Impact of social determinants of health on progression from potentially life-threatening complications to near miss events and death during pregnancy and post partum in a middle-income setting: an observational study.

OBJECTIVE: To assess the potential associations between social determinants of health (SDH) and severe maternal outcomes (SMO), to better understand the social structural framework and the contributory, non-clinical mechanisms associated with SMO. STUDY DESIGN: Prospective observational study. STUDY SETTING: Tertiary referral centre in south-eastern region of India. PARTICIPANTS: One thousand and thirty-three women with potentially life-threatening complications (PLTC) were identified using WHO criteria. RISK FACTORS ASSESSED: Social Determinants of Health (SDH). PRIMARY OUTCOMES: Severe maternal outcomes, which include maternal near-miss and maternal death. STATISTICAL ANALYSIS: Logistic regression to assess the association between SDH and clinical factors on SMO, expressed as adjusted ORs (aOR) with a 95% CI. RESULTS: Of the 37 590 live births, 1833 (4.9%) sustained PLTC, and 380 (20.7%) developed SMO. Risk of SMO was higher with increasing maternal age (adjusted OR (aOR) 1.04 (95% CI 1.01 to 1.07)), multiparity (aOR 1.44 (1.10 to 1.90)), medical comorbidities (aOR 1.50 (1.11 to 2.02)), obstetric haemorrhage (aOR 4.63 (3.10 to 6.91)), infection (aOR 2.93 (1.83 to 4.70)), delays in seeking care (aOR 3.30 (2.08 to 5.23)), and admissions following a referral (aOR 2.95 (2.21 to 3.93)). SMO was lower in patients from socially backward community (aOR 0.45 (0.33 to 0.61)), those staying more than 10 km from hospital (aOR 0.56 (0.36 to 0.78)), those attending at least four antenatal visits (aOR=0.53 (0.36 to 0.78)) and those referred from resource-limited facilities (aOR=0.62 (0.46 to 0.84)). CONCLUSION: This study demonstrates the independent contribution of SDH to SMO among those sustaining PLTC in a middle-income setting, highlighting the need to formulate preventive strategies beyond clinical considerations.

Impact of near-miss event during pregnancy and childbirth on maternal health at 12 months.

OBJECTIVE: To assess the impact of maternal near-miss on late maternal death and the prevalence of hypertension or chronic kidney disease (CKD) and mental health problems at 12 months of follow up. METHODS: This prospective cohort study was conducted in a tertiary hospital in the southeastern region of India from May 2018 to August 2019, enrolling those with maternal near-miss and with follow up for 12 months. The primary outcomes were incidence of late maternal deaths and prevalence of hypertension and CKD during follow up. RESULTS: Incidence of maternal near miss was 6.7 per 1000 live births. Among those who had a near miss, late maternal deaths occurred in 7.2% (95% confidence interval [CI] 3.1%-11.3%); prevalence of CKD was 23.0% (95% CI 16.2%-29.8%), and of hypertension was 56.2% (95% CI 50.5%-66.5%) and only two women had depression on follow up. After adjusting for age, parity, socioeconomic status, gestational age at delivery, hemoglobin levels, and perinatal loss, only serum creatinine was independently associated with late maternal death and CKD on follow up. CONCLUSIONS: Women who survive a life-threatening complication during pregnancy and childbirth are at increased risk of mortality and one or more long-term sequelae contributing to the non-communicable disease burden. A policy shift to increase postpartum follow-up duration, following a high-risk targeted approach after a near-miss event, is needed.

Comparison of Efficacy of Vaginal Misoprostol versus a Synthetic Osmotic Dilator (Dilapan-S) for Cervical Preparation before Operative Hysteroscopy: A Randomized Controlled Study.

