Oxidative stress in preeclamptic mother - newborn dyads and its correlation with early neonatal outcome - a case control study.

BACKGROUND: Preeclamptic mothers are likely to have increased oxidative stress during pregnancy which can adversely affect the outcome in their neonates. OBJECTIVES: To measure the oxidative stress in preeclamptic mother- newborn dyads and correlate it with the immediate neonatal outcome. METHODS: This case control study conducted in a tertiary care teaching hospital, South India included 71 preeclamptic mothers - newborn dyads (cases) and 72 normal mothers - newborn dyads (controls). Biochemical parameters including total antioxidant status (TAS), protein carbonyls and malondialdehyde levels (MDA) were measured in both maternal and cord blood. Association between these oxidative stress parameters and early neonatal outcome was studied. RESULTS: All oxidative stress markers were higher in the preeclampsia group compared to the controls. Cord blood protein carbonyl levels had significant correlation with maternal levels. Prematurity, low-birth weight, respiratory distress syndrome (RDS), early onset sepsis (EOS) and intra-uterine growth restriction (IUGR) were more among cases. Early neonatal outcomes like death, IUGR, EOS, and RDS had significant correlation with protein carbonyl levels among the cases. CONCLUSIONS: Oxidative stress is increased in preeclamptic mother - newborn dyads. Increased protein carbonyl levels in preeclampsia correlate with adverse early neonatal outcome.

Oxidative Stress, Antioxidant Status and Neurodevelopmental Outcome in Neonates Born to Pre-eclamptic Mothers.

OBJECTIVES: To measure the oxidative stress and antioxidant status in preeclamptic mother-newborn dyads and correlate them with neurodevelopmental outcome at one year of corrected age. METHODS: This cohort study conducted in a tertiary care teaching hospital, south India included 71 preeclamptic and 72 normal mother-newborn dyads. Biochemical parameters including total antioxidant status (TAS), protein carbonyls and malondialdehyde levels (MDA) were measured in both maternal and cord blood. Infants in both the groups were followed up to one year of corrected age and neurodevelopmental assessment was done using Developmental Assessment Scale for Indian Infants (DASII). Correlation and multivariate regression analysis was done to evaluate the oxidative stress markers in relation to neurodevelopmental outcome. RESULTS: All oxidative stress markers were higher in maternal and cord blood of pre-ecclampsia group compared to the normal group. Maternal Total antioxidant status (M-TAS) was lower in pre-eclampsia group than normal group. More neonates in the pre-ecclampsia group were preterm and intrauterine growth restriction (IUGR) and had higher incidence of morbidities like respiratory distress syndrome (RDS) and early onset sepsis (EOS). Infants in the preeclampsia group had lower motor age, motor score and motor developmental quotient (MoDQ). On multivariate logistic regression analyses, lower M-TAS levels were strongly associated with poor neuro-motor outcomes at 1 y of corrected age. Maternal TAS with a cut-off value of 0.965 mmol/L had a sensitivity of 77.8% and specificity of 55.3% in predicting MoDQ <70 at one year corrected age in infants born to preeclamptic mothers. CONCLUSIONS: Oxidative stress is increased in preeclamptic mother-newborn dyads. Low maternal TAS levels are associated with poor neuro-motor outcomes. Maternal TAS in preeclampsia is useful in predicting poor motor development at one year corrected age.

Decreased baroreflex sensitivity is linked to sympathovagal imbalance, low-grade inflammation, and oxidative stress in pregnancy-induced hypertension.

Pregnancy-induced hypertension (PIH) has been reported as a cardiovascular (CV) risk. We assessed the sympathovagal imbalance (SVI) and the association of inflammation and oxidative stress (OS) with CV risks in PIH. A total of 125 pregnant women having a risk factor for PIH were followed till term and the incidence of PIH was observed. Retrospectively, they were divided into two groups: Group I (those who did not develop PIH, n = 82) and Group II (those who developed PIH, n = 43). Blood pressure variability (BPV) parameters including baroreflex sensitivity (BRS), spectral heart rate variability (HRV), autonomic function tests (AFTs), inflammatory markers (interleukin-6, TNF-α, interferon-γ), and OS markers were measured in both the groups. Alterations in parasympathetic and sympathetic components of AFTs were analyzed. Link of various parameters to BRS was assessed by correlation and multiple regression analysis. Parasympathetic components of AFTs were decreased from the early part of pregnancy and sympathetic components were increased toward the later part of pregnancy. Decreased BRS, the marker of CV risk, was more prominent in Group II subjects. Independent contribution of interleukin-6 (ß = 0.276, P = 0.020), TNF-α (ß = 0.408, P = 0.002), interferon-γ (ß = 0.355, P = 0.008), and thiobarbituric-acid reactive substance (ß = 0.287, P = 0.015) to BRS was found to be significant. It was concluded that sympathetic overactivity that develops more in the later part (third trimester) of pregnancy contributes to SVI and genesis of PIH. In PIH women, CV risks are present from the beginning of pregnancy that intensifies in the later part of pregnancy. Retrograde inflammation and oxidative stress contribute to the decreased BRS in PIH.

