Combination of "Markers" and the Consequent Importance of Fetal Abdominal Circumference in the First Trimester for Predicting Complications Specific to Monochorionic Twin Pregnancies.

BACKGROUND: Multifetal pregnancies are considered high-risk pregnancies compared to singleton pregnancies. Monochorionic diamniotic (MCDA) twin pregnancies tend to have a more complicated intrauterine course than their dichorionic counterparts. The most common complications are twin-to-twin transfusion syndrome (TTTS), selective fetal growth restriction (sFGR), and unexplained intrauterine fetal demise (IUFD). Early recognition of pregnancies at risk of developing complications will be helpful for counselling the parents and preparing them for necessary interventions in case a complication arises. OBJECTIVES: The aim of our study was to assess the role of discordant crown-rump length (dCRL), discordant nuchal translucency (dNT), and discordant abdominal circumference (dAC) measurements in isolation and in combination at the 11-13+6 weeks' scan in predicting the development of TTTS, sFGR, and IUFD. METHODS: All MCDA twin pregnancies with structurally normal, both live fetuses at the 11-13+6 weeks' scan were followed up by FMF (Fetal Medicine Foundation)-certified operators for development of TTTS, sFGR, and single/double IUFD until delivery. Discordance of CRL, NT, and AC of more than or equal to 10% was considered a "marker," and its presence was correlated with the occurrence of specific antenatal complications, i.e., TTTS, sFGR, and single or double IUFD. RESULTS: Combination of two markers predicted MCDA-related complications in the majority of cases (70.8% positive predictive value). Combination of dNT and dAC was the strongest predictor (80% positive predictive value). CONCLUSIONS: In our population of MC twin pregnancies, dCRL, dNT, and dAC at the 11+0-13+6 weeks' scan, in isolation, had a low predictive value for antenatal complications, i.e., TTTS, sFGR, and single/double IUFD. However, the presence of at least two markers in the first trimester could predict complications in the majority of these pregnancies. The combination of dNT and dAC appears to be the best.

Prediction of Fetal Anemia in Subsequent Transfusions: Is There a Need to Change the Threshold of the Peak Systolic Velocity of the Middle Cerebral Artery?

INTRODUCTION: Peak systolic velocity (PSV) of the middle cerebral artery (MCA) shows 100% sensitivity for predicting fetal anemia before the first intrauterine transfusion (IUT). However, its ability to predict subsequent transfusions has remained mostly controversial. OBJECTIVES: To assess if there is a need to change the threshold of MCA-PSV from 1.5 to 1.69 multiples of the median (MoM) to predict fetal anemia and the need for subsequent IUT. METHODS: This is a retrospective audit, wherein case records of mothers who underwent IUT at the Bangalore Fetal Medicine Centre between April 2008 and May 2017 were reviewed; 86 cases were included, and the data were analyzed using MS Excel. The MCA-PSV and pretransfusion Hb were converted into MoM. 40 fetuses that had more than 1 IUT were included in the analysis. -Results: 31/40 fetuses that had >1 IUT had an MCA-PSV >1.5 MoM, of which 29 were anemic according to the post-IUT Hb MoM. 20/29 (69%) had an MCA-PSV >1.69, whereas 9/29 (31%) had an MCA-PSV between 1.5 and 1.69 MoM. Our study shows that changing the MCA-PSV threshold from 1.5 to 1.69 MoM will reduce the detection of fetal anemia and hence the need for repeat IUT by 31%. CONCLUSIONS: Increasing the fetal MCA-PSV threshold from 1.5 to 1.69 will miss out one-third of the fetuses that will require a 2nd, 3rd, or 4th IUT. This is more relevant in geographical areas where the parents must travel long distances for IUTs, which are performed in tertiary fetal care centers.

Outcome of Pregnancies Diagnosed with TRAP Sequence Prenatally: A Single-Centre Experience.

