Indian Journal of Neonatal Medicine & Research

Single Umbilical Artery and Associated Systemic Anomalies in Foetal and Perinatal Autopsy: An Observational Study

Introduction: Single Umbilical Artery (SUA) is a congenital anomaly that can occur either as an isolated finding or in association with other systemic anomalies. Several studies have reported that SUA is linked to dysplastic kidneys, ventricular septal defects, oesophageal atresia, spina bifida, diaphragmatic hernia and cystic hygromas. Therefore, investigating cases of SUA in autopsies is crucial. Aim: To estimate the frequency of SUA in foetal autopsies and determine the association between SUA and other systemic anomalies. Materials and Methods: The present ambispective observational study was conducted in the Department of Pathology, Shri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Dharwad, Karnataka, India, over a 13 year period from January 2009 to December 2021. A total of 63 cases of SUA detected during foetal autopsies were included. Factors such as age, parity and multiple births were collected where available. The hospital-based frequency of SUA was calculated as a percentage. The association between SUA and systemic anomalies was assessed using the Chi-square test. Results: A total of 1338 perinatal autopsies were performed during the study period, with SUA present in 63 (4.70%) cases. The most common associated anomaly was genitourinary defects identified in 16 (25.39%) cases. However, a statistically significant association was observed with musculoskeletal (11.11%), nervous (11.11%), and gastrointestinal system anomalies (19.04%) with a p-value of <0.0001. Conclusion: In the present study, SUA accounted for 4.70% of the foetal autopsies conducted during the study period. The most common associated anomalies were bilateral cystic kidneys, and VATER (Vertebral, Anal, Tracheo-oesophageal, and Renal anomalies) was the most common syndromic associations with SUA.

Clinico-bacteriological Study of Sepsis in VLBW Neonates in Tertiary Care NICU in Central India: A Descriptive Observational Study

Nivedita Shankar Kadam, Dipak Narayan Madavi, Shamama Subuhi

Introduction: Low Birth Weight (LBW) is one of the most serious challenges in maternal and child health in developing countries. Neonatal sepsis is responsible for about 30-50% of the total neonatal deaths in developing countries. Given the high prevalence of Very Low Birth Weight (VLBW) neonates and the increasing incidence of sepsis in this population, there is a need to study the clinical and bacteriological profile of sepsis. Aim: To study the clinico-bacteriological profile of neonatal sepsis in VLBW neonates (Birth weight <1500 gm) in a tertiary care NICU in central India. Materials and Methods: The descriptive observational study was conducted among VLBW neonates with clinically suspected sepsis admitted to the NICU of Indira Gandhi Government Medical College and Mayo Hospital in Nagpur, Maharashtra, India, from November 2019 to October 2021. All 160 VLBW neonates with clinically suspected sepsis and positive sepsis screen consisting of four parameters {Absolute Neutrophil Count (ANC), Total Leucocyte Count (TLC), Immature/Total Neutrophil Ratio (I/T Ratio), C-Reactive Protein (CRP)+} and whose mothers provided informed consent were included in the study within 24 hours of admission. Details such as demographic data, maternal risk factors and type of delivery, clinical signs of sepsis presentation, any Central Nervous System (CNS) signs, day of onset of sepsis, sepsis screen parameters (CRP, TLC, ANC, I/T Ratio), blood culture, and Cerebro-spinal Fluid (CSF) examination findings were studied. Continuous variables were evaluated using the student t-test, and categorical variables were evaluated using the chi-square test. Results: There were 96 (60%) males and 64 (40%) females. In the sepsis screen parameters, the majority of the neonates were CRP positive 148 (92.3%) followed by TLC positive among 119 (74.38%) neonates. Lethargy was the most common clinical presentation among 147 (91.88%) neonates followed by difficulty in feeding among 121 (75.63%) neonates. Blood culture was positive among 61 (38.13%) neonates, and Escherichia coli was the most common organism isolated among 21 (34.43%) neonates. Conclusion: The most common clinical presentation of neonatal sepsis was lethargy followed by difficulty in feeding. In the present study, the most common organism isolated was E.coli.

