Associations, follow up data, and postnatal outcome of antenatally diagnosed Urinary Tract Dilatation - Five-year single tertiary center experience from South India.

BACKGROUND: Urinary tract dilatations (UTD) are frequently diagnosed during Mid-Trimester Anomaly Scan (MTAS), at which time, given their variable progression and heterogeneous classification systems, offering suitable counsel to the couple is challenging. OBJECTIVE: Based on postnatal data, we aimed to guide parental counseling, and further evaluation of UTD diagnosed at MTAS. Specifically, the utility of multi-disciplinary UTD classification system was tested. METHODS: A retrospective observational study of all UTDs included from five years (2015-2020) MTAS register. The multi-disciplinary UTD classification system was used for antenatal/postnatal UTD categorization. Follow-up data were obtained from case records until the current age of children (2-6 years). RESULTS: Out of 527 fetal abnormalities, 103 had UTD at MTAS. Based on the third-trimester ultrasound, 49 were low-risk UTD A1, and 44 were increased-risk UTD A2-3 (including the nineteen UTD A1 at MTAS worsened to A2-3 by third-trimester). On postnatal follow-up of UTD A1 and A2-3, respectively, neonatal UTD P2/P3 was seen in 2% and 40.9%; complete spontaneous resolution was seen in 79.5% and 43.18%; none and 22.7% underwent surgical intervention; persistent P2/P3 UTD were seen on follow-up in 2% and 4.5% (excluding those who needed surgery); impaired renal function was seen in none and 36.3%, and recurrent UTI in 8.1% and 34.09%. The subgroup with progressive UTD (from A1 to A2-3 by third-trimester ultrasound) formed 43% of the final UTD A2-3 category. Among these 19 cases, surgical intervention was performed in eight (42%); impaired renal function was seen in 7 cases (36.8%), and recurrent UTI was seen in eight (42%). DISCUSSION: Given the diverse classification systems for UTD, ours is the second Indian data proving the prognostic utility of multi-disciplinary UTD classification system, specifically at third trimester scan, based on postnatal outcome. In contrast to published guidelines, our data suggests follow-up for renal pelvis anteroposterior diameter (APD) of 4-7 mm at MTAS, as some may worsen. Similar progression has been noted in other Indian studies, but the classification systems are different. Contrary to the published literature, we could not suggest a renal APD cut-off as a single criterion to predict surgical intervention. Significant limitations are retrospective observational design and multiple sonographers. CONCLUSION: Our data helps guide parental counseling and further evaluation for UTD diagnosed at MTAS. The multi-disciplinary Consensus UTD Classification system, was helpful in prognostication.

Clinical utility of aortic isthmus Doppler in the prediction of perinatal outcomes.

BACKGROUND: Doppler studies of uteroplacental-fetal circulation have been proven useful in diagnosing fetal growth restriction, appropriately timing delivery, and improving perinatal morbidity and mortality. There has been an extensive search for the ideal means to identify fetuses between the compensatory and acidemic phase (ie, the "preacidemic phase"), and the aortic isthmus Doppler seems to show promise. OBJECTIVE: This study aimed to investigate: (1) the prevalence of abnormal aortic isthmus Dopplers in a cohort of small-for-gestational-age fetuses and their correlation with other conventional Doppler abnormalities, and (2) the predictive ability of abnormal aortic isthmus Dopplers with regard to short-term adverse neonatal outcomes. STUDY DESIGN: Fetuses diagnosed as small-for-gestational-age at ≥24 weeks' gestation were included. Management was as per the standard protocol. Aortic isthmus Doppler was performed within a week of delivery with other conventional Dopplers. The adverse perinatal outcomes studied were: requirement of neonatal resuscitation at birth, Apgar score at 5 minutes <7, cord blood pH <7, presence of bronchopulmonary dysplasia, hypoxic-ischemic encephalopathy, grade III/IV intraventricular hemorrhage, necrotizing enterocolitis, sepsis, neonatal intensive care unit stay longer than 14 days, and stillbirth or neonatal death. RESULTS: Among 121 small-for-gestational-age fetuses, 67 showed Doppler abnormalities in ≥1 vessels. The prevalence of abnormal aortic isthmus Doppler was 14.87%. Analysis was between group 1 with 103 normal aortic isthmus and group 2 with 18 abnormal aortic isthmus fetuses; 41 cases had some form of adverse perinatal outcome, the frequency of which was comparable between the groups. Abnormal aortic isthmus Doppler had a significant correlation with low cerebroplacental ratio, absent or reversed end-diastolic flow in the umbilical artery, and high pulsatility index in the ductus venosus. The positive likelihood ratio for predicting composite adverse perinatal outcome was 10.2 for absent or reversed end-diastolic flow in the umbilical artery, 9.6 for low cerebroplacental ratio, 2.28 for absent or retrograde flow in the aortic isthmus, and 2 for abnormal ductus venosus. CONCLUSION: Predelivery abnormal aortic isthmus Dopplers performed worse than other conventional Dopplers in predicting abnormal perinatal outcomes.