Effect of postural changes on inferior vena cava dimensions and its influence on haemodynamics during caesarean section under spinal anaesthesia.

The effect of postural changes on inferior vena cava (IVC) dimensions and its influence on intra-operative haemodynamics in term parturients can be studied using abdominal ultrasound by a subcostal approach. Thirty-two term parturients scheduled to undergo elective caesarean section under spinal anaesthesia were recruited in this observational study. End expiratory diameter and collapsibility index of IVC was measured preoperatively in 3 different positions - supine, recumbent with wedge and left lateral positions. End expiratory diameter was significantly high in recumbent (10.79) and left lateral (12.27) compared with supine (9.96) position (P < 0.0001). A greater fall in systolic blood pressure (>20%) was noted in patients with collapsibility index of more than 11.5 in recumbent with wedge position with a positive predictive value of 86%. IVC dimensions change significantly with change in position and collapsibility index in recumbent position can be a useful parameter for predicting hypotension during caesarean section under spinal anaesthesia.

Obstetric patients requiring intensive care: a one year retrospective study in a tertiary care institute in India.

Background and Objectives. Critically ill obstetric patients are a particularly unique cohort for the intensivist. The objective of this study was to review the indications for admission, demographics, clinical characteristics, and outcomes of obstetric patients admitted to intensive care unit of a medical college hospital in southern India and to identify conditions associated with maternal mortality. Design. Retrospective analysis of pregnant/postpartum (up to 6 weeks) admissions over a 1-year result. We studied 55 patients constituting 11.6% of mixed ICU admissions during the study period. Results. The mean APACHE (acute physiology and chronic health evaluation) II score of patients at admission was 11.8. Most of the patients (76%) were admitted in the antepartum period. The commonest indications for ICU admission were obstetric haemorrhage (51%) and hypertensive disorders of pregnancy (18%). 85% of patients required mechanical ventilation and 78% required inotropic support. Conclusions. Maternal mortality was 13%, and the majority of the deaths were due to disseminated intravascular coagulation and multiorgan failure, following an obstetric haemorrhage. A dedicated obstetric ICU in tertiary hospitals can ensure that there is no delay in patient management and intensive care can be instituted at the earliest.

Spectrum of vaginal discharge in a tertiary care setting.

INTRODUCTION: Vaginal discharge is one of the common reasons for gynecological consultation. Many of the causes of vaginitis have a disturbed vaginal microbial ecosystem associated with them. Effective treatment of vaginal discharge requires that the etiologic diagnosis be established and identifying the same offers a precious input to syndromic management and provides an additional strategy for human immunodeficiency virus prevention. The present study was thus carried out to determine the various causes of vaginal discharge in a tertiary care setting. MATERIALS AND METHODS: A total of 400 women presenting with vaginal discharge of age between 20 and 50 years, irrespective of marital status were included in this study and women who had used antibiotics or vaginal medication in the previous 14 days and pregnant women were excluded. RESULTS: Of the 400 women with vaginal discharge studied, a diagnosis was established in 303 women. Infectious causes of vaginal discharge were observed in 207 (51.75%) women. Among them, bacterial vaginosis was the most common cause seen in 105 (26.25%) women. The other infections observed were candidiasis alone (61, 15.25%), trichomoniasis alone (12, 3%), mixed infections (22, 5.5%) and mucopurulent cervicitis (7 of the 130 cases looked for, 8.46%). Among the non-infectious causes, 72 (18%) women had physiological vaginal discharge and 13 (3.3%) women had cervical in situ cancers/carcinoma cervix. CONCLUSION: The pattern of infectious causes of vaginal discharge observed in our study was comparable with the other studies in India. Our study emphasizes the need for including Papanicolaou smear in the algorithm for evaluation of vaginal discharge, as it helps establish the etiology of vaginal discharge reliably and provides a valuable opportunity to screen for cervical malignancies.

