Endothelial nitric oxide synthase (eNOS) gene Glu298Asp polymorphism and expression in North Indian preeclamptic women

BACKGROUND

Pathophysiological processes in preeclampsia (PE) are influenced by genetic factors, nitric oxide synthases seem to play important roles, although their expression in and their role is still unclear. To better characterize the host genetic factors determining the susceptibility to PE, we evaluated the influence of polymorphisms (Glu298Asp) in the endothelial nitric oxide synthase (eNOS) gene on the risk of developing PE by checking the expression level.

METHODS

We conducted a hospital-based case-control study including 300 women with preeclampsia and 200 healthy pregnant women. Their blood samples were analyzed for levels of nitric oxide, eNOS gene polymorphism and expression. eNOS mRNA levels were determined using RT-PCR and expressed as arbitrary units after correction with control β-Actin gene mRNA levels.

RESULTS

The mRNA expression of eNOS gene was found to be significantly lower in blood (P<0.05) from women with PE compared to that from normal pregnancies. The total nitric oxide levels (P<0.001) were decreased in study Group as compared to healthy pregnant patients. The intergenotypic variation of nitric oxide levels in preeclamptic women was found to be significant (P<0.001).

CONCLUSIONS

These results indicate the relationship between reduced nitric oxide levels and eNOS gene polymorphism leading to its altered expression in preeclamptic women.

Hepatitis B vaccination with or without hepatitis B immunoglobulin at birth to babies born of HBsAg-positive mothers prevents overt HBV transmission but may not prevent occult HBV infection in babies: a randomized controlled trial

Vertical transmission of Hepatitis B virus HBV can result in a state of chronic HBV infection and its complications. HBV vaccination with or without hepatitis B immunoglobulin (HBIG) prevents transmission of overt infection to the babies. However, whether it also prevents occult HBV infection in babies is not known. Consecutive pregnant women of any gestation found to be HBsAg positive were followed till delivery, and their babies were included in the study. Immediately after delivery, babies were randomized to receive either HBIG or placebo in addition to recombinant HBV vaccine (at 0, 6, 10 and 14 weeks). The primary end-point of the study, assessed at 18 weeks of age, was remaining free of any HBV infection (either overt or occult) plus the development of adequate immune response to vaccine. The babies were further followed up for a median of 2 years of age to determine their eventual outcome. Risk factors for HBV transmission and for poor immune response in babies were studied. Of the 283 eligible babies, 259 were included in the trial and randomized to receive either HBIG (n=128) or placebo (n=131) in addition to recombinant HBV vaccine. Of the 222 of 259 (86%) babies who completed 18 weeks of follow-up, only 62/222 (28%) reached primary end-point. Of the remaining, 6/222 (3%) developed overt HBV infection, 142/222 (64%) developed occult HBV infection, and 12/222 (5%) had no HBV infection but had poor immune response. All 6 overt infections occurred in the placebo group (P=0.030), while occult HBV infections were more common in the HBIG group (76/106 [72%] vs. 66/116 [57%]; P=0.025). This may be due to the immune pressure of HBIG. There was no significant difference between the two groups in frequency of babies developing poor immune response or those achieving primary end-point. The final outcome of these babies at 24 months of age was as follows: overt HBV infection 4%, occult HBV infection 42%, no HBV infection but poor immune response 8% and no HBV infection with good immune response 28%. Women who were anti-HBe positive were a low-risk group, and their babies were most likely to remain free of HBV infection (occult or overt) and had good immune response to the vaccine. Maternal HBeAg-positive status and negativity for anti-HBe predicted not only overt but also any infection (both overt and occult) in babies. In addition, high maternal HBV DNA and treatment with vaccine alone were significant factors for overt HBV infection in babies. The current practice of administration of vaccine with HBIG at birth to babies born of HBsAg-positive mothers is not effective in preventing occult HBV infection in babies, which may be up to 40%. Because the most important risk factors for mother-to-baby transmission of HBV infection are the replicative status and high HBV DNA level in mothers; it will be worthwhile investigating the role of antivirals and HBIG administration during pregnancy to prevent mother-to-child transmission of HBV infection.

