Comparing the outcomes of rheumatic heart disease in pregnancy complicated with and without atrial fibrillation: A propensity score matched analysis.

BACKGROUND: Atrial fibrillation (AF) may increase the risk of adverse maternal and fetal outcomes among pregnant with rheumatic valvular lesions (RHD). We aimed to assess the rate of occurrence of AF in pregnant with RHD and its impact on cardiac and maternal-fetal outcomes compared to those without it. METHODS: The study group consisted of pregnant women with RHD and AF (cases) and a matched comparison group of pregnant women with RHD but without AF (controls) was derived from the database of pregnant women with RHD receiving care at our center between 2011 and 2021. Incidence of composite adverse outcomes(maternal death, heart failure, or thrombo-embolic events) and pregnancy outcomes were compared between them. RESULTS: Seventy-one (5.1%; 95%CI 4.1%-6.4%) pregnant women with RHD had AF during pregnancy and childbirth, most occurring in the late second or early third trimester. New-onset AF was diagnosed in 34 (47.9%) of them. After matching, the incidence of composite outcome was higher in women with AF (77.5% (95%CI 66.3%-85.7%) compared to women without AF (17.3%(95%CI 13.3%-22.1%), P < .001), with seven (9.9%) maternal deaths among cases and two (0.7%) in controls. Heart failure was the most common adverse cardiac event (26.7% vs. 4.2%, P < .001, cases vs controls). Those with AF had higher odds (adjusted OR 56.6 (14.1-226.8)) of adverse cardiac outcomes after adjusting for other risk factors. The frequency of most non-cardiac pregnancy complications was similar in both groups. However, there was a trend towards a higher rate of miscarriage (16.9% vs. 9.9%), small-for-gestational-age babies(16.3 vs. 9.0%), and cesarean rates(31.9% vs. 18.3%) women with AF compared to those who did not experience AF. CONCLUSIONS: Atrial fibrillation in pregnancy among women with RHD was associated with an increased risk of maternal morbidity and mortality, with a trend towards an increase in some non-cardiac pregnancy complications compared to those pregnant women without AF. Our study results provide background data for developing and implementing a pregnancy-specific management strategy tailored to middle-income settings.

Postpartum Mental Health Status & Role Transition to Mother in Primigravid Women: A Cross-Sectional Study.

OBJECTIVE: : To assess the incidence of postpartum depression, maternal confidence about parenting and maternal-infant bonding characteristics in first-time mothers. BACKGROUND: : First-time mothers are usually unprepared for the transition into motherhood and may find it difficult to cope-up with this challenge leading to parenting stress, maternal-infant bonding disorders, and mental health problems. METHODS: : This cross-sectional study was conducted in a tertiary centre in South India, on 151 primigravid mothers who delivered a live-born healthy infant after 37 weeks' gestation. Assessment was done using Patient Health Questionnaire scale, Tamil version of the Postpartum Bonding Questionnaire and Maternal Confidence Questionnaire on the 2nd or 3rd postpartum day. RESULTS: : Incidence of postpartum depression was found to be 18.5%, with 6% having features of severe depression. All mothers had good perceived maternal confidence. Nearly one-third had one or more of the maternal-infant bonding disorders. Those who had a vaginal delivery were associated with bonding disorders (OR = 10.3; 95% CI 2.13-47.21) whereas moderate to severe postpartum depression was not associated with it on multivariate analysis. CONCLUSION: : First-time mothers were found to have good confidence in the transition to motherhood. However, the high incidence of maternal-infant bonding difficulty, especially in those with moderate to severe depression, suggests the need for initiating systematic and routine screening for postpartum mental health problems.

Indicators for maternal near miss: an observational study, India.

Objective: To compare the incidence of maternal near miss using the World Health Organization (WHO) near-miss tool and six other criteria sets, including criteria designed for low-resource settings or specifically for India. Methods: In a cohort study we used WHO severity indicators to identify women with potentially life-threatening conditions during pregnancy or childbirth admitted to a referral hospital in Puducherry, India, from May 2018 to April 2021. We analysed sociodemographic, clinical and laboratory data for each woman and calculated the incidence of maternal near miss and other process indicators for each set of criteria. Findings: We analysed data on 37 590 live births; 1833 (4.9%) women were identified with potentially life-threatening conditions, 380 women had severe maternal outcomes and 57 died. Applying the different sets of criteria to the same data, we found the incidence of maternal near miss ranged from 7.6 to 15.6 per 1000 live births. Only the Global Network criteria (which exclude laboratory data that may not be available in low-resource settings) and the WHO criteria could identify all women who died. Applying the criterion of any number of units of blood transfusion increased the overall number of women identified with near miss. Conclusion: The WHO and Global Network criteria may be used to detect maternal near miss in low-resource settings. Future studies could assess the usefulness of blood transfusion as an indicator for maternal near miss, especially in low- to middle-income countries where the indicator may not reflect severe maternal morbidity if the number of units received is not specified.

