Maternal and perinatal outcome in rheumatic heart disease.

OBJECTIVES: To study the maternal and perinatal outcome of pregnancies complicated by rheumatic heart disease. METHODS: A retrospective study was carried out in the cardio-obstetric clinic of the Postgraduate Institute of Medical Education and Research, Chandigarh (India) over a period of 13 years (1987-1999) involving 486 pregnant patients with rheumatic heart disease. Maternal and perinatal outcome was reviewed. RESULTS: Three hundred and four patients (63.3%) had single valve involvement and mitral stenosis was the most predominant lesion (89.2%). One hundred and seventy one (38.6%) patients had undergone surgical correction prior to the onset of pregnancy. One hundred and thirteen patients (22.6%) were identified as NYHA class III-IV. Mitral valvotomy was performed during pregnancy in 48 patients. The incidence of preterm birth and small for gestational age newborns was 12% and 18.2%, respectively. There were 10 maternal deaths, of which eight patients were NYHA III and IV. CONCLUSIONS: Rheumatic heart disease in pregnancy is associated with significant maternal and perinatal morbidity in NYHA class III-IV patients.

Metastatic placental site trophoblastic tumor: a case report.

Placental site trophoblastic tumor (PSTT) is very rare. It is an unusual variant of gestational trophoblastic neoplasia usually confined to the uterus, although 10% of patients have metastases. The clinical behaviour of PSTT varies and despite knowledge of its histology, diagnosis of this rare form of trophoblastic disease and prediction of its biological behaviour remains difficult due to only a few cases reported in literature.

Non-cirrhotic portal hypertension in pregnancy.

OBJECTIVE: To study the outcome of pregnancy in women with non-cirrhotic portal hypertension (NCPH). METHOD: A retrospective analysis of 50 pregnancies in 27 women with NCPH was carried out. Pregnancy outcome was compared in extra hepatic portal vein obstruction (EHPVO) and non-cirrhotic portal fibrosis (NCPF). RESULTS: The mean maternal age was 24.60+/-2.857 years, and the disease was diagnosed during pregnancy in 15 (55.6%) patients. Variceal bleeding occurred in 17/50 (34%) pregnancies and the majority (88.2%) of them responded to endoscopic sclerotherapy. Incidence of variceal bleeding during pregnancy was lower in pregnancies where the disease was diagnosed prior to pregnancy (8.6%), and it was 43.5% in EHPVO and 25.9% in NCPF. The mean birth weight of the neonates was 2668.4+/-427.42 g, and the incidence of abortion, prematurity, small for gestational age babies and perinatal death was 20, 17.5, 12.5 and 20%, respectively. Variceal bleeding during pregnancy was associated with a higher incidence of abortion (29.4%) and perinatal death (33.3%). CONCLUSION: Variceal bleeding is the most common complication in pregnancies with NCPH. Pregnancies can be allowed and managed successfully in patients with NCPH.

Outcome of pregnancy in Takayasu arteritis.

Of 124 patients with Takayasu arteritis studied over a period of 20 years (1979-1999), 12 female patients experienced 24 pregnancies. The mean age was 23.6+/-3.6 years. The presenting features during pregnancy were severe hypertension (11 patients), congestive heart failure (two patients) and unequal pulses (one patient). Aortography revealed that abdominal aorta was involved in 11 patients and renal arteries in nine patients. Of 17 live babies born, intrauterine growth retardation was present in five babies and premature deliveries were encountered in four patients. Pregnancies resulted in abortion in two patients and intrauterine death in five patients. Maternal complications included superimposed pre-eclampsia in four patients, congestive heart failure and progression of renal insufficiency in two patients each and post partum sepsis in one patient. All patients with poor perinatal outcome had abdominal aortic involvement and a significant delay in seeking medical attention.

Maternal mortality associated with eclampsia and severe preeclampsia of pregnancy.

