Efficacy of fixed-dose phenylephrine bolus for treating post-spinal hypotension: Comparison between pre-eclamptics and normotensives.

Background and Aims: Pre-eclamptic parturients may have an exaggerated response to vasopressors. This study compares the efficacy of a 50 µg fixed bolus of phenylephrine for treatment of post-spinal hypotension in pre-eclamptic versus normotensive parturients. Material and Methods: After written informed consent and ethics committee approval, 30 normotensive and 30 pre-eclamptic parturients between 18 and 40 years with singleton term pregnancy about to undergo cesarean section (CS) under spinal anesthesia were included. Post-spinal hypotension was treated with a 50 µg fixed bolus of phenylephrine. The cumulative dose of phenylephrine, the number of boluses, and the median dose required to treat the first hypotensive episode, total number of hypotensive episodes, maternal side effects, neonatal appearance, pulse, grimace, activity, and respiration (APGAR) scores, and umbilical arterial cord blood pH were noted. Statistical analysis was done using Student's t-test, Mann-Whitney U-test, Chi-square test/Fisher's exact test as appropriate. A P <0.05 was considered significant. Results: The cumulative dose and number of boluses of phenylephrine required to treat post-spinal hypotension were comparable. The median dose required to treat the first episode of post-spinal hypotension was also similar (p = 0.792). The time to develop the first hypotensive episode was significantly earlier for group N (p = 0.002). The efficacy of a single fixed bolus of 50 µg phenylephrine was similar in both groups (p = 1.000). Neonatal median APGAR scores at 1 min after birth were significantly higher for group N (p = 0.016). Conclusion: A fixed-dose bolus of 50 µg phenylephrine is safe and effective in treating post-spinal hypotension in pre-eclampsia. The efficacy of phenylephrine is comparable in pre-eclamptic and normotensive parturients.

An Evaluation of the Second Trimester Thyroid Function Test in Gestational Diabetes Mellitus: A Case-Control Study.

INTRODUCTION: Gestational diabetes mellitus (GDM) is defined as glucose intolerance in a female with its onset or first recognition during pregnancy. Females with GDM are at higher risk of developing antenatal complications like preeclampsia during pregnancy and increased risk of type 2 diabetes as well as cardiovascular disorders later in their life. Maternal thyroid changes in the first and second trimesters of pregnancy have been widely related to the risk of GDM. Hypothyroidism during pregnancy is associated with early and late complications like abortions, anaemia, gestational hypertension, placental abruption and postpartum haemorrhage, impaired infant neurodevelopment, and low birth weight. OBJECTIVES: This study aims to compare the thyroid function test (TFT) (serum fT3, fT4, TSH) and thyroid peroxidase antibody (anti TPO) between GDM and non GDM pregnant women in the second trimester and to correlate the adverse pregnancy outcomes with TFT in GDM and non GDM women. METHODS: A nested case-control study was done in the Department of Obstetrics and Gynaecology, Department of Endocrinology, Department of Paediatrics, University College of Medical Sciences, and Guru Teg Bahadur (GTB) Hospital, Delhi. About 350 pregnant women from 13 weeks till 28 weeks period of gestation were screened out of which 40 GDM and 40 non GDM women were selected after performing an oral glucose tolerance test (OGTT). A TFT and anti TPO test were compared between GDM and non GDM participants. Furthermore, various parameters like sociodemographic profile, mode of delivery, pregnancy outcomes, and adverse maternal and adverse neonatal outcomes were compared. CONCLUSION: The mean age of GDM women is found to be more than non GDM women. The mean TFT values are significantly lower in women with GDM as compared to non GDM women. In addition, higher values of anti TPO antibody (thyroid autoantibody) were found in the GDM group which aids in insulin resistance. Maternal complications like polyhydramnios, preterm labour, and pregnancy-induced hypertension were found to be more frequent in the GDM group compared to the non GDM group, but the results were statistically not significant. There was a higher incidence of caesarean delivery in the GDM group. Thus, we recommend the implementation of routine thyroid function profile testing in all antenatal females especially those who are at risk of developing GDM. Our study is one of the few Indian studies to evaluate the association of TFT in GDM, and we recommend similar research with a larger sample size and postnatal follow-up.

Use of point of care quality improvement methodology to improve newborn care, immediately after birth, at a tertiary care teaching hospital, in a resource constraint setting.

