Rajiv Gandhi University of Health Sciences Karnataka



“A STUDY TO CORRELATE MATERNAL HEALTH STATUS WITH NEWBORN CHARECTERISTICS AMONG (PIH) MOTHERS ADMITTED IN SELECTED HOSPITALS IN BANGALAORE”

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

MS. TEENA RANI MATHEW

1st YEAR MSc NURSING

OBSTETRICS AND GYNACOLOGICAL NURSING

HARSHA COLLEGE OF NURSING

HARSHA HOSPITAL CAMPUS

NH-4, NELAMANGALA BYE PASS

BANGALORE, KARNATAKA

2010-2011

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF

SUBJECTS FOR DISSERTATION

| | |Ms. TEENA RANI MATHEW |

|1 |NAME OF THE CANDIDATE AND ADDRESS |1ST YEAR M.SC. NURSING, |

| | |HARSHA COLLEGE OF NURSING, |

| | |NELAMANGALA, |

| | |BANGALORE. |

|2 | |HARSHA COLLEGE OF NURSING, |

| |NAME OF THE INSTITUTION |NELAMANGALA, |

| | |BANGALORE |

| | |1st YEAR M.Sc NURSING |

|3 |COURSE OF THE STUDY AND SUBJECT |OBSTETRICS AND GYNACOLOGICAL NURSING |

|4 |DATE OF ADMISSION TO COURSE |05-09-2010 |

|5 |“A STUDY TO CORRELATE MATERNAL HEALTH STATUS WITH NEWBORN CHARECTERISTICS AMONG (PIH) MOTHERS ADMITTED IN SELECTED HOSPITALS |

| |IN BANGALAORE” |

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Prevention is better than cure”

In the last ten years, tremendous experience has been made to achieve progress towards “Health for all by 2000 A.D”. Nationwide programme have been launched to reach the goals. Most of these programmes are based on promotion of mother and child health because they are at risk.

In order to improve the health of woman and children the Reproductive and Child Health Programme” (RCH) was officially launched by government if India in October 15, 1997. It aims to enhance the quality and safety of life of girls and women through adoption of a combination of health and non-health strategies. It lays emphasis on the need for better varies widely available maternal health services, educating the woman and effective measures aimed at improving the status of women.

The hypertensive disorders of pregnancy and their complications are the major causes of maternal morbidity in the developed world and the third most common causes of maternal mortality in the world. Every year, half a million women die in pregnancy and child birth. The major obstetric causes are haemorrhage, sepsis, hypertensive disorders of pregnancy, obstructed labour and induced abortion.

Pregnancy induced hypertension (PIH) is a syndrome characterised by persistent hypertension with BP. 140/90 mm Hg. After 20 weeks of gestation, with protenuria and oedema (Dutta, 1998), pregnancy induced hypertension manifested in three ways: 1. Hypertension 2. Pre-eclampsia and 3. Eclampsia. Hypertension, the blood pressure of 140/90 mm Hg or higher or with a systolic increase of 30 mm Hg or a diastolic increase of 15 mm Hg. Above baseline values on at least two occasions six hour apart. Pre-eclampsia is diagnosed when hypertension is accompanied by proteinuria and / or edema after the 20th week of gestation. Proteinuria is diagnosed by the presence of 300 mg of protein in 24 hour urine collection or a protien presentation of 1g/ L in at least two random samples of urine. Oedema associated with pre-eclampsia involves swelling of the face and hands and is present in the morning upon getting out of bed. Eclampia is the complication of pre-eclampsia which is accompanied by seizures. Eclampsia is usually preventable and “probably occurs in one out of every 1000 to 1500 deliveries.”

The incidence of pre-eclampsia in hospital practice varies widely from 5 to 15% (Dutta 1998). Pre-eclampsia occurs in 5 to 7% of pregnancies superimposed HELLP (Haemolysis, Elevated Liver Enzymes and: Low Platelet count) Syndrome develops in 4 to 12% of women with pre-eclampsia or eclampsia.

A survey of 22,774 consecutive births in hospital Zaria, Northern Nigeria which showed an overall incidence of pre-eclampsia of 12% in primi parous women of all age groups, and of 5% in multi-para of all ages. For the first group, the incidence of eclampsia was 7% and for the second group, .4%.