OBJECTIVE: To analyse factors associated with maternal mortality in eclampsia and preeclampsia. METHOD: Retrospective analysis of 69 maternal deaths due to (eclampsia-61; severe preeclampsia-8) was carried out during a period of 17 years (1982-1998). Maternal condition on admission, associated complications and principal cause of death was analysed in each case. RESULTS: Mean time interval between hospitalization and maternal death was 49.56 +/- 62.01 hrs (1-240 hrs). Twenty (28.9%) women died undelivered. Twenty-three (37.7%) women were in grade IV coma and 52.4% of eclampsia patients had recurrent convulsions (> 10) prior to admission. Associated complications in form of hemorrhage, cerebrovascular accidents, acute renal failure, jaundice, aspiration pneumonia and pulmonary oedema were 30.4, 31.8, 34.8, 18.8, 17.8, and 5.8%, respectively. Maternal mortality in eclampsia was significantly low in time period B (4.1%) when magnesium sulphate was used as an anticonvulsant. CONCLUSIONS: Maternal condition on admission and associated complications are the major determinant of maternal outcome. Use of magnesium sulphate is associated with significant reduction of maternal mortality.

Calcium metabolism in pre-eclampsia.

OBJECTIVES: To study calcium metabolism in pre-eclampsia and normotensive gravid women. METHOD: Ten milliliters of heparinized blood samples and 24-h urine samples were collected from 50 pre-eclamptic and 50 normotensive primigravidae. Blood samples were studied for calcium uptake, intracellular calcium level and calcium-dependent adenosine triphosphatase activity of red blood cell ghost. Urinary calcium excretion was estimated from the 24-h urine samples. These values were compared in the two groups. RESULTS: The mean gestational age at recruitment was similar in both the groups. The mean maternal age was 24.28 +/- 2.41 years in pre-eclamptic and 23.48 +/- 4.16 years in normotensive women. In pre-eclampsia 24-h urinary calcium excretion (71.20 +/- 22.95 mg/day) and calcium-dependent ATPase activity (10.78 +/- 2.40 nmol/Pi/mg protein/min) was significantly lower compared to normotensive primigravidae (calcium excretion = 189.24 +/- 57.06 mg/day; Ca2+-dependent ATPase = 12.64 +/- 2.42 nmolPi/mg /protein per min; P < 0.001). Intracellular calcium levels and calcium uptake at 10 min by red blood cells were significantly higher in pre-eclampsia (P < 0.05). Calcium uptake by red blood cells at 20 and 30 min was similar in both groups. CONCLUSION: Pre-eclampsia is associated with increased levels of intracellular calcium, decreased calcium-dependent ATPase activity of erythrocytes and hypocalciuria.

Efficacy of magnesium sulphate and phenytoin in the management of eclampsia.

Fifty pregnant women admitted with diagnosis of eclampsia were randomly allocated to magnesium sulphate (Group A) or phenytoin sodium (Group B) treatment group. Incidence of recurrence of seizures maternal as well as perinatal morbidity and mortality were compared in both the groups. Mean maternal age, parity and gestational age was similar in both the groups. Mean birth weight was significantly lower in Group B compared to Group A. Seizure frequency prior to hospitalization was 5.4 +/- 4.7 in Group A and 4.8-3.6 in Group B. Mean time interval between occurrence of first seizure and hospitalization was 9.6 +/- 3.5 hours in Group A and 11.8 +/- 9.3 hours in Group B, the difference was not statistically significant. Women treated with phenytoin had a higher incidence of recurrent seizures (10/25-40%) than those treated with magnesium sulphate (2/25-8%). Majority of the women treated with phenytoin (6/10-60%) had single convulsion after initiation of anticonvulsant therapy and 1 woman of each group had recurrent convulsions (75). There was no significant difference in perinatal outcome in both the groups. Maternal morbidity was comparable in both the groups and there was no maternal death in either of the groups.

Obstetrical outcomes among women with extrapulmonary tuberculosis.

