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Purpose: To present the data on primary hyperparathyroidism (PHPT) in pregnancy from India obtained from a large database maintained over 15 years., Methods: We retrieved data of all women with gestational PHPT from the Indian PHPT registry between July 2005 and January 2020, and compared their clinical, biochemical, and other characteristics with age-matched non-pregnant women with PHPT., Results: Out of 386 women, eight had gestational PHPT (2.1%). The common presenting manifestations were acute pancreatitis (50%) and renal stone disease (50%); two were asymptomatic. Five women (62.5%) had a history of prior miscarriages. Seven patients (88%) had preeclampsia during the present gestation. Serum calcium and intact parathyroid hormone (iPTH) were not statistically different from the age-matched non-pregnant PHPT group. Six patients with mild-to-moderate hypercalcemia were medically managed with hydration with/without cinacalcet while one patient underwent percutaneous ethanol ablation of the parathyroid adenoma; none underwent surgery during pregnancy. Mean serum calcium maintained from treatment initiation till delivery was 10.5 ± 0.4 mg/dl. One patient had spontaneous preterm delivery at 36 weeks; the remaining patients had normal vaginal delivery at term. None had severe preeclampsia/eclampsia. Fetal outcomes included low birth weight in three newborns (37.5%); two of them had hypocalcemic seizures., Conclusion: The prevalence of gestational PHPT was 2.1% in this largest Indian PHPT cohort, which is higher than that reported from the West (< 1%). Gestational PHPT can lead to preeclampsia and miscarriage. Pregnant PHPT patients with mild-to-moderate hypercalcemia can be managed with hydration/cinacalcet; however, long-term safety data and large-scale randomized controlled trials are required.

Background: Nipple eczema is a less common presentation of atopic dermatitis. No studies in the literature have correlated nipple eczema in pregnancy as a manifestation of atopic dermatitis., Objective: To evaluate whether nipple eczema presenting in pregnancy is a manifestation of atopic dermatitis., Methods: This was a prospective observational study including 100 women who presented with nipple eczema for the first time during pregnancy. The exclusion criteria were any patient with previous history of nipple eczema, those already on oral or topical treatment for atopic dermatitis or nipple eczema, and other disorders mimicking eczema. Patients were divided into two groups ‒ nipple eczema with atopic dermatitis and without atopic dermatitis. Demographic data, clinical features, total leukocyte count, differential leukocyte count, absolute eosinophil counts, and serum IgE levels were compared between the two groups to detect association between nipple eczema in pregnancy and atopic dermatitis., Results: Out of 100 patients, 39 were diagnosed with atopic dermatitis, whereas 61 were ruled out to have any features suggestive of atopic dermatitis. There were no statistically significant differences in mean age, mean duration of symptoms, and serum IgE levels. In patients with atopic dermatitis, bilateral symptoms were noted more commonly than in patients without the disease, but this was statistically insignificant., Study Limitations: Lack of long term follow-up and no large studies in literature to compare results., Conclusion: Nipple eczema in pregnancy follows a similar pattern as in other age groups. The clinical profile of patients is similar in cases with and without atopic dermatitis., (Copyright © 2019. Published by Elsevier España, S.L.U.)