Increased regulatory T cells and impaired functions of circulating CD8 T lymphocytes is associated with viral persistence in Hepatitis B virus-positive newborns

Hepatitis B Virus (HBV) infection in infancy or early childhood leads to high rate of persistent infection (25-90%). The immunological basis of high rate of viral persistence in vertically acquired HBV infections is not completely understood. CD8 T cells play a pivotal role in clearing the Hepatitis B virus infection in adults. Herein, we sought to delineate the role of T cells in viral persistence in HBsAg+ve newborns. At birth peripheral and cord blood of HBsAg+ve (N = 12), HBsAg-ve (N = 10) and healthy newborns (HC: N = 15) were evaluated for T-cell frequency and functionality by flow cytometry. No significant differences were observed in the frequency of CD8 and CD4 T cells in all the three groups. However, significantly higher frequency of FoxP3 expressing regulatory T cells were observed in HBsAg+ve (63.79%) compared with HBsAg-ve (28.12%) and HC (11.06%) (P < 0.05). Moreover, HBsAg+ve newborns showed functional defect in CD8 T cells by decreased IFN-γ production and lower CD107A expression (cytotoxic capacity) compared with HBsAg-ve and HC, which positively correlated with decreased TCRζ-chain expression CD8 T cells (r(2) > 0.93, P < 0.05). Despite equal frequency of CD8 T cells in all the three groups, CD8 T cells in HBsAg+ve newborns are dysfunctional. An expansion of regulatory T cells and impaired TCR signalling may represent the immune tolerant state of the adaptive immune system in response to chronic HBV infection.

Persistent inflammation on Pap smear: does it warrant evaluation?

OBJECTIVE

Due to the low sensitivity of Pap smear, premalignant lesions of the cervix can be missed in women with inflammatory Pap smears. However, it is not practically possible to subject all women with inflammatory Pap smear to colposcopy. This study was carried out with the aim to evaluate whether women with persistent inflammation on Pap smear need further evaluation with colposcopy.

MATERIALS AND METHODS

Four hundred and twenty women were screened at a tertiary level hospital with Pap smear. Women with inflammation on Pap smear were given treatment as per WHO guidelines and Pap smear was repeated at an interval of 6-12 weeks. Women with persistent inflammation on Pap smear were then subjected to colposcopy and directed biopsy if required.

RESULTS

Of the 420 women screened, 102 (24.3%) women had a Pap smear showing inflammation. Thirty six women (8.6%) had persistent inflammatory Pap smear. Thirty women were subjected to colposcopy and 16 (53.3%) had abnormal findings on colposcopy. Five out of these 30 women (16.67%) had Cervical intraepithelial neoplasia (CIN) on biopsy.

CONCLUSIONS

Nearly 16.67% women with persistent inflammation on Pap smear had cervical intraepithelial neoplasia. Hence, a large number of women with CIN would be missed if persistent inflammation on Pap smear is not evaluated further.

Trial of labour after previous caesarean section: the predictive factors affecting outcome

A prospective observational study was conducted at Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, India on 300 pregnant women with one previous caesarean section fulfilling the eligibility criteria for trial of labour, to study the predictive factors and the outcome of trial of labour. The data obtained were analysed according to mode and outcome of labour and was then subjected to statistical analysis. The success rate of trial of labour was found to be 53.6%. Favourable Bishop's score (p = 0.000), spontaneous onset of labour (p = 0.005) and history of previous delivery after caesarean (p = 0.007) were significantly associated with a successful outcome of trial of labour. Higher chances of vaginal delivery were found with breech as an indication of previous caesarean section, i.e. 67.1% as compared to 39% with non-progress of labour as an indication.

A randomized clinical trial to compare the efficacy of different doses of intravaginal misoprostol with intracervical dinoprostone for cervical ripening and labor induction

OBJECTIVES

To compare the efficacy of 25 vs. 50 microg of intravaginal misoprostol vs. intracervical dinoprostone for cervical ripening and labor induction.

MATERIALS AND METHODS

210 women with Bishop's score <6 were randomized into 3 groups of 70 each to receive 6 hourly doses of either 25 or 50 microg of intravaginal misoprostol or 0.5 mg intracervical dinoprostone to maximum of 3 doses and outcome parameters were compared.

RESULTS

Induction to vaginal delivery interval was significantly lower (p < 0.05) for 50 microg (13.8 +/- 6.62 hours) as compared to 25 microg misoprostol (16.4 +/- 7.34 hours) or dinoprostone group (16.3 +/- 7.49 hours). Maximum improvement (p < 0.05) in Bishop's score and minimum oxytocin requirement (p < 0.05) was seen with misoprostol 50 microg. No significant difference was observed for women delivering vaginally within 24 hours (93.8 vs. 89.7 vs. 85.4%), patients delivering after one dose (24.3 vs. 21.4 vs. 20%), cesarean deliveries, fetal outcome, complications like hyperstimulation and fetal heart abnormalities for the 50 vs. 25 microg misoprostol vs. dinoprostone group.

