Eclampsia reduction with maternal early warning trigger tool.

OBJECTIVES: To observe the incidence of eclampsia before and after implementing Maternal Early Warning Trigger (MEWT) tool. STUDY DESIGN: A retrospective observational study to evaluate the effect of introduction of MEWT tool in a tertiary referral center with 10,000 annual births. Two epochs of five years duration were compared before and after implementing MEWT tool. MEWT tool has triggers for early identification of clinical deterioration and pathways for four most important maternal morbidity causes including hypertension. Hypertension pathway has emphasis on rapid control of severe acute hypertension, lab tests and magnesium sulfate prophylaxis. All pregnant women who registered and delivered at the study institute were included. MAIN OUTCOMES MEASURES: Primary outcome was effect of MEWT tool on the incidence of eclampsia. A subset analysis was done to study the effect of MEWT tool on maternal and perinatal outcomes in women with hypertensive disease. Maternal ICU admissions, HELLP, pulmonary oedema, intracranial bleed and maternal deaths, and perinatal mean birthweight and gestational age, NICU admissions, prematurity, stillbirths, and neonatal deaths were compared. RESULTS: The study period had 37,043 and 45,637 women in pre- and post-MEWT periods. The incidence of eclampsia reduced by 45.4 % from 1.1 to 0.6 per 1000 women (p 0.001). The most significant reduction was seen with antepartum eclampsia (0.8 to 0.3 per 1000, p = 0.02). There was significant reduction in all maternal and perinatal outcomes in women with hypertensive disorders (3,506 and 6,016 in pre- and post- MEWT periods) after introduction of MEWT tool. CONCLUSION: Integrating the MEWT tool into the obstetric practice helps in reducing the incidence of eclampsia and improving maternal and fetal outcomes.

Effect of second trimester and third trimester weight gain on immediate outcomes in neonates born to mothers with gestational diabetes: a retrospective observational study from India.

Aim: To evaluate the effect of second trimester and third trimester rate of weight gain on immediate outcomes in neonates born to mothers with Gestational Diabetes Mellitus (GDM).Method and material: This retrospective observational study enrolled 593 eligible mothers. The records of all pregnant women booked before 24 weeks and screened for diabetes were eligible if they were diagnosed with Gestational Diabetes Mellitus (GDM) anytime during pregnancy. All the necessary maternal and neonatal details were collected from hospital database. The rate of weight gain was calculated at 18-24 weeks, 28-30 weeks, and that before delivery. The enrolled women were categorized into: poor weight gain, normal weight gain, and increased weight.Results and discussion: The mean birth weight, length, and head circumference of neonates were significantly lower in women who had poor rate of weight gain in comparison with normal weight gain group. The mean prepregnancy BMI was significantly high in women with increased rate of weight gain when compared to normal weight gain women in second and third trimester. Regression analysis done to evaluate the independent effect of weight gain on C section and neonatal complications, showed that the independent predictors for cesarean section were previous cesarean section or 12.5 (95% CI 6.7-23) and conception by assisted reproductive technologies or 1.75 (95% CI 1.01-4.3), and the neonatal complications were influenced by birth weight or 1.5 (95% CI 1.1-2.2) and weight gain during second trimester or 1.26 (95% CI 1-1.6).Conclusion: In women with GDM, reduced weight gain during pregnancy is associated with small for gestational age neonates. Caesarean section is predicted by previous C-section, and mode of conception whereas neonatal complications were predicted by birth weight and maternal weight gain during second trimester.

Need for guidelines for the combined management of pregnancy and dengue: a retrospective study from an Indian tertiary care maternity hospital.

The incidence of dengue has risen in India in recent years. Evidence suggests that dengue in pregnancy may be associated with adverse maternal and fetal outcomes. The aim of our study was to analyse outcomes in pregnant women with confirmed dengue infection who had the benefit of close monitoring and intensive management at a tertiary maternity facility. We reviewed hospital data of 44 (0.11%) such women at Fernandez Hospital, a tertiary maternity unit, during the five-year period from 2011 to 2016. Maternal and fetal variables were collected from case sheets. Dengue haemorrhagic fever was seen in 15.9% and dengue shock syndrome in one fatal case (2.2%). Thrombocytopenia was seen in 31 cases (70.4%) and 14 (31.81%) received platelets transfusions. Fetal outcomes in our series were favourable, except for one stillbirth, with 45.4% preterm deliveries and 15.9% small for gestational age babies. Dengue in pregnancy is definitely associated with maternal and fetal morbidity and mortality. A high index of suspicion of dengue is required in pregnant women with pyrexia and thrombocytopenia.