Objectives: To compare the need for mechanical cervical dilatation following vaginal misoprostol or synthetic osmotic dilator (Dilapan-S) usage for cervical preparation before operative hysteroscopy. Materials and Methods: Fifty-five premenopausal women scheduled for operative hysteroscopic procedures with a 26 Fr resectoscope were included in this randomized, controlled clinical trial. After randomization, either 400 µg of vaginal misoprostol or intracervical synthetic osmotic dilator (Dilapan-S) was inserted 12 h before operative hysteroscopy. The need for additional mechanical cervical dilatation before insertion of the resectoscope was compared between the two groups. Initial cervical diameter before mechanical dilatation, intraoperative complications (cervical tears, creation of a false passage), and ease of dilatation were also compared between the two groups. Results: In the misoprostol group, 92% of women required additional mechanical cervical dilatation, whereas only 36% of women in the Dilapan-S group required additional dilatation (P < 0.05). The median initial cervical diameter achieved with Dilapan was 9 mm (Q1: 7 mm; Q3: 10 mm), and with misoprostol, it was 6 mm (Q1: 4.5 mm; Q3: 8 mm) (P < 0.05). There was no significant difference in other outcome parameters between the two groups. Conclusion: Synthetic osmotic dilator (Dilapan-S) is more efficacious than vaginal misoprostol at ripening the cervix before operative hysteroscopy.

Diagnostic challenges in cerebral tuberculoma presenting with seizures in pregnancy.

Tuberculoma is an uncommon presentation of tuberculosis and is found in regions with a high prevalence of tuberculosis. This is rarely diagnosed during pregnancy. The presentation can mimic other etiologies such as eclampsia or cerebral venous sinus thrombosis so the diagnosis can be challenging, particularly when presenting with seizures in pregnancy. Described here is a woman in her first pregnancy who presented with seizures mimicking eclampsia and was suspected to have a brain tumour on neuroimaging. She was diagnosed to have a intracerebral tuberculoma on histopathological examination following surgical decompression after delivery.

Maternal and perinatal outcome in pregnancies complicated with portal hypertension: a systematic review and meta-analysis.

BACKGROUND: Portal hypertension is secondary to either cirrhotic or non-cirrhotic causes, and complicating pregnancy poses a challenge to the treating team. A systematic review was performed to determine maternal and perinatal outcomes in women with portal hypertension. Outcomes were compared among those with cirrhotic (CPH) with non-cirrhotic portal hypertension (NCPH) as well as non-cirrhotic portal fibrosis (NCPF) with extra-hepatic portal vein obstruction (EHPVO). METHODS: Medline and EMBASE databases were searched for studies reporting outcomes among pregnant women with portal hypertension. Reference lists from relevant papers and reviews were hand-searched for appropriate citations. Data were extracted to describe maternal complications, obstetric and neonatal outcomes. A random-effects model was used to derive pooled estimates of various outcomes, and final estimates were reported as percentages with a 95% confidence interval (CI). Cumulative, sequential and sensitivity analysis was studied to assess the temporal trends of outcomes over the period. RESULTS: Information on 895 pregnancies among 581 patients with portal hypertension was included from 26 studies. Portal hypertension was diagnosed during pregnancy in 10% (95% CI 4-24%). There were 22 maternal deaths (0%, 95% CI 0-1%), mostly following complications from variceal bleeding or hepatic decompensation. Variceal bleeding complicated in 14% (95% CI 9-20%), and endoscopic interventions were performed in 12% (95% CI 8-17%) during pregnancy. Decompensation of liver function occurred in 7% (95% CI 3-12%). Thrombocytopenia was the most common complication (41%, 95% CI 23-60%). Miscarriages occurred in 14% (95% CI 8-20%), preterm birth in 27% (95% CI 19-37%), and low birth weights in 22% (95% CI 15-30%). Risk of postpartum hemorrhage was higher (RR 5.09, 95% CI 1.84-14.12), and variceal bleeding was lower (RR 0.51, 95% CI 0.30-0.86) among those with CPH compared to NCPH. Risk of various outcomes was comparable between NCPF and EHPVO. CONCLUSION: One in ten pregnancies complicated with portal hypertension is diagnosed during pregnancy, and thrombocytopenia is the most common complication. Hepatic decompensation and variceal bleeding remain the most common cause of maternal deaths, with reduced rates of bleeding and its complications reported following the introduction of endoscopic procedures during pregnancy. CPH increases the risk of postpartum hemorrhage, whereas variceal bleeding is higher among NCPH.