CONCLUSION

Intravaginal misoprostol 50 microg administered 6 hourly appears to be most effective as it has least induction to delivery time, has maximum improvement in Bishop's score, least oxytocin requirement without any increase in complication rate.

A rare case of intact rudimentary horn pregnancy presenting as hemoperitoneum

The availability of technological advances like ultrasonography (USG) and magnetic resonance imaging (MRI) has made the diagnosis of rudimentary horn pregnancy possible at an early gestation. However, in advanced pregnancy, such cases can sometimes pose a diagnostic dilemma and are recognized only when patient presents with abdominal pain and collapse and is taken for laparotomy. We report one such rare case of a nulliparous female who was carrying on well with her pregnancy till she developed symptoms of acute abdomen at 28 weeks of gestation. She underwent USG and MRI but it was only after laparotomy that a final diagnosis of a pregnancy in a rudimentary horn with placenta percreta perforating through the fundus could be made. There was a significant amount of hemoperitoneum; however, the horn was intact and the fetus could be salvaged. We excised the rudimentary horn with ipsilateral tube and ovary. Post operatively, both the mother and the baby were discharged in healthy condition.

Clinical profile of women with severe anaemia in the third trimester of pregnancy

Anaemia, the most common medical disorder associated with pregnancy, is a silent killer. Most severely anaemic pregnant women are asymptomatic and present late in the third trimester with medical and obstetric complications.

Dyslipidemia in pregnancy may contribute to increased risk of neural tube defects -a pilot study in north Indian population

Neural tube defects are congenital structural abnormalities of the brain and vertebral column resulting from improper or non-timely closure of the neural tube. Prevalence of neural tube defects is reported to be higher among women with diabetes mellitus and obesity. This study was designed to investigate the relation between the presence of dyslipidemia in antenatal patients and the risk of fetal neural tube defects. The present study was an observational, cross-sectional study involving 129 pregnant women in 16 to 18 weeks gestation period. Of these, 80 women had normal pregnancies and 49 were clinically high-risk cases for neural tube defects. Fasting blood samples were analyzed for blood sugar and lipid profile by enzymatic assay and alpha-fetoprotein levels using Enzyme Immunoassay. Alpha-fetoprotein (AFP) values were converted to Multiples of Median (MoM) appropriate for the gestational age. Based on AFP values, women were labeled as screen negative (AFP <2 MoM, n= 102) and screen positive (AFP > 2 MoM, n =27). Screen positive women were further evaluated by ultrasound and 21 women were found to carry a neural tube defects positive pregnancy. Statistical analysis was done on SPSS software. Body weight of the women showed a significant positive correlation with serum triglycerides, plasma sugar and AFP MoM values. A significant difference was observed in serum cholesterol levels (p= 0.038), triglycerides (p=0.001) and plasma sugar levels (p=0.002) between normal women and those with neural tube defects positive pregnancy. The Odds ratio for neural tube defects risk in dyslipidemic cases was 24.23 (CI 4.73 - 148.60) with a relative risk of 12.12. Dyslipidemia especially hypertriglyceridemia was found to be significantly associated with fetal neural tube defects.

Prong sign: a simple measure to enhance safety of laparoscopic sterilization

Laparoscopic female sterilization is widely practiced and is very safe. However, mesosalpingeal tears and mesosalpingeal haematomas are common complications especially when performed by an inexperienced surgeon. It was found that the observation of a simple 'prong sign' could prevent these complications and possibly reduce failure rates.

Teenage pregnancies and their obstetric outcomes

This study was conducted to evaluate the obstetric performance of teenage women in India. In total, 13,210 women were included in the study, of whom 840 were teenagers (<19 years) and 12,370 were > or =20 years. Antepartum, intrapartum and postpartum events were recorded and comparative analysis was done. We found that teenage women were at a significantly higher risk for development of severe anaemia (relative risk [RR] 1.61, P value <0.02), eclampsia (RR 1.95, P value <0.05), preterm labour (RR 1.25, P value <0.001), intrauterine growth retardation (RR 2.29, P value <0.001) and low birth weight (RR 1.24, P value <0.001). Assisted delivery (11.78% versus 2.23%, P value <0.001) was significantly more common and caesarean delivery (9.64% versus 17.18%, P value <0.001) was significantly less common in teenagers. Moderate anaemia, mild pregnancy-induced hypertension, preeclampsia, premature rupture of membranes, antepartum haemorrhage and post dates were all significantly higher in > or =20 years group. To conclude, we found that teenage women are a high-risk group, which is aggravated by social and cultural factors. Special attention is required to educate these women for more positive outcomes.

