Clinical profile & outcome of H1N1 infected pregnant women in a tertiary care teaching hospital of northern India.

BACKGROUND & OBJECTIVES: H1N1 influenza is a recognized cause of febrile respiratory infection worldwide. There are not many studies to show its impact on pregnancy. In the present study we aimed to assess clinical characteristics, obstetric and perinatal outcome of pregnant women with H1N1 infection. METHODS: A retrospective observational study was conducted at a tertiary care teaching hospital in New Delhi, India. A total of 24 pregnant women microbiologically positive for H1N1 were included. Maternal characteristics and outcome were recorded. Perinatal outcome which was defined as presence of any of the indicators such as abortion, preterm delivery, intrauterine death and neo natal death was noted. RESULTS: The mean age of the study group was 25.2 ± 3 yr with a mean gestational age of 34.9 ± 4.6 wk. Six patients (25%) had associated co-morbidities. Nine patients (37.5%) presented within 48 h of onset of symptoms and 15 (62.5%) reported after 48 h. In 17 (70.83%) patients treatment was delayed by >48 h. ICU admission was needed in 20.8 per cent patients and mortality rates was 8.3 per cent. There were seven cases of adverse perinatal outcome. INTERPRETATION & CONCLUSIONS: The presenting symptoms of pregnant women with H1N1 were similar to that of general population. Acquiring infection in late trimester, late initiation of antiviral treatment and presence of co-morbid illness were high risk factors for developing critical illness. Pregnant women with suspected H1N1 influenza should be started on antiviral therapy at the earliest. This is likely to help reduce the ICU admission rates and mortalities in this group of women.

Impact of injectable progestogen contraception in early puerperium on lactation and infant health.

INTRODUCTION: Unmet need for family planning approaches 40% or higher and many women are at risk of unintended pregnancy. Progesterone contraception after birth is frequently recommended, but concern remain of inhibition of lactation or effects on infant health. In present study we aimed to evaluate impact of short term use of injectable depot medroxy progesterone acetate (DMPA) if given in early post partum period on infant health and breast feeding performance. MATERIAL AND METHODS: A prospective case control study was conducted and 250 women immediately after delivery were recruited in the study. 150 women who were recruited as study group received Inj. DMPA 150 mg intra muscularly after initiation of lactation before discharge from hospital (Day 2-Day 10 of their delivery). 100 post partum women, not using hormonal contraception were taken as controls. All the subjects were followed to complete a full 6 months follow up. Duration and frequency of lactation, gain in weight, gain in height and any illness spells in the infant were noted at 6 weeks, 3 months and 6 months follow up. In the study group 100 subjects completed 6 months follow-up. The statistical analysis was carried out by using SPSS software version 7. The statistical technique used was z score(significance shown by z score> 1.96) and repeated measure analysis (two way Anova technique). RESULTS: Hundred percent of primigravidas in the study group and 95% in the control group were satisfied with their lactation amount. The average gain in height was comparable in both study and control group {4.36±0.56 vs 4.33±0.54 (z score 0.38) at 6 weeks, 12.44±0.73 vs 12.40±0.71 (z score 0.39) at 3 months 17.30±0.91 vs 17.28±0.83 (z score 0.16) at 6 months}. Similarly average gain in weight was also not significantly different in two groups {0.89±0.11 vs 0.93±0.10 (z score 0.71) at 6 weeks, 1.77±0.17 vs 1.78±0.16 (z score 1.07) at 3 months and 3.53±0.30 vs 3.46±0.33 (z score 1.19) at 6 months}. The results were comparable with other studies. CONCLUSION: Injectable DMPA use as a contraceptive in the immediate post partum period was found to be a safe and effective alternate method with no deleterious effect on mother's milk and infant's growth.

Minimal effective dose of mifepristone for medical abortion.