External validation of the Maternal Severity Index for predicting maternal death following potentially life-threatening complications during pregnancy and childbirth: a single-centre, prospective observational study.

OBJECTIVES: To perform an external validation to assess the usefulness of the Maternal Severity Index (MSI) in predicting maternal death among women with potentially life-threatening complications during pregnancy or childbirth. DESIGN: Prospective observational study. SETTING: A tertiary referral centre in southeastern India. PARTICIPANTS: 1833 women with potentially life-threatening complications identified using the WHO criteria. PREDICTOR ASSESSED: MSI calculated based on the severity markers of the WHO criteria for maternal near-miss. PRIMARY OUTCOME: Maternal death. STATISTICAL ANALYSIS: Receiver operating characteristics (ROC) curve analysis was performed to assess discriminative performance, and agreement between expected and observed deaths was plotted to determine calibration. RESULTS: The incidence of severe maternal outcomes was 10 per 1000 live births. There were 57 (151 per 100 000 live births) maternal deaths during the study period. Maternal Severity Score was significantly higher among those who died (2.8±1.3 vs 2.0±1.2, p<0.001). The mean MSI value was 1.03% (95% CI 0.7% to 1.2%). ROC curve analysis showed good discrimination (AUC(Area Under the Curve): 0.962, 95% CI 0.952 to 0.970); however, overfitting was seen with higher probabilities. The standardised mortality ratio (SMR) was 0.02 (95% CI 0.01 to 0.02), indicating good quality of care. CONCLUSIONS: The MSI has good discriminative performance in distinguishing who succumbs to life-threatening complications, but needs recalibration to avoid overfitting. SMR of less than 0.5 indicates fewer than expected deaths, suggesting good quality of care in reducing maternal mortality in the study population.

Indicators for maternal near miss: an observational study, India.

Objective: To compare the incidence of maternal near miss using the World Health Organization (WHO) near-miss tool and six other criteria sets, including criteria designed for low-resource settings or specifically for India. Methods: In a cohort study we used WHO severity indicators to identify women with potentially life-threatening conditions during pregnancy or childbirth admitted to a referral hospital in Puducherry, India, from May 2018 to April 2021. We analysed sociodemographic, clinical and laboratory data for each woman and calculated the incidence of maternal near miss and other process indicators for each set of criteria. Findings: We analysed data on 37 590 live births; 1833 (4.9%) women were identified with potentially life-threatening conditions, 380 women had severe maternal outcomes and 57 died. Applying the different sets of criteria to the same data, we found the incidence of maternal near miss ranged from 7.6 to 15.6 per 1000 live births. Only the Global Network criteria (which exclude laboratory data that may not be available in low-resource settings) and the WHO criteria could identify all women who died. Applying the criterion of any number of units of blood transfusion increased the overall number of women identified with near miss. Conclusion: The WHO and Global Network criteria may be used to detect maternal near miss in low-resource settings. Future studies could assess the usefulness of blood transfusion as an indicator for maternal near miss, especially in low- to middle-income countries where the indicator may not reflect severe maternal morbidity if the number of units received is not specified.

Risk factors associated with unplanned caesarean section in women with placenta previa: a cohort study.

