RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. / Name of the candidate
Address / Dr. NATARAJ .B
Department of Bio-chemistry
J.S.S MEDICAL COLLEGE,
S.S NAGAR, BANNIMANTAP,
MYSORE-570015.
2. / Name of Institution / J.S.S Medical College,
S.S Nagar, Bannimantap,
Mysore-570015.
3. / Course of the study & Subject / MD (Bio-chemistry)
4. / Date of admission to the course / 2004-2005 Batch
Readmission Vide RGUHS
Order no: AC2-Adm/ph-Med/2004-05/M 677 dated 22/8/2007.
5. / Title of the topic
“STUDY OF SERUM CALCIUM, MAGNESIUM, URIC ACID LEVELS AND SPOT URINARY ALBUMIN/CREATININE RATIO IN PREECLAMPSIA”.

6. Brief resume of the intended work:

6.1 Need for the study

Preeclampsia is classically defined as a syndrome characterised by the development of hypertension to the extent of 140/90mm Hg or more with edema or proteinuria or both induced by pregnancy after 20 weeks of gestation. Preeclampsia is a pregnancy specific disease associated with high incidence of maternal and fetal morbidity and mortality. Preeclampsia is resolved only on delivery.

The pathophysiological mechanism is characterised by a failure of the trophoblastic invasion of the spiral arteries, which may be associated with an increased vascular resistance of the uterine artery and a decreased perfusion of the placenta1. The precise cause of vascular endothelial dysfunction an important factor in the pathophysiology of preeclampsia, remains unknown.

The following biomarkers of pathophysiologic importance would assist greatly in the diagnosis and management of preeclampsia and potentially provide the underpinnings for targeted therapies. In preeclampsia the levels of serum uric acid is increased and also the levels of serum calcium and magnesium are reduced.

Uric acid is one of the most consistent and earliest detectable change in preeclampsia and has been cited as a better predictor of fetal risk than blood pressure2.

Studies have also demonstrated the diagnostic value of albumin / creatinine ratio in a single voided urine sample for quantitation of proteinuria, compared to those 24 hours of sample in patients with preeclampsia5.

However few studies have been conducted to see if there is any correlation between the levels of serum calcium, magnesium, uric acid and spot urinary albumin / creatinine ratio in patients with preeclampsia.

Hence in this study we propose to estimate and compare the serum levels of calcium, magnesium, uric acid and spot urinary albumin/creatinine ratio in women with preeclampsia and normal pregnant women.

6.2 Review of literature

Intense vasospasm affecting all the arteries particularly the arteries of uterus, kidney and brain is the underlying basic pathology for hypertension. The results from many clinical studies show the relationship between the aggravation of the hypertensive complications and changes in concentration of various chemistries in mothers serum. Interestingly variable serum calcium, magnesium and uric acid are found in preeclamptic mothers3.

Few studies on women with preeclampsia have been conducted which show that the serum levels of calcium and magnesium are low. Calcium plays an important role in muscle contraction and regulation of water balance in cells. Modification of plasma calcium concentration leads to the alteration of blood pressure. Magnesium has been known as an essential cofactor for many enzyme systems. It also plays an important role in neurochemical transmission and peripheral vasodilation1.

Studies have correlated the rise in uric acid with the severity of preeclampsia. There is strong association between hyperuricemia and the risk of small birth weight infant and over all the fetal mortality4.

The gold standard for measuring proteinuria is a 24 hrs urine sample for total proteins. Patients with mild preeclampsia have 300mg to 5000mg and those with severe preeclampsia have >5000mg of proteins. The 24 hour period required for collection of the urine may result in a delay in diagnosis and treatment or possible a prolonged hospital stay. Shortening the period for the diagnosis of preeclampsia would be valuable for management purposes, as well as for decreasing hospital cost and patient inconvenience. Also the collection is cumbersome often incomplete and is difficult to administer on out patient. Studies have shown the use of spot albumin / creatinine ratio correlates well with 24 hour urinary protein excretion5.

6.3 Objectives of study

1.  To estimate and compare the levels of serum calcium, magnesium, uric acid and spot urinary albumin / creatinine ratio in women with preeclampsia and normal pregnant women.

2.  To find if there is any relationship between serum calcium, magnesium, uric acid and spot urinary albumin / creatinine ratio in the study group.

3.  To ascertain if any of these parameters could be used as a marker for early detection of preeclampsia.

7. Material and Methods

7.1 Source of data

  1. Patients attending Obstetrics and Gynaecology Department of J.S.S Medical College Hospital, between the age group of 18-35 years who have been diagnosed to have preeclampsia after obtaining informed consent.
  2. Normal pregnant women attending Obstetrics and Gynaecology Department of J.S.S Medical College Hospital, between the age group of 18-35 years after obtaining informed consent.

Exclusion criteria

1.  Patients with chronic medical disorders such as Diabetes Mellitus, cardiovascular disease, chronic renal disease and chronic hypertension.