Background: Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child morbidity and mortality. Inadequate water and sanitation access (WASH) are risk factors for PTB and LBW in low-income countries. Physical stress from carrying water and psychosocial stress from addressing sanitation needs in the open may be mechanisms underlying these associations. If so, then living in a community with strong social capital should be able to buffer the adverse effects of WASH on birth outcomes. The objective of this study is to assess the relationships between WASH access and social conditions (including harassment and social capital) on PTB and LBW outcomes among Indian women, and to test whether social conditions modified the association between WASH and birth outcomes., Methods and Findings: This cohort study examined the effect of pre-birth WASH and social conditions on self-reported PTB status and LBW status for 7,926 women who gave birth between 2004/2005 and 2011/2012 Waves of the India Human Development Survey. PTB and LBW occurred in 14.9% and 15.5% of women, respectively. After adjusting for maternal biological and socioeconomic conditions, PTB was associated with sharing a building/compound latrine (Odds Ratio (OR) = 1.55; 95% Confidence Interval (CI) = 1.01, 2.38) versus private latrine access, but suggested an effect in the opposite direction for sharing a community/public latrine (OR = 0.67; CI = 0.45, 1.01). Open defecation, type of drinking water source, minutes per day spent fetching water, and one-way time to a drinking water source were not associated with PTB. LBW was associated with spending more than two hours per day fetching water compared to less than two hours (OR = 1.33; CI = 1.05, 1.70) and suggested an association with open defecation (OR = 1.22; CI = 1.00, 1.48), but was not associated with other types of sanitation, type of drinking water source, or time to a drinking water source. Harassment of women and girls in the community was associated with both PTB (OR = 1.33; CI = 1.09, 1.62) and LBW (OR = 1.26; CI = 1.03, 1.54). The data also showed a possible association of local crime with LBW (OR = 1.30; CI = 1.00, 1.68). Statistically significant (p<0.05) evidence of effect modification was only found for collective efficacy on the association between type of sanitation access and PTB. In addition, stratified analyses identified differences in effect size for walking time to the primary drinking water source and PTB by crime, sanitation access and PTB by harassment, and total hours per day fetching water and LBW by collective efficacy. Limitations of this observational study include risk of bias, inability to confirm causality, reliance on self-reported outcomes, and limited sub-group sample sizes for testing effect modification., Conclusions: The relationship between adverse birth outcomes and sanitation access, domestic water fetching, crime, and gender-based harassment suggests physical and psychosocial stress are possible mechanisms by which WASH access affects PTB and LBW among Indian women. Interventions that reduce domestic responsibilities related to water and sanitation and change social norms related to gender-based harassment may reduce rates of PTB and LBW in India., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Understanding health information-seeking behaviors and barriers to care and access among pregnant women can potentially moderate the consistent negative associations between poverty, low levels of literacy, and negative maternal and child health outcomes in India. Our seminal study explores health information needs, health information-seeking behaviors, and perceived information support of low-income pregnant women in rural India., Methods: Using the Wilson Model of health information-seeking framework, we designed a culturally tailored guided interview to assess information-seeking behaviors and barriers to information seeking among pregnant women. We used a local informant and health care worker to recruit 14 expectant women for two focus group interviews lasting 45 minutes to an hour each. Thirteen other related individuals including husbands, mothers, mothers-in-law, and health care providers were also recruited by hospital counselors for in-depth interviews regarding their pregnant wives/daughters and daughters-in-law. Interviews were transcribed and analyzed by coding the data into thematic categories., Results: The data were coded manually and emerging themes included pregnancy-related knowledge and misconceptions and personal, societal, and structural barriers, as well as risk perceptions and self-efficacy. Lack of access to health care and pregnancy-related health information led participants to rely heavily on information and misconceptions about pregnancy gleaned from elder women, friends, and mothers-in-law and husbands. Doctors and para-medical staff were only consulted during complications. All women faced personal, societal, and structural level barriers, including feelings of shame and embarrassment, fear of repercussion for discussing their pregnancies with their doctors, and inadequate time with their doctors., Conclusion: Lack of access and adequate health care information were of primary concern to pregnant women and their families., Policy Implications: Our study can help inform policies and multi-sectoral approaches that are being taken by the Indian government to reduce maternal and child morbidity and burdens.

