Obstetric Examination Research Articles

Assessment of Cardiac Dysfunction in the Intrauterine Growth-restricted Fetuses from Pre-eclamptic Mothers

ABSTRACT Background Although it is known that cardiac parameters have abnormal values in severely affected fetuses with intrauterine growth restriction (IUGR), recent research suggested that subclinical cardiac dysfunction may be present from the early stages of fetal deterioration. The identification and monitoring of cardiac dysfunction may be relevant for the management of these cases. Materials and methods In this prospective observational study, we evaluated 17 IUGR fetuses from nulliparous pregnant women diagnosed with pre-eclampsia. Cardiac structural assessment was performed using segmental sequential analysis. Cardiac function was assessed by conventional echocardiography and Tissue Doppler Imaging (TDI). Results Gestational age at admittance ranged between 24 and 30 weeks. A severe form of pre-eclampsia was diagnosed in 2 of 17 cases. Conventional cardiac examination showed low left and right ventricular diastolic filling with low E and A velocities, and increased myocardial performance indexes for both ventricles. Using TDI we observed decreased myocardial velocities and impaired contractility (demonstrated by low left and right diastolic velocities, as well as increased E’/A’ ratios). Conclusion Our study confirms the presence of early cardiac dysfunction in IUGR fetuses. Further studies are warranted to confirm the utility of TDI in obstetric ultrasound routine examination for monitoring fetal cardiac function in high-risk pregnancies. How to cite this article Caracostea G, Stamatian F. Assessment of Cardiac Dysfunction in the Intrauterine Growthrestricted Fetuses from Pre-eclamptic Mothers. Donald School J Ultrasound Obstet Gynecol 2014;8(2):123-127.

Association Between Obesity During Pregnancy and the Use of Prenatal Services

INTRODUCTION: Approximately 25% of women in the United States are obese (body mass index greater than 30 kg/m2). Obese women are at risk for poor perinatal outcomes, and studies imply that inadequate, late onset, or both of prenatal care are contributing factors in this population. We previously demonstrated that maternal obesity is actually associated with improved adequacy of prenatal care as measured by the Kotelchuck index and now further examine the use of specific prenatal services by otherwise uncomplicated obese women. METHODS: Retrospective cohort study of medically uncomplicated women who initiated prenatal care and delivered at our institution from January 2009 to December 2011. Maternal history and delivery information were obtained through chart abstraction. Use of specific prenatal care services including diabetic screening, ultrasound examinations, and hospitalization was compared between nonobese and obese women. RESULTS: A total of 320 women were evaluated, of whom 38% were obese. Mean (±standard error) length of hospital stay for combined intrapartum and postpartum care was 3.0±0.1 days in obese women compared with 2.9±0.1 days in nonobese women (P=.4). Both populations had similar diabetic screening compliance of 86.4% for nonobese and 86.8% for obese women (P=.9). However, obesity was significantly associated with more obstetrical ultrasonographic examinations with 48% obese women having five or more ultrasound scans compared with only 25% of nonobese women (P<.05). CONCLUSION: In our population, obesity in otherwise uncomplicated pregnant women is associated with increased use of obstetric ultrasound services, but there were no differences in use of other prenatal services.

Re: Which factors are associated with trainees' confidence in performing obstetric and gynecological ultrasound examinations? M. G. Tolsgaard, M. B. Rasmussen, C. Tappert, M. Sundler, J. L. Sorensen, B. Ottesen, C. Ringsted and A. Tabor. Ultrasound Obstet Gynecol 2014; 43: 444–451

Linked Comment: Ultrasound Obstet Gynecol 2014; 43: 444–451

Which factors are associated with trainees' confidence in performing obstetric and gynecological ultrasound examinations?