Risk factors of intracranial haemorrhage in preeclampsia: a case-control study.

Intracranial haemorrhage (ICH) is an uncommon but one of the most devastating and potentially fatal complications of preeclampsia. Most ICHs in pregnancy are reported in the absence of a vascular lesion, and severe systolic hypertension is thought to be an important risk factor even though many reports suggest that ICH can complicate preeclampsia even at lower blood pressure levels. In this case-control study of preeclamptic women, risk factors associated with ICH were compared in women who did and did not develop ICH. During the study period, ICH occurred in 1.8% (42/2167) pregnancies with preeclampsia, with 45.2% (n = 19/42) resulting in maternal mortality. HELLP syndrome (OR = 11.5; 95% CI 3.8-34.8), multiparity (OR 3.2; 95% CI 1.4-7.7), nausea/vomiting (OR = 3.6; 95% CI 1.4-9.3), and lower educational attainment (OR = 38.2; 95% CI 3.5-423.6) were associated with the increased probability of ICH. The incidence of caesarean birth (n = 29, 74.4% vs. n = 161, 34.5%) and neonatal mortality (n = 4, 13.3% vs. n = 17, 4.0%) were higher among preeclamptic who have ICH compared to those who did not have it. Improving awareness as well as early identification of those at risk of preeclampsia and complications can limit the impact of ICH among pregnant women with preeclampsia, especially in low- to middle-income countries.

Risk factors for posterior reversible encephalopathy syndrome in hypertensive pregnant women presenting with seizures.

Pregnant women developing generalised tonic-clonic seizures in the absence of a prior neurological disorder are often diagnosed as eclamptic. Posterior reversible encephalopathy syndrome (PRES) is a distinct neuroimaging condition associated with long-term sequelae, which may occur in pregnancy. Some reports suggested PRES to be the pathophysiological process leading to eclampsia, whereas others observed PRES and eclampsia to have varying clinical severity and risk factors. In this case-control study, risk factors associated with PRES were compared to those for eclampsia in women with hypertension presenting with seizures who had undergone neuroimaging. PRES was noted to occur in 22.5% (51/227) hypertensive pregnant women presenting with seizures that otherwise would have been classified as eclampsia. An additional 51 women with eclampsia underwent neuroimaging. Women who had PRES had higher systolic (155.3 vs 144.5, p = 0.04), diastolic (99.2 vs 93.4, p = 0.006) and mean (117.9 vs 110.4, p = 0.001) blood pressure at admission compared to those with eclampsia. Eclampsia and PRES may occur through a similar pathophysiological mechanism, resulting in the same spectrum of neurological complications of preeclampsia, with PRES being the severest form of the disease process. PRES is difficult to differentiate from eclampsia based on clinical and laboratory investigation, except for high blood pressures, without adjunctive MRI/CT neuroimaging. Future studies should assess the role of biomarkers as well as long-term neurological sequelae in pregnant women with a diagnosis of PRES.

Risk factors associated with unplanned caesarean section in women with placenta previa: a cohort study.