Hypertensive disorders complicating pregnancy PIH are common and constitute a leading cause of maternal, foetal and neonatal mortality and hence attempt to prevent them appears to be justified. Primary prevention is only possible by avoiding pregnancy. Secondary prevention requires identification of patient at risk.

Careful monitoring of the pregnant women is important because prompt therapy can reduce the incidence of eclampsia and other complications of pregnancy induced hypertension.

Recognition and treatment of pre eclampsia have improved and the incidence of eclampsia has dropped during the last 20 years. Eclampsia occurs in women who do not receive pre natal care.

Whether women with pregnancy induced hypertension receives her care in the hospital or at home, it is often a boost to her morale if she is able to participate in providing her own care by having regular check up.

6.1 NEED FOR THE STUDY

“Every problem in human life having a quest for an answer until it is resolved literates a need for study to find the solution to solve the problem”

In India, there was only less number literature available on maternal and new born characteristics. Hence the researcher was motivated to select the problem for investigation. To identify maternal and new born characteristics for the theoretical educational purpose and to reduce mortality and morbidity rates.

A study reveals that Hypertensive disorders are some of the most common complications of pregnancy and they are associated with a significantly a greater risk of maternal and foetal morbidity and mortality though maternal hypertension is present in only 6-8% of pregnancies it is responsible for 22% of all perinatal deaths and 30%maternal deaths. Pregnancy can induce hypertension in a normotensive women and it is also aggravates the magnitude of the disease process in cases of women with chronic hypertension.1

A study was conducted on epidemiological investigation of pregnancy induced hypertension (PIH) in a population of 3.7 millions in China. The incidence of PIH was 9.4%, that of mild, moderate –PIH, pre-eclampsia, eclampsia and chronic hypertension with PIH were 4.7, 2.6, 1.7, 0.2and 0.2% respectively. The maternal and perinatal mortality of PIH groups were significantly higher than the group without PIH. The result reveals that pathogenesis of PIH was positively related to age, primiparity, multiple pregnancy, labour, posture during pregnancy, physical labour intensity, maternal education level, body status, heredity and various complication during pregnancy.2

In a study conducted to assess the effect of pre-eclampsia, the hypertensive disorders of pregnancy, complication almost 10% of all pregnancies with a higher incidence in young. From 1980 to 1985, pre-eclampsia and eclampsia were responsible for 12% of maternal death, women die from abruption of the placenta, disseminated intravascular coagulation, cerebral haemorrhage and acute renal or heart failure.3

A cohort study carried out a case controlled prospective study of 250 cases of hypertension complicating pregnancy(study group) and 400 normal pregnant women(control group) to determined the effect of hypertension on maternal foetal outcome. PIH was present in 96% and cases chronic hypertension in 4% cases, preterm delivery 28.8% labour induction rate 52.8%, caesarean section rate 14.8% still birth 4.8% and overall perinatal mortality rate 14.8% were higher in study group compare to control. In study groups 49% babies required special nursery care compared to control 6.75%.4

A prospective study uncover that the total number of antenatal women with PIH admitted in Govt. Rajaji Hospital in the month of may, June ,July 2000 are 47,54 and (total=146) 45 respectively. Among 146 antenatal women with PIH, 12-had IUD, 7 had stillbirth, 5 had IUGR, with preterm baby delivery.5

In a retrospective study conducted on the selected needs and problems and the effects of individual instruction in self care as nursing intervention in primi gravida with PIH attending MCH clinics conducted by CHAD Hospital, Vellore and to develop a preparation guide for nurses in teaching self care module. A sample of 20 pregnant women with PIH included in the study. It was observed that the B.P has come down to normal range in 85% of the patient and the eclampsia was prevented among these patients. There was no significant increase in the weight of the patient after 10 days of follow up. IUGR, one of the commonest problems of PIH was prevented.6

In a research the investigator assessed the maternal health status of PIH mother in order to identify the characteristics of newborn. If any abnormalities identify in the newborn characteristics further interventions can be planned during antenatal periods in order to prevent problems like low birth weigh, apgar score ( below 7), jaundice , hypo active , cyanosis and congenital anomelies.7

Safe child birth is the goal of the RCH programme of the country. This kind of study will promote safe delivery. NRHM scheme not only reduce newborn mortality and morbidity but also support the study of identify high risk newborn.8

Early detection of disease and limitation of disability is a goal of today’s health care. This study focuses towards early detection of maternal health status and identifies the newborn characteristics.9

Identifying high risk newborn will help the nurses in labour room to take additional precaution in advanced safe guard the baby. And refer baby for supportive care. By doing the study maternal health satus can be identified and recommended for compositional delivery.10

6.2 REVIEW OF LITERATURE

The review of literature entails systematic identification, location, scrutiny and summary of the written material that contain information relevant to the problem under study. An extensive review of literature relevant to the research topic was done to gain insight and to collect maximum information for laying the foundation of the study.

