Association of serum placental growth factor and pregnancy associated plasma protein A between 11 to 14 weeks and pre-eclampsia

Background: Pre eclampsia complicates around 5-10% of pregnancies worldwide. Many countries in the world are far away of having interventions to predict and prevent preeclampsia. A number of biochemical, biophysical and sonographic parameters are emerging as a potential tool which can help us in a long way. This study was aimed to study association of biochemical markers of preeclampsia in early pregnancy with the development of preeclampsia.Methods: This cohort study was conducted over a period of one year in the Department of Obstetrics and Gynecology at King George’s Medical University, Lucknow.Results: Total number of women enrolled at 11-14 weeks were 56. The mean age of women enrolled was 28±4.2 years. Out of total 44.6% women were nulliparous. Mean crown rump length at testing was 60.55±11.26mm. There was a significant correlation between the levels of Placental growth factors and development of PE (p<0.01) and especially severe early onset disease, however we did not found a significant correlation between Pregnancy associated plasma protein and Preeclampsia.Conclusions: Placental growth factor is an emerging marker which could be incorporated in essential bundle of care at 11 to 14 weeks testing in order to enhance the detection rates of preeclampsia

Fetal Doppler for prediction of adverse perinatal outcome in preeclampsia in a low resource setting

Background: To assess the usefulness of fetal Doppler in predicting adverse perinatal outcome in preeclampsia.Methods: All the women with preeclampsia from 30 weeks onwards were enrolled in the study. The umblical artery (UA) Systolic-diastolic (S/D) ratio>2standard deviation (SD) or UA-Pulsatility Index (PI) and UA-Resistive Index (RI) >2SD were taken as abnormal. The middle cerebral artery (MCA) was visualized and cerebroumblical PI ratio calculated. MCA-RI2SD (RR 4.46, 95% CI 1.40-14.17) and RI>2SD (RR 3.36, 95% CI 1.03-10.61) and MCA RI2SD predicted acute fetal distress in labour (RR 2.33, 95% CI 1.21-4.47), there was no association on multivariate regression analysis.Conclusions: This study showed UA-S/D ratio and UA-RI>2SD are significant predictors of perinatal deaths and immediate neonatal resuscitation in preeclampsia. Acute fetal distress in labour or neonatal nursery admission could not be predicted

Hyperhomocysteinemia and MTHFR gene 677 C>T polymorphism: questionable role in female infertility

Background: Homocysteine is an intermediate in methionine metabolism required for the biosynthesis of nucleic acids. Hyperhomocysteinemia affects various organ systems and also has been implicated as a risk factor for infertility. Elevated levels result either from genetic mutations of the enzymes catalyzing the metabolic pathway or deficiency of micronutrients required as co-enzymes for the same. The aim of this cohort study was to evaluate serum homocysteine levels and MTHFR gene 677C&gt;T mutation and to establish a possible relation between hyperhomocysteinemia, genetic polymorphism and female infertility.  Methods: Ninety-five infertile women were enrolled over a period of one year and categorized as unexplained, anovulatory and male partner factor infertility according to the etiology. Thirty-one age-matched fertile women were enrolled as controls. Serum homocysteine levels were evaluated and genetic analysis for MTHFR gene mutation 677C&gt;T was done.  Results: Mean homocysteine levels for the women in three infertile groups were comparable (group I - 16.21 ± 3.39 µmol/l, group II - 16.36 ± 3.56 µmol/l, group III - 16.98 ± 3.14 µmol/l) within the groups as well as with the fertile group (15.85 ± 9.3 µmol/l) with no statistically significant difference (P = 0.573). Prevalence of hyperhomocysteinemia was 86.3% for infertile group and 90.3% for fertile group. Nineteen heterozygous (CT) and 3 homozygous (TT) mutations were noted among infertile subjects and 8 heterozygous (CT) mutations among fertile subjects prevalence being similar for both the groups.  Conclusions: Significant prevalence of hyperhomocysteinemia and MTHFR polymorphism was observed in the studied population. The study did not establish a positive role of hyperhomocysteinemia and MTHFR mutation in female infertility.

Correlation of serum homocysteine levels and pregnancy outcome: the dilemma continues

Background: Hyperhomocysteinemia has been implicated as a risk factor for complications in pregnancy including abortion, preeclampsia and placental abruption. The present study was designed to study the correlation, if any, of Hyperhomocysteinemia with pregnancy outcome.Methods: Pregnant women between 14 to 24 weeks of gestation were included as subjects. Serum homocysteine levels and MTHFR gene (Methylenetetrahydrofolate reductase 677C>T) polymorphism was estimated. The women were followed till delivery and obstetric & neonatal outcomes were noted.Results: A total of 81 women were followed till delivery. Out of these 42 women had an uncomplicated pregnancy and delivery and 39 women had at least one antenatal or perinatal complication. Difference between mean serum homocysteine in both the groups was not statistically significant (p=0.403).No significant difference was found in the occurrence of different genotypes in the 2 groups though women with TT genotype were found to have higher serum homocysteine levels as compared to other genotypes.Conclusions: Though the serum homocysteine levels were higher in the women with pregnancy complications as compared to women without complications but the difference was not statistically significant

