Clinical profile and obstetric outcome in pregnancies complicated by heart disease: a five year Indian rural experience

Background: Cardiac diseases are a major cause of morbidity and mortality in pregnant women in the developing world. This study illustrates the problem in rural India focusing on patterns of diseases, clinical features, and pregnancy outcome in these women.Methods: A retrospective analysis of five year data, from 2006 to 2010 for all patients admitted with cardiac disease in pregnancy.Results: Past history of heart disease was present in 70%. Rheumatic heart disease was predominant type in 83% and the chief complaint at admission was breathlessness in 44%.   Mitral stenosis was the commonest lesion in 55% and mitral regurgitation with or without stenosis in 48%. Preeclampsia was seen in 20% and preterm labor in 10%. Spontaneous vaginal delivery was seen in 41% and cesarean in 20.6%.Conclusions: Heart disease in pregnancy is a high risk condition has a major impact on pregnancy. Associated obstetric complications along with lack of knowledge and ignorance regarding the pathology lead to unpleasant obstetric outcomes

Oral misoprostol alone, compared with oral misoprostol followed by oxytocin, in women induced for hypertension of pregnancy: A multicentre randomised trial

Objective: To assess whether, in those requiring continuing uterine stimulation after cervical ripening with oral misoprostol and membrane rupture, augmentation with low‐dose oral misoprostol is superior to intravenous oxytocin. Design: Open‐label, superiority randomised trial. Setting: Government hospitals in India. Population: Women who were induced for hypertensive disease in pregnancy and had undergone cervical ripening with oral misoprostol, but required continuing stimulation after artificial membrane rupture. Methods: Participants received misoprostol (25 micrograms, orally, 2‐hourly) or titrated oxytocin through an infusion pump. All women had one‐to‐one care; fetal monitoring was conducted using a mixture of intermittent and continuous electronic fetal monitoring. Main outcome measures: Caesarean birth. Results: A total of 520 women were randomised and the baseline characteristics were comparable between the groups. The caesarean section rate was not reduced with the use of misoprostol (misoprostol, 84/260, 32.3%, vs oxytocin, 71/260, 27.3%; aOR 1.23; 95% CI 0.81–1.85; P = 0.33). The interval from randomisation to birth was somewhat longer with misoprostol (225 min, 207–244 min, vs 194 min, 179–210 min; aOR 1.137; 95% CI 1.023–1.264; P = 0.017). There were no cases of hyperstimulation in either arm. The rates of fetal heart rate abnormalities and maternal side effects were similar. Fewer babies in the misoprostol arm were admitted to the special care unit (10 vs 21 in the oxytocin group; aOR 0.463; 95% CI 0.203–1.058; P = 0.068) and there were no neonatal deaths in the misoprostol group, compared with three neonatal deaths in the oxytocin arm. Women's acceptability ratings were high in both study groups. Conclusions: Following cervical preparation with oral misoprostol and membrane rupture, the use of continuing oral misoprostol for augmentation did not significantly reduce caesarean rates, compared with the use of oxytocin. There were no hyperstimulation or significant adverse events in either arm of the trial

Feasibility of supervised self-testing using an oral fluid-based HIV rapid testing method:a cross-sectional, mixed method study among pregnant women in rural India

