Navigating portal hypertension: Unlocking safe passage to healthy pregnancy in EHPVO

BACKGROUND AND AIMS

Pregnancy is associated with hyperdynamic circulatory state and increased risk of portal hypertension related complications in patients with extra-hepatic portal vein obstruction (EHPVO). We aim to study the impact of EHPVO on pregnancy-related outcomes with focus on subset of patients with UGIB (upper GI bleed).

METHODS

Retrospective analysis of obstetric, maternal and neonatal outcomes of patients with EHPVO registered between January 2006 and December 2022. Forty-five patients were included. Forty-five healthy females with low-risk pregnancies formed the control group.

RESULTS

Adverse obstetric and neonatal outcomes were comparable between EHPVO and control group (22% vs. 28.6%; p > .05; low birth weight/ small for gestational age 17.8% vs. 36%, p = .0918 and 14.2% vs. 10%, p = .5698 respectively). Adverse outcomes were similar in patients with and without history of UGIB (26.3% vs. 19.4%, p = .0814; 17.8% vs. 36%, p = .0918; 14.2% vs. 10%, p = .5698). There was no maternal mortality in both the groups. A total of 7% pregnancies in EHPVO patients were complicated by ascites.

CONCLUSIONS

EHPVO pregnancies have successful obstetric and neonatal outcomes with adequate management of portal hypertension.

Incidence & factors influencing maternal near miss events in tertiary hospitals of Maharashtra, India

Background & objectives

Government of India (GoI) released operational guidelines for maternal near miss-review (MNM-R) in 2014 for use by programme managers of public health system to assist them for conducting MNM-R. The objective of the present study was to review the incidence and factors influencing MNM events in two tertiary hospitals of Maharashtra, India, as per the operational guidelines of the GoI released in 2014 and identify delays based on three-delay model to prevent such events in future.

Methods

This prospective observational study was conducted in two tertiary hospitals of Maharashtra, from July 2018 to November 2020. All women during pregnancy, childbirth or postpartum upto 42 days meeting the eligibility criteria of MNM as per the 2014 GoI guidelines were included as cases (n=228), interviewed and discussed during the monthly MNM meetings at these hospitals.

Results

The incidence of MNM was 11/1000 live births; the ratio of MNM to maternal deaths was 1.2:1. Leading causes of MNM were haemorrhage (36.4%) and hypertensive disorders of pregnancy (30.3%). Haemorrhage was maximum (70.6%) in abortion and ectopic pregnancies. Majority of the women (80.2%) were anaemic, of whom 32.4 per cent had severe anaemia. Eighty six per cent of women included in the study had MNM events at the time of admission and 81 per cent were referred from lower facilities. Level one and two delays were reported by 52.6 and 32.5 per cent of women, respectively. Level three delay at referral centres and at tertiary hospitals was reported by 69.7 and 48.2 per cent of women, respectively.

Interpretation & conclusions

The findings of this study suggest that MNM-R should be undertaken at all tertiary hospitals in India as per GoI guidelines to identify gaps based on three-delay model. These hospitals should implement interventions as per the identified gaps with emphasis on strengthening the infrastructure, facilities and manpower at the first-referral units.

Vaginal Dysbiotic Microbiome in Women With No Symptoms of Genital Infections

The vaginal microbiome plays a critical role in determining the progression of female genital tract infections; however, little is known about the vaginal microbiota of Indian women. We aimed to investigate the vaginal microbial architecture of women with asymptomatic bacterial vaginosis (BV) (n=20) and normal microbiota (n=19). Microbial diversity was analyzed in vaginal swabs from regularly menstruating women (18-45yrs) by 16S rRNA V3-V4 amplicon (MiSeq Illumina) sequencing. Rarefaction analysis showed a higher number of species in normal flora compared to BV. Alpha diversity as measured by Pielou’s evenness revealed microbial diversity was significantly greater in BV samples than normal microbiota (p= 0.0165). Beta diversity comparison using UniFrac metrics indicated distinct microbial communities clustering between normal and BV flora. Firmicutes were the major phyla observed in vaginal specimens of normal microbiota whereas Actinobacteria, Fusobacteria, Bacteroidetes were significantly abundant in BV samples. Notably, the relative abundance of Lactobacillus was significantly high in normal microbiota. Conversely Gardnerella, Sneathia, Prevotella, Atopobium, Ureaplasma, Dialister significantly dominated dysbiotic microbiota. Relative frequency of Lactobacillus decreased significantly in BV (6%) as compared to normal microbiota (35.2%). L. fermentum, L. gasseri, L. iners, L. jensenii, L. mucosae, L. ruminis, L. salivarius, L. coleohominis was more exclusively present in normal microbiota. L. iners was detected from both the groups with a relative frequency of 50.4% and 17.2% in normal and BV microbiota respectively. Lefse analysis indicated Atopobium vaginae, Sneathia amnii, Mycoplasma hominis Prevotella disiens in the vaginal microbiota as a biomarker for dysbiosis and L. jensenii as a biomarker of a healthy microbiota. Firmicutes were negatively correlated to Tenericutes, Actinobacteria, Bacteroidetes, and Fusobacteria. Proteobacteria positively correlated to Tenericutes, and Bacteroidetes were shown to be positively correlated to Fusobacteria. Predicted functional analysis indicated differences in the functional profiles between BV and normal microbiota. Normal microbiota utilized pathways essential for phosphatidylglycerol biosynthesis I & II, peptidoglycan biosynthesis, geranylgeranyl diphosphate biosynthesis I, mevalonate pathway, CoA biosynthesis pathway I and pyrimidine nucleotide salvage; whereas BV bacteria had characteristic aromatic amino acid biosynthesis, pentose phosphate pathway, carbohydrate degradation. In conclusion, women with asymptomatic BV have vaginal microbiota significantly different than women with normal microbiota. Furthermore, the study provides insights into the vaginal microbial structure of Indian women that will enable us to explore the prospective candidates for restoring the vaginal microbiota.