The purpose of the review of literature is to obtain comprehensive relationship between the maternal characteristics and effects of foetal outcome towards the promotion of child survival and safe motherhood.

The review of literature in the study will be organized as follows

1. Review of literature related to maternal characteristics

2. Review of literature related to new born characteristics

3. Review of literature related to epidemiology of maternal and new born

health condition

A double blind study in 200 subjects was conducted to know the predictive value of microalbuminuria in predicting possibilities of development of pregnancy induced hypertension / pre-eclampsia / transient hypertension, Out of 170 subjects who went to term and in which outcome could be, known 38 (22.35%) developed hypertensive disorders (PIH, Pre-eclampsia, Transient Hypertension). Of these 38 women, 21 (12.30%) had PIH, 9 (5.20%) pre-eclampsia and 8 (4.71%) developed transient hypertension. At 16.22 weeks, 5.89% were microalbuminuria positive 60% of them and out of microalbuminuria negative, 20% developed hypertensive disorders. By 29-34 weeks of gestation, 97.06% were microalbuminura positive, 22.5% of them and 20% of microalbuminuria negative also developed hypertensive disorders by term.11

A cohort study reviewed the records of 561 women with multiple pregnancies delivered consecutively at Meckey memorial hospital retrospectively. 13 mild cases and 39 severe cases of pre-eclampsia in multiple pregnancies were compared with 52 control cases of multiple pregnancies without pre-eclampsia, but matched for maternal age and parity. The incidence of pre-eclampsia in multiple pregnancies was 9.3% compared with 1.8% in singleton pregnancies. In primiparas with multiple pregnancies, the incidence of pre-eclampsia was 12.2% compared with 6.2% in multiparas. The pre-eclamptic group had a significantly higher rate of caesarean section compared with a control group, with prolonged labour and foetal distress were two main reasons for this difference. Severe pre-eclamptic patients had babies with significantly lower mean birth weights, higher incidence of intra uterine growth retardation and neonatal respiratory distress syndrome compared with those of the control group.12

A cohort study was conducted with the aim of assessing the development of hypertension and its relation to renal function 10 years after pregnancy complicated by pre-eclampsia and pregnancy induced hypertension. Women with pre-eclampsia (n-47), pregnancy induced hypertension (n-45) of normotensive (n-46) during 1998 were reviewed at king hussaien medical centre, amman, joprdan, for the development of hypertension and renal disorder. Their renal function was reviewed by measuring blood levels of urea, uric acid, creatinine, calcium and albumin. Urine was examined for microalbuminuria, it was concluded that the risk of development of chronic hypertension 10 years after pregnancy complicated by pre-eclampsia and pregnancy induced hypertension is increased and this is closely related to residual renal disorder.13

A prospective study carried out an epidemiological investigation of pregnancy induced hypertension (PIH) in a population of 3.7 millions in china. The incidence of PIH was 9.4% that of mild, moderate –PIH, Pre-eclampsia, eclampsia and chronic hypertension with PIH were 4.7, 2.6, 1.7 and 0.2% respectively. The maternal and prenatal mortality of PIH groups were significantly higher than the group without PIH. The results revealed that the pathogenesis of PIH was positively related to age, primiparity, multiple pregnancy, labour, posture during pregnancy, physical labour intensity, maternal education level, body status, heredity and various complications during pregnancy.14

A study conducted to assess the effect of cigarette smoking on first-to-trimester change in Hb concentration and the presence of pregnancy induced hypertension (PIH). In smokers and non smokers, that mean difference between the first-second-trimester Hb concentrations was 1.5-1.6 and 1.3 g/dl, respectively. The incidence of PIH among smokers and non smokers was 4.0 and 7.5% respectively. The risk of PIH increased with increasing second-trimester Hb.15