Unplanned/emergency caesarean section (CS) can lead to an increased risk of increased risk of adverse maternal and perinatal outcomes. This prospective observational study was conducted in a tertiary centre in South India to determine the factors associated with increased risk of unplanned/emergency CS among women with placenta previa (PP). Primary outcome was the unplanned CS defined as emergency CS performed, prior to the scheduled date of delivery, for profuse vaginal bleeding or onset of labour pains. Obstetric morbidity and maternal-foetal outcomes were also compared between major and minor degree of PP. Major degree PP (OR 3.56; 95% CI: 1.73-7.32), first episode of bleeding at less than 29 weeks of gestation (OR 6.25; 95% CI: 2.14-18.24), and the haemoglobin level at admission (OR: 0.72; 95% CI: 0.57-0.91) were found to be associated with higher odd for undergoing unplanned CS. Identifying these women at high risk of unplanned CS, especially in limited resource setting, helps for a timely and early referral to tertiary centres with expertise to manage complications along with facilities for blood transfusion and interventional radiology can help to optimise maternal and perinatal outcomes.Impact StatementWhat is already known on this subject? With increasing numbers of caesarean sections (CSs) and assisted reproductive techniques, the rate of PP is constantly on the rise. Unplanned CS is associated with increased risk of adverse maternal and perinatal complications.What do the results of this study add? Nearly, 40% among those who underwent CS were unplanned. Major degree placenta previa (PP) (OR 3.56; 95% CI: 1.73-7.32), first episode of bleeding at less than 29 weeks of gestation (OR 6.25; 95% CI: 2.14-18.24), and the haemoglobin level at admission (OR: 0.72; 95% CI: 0.57-0.91) were found to be associated with higher odd for undergoing unplanned CS.What are the implications of these findings for clinical practice and/or further research? Identifying women with PP at high risk of unplanned CS, especially in limited resource setting, helps for a timely and early referral to tertiary centres with expertise to manage complications, facilities for blood transfusion and interventional radiology, which optimise maternal and perinatal outcomes.

Serum biomarkers of maternal morbidity and adverse outcome in severe pre-eclampsia.

OBJECTIVE: To evaluate the association of maternal serum biomarkers of myocardial damage, oxidative stress and angiogenic imbalance with maternal adverse outcomes in women with severe pre-eclampsia. METHODS: This was a prospective cohort study, where maternal serum biomarkers were evaluated in women admitted with severe pre-eclampsia to a tertiary care centre between March 2019 and February 2020. Serum markers included brain naturetic peptide (BNP), cardiac troponin-T (cTnT), cystatin-C (cys-C), soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), Total Anti-Oxidant status (TAO) and malondialdehyde (MAO). Main outcome measures were adverse maternal outcomes defined as eclampsia, pulmonary oedema, acute kidney injury, placental abruption and HELLP syndrome. RESULTS: Adverse maternal outcomes occurred in 93(37.2%, 95% CI: 31.2%-43.6%) of the 250 women with severe pre-eclampsia included in the study, including 21 with pulmonary oedema, 25 with acute kidney injury and 36 with eclampsia. BNP levels were higher among women who developed pulmonary oedema (55.4 pg/mL vs 42.0 pg/mL, p = 0.008). TAO levels were higher in women who developed eclampsia (4.6 mM, IQR 3.1-5.7, p < 0.001) and acute kidney injury (4.1 mM, IQR 3.2-6.3, p = 0.002) compared to those who did not develop any complications (2.93 mM, IQR 2.3-4.1). CONCLUSIONS: Even though the endothelial dysfunction and oxidative stress biomarkers were associated with development of preeclampsia, it may have limited utility in identifying women who might develop adverse outcomes.

Migration of Ventriculoperitoneal Shunt to the Uterus in a Child: A Case Report.

BACKGROUND: A ventriculoperitoneal shunt (VPS) is usually placed inside the peritoneal cavity for cerebrospinal fluid drainage. Rarely, it can migrate to various pelvic visceral organs. Inside the pelvis, the distal end of the shunt can perforate anywhere from the uterus or adnexa to the vulva, and migration through the uterus is extremely rare. CASE: A three-and-a-half-year-old girl presented with a cerebrospinal fluid leak through the vagina after uterine perforation by a VPS. The diagnosis was made with an ultrasound. Her symptoms resolved after revision surgery. CONCLUSION: In a patient with a VPS in situ, presenting with a watery fluid leak through the vagina, perforation of the fornix or uterus must always be kept in mind. Timely diagnosis and intervention can result in the prevention of complications.

