress syndrome continued up to 49 days after delivery, when total bilirubin, ammonia, alkaline phosphatase, r-GT, and AST/ALT began to normalize. The discharge was recommended on the 88th postpartum day. Our result suggests that acute fatty liver of pregnancy can be diagnosed on the basis of clinical and laboratory findings. Prompt delivery, intensive supportive care and awareness of its complications can markedly improve maternal and perinatal outcome.