Interventions to reduce caesarean section rates at government medical college and hospital Aurangabad, India

Background: Caesarean sections are effective in saving maternal and infant lives, but only when they are performed for medically indicated reasons, The Objective of this study was to reduce caesarean Section rate at GMCH, Aurangabad and to improve overall birthing experience with respectful maternity care.Methods: The caesarean sections done at GMCH Aurangabad were audited using Robson`s Ten Group classification system to identify the major contributors to the overall CS rate. The following clinical and non-clinical interventions were applied dynamically to control the caesarean section rates. Clinical Interventions were changes in protocols regarding induction of labour, Intermittent auscultation as opposed to continuous electronic foetal monitoring in low risk cases, use of a partogram, encouragement of different birthing positions, promoting TOLAC to reduce the secondary CS rate. Nonclinical interventions include encouragement of DOULA (birth companion), ante-natal counselling of the expectant mothers, training of healthcare staff for respectful maternity care and use of evidence based clinical practice guidelines with mandatory second opinion for every non recurrent indication of CS. Auditing of caesarean section using Robson classification.Results: In this study there has been steady decline in LSCS rates from 33% to 26.9%. On analysis with Robson classification, group 5 (previous LSCS) made largest contribution of 36.9% followed by Group 1, 2, 10 each contributed 18.01%,13.2% and 11.2% respectively. Group 6 to 10 account for 23%. Various birthing positions lowered use of oxytocics from 33 % to 19% as well lowered episiotomy rates with greater success in vaginal delivery.Conclusions: Modification of induction protocols have reduced the primary LSCS rates and successful VBAC using FLAMM score was helpful in reducing the repeat caesarean Sections. Various birthing positions, DOULA gave greater success in vaginal delivery. LSCS rates in mothers with breech, multiple or oblique/transverse lies were largely unmodifiable. Limiting the CS rate in low-risk pregnancies by individualizing every labour and not to set a time limit as long as mother and baby are closely monitored.

An unusual cause of edema in a child with congenital heart disease post Fontan procedure

Protein Losing Enteropathy Post Fontan procedure. Protein Losing Enteropathy (PLE) is an uncommon cause of edema in children with congenital heart disease. Protein-Losing Enteropathy may be defined as excessive loss of proteins across the intestinal mucosa and is due to either a primary gastrointestinal abnormality or secondary to cardiac disease. Protein-losing enteropathy (PLE) is a rare complication of the Fontan palliation for functional single-ventricle. Although PLE occurs in about 3.5% of patients post-Fontan, it confers marked morbidity and high mortality within 5 years of diagnosis. The pathogenesis of Fontan-related PLE is not completely understood, and it is unclear why it develops in some patients post-Fontan and not others. We describe a child with Double Inlet Right Ventricle who had undergone Fontan procedure, and presented to us with generalised oedema. The child had hypoproteinaemia, the common causes for which were ruled out and was diagnosed as Protein Losing Enteropathy (PLE) related to his surgical intervention. Though, not frequently encountered it should be kept in mind as one of the causes of anasarca.

Neurocognitive outcome in young child with Isovaleric Acidemia

Isovaleric Acidemia (IVA) is inherited as an autosomal recessive trait, caused by the deficiency of the enzyme isovaleryl CoA dehydrogenase. It has the prevalence of 1 in 62,500 (in parts of Germany) to 1 in 250,000 live births (in the United States). Acute episodes of metabolic decompensations may occur, which may mimic sepsis, ketosis or shock. Early diagnosis & early initiation of treatment has been reported to correlate with a good neurocognitive outcome. This is case of child presenting in Paediatric emergency department with fever, vomiting, increased respiratory activity and lethargy. Child had GCS score of 8/15, acidotic breathing, hypotonia with hyporeflexia. Sepsis screen, metabolic work up and neuroimaging were all normal except for high anion Gap acidosis with ketosis. So further neurometabolic screening work up was done in view of persistent metabolic acidosis, developmental delay, and bad obstetric history in mother. It revealed increased excretion of isovalerylglycine 1(IVG 1), Isovalerylglycine 2 (IVG2) Lactate, 3-Hydroxypropionate (3HP) and 3-Hydroxybutyrate (3 HB).Serum lactate 358.54 (control 1.1-208.1) confirming the diagnosis of Isovaleric Acidemia. After recovery from the acute attack, the patient was advised low-protein diet (1.0-1.5 g/kg/24 hrs.) and carnitine (100 mg/kg/24 hrs. orally) supplements. On follow up child is asymptomatic & showing neurological improvement as he started achieving further developmental milestones during 6 months follow up.Early diagnosis and early treatment of IVA cases definitely results in favorable outcome and better prognosis. But chronic intermittent cases presenting late should not be neglected, proper medical management can reverse neuromotor consequences in them also.

Genotoxicity in lead treated human lymphocytes evaluated by micronucleus and comet assays.

Lead (Pb) which plays a significant role in modern industry is related to a broad range of physiological, biochemical, behavioural and genetical dysfunctions. Its exposure leads to an increased frequency of genetic aberrations in humans. Hence, this study was designed to assess the genotoxic effect of lead acetate at three dosage levels (10, 25 and 50 µg/mL) by employing: the Cytokinesis Block Micronucleus (CBMN) assay and the Comet assay in Peripheral Blood Lymphocyte Cultures. The results of this study revealed an increased level of DNA damage among treated groups. A significant increase in the tail length of comets and other indices was observed at 25 and 50 µg/mL concentrations comparatively. Thus, lead acetate induced single-strand breaks (SSB) and double strand breaks (DSB) in DNA, alkali-labile sites (ALS), oxidative DNA damage as well as DNA-DNA/DNA-protein/DNA-metal cross linking as evidenced by the Comet assay. The chromosome breakage, DNA misrepair, chromosome loss and telomere end fusion were determined by the Micronucleus assay. Micronucleus frequency in treated lymphocytes was significantly higher as compared to controls. Nucleoplasmic bridges increased significantly and Nuclear buds increased at higher two doses only in exposed cultures. Thus, these assays are better indices for lead induced genotoxicity and metal-nucleus interactions.