Cases Of IUGR Research Articles

Management of IUGR With Ksheera Basti

Number of cases of IUGR are increasing day by day and its treatment with Ayurveda is well established. Clinical trials are needed to support our treatment modalities on basis of modern parameters. Ayurveda has mentioned therapeutic utility of drugs like Shatavari, Madhuyashti, Ksheera and Ghrita and various routes of administration are advocated. In this context Ksheera Basti is highly recommended in our texts. Aims and objectives: To evaluate the efficacy of ksheera basti in management of IUGR. To assess the fetal weight gain and various maternal and fetal parameters after ksheera basti protocol. Methodology: Randomized clinical case series with 5 patients Result: Improvement was seen in maternal and fetal parameters in all 5 Patients. Discussion: In studying cases of IUGR, it was found that Ksheera Basti is much effective as a treatment protocol for IUGR. Marked improvement was seen in EFW, SFH, AC, FH AFI, maternal weight gain. Hence this therapy has capability to change the scenario and can prove as boom in field of Ayurveda in curing IUGR.

Fetomaternal Outcome of Referred Obstetric Patients in a Tertiary Centre in North East India: A Cross-sectional Study

Introduction: Referral of patients has improved fetomaternal outcomes in developing countries like India. Identifying high-risk obstetric cases, severe maternal complications, and promptly referring them to a centre equipped with Basic Emergency Obstetric and Newborn Care (BEmONC) helps reduce morbidity and mortality. Aim: To examine the clinical profile of referred obstetric patients admitted to a tertiary care centre and analyse the characteristics of admission, referral pattern, level of delay, and their fetomaternal outcomes. Materials and Methods: A hospital-based observational crosssectional study was conducted from July 1, 2021, to June 30, 2022, at Assam Medical College and Hospital, Dibrugarh in Assam, India. The study included 700 referred obstetric patients from private and public healthcare settings. Variables such as place of referral, referrer (medical officer/self-referral/staff nurse/ specialists), delay in referral, reasons for referral, pregnancy period during referral, diagnosis at admission and referral, availability of proper referral documents, and fetomaternal outcomes such as mode of delivery and gestational age at delivery were assessed. Categorical variables were summarised as proportions and percentages. Results: Out of the total 18,245 obstetric admissions during the study period, approximately 14,500 patients were referred, accounting for 80% of all admissions. Among the 700 study participants, 616 (88%) referrals were from nearby public sectors. A total of 147 (21%) experienced delay due to transportation. 644 (92%) had referral slips, but only 224 (32%) had proper documentation. A number of 322 (46%) were intrapartum referrals. A total of 350 (50%) were primigravida, while 344 (49%) were multigravida. Apart from these 694 pregnant mothers, six referrals were for babieswithout any maternal complications or high risk factors. 112 (16%) referrals were for cases of IUGR and oligohydramnios, and 98 (14%) were preterm referrals. A total number of 276 (47%) deliveries were performed via caesarean section. A total of 35 patients were discharged antepartum, and there were nine maternal deaths. Additionally, 148 neonates required ICU admissions, 225 were preterm, and 558 babies were discharged. Conclusion: Referrals were made for both maternal and foetal causes. The majority of obstetric admissions in our institution were referrals, resulting in an increased delivery rate and a higher trend of caesarean section. The presence of a well-equipped NICU also contributed to the referral pattern.

Clinical characteristics, CT features and perinatal outcome of COVID-19 pneumonia in pregnant women and comparison with non-pregnant women

Background and Objective: To evaluate the clinical course and CT findings of pregnant womenMethods: Fourthy (25 pregnant and 15 non-pregnant) patients were entered to the study. Chest CT features and clinical findings were evaluated between two groups. Data related to pregnancy and fetal status evaluated in the pregnant group.Result: The average age of pregnant patients was 33.1±5.75 years and the non-pregnant group was 35.4±6.88 years. The gestational age ranged from 7 weeks to 39weeks+2days (mean =31weeks+5days). No significant difference was seen between the two groups about clinical findings except the duration of symptoms before CT which was more in pregnant patients (6.71 ± 5.5 days vs 3.53 ± 1.92 days). Two mortalities in pregnant and one in non-pregnant patients , 2(8%) cases of premature rupture of membranes (PROM), 3 (12%) cases of intra-uterine fetal death (IUFD), 3 (12%) cases of fetal distress and 2 (8%) cases of IUGR in pregnant group. Fifteen pregnant patients gave birth .No positive PCR result was detected in newborns. Unlike the control group, the common CT findings were ground-glass pattern.Conclusion: In summary, although we found the clinical findings in pregnant and control group were similar but pattern of CT involvement was different in pregnant patients and rate of ICU admission and mortality rate were more than control group. This viral pneumonia was associated with some important complications such as IUFD in severely involved mothers. CT could be an efficient tool for the early detection and severity assessment in the pregnant patients with COVID-19 pneumonia.