Introduction: HIV self-testing can increase coverage of essential HIV services. This study aimed to establish the acceptability, concordance and feasibility of supervised HIV self-testing among pregnant women in rural India. Methods: A cross-sectional, mixed methods study was conducted among 202 consenting pregnant women in a rural Indian hospital between August 2014 and January 2015. Participants were provided with instructions on how to self-test using OraQuick® HIV antibody test, and subsequently asked to self-test under supervision of a community health worker. Test results were confirmed at a government-run integrated counselling and testing centre. A questionnaire was used to obtain information on patient demographics and the ease, acceptability and difficulties of self-testing. In-depth interviews were conducted with a sub-sample of 35 participants to understand their experiences. Results: In total, 202 participants performed the non-invasive, oral fluid-based, rapid test under supervision for HIV screening. Acceptance rate was 100%. Motivators for self-testing included: ease of testing (43.4%), quick results (27.3%) and non-invasive procedure (23.2%). Sensitivity and specificity were 100% for 201 tests, and one test was invalid. Concordance of test result interpretation between community health workers and participants was 98.5% with a Cohen’s Kappa (k) value of k=0.566 with p<0.001 for inter-rater agreement. Although 92.6% participants reported that the instructions for the test were easy to understand, 18.7% required the assistance of a supervisor to self-test. Major themes that emerged from the qualitative interviews indicated the importance of the following factors in influencing acceptability of self-testing: clarity and accessibility of test instructions; time-efficiency and convenience of testing; non-invasiveness of the test; and fear of incorrect results. Overall, 96.5% of the participants recommended that the OraQuick® test kits should become publicly available. Conclusions: Self-testing for HIV status using an oral fluid-based rapid test under the supervision of a community health worker was acceptable and feasible among pregnant women in rural India. Participants were supportive of making self-testing publicly available. Policy guidelines and implementation research are required to advance HIV self-testing for larger populations at scale

COVID-19 and cesarean section rates: A retrospective observational study at our rural tertiary center using robson's classification

Objective: This study aimed to evaluate the effect of COVID-19 infection on the rate and indications for cesarean section (CS) according to Robson's Ten-Group Classification system. Methodology: Our study was a 6-month retrospective observational study at the Maternal and Child Health Wing where every antenatal woman who was admitted irrespective of gestational age and whether in labor or not was customarily screened for COVID-19 infection. Based on the mode of delivery, all delivered women were classified into two groups: vaginal or cesarean, and the information was then further classified according to Robson's classification. Data collected were analyzed using Excel sheets, and Chi-square test was applied to evaluate if the difference in CS rates was statistically significant. Results: During COVID months, a total number of confinements were 877, among which the cesarean section were 381, contributing to a rate of 43.4%. The total COVID-19-positive confinements during the same period were 68. Group 2 formed the vast majority of CSs, followed by Group 1 and 5. During the post-COVID months, summation of confinements was 1443, among which the CS were 580, thereby contributing to a rate of 40.1%. In contrast to COVID time, Group 5 formed the greatest chunk contributing to CS rate, followed by Group 2 and 1. There was a statistically significant difference among confinements during COVID and post-COVID period and between CS rates among COVID-19 positive and negative women. Conclusion: During the COVID pandemic, there was a decrease in the number of confinement in our hospital. However, the CS rate increased and according to Robson's classification Group 1 and 2 made greatest contribution to CSs due to changed dynamics

Every second matters uterine balloon tamponade implementation across ten medical colleges in Maharashtra and Madhya Pradesh in India: A qualitative study

Objective: To understand facilitators, barriers, and perceptions of a uterine balloon tamponade (ESM-UBT) package implemented across ten medical colleges in India, three years after the program was introduced. Methods: Semi-structured interviews were conducted until thematic saturation in March 2020. Multiple provider cadres, including nurses, Ob-Gyn residents, professors, and program leads, were eligible. Interviews were transcribed and thematically coded using an inductive method. Results: Sixty-two obstetric providers were interviewed. Facilitators of implementation included recurrent training, improved teamwork and communication, strong program leadership, and involvement of lower level facilities. Barriers to implementation included administrative hurdles, high staff turnover, language barriers, and resources required to reach and train lower level facilities. Overall, the majority of clinicians viewed the ESM-UBT package as a useful intervention in aiding efforts to reduce maternal deaths from postpartum hemorrhage. Conclusions: Among 10 medical colleges in India the ESM-UBT package is seen as a beneficial intervention for managing refractory atonic PPH, and for reducing maternal morbidity and mortality. Identified facilitators of and barriers to implementation o

Innovative Uses of Condom Uterine Balloon Tamponade for Postpartum Hemorrhage in India and Tanzania

