Adverse Pregnancy Outcomes in Sickle Cell Trait: a Prospective Cohort Study Evaluating Clinical and Haematological Parameters in Postpartum Mothers and Newborns

Background

Sickle cell trait (SCT) is a congenital condition caused by the inheritance of a single allele of the abnormal haemoglobin beta gene, HbS. Carriers of SCT are generally asymptomatic, and they do not manifest the clinical and haematological abnormalities of sickle cell anaemia (SCA). However, there is evidence that they display some symptoms in stressful situations. Pregnancy is a stressful physiological event, and it is not clear if SCT adversely affects pregnancy outcomes, particularly in those from developing countries where people regularly suffer from nutritional insufficiency.

Objective

This study aims to investigate pregnancy outcomes in Sudanese women with SCT. Subjects and methods: Pregnant women with (HbAS, n=34) and without (HbAA, n=60) SCT were recruited during their first trimester at El Obeid Hospital, Kordofan, Western Sudan. Following appropriate ethical approval and informed consent from the participants, detailed anthropometric, clinical, haematological, obstetric, and birth outcome data were registered. In addition, blood samples were collected at enrolment and at delivery.

Results

At enrolment in the first trimester, the SCT group did not manifest SCA symptoms, and there was no difference in the haematological parameters between the SCT and control groups. However, at delivery, the women with SCT, compared with the control group, had lower levels of hemoglobin (Hb, p=0.000), packed cell volume (PCV, p=0.000), mean corpuscular haemoglobin (MCH, p=0.002) and neutrophil counts (p=0.045) and higher mean corpuscular volume (MCV, p=0.000) and platelet counts (p=0.000). Similarly, at delivery, the babies of SCT women had lower birth weight (p=0.000), lower Hb (p=0.045), PCV (p=0.000), MCH (p=0.000), and higher neutrophil (p=0.004) and platelet counts (p=0.000) than the babies of the healthy control group. Additionally, there were more miscarriages, stillbirths, and admissions to the Special Care Baby Unit (SCBU) in the SCT group.

Conclusions

The study revealed that SCT is associated with adverse pregnancy outcomes, including maternal and neonatal anaemia, low birth weight, and increased risk of stillbirth, miscarriage, and admission to SCBU. Therefore, pregnant women with SCT should be given appropriate pre-conceptual advice and multidisciplinary antenatal and postnatal care.

Effects of propofol and isoflurane on haemodynamics and the inflammatory response in cardiopulmonary bypass surgery

Cardiopulmonary bypass (CPB) causes reperfusion injury that when most severe is clinically manifested as a systemic inflammatory response syndrome. The anaesthetic propofol may have anti-inflammatory properties that may reduce such a response. We hypothesised differing effects of propofol and isoflurane on inflammatory markers in patients having CBR Forty patients undergoing elective CPB were randomised to receive either propofol or isoflurane for maintenance of anaesthesia. CRP, IL-6, IL-8, HIF-1α (ELISA), CD11 and CD18 expression (flow cytometry), and haemoxygenase (HO-1) promoter polymorphisms (PCR/electrophoresis) were measured before anaesthetic induction, 4 hours post-CPB, and 24 hours later. There were no differences in the 4 hours changes in CRP, IL-6, IL-8 or CD18 between the two groups, but those in the propofol group had higher HIF-1α (P = 0.016) and lower CD11 expression (P = 0.026). After 24 hours, compared to the isoflurane group, the propofol group had significantly lower levels of CRP (P < 0.001), IL-6 (P < 0.001) and IL-8 (P < 0.001), with higher levels CD11 (P = 0.009) and CD18 (P = 0.002) expression. After 24 hours, patients on propofol had increased expression of shorter HO-1 GT(n) repeats than patients on isoflurane (P = 0.001). Use of propofol in CPB is associated with a less adverse inflammatory profile than is isofluorane, and an increased up-regulation of HO-1. This supports the hypothesis that propofol has anti-inflammatory activity.