To explore the association between clinical training characteristics and trainees' level of confidence in performing ultrasound scans independently. A cross-sectional e-survey was distributed to members of the national societies of junior obstetricians/gynecologists in Denmark, Sweden and Norway (n = 973). Multiple linear regression models were used to explore the effect that amount of time spent in specialized ultrasound units and clinical experience had on trainees' confidence in performing ultrasonography independently. Exploratory factor analysis was used to identify factors that contributed to trainees' confidence in performing ultrasonography. Trainees' ultrasound confidence was finally compared with their expected levels of performance. Of the 682 respondents (response rate 70.1%), 621 met the inclusion criteria. Clinical experience and time spent in specialized ultrasound units were predictors of trainees' confidence in performing ultrasonography independently (P < 0.001). Trainees required more than 24 months of clinical experience and 12-24 days of training in specialized ultrasound units in order to feel confident about performing transvaginal and transabdominal ultrasound scans independently. Three factors were related to ultrasound confidence: technical aspects, image perception and integration of scan into patient care. There were significant differences between trainees' level of confidence and their expected levels of performance (P < 0.001). Clinical experience and time spent in specialized ultrasound units were predictors of trainees' confidence in performing ultrasonography independently. Discrepancies between trainees' confidence and their expected levels of performance raised concerns about the adequacy of current ultrasound training programs.

Reference Values of Fetal Peak Systolic Velocity in the Middle Cerebral Artery at 19–40 Weeks of Gestation in Nepalese Population

Aims: The purpose of this study was to construct new reference range for fetal middle cerebral artery peak systolic velocity (MCA-PSV) in uncomplicated pregnancy at 19-40 weeks of gestation. Methods: This was a prospective cross-sectional study involving 400 singleton pregnancies between 19 and 40 weeks of gestation without any known risk factors of adverse pregnancy outcome who were referred for routine obstetric examination. The protocol included the doppler examination of fetal middle cerebral artery (MCA) within 2 mm after its origin from the internal carotid artery and data were used to construct the normograms and percentile fitted curves of each doppler parameter for different gestational age. Results: Among 400 singleton uncomplicated pregnancies between 19 and 40 weeks of gestation maximum number of pregnancies (10%) was at 19 weeks of gestation and minimum (2.5%) was at 31 weeks. The fetal peak systolic blood flow in the MCA showed significant correlation with period of gestation. Mean MCA-PSV was 22.35 ± 3.05 at 19 weeks of gestation which increased to 67.73 ± 9.92 at 40 weeks. The MCA-PSV showed continuous increment with increasing gestational age.Conclusions: Continuous increment in the peak systolic volume with advancing gestational age was obtained which was consistent with the previous studies done by various authors. The percentile fitted values and normograms will be valuable for the serial measurement of the peak systolic volume of the middle cerebral artery for complicated pregnancies.Nepal Journal of Obstetrics and Gynaecology / Vol 8 / No. 2 / Issue 16 / July-Dec, 2013 / 42-45 DOI: http://dx.doi.org/10.3126/njog.v8i2.9769