Background & Aims: Pregnancy-specific liver diseases such as acute fatty liver of pregnancy; hemolysis, elevated liver enzymes and low platelet syndrome; and preeclampsia-associated liver disease are associated with considerable morbidity and mortality. We investigated the ability of the model for end-stage liver disease (MELD) to predict 1-month mortality among patients with pregnancy-specific liver diseases. We also developed and tested a model to predict mortality based on features of pregnancy-specific liver diseases., Methods: We performed a retrospective study, analyzing hospital admission, clinical, hematologic, and biochemical data collected from 130 patients with pregnancy-specific liver diseases admitted to the St. John's Medical College Hospital (Bangalore, India) from January 2000 through April 2011. Patients were followed up until 3 months after delivery or death. Logistic regression models were fitted using the MELD score and other variables identified as clinically or statistically significant. The predictive accuracy and calibration of the models were assessed by receiver operating characteristic curves and the Hosmer-Lemeshow goodness-of-fit test., Results: Thirty-two patients (24.6%) died. Mortalities from pregnancy-specific liver diseases within 1 month of admission among patients with MELD scores of 20 to 29, 30 to 39, or 40 or greater were 24.2%, 45.45%, and 90.9%, respectively. Univariate analysis identified encephalopathy, ascites, serum total protein, bilirubin, platelet count, alkaline phosphatase, serum creatinine, and international normalized ratio (INR) as significant variables. Multivariate analysis identified total bilirubin (P < .001) and INR (P < .003) as significant predictors of mortality. MELD score and a model based on only 2 variables (bilirubin level and INR) accurately predicted mortality (C statistics, 0.83 and 0.86, respectively) and were well calibrated (Hosmer-Lemeshow χ(2) = 9.7 [P = .28] and 1.9 [P = .98], respectively)., Conclusions: A new logistic model based on only 2 variables (INR and total bilirubin) was comparable with the MELD model in predicting mortality among women with pregnancy-specific liver diseases., (Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Introduction: Pyogenic granuloma (PG) is a solitary, benign vascular growth. The precise cause for the development of pyogenic granuloma is unknown. It is believed, however, to be an exuberant tissue response to local irritation or trauma. Up to date, few studies have been carried out among Asians, particularly on the Indian subcontinent., Materials and Methods: Biopsy services were researched from 1989 to 2009. Two hundred-fifteen histologically confirmed PGs were retrieved and retrospectively analyzed for incidence, age, gender, site distribution, clinical presentation and histopathology. These cases were also evaluated for recurrence., Results and Discussion: Pyogenic granuloma accounted for 50.35% among reactive lesions in this study with a mean age of 34.27 years and a peak incidence in the third decade of life. PG was more common in females with a greater predilection for the maxillary gingivae (50.23%). Eighteen cases occurred in pregnant women. Clinically, PG occurred more frequently as pedunculated lesions (103). Gingival irritation and inflammation due to poor oral hygiene were the major precipitating factors. Histologically, PG presented a greater number of vascular channels of varied sizes, lined with plump endothelial cells, capillary budding, and chronic inflammatory cells, namely lymphocytes and plasma cells. Recurrence was seen in 14.88% of patients, predominantly in females, especially in the maxillary anterior region., Conclusion: Among the reactive lesions, PG had the highest incidence. The frequency of pyogenic granuloma in the southern part of India was much higher compared to other studies. Additional epidemiological research is required to understand the frequency.

Background: The process of audit standardizes protocols in departments and has long-term benefits. Maternal autopsies though routinely performed, deserve a special attention., Aims: This study was carried out to calculate the maternal mortality ratio (MMR) in a tertiary care hospital and to correlate final cause of death with the clinical diagnosis. An audit of maternal autopsies was carried out to evaluate current practices, identify fallacies and suggest corrective measures to rectify them., Materials and Methods: Eighty-nine autopsies of maternal deaths in the period 2003 to 2007 were studied in detail along with the clinical details., Results: There were 158 maternal deaths and 13940 live births in this five-year period. Maternal mortality rate was found to be very high (1133/ 100000 live births) in our institution with a high number of complicated referral cases (68/89 cases, 76%). Of the 89 autopsies, acute fulminant viral hepatitis was the commonest cause of indirect maternal deaths (37 cases, 41.5%). This was followed by direct causes like pregnancy-induced hypertension (12 cases, 13.4%) and puerperal sepsis (10 cases, 11.2%). Certain fallacies were noted during the audit process., Conclusion: During the audit it was realized that in maternal mortality autopsies, special emphasis should be given to clinicopathologic correlation, microbiological studies, identification of thromboembolic phenomenon and adequate sectioning of relevant organs. We found difficulty in identification of placental bed in the uterus in postpartum autopsies. A systematic approach can help us for better understanding of the pathophysiology of diseases occurring in pregnancy.