Background. Postpartum hemorrhage is the most common cause of maternal deaths worldwide, the majority of which occur in low-resource settings. Uterine balloon tamponade (UBT) is an effective method of addressing uncontrolled postpartum hemorrhage (PPH) from uterine atony; however, UBT devices are often not affordable. We report on three novel uses of an ultra-low-cost condom uterine balloon tamponade (ESM-UBT) device. Cases. ESM-UBT devices were used in innovative ways to arrest severe uncontrolled pregnancy-related hemorrhage among three women in India and Tanzania. The first had sustained deep vaginal lacerations, the second a cervical pregnancy, and the third a complete molar pregnancy. Conclusion. The ESM-UBT device may be useful for control of obstetric hemorrhage caused by complex vaginal tears as well as cervical and molar pregnancies

Molecular genetic study to detect prevalence of high-risk human papilloma virus strains (type 16 and 18) in cervical lesions and asymptomatic healthy subjects of rural central India

Background: Carcinoma cervix of uterus (CaCx) is the most common malignancy affecting women worldwide. It is an established fact that infection of specific types of human papilloma virus (HPV) is essential for the development of cervical cancer. The present study reports the high-risk viruses (HPV 16 and 18) type distribution in rural central India, which has unique climatic condition. To our knowledge, no molecular study on HPV prevalence has been done in this region of rural population, this intended us do such study. Materials and Methods: Sexually active women reporting to the Gynecology were divided in three groups, first being asymptomatic women with normal cervix (52 cases), second group with benign cervical lesion (52 cases), and third group of women with frank cervical malignancy (40 cases). Cervical swabs were collected for HPV DNA sampling. The incidence of HPV positivity was recorded in each group. Results: Fifty-two women with asymptomatic normal cervix showed 44.23% positivity for HPV 16 and 5.76% positivity for HPV 18. Fifty-two women with benign cervical lesion showed 38.46% positivity for HPV 16 and 3.84% positivity for HPV 18. Forty women with frank cervical malignancy were with prevalence of 62.5% for HPV 16 and 22.5% for HPV 18. Conclusion: The results of the study are definitely helpful to know the prevalence of HPV in this region of rural population and will enrich the national epidemiological data related to HPV infection in cervical cancer

Rationale &amp; design of the PROMISES study:A prospective assessment and validation study of salivary progesterone as a test for preterm birth in pregnant women from rural India

Abstract Background In India, 3.6 million pregnancies are affected by preterm birth annually, with many infants dying or surviving with disability. Currently, there is no simple test available for screening all women at risk of spontaneous PTB in low income setting, although high resource settings routinely use cervical length measurement and cervico-vaginal fluid fetal fibronectin for identification and care of women at risk due to clinical history. In rural India, where the public health system has limited infrastructure, trained staff and equipment, there is a greater need to develop a low-cost screening approach for providing early referral, treatment and remedial support for pregnant women at risk of preterm birth. There is interest in the use of a salivary progesterone test as a screening tool preliminary evidence from India, Egypt and UK has shown promise for this type of test. The test requires further validation in a low resource community setting. Methods The Promises study aims to validate and test the feasibility of introducing a low-cost salivary progesterone preterm birth prediction test in two rural districts in India with high rates of prematurity. It is a prospective study of 2000 pregnant women recruited from Panna and Satna in Madhya Pradesh over approximately 24 months. Demographic and pregnancy outcome data will be collected, and pregnancies will be dated by ultrasound sonography. Saliva progesterone will be measured by ELISA in samples obtained between 24–28 weeks of gestation. The association between salivary progesterone and preterm birth will be determined and the utility of salivary progesterone to predict preterm birth < 34, as well as < 30 and < 37 weeks assessed. Additional qualitative data will be obtained in terms of acceptability and feasibility of saliva progesterone testing and knowledge of PTB. Discussion A validated cost-effective saliva test, which has potential for further adaptation to a ‘point of care’ setting will allow early identification of pregnant women at risk of preterm birth, who can be linked to an effective pathway of care and support to reduce preterm birth and associated adverse consequences. This will reduce both economic and emotional burden on the affected women and their families