Decoding the effect of time interval between hCG and IUI and sperm preparation and IUI

Background: The study was aimed to assess the difference in IUI outcome depending on the interval between hCG trigger and IUI and sperm preparation and IUI.Methods: The study was conducted in the Department of Obstetrics and Gynecology in Infertility unit at King George’s Medical University, Lucknow from January-December 2016. All the women eligible for IUI were included in the study. Once the follicle attained size of 17-18 mm, IUI was planned 36-48 hours after Inj. hCG 10,000 IU im. Semen processing was done in laboratory and time noted between sperm preparation and IUI. Outcome was confirmation of pregnancy by urine test. Cases were women in whom IUI was done 36-40 hours after hCG as against controls (>40 hours). Interval between sperm preparation and IUI was <30 minutes in cases and ≥30 minutes in controls.Results: A total of 624 cycles were included in the study. Clomiphene was used in 582/624 cycles (93.3%) gonadotropins used in 42/624 cycles (2.7%). There was a total of 23 conceptions in study (3.7%). Of these 8/98 (8.2%) were seen when the interval between ovulation trigger and IUI was 36-40 hours and 15/526 in cycles (2.9%) when the interval was more than 40 hours (p=0.023; OR-3.028 95% CI -1.247-7.352). Of a total of 23 conceptions in the study, 18/324 conceptions were seen when IUI was done within 30 minutes of sperm preparation as compared to 5/300 when interval was more than 30 minutes (p=0.01).Conclusions: IUI with ovarian stimulation is a simple and effective procedure and its outcome can be maximized keeping in consideration the availability of gametes. IUI performed within 36-40 hours of hCG trigger and within 30 minutes of sperm preparation can increase conception rates

Prediction of pre-eclampsia at 11-14 weeks of pregnancy using mean arterial pressure, uterine artery Doppler and pregnancy-associated plasma protein-A

Background: The possibility of prediction of preeclampsia (PE) at 11-14 weeks of pregnancy is a fairly new concept and in recent years, studies combining various parameters at 11-14 weeks of pregnancy have been undertaken, but an algorithm with a high predictive value is yet to be developed. The objective of this study was to develop such a protocol using mean arterial pressure (MAP), uterine artery Doppler and PAPP-A (pregnancy associated plasma protein-A) at 11-14 weeks of pregnancy (individually or in combination) for prediction of preeclampsia in a developing country like India.Methods: A prospective cohort study was done at the Department of Obstetrics and Gynecology, King George Medical University, Lucknow, Uttar Pradesh with pregnant women attending the antenatal OPD at 11- 14 weeks of gestation. A preformed questionnaire was filled for the enrolled women, MAP, blood pressure was recorded, uterine artery Doppler was done, serum sample for PAPP-A was drawn. Uterine artery Doppler pulsatility index (PI) at 11-14 weeks of pregnancy was found to be a good screening method (sensitivity-75.9%, specificity-79.6% at cut-off of 1.7) for prediction of preeclampsia and IUGR. The data was analyzed using SPSS (Statistical Package for Social Sciences) Version 15.0 statistical analysis software.Results: Out of the 78 women enrolled, 29 women (37.18%) developed complications. Uterine artery Doppler pulsatility index (PI) at 11-14 weeks of pregnancy was found to be a good screening method (sensitivity-75.9%, specificity-79.6%) for prediction of preeclampsia and IUGR. Presence of early diastolic notch on uterine artery Doppler was found predictive for IUGR. MAP and PAPP-A were not found to have a significant correlation with development of these complications.Conclusions: This study concluded that uterine artery Doppler alone was a good screening method at 11-14 weeks of gestation for women at high risk of developing preeclampsia and related complications

Increasing rates of cesarean section, an upcoming public health problem: an audit of cesarean section in a tertiary care center of North India based on Robson classification

Background: Increasing rates of cesarean section during last three decades has become a cause of alarm since and a need for ongoing studies. Objective of present study was to investigate cesarean section rates as per modified Robsons Criteria and to determine area of concern which requires maximum focus to decrease overall caesarean rateMethods: This cross sectional study was conducted over a period of one year (From January 2016 to December 2016) in the Department of Obstetrics and Gynecology at King George’s Medical University, Lucknow.Results: Total number of deliveries for one year was 8526. Out of them, 4275 (50.1%) were vaginal and 4251 (49.9%) were abdominal. Overall maximum caesarean section rate was contributed by group 5 of modified Robsons criteria i.e. previous section, singleton, cephalic, ≥37 weeks (17.7%).Conclusions: Robson 10 group classification provides easy way in collecting information about Cesarean section rate which obtains good insight into certain birth groups. It is important that efforts to reduce the overall CS rate should focus on reducing the primary CS rate (group 1 and 2) and on increasing vaginal birth after CS (group 5). The caesarean rate is commonest in group 5 that is previous section (17.7%)

