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ObjectiveTo assess the potential associations between social determinants of health (SDH) and severe maternal outcomes (SMO), to better understand the social structural framework and the contributory, non-clinical mechanisms associated with SMO.Study designProspective observational study.Study settingTertiary referral centre in south-eastern region of India.ParticipantsOne thousand and thirty-three women with potentially life-threatening complications (PLTC) were identified using WHO criteria.Risk factors assessedSocial Determinants of Health (SDH).Primary outcomesSevere maternal outcomes, which include maternal near-miss and maternal death.Statistical analysisLogistic regression to assess the association between SDH and clinical factors on SMO, expressed as adjusted ORs (aOR) with a 95% CI.ResultsOf the 37 590 live births, 1833 (4.9%) sustained PLTC, and 380 (20.7%) developed SMO. Risk of SMO was higher with increasing maternal age (adjusted OR (aOR) 1.04 (95% CI 1.01 to 1.07)), multiparity (aOR 1.44 (1.10 to 1.90)), medical comorbidities (aOR 1.50 (1.11 to 2.02)), obstetric haemorrhage (aOR 4.63 (3.10 to 6.91)), infection (aOR 2.93 (1.83 to 4.70)), delays in seeking care (aOR 3.30 (2.08 to 5.23)), and admissions following a referral (aOR 2.95 (2.21 to 3.93)). SMO was lower in patients from socially backward community (aOR 0.45 (0.33 to 0.61)), those staying more than 10 km from hospital (aOR 0.56 (0.36 to 0.78)), those attending at least four antenatal visits (aOR=0.53 (0.36 to 0.78)) and those referred from resource-limited facilities (aOR=0.62 (0.46 to 0.84)).ConclusionThis study demonstrates the independent contribution of SDH to SMO among those sustaining PLTC in a middle-income setting, highlighting the need to formulate preventive strategies beyond clinical considerations.

Pulmonary edema is a potentially life-threatening complication of preeclampsia, but only few studies have looked at possible risk factors. This study assessed the association between various potential risk factors and the development of pulmonary edema. An age-matched case-control design with hospital records from a tertiary care center in south India was used. A total of 55 pregnant women with preeclampsia who developed pulmonary edema were included as cases, who were 4:1 aged-matched as controls with 220 preeclamptic women, and who did not develop pulmonary edema. Multivariate conditional logistic regression was used to produce adjusted odds ratios with 95% confidence intervals for the likelihood to develop pulmonary edema (OR; 95% CI). Nulliparity (3.94; 1.44–10.7), multifetal pregnancy (5.06; 1.59–16.0), mean arterial blood pressure in mmHg (1.08; 1.03–1.13), and mild (3.25; 1.02–1.29) and moderate (4.43; 1.76–11.1) anemia showed increased odds. Multifetal pregnancy in nulliparous women had higher odds (39.5; 6.2–251) compared with those with singleton pregnancies (3.17; 1.13–8.88). While early aggressive blood pressure treatment can reduce the risk of pulmonary edema, the other risk factors are either non-modifiable or relate to disease severity; thus, continuous monitoring would be relevant for early diagnosis and management, especially among nulliparous preeclamptic women with multifetal pregnancies.

BackgroundThe annual births in our hospital (a regional perinatal centre for the southeastern coastal region) had increased to nearly 19 000 in 2019, straining the resources. Reduced low-risk childbirths due to the restrictions during the COVID-19 pandemic gave us an impetus to design and implement a risk-appropriate triage model referral system. We report its implementation process and examine its effect on birth rates and quality of care.MethodsInitially, the data on childbirths (2019) and the districts where the majority belonged were analysed. We discussed the need for triaging and the implementation process with these district health administrators. In the antenatal clinic, a dedicated team triaged and referred new cases to risk-appropriate facilities near their homes. Using WhatsApp groups, information about those referred back and the critically ill transferred to our hospital was shared. The impact of model implementation was assessed by the change in the number of births, proportion of high-risk cases, quality indicators and feedback from health workers.ResultsThe average number of childbirths per month decreased from 1530 in 2019 to 900 in 2023 after the implementation of triage on 15 December 2022. The quality indicators, such as stillbirth and scar rupture, declined after implementation, but caesarean deliveries rose from 20% to 30%. Better satisfaction among personnel and a change in the pattern to more high-risk pregnancies were noted; there was a reduction in bed occupancy rates, averting overcrowding.ConclusionA ‘risk-appropriate maternity care-based triage model’ could be implemented, reducing low-risk births and improving the quality of care for high-risk women in tertiary care institutes.

