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Introduction The pro‐ and anti‐inflammatory cytokines play crucial role in the development and functions of placenta. Any changes in these cytokines may be associated with many pregnancy‐related disorders like preeclampsia. Therefore, the present study is aimed to study the expression of pro‐inflammatory (TNF‐α, IL‐6) and anti‐inflammatory (IL‐4, IL‐10) cytokines in placenta and serum of preeclamptic pregnant women. Material and Methods For this study, a total of 194 cases of preeclamptic and control cases were enrolled in two Groups as per the gestational age that is, Group I (28‐36 weeks) and II (37 weeks onwards). The number of samples was 55 in Group I and 139 in Group II. The immunohistochemistry (IHC) and enzyme‐linked immunosorbent assay (ELISA) were conducted on placenta and serum of both preeclamptic and normal samples, respectively. IHC results were revalidated by reverse transcriptase PCR (RT‐PCR). Results Both Groups (I, II) of preeclampsia showed amended levels of pro‐ and anti‐inflammatory cytokines in placental tissues and serum samples. The levels of TNF‐α and IL‐6 were significantly increased in preeclamptic cases (P = 0.0001, P = 0.0001) while the IL‐4 and IL‐10 were downregulated (P = 0.0001, P = 0.0001) in comparison to control. In addition, a negative correlation was also observed between the two in preeclampsia (P = 0.0001). Conclusion The balanced ratio of pro‐ and anti‐inflammatory cytokines is essential to regulate the maternal inflammation system throughout pregnancy. Therefore, the gradual cytokine profiling of the pregnant women may be useful for the management of preeclampsia.

Hypothyroidism is the commonest endocrine disorder of pregnancy, with known adverse feto-maternal outcomes. There is limited data on population-based prevalence, risk factors and outcomes associated with treatment of hypothyroidism in early pregnancy. We conducted analysis on data from an urban and peri-urban low to mid socioeconomic population-based cohort of pregnant women in North Delhi, India to ascertain the burden, risk factors and impact of treatment, on adverse pregnancy outcomes- low birth weight, prematurity, small for gestational age and stillbirth. This is an observational study embedded within the intervention group of the Women and Infants Integrated Interventions for Growth Study, an individually randomized factorial design trial. Thyroid stimulating hormone was tested in 2317 women in early (9–13 weeks) pregnancy, and thyroxin replacement started hypothyroid (TSH ≥2.5mIU/mL). Univariable and multivariable generalized linear model with binomial family and log link were performed to ascertain risk factors associated with hypothyroidism and association between hypothyroidism and adverse pregnancy outcomes. Of 2317 women, 29.2% (95% CI: 27.4 to 31.1) had hypothyroidism and were started on thyroxin replacement with close monitoring. Overweight or obesity was associated with increased risk (adjusted RR 1.29, 95% CI 1.10 to 1.51), while higher hemoglobin concentration was associated with decreased risk (adjusted RR 0.93, 95% CI 0.88 to 0.98 for each g/dL) for hypothyroidism. Hypothyroid women received appropriate treatment with no increase in adverse pregnancy outcomes. Almost a third of women from low to mid socio-economic population had hypothyroidism in early pregnancy, more so if anemic and overweight or obese. With early screening and adequate replacement, adverse pregnancy outcomes may be avoided. These findings highlight the need in early pregnancy for universal TSH screening and adequate treatment of hypothyroidism; as well as for attempts to reduce pre and peri-conception overweight, obesity and anemia. Clinical trial registration: Clinical trial registration of Women and Infants Integrated Interventions for Growth Study Clinical Trial Registry–India, #CTRI/2017/06/008908 ; Registered on: 23/06/2017, ( http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=19339&EncHid=&userName=society%20for%20applied%20studies ).