Influence of Malaria Prevention on Malaria Parasitaemia during Pregnancy

Malaria infection control remains a challenge in Africa. According to the World Health Organization, an estimated 660,000 deaths occurred from malaria infection in 2010, with Sub-Saharan Africa accounting for 90% of the mortality. The aim of this study is to assess the prevalence of peripheral malaria parasitaemia and the methods of malaria prevention commonly used among pregnant women. The study is a cross sectional survey of pregnant women attending an antenatal booking clinic in a secondary health care center in Southwest Nigeria. In addition to obtaining information about patients' knowledge of malaria infection and protection, obstetric history, general and obstetric examinations were completed, and blood film and capillary tube samples were obtained through a finger prick. Thick and thin blood films were stained and examined for identification and quantification of malaria parasite, and the capillary tube blood sample was processed for haematocritestimation. Results of 502 participants were used in the analysis; 38 (7.6%) women were positive for malaria parasite on microscopy. Peripheral malaria parasitaemia was more common among primigravidae25 (65.8%) compared with multigravidae 13(34.2%) (p-value< 0.001). The mean parasite density was higher among primigravidae, 6824.39parasites/µl compared to multigravidae, 606.69 parasites/µl. A total of 337 (67.1%) of the participants had haematocrits less than 11g/dl. Malaria prevention methods used by the participants included untreated nets 204 (40.7%), insecticide sprays and coils 211 (42.0%), and insecticide treated nets (ITNs) 87 (17.3%). Among the participants with peripheral malaria parasitaemia, one (2.6%) used ITNs compared with 21 (55.3%) and 16 (42.1%) who used insecticides and untreated nets respectively (p-value 0.032). Further analysis showed higher odds of peripheral malaria parasitaemia among those who used insecticides, and untreated nets relative to ITNs (odds ratio8.763, 95% CI 1.136 - 67.592, and odds ratio 6.993, 95% CI 0.899 - 54.411). Fewer pregnant women use ITN compared with other methods such as insecti- cides and untreated nets despite the protective benefits against malaria infection in pregnancy. Therefore, further exploration regarding improved accessibility and increased effectiveness of utilization is necessary to decrease malaria infection rates, es- pecially among pregnant women.

A Retrospective Study of Maternal and Fetal Outcome in Severe Oligohydromnios

Amniotic fluid is the nourishing & protecting liquid of the amnion of a pregnant woman& at 10 weeks it contains proteins, carbohydrates, lipids, phospholipids, urea, electrolytes all of which helps in the growth of fetus & in later stages it consists of fetal urine. As the fetus grows amniotic fluid increases to maximum of 800-1000ml at 34 weeks and decreases to 600-800ml at 40 weeks. It protects the baby by cushioning too. Any decrease in the amniotic fluid leads to intra uterine growth restriction, meconium aspiration syndrome, severe birth asphyxia, low Apgar scores, congenital abnormalities, contracture of the limbs, clubbing of feet & hypoplastic lungs. so early detection and intervention might decrease the perinatal mortality and morbidity and decrease in the C-section rate also. Aims & Objectives: To study the effect of severe oligohydramnios on maternal morbidity, neonatal morbidity & mortality & incidence of congenital abnormalities. Materials & Methods: 100 cases of term pregnancies with severe Oligohydromnios admitted to labour room, between June 2013 to Dec 2013 were selected. After considering inclusions & exclusion criteria, a detailed history was taken and general physical examination, obstetric examination& clinical pelvimetry was done & Bishops score was assessed. Severe Oligohydromnios was confirmed by estimation of AFI by USG & in all cases Doppler study was done. Conclusion: Severe Oligohydromnios has been linked with adverse perinatal outcome which includes structural anomalies, SGA, IUGR, post maturity syndrome, cord compression, MAS &FHR variations & increased perinatal morbidity & mortality. Hence it demands early diagnosis, intense antenatal care of maternal & fetal factors, intervention with hydration and isotonic therapy, intense intrapartum care, intervention at the appropriate time to decrease fetal morbidity & mortality.

Unexpected diagnosis of fetal malformations: therapeutic itineraries

Ultrasonography was a technological breakthrough for obstetrics, allowing visualization of fetal structures. However, the lack of a systematic approach to obstetric ultrasound examinations causes in Brazil, pregnant women do the exam on their own, which can sometimes lead to unexpected diagnosis of fetal malformation. In order to describe the reaction of women when surprised by the diagnosis of fetal malformation and therapeutic itineraries that follow, we conducted a study with nine pregnant women after ultrasound confirmation of fetal malformation. Through semi-structured interviews and content analysis of the narratives, the following categories were identified: motivation to perform ultrasonography; care at the referral; and coping strategies from the confirmation of fetal malformation. The interviews revealed failure to comply with the correct sequence of the prenatal care process. Definition of suitable moment for ultrasound test and guidance at each stage of pregnancy now represent a challenge for the improvement of perinatal care.