ObjectivesTo perform an external validation to assess the usefulness of the Maternal Severity Index (MSI) in predicting maternal death among women with potentially life-threatening complications during pregnancy or childbirth.DesignProspective observational study.SettingA tertiary referral centre in southeastern India.Participants1833 women with potentially life-threatening complications identified using the WHO criteria.Predictor assessedMSI calculated based on the severity markers of the WHO criteria for maternal near-miss.Primary outcomeMaternal death.Statistical analysisReceiver operating characteristics (ROC) curve analysis was performed to assess discriminative performance, and agreement between expected and observed deaths was plotted to determine calibration.ResultsThe incidence of severe maternal outcomes was 10 per 1000 live births. There were 57 (151 per 100 000 live births) maternal deaths during the study period. Maternal Severity Score was significantly higher among those who died (2.8±1.3 vs 2.0±1.2, p<0.001). The mean MSI value was 1.03% (95% CI 0.7% to 1.2%). ROC curve analysis showed good discrimination (AUC(Area Under the Curve): 0.962, 95% CI 0.952 to 0.970); however, overfitting was seen with higher probabilities. The standardised mortality ratio (SMR) was 0.02 (95% CI 0.01 to 0.02), indicating good quality of care.ConclusionsThe MSI has good discriminative performance in distinguishing who succumbs to life-threatening complications, but needs recalibration to avoid overfitting. SMR of less than 0.5 indicates fewer than expected deaths, suggesting good quality of care in reducing maternal mortality in the study population.

Background Arterial stiffness independently predicts cardiovascular mortality and morbidity. It is shown to be increased in vascular mediated conditions, such as preeclampsia and foetal growth restriction. ARTSENS Plus device assesses arterial stiffness and is validated in older populations. The study aimed to validate its use for measuring arterial stiffness in pregnant women by comparing it with SphygmoCor XCEL as a reference standard. Methods This cross-sectional study was conducted in two centres in the south-eastern region of India, recruiting 147 pregnant women. Arterial stiffness was assessed by the carotid–femoral pulse wave velocity (cfPWV) using both devices and validated according to the ‘2024 recommendations for validation of non-invasive arterial pulse wave velocity measurement devices.’ Bland–Altman plot and coefficient of variation of the test–retest reproducibility were calculated. Results The mean age of the included women was 28 ± 4 years, and their mean gestational age was 24.6 ± 9.5 weeks. The mean difference in cfPWV values obtained from SphygmoCor XCEL and ARTSENS Plus was 0.16 ± 0.54 m/s ( p  = 0.12) with a measurement error of 0.85 m/s, indicating good accuracy of the ARTSENS plus device in assessing arterial stiffness. Both devices demonstrated good intra-observer reproducibility, with coefficients of variation of 2.53% for ARTSENS Plus and 3.48% for SphygmoCor XCEL. Conclusions ARTSENS Plus assesses arterial stiffness with good accuracy and intra-observer reproducibility when validated amongst pregnant women.