A study undertook a retrospective cohort study in Canada with the hypothesis that the risk of PIH lower among pregnancy complicated by placenta praevia compared with pregnancies occurring in women with fundally implanted placentas. Patients with PIH were clinically diagnosed by the presence of elevated BP, proteinuria or oedema. The risk of pregnancy induced hypertension was compared between women diagnosed with placenta previa and these with normally implanted placenta, during the 14 years (1989-1993) 121, 082 singleton pregnancies registered and 416 (0.4%) of which had a confirmed diagnosis of placenta previa. Women with chronic hypertension had a related risk of 1.2 for placenta previa compared with normotensive women. The results from this study clearly shoe a decreased frequency of pregnancy induced hypertension among those pregnancies with placenta previa.16

A correlation study compared the impact of pregnancy induced hypertension (PIH) and chronic hypertension on pregnancy outcome retrospectively data were collected from 109,428 consecutive deliveries from 1982-1987. It was found that among 109,428 women who delivered during the study period, 8019 (7.3%) were hypertensive. The hypertensive group included 5971 (74.5%) with PIH and 2048 (25.5%) with CHH. Hypertension was associated with a significantly higher risk for adverse pregnancy outcome. Compared with PIH, CHH was more likely to result in adverse outcome prematurity and intra uterine growth retardation. Chronic hypertension was associated with a 184g reduction in birth weight compared with 168g reduction in PIH. Mothers with CIH received public assistance, and have no prenatal care. In the study population, hypertension during pregnancy was associated with significant, increased morbidity and mortality rates. Women with chronic hypertension are at greater risk for adverse outcome than those with pregnancy induced hypertension.17

A prospective study was performed at L.T.M.G Hospital; Mumbai to assess the role of low dose aspirin therapy in the prevention of pregnancy induced hypertension. The results showed that there was a significantly decrease in the incidence of severe PIH in the aspirin treated group as compared to the control group. Careful examination of the neonates revealed no bleeding tendencies and any congenital anomalies.18

A prospective cohort study was done to determine the roll over test (ROT) performance in predicting pregnancy induced hypertension in primigravidae aged 15-29 years in a public primary care services. He enrolled 369 consecutive and initially normotensive primigravidae. The ROT was applied within 28-32 weeks of pregnancy. PIH was defined as diastolic blood pressure (SBP) 90 mm Hg or systolic Bp above 140 mm Hg, or a rise in DBP 15mm Hg or a rise in SBP 30 mm Hg. The ROT prognostic properties were calculated, and a receiver operating characteristic curve was obstructed. The results showed that 93% positive and negative predictive values were respectively 23% and 92% for a PIH cumulative incidence or 9.5% with other cut off points, the curve showed a poor discriminatory value of the test. It was concluded that the ROT was not successful for predicting PIH in a primary prenatal care setting.19

In a cross sectional study carried out with aim of measuring maternal mortality rate and to find out the medical causes of maternal death and behavioural factors associated with them. Maternal mortality ratio was estimated to be 275 per one lakh live births (298 rural and 82 urban). Major causes of death were sepsis (30%), haemorrhage (21%), abortion (5%), Eclampsia (3%) and Obstructed Labour (3%). 29% deaths occurred at home and 26% on the way to hospital. Out of 59% cases who could avail medical consultation, 61% arranged it within five hours after onset of symptoms and 78% availed two, 21% three and 11% four consultations.20

A prospective randomised clinical study done in 50 primi or multi gravida with history of essential hypertension or pregnancy induced hypertension (PIH) carried out between 28-39 weeks of pregnancy. The study group comprised of 25 women who received 50 mg Aspirin daily from the day of positive ROT till 37 weeks of pregnancy. Other 25 women served as control. The incidence of PIH in study and control group was 4% Vs 28% and that of pre-term birth was 4% Vs 24%. The mean birth weight of new borne in the two groups was 3.04+/-.38 Kg and 2.71+/-.48 Kg respectively. All these difference were statistically significant. No adverse maternal and neonatal complications due to Aspirin was observed.21

