Prenatal diagnosis of steroid 21-hydroxylase-deficient congenital adrenal hyperplasia: Experience from a tertiary care centre in India.

BACKGROUND & OBJECTIVES: Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder with a wide range of clinical manifestations. The disease is attributed to mutations in CYP21A2 gene encoding 21-hydroxylase enzyme. In view of severe phenotype in salt-losing cases, issues related to genital ambiguity in girls and precocity in boys, most families opt for prenatal testing and termination of affected foetus. CAH can be diagnosed in utero through direct molecular analysis of CYP21A2 gene, using DNA extracted from foetal tissues or cells obtained from chorionic villus sampling or amniocentesis. The objective of this study was to evaluate the feasibility and accuracy of prenatal diagnosis (PND) using sequencing and multiplex ligation probe amplification (MLPA) methods in families at risk for CAH. METHODS: Fifteen pregnant women at risk of having an affected offspring with CAH were included in this study. Ten families had previous affected children with salt-wasting/simple virilising form of CAH and five families did not have live children but had a high index of suspicion for CAH in previous children based on history or records. Mutation analysis was carried out by Sanger sequencing and MLPA method. RESULTS: Seven different mutations were identified in 15 families. Deletions and I2g mutation were the most common. Of the 15 foetuses analyzed, nine were unaffected while six were affected. Unaffected foetuses were delivered, they were clinically normal and their genotype was found to be concordant to the prenatal report. All except two families reported in the second trimester. None of the couples opted for prenatal treatment. INTERPRETATION & CONCLUSIONS: Our preliminary findings show that PND by direct mutation analysis along with MLPA is a feasible strategy that can be offered to families at risk.

Doppler changes as the earliest parameter in fetal surveillance to detect fetal compromise in intrauterine growth-restricted fetuses.

INTRODUCTION: It is estimated that 3-10% of infants are growth restricted. Growth disturbances may have long-term issues. Doppler allows insight into the fetal response to intrauterine stress. OBJECTIVE: The aim of this study was to detect fetal compromise in intrauterine growth-restricted (IUGR) fetuses by means of biophysical profile (BPP) vis-à-vis Doppler velocimetry studies of the fetal umbilical artery, and to find out which of the two is a better and earlier predictor of fetal compromise. METHODS: A prospective study was conducted on a total of 50 singleton pregnancies with IUGR between 28 and 42 weeks of gestation. Study patients were managed expectantly with nonstress testing and amniotic fluid assessment, BPP and Doppler velocimetry studies of the fetal umbilical artery. RESULTS: Fetal outcome was poor in 5/50 (10%) of the fetuses, defined as presence of all of the following: poor Apgar test score, neonatal intensive care unit stay, necrotizing enterocolitis, and low birth weight. Of the four with abnormal BPP, 50% had poor fetal outcomes. Out of 46 with normal BPP, 6.5% had poor fetal outcomes. CONCLUSION: Inference drawn from the study is that the Doppler technology provides us the opportunity for repetitive noninvasive hemodynamic monitoring in IUGR pregnancies.

Study of prognostic significance of antenatal ultrasonography and renin angiotensin system activation in predicting disease severity in posterior urethral valves.

AIMS: Study on prognostic significance of antenatal ultrasonography and renin angiotensin system activation in predicting disease severity in posterior urethral valves. MATERIALS AND METHODS: Antenatally diagnosed hydronephrosis patients were included. Postnatally, they were divided into two groups, posterior urethral valve (PUV) and non-PUV. The studied parameters were: Gestational age at detection, surgical intervention, ultrasound findings, cord blood and follow up plasma renin activity (PRA) values, vesico-ureteric reflux (VUR), renal scars, and glomerular filtration rate (GFR). RESULTS: A total of 25 patients were included, 10 PUV and 15 non-PUV. All infants with PUV underwent primary valve incision. GFR was less than 60 ml/min/1.73 m(2) body surface area in 4 patients at last follow-up. Keyhole sign, oligoamnios, absent bladder cycling, and cortical cysts were not consistent findings on antenatal ultrasound in PUV. Cord blood PRA was significantly higher (P < 0.0001) in PUV compared to non-PUV patients. Gestational age at detection of hydronephrosis, cortical cysts, bladder wall thickness, and amniotic fluid index were not significantly correlated with GFR while PRA could differentiate between poor and better prognosis cases with PUV. CONCLUSIONS: Ultrasound was neither uniformly useful in diagnosing PUV antenatally, nor differentiating it from cases with non-PUV hydronephrosis. In congenital hydronephrosis, cord blood PRA was significantly higher in cases with PUV compared to non-PUV cases and fell significantly after valve ablation. Cord blood PRA could distinguish between poor and better prognosis cases with PUV.

