Comparing Obstetric and Perinatal Outcomes Following Elective and Emergency Cervical Cerclage in Singleton and Multiple Pregnancies in a Tertiary Care Perinatal Centre.

Objective: To compare the success, failure rates and perinatal outcomes following emergency and elective cervical cerclage in singleton and twin pregnancies at a tertiary care perinatal centre over half a decade. Methods: All pregnant women, both with singleton and twin pregnancies, who had cervical cerclage between June 2014 and May 2019 were included in the retrospective study. Success rates, failure rates, maternal complications and perinatal outcomes were compared in both groups. Results: There were 129 women enrolled in the study, 48 in the emergency and 81 in the elective group. A significantly greater number of multiparous women were in the elective group (97.5% versus 68.7%; p-value < 0.001). Twins were nearly four times more in the emergency group as compared to  the elective group. The mean cervical length at time of cerclage was 2.05 cm and 1.5 cm; (p-value < 0.001) respectively in the elective and emergency groups. Almost half of the women in the emergency group had bulging membranes. (52.2%). Following cerclage, mean gestational age at delivery was similar in both groups. However, more women in the elective group delivered at or beyond 34 weeks in comparison to the emergency groups (71% versus 53.3%. P-value 0.05). Preterm labour leading to preterm births was almost twice in the emergency group than elective group (49% versus 22%, P-value 0.002). Rates of maternal chorioamnionitis were similar in both groups. The overall live birth rates were comparable (81.3% versus 84.4% P-value 0.85) in both the groups. These results were also seen on doing subgroup analysis of elective versus emergency cerclage in singleton pregnancies only. Failure rates were also similar in both groups (18.7% versus 15.6%, P-value 0.85) Composite neonatal morbidity was more in the emergency group than in the elective group (35.5 versus 14%, P-value 0.01). Conclusion: Live birth rates and failure rates were comparable following elective and emergency cerclage both overall and in singleton pregnancies. Maternal chorioamnionitis and neonatal sepsis  rates were similar in both the groups. However, composite neonatal morbidity was higher in the emergency cerclage group.

Serotype distribution and antimicrobial susceptibility profile of invasive group B streptococcal disease-in South Indian population.

PURPOSE: Invasive group B Streptococcal disease (iGBS) is an important cause of morbidity and mortality in neonates for which the development of an efficacious vaccine remains a global health imperative. The knowledge about the serotype distribution of iGBS is important component for formulation of Capsular polysaccharide (CPS)-based vaccine. However, there were absolute lack of information on serotype distribution in invasive GBS isolates from Indian subcontinent. Methods This study has assessed the serotype distribution and antimicrobial susceptibility profile of invasive group B streptococcal isolates for a period of 13 years from 2009 to 2022 from a tertiary care Center in South India. A total of 155 iGBS isolates were subjected to serotyping by conventional multiplex PCR for identification of all ten GBS serotype. Antimicrobial susceptibility profile and demographic details were extracted from microbiological records. Results Overall, the most common serotype causing invasive GBS were Ia (29%), V (26%), III (15%), II (12%), VI (6%), VII (5%) and Ib (5%). Serotypes IV, VIII and XI were not detected. Among the early-onset iGBS, the common serotype were Ia (36%), V (27%), and III (8%). In late onset iGBS, Serotype III (44%) was predominant. The common serotype in adults were Serotype V (31%) and III (20%). All the invasive GBS isolates were susceptible for penicillin (100%), but the susceptibility for clindamycin and erythromycin were 72% and 80% respectively. Conclusion The serotype distribution of invasive Group B streptococcal isolates from India suggest that hexavalent group B CPS vaccine will cover only 90% of GBS isolates causing invasive disease among the infants in India. Continued surveillance monitoring for serotype distribution and antimicrobial resistance patterns for iGBS are warranted to make public health interventions.

Successful Outcome of Pregnancy in Niemann-Pick Disease Type B: A Case Report and Review of Literature.

Niemann-Pick (NPD) is a rare autosomal recessive disease, caused by deficiency of acid sphingomyelinase enzyme leading to accumulation of lipids mainly in the reticuloendothelial system and lungs. We describe the case of a 29-year-old primigravida, recently diagnosed with NPD type B. At initial evaluation, her platelets were normal, liver enzymes slightly elevated and splenomegaly on scan. Pregnancy care was by a multidisciplinary team which routinely monitored her liver and pulmonary functions along with platelets. Labor was induced at 37 + 1 weeks of gestation because of fetal growth restriction. She underwent an cesarean section for failed induction and delivered a healthy male baby. Conclusion: Successful outcomes in such pregnancies depend upon close monitoring by a multidisciplinary team.