Lethal Developmental Defects: An Overview

About 3% of all conceptions are associated with major congenital malformations, many of them are lethal developmental defect and genetic in origin or teratogenic (adverse effects of the environment during gametogenesis or early embryogenesis). Genetics with or without adverse environment has role in virtually every developmental defect/malformation disorders in causation, predisposition, susceptibility & modulation of disease. Advances in genetics, introduction of triple marker screening, routine obstetric ultrasound examination into obstetric practice & accesses to prenatal diagnosis helped in secondary prevention (early detection & termination) of lethal developmental defects. Ultrasound detection of fetal developmental defects/malformation is common now and often decision on pregnancy solely based on ultrasonic morphological description. This practice leads to difficulty in providing accurate counseling as well as preventing disorder in subsequent pregnancy, in particular early. Hence an understanding of reproductive genetics of major developmental disorders is important for today’s perinatal care specialists. This overview will outline the various lethal developmental defects observed in an advanced reproductive genetics set up and various approaches adopted to derive diagnosis. Detailed assessment of fetus after termination of pregnancy (spontaneous/induced) for fetal anomalies was carried out in most cases. As most cases was referred after termination in formalin routine chromosomal analysis was not possible however, in selected cases targeted FISH analysis with specific chromosomal probe was carried out to confirm clinical diagnosis. Detailed evaluation of fetus is important as this practice often helped in modification of genetic counseling, as well as course of management in the next pregnancy. No molecular diagnostic or screening work was carried out due to non availability of information and facility in past. However, this is important today as many of the lethal developmental defects are yet to be categorized etiopathologically, and hence immediate need is to start clinical registry along with biorepository of developmental defects cases for future research work on informative families, in particular with multiple affected fetuses/sibs, using genomics, proteomics, metabolomics, platforms.

Obstetric and gynecological clinical examination of breeding stock cattle

In the breeding farm has been conducted and obstetric and gynecological clinical examination of high-producing cows. As a result of measures taken to improve the food supply and balance rations of the nutrient in dry cows returned to normal metabolic rate, improve the function of organs of reproduction, decreased the number of obstetrical and gynecological pathology.

Antenatal diagnosis of alobar holoprosencephaly.

A twenty-year-old second gravida presented to the department of radiodiagnosis for routine obstetric ultrasound examination. Ultrasonography revealed a live fetus of 17 weeks with absent falx, fused thalami, monoventricle, proboscis, and cyclopia. Fetal MRI was performed and the findings were confirmed. Even though ultrasonography is diagnostic in the detection of fetal anomalies, MRI plays a vital role due to its multiplanar capability and excellent soft tissue resolution. The importance of presenting this classical case of alobar holoprosencephaly is to sensitize the clinicians and radiologists to the imaging manifestations of holoprosencephaly and to stress the importance of early diagnosis. If diagnosed in utero at an early stage of pregnancy, termination can be performed and maternal psychological trauma of bearing a deformed fetus can be avoided.

Prevalence of Major Fetal Defects in Fallujah, Iraq

Background: The prenatal prevalence of congenital anomalies in Iraq is still under debate because of deficiencies in diagnostic capabilities and low reliability of medical registration. Early antenatal diagnosis of fetal defects is important for early counseling, intervention and possible fetal therapy. Objectives: The aim of this study was to estimate prenatal frequency of major congenital anomalies and malformation patterns diagnosed by ultrasound in Fallujah city. Patients and Methods: A cross-sectional study using the recorded data of antenatal diagnosis of major fetal congenital anomalies conducted in Fallujah Hospital—Fetal Medicine Clinic for a period of 20 months (January 2012 to August 2013). During this period one or more obstetrical ultrasound examinations were performed for 2120 pregnant ladies. Results: A total of 178 cases with obvious fetal anomalies were diagnosed. The prenatal prevalence of congenital anomalies was 84 per 1000. The median maternal age at diagnosis was 29 ± 6.3 years. The mean gestational age at diagnosis was 27 weeks ± 5 days. Extremities and urinary system anomalies were the most frequently detected anomalies. Conclusion: The prevalence of structural fetal malformation diagnosed by ultrasound in Fallujah city is obviously higher than internationally reported figures.