Direct fetal intravenous immunoglobulin infusion as an adjunct to intrauterine fetal blood transfusion in rhesus-allommunized pregnancies: a pilot study.

OBJECTIVES: To study the usefulness of direct fetal intravenous immunoglobulin (IVIG) infusion along with intrauterine transfusion (IUT) in the management of severe fetal anemia in rhesus (Rh) alloimmunized pregnancies. METHODS: Thirty-four consecutive Rh-isoimmunized pregnant women who required serial IUTs received either blood alone (control group, n = 16) or IVIG and blood (study group, n = 18). Pregnancies were followed up to delivery, and fetal outcome was recorded. The rate of fall of hematocrit was measured and compared between the two groups. RESULTS: There was a slower rate of fall of hematocrit in the study group (IUT and IVIG) compared to the control group (only IUT). The mean rate of fall was 0.72 ± 0.54% per day in the study group while it was 1.29 ± 0.95% per day in the control group (p = 0.005). CONCLUSION: Fall of fetal hematocrit was reduced in the study group. The results of this pilot study can be used to time the next transfusion in patients receiving IVIG along with IUT (taking the rate of fall as 0.70%). This may eventually result in decreasing the number of transfusions per fetus.

Successful management of heterotopic pregnancy after fetal reduction using potassium chloride and methotrexate.

Heterotopic pregnancy, the presence of two gestational sacs simultaneously, is a rare event but with the advent of Assisted Reproductive Technology, it is now an increasingly common complication. The reported incidence of a heterotopic pregnancy in a spontaneous cycle is quoted as 1 in 30,000. We report the case of a 38-year-old primigravida who was referred to our center at 11 + 2 weeks gestation with a diagnosis of heterotopic pregnancy for further management. A non-surgical intervention comprising of transvaginal ultrasound-guided potassium chloride and methotrexate into the cervical pregnancy resulted in a successful outcome. As an obstetrician, a high index of clinical suspicion and an early scan is mandatory to make a diagnosis of a heterotopic pregnancy and manage accordingly.

Clinical correlates of pain and anxiety in prenatal diagnostic procedures.

OBJECTIVE: To study patient perception of pain and anxiety before and after amniocentesis (AC) and transabdominal chorionic villus sampling (CVS) and the clinical correlates of pain and anxiety. METHODS: 92 women underwent AC and 78 CVS. Visual analog scale was used to quantify pain and anxiety, immediately before and after the procedure. Factors which could affect pain and anxiety were noted. RESULTS: The pain and anxiety anticipated before the procedures were significantly less than actually perceived. The pre-procedure anxiety did not correlate with post-procedure pain. There was no correlation between anticipated pain or anxiety and age, parity, education, socioeconomic status, and history of procedure in previous pregnancy in both the AC and CVS groups. Post-procedure pain did not correlate with age, parity, education, socioeconomic status, abdominal scar, placental location, number of needle insertion, repeat procedure or abdominal wall thickness in either group. However, on multiple linear regression the overall post-procedure pain was associated with the number of needle insertions. CONCLUSION: Though pre-procedure pain and anxiety levels are high, most patient experience less pain and anxiety after the procedure.

Predictive value of DNA integrity analysis in idiopathic recurrent pregnancy loss following spontaneous conception.

PURPOSE: Standard semen parameters are poor predictors of fertility potential. To date, apart from, paternal karyotyping sperm factors are not evaluated in recurrent pregnancy loss (RPL), only recent studies have emphasized the role of sperm factors in early embryonic development as sperm transcribes genes critical for early embryonic development. Sperm DNA integrity is useful diagnostic and prognostic marker and has clinical implications in idiopathic recurrent pregnancy loss (iRPL) following spontaneous conception. The aim of this study was to assess DNA integrity in cases experiencing iRPL following spontaneous conception. METHODS: Semen samples from 45 patients and 20 controls were analyzed as per WHO 1999 guidelines and sperm chromatin structure assay (SCSA) was used to measure DNA fragmentation index (DFI). RESULTS: By applying receiver operating curve (ROC) analysis, sperm DFI of approximately 26 % was found in male partner of couples experiencing iRPL. CONCLUSIONS: Our data indicate that sperm from men with a history of iRPL have a higher percentage of DNA damage as compared to control group, and this can explain pregnancy loss in these patients. Men with higher DFI are infertile whereas men with lower DFI (26 %) are able to conceive but experience recurrent pregnancy loss. Thus it is important to evaluate sperm DFI in couples experiencing iRPL to understand exact aetiology of RPL and determine prognosis and management.

