Nonlinear analysis of heart rhythm in preeclampsia: a route for translational clinical applications in neuroinflammation

Preeclampsia is a pregnancy-specific condition which gets detected through hypertension and excessive protein excretion in urine. While preeclampsia used to be regarded as a self-limiting maternal condition which resolved with the delivery of the placenta, it is nowadays considered a complex and multifactorial disease that affects the offspring. Unfortunately, the etiology and pathophysiology of this multifaceted disorder remain elusive. Recent findings have confirmed that an altered maternal autonomic function may play a vital role in developing preeclampsia in conjunction with an imbalanced maternal immune system. Additionally, further evidence supports the crucial role of an exacerbated immune response driven by a non-infectious trigger during preeclampsia. Therefore, as a sterile inflammation, the elucidation of the neuroinflammatory mechanisms of preeclampsia warrants obtaining relevant knowledge suitable for translational clinical applications.Heart rate variability (HRV) is an affordable and non-invasive method for indirectly assessing the autonomic nervous system and the cholinergic anti-inflammatory pathway (CAP). Notably, the nonlinear analysis of HRV offers novel indexes to explore the neuroimmune interactions in diverse preclinical and clinical settings of inflammation. Given that the dynamics of HRV is nonlinear in health, we hypothesized that a neuroinflammatory condition in preeclampsia might be associated with changes in nonlinear features of maternal and fetal HRV. Thus, the present review aims to present evidence of the potential changes in maternal-fetal HRV associated with neuroinflammatory modifications in preeclamptic women. We considered that there is still a need for assessing the nonlinear features of maternal and fetal HRV as complementary biomarkers of inflammation in this population in future studies, being a potential route for translational clinical applications.

Infective endocarditis in pregnancy requiring simultaneous emergent caesarean section and mitral valve replacement: a case report

Background Although infective endocarditis (IE) in pregnancy is rare, maternal and foetal mortality rates are very high. We herein report the successful treatment of a case of IE with simultaneous emergent caesarean section and mitral valve replacement performed at 27 weeks of gestation. Case summary A 29-year-old woman at 27 weeks of gestation was referred for congestive heart failure (HF) due to infective endocarditis (IE) with large mobile vegetations and overt disruption of the mitral valve. We held a multi-disciplinary conference and decided to perform mitral valve replacement immediately after caesarean section because of the high risk of embolism and sepsis, worsening and unstable haemodynamics, and sufficient foetal maturity for delivery. Although coronary artery embolization and asymptomatic multiple cerebral infarctions were observed, her post-operative course was uneventful. Ultimately, the patient was discharged 29 days after surgery. The neonate was treated in the NICU until the expected delivery date and was discharged home on Day 95 of life. Discussion Difficulties are associated with the selection of an operative plan and its timing for IE during pregnancy. Heart failure due to IE requires urgent surgery when medical treatment cannot stabilize the patient. However, cardiopulmonary bypass and medicine for pregnant women adversely affect the foetus. Therefore, the timing of surgery and delivery needs to be selected by a multi-disciplinary team and in consideration of the maternal condition and foetal maturity.

Clinical presentation and maternal-fetal outcomes of mirror syndrome: A case series of 10 affected pregnancies

Background Mirror Syndrome, also known as Ballantyne syndrome, is a rare condition with fewer than 120 cases described in the literature. A simultaneous edematous state of the mother, fetus and placenta is pathognomonic, with the maternal condition frequently presenting with signs and symptoms similar to that of preeclampsia. Objective Our aim was to add to the international body of literature through identification of all cases of Mirror Syndrome at two Canadian tertiary obstetric centres and characterize the maternal presentation, laboratory findings, and perinatal outcomes. Methodology We performed a retrospective chart review of all cases of fetal hydrops from two tertiary centres in Winnipeg (Manitoba, Canada) between 2000 and 2019. There were 276 cases of fetal hydrops during this period, of which 10 cases satisfied the diagnostic criteria for Mirror Syndrome where maternal and perinatal outcomes were analysed. Results The median gestational age at diagnosis with Mirror Syndrome was 23weeks and 3 days of gestation and at birth was 25 weeks and 0 days of gestation. The majority of women were multiparous (80%) and had elevated maternal body mass index (median 33 kg/m2). The most common maternal clinical findings included weight gain (100%) and hypertension (90%). The most common laboratory findings included low hematocrit (100%), hypoalbuminemia (80%), anemia (70%) and hyperuricemia (70%). Structural anomalies were observed in 50% of cases, over half of the fetuses were stillborn (66.7%) and one quarter of pregnancies resulted in neonatal deaths (25%). The median time until maternal improvement of Mirror Syndrome was 2 days postpartum. Conclusion Mirror Syndrome affected 3.6% of all cases of fetal hydrops in our cohort, and showed associations with multiparity, elevated BMI, hemodilution, hypoalbuminemia, anemia and hyperuricemia. Delivery is frequently required for fetal and/or maternal indications and symptoms usually improved rapidly after delivery.