Introduction and hypothesisReduced pelvic floor muscle (PFM) strength and thickness are considered critical factors in pregnancy-related stress urinary incontinence. Various methods have been evaluated for the measurement of these two factors, but validity needs to be well established. The objective was to assess the strength and thickness of pelvic floor muscles of continent and incontinent primigravida women using the digital method and transperineal ultrasound, and to study the correlation between the two methods.MethodsAssessment of pelvic floor muscle strength and thickness using digital assessment and transperineal ultrasound antepartum and postpartum in 100 primigravida women.ResultsA total of 100 primigravida women with 46 in the study group (incontinent) and 54 in the control group (continent) were assessed. PFM strength was lower in incontinent women, with a score of 3 or less in 82.61% (38 out of 46) compared with a score of 4 or more in 98.15% of continent women (53 out of 54; p < 0.0001) antenatally, as well as postnatally, with 81.25% of the incontinent women (26 out of 32), with a score of 3 or less compared with 100% of continent women (24 out of 24), with a score of 4 or more (p < 0.0001). The PFM thickness in the incontinent group compared with the continent group at relaxation was 5.94 ± 0.51 mm and 6.64 ± 0.26 mm (p < 0.0001) antenatally and 5.98 ± 0.55 mm and 6.69 ± 0.23 mm (p < 0.0001) postnatally; at contraction it was 7.29 ± 0.56 mm and 8.70 ± 0.24 mm (p < 0.0001) antenatally and 7.39 ± 0.56 mm and 8.77 ± 0.20 mm (p < 0.0001) postnatally. The Pearson correlation coefficient for the two methods during the antenatal and postpartum periods was 0.864 and 0.743 respectively, suggestive of a positive correlation between the two methods.ConclusionsPelvic floor muscle strength, as well as thickness, is significantly lower among the incontinent group than among the continent group, both during antenatal and during the postnatal period.

Background and aims Stillbirth rate is an indicator reflecting quality of maternal healthcare services available to a pregnant woman in a country. At the community and individual level, it continues to be a public health tragedy. This paper presents the stillbirth rate, its causes and characteristics of women who experienced stillbirth from five years data of hospital-based stillbirth surveillance system. We also attempted to study the association between number of antenatal check-ups and causes of stillbirths, period of gestation and maternal parameters like presence of anaemia at the time of delivery. Methodology A multisite hospital-based sentinel surveillance system for estimating the stillbirth rate and its causes was established across seven tertiary care government hospitals of Delhi, India in 2015. A standardized stillbirth form was used to record information, and data was collected using an online portal from all hospitals. The data from 2016 to 2020 was analysed for calculating the stillbirth rate, its causes and maternal characteristics using STATA version 17. Results Of the 12,569 stillbirths recorded among 416,677 deliveries, the still birth rate over the time period 2016–2020 was 29.3 per 1000 births. Nearly 50% women who experienced stillbirths did not receive any antenatal care. Antepartum stillbirths were more common (75.7%), the remaining were the intrapartum stillbirths (24.3%). Among antepartum causes, the most prevalent maternal cause was preterm labour (25.7%) followed by placental abruption/placenta previa/hemorrhage in 15.2%. Among foetal causes, majority of the still births were due to fetal growth restriction (31.2%) followed by congenital malformations (7%). Uterine rupture and eclampsia were reported as major intrapartum causes leading to still births in 11% and 8.3% cases, respectively. Conclusions The stillbirth rate of 29.3 per 1,000 births from hospital data underscores the need for community-based surveillance. Nearly half of pregnant women lacked antenatal care, and 75% of stillbirths were antepartum, stressing the need to strengthen antenatal care- both coverage and quality. Routine symphysio-fundal height measurements, mandatory third-trimester ultrasounds, and partograph use may help reduce intrapartum stillbirths.

ObjectivesSelf-collected vaginal swabs can facilitate diagnosis of vaginal discharge (VD) in resource-limited settings, provided reliability of the method is established. The aim of this study was to evaluate the concordance between self-collected and physician-collected vaginal swabs for aetiological diagnosis of VD and to determine the prevalence of bacterial vaginosis (BV), vulvovaginal candidiasis (VVC) and trichomonas vaginitis (TV).MethodsA total of 550 females (median age: 32 years; range: 18–45 years) attending two sexually transmitted infection/reproductive tract infection (STI/RTI) clinics with VD from January 2015 to May 2016 were included in the study after obtaining written informed consent. Swabs were self-collected by patients after instructions and subsequently by a physician under speculum examination. Samples were processed for standard bedside tests, Gram staining, wet mount and culture (gold standard) according to the national guidelines. Concordance between the two methods was determined by the Cohen’s kappa value.ResultsBV, VVC and TV were diagnosed in 79 (14.4%), 144 (26.2%) and 3 (0.5%) patients, respectively. VVC coexisted with BV in 58 (10.5%) patients. There was no coinfection of TV with BV or VVC. Candida albicans was isolated in 84 (58.3%) VVC cases. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of self-collected swabs for diagnosing BV was 91.1%, 100%, 100% and 98.5%, respectively, while for the C. albicans VVC and TV, sensitivity, specificity, PPV and NPV all were 100% as compared with physician-collected swabs. Highly concordant results were obtained between two methods by the Kappa values of 0.95 (BV), 0.99 (VVC) and 1.0 (TV).ConclusionThe comparative performance of self-collected and physician-collected vaginal swabs establishes self-collection of samples for BV, VVC and TV as a viable alternative tool in the management of STIs/RTIs, especially in peripheral and resource-constrained settings. This would be effective in implementing the diagnostic approaches for STIs/RTIs in community-based surveillance studies at national or regional level and therefore strengthening the National STI/RTI Control Programme.

