Despite treatment, HbA1c ≥ 37 mmol/mol in the first trimester is associated with premature delivery among South Asian women with gestational diabetes mellitus: a retrospective cohort study

PURPOSE

To examine the effects of first-trimester HbA1c (HbA1c-FT) ≥ 37 mmol/mol on preterm birth (PTB) and large-for-gestational-age (LGA) babies in a retrospective cohort of South Asian pregnant women with gestational diabetes (GDM).

METHODS

The cohort (n = 686) was separated into two groups based on HbA1c-FT values: Group A (n = 97) and Group B (n = 589), with values of 37-46 mmol/mol (5.5-6.4%) and < 37 mmol/mol (5.5%), respectively. HbA1c-FT's independent influence on PTB and LGA babies was examined using multivariable logistic regression in groups A and B women. The reference group (Group C) included 2031 non-GDM women with HbA1c-FT < 37 mmol/mol (< 5.5%). The effects of HbA1c-FT on PTB and LGA babies in obese women in Groups A, B, and C (designated as A-ob, B-ob, and C-ob, respectively) were re-analyzed using multivariable logistic regression.

RESULTS

Group A GDM women with greater HbA1c-FT had a higher risk for PTB (aOR:1.86, 95% CI:1.10-3.14) but not LGA babies (aOR:1.13, 95%: 0.70-1.83). The risk of PTB was higher for obese women in Group A-ob: aOR 3.28 [95% CI 1.68-6.39]. However, GDM women with normal HbA1c-FT exhibited no elevated risk for PTB: Groups B and B-ob had aORs of 1.30 (95% CI 0.86-1.98) and 1.28 (95% CI 0.88-1.85) respectively.

CONCLUSIONS

South Asian GDM women with prediabetic HbA1c FT; 37-46 mmol/mol (5.5-6.4%) are more likely to deliver preterm babies despite treatment, while the risk for LGA babies was the same as non-GDM women.

Abdominal wall reconstruction (AWR) for post-trauma laparotomy ventral hernia and follow-up assessment of functional quality of life (QOL): experience of a level-1 trauma centre in India

PURPOSE

The aim of this study was to examine the postoperative outcomes and follow-up QOL of patients after AWR at a level-1 trauma centre in India.

METHODS

The study cohort included AWR patients treated between January 2011 and July 2022. The Activities Assessment Scale (AAS) was used to measure QOL, and the Ventral Hernia Recurrence Inventory (VHRI) was used to determine the occurrence of recurrence. In patients suspected of having recurrence, thorough clinical examination and relevant imaging were performed to confirm or rule out recurrence.

RESULTS

Out of 89 patients, 35 patients whose complete perioperative and follow-up data were available were enrolled. The mean age of the patients was 28 (SD, 9) years. The mean defect size was 14. 9 (SD, 7) cm. The mean time from laparotomy to AWR surgery was 21 months. During the postoperative course, 37% of patients developed complications, such as SSI and seroma. The mean follow-up time was 53 (SD, 43) months. Upon comparing procedures involving the mesh placed in the sublay position with procedures involving the mesh placed in other positions, no statistically significant difference in the recurrence rate (one in each group, p = 0.99), surgical complication rate (33% v/s 66%, p = 0.6), or mean AAS QOL score (94.7 v/s 98, p = 0.4) was observed. The specificity of the VHRI for diagnosing recurrence was 79%.

CONCLUSION

Overall, the recurrence rate was low in these patients despite the presence of large hernia defects. Long-term QOL was not affected by the specific procedure used. Timely planning and execution are more important than the specific repair approach for post-trauma laparotomy ventral hernia.

Establishing Trimester-Specific Haemoglobin A1c Reference Intervals in Pregnant Women: A retrospective study of healthy South Asian women with normal pregnancy outcomes

Objectives

This study aimed to define trimester-specific haemoglobin A1c (HbA1c) reference intervals in healthy, pregnant South Asian women.

Methods

This retrospective study was conducted at St. Stephen's Hospital, Delhi, India, between January 2011 and December 2016. Healthy pregnant women were compared to a control group of healthy non-pregnant women. Pregnant participants had term deliveries of babies with appropriate gestational weights. The HbA1c levels were calculated in terms of non-parametric 2.5 and 97.5 percentiles for women in first (T1), second (T2) and third (T3) trimester groups. Statistical tests were used to obtain the normal HbA1c reference values and were considered significant when P <0.05.