Cognitive function and endogenous cytokine levels in children with chronic hepatitis C

Little is known about how hepatitis C (HCV) infection affects cognitive function in children. The aim of the study was to assess the impact of HCV infection on cognitive function of children with normal liver functions and their relationships to endogenous IFN-α, IL-6 and TNF-α. IFN-α, IL-6 and TNF-α were measured and the Arabic version of the Stanford-Binet test used to assess cognitive functions in 35 children with HCV infection and 23 controls. Serum levels of IL-6 and IFN-α were significantly higher in patients compared to controls. There was a significant effect on vocabulary, comprehension, and abstract visual reasoning, quantitative reasoning and bead memory tests, as well as total short-term memory and intelligence quotient in patients compared to controls. There was a significant positive correlation between IFN-α and IL-6. Also there were significant negative correlations between IFN-α and Abstract visual reasoning test, Quantitative reasoning test, Bead memory test, Total short-term memory and Intelligence quotient; and between IL-6 and Abstract visual reasoning test, Quantitative reasoning test and Intelligence quotient. There was no significant correlation between TNF-α and any of the cognitive functions. Cytokine levels were not related to demographic characteristics of the patients or viral load (PCR). Children with chronic hepatitis C infection in its early stages showed signs of cognitive impairment, with the memory tasks being mostly affected. There was a significant correlation between endogenous cytokines and cognitive impairment in these children. Further studies are needed to define the effect of successful antiviral treatment.

The efficacies of artesunate–sulfadoxine–pyrimethamine and artemether–lumefantrine in the treatment of uncomplicated,Plasmodium falciparummalaria, in an area of low transmission in central Sudan

In an efficacy trial of artemisinin-based combination treatments (ACT) in central Sudan, cases of uncomplicated, Plasmodium falciparum malaria were given artesunate-sulfadoxine-pyrimethamine (ASP) or artemether-lumefantrine (AL) as first-line treatment. On enrolment, the 71 patients given ASP were similar to the 72 given AL, apart from having generally lower parasitaemias (geometric mean counts of 4893 nu. 10,215 asexual parasites/microl) and having a lower mean age (15 nu. 23 years). Each patient was treated on days 0, 1 and 2, and all 137 who completed follow-up without further, unscheduled treatment were found aparasitaemic and afebrile from day 2 until the last follow-up, on day 28. No moderate or severe adverse side-effects, clinical failures or parasitological failures were observed among these 137 patients. ACT therefore appear both efficacious and safe for the treatment of uncomplicated malaria in central Sudan.

Outcome of cholelithiasis in Sudanese children with Sickle Cell Anaemia (SCA) after 13 years follow-up

BACKGROUND

SCA causes chronic haemolysis which is a risk factor for cholelithiasis.

OBJECTIVE

To determine the prevalence and outcome of children with SCA complicated with gallstones treated at the sickle cell clinic at the children emergency hospital Khartoum state.

METHODS

261 patients age 4 months to 16 years were studied. AUS examination was carried out. The 30 patients in whom gall stones were detected followed prospectively from June 1996 to September 2009 when a second AUS examination was obtained.

RESULTS

Gall stones occurred in 30 patients of whom four were lost to follow up in the first year. The overall prevalence of cholelithiasis was 11.5% and it increased with age. The youngest patient with cholelithiasis was 2 1/2 years old. Haematological variables, bilirubin and sex did not identify a subgroup of patients at higher risk for gallstones. All the patients were asymptomatic at the time of diagnosis. One patient developed symptoms 3years after the diagnosis and he was submitted to surgery. The 25 remaining asymptomatic patients were followed up for 13 years and none of them presented complications related to cholelithiasis during this period.

CONCLUSION

The prevalence of cholelithiasis in Sudanese children and adolescents with SCA was significant. The large majority patients remained asymptomatic over a long period.