Effect of positioning from supine and left lateral positions to left lateral tilt on maternal blood flow velocities and waveforms in full-term parturients.

Positioning the parturient from supine to the left lateral tilt position (supine-to-tilt) may not effectively displace the gravid uterus, but turning from the left lateral position to the left lateral tilt position (left lateral-to-tilt) may keep the gravid uterus displaced and prevent aortocaval compression. Fifty-one full-term parturients were randomly placed in the left lateral position, supine-to-tilt and left lateral-to-tilt positions using a Crawford wedge. Femoral vein area, femoral vein velocity, femoral artery area, pulsatility index, resistance index and right arm mean arterial blood pressure and heart rate were recorded. Our results showed a lower mean (SD) femoral vein area (82.2 (14.9) vs 96.2 (16.4) mm(2)), a lower pulsatility index (3.83 (1.3) vs 5.8 (2.2)), a lower resistance index (0.93 (0.06) vs 0.98 (0.57)), a higher femoral artery area (33.3 (3.8) vs 30.9 (4.4) mm(2)) and a higher femoral vein velocity (7.9 (1.2) vs 6.1 (1.6) cm.s(-1)) with left lateral-to-tilt when compared with supine-to-tilt (all p < 0.001). Our results suggest that moving a full-term parturient from the full left lateral to the lateral tilt position may prevent aortocaval compression in full-term parturients more efficiently than when positioning the parturient from a supine to left lateral tilt position.

Increased inflammatory response and imbalance in blood and urinary oxidant-antioxidant status in South Indian women with gestational hypertension and preeclampsia.

OBJECTIVE: The objective of this study is to assess the association of blood and urinary oxidative stress parameters and inflammatory markers in women with gestational hypertension and preeclampsia. DESIGN AND METHODS: Malondialdehyde, protein bound sialic acid and C-reactive protein were estimated in serum and urine of pregnant women diagnosed with preeclampsia (n=30) and gestational hypertension (n=30) and the results were compared with 30 normal pregnant women. RESULTS: Whole blood glutathione level was reduced, and malondialdehyde and C-reactive protein levels were significantly higher and correlated with each other in preeclampsia (p<0.05). Urinary malondialdehyde significantly correlated with urinary protein bound sialic acid in preeclampsia (r=0.412; p=0.02). Receiver operating curve analysis of serum protein bound sialic acid and serum malondialdehyde showed reasonable cutoff values for the differential diagnosis of preeclampsia. CONCLUSIONS: Oxidative stress and inflammatory response are greater in women with preeclampsia in comparison to pregnant women with gestational hypertension and there is an association between oxidative stress and inflammatory response.

A review of 93 cases of ruptured uterus over a period of 2 years in a tertiary care hospital in South India.

This was a retrospective descriptive study carried out on cases in JIPMER between July 2008 and June 2010 among 32,080 deliveries. The study sample included 93 women who had a ruptured uterus. Outcome variables included maternal characteristics, risk factors, management and complications of ruptured uterus. The incidence of ruptured uterus was 0.28%. Most of these women were multiparous (95%), between 20 and 30 years (82%). The majority had a scarred uterus (77%) and 83% were at term gestation. Among women with a scarred uterus, 57 women (79%) had an unknown uterine scar type and 46 women (64%) had < 18 months' duration from the last caesarean section. A total of 37 women (39.7%) presented with ruptured uterus and a dead fetus. Out of 71 women with previous caesarean section, 46 women (49.4%) were allowed trial of scar and developed a ruptured uterus in hospital. Among women with unscarred uterus, 14 presented with rupture and seven of these women were induced in hospital. Out of the 93 cases, 87% were managed with uterine repair and 12 women underwent hysterectomy. A total of 31 babies were born with good Apgar scores; 48 babies were stillborn. We conclude that the strongest association of ruptured uterus was with previous scarred uterus, multiparity and < 18 months' duration from the last caesarean section. There were no maternal deaths. Maternal morbidity was seen in 17% of cases. Perinatal mortality was 60.6%. As a result of the study, we have implemented changes to improve patients' care.

Vagal withdrawal and sympathetic overactivity contribute to the genesis of early-onset pregnancy-induced hypertension.