Results

This study included a total of 1,357 healthy pregnant women and a control group of 67 healthy, non-pregnant women. Pregnant women had a median HbA1c of 4.8% (4-5.5%) or 32 mmol/mol (20-39 mmol/mol); non-pregnant women had a median HbA1c of 5.1% (4-5.7%) or 29 mmol/mol (20-37 mmol/mol; P <0.001). The HbA1c levels for the T1, T2 and T3 groups were 4.9% (4.1-5.5%) or 30 mmol/mol (21-37 mmol/mol), 4.8% (4.5-5.3%) or 29 mmol/mol (20-34 mmol/mol) and 4.8% (3.9-5.6%) or 29 mmol/mol (19-38 mmol/mol), respectively. The HbA1c values were significant when comparing T1 versus T2 (P <0.001), T1 versus T3 (P = 0.002) and T1 versus the non-pregnant group (P = 0.001). However, T2 versus T3 was not significant (P = 0.111).

Conclusion

Compared to non-pregnant women, HbA1c levels were lower in pregnant women, despite women in the T2 and T3 groups having a higher body mass index than the women in the T1 and non-pregnant groups. Further research is recommended to understand the factors responsible and validate these findings.

Gestational diabetes mellitus in early pregnancy amongst Asian Indian women: Evidence for poor pregnancy outcomes despite treatment

AIM

To compare the pregnancy outcomes in women with gestational diabetes (GDM) based on the timing of diagnosis.

METHODS

This retrospective cohort study was conducted between January 2011 and September 2017 amongst 2638 Asian Indian pregnant women. The inclusion criteria included; singleton pregnancies having HbA1c <48 mmols/mol (6.5%) in the first trimester, GDM screening by 75 g OGTT using IADPSG criteria and delivery at our centre. The cohort was divided into 3 groups: Early GDM (E-GDM)-diagnosis <24 gestational weeks (Gw), Standard GDM (S-GDM)-diagnosis ≥24Gw, Non-GDM- No GDM ≥24 Gw. Multivariable logistic regression models compared the pregnancy outcomes between Non-GDM, S-GDM and E-GDM groups. A sub-group multivariable analysis was done amongst GDM women using gestational age at diagnosis both as a categorical and continuous variable.

RESULTS

Compared to Non-GDM women, the odds were higher for premature birth, large for gestational age (LGA) babies, macrosomia, Neonatal ICU(NICU) admission and lower for normal vaginal delivery in the E-GDM group, but for the S-GDM group, the risk was higher for premature birth, LGA babies, NICU admission and induction of labour. Compared to GDM women in the 24-28 Gw category significantly higher odds for premature birth and LGA babies were observed in the <14 Gw category. A continuous increase of 19% odds for premature birth with every 4 weeks decrease in gestational age at GDM diagnosis was observed.

CONCLUSIONS

Asian Indian women having a GDM diagnosis before 24Gw are at higher risk for adverse pregnancy events than those having diagnosis ≥24Gw or not having GDM.

Is HbA1c in the first trimester associated with adverse outcomes among pregnant Asian Indian women without gestational diabetes?

AIMS

The aim of this study is to determine the association of elevated HbA1c in the first trimester (HbA1c-FT) with adverse events among pregnant Asian Indian women without gestational diabetes (GDM).

METHODS

This retrospective cohort study included 1618 pregnant women who delivered at a single urban tertiary care center and had HbA1c-FT estimation between January 2011 and September 2017. Those with GDM according to a 75-g OGTT after 24 gestational weeks were excluded. Multivariable logistic regression models assessed the association between elevated HbA1c-FT and adverse events.

RESULTS

At a cutoff of ≥37 mmol/mol (5.5%), HbA1c-FT was associated with preterm birth at <37 gestational weeks (adjusted odds ratio (OR) 2.10, 95% CI 1.11-3.98). There was a continuum of risk for primary caesarean delivery with higher HbA1c-FT levels (adjusted OR per 5-mmol/mol (0.5%) increase in HbA1c-FT for primary caesarean delivery: 1.27, 95% CI 1.06-1.52). In the crude analysis, gestational hypertension was associated with HbA1c-FT, but not after adjustment for confounding factors. HbA1c-FT was not associated with other adverse events (macrosomia, large for gestational age babies, or other neonatal complications).

CONCLUSIONS

Even without GDM, the results suggest an association of HbA1c-FT with preterm birth and primary caesarian delivery among Asian Indian women.

Prevalence of 'Hyperglycemia in pregnancy' remained stable between 2006 and 2015, despite rise in conventional risk factors: A hospital based study in Delhi, North India

AIMS

Between 2006 and 2015, the trends in prevalence of Hyperglycemia in pregnancy (HIP); Gestational diabetes (GDM), Diabetes in Pregnancy (DIP), Pre existing diabetes (PDM) and GDM risk factors were studied in 30,692 pregnancies among Asian Indian women.