After birth, separation of mothers and newborn is a common practice in many hospitals in our country. After delivery, we take the normal newborn to the radiant warmer in the resuscitation area for routine care. This was the existing process of care at our hospital. The frontline delivery team undertook quality improvement initiative to understand and document factors creating challenges in delivering evidence-based practice of providing immediate skin-to-skin care (SSC), delayed cord clamp (DCC) and early breast feeding within 1 hour of birth. Some of the barriers identified were early newborn mother separation and late transfer of mother from delivery room to the observation area. Additionally, there was a challenge of high delivery load with variation in understanding and provision of SSC and drying on mother's abdomen. These made sustenance of improved care practices difficult. Using the Plan-Do-Study-Act (PDSA) approach some successful change ideas tested were pre-delivery counselling, avoiding separation of mother and newborn at birth by providing SSC and continuing it in the post-delivery observation area and getting family member's help in first breast feed. The delivery team adapted these successful change ideas by multiple iterations, group discussions and feedback. This resulted in improved and sustained compliance of pre-delivery counselling, SSC, DCC and initiating breast feed within 1 hour, from minimal compliance to a median compliance of 51%, 56%, 59% and 61%, respectively, over 36 months period. We undertook this quality improvement initiative at Delhi (India) at a tertiary care teaching hospital. The implementation of WHO recommended evidence-based practices benefitted more than 10 000 mother-newborn dyads annually over 2 years, using Point of Care Quality Improvement method. Implementation of evidence-based practice is possible in challenging situations using PDSA approach. The resultant contextualised processes are convenient and have better success at sustainability.

Role of repeat procalcitonin estimation at 48 hours for outcome in pregnancy associated sepsis: a prospective observational study.

OBJECTIVES: We assessed whether repeat procalcitonin (PCT) estimation has a role in detecting organ dysfunctions and mortality in pregnancy associated sepsis (PAS). METHODS: The study included 85 pregnant, post-abortal, and postpartum women with PAS, diagnosed using the quick Sequential Organ Failure Assessment criteria. Median interquartile range PCT levels were documented at admission and 48 hours later. Statistical comparisons were performed between the groups with non-severe and severe (≥1 organ failure) PAS, and between the survivor and mortality groups. The relationship between PCT and the number of organ failures was also assessed. RESULTS: Most of the subjects with PAS were young and in the postpartum period (mean age 26 years; postpartum 55%). Sixteen (19%) patients died due to PAS. Sixty-two patients (74%) had severe PAS at presentation. Bacteria were isolated on culture in 64% of the subjects. PCT levels at admission were higher in patients with severe PAS than in those who did not have severe PAS. At 48 hours, this difference was significant (P=0.014; severe PAS 2.23 ng/mL vs. non-severe PAS 0.20 ng/mL). Furthermore, the number of organ failures increased at 48 hours. The PCT levels were significantly higher in the mortality group than in the survivors' group at admission (8.31 ng/mL vs. 1.72 ng/mL), and the difference increased further at 48 hours (9.54 ng/mL vs. 1.37 ng/mL). CONCLUSION: Repeat PCT estimation at 48 hours could complement the clinical findings and enhance the prognostic value for PAS.

Serial Serum Lactic Acid in Pregnancy-Associated Sepsis for Maternal Outcome.

OBJECTIVE: To correlate serial monitoring of lactic acid in pregnancy-associated sepsis (PAS) subjects with maternal prognosis. METHODS: All pregnant, post-abortal (2 weeks) and postpartum women with suspected sepsis fulfilling any 2 of the Quick Sequential Organ Failure Assessment criteria were considered as cases. Lactic acid was measured at 0, 24 and 48 h of admission, and lactate clearance was calculated. RESULTS: The mean value of lactic acid was significantly higher in the Intensive Care Unit (ICU) group than the Non-ICU group at 0, 24, and 48 h with values being (6.00 ± 2.46 mmol/l vs 3.25 ± 1.92 mmol/l), (4.44 ± 2.24 mmol/l vs 2.91 ± 1.77 mmol/l) and (5.65 ± 2.91 mmol/l vs 2.99 ± 1.93 mmol/l), respectively. Lactic acid in the survivor group was significantly lower as compared to the mortality group (3.79 ± 0.32 mmol/l vs 7.3 ± 0.56 mmol/l). A cut-off of 3.8 mmol/l with area under the curve of 0.814 has a sensitivity of 84% and specificity of 68% for predicting ICU admission. The mean lactate clearance was 46% in cases who survived and 22.5% in cases who had mortality. When lactate clearance was 60%, no mortality was seen, whereas when there was 100% rise in lactic acid, they all had mortality. CONCLUSION: The mean lactic acid at 0, 24 and 48 hours was significantly higher in the ICU group as compared to the Non-ICU group. Serum lactic acid at zero hours of the presentation was significantly higher in ICU cases. Lactate clearance (fall) helps to prognosticate as fall of ≥ 60% lactic acid level is associated with 100% survival, whereas a rise of 100% in serum lactic acid is associated with 100% mortality.