Spectrum of Chromosomal Abnormalities Detected by Conventional Cytogenetic Analysis Following Invasive Prenatal Testing of Fetuses with Abnormal Ultrasound Scans.

Objectives: The frequent association between malformations and chromosomal abnormalities is now well-established. This study looks at the incidence and type of chromosomal abnormalities detected by conventional cytogenetic analysis in women undergoing invasive tests following detection of fetal anomalies on antenatal scans as well as incidence of other genetic abnormalities detected by DNA analysis of fetuses with congenital anomalies that had a normal karyotype. Materials and Methods: A retrospective, observational study of pregnant women undergoing invasive testing following identification of fetal anomalies by ultrasonography was carried out in a tertiary care facility, Vellore, India, between 2011 and 2018. Results: 169 women underwent an invasive diagnostic procedure following detection of fetal anomalies. The most common indication for doing fetal karyotype was the presence of major fetal structural anomalies (142/169, 84%) with over a third (48/142, 34%) having multisystem involvement. Fetal hydrops was the next most common indication, detected in 18/169 (10%) fetuses. Aneuploidy was seen 19 of 25 fetuses (76%) with an abnormal karyotype with autosomal aneuploidy accounting for 13 (68%) and sex chromosome aneuploidy for seven (37%) of the fetuses. One fetus had double aneuploidy. In fetuses with normal karyotype, no additional information was obtained from further genetic testing. Conclusions: The overall detection rate of chromosomal abnormalities in our study using conventional cytogenetic analysis was 14.8%, the majority (72%) being associated with structural malformations, 20% with non-immune hydrops and 4% with soft markers. Abnormal karyotypes were seen in 12.7% of fetuses with structural malformations.

A retrospective study analyzing indications and outcomes of mid-trimester emergency cervical cerclage in a tertiary care perinatal centre over half a decade.

We studied the indications, success rate, perinatal outcomes and maternal complications following mid-trimester emergency cervical cerclage. All women undergoing mid-trimester emergency cerclage at our centre during 2014-2019 were included in this retrospective study.There were 46 women in our cohort. Mean cervical length was 1.5 cm (SD ± 0.7), and 52.1% of them had bulging membranes. The mean gestational age at cerclage was 23.35 weeks (SD ± 3.341). Three were loss to follow up.Out of 43 pregnancies (23 singletons and 20 twins) analyzed, 37/43, 86.4% had livebirths. Success rate in the singletons and twins were 91.3% and 80% respectively. Maternal complications were seen in 56.5% of patients. Composite neonatal morbidity was significantly more in the twin group (p-value 0.04).Overall live birth rate was 86.4% with similar success rates in singleton and multiple pregnancies. Although, evidence for beneficial effect of prophylactic cerclage in multiple gestation is lacking, emergency cerclage may have a role in twin gestation.

Breast milk contains red cell isohaemagglutinins: An observational study of 176 mothers.

BACKGROUND AND OBJECTIVES: Maternal antibodies are transferred to the child, predominantly IgG, via the transplacental route, and mostly IgA through breast milk. Cases reported by us and others have shown the transfer of red cell allo-antibodies through breast milk. This study was conducted to assess the presence of isohaemagglutinins in breast milk, the range of titres, and the correlation between breast milk and maternal plasma titres. MATERIALS AND METHODS: A total of 176 mothers were recruited in this study. Breast milk was collected after sufficient feeding was established and within 2-5 days of delivery in a sterile container without any anticoagulant. Antibody screen, identification and titres were performed on maternal plasma as well as breast milk. RESULTS: Anti-A and anti-B in breast milk corresponding to their respective maternal blood groups were found in all the samples. This study has shown titres in the breast milk of anti-A and anti-B ranging from 2 to 1024 in both saline and Coombs phases. There was no association between plasma and breast milk titres, thus making it impossible to predict which mother may potentially transfer a larger amount of these haemagglutinins. Isotypes of anti-A and anti-B were evaluated in both plasma and breast milk of 11 samples, which showed predominantly IgG in 7 (63.63%) and predominantly IgA in 4 (36.36%) samples. CONCLUSION: Our study demonstrates the presence of a wide range of titres for IgG antibodies of the ABO blood group system in breast milk. The clinical impact of this finding needs to be studied further, as it assumes great relevance in developing countries where anaemia continues to challenge young infants.