Diagnostic Accuracy of Hysteroscopic Scoring System in Predicting Endometrial Malignancy and Atypical Endometrial Hyperplasia.

AIMS AND OBJECTIVES: The aim of this study was to determine the diagnostic accuracy of a hysteroscopic scoring system in predicting endometrial cancer and endometrial hyperplasia with atypia. MATERIALS AND METHODS: This is a prospective study involving 95 peri and postmenopausal women with abnormal uterine bleeding who underwent hysteroscopic-guided endometrial biopsy. After the calculation of hysteroscopic score, biopsy was obtained and sent for histopathological examination. Hysteroscopic diagnosis of carcinoma endometrium was made when the total score was ≥16 and a score ≥7 supported a diagnosis of endometrial hyperplasia with atypia. RESULTS: Out of the 95 women, 46 (48.4%) women had postmenopausal bleeding. The mean age of women was 50.4 ± 10.3 years. Eight women were diagnosed to have endometrial cancer and eight had endometrial hyperplasia with atypia on histopathological examination. Using a hysteroscopy score ≥16, the sensitivity and specificity were found to be 62.5% and 90.8%, respectively, for diagnosing endometrial cancer. Hysteroscopy score ≥9 was found to be a better cutoff for diagnosing endometrial cancer using Youden index. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for diagnosing endometrial cancer with score ≥9 was 100%, 67.8%, 22.2%, and 100%, respectively. The sensitivity, specificity, PPV, and NPV for diagnosing endometrial hyperplasia with atypia with score ≥7 was found to be 75%, 58.6%, 14.3%, and 96.2%, respectively. CONCLUSION: The hysteroscopic scoring system has a good diagnostic performance when a cutoff score ≥9 is used in predicting endometrial cancer. However, the scoring system has lower diagnostic accuracy in predicting endometrial hyperplasia with atypia.

Comparison of Bipolar Ball Endometrial Ablation and Transcervical Resection of the Endometrium in the Treatment of Heavy Menstrual Bleeding: A Randomized Clinical Trial.

OBJECTIVES: To compare the operative time, effectiveness, and patient satisfaction between ball endometrial ablation and transcervical resection of the endometrium (TCRE) using a bipolar resectoscope. MATERIALS AND METHODS: Forty-four women with heavy menstrual bleeding who were unresponsive to at least 3 months' medical management were included in this randomized, controlled clinical trial. After randomization, patients underwent either TCRE or ball endometrial ablation using a bipolar resectoscope. The operative time, fluid deficit, and postoperative pain were recorded. The patients were evaluated postoperatively at 3, 6, and 12 months after surgery. Patient satisfaction, amenorrhea rate, reintervention rate, and pictorial blood-loss-assessment chart (PBAC) score were compared between the two groups. RESULTS: The mean operative time in ball endometrial ablation group was 11.17 ± 2.24 min and in TCRE group was 22.33 ± 5.26 min (P < 0.001). There was no significant difference in the postoperative PBAC score, amenorrhea rates, patient satisfaction, and need for reintervention between the two groups. CONCLUSION: Operative time with ball endometrial ablation is significantly less when compared to TCRE when using a bipolar resectoscope.

Postpartum depression and its risk factors in women with a potentially life-threatening complication.