Spectrophotometric determination of two N-(4-quinolyl) anthranilic acid derivative (glafenine and floctafenine)

Spectrophotometric methods were developed for the determination of glafenine and floctafenine. The first method depends upon the determination of glafenine in raw material and tablets as well as in the presence of its main degradation product glafenic acid (up to 40%). Differential first derivative spectral response at 245 nm in 0.1 N hydrochloric acid, where the corresponding degradation product exhibits no contribution in 0.1 N sodium hydroxide. The method allows the determination of 2.5-30 microg ml(-1). The second method depends upon the reaction of floctafenine with 2,3-dichloro 5,6-dicyano-p-benzoquinone (DDQ) in acetonitrile to give highly colored complex that could be measured quantitatively at (about) lambda(max) 538 nm. The method permits the determination of 40-180 microg ml(-1) or by measuring the first derivative spectral response of the color at 610 nm. The method permits the determination of floctafenine in presence of thiocolchicoside. The methods mentioned both simplicity and sensitivity, having excellent precision and accuracy (100.31 +/- 0.63, 100.78 +/- 0.77 and 99.90 +/- 0.56 for glafenine and floctafenine, respectively). The results were of comparable accuracy and reproducibility with the reported methods.

Spectrophotometric determination of loperamide hydrochloride by acid-dye and charge-transfer complexation methods in the presence of its degradation products

Two simple, sensitive and accurate spectrophotometric methods for the determination of loperamide hydrochloride (lop. HCl) are described. The first method is based on the formation of ion-pair association complex (1:1) with bromothymol blue (BTB), bromophenol blue (BPB) and naphthol blue black B (NBB). The coloured products are extracted into chloroform, and measured spectrophotometrically at 414 (BTB), 415 (BPB) and 627 nm (NBB). Beer's law was obeyed in the ranges of 5-35, 5-30 and 0.8-11.2 microg ml(-1) for BTB, BPB and NBB methods, respectively. The method was found to be specific for the analysis of the drug in presence of its degradation products which can be detected by HPLC procedure. The second method is based on the reaction of the basic loperamide with iodine in chloroform to give molecular charge-transfer complex with intense bands at 295 and 363 nm. Beer's law was obeyed in the ranges 2.5-17.5 and 2.5-22.5 microg ml(-1) for the method at 295 and 363 nm, respectively. Optimization of the different experimental conditions are described for both methods. The proposed methods have been applied successfully for the analysis of the drug in pure form and in its dosage forms. The methods have the advantage of being highly sensitive and simple for the determination of a small dose drug, which is also a weak UV-absorbing compound.

Patients on hemodialysis visiting madina munawarah: communication between nephrologists

Two hundred and thirteen patients who were already on hemodialysis (HD) at other locations visited Al-Madina Al-Munawarah, Saudi Arabia, during the year 1996. These patients were accepted for temporary HD at the King Fahad hospital during their stay in the city. Only 29 (13.6%) patients had detailed medical reports with them. Forty-one (19.2%) patients had full serology reports with them. Those coming from within Saudi Arabia were comparable to those from other countries. Hemodialysis per se should not deter patients from leading as normal a life as possible, including visiting places for leisure or religious purposes. Full cooperation and communication between HD units would give appropriate and timesaving services to those patients at place of visit and would limit possible problems.

Prevalence of sexually transmitted diseases (STD) among women in a suburban Sudanese community

338 women with age ranging from 15 to 69 years in a suburban Sudanese community were randomly selected and studied. Urine sample, high vaginal swabs and blood samples were investigated for bacterial vaginosis, candidiasis, trichomoniasis, gonorrhoea, HIV and syphilis. The sensitivity and specificity of some laboratory tests were evaluated. Bacterial vaginosis was found in 17.2% of the subjects, candidiasis in 10.1%, trichomoniasis in 7.7%, gonorrhoea in 1.2%, HIV in 1.2% and syphilis in 0.9% of the subjects. The sensitivity and specificity of amine test as a criterion for diagnosing bacterial vaginosis was 58.6% and 73.2%, respectively. The respective values of clue cells in wet preparation were 43.1% and 99.6%. The vaginal discharge in women with bacterial vaginosis lacked pus cells unless associated with concurrent infection.