The aim of this study is to compare the effectiveness of 100 mg versus 200 mg mifepristone along with misoprostol for medical abortion in gestation upto 56 days. This is a prospective controlled study. Eighty women seeking medical abortion with a gestation up to 56 days were included in the study. The women were randomly allotted into two groups. They received 100 mg/200 mg mifepristone on day 1 followed by 800 mcg misoprostol two days later. Women who had not aborted completely by day 14, received a repeat dose of 400 mcg misoprostol and were evaluated on day 21 for completeness of the procedure. Five women in both the groups had incomplete abortion by day 14 (12.5%), while one woman in the test group had to undergo dilatation and evacuation on day 3 due to excessive bleeding. By repeating a second dose of misoprostol, all of them aborted completely and the complete abortion rates were markedly improved from 85% and 87.5% in the test and the control group, respectively to 97.5% and 100%, respectively. It may be concluded that 100 mg mifepristone is as effective as 200 mg and appears to be the lowest effective dose for medical abortion.

Management of complete heart block during pregnancy.

A 22-year-old second gravida presented to the antenatal clinic at 28 weeks of gestation with frequent fainting attacks (2-3 episodes/day), palpitations and dyspnea (New York Heart Association Functional Classification II). Her pulse rate was 40 b.p.m. A 12-lead electrocardiogram and 24-h Holter revealed complete heart block. A transvenous permanent pacemaker (ventricular demand rate-responsive), paced at a rate of 60 pulses/min, was successfully implanted. A multidisciplinary approach was taken and the patient delivered a healthy baby boy of 2.8 kg at 38 weeks. She remained asymptomatic and was discharged in good condition. Management varies from expectant management to temporary pacemaker insertion to permanent pacing during pregnancy. In a young patient with sinus bradycardia, the primary criterion for a pacemaker is the concurrent observation of a symptom (e.g., syncope) with bradycardia (e.g., heart rate 35-40 b.p.m. or asystole for 3 s). Symptomatic pregnant women should always be counseled for a permanent pacemaker.

Phaeochromocytoma in pregnancy: safe vaginal delivery, is it possible?

Pheochromocytoma in pregnancy is rare (1 in 50,000 full term pregnancies). Recognition of the condition is central to improving outcome (maternal and foetal mortality is reduced from 58% and 56%, respectively to 2% and 11-15%, respectively). An antenatal patient in third trimester diagnosed as pheochromocytoma has been described. Diagnosis of pheochromocytoma was confirmed by urinary VMA levels and demonstration of right adrenal mass on ultrasound. A multidisciplinary approach was used and the patient received antihypertensives for 10 days. Vaginal delivery was conducted under epidural analgesia and the patient was kept under close surveillance. She delivered a healthy baby girl weighing 2.5 kg. The intrapartum and the postpartum period were uneventful. Adrenalectomy was done at 6 weeks postpartum. Using multidisciplinary approach and individualised management decreases both maternal and foetal morbidity and mortality. Selected multigravidae cases and those with previous history of short uncomplicated labour, may be considered for vaginal delivery under epidural analgesia and with back up facilities available to manage hypertensive crisis.

A randomised comparison between sublingual, oral and vaginal route of misoprostol for pre-abortion cervical ripening in first-trimester pregnancy termination under local anaesthesia.

OBJECTIVE: To compare efficacy of sublingual (S/L), oral and vaginal routes of misoprostol administration for cervical priming before suction evacuation (SE) under local anaesthesia. METHODS: In a prospective randomised clinical trial, 200 women in the first trimester of pregnancy were randomised into four groups of 50 each. Patients in control group did not receive any medication before SE while other treatment groups received 400 microg of misoprostol three hours prior to SE either by sublingual/oral or by vaginal route. Main outcome measure was basal cervical dilatation while the secondary outcome measures were operative blood loss, time duration of surgery, patient satisfaction, pain perception and adverse effects. RESULTS: Sublingual group had a higher dilatation (9.9 +/- 2.1 mm; P < 0.001) and lower time duration of surgery (3.6 +/- 1.0 min; P < 0.01) as compared to oral (8.2 +/- 2.6 mm, 4.9 +/- 1.7 min) or vaginal routes (7.6 +/- 2.6 mm, 5.2 +/- 1.8 min). Mean pain score of the sublingual group was significantly lower (2.4 + 1.3; P < 0.001) as compared to oral (3.4 +/- 1.3) or vaginal routes (3.6 +/- 1.2). Patient acceptability was higher for sublingual (53 of 150) and oral routes (62 of 150) as compared to vaginal (35 of 150) route. CONCLUSION: Sublingual route was significantly more effective than oral or vaginal administration of misoprostol for cervical dilatation. To the best of our knowledge, this is the first study to simultaneously compare the efficacy of sublingual, oral and vaginal routes of misoprostol for cervical priming before SE.

