Eclampsia reduction with maternal early warning trigger tool.

OBJECTIVES: To observe the incidence of eclampsia before and after implementing Maternal Early Warning Trigger (MEWT) tool. STUDY DESIGN: A retrospective observational study to evaluate the effect of introduction of MEWT tool in a tertiary referral center with 10,000 annual births. Two epochs of five years duration were compared before and after implementing MEWT tool. MEWT tool has triggers for early identification of clinical deterioration and pathways for four most important maternal morbidity causes including hypertension. Hypertension pathway has emphasis on rapid control of severe acute hypertension, lab tests and magnesium sulfate prophylaxis. All pregnant women who registered and delivered at the study institute were included. MAIN OUTCOMES MEASURES: Primary outcome was effect of MEWT tool on the incidence of eclampsia. A subset analysis was done to study the effect of MEWT tool on maternal and perinatal outcomes in women with hypertensive disease. Maternal ICU admissions, HELLP, pulmonary oedema, intracranial bleed and maternal deaths, and perinatal mean birthweight and gestational age, NICU admissions, prematurity, stillbirths, and neonatal deaths were compared. RESULTS: The study period had 37,043 and 45,637 women in pre- and post-MEWT periods. The incidence of eclampsia reduced by 45.4 % from 1.1 to 0.6 per 1000 women (p 0.001). The most significant reduction was seen with antepartum eclampsia (0.8 to 0.3 per 1000, p = 0.02). There was significant reduction in all maternal and perinatal outcomes in women with hypertensive disorders (3,506 and 6,016 in pre- and post- MEWT periods) after introduction of MEWT tool. CONCLUSION: Integrating the MEWT tool into the obstetric practice helps in reducing the incidence of eclampsia and improving maternal and fetal outcomes.

Impact of introduction of the growth assessment protocol in a South Indian tertiary hospital on SGA detection, stillbirth rate and neonatal outcome.

OBJECTIVES: India has a high rate of stillbirths, and many deaths are due to fetal growth restriction and potentially preventable. Screening and identification of the small for gestational age (SGA) fetus during the antenatal period has been shown to reduce stillbirths. We set out to evaluate the impact of implementing the Growth Assessment Protocol (GAP), a programme designed for screening for SGA. METHODS: Observational study comparing two-time epochs; before (years 2011-2014) and after (years 2015-2018) introduction of GAP. The programme includes identification of risk factors, risk categorization, serial fundal height measurement, customised fetal growth charts and appropriate referral protocols. Fetal growth charts and birth centiles were generated based on the hospital database of normal outcome pregnancies, customised to women's ethnicity, parity, height, and weight. The protocol was introduced following training of obstetric and midwifery care providers. We evaluated SGA detection rates, stillbirth rates (from 28 weeks) and neonatal morbidity at term. RESULTS: There were 26,199 and 31,498 births, with 115 and 108 stillbirths in the pre and post-GAP implementation periods, respectively. SGA detection rates increased from 51.1 to 67.1%, representing a 31% improvement (p<0.001). Overall stillbirth rates declined from 4.4 to 3.4 per 1000 births (RR 0.78 CI 95% 0.60-1.02) and at term from 1.5 to 0.6 (RR 0.37 CI 95% 0.20-0.66). Neonatal intensive care admission and neonatal encephalopathy in term neonates also decreased significantly. CONCLUSIONS: Introduction of the GAP programme in an Indian tertiary maternity service was associated with improved antenatal detection of SGA and reduced stillbirth rates and neonatal morbidity.

The effect of the Covid pandemic and lockdown on stillbirth rates in a South Indian perinatal centre.

OBJECTIVES: The Covid-19 pandemic affected antenatal care in many parts of the world. It brought about many changes as part of control and containment measures. We examined the effect of the first and second waves of the pandemic in India on stillbirth rates, as indicators of quality of maternity care. METHODS: Observational study at a tertiary referral perinatal centre with approximately 10,000 births annually. The Covid-19 first wave period was taken as January to December 2020 with lockdown March to June 2020, which included complete shut down of clinics and ultrasound services. The second wave was from January to September 2021. All women with singleton pregnancy who had hospital based antenatal care were included. We investigated monthly trends in obstetric load (new antenatal registrations, total obstetric clinic numbers and total births) with stillbirth numbers as the pandemic continued (daily Covid case trend). We compared first and second wave stillbirth rates, overall as well as those that were small for gestational age (<10th centile) at delivery. RESULTS: There were 9,251 births with 32 stillbirths in the first wave (rate 3.46/1,000) and 6,228 births with 14 stillbirths in the second wave (2.25/1,000). This represented a 54% higher rate in the first phase and extended lockdown period (p=0.08). The incidence of stillbirths that were SGA was significantly higher in the first wave: 14 vs. 2, (p=0.03). CONCLUSIONS: Reduced access to planned antenatal care during Covid-19 pandemic lockdown was associated with a significant increase in SGA stillbirths.