IntroductionPre-eclampsia (PE) remains a major contributor to maternal morbidity and mortality globally. Early identification of risk factors and evaluation of prognostic models for severe adverse maternal outcomes are essential for improving management and reducing complications. While numerous studies have explored potential risk markers, there is still no consensus on the most reliable factors and models to use in clinical practice. This systematic review aims to consolidate research on both individual predictors and prognostic models of severe adverse maternal outcomes in PE, providing a comprehensive overview to support better clinical decision-making and patient care.Methods and analysisThis review follows the Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocol 2015 checklist. A systematic search will be performed using a detailed strategy across Medline, Embase, Cochrane, ProQuest dissertations, and grey literature from inception to 2 April 2024. Eligible studies will include those investigating clinical, laboratory-based, and sociodemographic predictors of severe adverse maternal outcomes in PE. Two reviewers will independently assess titles, abstracts, full texts, and extract data and assess study quality using the Quality In Prognostic Studies (QUIPS) tool for studies on risk predictors and the Prediction model Risk of Bias Assessment Tool (PROBAST) for prognostic models. The inclusion criteria will encompass cohort, case-control, and cross-sectional studies published in English and French involving women diagnosed with PE and reporting on the risk prediction for adverse maternal outcomes. The main outcomes of interest will include severe maternal morbidity and mortality during pregnancy, delivery, or within the postpartum period. Analyses will include both narrative synthesis and, where appropriate, meta-analysis using random-effects models. Pooled estimates will be calculated, with publication bias assessed through funnel plots and statistical tests (eg, Begg’s and Egger’s). Heterogeneity will be primarily assessed through visual inspection of forest plots, supported by statistical measures, such as the I² test, with further exploration through sensitivity, subgroup, and meta-regression analyses.Ethics and disseminationThis systematic review will be based on published data and will not require ethics approval. Results will be disseminated through peer-reviewed publications and presentations at academic conferences.PROSPERO registration numberCRD42024517097.

Abstract Pregnant women developing generalised tonic–clonic seizures in the absence of a prior neurological disorder are often diagnosed as eclamptic. Posterior reversible encephalopathy syndrome (PRES) is a distinct neuroimaging condition associated with long-term sequelae, which may occur in pregnancy. Some reports suggested PRES to be the pathophysiological process leading to eclampsia, whereas others observed PRES and eclampsia to have varying clinical severity and risk factors. In this case–control study, risk factors associated with PRES were compared to those for eclampsia in women with hypertension presenting with seizures who had undergone neuroimaging. PRES was noted to occur in 22.5% (51/227) hypertensive pregnant women presenting with seizures that otherwise would have been classified as eclampsia. An additional 51 women with eclampsia underwent neuroimaging. Women who had PRES had higher systolic (155.3 vs 144.5, p = 0.04), diastolic (99.2 vs 93.4, p = 0.006) and mean (117.9 vs 110.4, p = 0.001) blood pressure at admission compared to those with eclampsia. Eclampsia and PRES may occur through a similar pathophysiological mechanism, resulting in the same spectrum of neurological complications of preeclampsia, with PRES being the severest form of the disease process. PRES is difficult to differentiate from eclampsia based on clinical and laboratory investigation, except for high blood pressures, without adjunctive MRI/CT neuroimaging. Future studies should assess the role of biomarkers as well as long-term neurological sequelae in pregnant women with a diagnosis of PRES.

To compare cardiac complications and pregnancy outcomes in women with mechanical heart valves (MHVs) on two different anticoagulation regimens in a middle-income country. We conducted a retrospective cohort study comparing outcomes in pregnant women with MHVs that received vitamin K antagonists (VKAs) throughout pregnancy versus sequential anticoagulation (heparins in the first trimester and peripartum period and VKAs for the remainder of pregnancy), at a tertiary centre in South India, from January 2011 to August 2020. We identified 138 pregnancies in 121 women, of whom 32 received VKAs while 106 were on sequential anticoagulation. There were no differences between groups with regard to maternal deaths [0 vs. 6 (5.7%), p = 0.34], thromboembolic events [2 (6.3%) vs. 15 (14.2%), p = 0.36], haemorrhagic complications [4 (12.5%) vs. 12 (11.3%), p = 0.85], cardiac events [1 (3.1% vs. 17 (16%), p = 0.07], spontaneous miscarriages [5 (15.6%) vs. 13 (12.3%), p = 0.62], stillbirths [0 vs. 5 (5.4%), p = 0.581] or neonatal deaths [2 (8.7%) vs. 1 (1.1%), p = 0.11]. Both cases of warfarin embryopathy received >5 mg warfarin in the first trimester. Thromboembolic events were associated with subtherapeutic doses of heparin in the first and third trimesters and the early postpartum period. Fetal growth restriction and preterm birth complicated 34 (29.3%) and 26 (22.4%) pregnancies respectively. Pregnancy complications associated with MHVs in middle-income countries may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if daily doses >5 mg and ensuring therapeutic levels of heparin during bridging in the first and third trimesters and peripartum period. Administration of low-dose aspirin should be considered as this may prevent placentally-mediated complications of pregnancy. Pregnancy complications associated with MHVs in LMICs may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if the daily dose is >5 mg, ensuring therapeutic levels of heparin in the first trimester and peripartum period.Placentally-mediated complications of pregnancy can be prevented by administering low-dose aspirin.Vitamin K antagonists or sequential regimen can be used as suitable alternatives to LMWH for anticoagulation in pregnant women with MHVs.