Sublingual versus vaginal route of misoprostol for cervical ripening prior to surgical termination of first trimester abortions.

BACKGROUND: Sublingual and vaginal routes of misoprostol have been found to be effective for pharmacological ripening prior to surgical termination of first trimester abortions. We conducted this study to compare the effectiveness and acceptability of sublingual versus vaginal route of misoprostol for cervical priming prior to vacuum aspiration (VA). METHODS: In this prospective clinical trial, a total of 100 women with period of gestation between 6 and 12 weeks scheduled for day surgery abortion were sequentially allocated into two groups of 50 each. All participating women received 400 microg of misoprostol 3 h prior to VA either by sublingual (self-administered at home) or by vaginal route (inserted by the doctor in hospital) after wetting the tablet with water. RESULTS: Demographic characteristics of both the groups were comparable. For all periods of gestation, sublingual misoprostol significantly improved cervical dilatation (p<0.001) and reduced the time duration of surgery (p<0.001) compared to vaginal group without increasing the side effects. Mean pain score of the sublingual group was 2.7+/-1.1 as compared to 3.2+/-1.6 of the vaginal group (p=0.57). Misoprostol tablet was found intact in the vagina of three patients and was only partially absorbed amongst five patients at the time of VA. CONCLUSION: Sublingual route is an effective and convenient alternative to vaginal administration of misoprostol for cervical dilatation. It can be conveniently self-administered at home thereby decreasing hospital stay and cost. It also has a good patient acceptability rate.

Comparison between the sublingual and oral route of misoprostol for pre-abortion cervical priming in first trimester abortions.

BACKGROUND: Misoprostol has been used for achieving cervical priming before suction evacuation (SE) by the oral or vaginal route, although both routes have their shortcomings. We evaluated the efficacy of the sublingual versus oral route of misoprostol for cervical priming before SE. METHODS: A prospective clinical trial was carried out in 100 women with a period of gestation of between 6 and 12 weeks who were sequentially allocated to two groups of 50 each. Both groups received 400 microg of misoprostol 3 h prior to SE by either the sublingual or the oral route. RESULTS: Demographically, both groups were similar. For all periods of gestation, sublingual misoprostol significantly improved cervical dilation (P<0.001) with a reduction in duration of surgery (P=0.024) compared with the oral route. Mean (+/- SD) pain scores for the sublingual and oral groups were similar (2.6 +/- 1.4 versus 3.5 +/- 1.1). No major complications occurred in either of the two groups. CONCLUSION: the sublingual route is an effective alternative to oral administration of misoprostol for cervical dilation. To the best of our knowledge, this is the first study to compare the efficacy of the sublingual versus the oral route of misoprostol for cervical priming before SE.

Role of sublingual misoprostol for cervical ripening prior to vacuum aspiration in first trimester interruption of pregnancy.

This is a prospective randomized clinical trial evaluating, for the first time, the effectiveness of sublingual route of misoprostol for cervical priming prior to vacuum aspiration (VA). The trial included 100 women seeking first trimester abortion who were sequentially randomized into two groups of 50 each. Patients of study group received 400 microg sublingual misoprostol 3 h prior to VA while those of the control group did not receive any premedication for cervical ripening. For all periods of gestation between 6 and 12 weeks, misoprostol significantly reduced pain score, blood loss, time duration and rate of complications without increasing the side effects. Sublingual misoprostol is an effective alternative to mechanical cervical dilatation. It can be self-administered and has a good patient-acceptability rate. As no study has evaluated the role of sublingual route of misoprostol for cervical priming before VA, wider studies should be done to advocate its routine use.