Objective. In this study, we have assessed sympathovagal imbalance (SVI) by spectral analysis of heart rate variability (HRV) that contributes to the genesis of early-onset PIH. Methods. Body mass index (BMI), basal heart rate (BHR), blood pressure (BP) and HRV indices such as LFnu, HFnu, LF-HF ratio, mean RR, SDNN and RMSSD were assessed in normal pregnant women (Control group) and pregnant women having risk factors for PIH (Study group) at all the trimesters pregnancy. Retrospectively, those who did not develop PIH (Study group I) were separated from those who developed PIH (Study group II). Study group II was subdivided into early-onset and late-onset PIH. Sympathovagal balance (LF-HF ratio) was correlated with BMI, BHR and BP. Results. LF-HF ratio was significantly high in study group II compared to study group I and control group, and in early-onset PIH group compared to the late-onset category at all the trimesters of pregnancy, which was significantly correlated with BHR and BP. Alteration in HFnu in early-onset category was more prominent than the alteration in LFnu. Conclusion. Though the SVI in PIH is contributed by both sympathetic overactivity and vagal withdrawal, especially in early-onset type, SVI is mainly due to vagal inhibition.

Association of albumin-globulin ratio with sympathovagal imbalance in pregnancy-induced hypertension.

The early prediction of pregnancy-induced hypertension (PIH) is based on the demonstration of increased sympathetic activity in early part of pregnancy. However, the mechanisms that increase sympathetic activity in PIH have not yet been fully elucidated. Therefore, in the present study we have investigated the link of albumin-globulin ratio (AGR) to sympathovagal imbalance in PIH patients. Spectral analysis of HRV was performed in three groups of subjects (Group I: normal pregnant women; Group II: pregnant women with risk factors for PIH, but did not develop PIH; Group III: pregnant women with risk factors and developed PIH) and their biochemical parameters including AGR were recorded. It was observed that LF-HF ratio, the most sensitive indicator of sympathovagal balance was significantly high (P < 0.01) since early pregnancy in group III compared to other groups, which was considerably correlated with AGR in group III (PIH subjects). It was suggested that alteration in AGR could have direct contribution to the sympathovagal imbalance that plays a critical role in the genesis of PIH.

Spectral analysis of heart rate variability for early prediction of pregnancy-induced hypertension.

The early prediction of pregnancy-induced hypertension (PIH), a common morbid disorder of pregnancy is unsatisfactory. Therefore, in the present study we have investigated the role of spectral analysis of heart rate variability (HRV) in the early prediction of PIH. Spectral analysis of HRV was performed in three groups of subjects (Group I: normal pregnant women; Group II: pregnant women with risk factors, but did not develop PIH; Group III: pregnant women with risk factors and developed PIH). It was observed that the LF-HF ratio, the most sensitive indicator of sympathovagal balance, was significantly high (p < 0.01) since early pregnancy in group III compared to other groups, which was significantly correlated with heart rate and blood pressure. It was suggested that the predictive knowledge of sympathovagal imbalance should be utilized in designing the prevention and management of PIH.

Manual displacement of the uterus during Caesarean section.

Ninety ASA 1 and 2 pregnant women with term singleton pregnancies and no maternal and fetal complications, scheduled for elective or emergency Caesarean section, were randomly allocated to group LT (15 degrees left lateral table tilt, n = 45) and group MD (leftward manual displacement, n = 45). Subarachnoid block was established with a 25-gauge spinal needle at the L3-L4 interspace using 1.5 ml of 0.5% hyperbaric bupivacaine. A median sensory level of T6 was observed in both groups but the incidence of hypotension was markedly lower in group MD when compared to group LT (4.4% vs 40%; p < 0.001) with a significant reduction in mean (SD) ephedrine requirement (6 (0) vs 11.3 (4.9) mg; p < 0.001). The mean (SD) fall in systolic blood pressure was 28.8 (7.3) mmHg in group LT and 20 (12.7) mmHg in group MD. The time to maximum fall in systolic blood pressure was similar in both groups (4.5 min). We conclude that manual displacement of the uterus effectively reduces the incidence of hypotension and ephedrine requirements when compared to 15 degrees left lateral table tilt in parturients undergoing Caesarean section.

Maternal genital bacteria and surface colonization in early neonatal sepsis.