In a study to assess the neonatal developmental status, its causes of death and their possible correlation in women complicated with pregnancy induced hypertension. 46 Autopsies of neonatal death at term with PIH and their clinical data were collected. The developmental status was evaluated by body weight, body length and the weight of lungs, kidneys, liver and brain. The causes of death were reviewed by the clinic pathologic findings. The neonatal developmental features for mild PIH in term pregnancy approached to the normal level of 37-38 weeks of gestation. In the infants, with moderate and severe PIH, the body weight, the weight of lungs and liver are significantly decreased in comparison with those of the mild PIH, respectively while the weights of kidneys and brain were not significantly decreased. The cause of death showed that pulmonary hypoplasia accounted for 23.9% primary pulmonary atelectasis 10.9% pulmonary hyaline membrane disease 21.7% massive pulmonary haemorrhage 13%, the meconium aspiration 19.6% and other 10.9%. It was concluded that the PIH syndrome had retarded the process of foetal growth and development and associated with severity of PIH, mostly involving the lung and the liver. The pulmonary hypoplasia and immaturity were the primary causes of neonatal death in PIH women.22

A research studied 145 cases receiving Nifedipine and low dose MgSO4 in MGIMS, SEWAGRAM. The study revealed distinct relation between basal BP and the range of fall of BP after medication. Higher the B.P, more is the fall. Mean fall of 25.37/18.12mm of Hg of systolic and diastolic BP was recorded. Combination was found effective. None required induction before term due to PIH. There was no side effect in mother and foetus, there was decreased maternal morbidity and perinatal mortality.23

6.3 STATEMENT OF THE PROBLEM

A study to correlate the maternal health status with new born characteristics among (PIH) mothers admitted in selected hospitals in Bangalore.

6.4 OBJECTIVES OF THE STUDY

1. To identify the maternal health status of PIH mothers

2. To identify the characteristics of new born

3. To correlate the maternal health status with new born characteristics.

4. To associate the maternal health status of PIH mothers with selected demographic variables of the new born

5. To associate the new born characteristics with selected variables of PIH mothers.

6.5 OPERATIONAL DEFINITIONS

Correlate : In this study, it refers to obtaining the relation between the maternal health status and the new born characteristics

Maternal Health Status : In this study, it refers to the present health condition of any mother admitted for delivery and who is diagnosed to have hypertension and getting treatment for PIH.

New Born Characteristics : It refers to health condition of baby born to PIH mothers in terms of its condition immediately after birth, gestational age, Apgar Score at 5minutes, Birth weight, Length of the baby, Head circumference, Oxygen Saturation, Congenital anomalies, Umbilical cord Vein/ artery, Cyanosis

PIH : It is defined as the hypertension that develops as a direct result of pregnancy.

6.6 ASSUMPTIONS

The maternal health status may influence the new born characteristics.

6.7 HYPOTHESIS

1. There is a significant correlation between maternal health status and new born characteristics

2. There is a significant association between maternal health status and selected demographic variables of the mother

3. There is a significant association between the new born characteristics and selected demographic variables of the mother

6.8VARIABLES OF THE RESEARCH

Independent Variable : Health status of the mother

Dependent Variable : Characteristics of the new born

6.9 DELIMITATIONS OF THE STUDY

➢ The study is limited to PIH mothers who are admitted in the selected hospitals.

➢ The study is limited to mothers who are admitted in the hospital during the time period of data collection.

➢ The study is limited to mothers who are willing to participate in the study.

➢ The study is limited to mothers who can actively communicate.

7.0 MATERIALS AND METHODS

Methodology helps the researcher to project a blue print of research undertaken. This includes a series of steps from problem identification to the data collection

7.1 SOURCES OF DATA

The data will be collected from the PIH mothers admitted in the selected hospitals during the time period of data collection.

➢ RESEARCH APPROACH

The research approach for the present study is a descriptive research approach.

➢ RESEARCH DESIGN

The research design adopted for the study is a descriptive correlation design.

➢ SETTING OF THE STUDY

The study will be conducted in selected hospitals in Bangalore.

➢ POPULATION

The populatio0n in the study consists of admitted PIH mothers and their newborns.

➢ SAMPLE SIZE

The sample size consists of 50 samples.

➢ SAMPLING TECHNIQUE

Non probability sampling technique will used in the present study.

➢ SAMPLING CRITERIA

Inclusion Criteria

1. Mothers who are admitted with the signs of PIH.

2. Both the primi and multi para women who admitted with labour pain.

3. Mothers who are admitted for normal delivery or caesarean section.

4. Mothers who are able to understand and communicate in Kannada or English.

Exclusion Criteria

1. Mothers who were not willing to take part in the study.

2. Mothers with gestational diabetes mellitus.

3. Mothers with health problems like renal and cardiac diseases.

4. Mothers with local or systemic infection.

7.2 METHODS OF DATA COLLECTION

TOOL FOR DATA COLLECTION

The tool for the proposed study is a self administered questionnaire which would be developed by the researcher with the help of extensive literature and expert’s opinion.

