Disease burden of cardiovascular conditions complicating pregnancy in Sri Lanka: a protocol

Background

Cardiovascular diseases (CVD) are the commonest indirect medical cause of maternal deaths worldwide, both in high-income and low and middle-income countries. To minimize the effects of CVD in pregnancy, proper risk assessment and appropriate referral is required. In Sri Lanka, cardiovascular disease complicating pregnancy is a significant cause of maternal mortality, second only to postpartum hemorrhage. Screening for CVD in pregnancy in Sri Lanka is limited to a routine clinical assessment. Evidence-based guidelines are yet to be developed, and this deficit may have resulted in a substantial underestimation of the CVD burden. This study aims to determine the burden of CVD in early pregnancy and develop a risk prediction model to be used in field pregnancy clinics in Sri Lanka to reduce CVD effects in pregnancy.

Methods

A prospective cohort study was carried out in the Anuradhapura district, Sri Lanka. Following registration to the antenatal care, pregnant women fulfilling the eligibility criteria were invited to attend a special clinic at their relevant Medical Officer of Health (MOH) area. Risk assessment was done through history and a clinical examination, and suspected/probable cases were referred for an echocardiogram by a consultant cardiologist. All the recruited participants in the first trimester were prospectively followed up and screened again between 24-28 weeks of the period of amenorrhoea (POA). Antenatal ward admissions with CVD complicating pregnancy will be extracted, and a telephone interview will be carried out between 6-12 weeks after the expected delivery date to cover postpartum morbidities.

Discussion

This proposed study will be the largest of its kind carried out in the local setting. The study's findings will be beneficial for policymakers to develop guidelines to reduce maternal cardiovascular disease morbidities and mortalities in Sri Lanka.

Incorporating early pregnancy mental health screening and management into routine maternal care: experience from the Rajarata Pregnancy Cohort (RaPCo), Sri Lanka

Early identification of mental health problems in pregnancy in low-income and middle-income countries is scarcely reported. We present the experience of a programme assimilating screening and management of antenatal anxiety and depression in conjunction with the Rajarata Pregnancy Cohort, in Sri Lanka. We adopted a two-stage screening approach to identify the symptoms and the reasons for anxiety and depression. Pregnant women (n=3074), less than 13 weeks of period of gestation underwent screening with the Edinburgh Postnatal Depression Scale (EPDS). Scores were positive among 23% and 14% of women in the first and second trimesters, respectively. Clinical (telephone) interviews (n=78, response 56.9%) were held for women having high EPDS scores to screen for clinical depression using the 'mental health GAP' tool. Targeted interventions including counselling, financial and social support and health education were employed. The procedure was repeated in the second trimester with in-person clinical interviews and inquiry into intentional self-harm. Our findings indicated that (1) the majority of mental health problems in early pregnancy were anxiety related to early pregnancy-associated conditions manageable at the primary healthcare level, (2) coupling mental health screening using psychometric tools with clinical interviews facilitates targeted patient-centred care, (3) the majority of intentional self-harm during pregnancy is not in the routine health surveillance system and (4) promoting women to attend the psychiatry clinic in tertiary care hospital has been difficult. Following the experience, we propose a model for mental health service provision in routine pregnancy care programme starting from early pregnancy.

Heart disease complicating pregnancy as a leading cause of maternal deaths in LMIC settings: the Sri Lankan experience

Background

Heart disease (HD) is one of the leading indirect causes of maternal deaths worldwide, both in high- and low- and middle-income countries (LMICs). This study aims to describe maternal deaths due to cardiovascular disease complicating pregnancy in Sri Lanka.

Methods

The national Maternal Death Surveillance Response (MDSR) system in Sri Lanka investigates all female deaths during pregnancy and 12 months after delivery. These maternal death investigation records were perused in this analysis. Maternal deaths from 2006 to 2018 with HD complicating pregnancy as the immediate or underlying cause of death were re-coded using the ICD-11 classification.