Perinatal Outcome of Twin Pregnancies in Relation to Chorionicity at a Tertiary Care Centre in Central Kerala, India: A Prospective Cohort Study

P Hridya, AV Deepak, RP Reena

Introduction: In recent years, there has been a significant increase in the incidence of multiple births due to advanced maternal age at conception and the growing use of infertility treatment. Multiple pregnancies are associated with both maternal and perinatal complications. Maternal complications include anaemia, gestational hypertension, gestational diabetes, preterm labour, operative delivery and postpartum haemorrhage. Preterm birth, growth discordance and complications specific to monochorionic twins predispose these babies to adverse perinatal outcomes. Aim: To assess the perinatal outcomes of twin pregnancies and compare the outcomes of monochorionic and dichorionic pregnancies. Materials and Methods: The present prospective cohort study was conducted in the Department of Obstetrics and Gynaecology, Government Medical College (Tertiary care centre), Thrissur, Kerala, India, from September 2019 to August 2020. All twins who delivered at a gestational age of ≥28 weeks during the study period were recruited, totaling 76 twin pregnancies. A structured proforma was used to collect demographic and clinical details, including mode of conception, chorionicity, maternal complications, intrapartum events and neonatal outcomes. Data were analysed using Epi Info software. Results: The mean maternal age of the study participants was 28.39±6.29 years. The incidence of twin pregnancies delivering at ≥28 weeks at Government Medical College, Thrissur, during the study period was 2.8% (76 twins out of 2709 deliveries). Infertility treatment (ovulation induction alone or Assisted Reproductive Techniques (ART) was associated with dichorionic twinning in 19.7% (15 out of 76 twin pregnancies), with a p-value of 0.008. Maternal complications were similar in both dichorionic and monochorionic twins. Preterm Premature Rupture of Membranes (PPROM) occurred in 23 (28.75%) twin pregnancies, 19 (23.75%) had Gestational Diabetes Mellitus while 13 (16.25%) participants had anaemia. Foetal growth restriction, congenital anomalies, and discordant growth were more prevalent in monochorionic twin pregnancies compared to dichorionic twin pregnancies. Although the proportion of babies requiring Neonatal Intensive Care Unit (NICU) admission was higher in monochorionic twins (64% vs 53.9%), the proportion of neonatal deaths was nearly equal between monochorionic and dichorionic twins (10% vs 9.8%). Conclusion: In the present study, there was no statistical difference in maternal complications between monochorionic and dichorionic twins. However, monochorionic pregnancies had a poorer perinatal outcome compared to dichorionic pregnancies.

Effect of Sildenafil in Neonates with Persistent Pulmonary Hypertension: An Interventional Study

Jigar Jain, Jolly Vaishnav, Arif Vohra, Mansi Shah, Anika Goyal

Introduction: Persistent Pulmonary Hypertension of the Newborn (PPHN) reflects a disruption of the normal perinatal circulatory transition and is characterised by high pulmonary artery pressure. Inhaled Nitric Oxide (iNO) is considered the mainstay of treatment for PPHN. However, many developing and resource limited countries do not have access to such expensive therapy. Therefore, sildenafil, due to its easy availability and low cost, becomes the most commonly used drug in the management of PPHN in such settings. Aim: To study the treatment response and outcomes of neonates who received sildenafil for the management of PPHN. Materials and Methods: The present hospital-based prospective interventional study was conducted in the Neonatal Intensive Care Unit (NICU), BJ Medical College, Civil Hospital, Ahmedabad, Gujarat, between May 1, 2020, and April 30, 2021. Study was conducted on neonates with meconium aspiration syndrome and/or severe birth asphyxia admitted to the NICU. A total of 48 neonates with Two Dimensional (2D) echocardiography-proven PPHN were enrolled. Baseline clinical parameters including heart rate, respiratory rate, preductal and postductal Saturation of Peripheral Oxygen (SpO₂), Oxygenation Index (OI), Saturation Oxygen Distending Pressure Index (SOPI), and Non Invasive Blood Pressure (NIBP) were monitored every six hours. Neonates who were on invasive/non invasive ventilation had their Fraction of Inspired Oxygen (FiO₂), Positive End Expiratory Pressure (PEEP), Peak Inspiratory Pressure (PIP), respiratory rate and flow rate monitored every six hours. Data were statistically analysed using Analysis of Variance (ANOVA) test. Results: During the study period, a total of 1080 neonates were admitted with meconium aspiration syndrome and/or severe birth asphyxia, out of which 48 neonates showed findings suggestive of PPHN on 2D echocardiography. A statistically significant improvement in oxygenation after sildenafil treatment was indicated by a significant reduction in OI from 35.3±8.6 to 13.2±2.1 (p-value <0.001), a reduction in SOPI from 3.6±0.3 to 1.5±0.2 (p-value <0.001), a reduction in FiO₂ (%) from 94.6±8.19 to 24.2±4.5 (p-value <0.001), an increase in Partial pressure of oxygen (PaO₂) (mmHg) from 52±5.6 to 72±3.4 (p-value <0.001), and an increase in SpO₂ (%) from 83.5±8.6 to 93.5±5.1 (p-value <0.001). Conclusion: The findings of the present study suggest that oral sildenafil can be successfully used to improve oxygenation in patients with PPHN, especially in a resource limited setting where facilities like Extracorporeal Membrane Oxygenation (ECMO) and iNO are not available, as demonstrated in the present study.