Norrie disease: first mutation report and prenatal diagnosis in an Indian family.

Norrie Disease (ND) is a rare X-linked recessive disorder characterised by congenital blindness due to severe retinal dysgenesis. Hearing loss and intellectual disability is present in 30-50 % cases. ND is caused by mutations in the NDP gene, located at Xp11.3. The authors describe mutation analysis of a proband with ND and subsequently prenatal diagnosis. Sequence analysis of the NDP gene revealed a hemizygous missense mutation arginine to serine in codon 41 (p.Arg41Ser) in the affected child. Mother was carrier for the mutation. In a subsequent di-chorionic di-amniotic pregnancy, the authors performed prenatal diagnosis by mutation analysis on chorionic villi sample at 11 wk of gestation. The fetuses were unaffected. This is a first mutation report and prenatal diagnosis of a familial case of Norrie disease from India. The importance of genetic testing of Norrie disease for confirmation, carrier testing, prenatal diagnosis and genetic counseling is emphasized.

Indications of 1342 fetal cord blood sampling procedures performed as an integral part of high risk pregnancy care.

BACKGROUND: Fetal umbilical cord blood sampling is now being performed worldwide, using an ultrasound guided technique, for prenatal diagnosis in pregnancies at high risk for several congenital and genetic defects in the fetus. Awareness of feasibility of the procedure and indications for the same should be known to every obstetrician. AIMS AND OBJECTIVES: To study the indications for Fetal Cord Blood Sampling in high risk pregnancy patients in the last 20 years at a tertiary referral center in India. MATERIALS AND METHODS: Women referred to the Fetal Medicine Clinic for fetal blood sampling from January 1990 to November 2009, were assessed. An informed consent was taken. Under continuous ultrasound guidance, a 22 gauge long spinal needle was inserted through the maternal abdomen and uterine wall into the umbilical cord, and about 2-4 ml of blood, depending on the indication was aspirated by syringe. The various indications for fetal blood sampling in 1342 women were analyzed. RESULTS: Cord blood sampling was performed for the following indications: Hb in Rh Isoimmunized pregnancies-553 cases, Chromosomal analysis-427 cases, non-immune hydrops/pleural effusion/ascites-cases 88, Congenital Infections-131 cases, Intrauterine Growth Restriction-51 cases, Thalassemia-53 cases, Hemophilia-36 cases, and for Thyroid function test for fetal goiter in 3 cases, in total 1,342 women. CONCLUSION: There were several absolute indications for fetal cord blood sampling in high risk pregnant women, to provide state-of-the-art information on the health of the fetus. Awareness of the procedure and indications for the same should be known to every obstetrician as it is technically feasible, expertise is available in India; so that women who require the procedure may be referred in time.

Analysis of sperm nuclear protein gene polymorphisms and DNA integrity in infertile men.

Sperm nuclear proteins, the protamines (PRM) and transition nuclear proteins (TNP) play a crucial role in sperm nuclear condensation. The compact packaging of sperm DNA by protamines maintains sperm genome integrity, which is prerequisite for normal sperm function. However the effect of nucleotide variations in PRM and TNP genes on sperm DNA integrity and male fertility is not clear. This case-control study was planned to analyze PRM and TNP gene nucleotide variations and sperm DNA integrity in 100 oligozoospermic infertile men and 100 fertile controls. Protamine and TNP genes were amplified by polymerase chain reaction and sequenced. Flow cytometry-sperm chromatin structure assay (FC-SCSA) was applied to measure the DNA fragmentation index (DFI) in sperm. Semen analysis was performed as per WHO [1999] guidelines with slight modification. In total, 7 nucleotide variations including two novel changes, a non-synonymous mutation in the exon-2 of PRM2 gene (c.443C > A) and a novel insertion of T (c.396_397InsT) at the 3' UTR region of TNP1 were detected. None of the nucleotide changes were observed with increased risk frequency in the oligozoospermic infertile men compared to the controls. Though overall DFI was significantly (p < 0.0001) higher in infertile men compared to controls (36.31 ± 7.25 vs. 26.49 ± 2.78) irrespective of nucleotide changes, no such difference was observed between 100 infertile men or pooled population of 200 with and without mutations. However it was observed that two cases with novel nucleotide changes PRM2 c.443C > A and TNP1 c.396_397InsT had higher DFI value of 34.82% and 43.85%, respectively. In conclusion, our pilot study for the first time in the Indian population revealed two rare novel mutations in sperm nuclear protein genes that are perhaps associated with higher sperm DNA fragmentation.