An Integrated System for Fetal Scalp Visualization, Blood Collection and Analysis.

KEY MESSAGE: The new NB scope aids in better visualization of the scalp and blood collection and analysis at bed side. OBJECTIVE: Caesarean section rates and inherent complications are on the rise all over the world. One way to avoid a caesarean is to measure fetal scalp blood lactate levels. The methods available to visualize fetal scalp, obtain the blood sample and perform the blood test are separate, cumbersome and expensive, needing a certain level of expertise. We propose a device that incorporates all the steps of obtaining a fetal scalp blood lactate into one sleek, easy to use device. METHODS: The initial design, 3-D print and was tried on mannequin. After ethics committee approval, the prototype was experimented on patients in labour with singleton live fetus in cephalic presentation with no evidence of distress. RESULTS: There were (n = 9) patients recruited. There were (n = 5) primigravida and (n = 4) multigravida all of whom were in active labour. Parity did not seem to influence ease of instrumentation. Of the (n = 9) mothers (n = 2) had meconium-stained liquor and the rest (n = 7) had clear liquor, meconium-stained liquor did not affect visualization. The mean time taken to collect the sample was 184.11(± 33.04) seconds. CONCLUSION: The Neeraj-Bhaskar (NB) scope is an easy to use, affordable device that can be used time and again to decide on cases where emergency caesarean section can be avoided due to fetal distress.

Obstetric and perinatal outcomes in pregnant women with Takayasu's arteritis: single centre experience over five years

Objective: To study obstetric and perinatal outcomes among pregnant women with Takayasu arteritis (TA), attending our hospital for pregnancy and childbirth between January 2011 to December 2016. Material and Methods: Retrospective study was carried out by abstracting clinical charts on all pregnant women with TA who underwent antenatal care and/or delivery in our hospital during this period. American College of Rheumatology criteria was used for diagnosis of TA. Sixteen women with TA were included in the study. Maternal demographic data, stage of disease, complications related to disease, details of treatment taken prior to pregnancy, pregnancy outcomes, and neonatal outcomes were studied. Results: Forty-four percentage (7/16) belonged to type 5 angiographic type, however the same proportion (7/16) had undergone surgical corrections prior to pregnancy and the majority (15/16) were on medical management. Only three women (19%) were diagnosed during pregnancy. Most did not have active disease measured by Kerr's criteria (n=12; 75%), and Indian Takayasu clinical activity scores A. Chronic hypertension was the commonest antenatal complication (56.2%), nearly one-third had growth restricted babies and 25% had preterm labour. There were no cardiovascular events, no maternal deaths, nor fetal or neonatal deaths. Two-thirds of our women were delivered by caesarean section. Conclusion: Preconceptional counselling is of paramount importance in women with TA. Good maternal and fetal outcomes are observed with close antenatal surveillance and multidisciplinary care. Pregnancy should be planned during disease remission, with good antenatal care, close monitoring of clinical symptoms, early diagnosis and treatment of complications.

Decoding stillbirths using the Relevant Condition at Death classification: Study from the developing world

Objective: To determine the stillbirth rate in 2017 at Christian Medical College, a tertiary care perinatal center in South India, and to identify causes for the various stillbirths that occurred using the Relevant Condition at Death (ReCoDe) classification. Material and Methods: Medical records of the women with stillbirths between January 1st, to December 31st, 2017, were retrieved and analyzed using the SPSS software (IBM, version 23). The study was approved by the institutional review board (minute no: 11273, retro dated: 28/3/2018). Results: Of the total 14696 deliveries between January 1st, 2017, to December 31st, 2017, there were 247 stillbirths, a rate of 16.8 per 1000 births. Maternal factors: 156 (64.2%) women were booked and the rest were un-booked. Hypertensive disorders of pregnancy were detected in 27.5% (n=67). A greater number of un-booked women had gestational hypertension as compared with booked women (41% vs 24%, p=0.005). Fetal characteristics: still births secondary to lethal congenital anomalies were seen in 18.2% (n=45). Lethal congenital anomalies were diagnosed 10 times more in the booked patients than un-booked ones (24.7% vs 2.3%, p=0.001). Obstetric factors: one or two previous miscarriages were seen in 29.5% cases. Seventeen women (6.9%) had a prior stillbirth. ReCoDe Classification: we were able to successfully classify 84.2% of the stillbirths, leaving 15.78% unclassified. Fetal growth restriction secondary to uteroplacental insufficiency was found in 25.9% cases. Of the placental causes, abruption accounted for 10.9% of cases. Medical co-morbidities were seen in 46.5% pregnancies. Conclusion: The ReCoDe method of classifying stillbirths is useful in the developing world. It helped to elucidate the cause for stillbirths in 84.2% of cases. The majority of cases in our set were due to fetal growth restriction, hypertensive disorders of pregnancy, and uteroplacental insufficiency. Stillbirths can be prevented by a comprehensive antenatal care system, early recognition, and close monitoring of high-risk pregnancies.