A case of autoimmune myopathy in pregnancy

Autoimmune diseases are not found frequently with pregnancy in clinical practice. Polymyositis Dermatomyositis have a prevalence of 2.4-10.7/ 100,000 in general population. This is further low in pregnant women. It is associated with 57% perinatal morbidity and increased maternal and fetal mortality. Literature suggests that pregnancy outcomes are poorer if it manifests early in gestation while development or exacerbation in second or third trimester is associated with a better fetal prognosis. Not many case reports are published where the disease was diagnosed in third trimester. We present a case detected in third trimester, which was initially mistaken as a case of allergic reaction, however timely diagnosis and adequate management resulted in good fetal and maternal outcome.

A case of autoimmune myopathy in pregnancy

Autoimmune diseases are not found frequently with pregnancy in clinical practice. Polymyositis Dermatomyositis have a prevalence of 2.4-10.7/ 100,000 in general population. This is further low in pregnant women. It is associated with 57% perinatal morbidity and increased maternal and fetal mortality. Literature suggests that pregnancy outcomes are poorer if it manifests early in gestation while development or exacerbation in second or third trimester is associated with a better fetal prognosis. Not many case reports are published where the disease was diagnosed in third trimester. We present a case detected in third trimester, which was initially mistaken as a case of allergic reaction, however timely diagnosis and adequate management resulted in good fetal and maternal outcome.

Vitamin E and carotene status in pre-eclamptic pregnant women from India

BACKGROUND

The imbalance between oxidative stress and the protective antioxidant system of the body enhanced the free radical mediated membrane lipid peroxidation and possibly the vascular endothelial damage due to peroxidation plays a major role in the aetiology of pre-eclampsia. With present day awareness on micronutrient antioxidants, we did investigate vitamin E and carotene status in Indian pre-eclamptic pregnant and full term normotensive pregnant women. Fresh vegetables and oils are considered to be good sources of vitamin E and carotene. The subjects were used to have good intake of fresh vegetable and oil as per Indian standard prescribed by Indian council of Medical research (ICMR) for this sub-continent.

METHODS

The blood samples were processed for RBC vitamin E, serum carotene and serum cholesterol analysis. Routine laboratory tests like hemogram, serum urea, urate, malonyldialdehyde, urine sugar and albumin were performed.

RESULTS

All pregnant subjects, both cases and control were maternal and gestational age matched. Routine check up showed no significant differences in means of white blood cell count, Hb/hematocrit and platelets. Serum urate and malonyldialdehyde were significantly raised in pre-eclamptic cases. The severely affected pre-eclamptic cases (diastolic BP >100 mmHg with proteinuria 2+ and more) showed markedly low levels of vitamin E and carotene whereas their levels were comparable between mild cases (diastolic BP <100 mmHg with+/-trace albuminuria) and normotensive pregnant control.

CONCLUSIONS

The study concluded that the levels of vitamin E and carotene were markedly lowered in severe pre-eclamptic pregnant women from India. The mild pre-eclamptic cases did not show noticeable changes from that of control pregnant women. Further studies are needed to verify their therapeutic and prophylatic roles against pre-eclamptic complication suring pregnancy.

Unusual changes in colostrum composition in lactating Indian women having medical complications during pregnancy-A pilot study

Colostrum, the mammary secretion during first 2-4 days of lactation, provides all the essential components of nutrition and passive immunity required by the newborn. Pregnancy induced hypertension (PIH), glucose intolerance and anaemia are common medical complications observed during pregnancy in Indian women and their effects were studied on the composition of colostrum collected within 24 hours of delivery from lactating women included in the study. PIH during pregnancy significantly decreased colostrum IgA and total proteins, but showed a significant increase in K(+) levels, where as women with glucose intolerance showed a significant decrease in total lipids and lactose and an increase in Na(+) levels in colostrum compared to normal controls. The group with anaemia also showed a significant decrease in colostrum IgA and total protein levels when compared with the control group. Awareness about the changes that occur in the composition of colostrum during complicated pregnancies can be an important and useful tool for preventive and protective paediatrics.

Hysteroscopic management of intra-uterine devices with lost strings

We report a series of 38 patients with intra-uterine devices with lost strings where hysteroscopic aid was required after routine retrieval procedures failed. Thirty-five intra-uterine devices could be removed easily with hysteroscope. In one patient a fragmented Lippes Loop was removed piecemeal hysteroscopically. Laparotomy was required in only one patient, for an extra-uterine Copper T. Hysteroscopy is thus a simple, safe and effective method for removing misplaced intra-uterine devices.