Successful outcome in pregnancy complicated by prior uterine rupture: a report of two cases.

BACKGROUND: Rupture of the uterus, especially in a scarred uterus, intrapartum is well known. The risk of uterine rupture in women with a previous lower segment caesarean section is 0.2-1.5%, whereas in an unscarred uterus it is extremely rare. CASE: Case 1 A 26-year-old woman in her third pregnancy was referred at 16 weeks from a community hospital. She had a history of uterine perforation at the fundus in her first pregnancy during a dilatation and curettage requiring laparotomy and repair. In her second pregnancy, fetal death had occurred in the second trimester. She conceived subsequently and in her third pregnancy, the risk of silent rupture of uterus was explained, but the couple opted for continuation of this pregnancy. Case 2 A 25-year-old woman in her third pregnancy was referred. In her first pregnancy, she had a septic abortion during the fifth month of pregnancy. Two years later, she presented at 16 weeks gestation with a severe abdominal pain. An ultrasound/MRI revealed a uterine wall defect with an empty uterus, fetus lying outside the uterine cavity with moderate free fluid. In her third pregnancy, 18 months later, at 10 weeks gestation an ultrasound revealed a single live intrauterine pregnancy with an indistinct thinning and sacculation of the fundo-posterior uterine wall. CONCLUSION: With increasing caesarean rates, every obstetrician is bound to face the challenge of this life-threatening obstetric hazard and must be prepared to handle this emergency with an expeditious recourse to laparotomy.

Primary umbilical endometriosis: a rare entity.

Primary umbilical endometriosis accounts for 0.5-1% of extragenital endometriosis. Clinical presentation is typical and treatment involves complete excision. It is important to consider it in differential diagnosis of an umbilical nodule.

Multifocal polypoid endometriosis in a young woman simulating vaginal and pelvic neoplasm.

A 27-year-old nulliparous woman presented with large finger-like projections protruding from her vagina. Intraoperatively there were deposits in the pouch of Douglas. Clinical presentation and history of vaginal bleeding suggested malignancy. Histopathology of both the vaginal and pouch of Douglas masses showed endometrial glands and stroma. There was no architectural complexity or cytological atypia of glands or stroma. Immunohistochemistry for oestrogen receptor, progesterone receptor and CD10 was positive. Based on morphological and immunohistochemical findings, multifocal polypoid endometriosis was diagnosed; this is a recently described entity having a clinical presentation and age range completely different from conventional or non-polypoid endometriosis. Although an association between tamoxifen use, unopposed oestrogen therapy and polypoid endometriosis has been suggested, the patient had no history of tamoxifen or oestrogen intake. Polypoid endometriosis should be part of the differential diagnosis in young women presenting with vaginal growth.

Rupture of a malignant ovarian tumor in pregnancy presenting as acute abdomen.

INTRODUCTION: Ovarian neoplasms in pregnancy are usually asymptomatic rarely leading onto complications. A 30-year-old G2 P1+0+0+1 was referred at 30 weeks of pregnancy with an ultrasound diagnosis of a large multicystic ovarian cyst with no solid areas, ascites or evidence of metastasis. Antenatal corticosteroid was administered and she was advised to follow-up with reports of tumor markers. She presented a week later with acute pain abdomen and breathlessness. Clinical examination revealed a relaxed uterus and ultrasound was suggestive of rupture of the ovarian cyst. Exploratory laparotomy revealed a ruptured left mucinous ovarian cyst with no evidence of solid areas or metastasis. Left ovariotomy with infracolic omentectomy and concurrent cesarean section was done. A healthy male baby of weight 1.880 kg was delivered. Histopathology revealed stage-1c mucinous cyst adenocarcinoma of left ovary. This was followed-up, with a complete surgery done after a month. She is now receiving postoperative chemotherapy. CONCLUSION: This is the first reported case of a ruptured malignant ovarian tumor in pregnancy. Torsion or rupture of ovarian masses is an important differential diagnosis of abdominal or pelvic pain during pregnancy.