Still Birth classification: Application of Relevant Condition at Death (ReCoDe) classification system in a tertiary care hospital of Pakistan

Objectives: To determine the cause of stillbirth after application of relevant condition at death (ReCoDe) classification system. Methods: This was a retrospective cross sectional study of 207 women diagnosed with stillbirth after 24 completed weeks of pregnancy at the Aga Khan University Hospital (AKUH), Karachi between 1st January 2015 and 31st December 2019. The primary objective was to find the cause of stillbirth according to the new classification of relevant condition at death (ReCoDe). Results: There were a total of 32413 live births and 207 stillbirths during the study period thus stillbirth rate of 6 per 1000 live births. In this study, 80% of women were in the age group of 20-35 years, 16% had advanced maternal age while 3.8% of women accounted for less than 20 years. Among the maternal factors; 54.5% cases were booked and the remaining were were un-booked cases. Pre-eclampsia was the most common associated maternal condition (14.9%). Fetal cause accounted for 34.7% of stillbirths and the fetal growth restriction (FGR) was the most common; 23.6%. After application of ReCoDe classification, in 81% of stillbirth cases associated condition were found and only 18.8% of cases were categorized unexplained. Conclusion: Application of ReCoDe classification is easy to understand and applicable, especially in low resource settings with associated causes identified in vast majority of cases. doi: https://doi.org/10.12669/pjms.38.1.4470 How to cite this:Kashif U, Bhamani S, Patel A, Shamsul Islam Z. Still Birth classification: Application of Relevant Condition at Death (ReCoDe) classification system in a tertiary care hospital of Pakistan. Pak J Med Sci. 2022;38(1):133-137. doi: https://doi.org/10.12669/pjms.38.1.4470 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

PEMBERIAN SARI DAPAT MENINGKATKAN KADAR HB PADA IBU

Background Anemia in pregnancy is a maternal condition with hemoglobin values below 11 g/dl in the first and third trimesters, or hemoglobin levels less than 10 g/dl in the second trimester. Data on visits by pregnant women at Independent Practice Midwife Betty, Amd. Keb Based on a pre-survey conducted at BPS Okdiah Betty Amd. Keb Kec. Trimurjo Kab. Central Lampung, by looking at the visit data of pregnant women TM I-TM II for the last 3 months as many as 67 people, with the results of HB 8.0-10.0 examination with mild anemia category as many as 26 pregnant women (38.8%), and HB 10.1-13.0 with normal category as many as 14 people (20.9%), from the overall data it can be seen if there are 27 people (40.2 %) who did not do Hb checks during pregnancy. The purpose of this study was to determine the effect of giving date palm juice on increasing HB levels in pregnant women in the Independent Practice of Midwife Okdiah Betty, Amd. Keb Kec. Trimurjo Kab. Lampung in the middle of 2021..Methods This type of research is quantitative, the research design is pre-experimental method with a one group pretest - posttest design approach. Data on visits by pregnant women at Independent Practice Midwife Betty, Amd. Kec. Trimurjo Kab. Central Lampung, obtained the number of pregnant women TM I and III during the last 3 months as many as 67 people, purposive sampling technique., univariate and bivariate data analysis using t-testResult The average HB level in pregnant women before being given date palm juice with a mean of 10, 270gr/dl, a min value of 9.3gr/dl and a max value of 10.8gr/dl. The average Hb level at week 7 with a mean of 10.480gr/dl, a min value of 9.7gr/dl and a max value of 11.0gr/dl, and a Hb at week 14 with a mean of 10,807gr/dl, a min value of 10.2gr/dl and a max 11.2gr/dl. Conclusion there is an effect of giving date palm juice to increase Hb levels in pregnant women Suggestion Conducting outreach to the community as a form of promotional and preventive efforts to overcome and minimize the incidence of anemia. Keywords: Dates Extract, Hb Level, Pregnant Women ABSTRAK Latar Belakang Anemia dalam kehamilan merupakan suatu kondisi ibu dengan kadar nilai hemoglobin di bawah 11 gr/dl pada trimester satu dan tiga, atau kadar hemoglobin kurang dari 10 gr/dl pada trimester dua. Data Kunjungan ibu hamil di Praktik Mandiri bidanokdiah Betty, Amd. Keb Berdasarkan prasurvey yang dilakukan di BPS Okdiah Betty Amd.Keb Kec.Trimurjo Kab.Lampung Tengah, dengan melihat data kunjungan ibu hamil TM I-TM II selama 3 bulan terakhir sebanyak 67 orang,dengan hasil pemeriksaan HB 8,0-10,0 dengan kategori anemia ringan sebanyak 26 ibu hamil (38,8%),dan HB 10,1-13,0 dengan kategori normal sebanyak 14 orang (20,9%),dari data keseluruhan dapat diketahui jika terdapat 27 orang (40,2%) yang tidak melakukan pemeriksaan Hb saat hamil. Tujuan penlitian ini diketahuipengaruh pemberian sari kurma terhadap peningkatan kadar HB pada ibu hamildi Praktik Mandiri Bidan Okdiah Betty, Amd. Keb Kec.Trimurjo Kab.Lampung tengahtahun 2021..Metode Jenis penelitian kuantitatif, desain penelitian metode Pra Eksperimental dengan pendekatan one group pretest – posttest design. Data Kunjungan ibu hamil di Praktik Mandiri bidanokdiah Betty, Amd. Kec.Trimurjo Kab.Lampung Tengah, didapat jumlah ibu hamil TM I dan III selama 3 bulan terakhir sebanyak 67 orang, teknikpurposive sampling., analisa data univariat dan bivariat menggunakan t-testHasil Rata-rata kadar HB pada ibu hamilsebelum diberi sari kurma dengan Mean10, 270gr/dlnilai min 9,3gr/dl dan nilai max 10,8gr/dl.Rata-rata kadar Hb minggu ke 7 dengan Mean10,480gr/dlnilai min 9,7gr/dl dan nilai max 11,0gr/dl, dan Hb minggu ke 14 dengan Mean10,807gr/dlnilai min 10,2gr/dl dan nilai max 11,2gr/dl. Kesimpulan terdapat pengaruh pemberian sari kurma terhadap peningkatan kadar Hb pada ibuSaran Melakukan penyuluhan kepada masyarakat sebagai bentuk upaya promosi dan preventif untuk menanggulangi dan meminimalkan angka kejadian anemia. Kata Kunci : Sari Kurma, Kadar Hb, Ibu Hamil