Unplanned/emergency caesarean section (CS) can lead to an increased risk of increased risk of adverse maternal and perinatal outcomes. This prospective observational study was conducted in a tertiary centre in South India to determine the factors associated with increased risk of unplanned/emergency CS among women with placenta previa (PP). Primary outcome was the unplanned CS defined as emergency CS performed, prior to the scheduled date of delivery, for profuse vaginal bleeding or onset of labour pains. Obstetric morbidity and maternal-foetal outcomes were also compared between major and minor degree of PP. Major degree PP (OR 3.56; 95% CI: 1.73-7.32), first episode of bleeding at less than 29 weeks of gestation (OR 6.25; 95% CI: 2.14-18.24), and the haemoglobin level at admission (OR: 0.72; 95% CI: 0.57-0.91) were found to be associated with higher odd for undergoing unplanned CS. Identifying these women at high risk of unplanned CS, especially in limited resource setting, helps for a timely and early referral to tertiary centres with expertise to manage complications along with facilities for blood transfusion and interventional radiology can help to optimise maternal and perinatal outcomes.Impact StatementWhat is already known on this subject? With increasing numbers of caesarean sections (CSs) and assisted reproductive techniques, the rate of PP is constantly on the rise. Unplanned CS is associated with increased risk of adverse maternal and perinatal complications.What do the results of this study add? Nearly, 40% among those who underwent CS were unplanned. Major degree placenta previa (PP) (OR 3.56; 95% CI: 1.73-7.32), first episode of bleeding at less than 29 weeks of gestation (OR 6.25; 95% CI: 2.14-18.24), and the haemoglobin level at admission (OR: 0.72; 95% CI: 0.57-0.91) were found to be associated with higher odd for undergoing unplanned CS.What are the implications of these findings for clinical practice and/or further research? Identifying women with PP at high risk of unplanned CS, especially in limited resource setting, helps for a timely and early referral to tertiary centres with expertise to manage complications, facilities for blood transfusion and interventional radiology, which optimise maternal and perinatal outcomes.

Managing pregnancy in women with Sturge-Weber syndrome: case report and review of the literature.

Sturge-Weber syndrome (SWS) is a sporadic congenital neuro-cutaneous anomaly with capillary-venous malformation involving the brain, eye, and the ophthalmic division of the trigeminal nerve. In these cases, physiological changes in pregnancy, including hormonal and hemodynamic changes, may predispose to increased seizure frequency and even a life-threatening intracranial haemorrhage. There are only few case reports available about the management of women with pregnancy and SWS. We report two patients with SWS diagnosed in childhood and managed during pregnancy and reviewed the outcomes and complications during pregnancy in women with this disorder.

Ebstein's anomaly during pregnancy: experience from a tertiary care centre - a case series and review of literature.

Pregnancy complicated with uncorrected Ebstein's anomaly is uncommon and may pose a serious threat to maternal and foetal life in the clinical setting of altered hemodynamics of pregnancy. Data of eight pregnancies in four women with Ebstein's anomaly who delivered in a tertiary care institute was analysed. Among the four women, one had associated atrial septal defect, one had pulmonary hypertension and three had right bundle branch block. There were two miscarriages and six successful pregnancies resulting in live births. Three of the pregnancies were delivered by caesarean section. There was one pregnancy complicated by severe preeclampsia, no preterm births or maternal cardiac complications. There was one neonate with congenital ostium secundum atrial septal defect. All patients were managed by a multidisciplinary team involving Obstetrician, Cardiologist, Anaesthesiologist and Neonatologist.IMPACT STATEMENTWhat is already known on this subject? Ebstein's anomaly is a rare congenital anomaly with apical displacement of the septal tricuspid leaflet in association with leaflet dysplasia. It may cause varied presentation in pregnancy depending on the severity of the lesion.What do the results of this study add? Ebstein's anomaly may become symptomatic for the first-time during pregnancy. Patients with NYHA class II symptoms and no cyanosis generally tolerate pregnancy well. Miscarriages and intrauterine growth restriction may occur in the presence of this condition. Vaginal delivery is advised and caesarean is done only for obstetric indications.What are the implications of these findings for clinical practise and/or future research? The management of pregnancy with uncorrected Ebstein's anomaly is highly challenging especially in a low resource setting and requires tertiary centre care. Multidisciplinary team involvement can help to improve the outcomes in such pregnancies.

Postpartum urinary retention in women undergoing instrumental delivery: A cross-sectional analytical study.