Rab11a drives adhesion molecules to the surface of endometrial epithelial cells

STUDY QUESTION

Is Rab11a GTPase, a regulator of intracellular trafficking, of significance in endometrial functions?

SUMMARY ANSWER

Rab11a is an important component of the cascades involved in equipping the endometrial epithelium (EE) with 'adhesiveness' and 'cohesiveness'.

WHAT IS KNOWN ALREADY

Cell adhesion molecules (CAMs) have been investigated extensively for modulation in their endometrial expression during the peri-implantation phase. However, the mechanisms by which CAMs are transported to the EE surface have not received the same attention. Rab11a facilitates transport of specific proteins to the plasma membrane in endothelial cells, fibroblasts, embryonic ectodermal cells, etc. However, its role in the transport of CAMs in EE remains unexplored.

STUDY DESIGN, SIZE, DURATION

In-vitro investigations were directed towards deciphering the role of Rab11a in trafficking of CAMs (integrins and E-cadherin) to the cell surface of Ishikawa, an EE cell line. Towards this, Rab11a stable knockdown (Rab-kd) and control clones of Ishikawa were generated. JAr (human trophoblastic cell line) cells were used to form multicellular spheroids. Pre-receptive (n = 6) and receptive (n = 6) phase endometrial tissues from women with proven fertility and receptive phase (n = 6) endometrial tissues from women with unexplained infertility were used.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Rab-kd and control clones were used for in-vitro assays. Live cells were used for biotinylation, JAr spheroid assays, flow cytometry, trans-epithelial electrical resistance assays and wound-healing assays. Lysosome and Golgi membranes were isolated by ultracentrifugation. Confocal microscopy, immunoblotting, qRT-PCR and immunohistochemistry were employed for assessing the expression of Rab11a, integrins and E-cadherin.

MAIN RESULTS AND THE ROLE OF CHANCE

shRNA-mediated attenuation of Rab11a expression led to a significant (P < 0.01) decline in the surface localization of αVβ3 integrin. Cell surface protein extracts of Rab-kd clones showed a significant (P < 0.05) reduction in the levels of αV integrin. Further, a significant (P < 0.01) decrease was observed in the percent JAr spheroids attached to Rab-kd clones, compared to control clones. Rab-kd clones also showed a significant (P < 0.001) decline in the total levels of E-cadherin. This was caused neither by reduced transcription nor by increased lysosomal degradation. The role of Rab11a in maintaining the epithelial nature of the cells was evident by a significant increase in the migratory potential, presence of stress-fibres and a decrease in the trans-epithelial resistance in Rab-kd monolayers. Further, the levels of endometrial Rab11a and E-cadherin in the receptive phase were found to be significantly (P < 0.05) lower in women with unexplained infertility compared to that in fertile women. Taken together, these observations hint at a key role of Rab11a in the trafficking of αVβ3 integrin and maintenance of E-cadherin levels at the surface of EE cells.

LARGE-SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

The in-vitro setting of the study is a limitation. Further immunohistochemical localizations of Rab11a and CAMs were conducted on a limited number of human endometrial samples.

WIDER IMPLICATIONS OF THE FINDINGS

Rab11a-mediated trafficking of endometrial CAMs in EE cells can be explored further for its potential as a target for fertility regulation or infertility management.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Indian Council of Medical Research (ICMR), the Department of Science and Technology (DST), the Council of Scientific and Industrial Research (CSIR), Government of India. No competing interests are declared.

