Serum creatinine and estimated glomerular filtration rate (eGFR) in early pregnancy and changes during the pregnancy.

Renal functions in pregnancy undergo rapid changes, and the thresholds for normal values are a major research gap and are still debatable. The lack of prospective population-based studies with early pregnancy recruitment hampered the decision-making process on the best thresholds to be used in clinical practice. We present the serum creatinine (sCr) and sCr-based estimated glomerular filtration rates (eGFR) in early pregnancy with changes over the gestational period in a large prospective, community-based cohort, the Rajarata Pregnancy Cohort (RaPCo). We carried out a community-based prospective cohort study with 2,259 healthy pregnant women with a gestation period of less than 13 weeks and without pre-existing medical conditions. Gestational period-specific sCr and sCr-based eGFR were calculated for different age strata, and the participants were followed up until the second trimester. Renal functions of pregnant women were compared with 2.012 nonpregnant women from the same geographical area. The mean (SD) sCr of the 2,012 nonpregnant women was 62.8(12.4) µmol/L, with the 97.5th percentile of 89.0 µmol/L. Among the pregnant women, mean (SD) sCr was 55.1(8.3), 52.7(8.1), 51.1(9.1), 47.1(7.2), and 49.3 (9.9), while the 97.5th percentile for sCr was 72.4, 69.1, 70.0, 63.6, and 66.0 µmol/L respectively during the 4-7, 8-9, 10-12, 24-27 and 28-30 weeks of gestation. The average sCr value was 84.7% and 76.4% of the nonpregnant group, respectively, in the first and second trimesters. The mean eGFR was 123.4 (10.7) mL/min/1.73 m2 in the first trimester and increased up to 129.5 mL/min/1.73 m2 in the 24th week of gestation. The analysis of cohort data confirmed a significant reduction in sCr with advancing pregnancy (p<0 .001). This study provides thresholds for renal functions in pregnancy to be used in clinical practice. Clinical validation of the proposed thresholds needs to be evaluated with pregnancy and newborn outcomes.

Asthma in a prospective cohort of rural pregnant women from Sri Lanka: Need for better care during the pre-conceptional and antenatal period.

OBJECTIVES: To describe the epidemiology and the effect of asthma on pregnancy outcomes in pregnant women from a rural geography. METHODS: We conducted a prospective cohort study in Anuradhapura district, Sri Lanka enrolling all eligible pregnant women registered in the maternal care program. An interviewer-administered questionnaire-based symptom analysis and clinical assessment was conducted in the first and second trimesters. RESULTS: We recruited 3374 pregnant women aged 15-48 years at conception. Self-reported physician-diagnosed asthma prevalence was 6.6% (n = 223) with only 41.7% (n = 93) on regular medical follow-up for asthma. The prevalence of wheeze reduced from pre-pregnancy (67.0%) to the first (46.4%) and second trimesters (47.7%; p<0.01). Of the 73 asthmatic women who did not have wheeze in the last 3 months preceding pregnancy, new-onset wheeze was reported by 6(8.2%) and 12(16.4%) in the first and second trimester, respectively. Pregnant women who sought medical care for asthma in the private sector had a lower likelihood of developing new-onset wheeze in the first trimester (p = 0.03; unadjusted OR = 0.94;95%CI 0.89-0.99). Thirty-four (33.3%) pregnant women had at least one hospital admission due to exacerbation of wheeze during the first and second trimester. The prevalence of low birth weight (16.0%) was higher among pregnant asthmatic women. CONCLUSION: This study reports the high prevalence of asthma and asthma-associated pregnancy outcomes in women from a rural geography signifying the importance of targeted management.

Fatty Liver Index is a valid predictor of non-alcoholic fatty liver disease (NAFLD) in pregnancy.