Topographic mapping of cerebral blood flow and behavior

This paper describes the methods for presenting (i) scores obtained by a subject in neuropsychologic tests as a map of the brain by assigning the various scores to those regions or areas of the brain where the specific function is supposed to be localized and (ii) similar maps of the regional cerebral blood flow measured by the extra-cranial detectors. The maps so produced can be displayed as top or side view topographic images. These imaging methods enable the user to comprehend large arrays of numbers in a readily interpretable manner, and will be useful in identifying the brain activity patterns associated with various neurological and psychiatric disorders. The methods described here also present an opportunity to integrate the behavioral information with anatomical and physiological data obtained using various neuro-imaging techniques.

Primary antituberculosis drug resistance and acquired rifampicin resistance in Gujarat, India

The prevalence of primary antituberculosis drug resistance in Gujarat, as studied between 1983 and 1986, was found to be significantly high, especially for isoniazid (13.9%) and streptomycin (7.4%). Primary rifampicin and pyrazinamide resistance were not detected in any strain. The prevalence of rifampicin resistance among treatment failure and relapse cases of pulmonary tuberculosis increased significantly from 2.8% in 1980 to 37.3% in 1986. In about 95% of the rifampicin resistant strains there was also resistance to isoniazid or streptomycin or both: resistance to isoniazid was detected in more than 90%.

Pyrazinamidase activity of Mycobacterium tuberculosis--a test of sensitivity to pyrazinamide

Pyrazinamidase activity has been found to correlate with pyrazinamide sensitivity in strains of Mycobacterium tuberculosis. In vitro sensitivity to pyrazinamide in acidified Löwenstein-Jensen medium, and pyrazinamidase activity by the Wayne method, were determined in 378 clinical isolates of M. tuberculosis. A close correlation was observed between the results of both tests. This method of detecting pyrazinamidase activity was found to be a rapid, simple and reliable substitute for pyrazinamide sensitivity testing, and it overcomes the difficulty of growing M. tuberculosis at pH 5.5, as required in the standard method.

Dynamic three-dimensional reconstruction of the left ventricle from two-dimensional echocardiograms

Using an open chest canine model, a method was developed for three-dimensional reconstruction of the contracting left ventricle from two-dimensional echocardiograms, which is applicable to intraoperative studies in humans. A mechanically held 5 MHz transducer was used to record parallel high resolution cross-sectional images with precise spatial registration. Myocardial borders were tracked manually and entered into a computer system. Regional filling and interpolation routines were applied to reconstruct the endocardial and epicardial surfaces of the ventricle. The myocardium can be displayed as a translucent, shaded three-dimensional solid surrounding the ventricular cavity. One or both surfaces can be rotated about any axis, sectioned through any plane and viewed in motion through systole and diastole. Studies before and after left anterior descending coronary artery occlusion showed the three-dimensional extent of abnormal left ventricular cavity and myocardial deformation. Quantitative examination of regions of interest permits the analysis of global and regional volumetric and myocardial thickness changes throughout the cardiac cycle. Thus, open chest three-dimensional echocardiography provides a powerful tool for the quantitative physiologic investigation of the left ventricle.

Segmentation into three classes using gradients

Consider a three-dimensional "scene" in which a density f(x, y, z) is assigned to every point (x, y, z). In a discretized version of the scene the density D(i, j, k) assigned to the (i, j, k) th volume element (voxel) is the average value of f(x, y, z) over the voxel. Suppose that the points in the original scene can be meaningfully segmented into classes 1, 2, and 3 separated by two threshold values l and u. Partial volume artifact is the phenomenon that a voxel (i, j, k) which is at the interface of class 1 and class 3 (and thus contains only points with low and high densities) usually has a density D(i, j, k) between l and u, and so cannot be distinguished by density alone from a voxel which contains only points in class 2. We describe how a two-dimensional (gradient, density) feature space can be used for the segmentation of such discrete scenes into three classes in a meaningful way. We illustrate the method using examples from medical imaging.

A comparative study of two postreconstruction beam hardening correction methods

The general nature of postreconstruction beam hardening correction methods is discussed. A methodology for choosing the energy of reconstruction is presented based on a technique of evaluating the "nearness" of two projection data sets. Two previously published postreconstruction beam hardening correction methods are described within a common framework. These methods differ at a number of independent places and so one can produce hybrid methods by interchanging some but not all of the choices. A basic difference between the methods is that one needs only the initial reconstruction during the postreconstruction correcting phase, while the other needs the original projection data as well. Both methods have been implemented and are compared (using a mathematical head phantom) from the points of view of the nearness of the corrected polychromatic projection data to the desired monochromatic projection data and the visual quality of the reconstructions. Variants and hybrids of the two methods are also investigated and recommendations based on the results are presented.