Surgical Management of a Second Degree Perineal Laceration in a Buffalo Sequel to Dystocia

A 3-year-old female Murrah-Ravi Buffalo weighing approximately 300kg suffered a second degree perineal laceration following forced extraction due to dystocia caused by malpresented fetus on 13th October, 2012. Physical examinations modification as a detailed clinical examination that included both physical examination and an obstetrical examination revealed extensive, necrotic and foul smelling vulva with tear which extends from the ventral aspect of the anus to dorsum of the vulva and vagina. In rural or urban conditions fetal traction attempted by farm workers or the owners themselves without veterinary supervision and guidance always lead to complication. Flunixin meglumine (Banamine® ) was administered before the wound cleaning and uterine lavage. Epidural anaesthesia was performed before debridement of necrotic tissues and surgical repair of the perineal laceration. The buffalo responded well to the treatments, however handling of dystocia cases under the supervision of veterinary surgeon is imperative even in farms which are aimed at the welfare of inflicted animals in order to avoid serious mishaps’ and future breeding of the buffalo is not advisable.

Prenatal Detection of Congenital Heart Disease: Time for a Breakthrough

To borrow Churchill’s 1939 description of Russia, fetal wellbeing ever since man’s creation was a ‘‘riddle, wrapped in a mystery, inside an enigma’’ till the advent of medical ultrasonography. We are now able to identify with increasing accuracy the intricacies of cardiac pathology; however, the rates of prenatal detection of congenital heart disease (CHD), the most common type of birth defects in humans, continue to be suboptimal at best. The reported rates have been quite disappointing, ranging between 15 and 48 % with most being reported to be less than 30 % [4, 6, 9]. Even more recently, two published retrospective studies in high-risk populations at four major United States tertiary care centers, which take into account the use of more advanced technology and equipment, reported rates of detection of 24–36 % [5, 8]. This obviously continues to emphasize the poor prenatal detection rate and to stress the need for further improvement in this area. This year, the American Institute of Ultrasound in Medicine (AIUM), in conjunction with the American College of Radiology (ACR), the American College of Obstetricians and Gynecologists (ACOG) and the Society of Radiologists in Ultrasound (SRU), published the revised practice guidelines for the performance of Obstetric Ultrasound Examinations [1]. These guidelines, like those previously published, include essential minimal or mandatory elements as part of the standard ultrasound examination of fetal anatomy during the secondand thirdtrimester scan. Unlike the previous guidelines, however, this year’s publication includes a major change in screening the fetal heart in low risk pregnancies. The previous guidelines state that a basic cardiac examination should include a 4-chamber view of the fetal heart and, only when ‘‘technically feasible’’, views of the outflow tracts. The current guidelines, finally, clearly emphasize the inclusion of both the right and left outflow tracts view in addition to the 4-chamber view as an integral part of the minimal elements of the ultrasonographic assessment of the fetal heart. This significant change comes after various studies demonstrated the importance of adding the outflow tracts view to the routine prenatal screening ultrasound in addition to the four-chamber view. This has been shown to result in significant improvement in the detection rate of CHD of up to 70 %, as has been shown by Carvalho et al. [3] in a high-risk population and 74 % as recently shown by a study by Levy et al. [7] in a large low-risk population. The outflow tracts view has been shown to be more sensitive than the four-chamber view in detecting CHD in general as well as in detecting ductal-dependent forms of CHD [8]. This leaves no doubt that, in order to achieve a better prenatal detection rate of CHD in the general population, the addition of the outflow views to the routine fetal screening examination has to become mandatory. Given the importance of prenatal and early detection of congenital heart disease on postnatal outcome [2], these published practice guidelines will undoubtedly have a significant impact on the practice of fetal medicine. These guidelines represent an important effort to raise the bar and improve the rate of prenatal detection of CHD and as such advance the field of fetal cardiology. The inclusion of the assessment of both the 4-chamber and outflow tracts views in the screening process in large low-risk pregnancies, however, undoubtedly places a significant burden on practicing obstetricians and obstetric sonographers, many of whom were not trained to obtain K. A. Diab (&) S. Awad Pediatric Cardiology, Rush University Medical Center, 1653 W Congress Parkway, Chicago, IL 606012, USA e-mail: karim_diab@rush.edu