Implementing Professional Midwife-Led Maternity Care in India for Healthy Pregnant Women: A Community Case Study.

More women and neonates die each year in India than in almost every other country of the world. Since 1947, India has in principle provided free medical maternal health care to all pregnant and childbearing women. Although rates of maternal and neonatal deaths have fallen since the 1990s, major inequalities remain. Some Indian States have very high rates of interventions, (e.g., cesarean section), while others have intervention and care rates that are too low. Disrespectful treatment of women in labor and lack of evidence-based practice have also been reported. The World Health Organization and others have strongly recommended that professional midwives (trained in a woman-centered philosophy and to international standards) have a key role for reducing mortality and morbidity, minimizing unnecessary interventions in pregnancy and labor, and improving maternal care quality in low- and medium-income countries. This paper provides a community case-report of the first professional midwifery programme in India designed to international standards, implemented in 2011 in Hyderabad. We describe the design and implementation in the programme's first eleven years, as a basis for further scale-up and testing in India, and in other low- or medium-income countries. The ultimate aim is to improve maternal care quality, choice and outcomes in India and in similar socio-economic and cultural settings.

Biochemical markers in the pathogenesis of preeclampsia: novel link between placental growth factor and interleukin-6.

Preeclampsia (PE) is a multisystem disorder of pregnancy characterized by sudden onset of hypertension and proteinuria. The appearance and diagnosis of the disease remain elusive and the only treatment is the termination of pregnancy. The onset of the disease is preceded by a shift in the balance of the angiogenic and antiangiogenic proteins in the maternal circulation. We surmised that the assessment of the levels of these proteins during pregnancy could lead to a proper diagnosis of the disease. In this study, we determined the levels of angiogenic and antiangiogenic proteins and IL-6 in maternal circulation during normotensive and hypertensive pregnancy, including PE. Serum isolated from pregnant women during antenatal visits was used to determine the concentrations of these proteins. The levels of antiangiogenic proteins, sFlt-1 and sEng, were higher in hypertensive disorders [gestational hypertension (GH), mild PE, and PE] of pregnancy and were significantly higher for PE than for GH. The levels of sFlt-1 and sEng were higher in PE samples compared to those in GH and NT samples. These proteins may have contributed to increased blood pressure. The levels of PlGF were decreased in pregnant women having GH, mild PE, and PE. The levels of the inflammatory intermediate, IL-6, were increased in PE samples compared to those in the GH and normotensive samples. The evaluation of the altered levels of antiangiogenic and angiogenic proteins can be useful for diagnosis of PE.

One-Year Follow-Up of Women with Severe Acute Maternal Morbidity (SAMM): A Cohort Study.

BACKGROUND: Some women experience unforeseen complications during pregnancy and childbirth, which may be life threatening; their survival depends on intensive support and timely interventions. The aim of this study was to assess the long-term prevalence of adverse health conditions and their impact on quality of life in women who had severe acute maternal morbidity (SAMM). METHODS: This is a prospective cohort study comprising 43 women with SAMM during 2015 (exposure group) and 43 women who had an uneventful pregnancy and delivery (non-exposure group) during the same study period. Those who consented were given an additional follow-up date for free medical health check at 1 year. RESULTS: The incidence of SAMM during study period was 8.6/1000 births. There were five deaths in the exposure group. Adverse health events were seen in 30 (78.94%) out of 38 survivors. Abnormal lipid profile, thrombocytopenia, cardiac diastolic dysfunction, amenorrhoea, Sheehan and Asherman syndrome were major findings in the exposed group. Four (10.52%) women required re-admission, and eight (20.05%) required additional procedures to confirm screening abnormalities. The exposure group had higher mean scores on the EPDS scale, incidence of suicidal thoughts and poorer performance in the WHOQOL BREF psychological domain. CONCLUSION: Health programmes need to focus on maternal health, provide medical treatment and psychological support for a longer duration than the traditional 6 weeks postpartum in women who experience SAMM.

Need for guidelines for the combined management of pregnancy and dengue: a retrospective study from an Indian tertiary care maternity hospital.

The incidence of dengue has risen in India in recent years. Evidence suggests that dengue in pregnancy may be associated with adverse maternal and fetal outcomes. The aim of our study was to analyse outcomes in pregnant women with confirmed dengue infection who had the benefit of close monitoring and intensive management at a tertiary maternity facility. We reviewed hospital data of 44 (0.11%) such women at Fernandez Hospital, a tertiary maternity unit, during the five-year period from 2011 to 2016. Maternal and fetal variables were collected from case sheets. Dengue haemorrhagic fever was seen in 15.9% and dengue shock syndrome in one fatal case (2.2%). Thrombocytopenia was seen in 31 cases (70.4%) and 14 (31.81%) received platelets transfusions. Fetal outcomes in our series were favourable, except for one stillbirth, with 45.4% preterm deliveries and 15.9% small for gestational age babies. Dengue in pregnancy is definitely associated with maternal and fetal morbidity and mortality. A high index of suspicion of dengue is required in pregnant women with pyrexia and thrombocytopenia.