Background The burden of gestational diabetes mellitus (GDM) appears to be increasing in India and may be related to the double burden of malnutrition. The population-based incidence and risk factors of GDM, particularly in lower socio-economic populations, are not known. We conducted analyses on data from a population-based cohort of pregnant women in South Delhi, India, to determine the incidence of GDM, its risk factors and association with adverse pregnancy outcomes (stillbirth, preterm birth, large for gestational age babies) and need for caesarean section. Methods We analyzed data from the intervention group of the Women and Infants Integrated Interventions for Growth Study (WINGS), an individually randomized factorial design trial. An oral glucose tolerance test (OGTT) was performed at the time of confirmation of pregnancy, and for those who had a normal test (≤140 mg), it was repeated at 24–28 and at 34–36 weeks. Logistic regression was performed to ascertain risk factors associated with GDM. Risk ratios (RR) were calculated to find association between GDM and adverse pregnancy outcomes and need for caesarean section. Results 19.2% (95% CI: 17.6 to 20.9) pregnant women who had at least one OGTT were diagnosed to have GDM. Women who had prediabetes at the time of confirmation of pregnancy had a significantly higher risk of developing GDM (RR 2.08, 95%CI 1.45 to 2.97). Other risk factors independently associated with GDM were woman’s age (adjusted OR (AOR) 1.10, 95% CI 1.06 to 1.15) and BMI (AOR 1.04, 95% CI 1.01 to 1.07). Higher maternal height was found to be protective factor for GDM (AOR 0.98, 95% CI 0.96 to 1.00). Women with GDM, received appropriate treatment did not have an increase in adverse outcomes and no increased need for caesarean section Conclusions A substantial proportion of pregnant women from a low to mid socio-economic population in Delhi had GDM, with older age, higher BMI and pre-diabetes as important risk factors. These findings highlight the need for interventions for prevention and provision of appropriate management of GDM in antenatal programmes. Clinical trial registration Clinical Trial Registry – India, #CTRI/2017/06/008908 ( http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=19339&EncHid=&userName=society%20for%20applied%20studies ).

ObjectiveMaternal morbidity affects millions of women, the burden of which is highest in low resource settings. We sought to explore when this ill-health occurs and is most significant.SettingsA descriptive observational cross-sectional study at primary and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi.ParticipantsWomen attending for routine antenatal care, childbirth or postnatal care at the study healthcare facilities.Primary and secondary outcomesPhysical morbidity (infectious, medical, obstetrical), psychological and social comorbidity were assessed at five stages: first half of pregnancy (≤20 weeks), second half of pregnancy (>20 weeks), at birth (within 24 hours of childbirth), early postnatal (day 1–7) and late postnatal (week 2–12).Results11 454 women were assessed: India (2099), Malawi (2923), Kenya (3145) and Pakistan (3287) with similar numbers assessed at each of the five assessment stages in each country. Infectious morbidity and anaemia are highest in the early postnatal stage (26.1% and 53.6%, respectively). For HIV, malaria and syphilis combined, prevalence was highest in the first half of pregnancy (10.0%). Hypertension, pre-eclampsia and urinary incontinence are most common in the second half of pregnancy (4.6%, 2.1% and 6.6%). Psychological (depression, thoughts of self-harm) and social morbidity (domestic violence, substance misuse) are significant at each stage but most commonly reported in the second half of pregnancy (26.4%, 17.6%, 40.3% and 5.9% respectively). Of all women assessed, maternal morbidity was highest in the second half of pregnancy (81.7%), then the early postnatal stage (80.5%). Across the four countries, maternal morbidity was highest in the second half of pregnancy in Kenya (73.8%) and Malawi (73.8%), and in the early postnatal stage in Pakistan (92.2%) and India (87.5%).ConclusionsWomen have significant maternal morbidity across all stages of the continuum of pregnancy and childbirth, and especially in the second half of pregnancy and after childbirth.