Findings

Of the 2855 pregnancy-related deaths reported to the MDSR from 2006 to 2018, 1646 (57.7%) were confirmed as maternal deaths. Of those, 284 (17.25%) were attributed to HD complicating pregnancy. The cause-specific maternal mortality ratio due to heart disease from 2006 to 2018 was 7.24 per 100,000 live births. Rheumatic heart disease was the leading cause of HD (60, 21.1%), while cardiomyopathies (59, 20.7%) and congenital anomalies (34, 12.0%) accounted for a sizeable share. Medically contraindicated pregnancies accounted for 54 (19%) deaths. Application of the 3-delay model identified 186 (65.5%) cases with possible delays. Out of all deaths, 158 (55.6%) cases were categorized as preventable.

Interpretation

Preventing maternal mortality from HD in LMICs requires a lifecycle approach with situation-specific interventions and highly specialized care. Community awareness, capacity building related to management, and specific infrastructure development will be key strategies.

Funding

None.

Can Homocysteine Be Used to Identify Vitamin B12 or Folate Deficiencies During Pregnancy in Low Resource Settings?

Objectives

With universal iron supplementation during pregnancy, role of other nutritional causes of anemia such as Vitamin B12 and folate deficiencies are increasingly coming to light. Testing vitamin B12 and folate levels is costly and inconvenient in low and middle income settings. Serum Homocysteine level is proposed as a cheaper and more feasible alternative to indicate vitamin B12/folate deficiency. We evaluated the role of Homocysteine as a predictor of B12/folate level among anaemic pregnant women in Sri Lanka.

Methods

We measured fasting serum total Homocysteine in a randomly selected sub sample of anaemic pregnant women (hemoglobin less than 11g/dl) from the Rajarata Pregnancy Cohort (RaPCo), Anuradhapura, Sri Lanka. They were referred to a special hospital clinic for B12 and folate assessment within 2 weeks of the initial assessment. Homocysteine levels > 6.9 µmol/L in first and > 9.6 µmol/L in second trimesters were defined as Hyperhomocysteinaemia. B12 levels below 203 pg/ml and folate levels below 4ng/ml were defined as deficiency. Sensitivity and specificity were calculated and Spearmen correlation was performed.

Results

Twenty two anaemic pregnant women in 6 to 18 weeks of gestation were included in the assessment. Median haemoglobin level of the selected sample was 10.2 g/dl (Range 8.2–10.9). Homocysteine (Range 4.43–17, median 8 µmol/L), B12 (Range 149.6–721, median 299.8 pg/ml) and folate (Range 5.5–40, median 16.6 ng/ml) showed skewed distribution. Hyperhomocysteinaemia was observed in 12/22 (50%) pregnant women and B12 deficiency was observed in five participants (22.7% CI 10.1–43.4). None had folate deficiency. Hyperhomocysteinaemia was present in 2/5 (40%) B12 deficient and 10/17 (58.8%) B12 normal participants. Sensitivity of Homocysteine to indicate B12 deficiency was 40% (95% CI 11.8 to 76.9) and specificity was 41.2% (21.6, 67). Predictive values of positive and negative tests were 16.7% and 70% respectively. Homocysteine levels did not correlate with B12 level (Spearmen r = -0.26, p = 0.24) or folate level (spearmen r = 0.04, p = 0.86).

Conclusions

Elevated Homocysteine levels cannot be used as a reliable indicator of B12 or Folate deficiency in anaemic pregnant women.

Funding Sources

Accelerating Higher Education Expansion and Development (AHEAD) Operation of the Ministry of Higher Education, Sri Lanka.

The Rajarata Pregnancy Cohort (RaPCo): study protocol

Background

Ending preventable maternal deaths remains a global priority and in the later stages of obstetric transition, identifying the social determinants of maternal health outcomes is essential to address stagnating maternal mortality rates. Countries would hardly achieve the Sustainable Development Goal (SGD) targets on maternal health, unless the complex and context-specific socio-economic aetiologies associated with maternal mental health and suicide are identified. The Rajarata Pregnancy Cohort (RaPCo) is a prospective cohort study, designed to explore the interactions between social determinants and maternal mental health in determining pregnancy and new-born outcomes.