Prediction of Gestational Diabetes from First Trimester Serum Adiponectin Levels in Indian Women.

INTRODUCTION: The prediction of gestational diabetes mellitus (GDM) by serum adiponectin levels has shown promise in Western literature. This study looks at the first trimester serum adiponectin levels as a predictor of gestational diabetes in Indian women. MATERIAL AND METHODS: A total of 450 pregnant women were screened at 11-- 13 weeks of gestation and serum samples were stored. All the women underwent an oral glucose tolerance test to diagnose GDM by International Association of Diabetes and Pregnancy study Group criteria at 24-- 28 weeks of gestation. Amongst these, 45 women who had developed GDM were compared with 45 controls. The first trimester serum adiponectin levels were compared between the two groups. RESULTS: Mean first trimester adiponectin in GDM and non-GDM group was 7.21 ± 2.49 µg/ml and 12.20 ± 2.91 µg/ml, respectively (P < 0.001). Logistic regression revealed that low adiponectin was the strongest independent risk factor followed by body mass index and HbA1c. Receiver operating characteristic curve revealed that a cut-off value of adiponectin of 9.10 µg/ml in the first trimester was associated with a sensitivity of 100% and specificity of 95.6% in predicting GDM. CONCLUSIONS: This is the first study from India which has studied the prediction of GDM by first trimester adiponectin levels. First trimester serum adiponectin may be a strong predictor of GDM in Asian Indian women.

Pure Primary Squamous Cell Carcinoma of Ovary - A Rare Case Report.

Primary Squamous Cell Carcinoma (SCC) is a rare tumour which arises in a mature cystic teratoma, endometrioma or Brenner tumour. The pure variety arises from metaplasia of surface epithelium of ovary and it is the rarest type. For optimal management no definitive treatment protocol is available till date. Also, there is no agreement concerning the postoperative therapy-chemotherapy or radiotherapy. We present a rare case of pure primary SCC of ovary which was managed by aggressive cytoreductive surgery followed by chemotherapy.

Admission Cardiotocography: A Predictor of Neonatal Outcome.

BACKGROUND: Screening for fetal distress is a big challenge for obstetricians. Labor admission test by cardiotocography (CTG) can be utilized to differentiate between mothers, in whom continuous fetal monitoring is needed and those who can be managed by intermittent auscultation. Admission CTG is commonly used screening test which aims to identify on admission to the delivery unit the fetus at increased risk of intrapartum hypoxia. We conducted a study to evaluate the efficacy of CTG in low- and high-risk women. METHODS: A prospective longitudinal study was conducted on 200 low-risk and high-risk antenatal women, beyond 32-week gestation with live pregnancy in labor and admitted in labor ward. RESULTS: Correlation of labor admission test with meconium in low risk and high risk was found statistically significant (p = 0.0010 and p = 0.000046, respectively). Correlation of labor admission test with low Apgar score, NICU admission and mortality was found statistically insignificant in low-risk and high-risk groups. CONCLUSION: Admission CTG does not benefit the neonatal outcome in normal- or low-risk women and rather results in increased obstetric intervention. Thus, it is not beneficial as a screening test to detect intrapartum fetal distress in normal- or low-risk women.

Randomized controlled trial of thermal balloon ablation versus vaginal hysterectomy for leiomyoma-induced heavy menstrual bleeding.

OBJECTIVE: To compare the efficacy of thermal balloon ablation (TBA) with that of vaginal hysterectomy in the treatment of leiomyoma-induced heavy menstrual bleeding (HMB). METHODS: An open-label randomized controlled trial was conducted between November 1, 2012, and October 31, 2014, in a tertiary care hospital in Delhi, India. Eligible women with HMB (aged ≥40 years, uterus size ≤14 weeks of pregnancy, leiomyoma ≤5 cm, uterocervical length ≤12 cm) were randomly assigned (1:1) to undergo TBA or vaginal hysterectomy using computer-generated random number tables. The primary outcome was the number of women in the TBA group with HMB 6 months after surgery. Analyses were by intention to treat. RESULTS: Each group contained 20 women. No women in the TBA group had HMB at 6 months. Nineteen women were amenorrheic by 6 months and one was hypomenorrheic. CONCLUSION: TBA can replace vaginal hysterectomy in some perimenopausal women with uterine leiomyomas. Clinical Trials Registry India: CTRI/2016/07/007119.