A case series of rare neurological and cardio-pulmonary manifestations of thiamine deficiency in pregnancy and lactation.

Thiamine (vitamin B1) is a sulfur-containing, water-soluble vitamin that plays an essential role in energy metabolism and the tricarboxylic acid cycle. There is an increased need for vitamin B1 (1-1.2 mg daily) during pregnancy and lactation. Hyperemesis during pregnancy can cause severe polyneuropathy (Wernicke's encephalopathy) as a result of thiamine deficiency. Thiamine deficiency has also been associated with beriberi. A number of atypical cases with reversible right heart failure and severe pulmonary hypertension have also been reported in non-pregnant individuals, but have never been reported in pregnancy. Here we present five such cases of thiamine deficiency with neurological and cardio-pulmonary manifestations.

Multimodality Screening for Lower Genital Tract Infections Between 18 and 24 Weeks of Pregnancy and its Efficacy in Predicting Spontaneous Preterm Delivery.

BACKGROUND: Predicting spontaneous preterm birth (SPTB) during mid-trimester would be very useful. We used a multimodality screening approach mainly focusing on urogenital infections among unselected obstetric population between 18 and 24 weeks in a tertiary center. METHOD: Diagnosis of lower genital tract infection (LGTI) was attempted among 228 pregnant women using several factors-symptom of vaginal discharge, characteristic appearance of discharge on speculum, point of care tests using Amsel's criteria and gram staining of vaginal swab. Nugent's scoring was taken as gold standard. Urine microscopy/culture was obtained. Serum inflammatory markers were done. Total leukocyte count, neutrophil/lymphocyte ratio and C-reactive protein were obtained. Data on cervical length were obtained from mid-trimester scan. RESULTS: Thirty patients complained of vaginal discharge. Speculum examination revealed discharge in 221 (96.92%), appearing pathological in 192 (86.87%). Amsel's criteria showed poor sensitivity to detect full (57%) and partial (24%) bacterial vaginosis (BV). On gram staining, 104 (45.61%) showed evidence of LGTI; 14 full BV (6.1%); 45 partial BV (19.5%); 40 candidiasis (17.5%); and two each of trichomoniasis and aerobic vaginitis. Appearance of vaginal discharge and microscopic diagnosis of LGTI were poorly correlated. Forty women (17.5%) had SPTB, 24 following membrane rupture and 16 following spontaneous labor. The presence of BV (specifically partial) increased the likelihood of SPTB with OR of 3.347 (CI 1.642, 6.823). Three of seven women with short cervix delivered preterm. No other screening modality was associated with SPTB. CONCLUSION: Active screening for LGTI between 18 and 24 weeks shows high prevalence of BV in Indian setting. There is a strong link between partial BV and SPTB.