METHODS

GDM (n = 4089) and DIP (n = 259) diagnoses were by 75 g OGTT, while PDM (n = 103) was identified by ICD code O24. Women with DIP and PDM were grouped together as pre-gestational diabetes (PGDM n = 362). Crude and age-adjusted prevalence trend analysis by Poisson and Jointpoint regression models respectively, were done in GDM and PGDM groups.

RESULTS

During study years, the GDM prevalence by WHO 1999 and modified IADPSG criteria, showed decreasing and static trends respectively, while PGDM prevalence remained static. In a subgroup of 2560 women, mean BMI increased from 24.12 ± 4.16 in year 2011 to 25.18 ± 4.7 Kg/m² in 2015 (p < 0.014), but this rise had no impact on GDM prevalence. GDM risk factors; maternal age, gravidity ≥3, previous GDM and abortion, high income, diabetes and hypertension in family, were higher in 2011-2015 than in 2006-2010 period. On multivariate analysis, BMI was not an independent GDM risk factor.

CONCLUSION

Despite rise in conventional GDM risk factors, HIP prevalence was static for a decade among pregnant Asian Indian women.

Glycated haemoglobin in the first trimester: A predictor of gestational diabetes mellitus in pregnant Asian Indian women

AIM

To assess the efficacy of first trimester glycated hemoglobin (HbA1c-FT) in diagnosing or predicting gestational diabetes mellitus (GDM) in Asian Indian women.

METHODS

This retrospective cohort study involved 2275 women who underwent both HbA1c-FT estimation and GDM screening with a one-step 75 g oral glucose tolerance test. Receiver Operating Characteristic (ROC) curve statistics were applied to assess the discriminative ability of HbA1c-FT in GDM diagnosis. A multivariable logistic regression analysis after adjusting for plausible confounders was used to evaluate the independent effect of HbA1c-FT on GDM diagnosis.

RESULTS

The mean HbA1c-FT of GDM (n = 578) and non-GDM women (n = 1697) were 5.04 + 0.04% and 4.9 + 0.37%, respectively (p < 0.001). Compared to women with a HbA1c-FT < 5.2%, the adjusted odds ratio to develop GDM of women with an HbA1c-FT range of 5.2-5.5% and those >5.6% to develop GDM were 1.627 (p < 0.004) and 2.6 (p < 0.001), respectively. The area under the ROC curve to detect GDM was 0.606 (95% CI: 0.519-0.633 p < 0.001), but the sensitivity and specificity of the HbA1c-FT were not sufficient to diagnose, rule in or rule out GDM.

CONCLUSIONS

HbA1c-FT is an independent GDM predictor in Asian Indian women but lacks sufficient sensitivity or specificity for use as a diagnostic test.

Bimodal distribution of fasting, one and two hour post load plasma glucose in Asian Indian pregnant women without pre-gestational diabetes: Gestational age related changes

•After exclusion of pre-gestational diabetes, Asian Indian pregnant women have bimodal distribution of plasma glucose.•Bimodality is observed for fasting, 1 and 2 h post glucose load plasma glucose distribution.•Cut off values for gestational diabetes diagnosis could not identified for any glucose parameter.•In women with high gestational diabetes risk factors, the bimodality is evident before 24 weeks of gestation.•By third trimester, the bimodality is significant for all glucose parameters.

Bimodal glucose distribution in Asian Indian pregnant women: Relevance in gestational diabetes mellitus diagnosis

•

Pregnant Asian Indian women have bimodality in plasma glucose distribution.

•

Bimodality is evident even in very young pregnant women of age 18–23 years.

•

Glucose cut points may suggest thresholds for gestational diabetes diagnosis.

Aims

Presence of bimodality in plasma glucose distribution (BPG) and its relevance for gestational diabetes mellitus (GDM) diagnosis were studied in Asian Indian pregnant women.

Methods

Fasting (FPG) and two hour plasma glucose (2-h PG) values of oral glucose tolerance tests performed in 36,530 pregnant women for GDM screening (2006–16 period), were analyzed for BPG. A unimodal normal and a mixture of two normal distributions were fitted to log-transformed FPG and 2-h PG data. The mixture model was compared to unimodal model for BPG using likelihood ratio test (LRT) and the comparison was further verified by bootstrapping. The cut points of the two normal distribution curves in the mixture models of FPG and 2-h PG were noted.