In Vitro Fertilization in Women with Asherman's Syndrome - Comparison of Maternal and Neonatal Morbidity

Study Objective We seek to examine effects of in vitro fertilization (IVF) on the maternal and neonatal morbidities of patients previously treated for Asherman's syndrome. Design A retrospective cohort study using fertility and obstetrical data from our institution's electronic medical records. Setting A community teaching hospital affiliated with a large academic medical center. Patients or Participants 43 singleton births identified from 40 women previously treated at our institution for Asherman's syndrome. Interventions Data analysis comparing the maternal and neonatal outcomes in singleton births from Asherman's syndrome patients who had been treated with hysteroscopic adhesiolysis, then either conceived spontaneously versus IVF. Measurements and Main Results Of the 43 singleton births, 27/43 (62.8%) were conceived spontaneously and 16/43 (37.2%) were conceived through IVF. No statistical differences were found in antepartum conditions within clinical pregnancies in patients who conceived spontaneously versus through IVF. There was no difference in the rate of preterm birth in Asherman's pregnancies (11.6%) regardless of conception method. We documented 4/43 (9.3%) cases of IUGR in our study, with no difference in between spontaneous versus IVF conception groups. The rate of morbidly adherent placenta (MAP) in Asherman's syndrome patients was 14.0%, with no differences in the rate of MAP found in the two conception groups. Postpartum hemorrhage in Asherman's patients was documented at 32.6% (14/43). Newborn anatomic malformations of any cause were documented in 18.6% (8/43) of all singleton births. Conclusion Our series indicates a higher prevalence of IUGR, MAP, post-partum hemorrhage, and newborn anatomical malformations in Asherman's syndrome pregnancies compared to incidences reported in pregnancies within the general population. However, we found no significant differences in the maternal and neonatal outcomes of Asherman's syndrome patients who conceived either spontaneously or through IVF after being treated with hysteroscopic adhesiolysis.

TO ASSESS THE MATERNAL ANAEMIA, INTRA-UTERIAN GROWTH RESTRICTION AND NEONATAL OUTCOME IN TERTIARY CARE HOSPITAL, BIHAR

Aim: To assess the maternal anaemia, intra-uterian growth restriction and neonatal outcome.
 Materials and methods: a prospective, observational study conducted in Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College and Hospital, Bhagalpur, Bihar India. A total of 240 consecutive clinically suspected cases of IUGR with singleton pregnancies at 34-40 weeks of gestation were included in the study. Their socio-demographic profile and hemoglobin levels were recorded. A descriptive analysis of the data was performed.
 Results: Of 240 study subjects with IUGR at 34-40 weeks, 70.4% were anaemic, (48.8% had mild, 20.8% had moderate, 0.83 % had severe anaemia) while 29.6% were not anaemic. Significantly, the ratio of anaemic to non anaemic in antenatal IUGR pregnancies was 2.48:1. A birth weight of less than 2.5 kgs was recorded in 84% of pregnancies with moderate anaemia and 83.8% pregnancies with mild anaemia. Out of the 240 clinically diagnosed cases of IUGR 71.25% (n=171) were from the rural background and 28.75% (n=69) were urban area.
 Conclusion: Mild to severe anaemia in IUGR may increase the chances of low birth weight and adverse neonatal outcomes but larger studies with standardized definitions and measurements of exposure outcomes to bring about uniformity are required to determine an accurate assessment of association between low maternal hemoglobin and IUGR

Buprenorphine Versus Methadone in Pregnant Women With Opioid Use Disorder: A Cost-Effectiveness Analysis [06E