Fetal Doppler for prediction of adverse perinatal outcome in preeclampsia in a low resource setting

Background: To assess the usefulness of fetal Doppler in predicting adverse perinatal outcome in preeclampsia.Methods: All the women with preeclampsia from 30 weeks onwards were enrolled in the study. The umblical artery (UA) Systolic-diastolic (S/D) ratio&gt;2standard deviation (SD) or UA-Pulsatility Index (PI) and UA-Resistive Index (RI) &gt;2SD were taken as abnormal. The middle cerebral artery (MCA) was visualized and cerebroumblical PI ratio calculated. MCA-RI&lt;2SD was taken as abnormal. Adverse perinatal outcome was taken as major if there was stillbirth, immediate neonatal death, need of respiratory support and minor if neonatal nursery admission was done. Presence of acute fetal distress in labour was also noted.Results: There were 107 women in the study. Major adverse outcomes were 11. Umbilical artery-S/D ratio&gt;2SD (RR 4.46, 95% CI 1.40-14.17) and RI&gt;2SD (RR 3.36, 95% CI 1.03-10.61) and MCA RI&lt;2SD (RR 4.46, 95% CI1.4-14.17) had a high relative risk to predict adverse major perinatal outcome. 39 babies were admitted in neonatal nursery and no parameters could predict them. Though UA-PI&gt;2SD predicted acute fetal distress in labour (RR 2.33, 95% CI 1.21-4.47), there was no association on multivariate regression analysis.Conclusions: This study showed UA-S/D ratio and UA-RI&gt;2SD are significant predictors of perinatal deaths and immediate neonatal resuscitation in preeclampsia. Acute fetal distress in labour or neonatal nursery admission could not be predicted

Vaginal probiotics as an adjunct to antibiotic prophylaxis in the management of preterm premature rupture of the membranes

Preterm birth is a leading cause of perinatal morbidity and mortality and Preterm premature rupture of the membranes (PPROM) is a major risk factor contributing to approximately one third of preterm deliveries. Vaginal infections are often associated with PPROM and are characterised by loss of lactobacillin normal vaginal flora and overgrowth of other pathogenic microorganisms. Probiotics appear to have an emerging role in prolonging pregnancy after PPROM. This trial compared the efficacy of a vaginal probiotic in combination with standard antibiotic prophylaxis versus only antibiotic in prolongation of latency period and on perinatal outcome in cases of PPROM between 24 and 34 weeks. Although no significant difference was observed in the mean latency period (p = 0.937) and mean gestational age at birth (p = 0.863) between the two groups, the overall neonatal outcome was better in the study group. There is need of further large-scale clinical trials to demonstrate effectiveness of probiotics.IMPACT STATEMENT What is already known on this subject? PPROM is an important cause of preterm birth. Prematurity leads significant global burden of neonatal morbidity and mortality. Antibiotics in PPROM have a proven benefit to prolong latency period from start of PPROM to birth. Probiotics have a role in improving vaginal flora and reducing infections and have been tried in PPROM. What do the results of this study add? The usefulness of probiotics in prolonging latency period and improving neonatal outcome has been reported in limited trials. In our study it has shown an improvement in neonatal outcome overall but not statistically significant compared to few studies which have reported significant beneficial effects. This might be due to existence of variation in the type of the vaginal microflora in different study population. What are the implications of these findings for clinical practice and/or further research? Preliminary results suggest that use of probiotic may benefit women with PPROM. This also implies need of multicentric larger scales trials with different types of probiotics so as to clarify whether any intervention in vaginal microflora can lead to any benefits in reducing the prematurity and its consequence, both on the neonate and heath care infrastructure

Correlation of serum homocysteine levels and pregnancy outcome: the dilemma continues

Background: Hyperhomocysteinemia has been implicated as a risk factor for complications in pregnancy including abortion, preeclampsia and placental abruption. The present study was designed to study the correlation, if any, of Hyperhomocysteinemia with pregnancy outcome.Methods: Pregnant women between 14 to 24 weeks of gestation were included as subjects. Serum homocysteine levels and MTHFR gene (Methylenetetrahydrofolate reductase 677C&gt;T) polymorphism was estimated. The women were followed till delivery and obstetric &amp; neonatal outcomes were noted.Results: A total of 81 women were followed till delivery. Out of these 42 women had an uncomplicated pregnancy and delivery and 39 women had at least one antenatal or perinatal complication. Difference between mean serum homocysteine in both the groups was not statistically significant (p=0.403).No significant difference was found in the occurrence of different genotypes in the 2 groups though women with TT genotype were found to have higher serum homocysteine levels as compared to other genotypes.Conclusions: Though the serum homocysteine levels were higher in the women with pregnancy complications as compared to women without complications but the difference was not statistically significant