Background: An audit of autopsies of maternal deaths is important for the establishment of accurate cause of maternal deaths and to determine the contribution of various etiologies responsible in a given community., Aim: To study the causes of maternal deaths as determined by a pathological autopsy., Settings and Design: A retrospective study of all the cases of maternal deaths that underwent a pathological autopsy in a tertiary healthcare center from January 1998 to December 2006., Materials and Methods: The autopsy records with clinical notes were retrieved; gross and histopathology specimens and slides were studied to establish the accurate cause of maternal deaths. The variables like age (years), stay in the hospital, gravidity, trimester of pregnancy and method of delivery were used to classify and analyze the data from the autopsies. The causes of maternal deaths were divided in to direct and indirect; each being classified into subgroups based on the most evident pathology on autopsy., Results: The Maternal Mortality Rate (MMR) over a nine-year period (1998-2006) was 827/100000 live births (471 maternal deaths against 56944 live births). An autopsy was performed in 277 cases (58.8%). In the autopsy group, the most common causes of maternal mortality were pre-ecclampsia/ecclampsia (40 of 277, 14.44%) and hemorrhage (32 of 277; 11.55%); However, indirect causes like infectious diseases (27 of 277; 9.75%) and cardiac (27 of 277; 9.75%) disease also contributed to maternal deaths., Conclusion: Indirect causes like rheumatic heart disease and infections like tuberculosis, malaria or leptospirosis and nutritional anemia are still major causes of maternal mortality in developing countries like India. Intensive efforts need to be taken in these areas to reduce the maternal mortality in developing countries like India.

Unlabelled: Pregnant patients with acute liver failure (ALF) are believed to have a worse outcome than nonpregnant women and men with ALF. However objective data supporting this supposition are scant. Therefore, the current study compared the outcome, complications, and causes of ALF among pregnant women and girls with age-matched nonpregnant women and girls and men and boys with ALF. One thousand fifteen consecutive ALF patients in the reproductive age group, admitted at the All India Institute of Medical Sciences, New Delhi, from January 1986 to December 2006, were included in the study. A total of 249 (38.5%) women were pregnant. They were compared with 341 nonpregnant women and girls and 425 men and boys, aged 15 to 45 years. The mortality rate of pregnant women and girls (53.8%) was similar to age-matched nonpregnant women and girls (57.2%), and men and boys (57.9%); P = 0.572. The clinical and biochemical features, disease severity, and complications were also similar in the three groups. A significantly higher proportion of ALF was attributable to hepatitis E virus (HEV) among women and girls who were pregnant (59.4%), as compared with both nonpregnant women and girls (30.4%), and men and boys (23.1%); P < 0.001. However, the outcome of HEV-related ALF was independent of the sex and pregnancy status of the patients (P = 0.103). Mortality in HEV-ALF and non-HEV-ALF patients in pregnant women and girls was 51% (74/145) and 54.7% (52/95)(P > 0.1), respectively. The outcome of pregnant ALF patients was also unrelated to the trimester of pregnancy. The mortality of non-HEV-related ALF among the pregnant women and girls (54.7%), age-matched nonpregnant women and girls (61.7%), and men and boys (62.8%) were also similar (P > 0.1)., Conclusion: The mortality of pregnant patients with ALF is similar to that of nonpregnant women and girls and men and boys and is independent of the cause or trimester. Pregnancy per se should not be regarded as a poor prognostic factor for a patient with ALF.

Sudden unexpected death in many instances comes with stimulating or interesting findings, often in contrast to the history provided. Two cases of sudden death in pregnant females with central venous thrombosis are described, because of their rarity. The incidence, etiological factors, predisposing conditions and the ethical and legal questions arising from such deaths are discussed.