INTRODUCTION: Opioid use disorder (OUD) during pregnancy has increased more than fourfold since 1999. Methadone is the longstanding treatment of choice for OUD in pregnancy, but recent data demonstrate benefits of buprenorphine, as it is associated with improved neonatal outcomes despite increased drug cost and rates of discontinuation of therapy. This model compares cost-effectiveness of buprenorphine versus methadone in management of OUD during pregnancy. METHODS: We used a theoretical cohort of 22,400 pregnant women to approximate the number of pregnancies affected by OUD per year in the United States. Outcomes included maternal retention in maintenance treatment, maternal overdose, neonatal abstinence syndrome, preterm birth, intrauterine growth restriction, and cerebral palsy in addition to cost and quality-adjusted life-years. The cost-effectiveness threshold was set at $100,000/QALY. Model inputs were derived from the literature and varied in sensitivity analyses to assess robustness of the model. RESULTS: Despite lower rates of retention and higher associated overdoses, buprenorphine treatment during pregnancy saved over $102 million healthcare dollars and 563 QALYs, making it the dominant strategy over methadone treatment. In our cohort, buprenorphine treatment resulted in 2,886 fewer cases of NAS, 1,006 fewer preterm births, 299 fewer cases of IUGR, 32 fewer stillbirths, and 12 fewer cases of CP. Sensitivity analyses showed that our results were robust over a wide range of assumptions. CONCLUSION: Buprenorphine treatment should be considered a first-line option for opioid dependence in pregnancy, as it leads to improved neonatal outcomes compared to methadone despite increased drug cost and risk of treatment discontinuation.

PL 10 Molecular insights into placental pathophysiology in IUGR

Introduction IUGR is frequently associated with deficient remodelling of the maternal spiral arteries supplying the placenta. It is postulated that this deficiency results in malperfusion, leading to placental stress and impoverished growth of the villous trees. In the most severe cases there is reversed end-diastolic flow (REDF) in the umbilical arteries, indicative of raised resistance in the feto-placental vasculature. Material and methods Non-laboured placentas from cases of early-onset IUGR with and without REDF, and pre-term and term controls were collected with informed consent. Markers of oxidative stress and activation of the Unfolded Protein Response (UPR) were assessed by western blotting and immunohistochemistry. Morphology was assessed at the ultrastructural level by transmission electron microscopy. Results Dilation of the endoplasmic reticulum cisternae and activation of the UPR stress-response pathways were evident in the IUGR placentas compared to term and pre-term controls, with increased levels of p-eIF2 α and evidence of attenuation of protein translation. Consequently, levels of AKT were reduced at the protein, but not mRNA level. There was reduced cyclin D1, and lower activity in the mTOR pathway. These changes could be mimicked in trophoblast-like cell lines by exposure to cycles of hypoxia-reoxygenation (HR), and were associated with a reduction in cell proliferation. IUGR placentas associated with REDF, but not those with normal umbilical flow, displayed reduced levels of cystathionine- γ -lyase, the enzyme synthesising hydrogen sulphide. Immunohistochemistry localised the enzyme to the smooth muscle cells surrounding the resistance arteries within stem villi. Exposure of stem villus artery explants to HR induced loss of the enzyme, de-differentiation of the smooth muscle cells and vascular remodelling. Inhibition of the enzyme produced similar results, while treatment with a hydrogen sulphide donor mitigated the effects. Conclusions Malperfusion of the placenta activates the UPR, which is capable of reducing placental cell proliferation. Oxidative stress induced by malperfusion can also induce remodelling of the placental vasculature. A smaller placenta, combined with reduced umbilical blood flow, may contribute to the IUGR phenotype.