BACKGROUND: Despite the evidence for adverse pregnancy outcomes, non-alcoholic fatty liver disease (NAFLD) is not routinely addressed in early pregnancy. The Fatty Liver Index (FLI) has been proposed as a screening tool for NAFLD in the general population. We aim to develop mathematical models for predicting NAFLD in pregnancy and validate the FLI for first-trimester pregnant women. METHODS: Biochemical and biophysical parameters were analysed in pregnant women with period of gestation <12 weeks was done among Rajarata Pregnancy Cohort, Sri Lanka. Fatty liver was graded as (FLG) 0, I or II by ultrasound scan. Binary logistic regression models were employed to identify the factors predicting FLG-II. Six FLIs were developed to predict FLG-II. Validity of the FLIs was compared using the receiver operating characteristic curves. RESULTS: The study sample consisted of 632 pregnant women with a mean age of 28.8 years (SD: 5.8 years). Age (OR: 1.6, 95% CI 1.1 to 2.3), body mass index (OR: 1.7, 95% CI 1.1 to 2.5) and gamma-glutamyl transferase levels (OR: 2.1, 95% CI 1.5 to 3.0) were the independent predictors of FLG-II. While the model with liver enzymes provided the best prediction of NAFLD (both FLG I and II) (area under the curve [(AUC]): -0.734), the highest AUC (0.84) for predicting FLG-II was observed with the full model (model with all parameters). The proposed budget model (AUC >0.81) is the best model for screening fatty liver in community health setup. CONCLUSION: FLIs could be used as screening tools for NAFLD based on resource availability in different settings. External validation of the FLI and further investigation of the proposed FLI as a predictor of adverse pregnancy outcomes are recommended.

Non-alcoholic fatty liver disease (NAFLD): a significant predictor of gestational diabetes mellitus (GDM) and early pregnancy miscarriages-prospective study in Rajarata Pregnancy Cohort (RaPCo).

BACKGROUND AND AIMS: Non-alcoholic fatty liver disease (NAFLD) is increasing globally with a mounting body of evidence on various adverse effects on pregnancy. Yet, prospective studies, especially from low-income and middle-income countries, are lacking in examining the impact of NAFLD in pregnancy. In this study, we explored the effect of NAFLD on the development of gestational diabetes mellitus (GDM) and early pregnancy miscarriages. METHODS: A population-based prospective cohort study was conducted among first-trimester pregnant women who registered in the national pregnancy care programme during July-September 2019 in Anuradhapura district, Sri Lanka. Baseline clinical-biochemical parameters and ultrasound scan (USS) of the liver were done to assess fatty liver. Those who were normoglycaemic based on WHO criteria were followed up, and a repeat oral glucose tolerance test was performed between 24 and 28 weeks of gestation. RESULTS: Of the 632 pregnant women studied, 90 (14%) and 234 (37%) were diagnosed as having fatty liver grade (FLG) II and I, respectively. The cumulative incidence of GDM in FLG 0, I, and II were 11, 44, and 162 per 1000 pregnancies, respectively. After adjusting for age and other known risk factors, women with FLG II had a relative risk (RR) of 12.5 (95% CI 2.2 to 66.4) for developing GDM compared with FLG 0. In addition, women with FLG I (RR 2.1, 95% CI 1.01 to 4.64) and FLG II (RR 4.5, 95% CI 2.1 to 9.9) were significant risk factors for early pregnancy miscarriages, and FLG II remained as the only independent predictor of miscarriages after adjusting for age, parity, body mass index, blood sugar, blood pressure, and haemoglobin level (adjusted OR 4.2 (95% CI 1.9 to 9.1)). CONCLUSION: In this rural south Asian community, NAFLD is shown to be a major risk factor for GDM and early pregnancy miscarriages. Therefore, routine identification of NAFLD through a simple USS may help in the early identification of high-risk mothers.

Early pregnancy hyperglycaemia as a significant predictor of large for gestational age neonates.

AIMS: We aimed to determine the effect of early pregnancy hyperglycaemia on having a large for gestational age (LGA) neonate. METHODS: A prospective cohort study was conducted among pregnant women in their first trimester. One-step plasma glucose (PG) evaluation procedure was performed to assess gestational diabetes mellitus (GDM) and diabetes mellitus (DM) in pregnancy as defined by the World Health Organization (WHO) criteria with International Association of Diabetes in Pregnancy Study Group (IADPSG) thresholds. The main outcome studied was large for gestational age neonates (LGA). RESULTS: A total of 2,709 participants were recruited with a mean age of 28 years (SD = 5.4) and a median gestational age (GA) of eight weeks (interquartile range [IQR] = 2). The prevalence of GDM in first trimester (T1) was 15.0% (95% confidence interval [CI] = 13.7-16.4). Previously undiagnosed DM was detected among 2.5% of the participants. Out of 2,285 live births with a median delivery GA of 38 weeks (IQR = 3), 7.0% were LGA neonates. The cumulative incidence of LGA neonates in women with GDM and DM was 11.1 and 15.5 per 100 women, respectively. The relative risk of having an LGA neonate among women with DM and GDM was 2.30 (95% CI = 1.23-4.28) and 1.80 (95% CI = 1.27-2.53), respectively. The attributable risk percentage of a LGA neonate for hyperglycaemia was 15.01%. T1 fasting PG was significantly correlated with both neonatal birth weight and birth weight centile. CONCLUSIONS: The proposed WHO criteria for hyperglycaemia in pregnancy are valid, even in T1, for predicting LGA neonates. The use of IADPSG threshold for Fasting PG, for risk assessment in early pregnancy in high-risk populations is recommended.