PROCEDURE FOR DATA COLLECTION

The plan of data collection for the proposed study is as follows.

• Permission will be obtained from the hospital authorities and the respondents.

• Setting and validation of the tool.

• Selection of the samples according to the set criteria.

• Collection of data by administering the tool in the selected samples.

METHOD OF DATA ANALYSIS AND INTERPRETATION

The collected data will be spread into master sheet for easy statistical analysis.

❖ Descriptive Statistics

To describe demographic variables for the mother and the baby for frequency and percentage.

❖ Inferential Statistics

1. Chi square test to determine the association between the selected demographic variables and the knowledge level of educators regarding the importance of play activities in all-round development of young children.

2. Karl Pearson correlation co-efficient formula to determine the Correlation between the knowledge and attitude of educators

DURATION OF THE STUDY

The research is intended to complete within an time frame of 4 weeks.

7.3 Does the study require any investigation or interventions to be conducted on patients or other human or animal?

No.

7.4 Has the ethical clearance been obtained from your institution?

Yes. The ethical clearance will be obtained from the research committee of Harsha College of Nursing, Bangalore.

The informed consent will be obtained from the samples for their willingness to participate in the study.

Consent will be obtained from the management, Nursing Superintendent, ward staff nurse where the study is going to be conducted.

Priority will be given to Patients’ privacy, self esteem and confidentiality throughout the study.

LIST OF REFERENCE

1. Morning%20Topics/Obstetrics/Stillbirth.pdf

2. Emmanuelle Baulon, William D Fraser, Bruno Piedboeuf, Pregnancy-induced hypertension and infant growth at 28 and 42 days postpartum, BMC Pregnancy Childbirth. 2005; 5: 10.

3. ubccriticalcaremedicine.ca/.../Acute%20Complications%20of%20Preeclampsia%20(Apr-30-09).p... 

4. Yadav S, Saxena U, Yadav R, Gupta S, Hypertensive disorders of pregnancy and maternal and foetal outcome: a case controlled study, J Indian Med Assoc. 1997 Oct;95(10):548-51

5. ncbi.nlm.pubmed/9567600

6. id36.html

7. ninds. › Disorders A - Z › Cerebral Palsy

8. pdf/NCHRC-Publications/HandbookForCHM-Eng.doc

9. n.wiki/Down_syndrome

10. fdsys/.../CFR-2010-title29-vol8-subtitleB.pdf - United States

11. Chhabra S; Gandhi D, Prediction of pregnancy induced hypertension/preeclampsia by detecting microalbuminuria, The Journal of Obstetrics and Gynecology of India. 2002 Jan-Feb; 52(1): 56-60

12. perinatalpriorities.co.za/system/files/Proceedings%202004.doc

13. hcmv.vn.moodle/file.php/1/.../preeclampsia-pathology.pdf

14. lshtm.academia.edu/.../Manifestations_of_Metabolic_Syndrome_After_Hypertensive_Pregnancy

15. Rasmussen S, Oian P, Smoking, hemoglobin concentration and pregnancy-induced hypertension, Gynecol Obstet Invest. 1998;46(4):225-31, PMID 9813439. Available on web: ncbi.nlm.pubmed/9813439

16. en.wiki/Pre-eclampsia 

17. .../Effect_of_pregnancyinduced_and_chronic_hypertension_on_pregnancy_outcome 

18. ww.bama/files/01.pdf

19. Marcopito LF, Roll-over test in primigravidae attending a public primary care service, Sao Paulo Med J. 1997 Sep-Oct;115(5):1533-6, PMID:9609071 Available on ncbi.nlm.pubmed/9609071

20. .in/showbackissue.asp?issn=0970-0218;year=1997;

21. fk.uwks.ac.id/.../OCR_BlueprintsSeries_Obstetrics&Gynecology3ed2003Callahan.txt

22. Z I Kostina, N A Brazhenko, E V Gerasimova, Iu E Godes, O V Kol'nikova, N N Loshchinskaia, Causesn of fatal outcomes in patients with sarcoidosis, Probl Tuberk. 1999 ;(5):34-6  10565216

23. persmin.nic.in/civillist/AppendixQryCL.asp?fmAppNum=H

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