INTRODUCTION: Women undergoing instrumental delivery are known to be at higher risk of urinary retention, which can lead to long-term complications such as voiding dysfunction. Nulliparous women undergo a pronounced and sudden change in the perineum due to stretching during delivery, which may add to the perineal trauma from an episiotomy, increasing the risk of urinary retention. We aim to study the incidence and risk factors associated with postpartum urinary retention in women undergoing instrumental delivery. MATERIAL AND METHODS: Pregnant women who had an instrumental delivery after 37 weeks of gestation at JIPMER, Puducherry, India, between January 2017 and June 2017 were included in the study. Postpartum urinary retention was defined as the inability to void spontaneously or ultrasonographic documentation of post-void residual volume of >150 mL, 6 hours after delivery. Demographic factors, clinical profile and follow-up of these patients were noted. Multivariate logistic regression analysis was performed to assess the risk factors associated with urinary retention and was presented as adjusted odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Postpartum urinary retention was noted in 124 (20.6%) women undergoing instrumental delivery. Overt and covert urinary retention occurred in 2.3% and 18.3%, respectively. After adjusting for other risk factors, nulliparity (adjusted OR = 4.05, 95% CI 2.02-8.12 compared with multiparity) and prolonged second stage (OR = 3.96, 95% CI 1.53-10.25) compared with suspected fetal compromise as an indication for instrumental delivery was associated with increased risk of postpartum urinary retention. Interaction was noted between parity and episiotomy on the occurrence of postpartum urinary retention (P = .010). Among nulliparous women, those with episiotomy (adjusted OR = 6.10, 95% CI 2.65-14.04) have higher odds of developing postpartum urinary retention compared with those without episiotomy. CONCLUSIONS: Approximately one of five (20.6%) women undergoing instrumental delivery developed postpartum urinary retention. Among women undergoing instrumental delivery, episiotomy increased the chances of developing postpartum retention in nulliparous but not multiparous women. Prolonged second stage as an indication for instrumental delivery also increased the chances of retention. Future studies are needed to define the cutoff for diagnosis and to evaluate the long-term effects of covert postpartum urinary retention, as well to study the effect of episiotomy on development of postpartum urinary retention in women undergoing instrumental delivery.

Percutaneous balloon mitral valvotomy during pregnancy: A systematic review and meta-analysis.

INTRODUCTION: The objective of this study was to systematically review the maternal and fetal outcomes in pregnant women who underwent percutaneous balloon mitral valvuloplasty (PBMV) during pregnancy. MATERIAL AND METHODS: A search was conducted on MEDLINE and Embase databases to identify studies published between 2000 and 2018 that reported on maternal and fetal outcomes following PBMV performed in pregnancy. Randomized controlled trials, cohort studies, case-control studies, cross-sectional studies and case series with four or more pregnancies in which PBMV was performed during pregnancy were included. Reference lists from relevant articles were also hand-searched for relevant citations. A successful procedure was defined as one where there was a reported improvement in the valve area or reduction in the mitral valve gradient. A random effects model was used to derive pooled estimates of various outcomes and the final estimates were reported as percentages with a 95% confidence interval (95% CI). RESULTS: Twenty-one observational studies reporting 745 pregnancies were included in the review, all of them having reported outcomes without a comparison group. Most of the studies fell into the low-risk category as determined using the Joanna Briggs Institute (JBI) critical appraisal checklist for case series. Most of the studies (86%) were reported from low- to middle-income countries and PBMV was mostly performed during the second trimester of pregnancy. Forty-three procedures (5.7%) were unsuccessful, nearly half (n = 19) of them reported among women with the severe subvalve disease (Wilkins subvalve score 3 or more). There were 11 maternal deaths among those with suboptimal valve anatomy (severe subvalve disease or Wilkin score >8). Mitral regurgitation was the most common cardiac complication (12.7%; 95% CI 7.3%-19.1%), followed by restenosis (2.4%; 95% CI 0.02%-7.2%). Pooled incidence of cesarean section was 12.1% (95% CI 3.6%-23.8%), preterm delivery 3.9% (95% CI 0.6%-9.0%), stillbirth 0.9% (95%CI 0.2%-2.2%) and low birthweight 5.4% (95% CI 0.2%-14.7%). CONCLUSIONS: PBMV may be an effective and safe procedure for optimizing outcomes in pregnant women with mitral stenosis in the absence of severe subvalve disease.

Efficacy and safety of Tramadol as an analgesic in women undergoing vaginoscopic hysteroscopy: a randomized placebo-controlled trial.