Methods

The study will recruit all eligible pregnant women in the maternal care programme of Anuradhapura district, Sri Lanka from July to September 2019. The estimated sample size is 2400. We will assess the socio-demographic and economic status, social capital, gender-based violence and mental health, including a clinical examination and biochemical investigations during the first trimester. Participants will undergo four follow-ups at 2nd and 3rd trimesters, at delivery and in early postpartum. The new-borns will be followed up at birth, neonatal period, at 6 six months and at 1 year. Pregnancy and child outcome data will be collected using direct contact. Qualitative studies will be carried out to understand the complex social factors and behavioural dimensions related to abortion, antenatal depression, maternal deaths and near misses.

Discussion

This is the first reported maternal cohort in Sri Lanka focusing on social determinants and mental health. As a country in stage four of obstetric transition, these findings will provide generalizable evidence on achieving SGD targets in low- and middle-income countries. The study will be conducted in a district with multi-cultural, multi-ethnic and diverse community characteristics; thus, will enable the evidence generated to be applied in many different contexts. The study also possesses the strength of using direct participant contact, data collection, measurement, examination and biochemical testing to minimise errors in routinely collected data. The RaPCo study will be able to generate evidence to strengthen policies to further reduce maternal deaths in the local, regional and global contexts particularly focusing on social factors and mental health, which are not optimally addressed in the global agenda.

Female Obesity: An Emerging Threat in Sri Lanka

Objectives

Emerging body of evidence clearly shows a transgenerational effect of obesity. The maternal health programme in low- and middle-income countries are typically focusing on undernutrition, while the burden of overweight and obesity are mostly overlooked. The objective of this study was to evaluate the burden of malnutrition in a cohort of pregnant mothers in Sri Lanka.

Methods

A cross sectional analysis was conducted as a part of an ongoing cohort of all pregnant women registered in the public health system and having a period of gestation less than 12 weeks in Anuradhapura district, Sri Lanka were recruited over three months period during 2019. Clinical and anthropometric assessments were done in 240 dedicated clinics.

Results

Total of 3190 mothers were recruited with full anthropometric profile with mean age of 28.3 years (SD 5.6). Prevalence of overweight, obesity grade I, II and III according to Asian cut off limits were 15.3% (n = 520), 31.4%(n = 1065), 1.5% (n = 51) and 2% (n = 7) respectively. Prevalence of underweight was only 15.9%. Waist circumference >80 cm was reported among 1189 (35%) mothers. A marked spatial distribution of obesity was observed with ranging from 23% to 46%. As a more important and unbiased factor in the first trimester of pregnancy, we looked at the predictors of WC >80. After the adjustment for POA and age, living environment variables indicating higher level of financial status such as using electricity as main cooking fuel (OR 2.276), having a wooden floor (OR 1.688), floor tiles (OR 1.377), three-wheeler (OR 1.22) or other vehicle ownership (OR 1.287) were associated with central obesity. Higher education level of women and lower educational level of husband were also identified as predictors. Women from moor ethnic group were also at a higher risk compared to others.

Conclusions

Context specific strategies are required to tackle the double burden of malnutrition and the observed gross micro geographical variation in obesity needs further studies.

Funding Sources

Accelerating Higher Education Expansion And Development (AHEAD) Operation.

Cryopreservation of lateral buds of in vitro-grown innala plants (Solemostemon rotundifolius) by vitrification

We succeeded in cryopreserving of innala (Solenostemon rotundifolius) in vitro-grown young lateral buds by vitrification. Nodal segments from in vitro-grown shoots (2-4 mm in length) were cultured on MS medium containing 0.1M sucrose in Petri dishes for 3 weeks under 16-h photoperiod at 25 degree C. This pre-growth induced a large number of uniform young lateral buds. Nodal segments (0.5 to 1.0 mm in length) with two lateral buds were dissected from the shoots and precultured with 0.3 M sucrose for 2 days at 25 degree C. They were then treated with loading solution containing 2 M glycerol and 0.4 M sucrose (LS solution) for 20 min at 25 degree C and dehydrated with the PVS2 vitrification solution for 18 min at 25(C prior to either rapid immersion in liquid nitrogen. Surviving lateral buds resumed growth within 3 days and developed shoots without intermediary callus formation. The average growth recovery after cryopreservation amounted to 85%.