English

OBJECTIVES : To search out IUGR cases on the basis of clinical examination (symphysiofundal height) & to confirm them with USG at 32 weeks of gestation. To validate Modified Biophysical Profile in all confirmed cases of IUGR from 32 weeks of gestation & all cases where AFI is decreased, NST is reactive & pregnancy is less than 36 weeks of gestation. To validate Complete Biophysical Profile & Color Doppler in cases: When pregnancy is less than 36 weeks of gestation & both NST & AFI are abnormal. STUDY DESIGN: prospective study carried out over 100 confirmed IUGR cases. MATERIALS AND METHODS: The IUGR cases were identified first by screening with SFH then confirmation with fetal abdominal circumference by USG at 32 weeks. All the cases were initially monitored with MBPP and BPP and color Doppler of Umbilical and MCA were performed in cases with abnormal MBPP having a non reactive NST. RESULTS: The incidence of IUGR was 3.86% in present study. The MBPP proved to be an effective tool for initial monitoring of IUGR cases with high specificity of 70.83%. The BPP and PI indices of Umbilical and middle cerebral arteries had good correlation with perinatal outcome i.e. BPP with sensitivity and PPV of 92.3% and 85.71%, Umbilical artery PI with sensitivity of 69.23% & positive predictive value of 90% and MCA PI with high specificity of 83.33% and PPV of 93.33%. CONCLUSION: MBPP is an effective initial surveillance tool in IUGR cases. The Biophysical profile, umbilical artery Doppler and Middle Cerebral artery Doppler have good correlation with perinatal outcome but further guidelines are required to integrate these surveillance modalities with each other.

OP31.02: Single nucleotide polymorphism in pre‐eclampsia prediction

prenatal clinic setting. Maternal levels of PAPP-A were measured at the time of the first prenatal visit (9 to 13+6 weeks) as part of the combined ultrasound and biochemical screening study. Low PAPP-A was defined as the lowest 5% of values for gestational age ( 1.9 MoM). Intrauterine growth restriction was defined as birth-weight ≤3th centile according to our local customized charts. The risk of IUGR in women with a low PAPP-A and normal AFP was compared with a control group with low PAPPA and high AFP. No results were reported to either the obstetrician or patient. Results: A total of 5617 pregnant women were attended for prenatal care in our institution between January 2010 and December 2011. Of the 301 patients with a PAPP-A < 0.4 MoM, 141 had a determination of AFP done between 15 and 18 weeks and perinatal outcome is known for 96 of these patients. Women with a low PAPP-A were not more likely to have elevated levels of AFP. Only 4 patients (4.2%) had a low PAPP-A and high AFP. We had 6 cases of IUGR (6%): 3 cases (3.2%) in the group of low PAPP-A and normal AFP and 3 cases (75%) in the group of low PAPP-A and high AFP. The odds ratio for delivering a baby with IUGR for women with low PAPP-A and high AFP was 89 (95% confidence interval [CI] 7–1127). Conclusions: Although the small numbers of the study, this preliminary data suggest that low maternal levels of PAPP-A between 8 and 13+6 weeks and high levels of AFP between 15 and 18 weeks are highly associated with IUGR.

OP09.08: Triple vascular test for prediction of pre-eclampsia

Objectives: Uterine Doppler is used in screening for placentaassociated diseases, such as pre-eclampsia and intrauterine growth restriction of the fetus (IUGR). The aim of this study was to examine the predictive value of second trimester uterine Doppler in pregnancies complicated by systemic lupus eritematosus (SLE). Methods: Observational study on 55 pregnancies in women with SLE treated at our Unit from 2000 to 2008. The Doppler examination was performed between 23+0 and 25+6 weeks of gestation. The mean uterine artery pulsatility index (UtA PI) was calculated. Results: The median (interquartile range, IQR) UtA PI was 1.00 (0.90–1.20). Three patients had a mean uterine artery PI above the 95th centile for gestational age. All these patients developed pre-eclampsia and IUGR. No cases of pre-eclampsia or IUGR were observed in patients with the mean uterine artery PI below the 95th centile for gestational age. The sensitivity was 100% (95% CI 0.44–1.00), specificity was 100% (95% CI 0.93–1.00). Conclusions: In our series, the mean uterine artery PI was an excellent predictor for pre-eclampsia and IUGR in women with SLE.