Quality Control of Obstetric and Gynecologic Ultrasound in Hungary: Education and Expectations

ABSTRACT The result of ultrasound examinations depends heavily on the preparation of the personnel carrying out the examination and the technical capabilities of the equipment they use. Only wellorganized regional or national programs are able to provide high level, cost-effective care based on certification of quality. Such certification must include the training of professionals, the definition of competence levels, accreditation of laboratories and the establishment of professional protocols. The ultrasound examinations in Hungary are performed by obstetricians under the recommendation of the Hungarian Society of Ultrasound in Obstetrics and Gynecology and there are well defined levels and protocols of attendance. The different levels of attendance require proficiency at different levels and this requires regular training which is assured by the Society and gives a concern for all doctors and sonographers who perform ultrasound examinations and for all patients who receive them. The well organized quality assurance in obstetric and gynecologic ultrasound examinations is an essential dimension of high quality obstetric and gynecologic medical attendance. How to cite this article Belics Z, Papp Z. Quality Control of Obstetric and Gynecologic Ultrasound in Hungary: Education and Expectations. Donald School J Ultrasound Obstet Gynecol 2013;7(4):492-495.

English

Twin reverse arterial perfusion (TRAP) sequence occurs in 1 in 35,000 births and one percent of monochorionic twins. This condition is fatal for the recipient and carries a high mortality rate for the twin. The following case reports a monsterous acardiac co-twin with a normal surviving twin. INTRODUCTION: Acardiac twinning is a rare malformation characterized by a pump twin perfusing an anomalous recipient via an artery-to-artery anastomosis, with reversed direction of flow of arterial blood to the perfused fetus leading to total or partial agenesis of the heart and acephaly in the recipient twin with absence of one or more anatomical structures. At least 20% of the monozygotic co-pump twins can be expected to have congenital anomalies, and 55% of the twins die in the newborn period.(1) CLINICAL REPORT: A 27 year, unbooked primigravida was admitted in active labour at 39 weeks gestation. Her general physical and systemic examination was normal. On obstetrical examination, the uterus was overdistended with excessive liquor and multiple fetal parts were felt. Ultrasonography revealed a twin pregnancy with both fetuses in breech presentation and an emergency cesarean was performed. The first twin was a normal live born male weighing 2.25 kg. Apgar score was 8 and 9 at 1 and 5 minutes, respectively. The other twin was huge, warranting an extension of the incision in a J-shaped manner. The twin weighed 5.5 kg (fig. 1). The head and upper extremities were absent. The upper portion of the torso contained soft globular masses with a defect in the anterior abdominal wall. The external male genitalia was incompletely fused. The right foot had one toe whereas left foot had four digits. The lower spinal column and lower leg bones were apparently normal. The placenta was single and weighed 800 gm. The histopathology of the placenta confirmed the monochorionic placentation. Minimal autopsy was done which showed absent bony cage and thoracic organs. Neonatal assessment of the first twin including scan of the brain, chest and abdomen was normal. The baby was roomed in with the mother. DISCUSSION: A variety of acardiac twins have been described based on the degree of cephalic or truncal maldevelopment. (2). Reversed blood flow in the umbilical artery of the acardiac twin causes atrophy of the heart and other organs. The twin with cardiac activity may be hydropic or malformed in 9% of cases. Perinatal mortality for the twin is estimated around 55%. (3, 4) First trimester discordance in these cases represent an early manifestation of TRAP sequence. (5) Color Doppler confirms TRAP sequence by showing reversal in the flow direction in umbilical artery of perfused twin, smaller resistive index (<0.2) is associated with poor outcome including cardiac failure and central nervous system hypoperfusion. (6) In our case no antenatal ultrasound was done as she was an unbooked patient and had received no antenatal care.