Viral hepatitis in renal transplant patients

Hepatitis is emerging as a common serious problem in renal transplant patients. To determine the prevalence of viral hepatic in our transplant population, we screened the patients who received renal transplants in the period from 1979-1997, inclusive, for hepatitis B virus (HBV) and for hepatitis C virus (HCV) infection. Of those patients screened for HBV infection, seven o f101 recipients (6.9%) were found positive for HbsAg. During the follow up, one patient cleared HbsAg and one from the negative group acquired it. Of the recipients screened for HCV antibodies 32 of 78 patients (41%) had positive tests. Higher incidence of chronic liver disease (37.5%) was found in the HCV positive group, compared to zero in the negative group. However, no difference in the short-term graft loss (25%), was noted between these two groups. We conclude that prevalence of hepatitis C in our transplant patients is high and may have an impact on their long-term outcome.

CAPD: Experience at Al Madinah Al Munawarah

CAPD is not as popular mode of renal replacement therapy (RRT) in this country as it is in the west and hence the experience with CAPD is limited. At our center 16 patients (8 Males, 8 Females) with ESRD with a mean age of 46.3 +/- 15.6 years were managed by CAPD during 1990-1994. CAPD was the first option as a renal replacement therapy (RRT) in seven (44%) and second option in nine (56%) patients. Indications for CAPD were: Vascular access problems in 10 (62.5%), cardiovascular instability in three (19%), patient preference in two (12.5%) and non-availability of nearby HD center in one (6%) patient. Standard safe leur-lock system was used for dialysis. All patients were well dialyzed with good quality of life. Peritonitis was the main complication encountered (one episode/eight patient months), cause of hospital admission and reason for returning back to hemodialysis (HD). Other complications encountered were intraperitoneal bleeding in three, accidental cutting of outline in two, leakage in one and exit site infection in one. Average survival of this method was 15 + 10.5 months (range 1-37 months). At the time of reporting this study seven patients continued to be on CAPD, six were transferred back to hemodialysis, one was transplanted and two died due to other reasons. We conclude that CAPD is an acceptable mode of RRT in this part of the world.

Prevalence of hepatitis C virus antibodies in hemodialysis patients in madinah Al munawarah

This study was carried out to evaluate the prevalence of antibodies against hepatitis C virus (HCV) in our hemodialysis (HD) unit at Madinah Al Munawarah in Saudi Arabia. Fifty six of the 94 patients (60%) studied were positive for HCV, while none of the thirty staff members working in the same unit were positive. The positivity of HCV correlated significantly with duration on HD. No significant correlation was found with the number of blood transfusions, hepatitis B markers or liver enzymes.

Ramadan fasting and renal transplant recipients: Clinical and biochemical effects

Eleven renal transplant recipients were studied while fasting during the month of Ramadan. All were asymptomatic. The serum and urinary bichemical analysis showed no significant changes. Also, there were no adverse effects on the allograft and the cyclosporine A levels did not change significantly. There was a significant elevation of serum potassium levels during fasting, but the levels always remained within normal limits. Our study indicates that fasting during Ramadan does not seem to be associated with any significant ill effects in renal transplant recipients. However, studies involving larger numbers of patients are needed to confirm this observation.

Increased in vivo activation of neutrophils and complement in sickle cell disease

Eight patients with homozygous sickle cell anemia, 15 heterozygotes, and eight control individuals were investigated with respect to plasma concentrations of the inflammatory markers lysozyme and myeloperoxidase and the complement activation marker C3d. The patients showed significantly increased levels of myeloperoxidase and C3d, but not lysozyme, compared with the heterozygotes and the controls. The heterozygotes were also significantly different from the controls with regard to C3d concentration. The concentrations of myeloperoxidase and C3d in plasma showed a significant inverse correlation with the hemoglobin concentration. Myeloperoxidase and C3d showed a significant positive correlation. This suggests a role for the neutrophil and the complement system in the pathophysiology of sickle cell disease.