Results

Fasting and 2-h PG distribution was bimodal in all pregnant women. The comparison of mixture and unimodal models using LRT revealed p value <0.001 in all age groups. The cut points for FPG and 2-h PG were 5.81 mmol/L (95% CI: 5.69–5.92) and 8.41 mmol/l (95% CI: 8.09–8.75) respectively.

Conclusion

BPG is noted for both FPG and 2-hPG in Asian Indian pregnant women. The cutpoints of normal distribution curves are close to threshold values for FPG and 2-h PG proposed in NICE (National Institute for health and Care Excellence) and IADPSG (International Association of Diabetes and Pregnancy Study Group) GDM diagnostic criteria respectively. Further research on BPG in pregnant women of racial groups with high GDM prevalence, is likely to be of value in GDM diagnosis.

Persistent Trophoblastic Disease at Cesarean Scar

Pregnancy over the cesarean scar is the rarest cause of ectopic pregnancy and development of persistent trophoblastic disease at the scar site is extremely rare. A high index of suspicion is needed for early diagnosis and management of cesarean scar molar pregnancy. This condition is difficult to diagnose and must be considered in the patient with a history of cesarean section who has persistent vaginal bleeding or symptoms of pregnancy after suction evacuation. Diagnosis can be confirmedby measuring ß Human Chorionic Gonadotropin levels, transvaginal ultrasound with doppler flow evaluation. As this is an uncommon condition, this case report with conservative non surgical approach will add up to its clinical spectrum.

Use of ABO-incompatible grafts in living donor liver transplantation--first report from India

ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre-conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO-i) LDLT: a 42-year-old male, an 8-month-old male and a 28-month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab(®)) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤ 1:16 IgG and ≤ 1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8-17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT.

Development of Primers and Probes for Genus and Species Specific Detection of 'Candidatus Liberibacter Species' by Real-Time PCR

Huanglongbing (HLB), also known as citrus greening, is currently the most devastating disease impacting citrus production. The disease is associated with three different 'Candidatus Liberibacter species', 'Ca. Liberibacter asiaticus', 'Ca. Liberibacter americanus', and 'Ca. Liberibacter africanus', which induce similar and overlapping symptoms. When HLB-symptomatic trees are tested, one of the Candidatus Liberibacters is normally detected by conventional or real-time PCR (qPCR). The most widely used assays use primers and probes based on the 16S ribosomal RNA (rRNA) gene. The 16S rRNA-based assays to detect the three species are species-specific and must be performed sequentially. We describe a single assay that detected all species of 'Ca. Liberibacter' at the genus level, providing increased convenience. Recent molecular analyses of 'Ca. Liberibacter species' and other bacteria suggest that the rpoB gene (encoding the β-subunit of RNA polymerase) provides an alternative target for bacterial identification. We report here the design of a single pair of degenerate primers and a hybridization probe corresponding to the rpoB region and their application for the detection of all three citrus 'Ca. Liberibacter species', enabling detection of 'Ca. Liberibacter' at the genus level. In addition, species-specific primers and probes based on the rplJ/rplK genes were designed and used for detection at the species level in a multiplexed format. Both the genus- and species-specific assays were validated in both SYBR Green I and TaqMan formats, and with both plant and insect extracts that contained the pathogen. These one-step qPCR diagnostic methods are useful for the detection of all species of Liberibacter infecting citrus. In addition, the degenerate genus-specific primers and probe successfully detected 'Ca. Liberibacter solanacearum', a psyllid-transmitted pathogen associated with disease in tomato, carrot, and potato.

Electrophysiological characteristics of seizure clusters

The phenomenon of temporal clustering of seizures is well known, but its effect on seizure localization has not been rigorously analyzed. The aim of our study was to assess electrophysiological localization during Video EEG (VEEG) monitoring in patients with intractable epilepsy demonstrating a cluster of seizures. The study was conducted on 203 intractable epilepsy patients, aged 2 to 60 years (19.96 +/- 10.87). Patients with unilateral temporal lobe epilepsy having clusters were compared with patients not having clusters, and the effect of clustering on concordance was addressed. Fully consistent localization was observed in 116 patients, partially consistent localization in 18 patients, and inconsistent localization in 19 patients. ANOVA did not reveal any significant difference in these groups (p=0.65). A total of 770 seizures recorded from 149 patients was analyzed for clustering effect. Clustering was present in 603/770 seizures pairs (78.31%). In the cluster group, 483 (80.09%) seizure pairs were concordant for seizure onset, while 98 (16.25%) were discordant and 22 (3.65%) were indeterminate. In the noncluster group, 134 (80.24%) seizure pairs were concordant for seizure onset, while 23 (13.77%) were discordant and 10 (5.98%) were indeterminate. The study found that cluster seizures occurring within an interseizure interval (ISI) less than 8 hours are independent and have the same localizing value as those seizures with longer ISIs.

