Understanding biological mechanisms underlying adverse birth outcomes in developing countries: protocol for a prospective cohort (AMANHI bio-banking) study.

OBJECTIVES: The AMANHI study aims to seek for biomarkers as predictors of important pregnancy-related outcomes, and establish a biobank in developing countries for future research as new methods and technologies become available. METHODS: AMANHI is using harmonised protocols to enrol 3000 women in early pregnancies (8-19 weeks of gestation) for population-based follow-up in pregnancy up to 42 days postpartum in Bangladesh, Pakistan and Tanzania, with collection taking place between August 2014 and June 2016. Urine pregnancy tests will be used to confirm reported or suspected pregnancies for screening ultrasound by trained sonographers to accurately date the pregnancy. Trained study field workers will collect very detailed phenotypic and epidemiological data from the pregnant woman and her family at scheduled home visits during pregnancy (enrolment, 24-28 weeks, 32-36 weeks & 38+ weeks) and postpartum (days 0-6 or 42-60). Trained phlebotomists will collect maternal and umbilical blood samples, centrifuge and obtain aliquots of serum, plasma and the buffy coat for storage. They will also measure HbA1C and collect a dried spot sample of whole blood. Maternal urine samples will also be collected and stored, alongside placenta, umbilical cord tissue and membrane samples, which will both be frozen and prepared for histology examination. Maternal and newborn stool (for microbiota) as well as paternal and newborn saliva samples (for DNA extraction) will also be collected. All samples will be stored at -80°C in the biobank in each of the three sites. These samples will be linked to numerous epidemiological and phenotypic data with unique study identification numbers. IMPORTANCE OF THE STUDY: AMANHI biobank proves that biobanking is feasible to implement in LMICs, but recognises that biobank creation is only the first step in addressing current global challenges.

Multiple repeat cesarean sections: operative difficulties, maternal complications and outcome.

OBJECTIVE: To determine maternal/neonatal complications and outcome in patients with multiple repeat cesarean sections (CSs). STUDY DESIGN: A retrospective case-control study of 144 pregnant women with > or = 4 cesarean sections was compared with a control group of 288 women having 2-3 cesarean sections for maternal, operative and neonatal complications. RESULTS: The study patients had longer operating times (p = 0.0001) due to severe adhesions (p = 0.0005), with increased blood loss and blood transfusion (p = 0.0001). Rupture of the uterus (p = 0.0015), placenta previa (p = 0.0372), gestational age at delivery (p < 0.0002), preterm birth (p = 0.0497) and Apgar scores < 7 at 5 minutes (p = 0.0140) were significant in the study group. There was no significant difference of placenta accreta, bladder and bowel injury, cesarean hysterectomy, wound infection and postoperative pyrexia between the 2 groups. Among the neonates of the 2 groups, NICU admissions, small-for-gestational-age birth weights, large-for-gestational-age birth weights and perinatal mortality were similar. No mother died in the series. The incidence of a single major complication was higher in women with > or = 4 cesarean deliveries (p = 0.0011). CONCLUSION: Repeated CS increases the risk of uterine rupture and intraoperative complications, making these patients a high-risk group. No absolute upper limit for the number of repeat cesarean deliveries can be given. Patients must be informed of the risks of multiple CSs and encouraged to have tubal ligation.

Shoulder dystocia in a 16-year experience in a teaching hospital.