INTRODUCTION: Twin reversed arterial perfusion (TRAP) sequence is a phenomenon seen in 1-3% of monochorionic twin pregnancies, where the acardiac fetus is found to have multiple anomalies. The normal pump twin maintains its own perfusion in addition to that of its acardiac co-twin. As a result, if the acardiac twin increases in size, the burden on the pump twin is increased, leading to cardiac failure, hydrops fetalis, polyhydramnios, premature delivery, and perinatal death. The outcome of pregnancy is largely dependent on the growth of the acardiac twin. In view of high perinatal loss, surgical techniques to interrupt the blood flow to the acardiac twin have been evaluated. METHODS: We evaluated interstitial laser therapy, which is the main mode of therapy in our unit, of TRAP pregnancies referred over a 5-year period. Interstitial laser was offered if the blood flow in the acardiac twin was found to be persistent at 2 consecutive examinations or if there were cardiac or hydropic changes in the pump twin at the first examination. RESULTS: A total of 18 cases of TRAP were referred during this period and all were counselled regarding fetal therapy if the situation were to deteriorate; 5 couples (27.7%) opted for termination of pregnancy; of the remaining 13, 7 (53.8%) agreed to perform intervention following confirmation of a normal karyotype. Six (85.7%) and 1 (14.3%) lasers were performed in the second and third trimesters, respectively; all 7 had a normal outcome of the pump twin. There were 6/13 (46.2%) in the expectant group who continued the pregnancy with no intervention, with 2 term live births (33.3%). CONCLUSIONS: Our study confirms that there is a high risk of spontaneous loss in untreated pregnancies with TRAP, primarily due to polyhydramnios and fetal hydrops. In the pregnancies that underwent interstitial laser, there was a more favourable outcome. Interstitial laser is minimally invasive, safe, and feasible in experienced hands.

A comparative study between cleavage stage embryo transfer at day 3 and blastocyst stage transfer at day 5 in in-vitro fertilization/intra-cytoplasmic sperm injection on clinical pregnancy rates.

OBJECTIVE: To evaluate the efficacy of blastocyst transfer in comparison with cleavage stage transfer. STUDY DESIGN: A randomized, prospective study was conducted in Infertility clinic, Department of Obstetrics and Gynecology, Mahatma Gandhi Hospital, Jaipur on 300 patients aged 25-40 years undergoing in-vitro fertilization (IVF)/intra-cytoplasmic sperm injection (ICSI) cycle from May 2010-April 2011. When three or more Grade-I embryos were observed on day 2 of culture, patients were divided randomly into two study groups, cleavage stage transfer and blastocyst transfer group having 150 patients each. Primary outcomes evaluated were, Clinical pregnancy rate and Implantation rate. The results were analyzed using proportions, standard deviation and Chi-square test. RESULTS: Both the groups were similar for age, indication and number of embryos transferred. Clinical pregnancies after blastocyst transfer were significantly higher 66 (44.0%) compared to cleavage stage embryo transfer 44 (29.33%) (P < 0.01). Implantation rate for blastocyst transfer group was also significantly higher (P < 0.001). CONCLUSION: Blastocyst transfer having higher implantation rate and clinical pregnancy rate lead to reduction in multiple pregnancies.

Atypical presentation of atypical amyloid.

Amyloidosis is a group of diseases categorized by precipitation of a group of protein aggregates (amyloid) in tissues, including the kidney, and proteinuria is usually the commonest, though not exclusive, hallmark of clinical presentation. AL and AA are the most commonly recognized forms of amyloidosis involving the kidney, but other forms have been described. We present a case of renal amyloidosis due to a novel amyloidogenic protein, leucocyte cell-derived chemotaxin 2, without proteinuria at presentation or on subsequent follow-up.

Role of HIV-1 DNA levels as clinical marker of HIV-1-associated nephropathies.

BACKGROUND: HIV-associated nephropathy (HIVAN) is usually diagnosed in virologically uncontrolled infected patients. However, HIVAN can occur in some cases with undetectable HIV-1 RNA levels. We suggested that intracellular HIV-1 proviral DNA load can be used as a marker in this particular patient population. METHODS: Renal tissue HIV-1 proviral DNA, peripheral blood mononuclear cells (PBMCs) HIV-1 proviral DNA, plasma HIV-1 RNA and peripheral blood CD4-positive lymphocyte counts were quantified and assessed in 100 HIV-1-infected individuals (49 with undetectable HIV-1 RNA level viraemia) who underwent a kidney biopsy for renal abnormalities in a prospective study. RESULTS: A proviral DNA load was detected in patients with HIV-1-associated nephropathy with a negative plasma viral RNA load. None of the patients with a proviral DNA load of <10 copies/1.5×10(5) PBMCs had HIVAN. In renal tissue, proviral DNA load was detected in all patients with HIVAN. CONCLUSIONS: PBMC HIV-1 proviral DNA load is potentially the optimal clinical marker to exclude the diagnosis of HIVAN. On the other hand, cellular incorporation of HIV-1 within the kidney is a requisite for the development of this disorder.