Abortion procedures in a tertiary care institution in India

OBJECTIVE

To determine the complications rate of termination of pregnancy (TOP) and the risk factors for complications following TOP.

METHODS

Retrospective observational study of the records of 1287 women who underwent TOP in the Department of Obstetrics and Gynaecology of the Postgraduate Institute of Medical Education and Research, Chandigarh, India, between 1997 and 2001. First-trimester abortion was performed in 1088 women (85%) and second-trimester abortion in 199 women (15%). Most women (76%) were aged between 26 and 30 years; they were educated and requested TOP primarily to limit the number of their children or to space their births. A malformed fetus was the indication for TOP in 5.9% cases, and 16% of the women had medical disorders associated with the pregnancy. Suction evacuation was the method of choice for first-trimester abortion (88%); dinoprostone gel and extra-amniotic saline solution plus oxytocin infusion were the primary methods (71%) for second-trimester abortion.

RESULTS

Uterine perforation occurred in 1 patient (0.09%) after a first-trimester abortion. The total rate of complications was 3.79% after first-trimester and 4.0% after second-trimester abortions. Excessive hemorrhage and retained placenta were chief complications associated with second-trimester abortion. Incomplete abortion (1.5%) and minor infection were seen in 2.3% patients. The rate of complications was higher among parous women. Postabortion insertion of a CuT intrauterine device increased the need for a second course of antibiotics.

CONCLUSION

Termination of pregnancy is safe if adequate care is taken while performing the procedure.

Chlamydia pneumoniae exposure and inflammatory markers in acute coronary syndrome (CIMACS)

Previous studies have shown higher levels of Chlamydia pneumoniae (C. pneumoniae, CP) antibody titers (CPIgG), C-reactive protein (CRP), and fibrinogen in patients with coronary artery disease. The role of these infectious and inflammatory markers in precipitating acute coronary syndrome (ACS) is unclear. We conducted a cross-sectional study on patients (n = 830, mean age 63 +/- 15 years, 57% male) admitted to the chest pain center of our institution. The differences in the CPIgG, CRP, and fibrinogen levels in patients who were diagnosed with ACS versus those who were not (non-ACS) were evaluated. CPIgG titers tended to be higher in the ACS group than in the non-ACS group. However, when different titers were used to define seropositivity, the difference achieved statistical significance only at the titer of > or =1:1,024 (35% vs 26%, p = 0.004). CRP (median 0.48 vs 0.33 mg/dl, p <0.0001), fibrinogen (median 317 vs 293 mg/dl, p <0.0001), and leukocyte count (median 7.7 vs 6.9 10(9)/L, p <0.0001) were higher in the ACS group. On multivariate analysis, CPIgG > or =1:1,024 (odds ratio [OR] 1.62), diabetes (OR 1.91), hypertension (OR 1.46), prior myocardial infarction (OR 1.78), smoking (OR 1.70), Caucasian race (OR 1.7), high-density lipoprotein (OR 0.98), and elevated troponin-T (OR 12.44) were the only factors independently associated with ACS. Thus, we found a strong association between high level seropositivity to CP and ACS. This may indicate recent re-infection or an exaggerated immune response to CP as an etiologic factor for ACS. This study also suggests that therapeutic interventions may need to be specifically targeted to these patients.

High prevalence of HBV infectivity in blood donors detected by the dot blot hybridisation assay

Hepatitis B virus (HBV) continues to be a significant cause for post-transfusion hepatitis in India, in spite of the introduction of compulsory hepatitis B surface antigen (HBsAg) screening. To understand the true HBV-infective pool in the blood donor population, HBV DNA was detected by a 32P-labelled dot blot hybridisation assay in 605 donor units that were negative for HBsAg by a third-generation Elisa. Serum alanine aminotransferase (ALT) was estimated in all these samples and correlated with DNA positivity. The frequency of HBV DNA positivity in HBsAg-negative units was very high (9.91%) and correlated well with the elevation in ALT (p < 0.00005). However, the frequency of elevated ALT was high (11.9%), using the locally determined upper limit of normal, and half of the DNA-positive samples had a normal ALT. Thus, ALT is a poor surrogate marker for HBV infectivity and efforts should be made to apply DNA detection systems in blood banks.