BACKGROUND: The prevalence of tuberculosis, especially extrapulmonary tuberculosis, is increasing worldwide. Because information on the outcome of pregnancy among women with extrapulmonary tuberculosis is limited, we studied the course of pregnancy and labor and the perinatal outcome in these women and their infants. METHODS: From 1983 to 1993, we followed 33 pregnant women who had extrapulmonary tuberculosis (12 with tuberculous lymphadenitis and 9 with intestinal, 7 with skeletal, 2 with renal, 2 with meningeal, and 1 with endometrial tuberculosis) through their deliveries. Of the 33, 29 received antituberculosis treatment during pregnancy. The antenatal complications, intrapartum events, and perinatal outcomes were compared with those among 132 healthy pregnant women without tuberculosis who were matched for age, parity, and socioeconomic status. RESULTS: Tuberculous lymphadenitis did not affect the course of pregnancy or labor or the perinatal outcome. However, as compared with the control women, the 21 women with tubercular involvement of other extrapulmonary sites had higher rates of antenatal hospitalization (24 percent vs. 2 percent, P< 0.001), infants with low Apgar scores (< or =6) soon after birth (19 percent vs. 3 percent, P=0.01), and low-birth-weight (<2500 g) infants (33 percent vs. 11 percent, P=0.01). CONCLUSIONS: Extrapulmonary tuberculosis that is confined to the lymph nodes has no effect on obstetrical outcomes, but tuberculosis at other extrapulmonary sites does adversely affect the outcome of pregnancy.

Pregnancy following cardiac valve replacement surgery.

OBJECTIVES: To study the outcome of pregnancy in women with artificial heart valves and to compare the maternal and perinatal outcome in mechanical and bioprosthetic valves. METHOD: Retrospective analysis of 34 pregnancies in 29 women who conceived after cardiac valve replacement was carried out. RESULTS: The majority of women (76.4%) delivered within 5 years of valve replacement. Anticoagulants were administered in 79.4% of pregnancies. Maternal mortality was 2.9% and maternal morbidity in the form of heart failure, atrial fibrillation, valve thrombosis, thromboembolism, bleeding complications and non-functioning prostheses were 2.9%, 5.8%, 2.9%, 2.9%, 11.7% and 2.9%, respectively. The incidence of prematurity was 5.8% and small for gestational age babies was 11.7%. There was no case of abortion. Two babies (5.8%) were still born, one of which had malformations. Maternal complications were significantly higher in women with bioprostheses, though the complications were more grave in the mechanical prostheses group. The perinatal outcome was almost similar in both the groups. CONCLUSION: The perinatal outcome was not different in women with bioprosthetic valves from the ones with mechanical prostheses, but the maternal morbidity was more in women with bioprosthetic valves. Coumarin derivatives were safe and effective and did not lead to embryopathy.

Pregnancy in patients with systemic lupus erythematosus.

We reviewed the obstetrical performance and outcome of 15 pregnancies in patients with systemic lupus erythematosus (SLE) (study group) and compared them with 45 age and parity-matched normal pregnancies (control group). Eleven women (73.8%) were in remission phase and 4 (26.7%) had active disease at the time of conception. The time interval between disease diagnosis and the index pregnancy was 4.2 +/- 2.5 years. Two patients with renal involvement had lupus flare-up during the antenatal period. There was no case of lupus flare-up in the postpartum period. Gestational age at delivery was significantly lower in SLE patients (35.9 +/- 2.5 weeks) compared to the control group (37.4 +/- 2.2 weeks). The incidence of intrauterine growth retardation was significantly higher in the SLE patients (40%). There was no case of neonatal lupus or congenital heart block.

Histopathological study of placental bed biopsy in placenta previa.

BACKGROUND: To study placental bed biopsy changes in placenta previa and normally implanted placenta. SUBJECT AND METHOD: Fifty placental bed biopsies from 50 patients with placenta previa and 50 placental bed biopsies from normally implanted placenta were taken at cesarean section. Placental bed biopsy was stained with hematoxyline and eosin for histological examination. Both the groups were compared for trophoblastic invasion and vascular changes of placental bed spiral arteries. Statistical analysis was done by Chi-square test. RESULTS: Placenta bed biopsy was representative in 42/50 (84%) biopsy samples of the study group (placenta previa) and 35/50 (70%) of the control group (normally located placenta). Trophoblastic giant cell migration into decidua was present in 100% of representative samples of both the groups while migration into myometrium was seen in 66.67% and 51.14% of samples of study and control group. Average number of trophoblastic giant cells per sample was significantly higher in placenta previa (decidua 41.3%, myometrium 52%) than the control group (decidua 17.4%; myometrium 14.5%). Trophoblastic giant cell infiltration into myometrial spiral arterioles was higher in placenta previa (81.83 cells per vessel). Percentage of myometrial spiral arterioles showing physiological changes was significantly higher in the study group (50.39%) compared to the control group (21.14%). Incidence of inflammatory cell infiltration was higher in the study group (42.86%). Hemorrhage into decidua and myometrium were seen in biopsy samples of the placenta previa. CONCLUSION: Placenta previa is associated with significantly higher trophoblastic giant cell infiltration and physiological changes of the myometrial spiral arterioles.