World Health Organization (WHO) modified partogram fill audit at Matam Communal Medical Center

Objective: To assess the quality of filling of the modified partograph from WHO at CMC Matam. Methods: This was a retrospective descriptive study by clinical audit (AC), carried out on a sample of obstetric records of parturients who gave birth in the maternity unit of the CMC of Matam from January 1 to December 31, 2020, it consisted of a evaluation of the use of the partograph using an audit sheet prepared for this purpose. The random sampling with one step in ten 1/10 was used for the sampling. The parameters related to the performance of the partograph, the progress of labor (hourly rate, fetal state, materno-fetal outcome.) Were evaluated, the traceability of events related to maternal condition, acts and treatments carried out during labor as well as immediate postpartum surveillance data. Data was collected and analyzed using SPSS 20.0 and MS Excel 2010 software. Results: We retained 470 files. The sample represented 87.45% of all parturients whose monitoring required the opening of a partograph during the study period; its behavior met the standard in more than 87, 41% of cases; The hourly rhythm, and the precise moment of each act were notified and respected in 66.60% of the cases, the progress of the work was correctly notified and respected in 28.72% of the cases; the presentation level and the fetal heart rate were reported and respected in 28.78% and 85.96% respectively; the method of entering into labor was notified and complied with in 95.7% of cases. Conclusion: The modified WHO partograph has some shortcomings in relation to its performance, which can be corrected by supportive supervision.

Social information use for spatial decision in Zootoca vivipara

Movements of individuals are conditioned by information acquisition coming from either personal or social sources. Yet, little is known about the processes used by individuals to make movement decisions when facing multiple sources of social information simultaneously. This study aimed to test experimentally how social information from multiple sources is used to make movement decisions, and whether a contrast in this information allows individuals to orientate in space. We used common lizards (Zootoca vivipara) in a replicated experimental setting: one focal individual received information from two other individuals coming from peripheral environments, before being given the opportunity to relocate in one or another of the peripheral environments. Our analyses revealed that the behavior of informants, their mothers' morphology, as well as the quality of informants' environment, affected movement decisions: the probability to relocate from the focal area increased when informants displayed traits associated with low resources (no food intake, poor maternal condition) or high competition (high activity). The physical condition of individuals also mediated the use of social information about food intake, with a match between resource availability in informants and personal condition. Conversely, spatial orientation was not affected by the contrast of phenotype between informants nor by spatial variability in resource availability. This study highlights that multiple social information sources can be used for movement decisions, likely because these information sources reflect the quality of the surrounding environment (e.g., competition level or resources availability). It also emphasizes that social information use for movement is conditioned by individual phenotype.