Prevalence of group B Streptococcal colonization among pregnant women and neonates in a tertiary hospital in India.

OBJECTIVE: To estimate the prevalence of group B Streptococcus (GBS) carriage among pregnant women attending the antenatal clinic, and the colonization rates among newborn born to colonized mothers. MATERIAL AND METHODS: Women attending the antenatal clinic between 35-37 weeks were screened using rectal and lower vaginal swab. Swabs were initially plated on sheep blood agar and LIM broth. The LIM broth was subcultured after 24 hours onto blood agar and CHROMagar StrepB plates with all plates checked for growth at 24 and 48 hours. All babies born to mothers in the study had surface swabs taken to estimate the vertical transmission rate. RESULTS: Between September 2012 and March 2013, 305 consecutive mothers were screened. Of these, eight mothers were GBS positive in 5% blood agar (2.6%) and 23 mothers showed GBS positivity in enriched media (7.6%). Sixteen of 238 babies (6.7%) were colonized. CONCLUSION: Though lower than rates from most countries, 7.6% of mothers attending an antenatal clinic in south India were colonized with GBS. Use of enrichment media markedly increased the detection rate. Approximately two-thirds of newborn born to colonized mothers were also colonized. There were no instances of invasive GBS disease, indirectly proving the efficacy of intrapartum prophylaxis in preventing neonatal GBS disease.

Harlequin Ichthyosis: Prenatal Diagnosis of a Rare Yet Severe Genetic Dermatosis.

Harlequin Ichthyosis (HI) is an extremely rare genetic skin disorder. It is the most severe type of ichthyosis. It is characterized by thickened, dry, rough and armor like plates of skin with deep cracks in between. Alternative names for HI include- keratosis diffusafetalis, ichthyosis congenital, icthyosis fetalis, harlequin fetus and icthyosis congenital gravior. It is an autosomal recessive disorder with the majority of affected individuals being homozygous for mutation in the ABCA 12 gene. This condition presents with a wide range of severity and symptoms. Affected neonates usually do not survive beyond first few days of life. We are presenting prenatal diagnosis of a case of this rare condition.

Risk Factors for Stress During Antenatal Period Among Pregnant Women in Tertiary Care Hospital of Southern India.

BACKGROUND: The well-being of an infant may be affected when the mother is subjected to psychosocial stress during her pregnancy. Mothers exposed to stressful conditions were more prone for preterm birth than those without any stress. In this study perceived stress has been used as an indicator of levels of stress. There are very few studies published from developing countries on the levels of perceived stress and its causes in pregnant women. MATERIALS AND METHODS: This study employed a cross-sectional assessment of pregnant women attending the outpatient services of a tertiary care hospital for regular antenatal check-up. Women not known to have any risk factors at 28 weeks to 34 weeks of pregnancy who agreed to participate in the study were interviewed to assess the perceived stress score. RESULTS: Among the total patients 57.7% were primigravida and the mean score on perceived stress scale was 13.5±5.02. The majority of the group (102; 65.4%) scored higher than the mean value of total score on the perceived stress scale. Unplanned pregnancy and husband's employment status were associated with high levels of perceived stress in multivariate analysis in this set of women. CONCLUSION: Individual as well as pregnancy related factors can contribute to perceived stress in pregnant women. With the established relationship between maternal mental health, pregnancy outcome and infant growth, the assessment and management of stress early in the pregnancy is crucial.