OBJECTIVE: To assess the incidence of postpartum depression (PPD) and its risk factors in women with potentially life-threatening complications. METHODS: Eight hundred and ninety women admitted to a tertiary center in South India with potentially life-threatening complications were recruited for the study. Within seven days of delivery, women underwent mental health assessments using the EPDS and PHQ-9 scale. Counseling was provided and follow-up assessment carried out at 3 months postpartum. Bivariate and multivariate analysis was done to assess the association of risk factors to depression. RESULTS: PPD was observed in 21% of the study cohort. Women with no formal education (OR -2.66, 95% CI: 1.10- 6.40) and those who had a stillbirth (OR 2.48, 95%CI: 1.57-3.93) were found to be associated with PPD after adjusting for other factors. Occurrence of an obstetric near-miss event did not increase the risk of depression. Most women recovered with postnatal counseling, with only three requiring medication at the end of 3 months. CONCLUSION: One in five women who develop potentially life-threatening complications developed PPD. A strategy of screening focused on this high-risk group, especially in low resource settings, can lead to early recognition and treatment. This in turn can lead to a reduction in the long-term morbidity associated with PPD.

Maternal-fetal outcome in pregnancies complicated with non-cirrhotic portal hypertension: experience from a Tertiary Centre in South India.

OBJECTIVE: To assess the maternal and perinatal outcomes of pregnant women with non-cirrhotic portal hypertension (NCPH). METHODS: This was an observational study done by retrieving the records of pregnant women with non-cirrhotic portal hypertension admitted to a tertiary hospital in South India, over a 9-year study period. Data regarding the clinical course, complications during pregnancy, labor, and delivery details were reviewed. We also compared the outcomes among women with non-cirrhotic portal fibrosis (NCPF) with extrahepatic portal vein obstruction (EHPVO). RESULTS: During the study period, portal hypertension was noted in 0.07%(n = 108) of the pregnancies and 74.1% of them had NCPH. The diagnosis was made for the first time in 54.7% of them when presented with pancytopenia or splenomegaly. Variceal bleeding complicated 25% of the pregnancies in women with NCPH pregnancies, with three among them having a massive bleed. Eighteen among them underwent endoscopy following bleeding; variceal banding procedure was performed in nine of them without any complications. Preterm birth was the most common (20.6%) obstetric complication. There was one maternal death from severe sepsis, acute kidney injury, and disseminated intravascular coagulation, following a massive variceal bleed. Obstetric outcomes and medical complications were similar in women with NCPF and EHPVO. Perinatal loss was comparable in both the groups (14.3% vs. 9.6%, p = 0.417) CONCLUSION: Multidisciplinary team approach, with optimal and timely intervention with intensive monitoring, can reduce the morbidity and help achieve an optimal maternal-perinatal outcome in pregnancies complicated with portal hypertension.

Referral chain of patients with obstetric emergency from primary care to tertiary care: A gap analysis.

BACKGROUND: The referral system plays a crucial role in antenatal care and childbearing by providing access to emergency obstetric care. Excess referral from primary care and bypassing secondary levels of care leads to overcrowding of high risk and normal mothers in tertiary centers. Hence, this study aims to assess the gaps in the referral of patients with obstetric emergency from primary care to tertiary care. METHODOLOGY: In this hospital-based descriptive study, all obstetric patients referred to the Obstetric emergency facility and admitted in postnatal wards during the study period were included. They were interviewed using a pretested questionnaire. Data entry was performed using EpiData version 3.1 and analysis was done using SPSS version 22 software. RESULTS: Of the 505 eligible women who attended the facility, 286 (56%) were referred from other institutions, while 44% were self-referred. Among those referred, one-third were from tertiary level facility and 40% from primary care facility. More than half of the referral was through verbal communication to the patient (60%); only one-third had referral slips. Around 40.4% chose bus and private vehicles (37.6%) as their means of transport; only around 10% traveled in 108 ambulances. CONCLUSIONS: Measures to improve the capacity building at primary setting, hierarchy of referral, quality of documentation, and emergency transport mechanism for obstetric patients are vital. The deficits identified in the existing referral system will be useful to give feedback to the health systems of the neighboring regions on emergency obstetrics referrals and to propose referral guidelines.