Estimation of oxidative products of nitric oxide (nitrates, nitrites) in preeclampsia.

Oxidative products of nitric oxide, serum nitrates and nitrites were estimated in 50 primigravidas with preeclampsia and in 50 gestation and age-matched normotensive primigravidas. Thirty three (66%) of these women had mild preeclampsia and 17 (34%) had severe preeclampsia. Serum nitrate and nitrite levels were significantly higher in preeclamptic women (nitrates - 15 +/- 1.17; nitrites - 11.82 +/- 1.16 micromol/L) than in the normotensive pregnant women (nitrates 11.82 +/- 1.16; nitrites - 5.08 +/- 0.47 micromol/L, p < 0.001). In preeclamptic women, serum nitrate and nitrite levels correlated with the severity of the disease (mild preeclampsia nitrate - 14.46 +/- 1.98; nitrite 6.21 +/- 0.84 micromol/L, severe preeclampsia nitrate - 16.65 +/- 3.64; Nitrite - 6.87 +/- 1.56 micromol/L). In preeclampsia there was significant positive correlation between nitrate and nitrite levels and diastolic blood pressure and proteinuria.

Pregnancy and cirrhosis of the liver.

Pregnancy in patients with cirrhosis of the liver is uncommon. We reviewed 9 pregnancies in 7 patients with cirrhosis. One patient conceived within 1 month of diagnosis and in another the disease was diagnosed during the index pregnancy. Four patients has associated portal hypertension and 1 of them conceived after lienorenal shunt. Complications associated with these pregnancies were jaundice (1) jaundice plus ascites (2) and gastrointestinal bleeding (1). In 2 patients endoscopic sclerotherapy was done during the index pregnancy. The incidence of preterm delivery was 50% (4 of 8) and the majority (75%) occurred in pregnancies where associated complications were present. There was 1 maternal death in the postpartum period due to fulminant hepatic failure.

Neurological complications of eclampsia.

OBJECTIVE: A prospective study was conducted to evaluate the various neurological (clinical, radiological and EEG) complications in patients of eclampsia. METHODS: Thirty nine patients of eclampsia were studied regarding neurological findings at presentation and electroencephalographic (EEG) tracings were recorded in each patient. Patients with an abnormal neurologic examination and/or focal or lateralizing findings on EEG, underwent a CT scan (n = 18). Foetal and maternal outcome were recorded. RESULTS: The age of the patients ranged from 19-30 (mean +/- SD, 24.2 +/- 3.5) years thirty six patients (92%) had seizures in the antenatal period, 2 (5.4%) patients developed post partum eclampsia and 1 (2.6%) patient had seizures before and after delivery. A diffuse encephalopathy was seen in 9 patients (23.1%), 4 patients (10.2%) had hemiparesis and 1 patient (2.6%) had papilledema. EEG abnormalities were seen in 29 cases (74%) and included generalized slowing (n = 19), generalized sharp waves (n = 9), focal slowing (n = 4), focal sharp waves (n = 2) and spikes (generalized and focal) were seen in 1 patient each. Abnormal CT scan was seen in 10 cases (n = 18). Five patients had generalized infarct was seen in 1 patient each. There were 8 (20.5%) still births and 31 (19.5%) live births and no maternal mortality. CONCLUSIONS: Antenatal seizures occur in > 90% cases of eclampsia and less than 10% cases have seizures after delivery. A diffuse encephalopathy is the commonest clinical abnormality along with generalized slowing on EEG. Although cerebral oedema is common focal infarcts may be seen on CT scan.

Comparison of lytic cocktail and magnesium sulphate regimens in eclampsia: a retrospective analysis.