Analysis of use of a single best answer format in an undergraduate medical examination.

Examinations at the Faculty of Medicine of Mu'tah University are based on a single best answer multiple-choice questions (MCQs) format. However, the reliability of this examination format has not been determined. Objective: Using an examination of obstetrics and gynaecology as a model, this study aims to analyze the difficulty (facility) index, the discriminatory power and reliability of the examination format. Materials, Subjects and Methods: A prospective study on the psychometric performance was carried out for an undergraduate examination in obstetrics and gynaecology. The performance of the items was measured in terms of facility, discrimination and reliability. Two statistical tests were used to estimate the reliability of the exam: The Kuder-Richardson Formula 20 (KR-20) and the Cronbach alpha test. Results: The items scored well in facility with a significant portion (26%) achieving a positive point biserial of over 0.3 and a Cronbach alpha score of 0.947. However, 23% of the items had a negative point biserial and the Kuder-Richardson 20 (KR20) score was only 0.599. Conclusion: In order to improve the reliability of examinations, we recommend removing the items with negative point biserials and increasing the total number of items.

The screening and treatment of abnormal glucose metabolism during pregnancy

Objective To screen the abnormal glucose metabolism in pregnant women without diabetes and to give early intervention to reduce perinatal maternal and fetal adverse complications.Methods 2 579 pregnant women who received obstetric examination and revealed no diabetes,underwent GCT screening and OGTr reexamination.The results confirmed the 263 GIGT patients,22 GDM patients.They were givien intervention therapy until delivery and their pregnancy outcome was compared with the normal pregnant women.Results The pregnancy outcome of GIGT pregnant women received intervention and the normal pregnant women had no significant difference.The incidence rates of macrosomia and cesarean section in GDM group were higher than those of normal pregnant women (P ＜0.05,P ＜ 0.01).Conclusion Development of gestational abnormal glucose tolerance screening is important to the early diagnosis and intervention of potential IGT,GDM patients,which can significantly reduce the incidence rate of maternal and fetal adverse complications. Key words: Pregnancy complications; Sugar metabolic abnormalities ; Glucose tolerance test; Pregnancy outcome