Uterine Torsion Masquerading as Abruptio Placentae: Diagnosed on Laparotomy

Uterine torsion is a rare, life-threatening and unexpected obstetric emergency. It is almost always diagnosed at caesarean section. Its ill-defined clinical presentation may pose a diagnostic dilemma. Here the authors present a case of 32-year-old, Primigravida, 36 weeks pregnancy with acute abdomen and intrauterine foetal demise. Clinical features resembled Abruptio Placentae. The diagnosis of uterine torsion (180°) was established on laparotomy where the left ovarian ligament was seen on the right side anteriorly. A posterior hysterotomy was done to extract the baby which was followed by detorsion of the uterus. The postoperative period was uneventful.

Spontaneous Haemoperitoneum in Pregnancy- A Diagnostic Challenge

Spontaneous haemoperitoneum in pregnancy is an extremely rare condition that poses a diagnostic dilemma for the obstetrician. The authors here present a case of 23-year-old primigravida presenting at 34-weeks with acute pain in abdomen masquerading as clinical chorioamnionitis secondary to prolonged rupture of membranes. Abdomen palpation revealed uterine tenderness and pathological cardiotocography tracings suggesting the need for immediate delivery of the foetus by emergency caesarean section. Intraoperatively, there was haemoperitoneum (800 mL) and bleeding superficial uterine serosal veins on the posterior surface of uterus seen on exploration. The patient was successfully managed with favourable maternal and fetal outcome.

Cross sectional analysis of vaginal Lactobacillus in asymptomatic women of reproductive age in Mumbai, India

Introduction: Lactobacillus dominated vaginal microenvironment is associated with lower risk of genital infections. Numerous studies have reported geographic and ethnic variations in vaginal microbiome structure between healthy individuals from different race and ethnicity. India has a great diversity, so it is intriguing to find out if such divergences exist in vaginal lactobacilli. The present study aimed to investigate predominant Lactobacillus species in vaginas of healthy Indian women and screen isolates for lactic acid and H2O2 production. Methodology: 203 premenopausal women asymptomatic for any vaginal complaints were recruited. The lactobacilli isolates on MRS agar were identified by Multiplex-PCR and 16sRNA gene sequencing. RAPD was used to differentiate strains of same species. H2O2 and lactic acid was evaluated on TMB-HRP MRS agar and BCP-MRS agar respectively. Results: Lactobacilli were recovered from 107/109 (98.2%) women with normal microflora. L. iners 64.7% (68), L. crispatus 26.7% (28), L. reuteri 21.9% (23), L. jensenii 16.2% (17) and L. gasseri 15.2% (16) were the most frequently occurring vaginal lactobacilli in normal women. The vaginal microflora was dominated by either by a single (80%, n = 84) or a combination (20%, n = 21) of Lactobacillus species. Though most frequently identified, L. iners, coexisted only with other Lactobacillus species. All isolates were acid producers but H2O2 was produced by 94.2% isolates. Conclusions: Our study reports prevalent vaginal lactobacilli which could be explored as probiotics. Presence of heterogeneous Lactobacillus population highlights the cumulative effects of different lactobacilli maintaining vaginal health. Contrasting observations about L. iners reiterates its puzzling role in vaginal immunity, advocating further research.

Trends in cesarean delivery: rate and indications

OBJECTIVES

To compare the cesarean delivery rates over the last decade and to examine the indications contributing to changed trends, if any.

METHODS

To compare the rate and indications of cesarean delivery over the last decade, the data were collected in a retrospective manner from all the deliveries that occurred between January 1 and December 31 in 2001, 2006, and 2011, in the department of obstetrics and gynecology, Seth G.S. Medical College and K.E.M. Hospital, a large tertiary care municipal hospital in Western India. A cohort of 20853 delivered women was studied. The rates and indications of primary and repeat cesarean sections were analyzed among the live births to estimate the relative contribution of each indication to the overall increase in rate.

RESULTS

The cesarean delivery rate increased from 171.70 to 289.30 per 1,000 live births, with an increase in primary cesarean delivery rate from 118.53 (69.03 %) in 2001 to 210.09 (72.62 %) in 2011 per 1,000 live births. Fetal distress, arrest of descent, multiple gestations, and fetal indications contributed to this increase.

CONCLUSIONS

There is a significant increase in the total cesarean rate with primary cesarean accounting for most of the increase.

Ligation of internal iliac arteries for control of pelvic haemorrhage

This is a retrospective review of the internal iliac ligations (IAL) done over a period of 3 years. Both gynaecological and obstetric cases were considered. A total of 46 ligations were performed. The additional treatment required was hysterectomy to control haemorrhage. Intra-and post-operative complications were noted. A comparative review of the effectiveness of IAL in different situations is done and alternative modalities of treatment are considered.