A Review of Outcomes in Pregnant Women with Portal Hypertension.

BACKGROUND: The course of pregnancy in a woman with portal hypertension is a difficult one as it is associated with complications like variceal bleeding, splenic artery rupture and coagulopathy. All these pose a threat to a woman's life. Although this condition is rare, every obstetrician should have a high index of suspicion when an antenatal mother presents with splenomegaly, thrombocytopenia or hematemesis. Hence, we aimed to review maternal and fetal outcomes in pregnant women with portal hypertension. METHODS: In a retrospective observational study, 41 women and 47 pregnancies were evaluated, from January 2000-December 2015 at Fernandez Hospital, a tertiary referral perinatal center. Maternal outcomes studied were variceal bleed during pregnancy, surgical procedures, morbidity and mortality. Neonatal variables were gestational age at delivery, birth weight and morbidities. RESULTS: Mean maternal age was 26.4 years. Average gestational age at delivery was 36.5 weeks. Mean birth weight was 2507.5 g. There were three maternal deaths out of 47 deliveries, the cause of death was massive variceal bleed in one, the second one was due to cardiac arrest on MRI table, and the third death was due to splenic hilar vessel bleed. There was one stillbirth, and no neonatal deaths. CONCLUSION: A multidisciplinary approach is essential to improve perinatal outcomes in pregnancy complicated by portal hypertension. Surgical measures to reduce portal venous pressure done before pregnancy or beta blockers during pregnancy might help reduce sudden variceal bleeds.

Synthetic osmotic dilators in the induction of labour-An international multicentre observational study.

INTRODUCTION: To evaluate the effects of synthetic osmotic dilators (Dilapan-S/ Dilasoft) in women who required induction of labour in a large prospective multicentre international observational study. MATERIALS AND METHODS: Primary outcomes were duration of Dilapan-S/Dilasoft insertion (hours), total induction - delivery interval (hours) and the rate of vaginal deliveries within 24 h (%). Secondary outcomes were the number of dilators inserted, Bishop score increase after extraction of Dilapan-S/Dilasoft, complications during induction (uterine contractions, uterine tachysystole and hyperstimulation, effect on the fetus) and post induction (infections and neonatal outcomes), agents / procedures used for subsequent induction of labour, immediate rate of spontaneous labours following cervical ripening period, rate of spontaneous vaginal deliveries, rate of instrumental vaginal deliveries and caesarean sections. RESULTS: Total of 543 women were recruited across 11 study sites, of which, 444 women were eligible for analysis. With Dilapan-S/Dilasoft use of <12 h (n = 188) the overall vaginal delivery rate was 76.6% with 45.7% of these births occurring within 24 h, 66% within 36 h and 75.5% within 48 h from insertion of Dilapan-S/Dilasoft. The mean insertion-delivery interval for this group was 24.3(±10.4) hours. With Dilapan-S/Dilasoft use of >12 h (n = 256), the overall vaginal delivery rate was 64.8%, with 16% of these births occurring within 24 h, 48.4% within 36 h and 54.7% within 48 h from insertion of Dilapan-S/Dilasoft. The mean insertion-delivery interval for this group was 39.1(±29.2) hours. The mean gain in the Bishops score was +3.6(±2.3). The mean number of Dilapan-S/Dilasoft dilators used was 3.8 (±1.1). The overall rate of caesarean section was 30.1%. The overall complication rate was low including infection risk. No adverse neonatal outcome was attributable to the use of Dilapan-S/Dilasoft. CONCLUSION: Dilapan-S/Dilasoft are safe and effective methods for cervical ripening. Their use is associated with low maternal and neonatal complication rates. Future research should aim at level I clinical trials comparing Dilapan-S to other mechanical or pharmacological cervical ripening agents. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT02318173.