Gender Difference in Community’s Health Care Seeking Behaviour towards Male and Female Newborns in Today’s Scenario- A Cross-sectional Study

Avyact Agrawal, S Priyadharshini, Preeti Singh

Introduction: The sex ratio is a crucial social indicator to assess the level of equality between men and women. In several aspects, the gender difference between men and women is the major expression of social and cultural trends of the society. Aim: To analyse sex ratio at birth and the gender difference in health seeking behaviour among newborns and the natural survival advantage of female newborns by studying the admission, discharges, mortality, follow-up and Leave Against Medical Advice (LAMA) in Special Newborn Care Unit. Materials and Methods: This cross-sectional study was conducted in Netaji Subash Chandra Bose Medical College and Hospital, Madhya Pradesh and Lady Elgin Hospital, Madhya Pradesh from July 2017 to June 2019. The total number of newborns included in the study was 37,256. The difference in male and female newborns in terms of birth, LAMA, morbidity, mortality and follow-up were studied. The monthly statistical data were entered in an excel sheet. The data were analysed using SPSS version 22.0 for Windows. The mean values of the monthly percentage were compared gender-wise using the t-test. Results: Out 20108 male newborns and 17,148 female newborns advised for follow-up care, 1897 females (mean-14.64, SD- 11.47) and 3029 males (mean-16.94, SD-12.47) came for follow-up care. The gender difference was statistically significant (p ≤0.001). Females (mean outborn unit-3.07, inborn unit-1.05) took LAMA more than males (mean outborn-2, inborn-0.84) which was statistically significant (outborn: p≤0.001, inborn: p=0.0254). This imples less health seeking behaviour towards females. Mortality (p-value: outborn-0.0041, inborn-0.0105) and morbidity (p≤0.001) were lesser in females compared to males which was statistically significant. These factors imply natural survival advantage in females. Conclusion: The present study concludes that the health seeking behaviour was less towards female newborns despite their natural survival advantage which plays an important role in the declining sex ratio.

Umbilical Cord Blood Culture as an Aid to the Diagnosis of Early Onset Neonatal Sepsis: A Cross-sectional Study

Introduction: Neonatal sepsis is one of the leading causes of neonatal morbidity and mortality globally, accounting for an estimated neonatal mortality rate of 23.9 per 1000 live births. Due to overlapping signs and symptoms, a specific diagnosis of sepsis poses a diagnostic challenge. Blood collected from a peripheral vein for sepsis screening and blood culture remains the gold standard for diagnosing neonatal sepsis. The umbilical cord is still not routinely used as a site for collecting blood for sepsis screening and blood culture. Aim: To determine the diagnostic efficacy of Umbilical Cord Blood Culture (UCBC) compared to Peripheral Venous Blood Culture (PVBC) in Early Onset Neonatal Sepsis (EONS). Materials and Methods: This cross-sectional observational study was conducted at the Neonatology Unit, Department of Paediatrics, Assam Medical College and Hospital (AMCH), Dibrugarh, Assam, India, involving 110 neonates with two or more risk factors for EONS over a one-year period (August 2021-July 2022). Umbilical cord blood and peripheral venous blood were collected and cultured, and the neonates were monitored throughout their hospital stay. Statistical significance was determined using the Chi-square test for categorical variables and the t-test for continuous variables (with a p-value <0.05 considered statistically significant). The validity of UCBC for diagnosing early neonatal sepsis was assessed based on sensitivity, specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV). Results: The mean gestational age was 34.95±3.314 weeks and mean birth weight was 2.08±0.790 grams. Of the 110 high-risk neonates, sepsis screening was positive in 67 (61%), while UCBC and PVBC were positive in 19 (17.3%) and 10 (9.09%), respectively. Acinetobacter was the most common organism found in both cultures. The sensitivity and specificity of sepsis screening were 100% and 47.25% compared to UCBC and 90% and 42% compared to PVBC. In comparison to PVBC, UCBC demonstrated a sensitivity and specificity of 70% and 88%, with a diagnostic accuracy of 86.36%. Conclusion: The UCBC exhibits good diagnostic accuracy for diagnosing EONS and can be utilised due to it being a painless and technically less challenging method of blood sampling, with high sensitivity and specificity.