OBJECTIVE: The study was intended to evaluate the role of maternal genital bacteria and baby's surface colonization in early onset neonatal sepsis. METHODS: Babies (born in the hospital of Jawaharlal Institute of Postgraduate Medical Education and Research) who developed clinical signs of sepsis were studied. Swabs were collected for culture from baby's umbilicus, ear, throat in addition to gastric aspirate and blood culture. The genital tract of the mother was also studied for bacterial colonization. The organisms isolated from the maternal genital tract and baby's surface colonization were correlated with those isolated from blood culture by calculating Phi correlation coefficient. RESULTS: Esch coli was the most common organism isolated from maternal genital tract and surface cultures of babies, but Klebseilla-Spp was the most common organism isolated from blood. There was a significant correlation between surface colonization of babies and maternal genital bacteria, so also was baby's surface culture and blood culture. However, correlation between maternal genital bacteria and baby's blood culture was not significant. CONCLUSION: Surface colonizing bacteria and not maternal genital bacteria are important in early onset neonatal sepsis.

Pruritus gravidarum: a clinical and laboratory study.

Five hundred pregnant women attending obstetrics OPD were screened for the presence of pruritus. The patients with other dermatological causes of pruritus (other than specific dermatosis of pregnancy) were excluded from the study. The selected patients were further subjected to routine laboratory investigations including liver function tests and IIBs Ag detection. The prevalence of pruritus in pregnancy was found to be 4.6% (23 cases). Ten patients were found to have specific dermatoses of pregnancy, including four cases of pruritus gravidarum and four of pruritic urticarial papules and papules of pregnancy. The prevalence of pruritus gravidarum was 0.8% of pregnancies. All the patients with pruritus gravidarum were primigravidae and had no clinical overlap with other specific dermatoses of pregnancy, jaundice, or intrahepatic cholestasis. One case of perinatal death was recorded among the pruritus gravidarum cases. This study has been helpful in determining the prevalence and severity of pruritus gravidarum in South India.

Ectopic pregnancy--changing trends.

This study is an attempt to have an overall view of the changing trends in the clinical presentation, diagnostic modalities and management of ectopic pregnancy over a period of three and a half decades. The incidence of ectopic pregnancy was one in 368 during the 15-year period from 1959-1973 (group A) and has increased to one in 160 during the latter part of the study period from 1988-1993 (group B). Medical termination of pregnancy, abortion, intra-uterine contraceptive device and previous tubal ligation were the important risk factors recently (group B). Unruptured tubal pregnancy was diagnosed in 9.8% (group B) as compared to only 3% in group A. However, as most of the patients came to the hospital with disturbed pregnancy, the use of ultrasonography and urine gravindex test was helpful in only 14% in the latter part of the study. The characteristic clinical features like pain abdomen with amenorrhoea, vaginal bleeding and positive culdocentesis were the most reliable diagnostic criteria in both the groups. There is an increasing trend towards conserving the tubes and methotrexate use recently.

Impact of mode of delivery on maternal mortality in eclampsia.

Determinants of maternal mortality and causes of death pertaining to mode of delivery have been discussed. There were 23 deaths (case fatality rate of 7.2%) and maximum deaths occurred in intrapartum eclampsia (12 ie, 52.17%). Caesarean section was performed in 92 cases (28.7%) of which 4 women died (4.3%). Maternal mortality in cases who delivered vaginally was 7.1% (16 out of 225) and 3 cases died undelivered. Authors feel that at the referral centres early caesarean section in eclampsia may help in reducing maternal mortality.

PIP: Of the 25,257 deliveries that occurred in 1984-93 at the Jawaharlal Institute of Postgraduate Medical Education and Research in Pondicherry, India, 320 involved eclampsia. Eclampsia accounted for 23 (17.6%) of the 131 maternal deaths during the study period, for a case fatality rate of 7.2%. 12 of the eclampsia deaths occurred during the intrapartum period. 225 women with eclampsia (70.3%) had a spontaneous or operative vaginal delivery; there were 16 deaths (7.1%) among women in this delivery group. Cesarean section under general anesthesia was performed in 92 cases (28.7%); 4 of these women (4.3%) died (3 from intracranial hemorrhage). These findings confirm the general opinion that efficient control of eclampsia-related convulsions and a prompt delivery are key to the prevention of maternal morbidity and mortality.

Rectal bleeding: a rare complication of abdominal pregnancy.

A rare case of abdominal pregnancy, causing massive rectal bleeding due to invasion of the rectal wall by the placenta, is reported.

Two cases of gas gangrene complicating uterine rupture and fetal death at term.

Two patients with obstructed labor and uterine rupture complicated by clostridial septicemia are reported. The diagnosis was apparent clinically. The importance of early diagnosis and prompt treatment are emphasized. The place of hysterectomy, which should be individualized is discussed. All efforts should be directed towards prophylaxis in high risk cases.