A Review of Outcomes in Pregnant Women with Portal Hypertension.

BACKGROUND: The course of pregnancy in a woman with portal hypertension is a difficult one as it is associated with complications like variceal bleeding, splenic artery rupture and coagulopathy. All these pose a threat to a woman's life. Although this condition is rare, every obstetrician should have a high index of suspicion when an antenatal mother presents with splenomegaly, thrombocytopenia or hematemesis. Hence, we aimed to review maternal and fetal outcomes in pregnant women with portal hypertension. METHODS: In a retrospective observational study, 41 women and 47 pregnancies were evaluated, from January 2000-December 2015 at Fernandez Hospital, a tertiary referral perinatal center. Maternal outcomes studied were variceal bleed during pregnancy, surgical procedures, morbidity and mortality. Neonatal variables were gestational age at delivery, birth weight and morbidities. RESULTS: Mean maternal age was 26.4 years. Average gestational age at delivery was 36.5 weeks. Mean birth weight was 2507.5 g. There were three maternal deaths out of 47 deliveries, the cause of death was massive variceal bleed in one, the second one was due to cardiac arrest on MRI table, and the third death was due to splenic hilar vessel bleed. There was one stillbirth, and no neonatal deaths. CONCLUSION: A multidisciplinary approach is essential to improve perinatal outcomes in pregnancy complicated by portal hypertension. Surgical measures to reduce portal venous pressure done before pregnancy or beta blockers during pregnancy might help reduce sudden variceal bleeds.

Implications of the revised consensus body mass indices for asian indians on clinical obstetric practice.

BACKGROUND: The body mass index (BMI) categories for Asian Indians has been revised based on consensus guidelines. The revised guidelines categorize overweight as a BMI of 23.0 - 24.9 and obesity as a BMI≥25. AIM: To determine the change in prevalence of overweight and obese pregnant women, and maternal and fetal associations with overweight and obese pregnant women classified using the revised consensus guidelines for BMI in Asian Indians. MATERIALS AND METHODS: A retrospective analysis of case records of pregnant women between January 2010 and December 2012 at a tertiary care institute in India. BMI was classified using the revised consensus guidelines for Asian Indians and the World Health Organization (WHO) criteria. The strength and direction of associations with maternal and fetal outcomes was explored with a multivariate regression model. RESULTS: The prevalence of obesity increased from 11.81% with the WHO criteria to 43.11% with the revised consensus guidelines and led to the re-classification of 1,345 (18.47%) pregnant women from a low risk category to a high risk category.Gestational hypertension, gestational diabetes and large for gestational age babies was associated with overweight or obesity (both Indian and WHO guidelines). Obesity (both Indian and WHO guidelines) was also significantly associated with caesarean sections (adjusted OR 1.23 and 1.51 respectively). CONCLUSION: The use of the revised guidelines led to a larger classification of high risk Asian Indian pregnant women. Retention of adverse associations of overweight and obesity support adoption of the revised guidelines in obstetric management of Asian Indians.

Pallister-Hall syndrome presenting as an intrauterine fetal demise at 39 weeks' gestation.

Pallister-Hall syndrome (PHS) is a pleiotropic autosomal-dominant malformation syndrome rarely presenting with genitourinary malformations. Literature has recorded 14 cases of PHS with genitourinary findings out of which only six have been females presenting with hydrometrocolpos and/or vaginal atresia. Fetal autopsy findings on a 39 weeks' gestation including demonstration of corticotroph deficiency in the pituitary, along with the review of literature is being presented here. None of the earlier literature pertaining to PHS with hydrometrocolpos and/or vaginal atresia describes an intrauterine fetal demise due to corticotroph deficiency.

Clinical symptoms and laboratory parameters do not predict adverse maternal and fetal outcomes in HELLP.

AIM: To determine the ability of clinical symptoms and laboratory parameters to predict adverse outcomes in HELLP syndrome. METHODS: A retrospective chart analysis of pregnant women diagnosed with HELLP during a 5year (2005-2009) period at a tertiary care perinatal center. The diagnosis of HELLP was based on Sibai's criteria and categorized based on the Mississippi classification. Clinical symptoms and the presence of maternal and fetal adverse events were noted from the records. Receiver operator characteristics, likelihood ratios and adjusted odds ratios were used to determine the predictive ability of clinical symptoms and laboratory parameters. RESULTS: The medical records of 74 pregnant women with HELLP were analyzed. Any adverse (maternal and/or fetal) event was present in 40 (54.1%, 95% CI: 42.4%, 65.7%) pregnancies with HELLP syndrome in this population. One in four pregnancies with HELLP resulted in an adverse maternal event and 35% of pregnancies with HELLP in an adverse fetal event. There were no maternal deaths in this series and the perinatal mortality rate was 149 per 1000 births. Clinical symptoms or laboratory parameters were not predictive of adverse events. CONCLUSIONS: Further research is needed to identify factors that can predict adverse perinatal outcomes in HELLP.