Pain or discomfort during the hysteroscopy remains a challenge even after the introduction of small calibre instruments and vaginoscopic techniques. Tramadol, a centrally acting analgesic, is one among the medications used to reduce pain; however, the experience with its use in the vaginoscopic technique is limited. This was a randomised double-blind placebo-controlled trial conducted to study the effectiveness of oral Tramadol as an analgesic in 100 women undergoing diagnostic vaginoscopic hysteroscopy. Median pain score assessed by the Visual Analogue Scale was lower in the study group compared to the placebo group during the procedure (7 versus 8; p < .001) and immediately after the procedure (6 versus 7; p < .001) Ease of entry, procedure entry time and the adverse effects were similar in both the groups. Administration of oral Tramadol 50 mg, 1 h prior to the procedure may be a safe and effective analgesic in women undergoing diagnostic vaginoscopic hysteroscopy.Impact statementWhat is already known on this subject? Even with the use of newer hysteroscopes with small calibres and vaginoscopic techniques, pain and discomfort to the patient during negotiation through the cervix remain the main challenge to the surgeon. Among the several medications reported to reduce pain during the procedure, Tramadol a centrally acting drug with dual analgesic action, both by the µ opioid receptor agonist action and by the inhibiting uptake of serotonin and norepinephrine, can be used. However, studies using oral Tramadol during vaginoscopic hysteroscopy are limited.What do the results of this study add? The median pain score assessed by the Visual Analogue Scale was lower in the study group compared to the placebo group during the procedure (7 versus 8; p < .001) and immediately after the procedure (6 versus 7; p < .001). Ease of entry, procedure entry time and the adverse effects were similar in both the groups.What are the implications of these findings for clinical practice and/or further research? This study suggests that administration of oral Tramadol 50 mg, 1 h prior to the procedure, may be used as a safe and effective analgesic in women undergoing diagnostic vaginoscopic hysteroscopy. Future trial with a larger sample size is required to confirm the tolerability of its use, as the incidence of adverse effects was low in the study.

Comparison of 'push method' with 'Patwardhan's method' on maternal and perinatal outcomes in women undergoing caesarean section in second stage.

A deeply impacted foetal head in a second stage caesarean section is associated with an increased risk of maternal and neonatal complications. For the present study, we compared the maternal and neonatal outcomes during the use of the 'Push method' and of 'Patwardhan's method' for a foetal head delivery in a second-stage caesarean section. This was a retrospective observational study involving 298 women who underwent a second stage caesarean section with a foetal head at or below the level of their ischial spines and was conducted in a tertiary teaching hospital in South India. The rates of uterine incision extension and other maternal complications were similar in both methods (24.9% vs. 26.0%, p = .850). The rates of neonatal sepsis (2.3% vs. 9.2%) and admission to neonatal intensive care unit (36.7% vs. 60.0%) were higher when Patwardhan's method was used. Although the maternal complications were similar, the use of Patwardhan's method resulted in higher rates of neonatal complications compared to the Push method during a second stage caesarean section. Future randomised, controlled studies comparing these two methods are needed to confirm their safety and benefits, prior to its routine use in second stage caesarean sections. Impact statement What is already known on this subject? Use of a second-stage caesarean section increases the risk of maternal and neonatal complications. A deeply engaged foetal head, along with the stretching and thinning of the lower uterine segment predisposes to these complications. The recent literature mainly compares the complication rates of the Push method to a Reverse breech extraction, with only small studies reporting the use of Patwardhan's technique for the delivery of a deeply engaged foetal head. What do the results of this study add? This study suggests that the use of either the Push method or of Patwardhan's method results in similar maternal complications such as extension of a uterine incision or postpartum haemorrhage. But neonatal complications such as neonatal sepsis (2.3% vs. 9.2%) and admission to neonatal intensive care unit (36.7% vs. 60.0%) were higher when Patwardhan's method was used. What are the implications of these findings for clinical practice and/or further research? The extension of uterine incision is similar in both methods; however, the neonatal complications were noted to be higher in those delivered with Patwardhan's technique. A future, randomised controlled trial comparing these two techniques is required to confirm the findings, before either of the methods are used in routine practice.

Effect of cervical priming with misoprostol on cervical entry in women undergoing vaginoscopic hysteroscopy for evaluation of abnormal uterine bleeding: a randomized controlled trial.