English

INTRODUCTION: The blood group serology plays an important role in transfusion medicine. The discovery of a rare blood group, Bombay (Oh) Phenotype by Bhende et al in 1952 in Mumbai formerly (Bombay) was important in the field of immunohematology. The discovery later helped Watkins and Morgan1 (1959) and Gerard et al2 (1982) to elucidate biosynthetic pathway for ABH and Lewis (Le) antigens suggesting the secretor (Se) and (H) are closely linked structural genes. Recently, molecular genetic studies were carried out to determine the role of the H, Se and Le genes in the expression of H antigen in secretions and Lewis blood group antigen on erythrocytes. 3,4. It is known that the precursor protein from which all blood groups are formed is termed as the “H” Antigen. This ‘H’ antigen either translates into ‘A’ antigen (blood group A) or into ‘B’ Antigen (blood group B) or into both A and B Antigens (blood group AB) or it remains as ‘H’(blood group ’O’).In the case of Bombay blood group, there is absence of ‘H’ Antigen itself. Therefore ‘A’, ‘B’, ‘AB’ and ‘O’ which are all different manifestations of ‘H’ are alien to persons with Bombay blood group. The Bombay blood group is termed ‘Oh’ meaning absence of ‘H’ Antigen. CASE REPORT: A 25 year old Post C.S. 2nd gravidae, at term pregnancy was referred from Purulia District Hospital and admitted in our hospital through emergency. The patient gave history of irregular antenatal checkup and did not consume iron folate tablets. Her menstrual history was normal. Her previous pregnancy and caesarean section were uneventful with no previous history of blood transfusion. There was no family history of Thalassemia or blood transfusion. On examination the patient was severely anaemic (Hb-4.5 gm %) with tachycardia and pedal oedema of lower limbs. Her blood pressure was 110/68 mm Hg Obstetric examination revealed full term post caesarean pregnancy with longitudinal lie, cephalic presentation, F.H.S.-146/min, regular with mild uterine contraction. Per vaginal examination suggested that she was in early labour. Immediate decision for blood transfusion and termination of pregnancy by LUCS was taken. The blood was sent for grouping and cross matching to our Blood Bank where she was diagnosed to have the Bombay Blood group after reverse grouping. As this group is very rare, we could not find a single unit of this group in Bankura district and immediate blood transfusion could not be performed. Ultimately, after 4hours of admission, LUCS was performed without blood. After emergency caesarean section the first 72 hours were uneventful. On the 4 th post-operative day, the

What urinary incontinence can hide? — Craniopharyngioma in an elderly female patient

Background: A benign tumor invading the surrounding structures just like a malignant one — the craniopharyngioma, situated near the sellar area, a rare clinical entity, usually accompanied by both neurological and endocrine dysfunctions, challenges the young clinician faced with vague, unspecific systemic symptoms. Clinical case: A 76 year old woman previously diagnosed with coronary heart disease, type 2 diabetes mellitus and hyperthyroidism presents at the emergency department with a 6 month history of physical asthenia, difficulty maintaining balance and recurrent urinary incontinence with polachiuria. She describes the symptoms as mild at debut but with a progressive evolution which urged her to seek medical advice. On physical examination the patient appears conscientious yet somnolent, with difficulties in maintaining walking balance. She is afebrile, with a regular heart rate of 75 bpm and a blood pressure of 120/60 mm Hg. The general physical examination reveals no abnormalities in the head, neck, chest, abdomen, or extremities. A thorough neurologic examination is performed, which reveals abolished tendon reflexes. Other neurologic examinations, including sensory and motor examinations and cerebellar tests are all within normal range. Her blood test results reveal an elevated ESR (30 mm/h), hyperglycemia (173 mg/dL), increased serum triglycerides (240 mg/dL), mildly increased blood urea nitrogen (51.70 mg/dL), low serum TSH (0.007 μUl/mL) with low fT3 and T4 values. Urine exam and cultures were negative for infection. Heart and carotid artery ultrasound exams found no significant abnormalities (LVEF 55%, impaired diastolic relaxation patterns and carotid atheromatosis, without significant stenosis). The obstetric examination excluded a perineal rupture as possible cause of the patient's urinary incontinence. Finally, the CT exam reveals a sellar and subsellar tumor with multiple calcifications, near the third ventricle. The mass causes hydrocephalus with periventricular edema. The native brain MRI exam describes the tumor with a craniocaudal diameter of 4 cm and axial 2.4/1.6 cm, with mixed solid and cystic structure and an aspect of a craniopharyngioma, with frontal lobe compression, coming in close contact to the optic chiasm. Thus, the common base between neurological symptoms and endocrine dysfunctions was revealed in the clinical entity described as a brain tumor associated with pituitary deficiency. Conclusion: We are presenting a rare and unspecific symptomatology for a craniopharyngioma, the patient showing none of the common signs of nausea, vomiting and headaches. The patient had previously been misdiagnosed and treated for hyperthyroidism while actually suffering from pituitary deficiency. After diagnosing the neoplasm, she was referred for further treatment by surgical resection and radiotherapy.