Increased activity of 5' nucleotidase in serum of patients with sickle cell anaemia

Fifty-nine patients with homozygous sickle cell anaemia, 17 heterozygous individuals and 22 controls were investigated in respect to serum (S) 5'nucleotidase (5'NT, EC 3.1.3.5). The patients showed a significantly higher mean value of S-5'NT compared to the controls. However, this rise was heterogeneous as it occurred only among a subgroup of patients. The heterozygous individuals were not different from either the patients or the controls generating a situation which puts the heterozygous individuals in an intermediate position between the patients and the controls. S-5'NT showed significant correlation with S-bilirubin, S-aspartate aminotransferase, S-alanine aminotransferase and especially S-gammaglutamyl transferase. However, it was not correlated with S-alkaline phosphatase, which is another marker for hepatobiliary disease. These results suggest that the liver involvement in a subgroup of patients with sickle cell anaemia is a mixture of hepatocyte damage and the biliary tree involvement.

Increased membrane activity of glyceraldehyde 3-phosphate dehydrogenase in erythrocytes of patients with homozygous sickle cell anaemia

Membrane-bound glyceraldehyde 3-phosphate dehydrogenase activity was measured in erythrocytes from 43 patients with sickle cell anaemia, 24 heterozygous and 27 controls. A significant increase of the activity was found among the patients but no such difference was observed between the heterozygous and the control individuals. The patients showed nearly non Gaussian distribution of the enzyme activity and were subgrouped on the basis of these results, subgroup I had normal values and subgroup II showed markedly increased activities. The patients in subgroup II had significantly lower blood haemoglobin concentrations and significantly higher lactate dehydrogenase activities in serum than subgroup I. The subgroups did not differ in blood reticulocyte counts, serum bilirubin, serum iron concentrations or band 3 protein content of erythrocyte membranes.

Lack of evidence for altered complement and immunoglobulin levels in patients with sickle cell anaemia

Forty-three patients with homozygous sickle cell disease (haemoglobin SS), 24 heterozygous (AS) subjects and 24 controls (AA) from Sudan were investigated by haemolytic activation for complement function via the classical and the alternative pathways, respectively, and by determination of the plasma levels of C3, C4 and factor B as well as of immunoglobulins IgG, IgA and IgM. The study failed to reveal any direct involvement of the complement system in sickle cell disease and nor was any alteration of the immunoglobulin levels registered as a possible cause of increased susceptibility to infections in patients with homozygous sickle cell anaemia.

Sickle cell anaemia in Sudan: clinical findings, haematological and serum variables

Ninety homozygous patients with Hb S haemoglobinopathy from Sudan were reported with respect to clinical findings, haematological and serum parameters. For comparison, 27 Hb AS heterozygous subjects and 28 Hb AA controls were investigated also. The patients showed an extreme type of illness presenting with severe clinical signs such as dactylitis, liver enlargement and cardiac complications. There was marked haemolytic anaemia (mean haemoglobin 66 g/l). Some patients also presented with low serum (S)-iron levels, indicating iron deficiency. S-bilirubin, S-ASAT, S-ALAT, S-GT and S-urate were notably raised, most probably as a consequence of haemolysis with liver involvement. The patients had lower S-calcium levels when compared with the AS and AA subjects. This may suggest a possible role of HB S in the production of this feature.

Reduction in band 3 protein of red cells in sickle cell anaemia

Twelve patients suffering from sickle cell anaemia (Hb less than 75 g/l) with SS-haemoglobin were studied with special regard to Band 3-protein content in their erythrocyte membranes on SDS-PAGE. They were compared in this respect with 7 asymptomatic individuals with AS-haemoglobin and 10 healthy controls with the ordinary adult haemoglobin. A heterogeneity in Band 3-protein content was evident among the 12 patients. Six of them belonged to a low content group while the other 6 belonged to a high content group comparable with the asymptomatic subjects and the controls. No simple relationship seemed to exist between Band 3-protein reduction and the clinical presentation.