OBJECTIVE: To determine incidence of shoulder dystocia and evaluate associated maternal, obstetric and fetal risk factors. STUDY DESIGN: Records of patients and neonates with shoulder dystocia at delivery were studied for demography, labor complications and neonatal outcome. Two control cases who delivered vaginally following each patient were selected that matched the maternal demography of the patient group. Incidence of shoulder dystocia and related risk factors were analyzed and compared with controls. Maternal and fetal morbidity and mortality were determined. RESULTS: Among 32,312 singleton vaginal deliveries, 104 cases of shoulder dystocia were recorded. Several reported high-risk factors related to increased incidence of shoulder dystocia reported were confirmed by the study, although 26% of the neonates with shoulder dystocia weighed < 4,000 g. Postpartum hemorrhage and third-degree perineal tear were significant complications; neonatal brachial plexus injury occurred in 20%, clavicle and humerus fracture in 10.6% and neonate asphyxiation in 8.6%. No maternal death occurred; high perinatal mortality was no surprise. CONCLUSION: Training clinicians to manage shoulder dystocia is difficult because of rare occurrence and lack of standardized management; simulation training with mannequins is helpful. Obstetricians should formulate a management plan and act promptly and decisively when confronted with this complication.

Pregnancy outcome in patients with homozygous sickle cell disease in a university hospital, Eastern Saudi Arabia.

OBJECTIVE: To evaluate the maternal and fetal outcome in pregnant women with sickle cell disease and to highlight the complications encountered during pregnancy and delivery at a university hospital in the Eastern Saudi Arabia. STUDY DESIGN: A retrospective study of 255 pregnancies in 145 patients with sickle cell disease (SCD) over an 8-year-period analyzed the perinatal complications and maternal and fetal outcomes compared with a control group of 500 Saudi females with the normal hemoglobin phenotype selected randomly that matched for age, parity and delivered during the study period. RESULTS: The incidence of SCD was 1.3% of all deliveries with one maternal death (0.4%) and a perinatal mortality rate of 78.2/1,000 deliveries in the series. The major maternal complications in the 255 pregnancies were anemia 84.3%, sickle cell crisis 44.3% (26.6% painful and 17.7% hemolytic crises), infection 45.9%, fetal growth restriction 20.1%, preterm delivery 12.6%, and pregnancy-induced hypertension 10.6%. Blood transfusion was necessary in 34% pregnancies. Stillbirths accounted for 63% of the perinatal mortality. CONCLUSIONS: Saudi women with SCD are at a greater risk of morbidity and mortality in pregnancy than previously reported, with a high perinatal mortality rate. Early booking, meticulous antenatal care and supervised hospital delivery will improve the maternal and fetal outcomes in these patients.

Obstetric and gynecologic complications in women with Marfan syndrome.

OBJECTIVE: To analyze the maternal and fetal outcomes of pregnancy and gynecologic problems in women with Marfan syndrome. STUDY DESIGN: The outcomes of 14 pregnancies in 4 women with Marfan syndrome were prospectively observed between January 1988 and December 2000. The cardiovascular and obstetric complications were analyzed. During pregnancy all the patients were carefully monitored with serial echocardiography and close attention to symptoms. RESULTS: Of the 14 pregnancies, 5 (35.7%) ended in abortion, and 3 of them occurred in the early second trimester due to cervical incompetence. Premature onset of labor occurred in 2 pregnancies at 31 and 34 weeks. Postpartum hemorrhage complicated 3 deliveries, and inversion of the uterus occurred in 1 patient. Significant cardiovascular complications occurred in 2 patients, who required surgical correction of the aortic aneurysm and replacement of the aortic valve. In one patient the operation was performed within hours of vaginal delivery, and the other patient underwent surgery 8 weeks postpartum. No maternal death occurred in the study. One infant in the series was diagnosed as having Marfan syndrome. A premature infant delivered at 31 weeks died on the second day of life. CONCLUSION: Women with Marfan syndrome are at high risk of aortic dissection in pregnancy even in the absence of preconceptional aortic root dilatation. Obstetric complications in patients with this condition have been underreported in the past. Women with aortic root dilatation of < 40 mm usually tolerate pregnancy well, with good maternal and fetal outcomes. Women with Marfan syndrome should be counseled regarding the risk of pregnancy to both mother and fetus. Patients who have cardiac decompensation or aortic dilatation > 40 mm are advised to avoid pregnancy.