The incidence of burns in pregnant females is on the rise in villages in and around Aligarh. Hence, the study of such cases epidemiologically is of paramount importance to throw light on the exact nature of the incidents. This study was done on 1200 patients over a period of 5 years in JNMCH, AMU, Aligarh and data revealed 384 (32%) cases of burnt pregnant females who were in the age group of 19-35 years (median age = 27 years). Maximum number of deaths occurred in patients with a TBSA more than 50 and 70% burns. Period of amenorrhoea ranged from 1 to 8 months. Number of patients who expelled the dead foetus were 86. This study throws light on the bias against pregnant females, dowry factor and still further, female foeticide and oedipal dominance of mother in law over the grooms.

Objectives: To obtain an insight into the underlying disorder or pathologies in different organs or systems, and to attempt clinicopathologic correlation in maternal deaths., Methods: This is a retrospective study of 95 maternal autopsies done from 1993 to 2000 in Sassoon General Hospital, Pune, India. External examination, in situ examination, gross and microscopic examination was done in each case. The cause of death was arrived at after reviewing clinical details, available investigations, morphological findings, and clinicopathologic correlation., Results: Ninety-five (45.02%) out of 211 maternal deaths were autopsied. Out of 95, there were 47 (49.5%) direct obstetric deaths, and 33 (34.7%) indirect obstetric deaths. Fifteen (15.8%) deaths were unrelated to pregnancy, 14 of which were due to infections., Conclusions: Hypertensive disorders associated with pregnancy (24.2%) and anemia (14.7%) were most common. In the hypertensive group, important findings were disseminated intravascular coagulation, hemorrhages in different organs and thromboemboli. Two cases were HIV seropositive. The autopsy helped to elucidate factors contributing to death and pathology in different organ systems.

Burn injury in pregnant patients is not uncommon in developing countries. The results of the management of six pregnant burns patients, admitted during an 18-month period, were analysed. Successful management of burn injuries ranging from 25 to 65 per cent TBSA occurred in patients during the second and third trimester of pregnancy, using early burn wound excision and skin grafting in four patients and by late skin grafting of a granulating wound in one patient. All five patients delivered live babies with no congenital anomalies. One patient with 60 per cent TBSA burns who was unsuitable for early excision, died of septicaemia. This report suggests the need for early burn wound excision and skin grafting in burns patients with pregnancy, in order to improve maternal and fetal survival. However, in developing countries early surgery is not advisable in patients with extensive burns because of the non-availability of biological skin substitutes.

The pattern of cerebrovascular disease in North-West India has been studied in a necropsy series of 362 cases over a 14 year period. One hundred and thirty eight cases of intracranial haemorrhage were found, 89 of cerebral embolism, 101 of cerebral arterial thrombosis and 34 of cerebral venous thrombosis. Nearly 37% of the affected patients were below 40 years of age. Cerebral embolism and cerebrovenous thrombosis were important causes of stroke in the young. Rheumatic heart disease and infective endocarditis formed the major causes of cerebral embolism. Cerebral venous thrombosis associated with pregnancy and puerperium was relatively more common in our series than has been reported in the West.

Forty-nine out of 662 patients (7.4%) dialysed for acute renal failure were found to have bilateral renal cortical necrosis. Amongst 6061 autopsies carried out in our centre during the same period, the incidence of cortical necrosis was 0.7%. Obstetric causes were responsible for the renal lesion in 35 (71%) and non-obstetrical causes in 14 patients. In the obstetric group, cortical necrosis was observed in association with spontaneous or induced abortion in 39% and as a complication of late pregnancy in 33%. The non-obstetric causes included snake bite in 26 (12%), acute gastro-enteritis in 5 (10%), haemolytic uremic syndrome in 2 (4%) and G6PD deficiency with intravascular haemolysis in one patient (2%). Thirty-nine (80%) patients were anuric or severely oliguric throughout their illness but a steady rise in urinary output following a protracted phase of oligo-anuria was observed in ten patients. Forty-two (86%) patients died and seven survived. None of the survivors, however, achieved a normal renal function (Ccr 8 ml to 28 ml/min). The diagnosis of renal lesion was confirmed during life in 8 and after death in 41 patients. Morphological lesions were consistent with bilateral diffuse cortical necrosis in 39 (80%) and patchy lesions in 10 patients. Factors responsible for the high incidence of cortical necrosis amongst Indian patients have been high-lighted.