Antimicrobial use and Adverse Drug Reaction in Newborns with Neonatal Sepsis: A Prospective Observational Study from a Tertiary Care Teaching Hospital

Riddhi C Parmar, Anil P Singh

Introduction: Neonatal Sepsis (NS) is a major cause of morbidity and mortality worldwide, especially in developing countries like India. The role of antimicrobials is life-saving in NS. To achieve a good prognosis, early diagnosis and appropriate treatment are required. Data related to the irrational use of antimicrobials in neonates are limited. Aim: To evaluate the drug usage pattern and Adverse Drug Reactions (ADRs) of antimicrobials in NS. Materials and Methods: A prospective observational study was conducted among 350 neonates who were admitted and diagnosed with NS from January to December 2021 in the Neonatal Intensive Care Unit (NICU) of PDU Medical College and Civil Hospital, Rajkot, Gujarat, India. Demographic data such as age, sex, birth weight, and clinical data such as type of delivery, type of sepsis, culture-sensitivity status, and antimicrobials used were recorded. Suspected ADRs were reported in the pharmacovigilance database. Categorical data were analysed in percentage, whereas some clinical data were analysed with mean and median using Microsoft Office Excel-2019. Results: In the present study, 172 (49.15%) male and 178 (50.85%) female neonates were almost equally affected. The mean gestational age and birth weight were 35±3.6 weeks and 2±0.7 kg, respectively. Early-Onset Neonatal Sepsis (EONS) cases were more at 273 (78%) compared to Late-Onset Neonatal Sepsis (LONS). Seventeen different antimicrobials were used. The average number of antimicrobials used per case was 2.9. The Piperacillin Tazobactam was the most commonly used antimicrobial in 173 cases (49.43%) in early-onset sepsis, while Meropenem was used in 40 cases (11.43%) in late-onset sepsis. Coagulase-negative Staphylococcus was the most commonly isolated organism in 15 cases (4.2%), followed by Klebsiella Pneumoniae in 13 cases (3.7%). Twelve out of 17 antimicrobials (70.59%) were not included in the first list of essential medicines for children of India in 2011. Six ADRs were reported in the present study. Conclusion: In all admitted cases of sepsis, empirical therapy was given, but variations from standard recommendations were observed in dose and frequency. A periodic survey of antimicrobial use patterns in NS will be useful in the rational selection of empirical therapy.

Effect of Educational Intervention on Knowledge, Attitude and Practice of Nursing Mothers of Babies Receiving Kangaroo Mother Care and its Impact on Weight Gain: A Randomised Controlled Trial