Retrospective analysis of eclamptic patients was done during two time periods. In time period A (Jan. 1987-Dec. 1988), 79 patients of eclampsia were treated with lytic cocktail and in time period B (April 1992-April 1994), 104 eclamptic patients were treated with magnesium sulfate. The severity of disease, details of labour, delivery, incidence of persistent convulsions and the maternal and perinatal outcomes were compared. Incidence of persistent convulsions was significantly lower with magnesium sulphate (4.8%) compared to lytic cocktail (26.6%). No difference was observed in duration of labour and mode of delivery. Perinatal mortality was significantly lower in magnesium sulphate treated group. Maternal mortality was similar in both the groups (lytic cocktail-3.8%, Magnesium sulphate-2.9%).

Pregnancy and congenital heart disease--maternal and fetal outcome.

Two hundred and seventy five pregnancies in patients with congenital heart disease during 1980-1996 were analyzed retrospectively. Maternal and perinatal outcome was compared in 251 pregnancies of women with acyanotic and 24 pregnancies of women with cyanotic heart disease. Congenital heart disease was diagnosed during the index pregnancy in 26.1% of patients and the majority (88.4%) were in NYHA classes 1 and 2. Atrial septal defect (27.7%) was the most common lesion in women with acyanotic heart disease and the majority with cyanotic heart disease had Eisenmenger syndrome, 13 of 21 (61.9%). Sixty pregnancies occurred in patients with surgically corrected lesions (acyanotic, 56; cyanotic, 4). The incidences of abortions (8.3%), stillbirths (13.6%) and small for gestational age (SGA) (36.4%) were higher in cyanotic heart disease compared to acyanotic heart disease (stillbirth, 0.8%; SGA, 6.9%). There was a statistically significant difference in mean maternal age, mean gestational age and mean birth-weight in the surgically corrected and noncorrected lesions in both acyanotic and cyanotic heart disease. There was 1 maternal death in a woman with Eisenmenger syndrome.

Safety and efficacy of stripping of membranes at term.

OBJECTIVES: To assess the efficacy of stripping of membranes in initiation of labor and to study its effect on maternal and perinatal morbidity. METHOD: One-hundred primigravidae with certain gestational dates were randomized at 38 weeks gestation to either receive stripping of membranes or only gentle cervical examination. Cervical swabs were taken before pelvic examination at 38 weeks and again at the onset of labor. Placental membranes were sent for bacteriological study after delivery in all patients. RESULTS: The mean gestational age, parity and Bishop score were similar in both groups at recruitment. Gestational age at delivery was lower in the study group (38.70 +/- 0.63) compared to the control group. Seventy-two percent of the study group and 8% of the control group had spontaneous onset of labor within 7 days of examination. Labor was induced in one patient (2%) of the study group and 16 patients (32%) of the control group. No statistically significant difference was noted in incidence of premature rupture of membranes (PROM), mode of delivery, intrapartum events and perinatal outcome. No increase in neonatal morbidity was seen in association with this procedure. No patient in the study group had clinical evidence of chorioamnionitis. There was no statistically significant difference in the microbiological flora of both groups. CONCLUSION: Stripping of the fetal membranes is a safe and efficacious procedure for induction of labor. It decreases the incidence of induction of labor with no increase in incidence of maternal and neonatal morbidity.

Effect of maternal low dose aspirin on neonatal platelet function.

OBJECTIVE: To evaluate the effect of maternal low dose aspirin ingestion in platelet function of newborn. DESIGN: Prospective randomized placebo controlled study. METHODS: 25 neonates born to mothers receiving low dose aspirin and 25 matched neonates with no maternal exposure to aspirin were studied. 2 ml of EDTA and 4.5 ml of citrate blood was collected from umbilical vein using double clamped umbilical stump for hemogram, coagulation profile and platelet functions. RESULTS: The platelet counts (10(9)/l) of study and control groups were 186.4 +/- 22.76 (116-225) and 205.28 +/- 17.34 (176-225), respectively. There was no significant difference in coagulation parameters. Prothrombin time index (PTI) was 86.24 +/- 6.623 and 87 +/- 6.43, respectively in the study and control group while PTTK (sec) was 55.88 +/- 20.54 and 52.12 +/- 11.82 in study and control subjects, respectively. The platelet aggregation studies (platelet function) with various platelet agonists in study and control group did not show any significant difference. Clinically, none of the babies had bleeding. CONCLUSIONS: Use of low dose aspirin in pregnant women was found to be safe and had no adverse effects on platelet functions of newborn.