OBJECTIVE: To study the effect of cervical priming with misoprostol on cervical entry in women undergoing diagnostic hysteroscopy for evaluation of abnormal uterine bleeding. METHODS: Randomized controlled trial conducted in teaching hospital and tertiary referral center on 122 women requiring diagnostic hysteroscopy for evaluation of abnormal uterine bleeding. Women were randomized into two equal groups (n = 122). Study group received 200-µg vaginal misoprostol, 3 h prior to vaginoscopic hysteroscopy. No drug was used in control group. No analgesia or anesthesia was used in either group. Outcome measure included (i) ease of cervical entry (Likert scale), and (ii) pain scoring (Visual Analog Scale) and procedural entry time. RESULTS: Forty-six (75.41%) patients in the study group and 17 (27.87%) in control group had easy or very easy entry (Likert scale-4 and 5) (p < 0.001). Median pain scoring by VAS and the median procedural entry time was significantly lower in the study group compared to the control group (p < 0.001). CONCLUSION: Use of 200-µg vaginal misoprostol, administered vaginally 3 h before diagnostic vaginoscopic hysteroscopy, was found to be simple and effective method of cervical priming in facilitating cervical entry with minimal side effects. Clinical Trial registry of India (CTRI): (CTRI/2015/04/005666) (website: http://ctri.nic.in ).

Prophylactic magnesium sulphate in prevention of eclampsia in women with severe preeclampsia: randomised controlled trial (PIPES trial).

Optimum dose, route and duration of use of prophylactic magnesium sulphate in women with severe pre-eclampsia is still controversial. We compared the efficacy and safety of 'low-dose Dhaka' regime with 'Loading dose only' regime for seizure prophylaxis in severe preeclampsia using a randomised controlled trial in 402 women. The incidence of eclampsia in the 'low-dose Dhaka' regime group was 1.49% and that in the 'Loading dose only regime' was 2.98% (p = .321). In the low-dose Dhaka regime, injection site abscess and respiratory depression occurred in one woman each. Neonatal outcomes such as Apgar score at 5 minutes (5.0% vs. 8.05% p = .251) and perinatal mortality (20.4% vs. 21.9%, p = .724) were similar in both groups. Loading dose only regime may be considered an effective alternative regime for the prevention of eclampsia in women with severe preeclampsia. Impact statement What is already known on this subject: Efficacy of therapeutic short regime magnesium sulphate in eclampsia has already been reported. Data regarding prophylactic short regime in women with preeclampsia is sparse. What the results of this study add: We have shown that short regime of magnesium sulphate using only the loading dose in the prevention of seizure in preeclampsia is an effective alternative to the low-dose Dhaka regime. What the implications are of these findings for clinical practice and/or further research: The short regime is less resource-intensive. Further larger studies are needed to confirm the efficacy of this short regime and to establish its cost-effectiveness.

Maternal ascites an independent prognostic factor in severe preeclampsia: a matched cohort study.

BACKGROUND: Preeclampsia is a multi-systemic, multi-organ dysfunction associated with increased maternal and perinatal complications. The presence of maternal ascites, a manifestation of endothelial dysfunction and increased capillary permeability, is shown to be associated with adverse outcomes. We aim to investigate the impact of maternal ascites on pregnancy outcome in women with severe preeclampsia. METHODS: A matched cohort study was conducted in a tertiary care teaching hospital in South India between March 2014 and March 2015. One hundred and twenty-one severe preeclamptic women with ascites formed the study cohort while age-, parity-, and gestational age-matched group of 121 severe preeclamptic women without ascites formed the control. Primary outcome was the composite maternal adverse outcome defined as the development of any of eclampsia, pulmonary edema, renal failure, or disseminated intravascular coagulation (DIC). Secondary outcome was the composite perinatal outcome defined as the occurrence of any of still birth, hypoxic ischemic encephalopathy or early neonatal death. RESULTS: Four maternal deaths occurred in the study group. The rates of pregnancies with composite maternal adverse outcome [42 vs 9% RR 4.6 (95% CI 2.5-8.4)] and composite perinatal adverse outcome [36 vs 17% RR 2.1, (95% CI 1.3-3.3)] were significantly more in ascites group than in control group. After adjusting for other confounding variables, ascites was independently associated with adverse maternal events [adjusted OR 16.40 (95% CI 2.88-93.31)] but not adverse perinatal outcome. CONCLUSION: In women with severe preeclampsia, maternal ascites is an independent risk factor for adverse maternal outcome.

Impact of near-miss event during pregnancy and childbirth on maternal health at 12 months.