There is a growing interest in the life course approach for the prevention, early detection and subsequent management of morbidity in women of reproductive age to ensure optimal health and nutrition when they enter pregnancy. Reliable estimates of such morbidities are lacking. We report the prevalence of health or nutrition-related morbidities, specifically, anemia, undernutrition, overweight and obesity, sexually transmitted infections (STIs) or reproductive tract infections (RTIs), diabetes or prediabetes, hypothyroidism, hypertension, and depressive symptoms, during the preconception period among women aged 18 to 30 years. A cross-sectional study was conducted among 2000 nonpregnant married women aged 18 to 30 years with no or one child who wished to have more children in two low- to middle-income urban neighborhoods in Delhi, India, in the context of a randomized controlled trial. STIs and RTIs were measured by symptoms and signs, blood pressure by a digital device, height by stadiometer and weight by a digital weighing scale. A blood specimen was taken to screen for anemia, diabetes, thyroid disorders and syphilis. Maternal depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9). Multivariable logistic regression analysis was performed to identify sociodemographic factors associated with individual morbidity. Overall, 58.7% of women were anemic; 16.5%, undernourished; 26%, overweight or obese; 13.2%, hypothyroid; and 10.5% with both symptoms and signs of STIs/RTIs. There was an increased risk of RTI/STI symptoms and signs in undernourished women and an increased risk of diabetes or prediabetes in overweight or obese women. An increased risk of undernutrition was also observed in women from lower categories of wealth quintiles. A decreased risk of moderate to severe anemia was seen in overweight women and those who completed at least secondary education. Our findings show a high burden of undernutrition, anemia, RTIs, hypothyroidism and prediabetes among women in the study. This information will aid policymakers in planning special programs for women of reproductive age.

Background: Adiponectin and leptin play a major role in metabolic homeostasis. Adiponectin to Leptin ratio can be used as an indicator of insulin resistance and a marker of polycystic ovarian syndrome (PCOS). The study was planned to compare serum adiponectin, leptin, and adiponectin to leptin ratio in age and BMI matched women with and without PCOS and to find out the association of adiponectin to leptin ratio with Insulin resistance in these women. Methods: It was a cross-sectional study done in the Gynecology outpatient clinic in a tertiary care center. A total of 120 women, 60 with PCOS and 60 age and BMI matched women without PCOS, who presented in the clinic after the index cases were enrolled and tested for serum adiponectin, leptin, and insulin sensitivity. The main outcome measures were serum levels of adiponectin, leptin, adiponectin to leptin ratio, oral glucose tolerance test, serum insulin and HOMA-IR. Results: PCOS women had lower serum Adiponectin, higher serum Leptin level and lower Adiponectin to Leptin ratio compared to non PCOS women, 2.15 ± 3.07 ng/ml vs 10.7 ± 27.91 ng/ml, P < 0.0001; 24.25 ± 16.5 ng/ml vs 13.89 ± 11.19 ng/ml, P = 0.0003 and 0.15 ± 0.24 vs 3.03 ± 15.04, P < 0.0001, respectively. Plasma glucose 2 hours after 75 gm glucose and serum Insulin was significantly increased in PCOS women (108.78 ± 10.22 mg/dl vs 100.18 ± 4.89 mg/dl, P = 0.001 and 5.7 ± 9.53 μU/ml vs 3.02 ± 5.34 μU/ml, P = 0.02, respectively). The mean values of fasting plasma glucose and HOMA-IR were comparable in both groups, P = 0.145, P = 0.719, respectively. There was no significant association of A/L Ratio with BMI, plasma glucose 2 hours after 75 gm glucose, serum Insulin and HOMA-IR, in these women, r = -0.074, P = 0.5754; r = -0.203, P = 0.12; r = -0.018, P = 0.8915; and r = -0.041, P = 0.757, respectively. Conclusion: Adiponectin to leptin ratio is significantly reduced in women with PCOS but has no association with insulin resistance.

Utility of syndromic case management (SCM) in women visiting obstetrics & gynecology department needs to be evaluated as it is subjective and imperfect. Consequently, antibiotic resistance has accelerated along with increased risk of infection to the partners. To understand the effectiveness and/or inadequacies of SCM, 11000 women were recruited and examined by clinicians for infection by Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV), Bacterial vaginosis (BV) and others. Amongst these patients, 1797 (16.3%) reported vaginal discharge (VD). Other symptoms included: vaginitis (97%), cervicitis (75%), genital ulcers (60%), abnormal vaginal discharge (55%) and lower abdominal pain (48%). The patients were treated for single or co-infections using pre-packed National Aids Control Program III STI/RTI Kits. However, based on PCR diagnostics, 1453/1797 (81%) subjects were uninfected for NG/TV/CT. Amongst 344 (19%) infected patients, 257 (75%) carried infection with single pathogen (TV/NG/CT) while 87/344 (25%) were co-infected with multiple pathogens. Prevalence of TV, NG & CT was 4%, 7% and 8% respectively. Co-infection with CT + NG was highest, 51% (44/87), whereas, co-infection with CT + TV was 21% and NG + TV was 18% while co-infection with all three pathogens was 1.3%. We conclude that SCM is imprecise and successful intervention requires accurate and confirmatory diagnostic approach.