Efficacy and safety of Tramadol as an analgesic in women undergoing vaginoscopic hysteroscopy: a randomized placebo-controlled trial.

Pain or discomfort during the hysteroscopy remains a challenge even after the introduction of small calibre instruments and vaginoscopic techniques. Tramadol, a centrally acting analgesic, is one among the medications used to reduce pain; however, the experience with its use in the vaginoscopic technique is limited. This was a randomised double-blind placebo-controlled trial conducted to study the effectiveness of oral Tramadol as an analgesic in 100 women undergoing diagnostic vaginoscopic hysteroscopy. Median pain score assessed by the Visual Analogue Scale was lower in the study group compared to the placebo group during the procedure (7 versus 8; p < .001) and immediately after the procedure (6 versus 7; p < .001) Ease of entry, procedure entry time and the adverse effects were similar in both the groups. Administration of oral Tramadol 50 mg, 1 h prior to the procedure may be a safe and effective analgesic in women undergoing diagnostic vaginoscopic hysteroscopy.Impact statementWhat is already known on this subject? Even with the use of newer hysteroscopes with small calibres and vaginoscopic techniques, pain and discomfort to the patient during negotiation through the cervix remain the main challenge to the surgeon. Among the several medications reported to reduce pain during the procedure, Tramadol a centrally acting drug with dual analgesic action, both by the µ opioid receptor agonist action and by the inhibiting uptake of serotonin and norepinephrine, can be used. However, studies using oral Tramadol during vaginoscopic hysteroscopy are limited.What do the results of this study add? The median pain score assessed by the Visual Analogue Scale was lower in the study group compared to the placebo group during the procedure (7 versus 8; p < .001) and immediately after the procedure (6 versus 7; p < .001). Ease of entry, procedure entry time and the adverse effects were similar in both the groups.What are the implications of these findings for clinical practice and/or further research? This study suggests that administration of oral Tramadol 50 mg, 1 h prior to the procedure, may be used as a safe and effective analgesic in women undergoing diagnostic vaginoscopic hysteroscopy. Future trial with a larger sample size is required to confirm the tolerability of its use, as the incidence of adverse effects was low in the study.

Gestational impaired glucose tolerance (GIGT)-induced suppression of fetal thyroid secretion: effect on fetal outcome.

INTRODUCTION: Gestational impaired glucose tolerance (GIGT) is a milder form of gestational diabetes mellitus (GDM), which is often poorly managed. Although, GDM is known to be associated with increased incidence of thyroid dysfunction, no study has been done to study the effect of GIGT on thyroid status and its effect on fetal outcome. Here, we carried out a study to assess thyroid function and glycemic status in both maternal and cord blood of the subjects with GIGT, and to find their association with the fetal outcome. MATERIALS AND METHODS: Women who came to the hospital for safe confinement during 37-40th weeks of gestation were recruited in the study. Based on the 2 hours post prandial blood glucose levels with 75 grams OGTT, done at 24-28 weeks of gestation, all the subjects were stratified into two groups: (1) Cases or GIGT group - women with blood glucose levels between 120 and 140 mg/dl and (2) Controls - women with blood glucose levels of less than 120 mg/dl. Three milliliters of venous blood was collected from mothers and 3 ml of cord blood was collected during delivery. New-borns were assessed for birth weight, head circumference, abdominal circumference, thigh circumference, and crown-heel length. Glycated hemoglobin was carried out using immunoturbidimetry (DiaSys Diagnostic Systems GmbH, Holzheim, Germany) and fructosamine was estimated using dye binding method (Biosystems, Spain). Estimation of total T3 (TT3), free T3 (FT3), total T4 (TT4), free T4 (FT4), and TSH was done by chemiluminescence in Siemens Advia Centaur CP using competitive immunoassay. RESULTS: Although within the normal reference range, GIGT mothers had higher concentration of free and total T4 than controls. Cord fructosamine levels were significantly higher in babies of GIGT mothers than controls, indicating the reflection of maternal hyperglycemia. There was a positive correlation between the maternal glycated hemoglobin and cord blood fructosamine in the GIGT group. Statistically significant lower levels of total T3 and T4 with high TSH levels were found in babies with GIGT mothers, indicating the suppressive effect of maternal hyperglycemia on fetal thyroid function. Birth weight, head circumference, and thigh circumference were significantly higher in babies born to mothers with GIGT, which may be a combined effect of maternal hyperglycemia and fetal thyroid suppression. CONCLUSIONS: Maternal hyperglycemia, even in milder form of GIGT may cause suppression of fetal thyroid function. Both these factors may predispose to change in fetal anthropometry, leading to a large baby. Therefore, it is recommended to evaluate maternal and cord thyroid function for timely management strategies.