OBJECTIVE: To assess the impact of maternal near-miss on late maternal death and the prevalence of hypertension or chronic kidney disease (CKD) and mental health problems at 12 months of follow up. METHODS: This prospective cohort study was conducted in a tertiary hospital in the southeastern region of India from May 2018 to August 2019, enrolling those with maternal near-miss and with follow up for 12 months. The primary outcomes were incidence of late maternal deaths and prevalence of hypertension and CKD during follow up. RESULTS: Incidence of maternal near miss was 6.7 per 1000 live births. Among those who had a near miss, late maternal deaths occurred in 7.2% (95% confidence interval [CI] 3.1%-11.3%); prevalence of CKD was 23.0% (95% CI 16.2%-29.8%), and of hypertension was 56.2% (95% CI 50.5%-66.5%) and only two women had depression on follow up. After adjusting for age, parity, socioeconomic status, gestational age at delivery, hemoglobin levels, and perinatal loss, only serum creatinine was independently associated with late maternal death and CKD on follow up. CONCLUSIONS: Women who survive a life-threatening complication during pregnancy and childbirth are at increased risk of mortality and one or more long-term sequelae contributing to the non-communicable disease burden. A policy shift to increase postpartum follow-up duration, following a high-risk targeted approach after a near-miss event, is needed.

Impact of social determinants of health on progression from potentially life-threatening complications to near miss events and death during pregnancy and post partum in a middle-income setting: an observational study.

OBJECTIVE: To assess the potential associations between social determinants of health (SDH) and severe maternal outcomes (SMO), to better understand the social structural framework and the contributory, non-clinical mechanisms associated with SMO. STUDY DESIGN: Prospective observational study. STUDY SETTING: Tertiary referral centre in south-eastern region of India. PARTICIPANTS: One thousand and thirty-three women with potentially life-threatening complications (PLTC) were identified using WHO criteria. RISK FACTORS ASSESSED: Social Determinants of Health (SDH). PRIMARY OUTCOMES: Severe maternal outcomes, which include maternal near-miss and maternal death. STATISTICAL ANALYSIS: Logistic regression to assess the association between SDH and clinical factors on SMO, expressed as adjusted ORs (aOR) with a 95% CI. RESULTS: Of the 37 590 live births, 1833 (4.9%) sustained PLTC, and 380 (20.7%) developed SMO. Risk of SMO was higher with increasing maternal age (adjusted OR (aOR) 1.04 (95% CI 1.01 to 1.07)), multiparity (aOR 1.44 (1.10 to 1.90)), medical comorbidities (aOR 1.50 (1.11 to 2.02)), obstetric haemorrhage (aOR 4.63 (3.10 to 6.91)), infection (aOR 2.93 (1.83 to 4.70)), delays in seeking care (aOR 3.30 (2.08 to 5.23)), and admissions following a referral (aOR 2.95 (2.21 to 3.93)). SMO was lower in patients from socially backward community (aOR 0.45 (0.33 to 0.61)), those staying more than 10 km from hospital (aOR 0.56 (0.36 to 0.78)), those attending at least four antenatal visits (aOR=0.53 (0.36 to 0.78)) and those referred from resource-limited facilities (aOR=0.62 (0.46 to 0.84)). CONCLUSION: This study demonstrates the independent contribution of SDH to SMO among those sustaining PLTC in a middle-income setting, highlighting the need to formulate preventive strategies beyond clinical considerations.

Efficacy of combination of transcervical Foley catheter and sublingual misoprostol versus sublingual misoprostol for labor induction in pre-eclampsia at 28-34 weeks.

OBJECTIVE: To compare the efficacy of using a combination of transcervical Foley catheter and sublingual misoprostol with sublingual misoprostol alone for induction of labor (IOL) in women with pre-eclampsia between 28 and 34 weeks of pregnancy. METHODS: This randomized controlled trial was conducted on women with pre-eclampsia at 28-34 weeks of pregnancy, with unfavorable cervix, admitted to a tertiary hospital in south India. They were randomized to receive either a combination of transcervical Foley catheter and sublingual misoprostol, or sublingual misoprostol alone. Vaginal birth within 24 h of induction, induction to delivery interval, and neonatal morbidity/mortality were the main outcome measures. RESULTS: Vaginal birth within 24 h was higher with the combination of Foley catheter and sublingual misoprostol compared with sublingual misoprostol alone (60% versus 41.4%, P = 0.028). Overall vaginal delivery rates were comparable between the groups (90% versus 80%, P = 0.051). There was no difference in number of doses of misoprostol, and induction to delivery interval between groups. After excluding those with lower likelihood of neonatal survival, live birth rates, mean birth weight, and neonatal intensive care unit admission rates were similar in both groups. CONCLUSIONS: Combination of transcervical Foley catheter and sublingual misoprostol was found to be more effective in achieving vaginal birth within 24 h compared with sublingual misoprostol for IOL in pre-eclampsia between 28 and 34 weeks of pregnancy. TRIAL REGISTRATION NUMBER: CTRI/2018/09/015766; http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=27984.