Introduction: Kangaroo Mother Care (KMC) has proven to be a humane, powerful, easy-to-use, and low-cost method to promote the health of Low Birth Weight (LBW) neonates. The level of Knowledge, Attitude and Practice (KAP) of nursing mothers on KMC is variable. The KAP of mothers on KMC can be improved through mass media communication, which In turn improves the outcome of LBW. Aim: To determine the level of KAP regarding KMC among the mothers admitted to the KMC ward and to assess the impact of educational intervention on babies’ weight gain during KMC stay and on follow-up. Materials and Methods: This was a Randomised Controlled Trial conducted in the KMC ward, Belagavi Institute of Medical Science (BIMS) (a tertiary care centre), Northern Karnataka, India, from March 2021 to February 2022. A total of 79 subjects were included in the study and randomised into two groups: the case group (n=39) and the control group (n=40). The case group received educational intervention on KMC using audiovisual aids, while the control group received standard KMC counselling. Mothers from both groups were assessed for KAP using a prestructured questionnaire. Babies were followed-up at the 1st, 2nd, and 3rd months after discharge for weight gain. Data were analysed using Statistical Package for Social Sciences (SPSS) software version 23.0. Chi-square tests and Mann-Whitney U tests were applied for analysis. Results: The study comprised 79 KMC mother-baby dyads, with 39 in the case group and 40 in the control group. Most mothers (91%) were in the age group of 20-30 years, and 92% of the mothers had an educational status of Secondary School Leaving Certificate (SSLC), and Pre-university Course (PUC). The mean birth weight was 2.1 kg, 57% of babies were delivered by Lower Segment Caesarean Section (LSCS), and the mean gestational age was 34.48 weeks. There were no significant differences in demographic characteristics between the two groups. At admission, there was no significant difference in knowledge scores between the case and control groups (20.83±1.89 vs 19.19±3.04, p-value=0.06), but there was a statistically highly significant difference at discharge (23.9±0.38 vs 21.63±3.31, p-value <0.001). Statistically significant differences were also found in attitude (6.98±0.16 vs 6.7±0.62, p-value=0.005) and practice scores (9.38±1.39 vs 6.0±1.97, p-value <0.001). The present study found that 89.74% of mothers in the case group and 90% in the control group had good knowledge at admission, and 100% and 95% at discharge, respectively. In terms of practice, 51.3% of mothers in the case group and 15% in the control group had good practices, while only 2.56% in the case group and 70% in the control group had poor practices, which was statistically significant across all grades. All mothers in the case group and 97.5% in the control group had a good attitude. The mean weight gain (grams per day) during follow-up was statistically significant at two months (25.32±8.09 g/day vs 22.43±4.99 g/day, p-value=0.005) and at three months (25.21±6.75 g/day vs 22.69±3.81 g/day, p-value=0.004). Conclusion: Kangaroo mother care is a very effective and easy-to-practice method to improve the outcomes of LBW babies. Counselling using educational audiovisual aids will improve the KAP of mothers. Therefore, improved counselling should be advocated to enhance the efficacy of KMC and promote better weight gain.

Clinical Profile and Outcomes of Severe Acute Maternal Morbidities in a Tertiary Care Centre, Bangalore, India: A Descriptive Study

Sushma Yalagandula, Ravi N Patil, C Sathyavani

Introduction: Many complications can occur during pregnancy, delivery, and the immediate post-partum period that necessitate admission to the Intensive Care Unit (ICU). As maternal mortality is declining in many areas of the developing world, studying it alone may not be sufficient to provide information on the quality of care given. Therefore, the emphasis is more on Severe Acute Maternal Morbidity (SAMM) or Maternal Near Miss (MNM), which has emerged as a promising alternative to maternal mortality reviews. This approach has an advantage over maternal mortality as it draws attention to the reproductive health of surviving women. Aim: To determine the clinical profile, predisposing clinical conditions, and outcomes of SAMM. Materials and Methods: A descriptive study was conducted at Bangalore Baptist Hospital, Bangalore, Karnataka, India, from November 2020 to June 2022. Data were collected on all pregnant women and postpartum women up to 42 days after delivery who were admitted to the high-risk labour room, High Dependency Unit (HDU), and ICU. A total of 191 patients were enrolled, and various variables were studied, including demographic details, gestational age, co-morbidities, intensive care management, and neonatal outcomes. Women with Life-Threatening Conditions (WLTC), SAMM, and Maternal Deaths (MD) were noted, and using these parameters, the Severe Maternal Outcome Ratio (SMOR), MNM incidence ratio, and mortality index were calculated. Results: Among the 191 women with life-threatening conditions, 187 had SAMM, and four patients succumbed to death. The majority of SAMM cases were due to obstetric haemorrhage, observed in 73 patients (46.2%). This was followed by hypertensive disorders in pregnancy, seen in 65 patients (41.1%), and sepsis, seen in 15 patients (15.24%). The SMOR was calculated to be 44.05%. The MNM ratio was 43.13%, and the MNM mortality ratio was 46.75:1. A mortality index of 20.94% was reported in the study. Out of 155 births, 128 were live births, 14 were intrauterine deaths, 10 were fresh still-births, and three were early neonatal deaths. Conclusion: Screening for high-risk pregnancies and timely detection of severe maternal morbidity are important steps toward promoting safe obstetric care. A multi-disciplinary team with good ICU care and availability of blood and blood products will help decrease maternal mortality.