Predicting orthopedic involvement in patients with lipomyelomeningoceles.

INTRODUCTION: Lipomyelomeningoceles (LMM) occur in approximately 1 in every 4,000 live births in the United States. They are associated with a wide range of problems in affected patients, including skin abnormalities, sensory and motor deficits, pain, urinary bladder and anal sphincter dysfunction, and orthopedic deformities. MATERIALS AND METHODS: In an effort to better understand the orthopedic complications associated with LMM, the present study examined the long-term orthopedic deformities in 50 patients after surgical correction of their LMM and observed for correlation between these deformities and the type and level of LMM. RESULTS: Analysis of the collected data revealed a statistically significant relationship between of the type of LMM and the presence of orthopedic complications. However, no statistically significant relationship existed between the vertebral level of the LMM and the presence of orthopedic deformities. No correlation was identified between the level and type of LMM. CONCLUSION: In this study, caudal LMM were much more likely than either dorsal or transitional types to have orthopedic complications. These data may prove useful to clinicians in predicting outcome and in counseling patients and their parents.

Microbial and cytopathological study of intrauterine contraceptive device users.

CONTEXT: Intrauterine contraceptive device (IUCD) is a commonly used birth-spacing method which is fitted into maternal system. Clinical, microbial and cytopathological monitoring of women using these devices are important for ascertaining their side effects, risk of genital tract infection and carcinogenic potential. AIMS: To study clinical, microbial and cytopathological changes in IUCD users in a tertiary care hospital. DESIGN: Prospective analytic. SETTING: Tertiary hospital. MATERIAL AND METHODS: women visiting Family Planning clinic for follow up (IUCD users, n=100) or for IUCD insertion (controls, n=50) were enrolled in the study. Each subject underwent detailed history, general physical, systemic, and per local examination. Vaginal discharge was subjected to pH testing, KOH and wet mount examination, gram staining, and for culture and sensitivity. Bacterial vaginosis was defined using Nugent criteria. Cervical smears were examined and reported as per Bethesda system. STATISTICAL ANALYSIS: The information was entered into Microsoft Excel spreadsheet. The results were analyzed using EPI Info version-6 and Stata statistical software version 7 packages. Two-tailed t-test, chi2 test with Yates correction and two-tailed Fisher Exact tests were applied. RESULTS: Most women used CuT 200 (92%). Median duration of use was 2 years. Chief complaints of IUCD users included backache (54%), vaginal discharge (46%), pain lower abdomen (34%), dyspareunia (22%), menorrhagia (18%) and dysmenorrhea (14%). Mean hemoglobin was lower in IUCD users than controls (11.2+/-1.7 versus 11.9+/-1.8 g/dL, p 0.02). Proportion of women with anemia was higher in IUCD users than in controls (29% versus 16%, p 0.12). Cervical erosion was significantly increased in study group as compared the controls (20% versus 0%, p=0.00) whereas only insignificant increase in vaginitis (6% versus 0%, p=0.17). Trichomonas vaginalis and fungal hyphae positivity and gram stain findings and bacterial vaginosis rate were not significantly different in two groups. Vaginal discharge bacterial culture revealed comparable results in two groups. Cytological findings were predominantly inflammatory. None of cases revealed Actinomycosis infection. High-grade squamous intraepithelial lesion (n=2) and low grade squamous intraepithelial lesion (n=1) cytological finding were present in IUCD users compared to none in controls. None of the cases had any malignant transformation. CONCLUSION: IUCD use results in lower hemoglobin concentration and cervical erosion. Women using IUCD requires a regular follow up, clinical examination, counseling and further investigation if required.

Breast cancer incidence and exposure to pesticides among women originating from Jaipur.

Environmental contamination by pesticides has been documented in biotic and abiotic components. These persistent organic pollutants are lipid soluble, nonbiodegradable, and endocrine disrupters. The present study was therefore planned to determine whether the levels of these pesticides like DDT and its metabolites DDD and DDE, dieldrin, heptachlor, and HCH and its isomers (alpha, beta, and gamma) were higher in blood of breast cancer patients when compared with normal women who did not suffer from major diseases like blood pressure, tuberculosis, diabetes, thyroid dysfunction, arthritis, cancer, etc. and had not undergone any major surgery. The results indicated that organochlorine pesticides taken for analysis were found significantly high in breast cancer patients irrespective of age, diet, and geographic distribution.