The hidden burden of adolescent pregnancies in rural Sri Lanka; findings of the Rajarata Pregnancy Cohort.

BACKGROUND: Adolescent fertility is a main indicator of the Sustainable Developmental Goal (SGD) three. Although Sri Lanka is exemplary in maternal health, the utilization of Sexual and Reproductive Health services (SRH) by adolescents is less documented. We describe the hidden burden, associated biological and psychosocial factors and utilization patterns of pre-conceptional services among pregnant adolescents in rural Sri Lanka. METHODS: The study is based on the baseline assessment of the Rajarata Pregnancy Cohort (RaPCo) in Anuradhapura. Pregnant women newly registered from July to September 2019 were recruited to the study. The period of gestation was confirmed during the second follow-up visit (around 25-28 weeks of gestation) using ultra sound scan data. A history, clinical examination, anthropometric measurements, blood investigations were conducted. Mental health status was assessed using the Edinburgh Postpartum Depression Scale (EPDS). RESULTS: Baseline data on gestation was completed by 3,367 pregnant women. Of them, 254 (7.5%) were adolescent pregnancies. Among the primigravida mothers (n = 1037), 22.4% (n = 233) were adolescent pregnancies. Maternal and paternal low education level, being unmarried, and less time since marriage were statistically significant factors associated with adolescent pregnancies (p < 0.05). Contraceptive usage before pregnancy, utilization of pre-conceptional health care services, planning pregnancy and consuming folic acid was significantly low among adolescents (p < 0.001). They also had low body mass index (p < 0.001) and low hemoglobin levels (p = 0.03). Adolescent mothers were less happy of being pregnant (p = 0.006) and had significantly higher levels of anxiety (p = 0.009). CONCLUSION: One fifth of women in their first pregnancy in this study population are adolescents. Nulli-parous adolescents exert poor social stability and compromised physical and mental health effects. The underutilization and/or unavailability of SRH services is clearly associated with adolescent pregnancies.

Estimating the burden of leptospirosis in Sri Lanka; a systematic review.

BACKGROUND: Although the assessment of disease burden should be a priority for allocating resources, leptospirosis is grossly underestimated despite its true burden in Sri Lanka. This study aimed to assess the morbidity and mortality of leptospirosis based on routine surveillance data, hospital reported data and scientific publications from Sri Lanka. METHOD: A systematic review was carried out, and Pub Med, MEDLINE®, BIOSIS Previews, Zoological Record, Web of Science Core Collection, Current Contents Connect, KCI-Korean Journal Database, BIOSIS Citation Index, Data Citation Index, SciELO Citation Index and Google Scholar databases were searched. Quarterly epidemiological bulletin (QEB), indoor morbidity & mortality returns (IMMR) and hand searches of local literature were performed in local libraries. Forty-two relevant full texts, 32 QEBs, and 8 IMMR were included in the full text review. Adjustments were made for under diagnosis, underreporting and chance variability. RESULTS: The estimated annual caseload of leptospirosis in Sri Lanka from 2008 to 2015, was 10,423, and the cumulative annual incidence of leptospirosis that required hospitalization was 52.1 (95% CI 51.7-52.6) per 100,000 people. The estimated number of annual deaths due to leptospirosis was approximately 730 (95% CI 542-980), with an estimated pooled case fatality ratio of 7.0% (95% CI 5.2-9.4). The most common organs involved were the kidney, liver and heart, with median rates of 48.7, 30, and 14.2%, respectively. CONCLUSION: Our systematic review shows gross underestimation of the true leptospirosis burden in the national statistics of Sri Lanka, and the hospitalization rates estimated in our study were compatible with the total burden estimate of 300·6 (95% CI 96·54-604·23) per 100,000 people published previously.