A 26-year-old primiparous female patient underwent caesarean section for persistent occipito-posterior position in 2018 at the Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India. Upon postnatal followup six weeks later, both mother and baby were reported to be fine. At eight weeks postpartum she had an episode of heavy vaginal bleeding which was treated symptomatically with tranexamic acid and antibiotics at a local hospital. One month after this, she had another episode of heavy vaginal bleeding at home and was referred to the emergency department at Jawaharlal Institute of Postgraduate Medical Education & Research. On examination, she was pale, had a pulse rate of 90 per minute and blood pressure of 120/70mm Hg. She had a transverse abdominal scar that had healed by primary intention and the uterus was involuted normally. On speculum examination, minimal bleeding was only noted through the cervix. Intravenous antibiotics was started with a suspicion of infective aetiology for haemorrhage. An ultrasound showed a normal-sized uterus with heterogeneous myometrial echotexture, due to the presence of multiple anechoic areas, and thin endometrial lining with no retrained products of conception [Figure 1A]. Colour Doppler sonography showed intense myometrial hypervascularisation with turbulent flow in the hypoechoic region suggestive of a pseudoaneurysm, near the uterine incision site on the right side involving the right uterine artery [Figure 1B]. Her haemoglobin at admission was 8.2 g/dL. She underwent bilateral uterine artery embolisation under fluoroscopic guidance which confirmed pseudoaneurysm in the right uterine artery. The pseudoaneurysm was embolised with platinum coils and gel foam particles; postembolisation images ensured a complete occlusion [Figure 2]. The patient did not have any further bleeding and was discharged five days later. She resumed normal menstruation two months following the procedure. Open in a separate window Figure 1 A:Greyscale two-dimensional ultrasound of a 26-year-old primiparous female patient after a caesarean section showing a normal-sized uterus with heterogeneous myometrial echotexture and thin endometrium lining.B:Colour Doppler sonography showed intense myometrial hypervascularisation with turbulent flow in the hypoechoic region, near the uterine incision site on the right side, involving the right uterine artery. Open in a separate window Figure 2 Selective right internal iliac angiogram images of a 26-year-old primiparous female patient after a caesarean section showing(A)the pseudoaneurysm in the right uterine artery which was embolised with platinum coils and gel foam particles and(B)the postembolisation occlusion that ensured a complete occlusion.

Early onset pre-eclampsia (pre-eclampsia at less than 34 gestational weeks) is a severe form of preeclampsia; in addition, some women may also develop nephrotic range proteinuria. De novo diagnosis of lupus nephritis (LN) in pregnancy is challenging as it may present with features similar to commonly occurring preeclampsia. We report three cases of early onset pre-eclampsia with nephrotic range proteinuria and subsequent diagnosis of LN at the Women and Children hospital attached to Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, between 2014 and 2017. These cases highlights the need for further evaluation of the association between nephrotic-range proteinuria and early onset pre-eclampsia. The index of suspicion for underlying LN of these type of cases should be high. Earlier detection of LN will prompt better management that can avert or delay short- and long-term morbidity.