2.  Patients with molar pregnancy/acute polyhydramnios/twin pregnancy will be excluded.

3.  Patients with intra uterine fetal death.

4.  Patient with ruptured membranes, vaginal bleeding, urinary tract infection will be excluded.

Inclusion criteria

This will include diagnosed cases of preeclampsia between the age group of 18-35 years with singleton pregnancy and gestational period of more than 20 weeks, from Obstetrics and Gynaecology Department of J.S.S Medical College & Hospital, Mysore.

7.2 Method of data collection

The sample size will consist of 30 pregnant women between the age group of 18-35 years, who have been diagnosed as preeclampsia from the Obstetrics and Gynaecology department of J.S.S Medical College & Hospital, Mysore, and 30 age matched healthy pregnant women.

Statistics methods to be employed:

1.  Descriptive statistics

2.  Cross tabs

3.  Product Moment Correlation

4.  Independent sample ‘t’ test

All the above mentioned statistical methods will be performed through software SPSS (Statistical presentation system software) for windows.

7.3 Does the study require any investigations or interventions to be conducted on patients or other human or animals? If so, please describe briefly

Yes, Venous blood samples and urine samples will be collected under aseptic precautions after obtaining informed consent from patients diagnosed as preeclampsia. Venous blood samples and urine samples will also be collected under aseptic precautions from healthy pregnant women.

Proposed investigations include the estimation of the following

1.  Serum calcium will be estimated colorimetrically by using Arsenazo III Reagent.9

2.  Serum magnesium will be estimated colorimetrically9.

3.  Serum uric acid will be estimated by enzymatic colorimetric method.10

4.  Urinary albumin will be estimated by immunoturbidimetric method.11

5.  Urinary creatinine will be estimated by colorimetric method.10

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes

8. List of references

  1. Sukonpan K., Phupong V. Serum calcium & serum magnesium in normal and preeclamptic pregnancy. Arch Gynecol Obstet 2005; 273: 12-16.
  2. Robots J.M., Bodnar L.M., Lain K.Y., Hubel C.A., Markovic N., Ness R.B., Powers R.W. Uric acid is as important as proteinuria in identifying fetal risk in women with gestational hypertension. Hypertension Journal of the American Heart Association 2005; 46:1263-1269.
  3. Punthumapol C., Kittichotpanich B. Serum calcium, Magnesium & Uric acid preeclampsia and normal pregnancy. J med Assoc Thai 2008; 91(7): 968-973.
  4. Thadhani R.I., Johnson R.J., Karumanchi S.A. Hypertension during pregnancy - A disorder begging for pathophysiological support. Hypertension journal of the American Heart Association 2005; 46:1250.
  5. Eigbefoh J.O., Abebe J., Odike M.A.C., Isabu P. Protein / Creatinine ratio in random urine specimens for quantitation of proteinuria in preeclampsia. The internet Journal of Gynecology and obstetrics 2007;8:1.
  6. Malas O.N., Shurideh M.Z. Does serum calcium in preeclampsia and normal pregnancy differ? Saudi Med J 2001; 22(10):868-871.
  7. Frishman W.H., Veresh M., Schlocker J.S., and Tejani.N. Pathophysiology and medical management of systemic hypertension in preeclampsia. Current hypertension reports 2006; 8:502-511.
  8. Cote A.M., Brown M.A., Lam E., Dadelszan P.V., Firoz T., Liston R.M., and Magee L.A. Diagnostic accuracy of urinary spot protein / creatinine ratio for proteinuria in hypertensive pregnant women: systematic review. BMJ 2008; May 3; 336(7651): 1003-1006.
  9. David BE, Robert KR. Mineral and Bone metabolism. In: Carl AB, Edward RA, David EB, editors. Tietz Textbook of clinical chemistry and molecular diagnostics. 4th edition: Philadelphia: W.B Saunders; 2006:1891-1965.
  10. Edmun L, David JN, Chistopher PP. Kidney Function Tests. In: Carl AB, Edward RA, David EB, editors. Tietz text book of clinical chemistry and molecular diagnostics. 4th edition: Philadelphia: W.B Saunders; 2006:797-835.
  11. David BS. Carbohydrates. In: Carl AB, Edward RA, David EB, editors. Tietz Textbook of clinical chemistry and molecular diagnostics. 4th edition: Philadelphia: W.B Saunders; 2006:837-901.

9. / Signature of Candidate
10. / Remarks of the guide / EVALUATION OF SERUM CALCIUM, MAGNESIUM, URIC ACID LEVELS AND SPOT URINARY ALBUMIN / CREATININE RATIO AS MARKERS EITEHR INDIVIDUALLY OR IN COMBINATION FOR DIAGNOSIS OF PREECLAMPSIA.
11. / 11.1 Name and designation of guide
11.2 Signature / Dr. M.N Suma M.D
Associate Professor
Dept of Biochemistry
J.S.S Medical College,
Mysore – 570 015
11.3 Co-guide
11.4 Signature
11.5 Head of the Department
11.6 Signature / Dr. H.S Virupaksha M.D, FIAMS
Professor & HOD
Dept. of Biochemistry
J.S.S. Medical College
Mysore – 570 015s.
12. / 12. 1 Remarks of the Chairman and Principal
12.2 Signature

9