Clinical study on effect of Chinese herbal medicine for supplementing kidney and Qi and activating blood circulation in treating intrauterine growth retardation of fetus

To explore the therapeutic effect and its possible mechanism on using Chinese herbal medicine (CHM) for supplementing Kidney and Qi, and activating blood circulation in treating intrauterine growth retardation of fetus (IUGR). Fifty-five cases of IUGR were observed, 30 of them were treated with CHM and 25 treated with amino acid for control. The neonatal birth weight in the CHM group was markedly greater than that in the control group. Not only the maternal fundal height and abdominal circumference, but also the fetal growth parameters, including biparietal diameter, head circumference, abdominal circumference, femur length in the CHM group increased much faster than those in the control group. After CHM treatment, the maternal serum levels of estriol (E3) and human placental lactogen (hPL) were close to the normal pregnancy group, but the levels in the control group were significantly different from the normal range. The umbilical venous plasma concentration of essential amino acids was markedly improved after treatment, however, the improvement in the CHM group was more significant than that in the control group. No adverse effect of CHM was found both in mother and fetus. CHM for supplementing Kidney and Qi, and activating blood circulation was more effective in the improvement of placental function and amino acid transportation than those of amino acid.

Telomerase activity in human chorionic villi and placenta determined by TRAP and in situ TRAP assay

Telomerase activity (TA) was analysed in human chorionic villi and placenta in normal and abnormal pregnancy using the telomeric repeat amplification protocol (TRAP) and in situ TRAP assay. Twenty chorionic villi specimens and 25 placenta specimens from normal pregnancies were examined as well as placenta specimens from 10 cases of intrauterine growth retardation (IUGR; nine asymmetric and one symmetric). TA was detected in 18 of the 20 (90 per cent) chorionic villi specimens and in 18 of the 25 (72 per cent) placenta specimens from normal pregnancy. However, no or only weak TA was exhibited in the placenta specimens of the nine asymmetric IUGR cases. In situ TRAP assay detected TA in trophoblastic cells from normal pregnancy, but not in trophoblastic cells from cases of asymmetric IUGR.

Cordocentesis for rapid karyotyping in fetuses with congenital anomalies or severe IUGR

The objective was to determine the role of percutaneous umbilical blood sampling (cordocentesis) as a rapid technique for chromosome analysis in a high risk obstetric population. Cordocentesis was attempted in 167 pregnant women (168 fetuses) with IUGR, a single anomaly or multiple anomalies. Gestational age ranged between 17 and 37 weeks. The procedure was successful in 152 (90%) fetuses with a blood sample withdrawn at first attempt in 80%. Neither technique was associated with any false negative or false positive findings. Postprocedural complications included one case of persistent fetal bradycardia, but no fetal death. In nine cases amniotic fluid was collected, resulting in 161 fetal blood or amniotic fluid samples for chromosome analysis. An abnormal chromosome pattern ( n = 26) was established in 1 12 cases (8%) of severe IUGR, 6 88 cases (7%) with a single structural anomaly and 19 61 cases (31%) with multiple structural anomalies. In the presence of an abnormal chromosome pattern, the perinatal mortality rate was as high as 96%. There is a high association between multiple fetal anomalies and abnormal chromosome pattern.

Fetal renal anomalies, a diagnostic dilemma in the presence of intrauterine growth retardation and oligohydramnios.

Measurement of the head-to-abdomen (H/A) ratio for differentiating between symmetrical and asymmetrical IUGR may be difficult in the presence of marked oligohydramnios. A total of 76 cases of IUGR with various degrees of oligohydramnios was studied. Sixteen (59%) out of 27 structural defects represented bilateral renal agenesis, 11 of which were diagnosed prenatally. When only the H/A ratio was measured (n = 29) the sensitivity in picking up a structural defect was 50%. Calculation of the pulsatility index in the umbilical artery and fetal internal carotid artery (n = 47), whether or not combined with amnioinfusion (n = 5), resulted in a sensitivity of 76%. It is suggested that the latter two techniques may provide valuable additional information as to the cause of IUGR.

Catecholamine metabolites in amniotic fluid as indicators of intrauterine stress

The catecholamine metabolites HMPG and VMA have been determined in samples of amniotic fluid in 38 uncomplicated pregnancies, seven cases of IUGR, and six cases of diabetes. A successive increase of HMPG and VMA was found toward the end of the pregnancy. HMPG and particularly the HMPG/VMA ratio were significantly higher in the amniotic fluid of the growth-retarded fetuses than in the uncomplicated cases. No significant difference was found between the diabetic and uncomplicated cases.