Fatal Association of Mirror and Eisenmenger Syndrome during the COVID-19 Pandemic

Mirror syndrome (MS) or Ballantyne’s syndrome is a rare maternal condition that can be life-threatening for both mother and fetus. The condition is characterized by maternal signs and symptoms similar to those seen in preeclampsia in the setting of fetal hydrops. Despite recent advances in the field of maternal-fetal medicine, the etiopathogenesis of MS remains elusive. For patients and doctors, the COVID-19 pandemic has become an extra hurdle to overcome. The following case illustrates how patients’ non-compliance associated with mirror syndrome and SARS-CoV-2 infection led to the tragic end of a 19-year-old patient. Therefore, knowledge of the signs and symptoms of mirror syndrome should always be part of the armamentarium of every obstetrician.

Obstetric and perinatal aspects of multiple pregnancy

The article presents epidemiological data, modern terminology, features of the course of gestation, as well as obstetric and perinatal outcomes of childbirth in women with multiple pregnancy. The relevance of study this problem is due to the fact that the course of multiple pregnancy in almost all patients is accompanied by various complications, and their prognosis and prevention are of paramount importance. Despite the attention paid to multiple pregnancy, the complication rate remains high. Their treatment should be carried out in III level of perinatal care facilities. Attention is focused on the features of childbirth of pregnant women in accordance with the procedure for providing medical care to women with multiple pregnancies. An important issue remains to determine the time and tactic of delivery in multiple pregnancy. The choice of childbirth method depends on the obstetric anamnesis, gestational age, position and presentation of fetuses, estimated weight and size of fetuses, chorionicity, fetal and maternal condition, and the presence/absence of indications for caesarean section also matters. The optimal delivery time for uncomplicated twins is 37 weeks of pregnancy (monochorionic diamniotic twins — 36–37 weeks, dichorionic — 37–38 weeks), since in this period of pregnancy, the risks of antenatal fetal death and early neonatal death are minimal. Delivery of women with monochorionic monoamniotic twins is performed at the full 32 weeks of pregnancy by caesarean section. Among other indications for caesarean section are triplets and a larger number of fetuses, as well as conjoined twins, transverse or breech presentation of the first fetus, twins in combination with a scar on the uterus, an unsuccessful attempt of external-internal rotation of the second fetus in a transverse position after the birth of the first fetus, and others. An analysis of domestic and foreign publications was carried out in the article, which indicates the need for in-depth research in this direction, namely the elucidation of new pathogenetic links in multiple pregnancies, depending on the type of placentation, the search for new ways of management and the development of diagnostic criteria for the childbirth of this contingent of women.

Obstetric Patients Characteristics Labor in Dr. M. Djamil General Hospital Padang December 2019-February 2020 Period

Introduction : Maternal death in Indonesia was still high therefore efforts was needed to suppress this maternal mortality rate.Objective : To determine risk factors of maternal mortality and morbidity.Methods : This was a descriptive study using cross sectional design with study sample including all laboring mother in Obstetric Department of Dr. M. Djamil General Hospital Padang from December 2019 to February 2020 period. Sample were collected using total sampling technique with total of 119 samples included in this study. Data was collected from patients’ medical record, including age, gestational age, gravidity, history of labor, diagnosis, method of delivery, maternal condition, and neonates condition at birth.Results : Mean of age was 30.6 ± 5.4 years, mean of maternal age was 36.1 ± 3.8 weeks, about 77 patients (64.7%) were multipara, 49 patients (41.2%) had history of spontaneous labor, most frequent diagnosis were severe preeclampsia in 20 patients (16.8%), impending eclampsia in 9 patients (7.6%), history of cesarean section 8 patients (6.7%), twin pregnancy 7 patients (5.9%), and pregnancy with positive HBsAg in 7 patients (5,9%). Total 32 patients (26.9%) were referred patients from various general hospital in West Sumatra. A total of 105 patients (88.2%) had cesarean section. Mean birth weight of neonates was 2363.4 ± 964.7 gram, mean birth length was 44.1 ± 5.9 cm, mean apgar score in the first 1 minutes was 5,9 ± 2,2, and mean apgar score in the first 5 minutes 7.4 ± 2.3. During 3 months of study, total maternal deaths were found in 3 patients due to complicated eclampsia, severe preeclampsia, and maternal congenital heart disease, while neonatal death was found in 8 babies, where 6 (75%) had IUFD, and 2 (25%) had very low birth weight dying in the first 24 hours of life due to respiratory failure.Conclusion : Most of labored mother were multiparas with history of spontaneous birth, and mostly diagnosed as severe preeclampsia with method of delivery of cesarean section, and maternal and neonatal death were still occurred.Keywords: Death, Maternal, Neonatal