Addition of power Doppler to grey scale transvaginal ultrasonography for improving the prediction of endometrial pathology in perimenopausal women with abnormal uterine bleeding.

BACKGROUND & OBJECTIVES: Transvaginal ultrasonography (TVS) is a non-invasive procedure and can be used as a screening tool among women with abnormal uterine bleeding (AUB). Power Doppler is useful in depicting the vascular architecture better than the conventional Doppler. Hence, this study was conducted to evaluate whether addition of power Doppler to grey scale TVS can replace invasive hysteroscopy for the prediction of endometrial pathology in perimenopausal women with AUB. METHODS: One hundred women (>45 yr) with perimenopausal AUB underwent evaluation with TVS, power Doppler and hysteroscopy-guided biopsy after a detailed history and examination. Histopathology was considered as gold standard and other tools such as grey scale TVS with power Doppler and hysteroscopy were compared with it. RESULTS: Fifty six per cent women had no vascularity on power Doppler. Among those who had vascularity, the vascular patterns noted were single-vessel in 18 per cent, scattered-vessel in 15 per cent and multiple-vessel in 11 per cent. The sensitivity, specificity, positive predictive value and negative predictive value of TVS-endometrial thickness with power Doppler in detecting hyperplasia were 50, 86.5, 13.3 and 97.6 per cent, respectively, whereas the same for hysteroscopy were 100, 97.6, 88.1 and 100 per cent, respectively. INTERPRETATION & CONCLUSIONS: Addition of power Doppler to grey scale TVS improved the specificity and negative predictive value almost comparable to hysteroscopy for evaluation of AUB, but sensitivity and positive predictive value remained poor.

Effect of cervical priming with misoprostol on cervical entry in women undergoing vaginoscopic hysteroscopy for evaluation of abnormal uterine bleeding: a randomized controlled trial.

OBJECTIVE: To study the effect of cervical priming with misoprostol on cervical entry in women undergoing diagnostic hysteroscopy for evaluation of abnormal uterine bleeding. METHODS: Randomized controlled trial conducted in teaching hospital and tertiary referral center on 122 women requiring diagnostic hysteroscopy for evaluation of abnormal uterine bleeding. Women were randomized into two equal groups (n = 122). Study group received 200-µg vaginal misoprostol, 3 h prior to vaginoscopic hysteroscopy. No drug was used in control group. No analgesia or anesthesia was used in either group. Outcome measure included (i) ease of cervical entry (Likert scale), and (ii) pain scoring (Visual Analog Scale) and procedural entry time. RESULTS: Forty-six (75.41%) patients in the study group and 17 (27.87%) in control group had easy or very easy entry (Likert scale-4 and 5) (p < 0.001). Median pain scoring by VAS and the median procedural entry time was significantly lower in the study group compared to the control group (p < 0.001). CONCLUSION: Use of 200-µg vaginal misoprostol, administered vaginally 3 h before diagnostic vaginoscopic hysteroscopy, was found to be simple and effective method of cervical priming in facilitating cervical entry with minimal side effects. Clinical Trial registry of India (CTRI): (CTRI/2015/04/005666) (website: http://ctri.nic.in ).