Comparing the efficacy of oral labetalol with oral amlodipine in achieving blood pressure control in women with postpartum hypertension: randomized controlled trial (HIPPO study-Hypertension In Pregnancy & Postpartum Oral-antihypertensive therapy).

De novo - or as a continuum of antenatal hypertension -postpartum hypertension complicates ~2% of pregnancies. Many maternal complications, such as eclampsia and cerebrovascular accidents, occur in the postpartum period. Despite widespread use of antihypertensives during pregnancy and childbirth, there is a paucity of data on preferred medications in the postpartum period. This randomized controlled study enrolled 130 women who were started on antihypertensives. They were randomized to receive oral Labetalol(LAB, maximum 900 mg per day in three doses) or oral Amlodipine(AML, maximum 10 mg per day given in two doses). In the immediate postpartum, all women were closely monitored for neurological symptoms, blood pressure, heart rate, respiratory rate, urine output, and deep tendon reflex. The primary outcome was the time to achieve sustained blood pressure control for 12 h from the initiation of medication; secondary outcomes included side effects of both medications. Mean time to achieve sustained blood pressure control was lower in women who received AML than in those who received LAB-(mean difference 7.2 h; 38 95% CI 1.4, 12.9, p = 0.011). There were fewer severe hypertensive episodes among those with AML than in those who received LAB. However, the proportion of women who continued to require antihypertensives at discharge was higher in the AML group than in the LAB group (55.4% versus 32.3%, p = 0.008). None of the participants developed drug-related side effects. Among women with postpartum persistence or new-onset hypertension, oral AML achieved sustained blood pressure control in a shorter duration, with fewer hypertensive emergencies than oral LAB. (CTRI/2020/02/023236).Trial Registration details: The study protocol was registered with Clinical Trial Registry of India with CTRI Number CTRI/2020/02/023236 dated 11.02.2020. Protocol can be accessed at https://www.ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=40435&EncHid=&modid=&compid=%27,%2740435det%27 .

Growth Pattern of Preterm Neonates with Fetal Growth Restriction: A Prospective Cohort Study.

OBJECTIVES: To compare the growth of preterm neonates with fetal growth restriction (FGR) and preterm neonates born appropriate-for-gestational-age (AGA) from birth to 12-18 mo of corrected age (CA). METHODS: In this prospective cohort study, 85 preterm neonates with FGR and 85 gestation- and gender-matched AGA neonates were followed up from birth till 12-18 mo corrected age. Anthropometric indices were compared at specific time points and the risk factors for underweight status were analyzed. RESULTS: Mean gestational age of the cohort was 32.8 ± 2.1 wk. Mean birth weight was 1414 ± 248 g in the FGR and 1806 ± 416 g in AGA neonates. At 12-18 mo of corrected age, a significantly greater proportion of FGR infants were wasted (24.3% vs. 7.2%, P = 0.005). A greater proportion of FGR infants were underweight (27% vs. 17.4%, P = 0.11), stunted (41.9% vs. 36.2%, P = 0.30), and microcephalic (27% vs. 23.1%, P = 0.36), although the differences were not statistically significant. Significant catch-up growth from 40 wk postmenstrual age (PMA) to 12-18 mo corrected age in weight (52.8% vs. 13.1%, P <0.001) and length (37.9% vs. 8.7%, P <0.001) was observed in the FGR neonates. The z-score of weight for age at 3 mo (adjusted OR 0.65, 95% CI: 0.52-0.8; P <0.001), the median time to full feeds (aOR: 1.10, 95% CI: 1.04-1.15; P = 0.001), and hypothyroidism (aOR 2.44, 95% CI: 1.46-4.08; P = 0.001), were independent predictors of underweight status at 12-18 mo. CONCLUSIONS: At 12-18 mo of corrected age, a significantly greater proportion of preterm FGR neonates were wasted compared to AGA ones. The former also exhibited significantly greater catch-up growth than the latter.