Case Report: Anaesthetic Management of Placenta Percreta

Background: The placenta is a complicated organ and is partially understood. It is the essential part for physiological changes leading to a successful pregnancy. Placenta percreta is the most severe and least common form of placenta accreta in which villi penetrate the entire myometrial thickness and reach or traverse the serosa to encroach adjacent organs. Patients with placenta percreta are at a greater risk of life-threatening perioperative bleeding as well as massive and deadly thromboembolic events. Case report: Our patient was a 34-year-old gravida 5female who underwent elective cesarean section at 37 weeks of gestation with a diagnosis of placenta accreta or percreta. Intraoperative findings showed placenta percreta with bladder wall involvement. Hence, hysterectomy was done. Anticipated intraoperative haemorrhage and hemodynamic instability were managed properly. Discussion: Placenta percreta is the most serious among abnormal placentation, sometimes leading to catastrophic blood loss and very high maternal mortality and morbidity up to 10%. The most important risk factor in placenta percreta is placenta previa (low lying placenta) after cesarean delivery. Our patient met all these risk factors. Prenatal diagnosis of an invasive placenta is paramount for reducing maternal morbidity and mortality by implementing a multidisciplinary approach. Keywords: haemorrhage, placenta percreta, hysterectomy, high-risk pregnancy.

Urinary Nephrin and Podocalyxin Levels as Predictors of Pre-eclampsia in High-Risk Pregnant Women

Introduction: Pre-eclampsia (PE) is characterized by new-onset hypertension and proteinuria. Damage of podocyte cells has been reported in pre-eclamptic women, thus podocyte specific proteins such as nephrin and podocalyxin could be useful biomarkers in PE. Aim: To investigate the role of urinary nephrin (u-nephrin) and urinary podocalyxin (u-PDX) levels in predicting PE in women with a high-risk pregnancy. Materials and methods: We included 101 pregnant women in this study and allocated them into three groups: group 1 included pregnant women at high risk of developing PE (n=41), group 2 - pregnant women with PE (n=30), and group 3 was the controls including healthy pregnant women (n=30). The inclusion criteria for women with PE were de novo hypertension >140/90 mm Hg, proteinuria >300 mg/24 hours, and presence of edema after 20 weeks of gestation, while the exclusion criteria were a history of renal diseases and pregnant women younger than 18. Inclusion criteria for the group of women with a high-risk pregnancy was gestational week >15, a history of PE in a previous pregnancy, pre-existing diabetes type 1 or 2, pre-existing hypertension, multiple gestations, prior placental abruption, obesity women, nulliparity, maternal age >35 years, and a family history of PE. The study was conducted from March 2016 to May 2017 in the Medical Faculty at the Institute of Medical and Experimental Biochemistry in Skopje. Urine samples were used to measure the nephrin and podocalyxin levels using immunoenzyme assay, creatinine and microalbumin. Blood samples were collected for biochemical analyses. Results: U-nephrin levels were elevated in 96.7% of women with PE, and 73% of women with a high-risk pregnancy. U-PDX levels were elevated in 63% of the women with PE and 100% of the women with a high-risk pregnancy. U-nephrin and u-PDX levels were significantly increased in women with a high-risk pregnancy and women with PE compared with a control group (p<0.001). A significant difference was found between the subgroups of pregnant women classified according to gestational age in their u-nephrin and u-PDX levels. There was a significant positive correlation between the levels of both markers and glomerular filtration rate, and significant negative correlation between the levels of both markers and gestational age. ROC analysis revealed that the cut-off value of 304.6 ng/ml of u-nephrin had a sensitivity (Se) of 96.7%, specificity (Sp) of 96.7% (for both Se and Sp 95% confidence interval (CI) 82.8-99.9), while the cut-off value of 59.5 ng/ml of u-PDX had a sensitivity of 100% and Sp of 93.3% (Se - 95% CI 88.4-100, Sp - 95% CI 77.9-99.2), in distinguishing women with PE and healthy pregnancies. Both markers showed excellent clinical utility (CUI&ge;0.81), for u-nephrin (CUI+ and CUI&minus; is 0.934), for u-PDX (CUI+ is 0.938; CUI&minus; is 0.933). Conclusions: U-nephrin and U-PDX levels could be useful as predictors of PE in women with a high-risk pregnancy.

Diabetes Mellitus Gestacional com ênfase nas Gestantes de Alto Risco / Gestational Diabetes Mellitus with an emphasis on High-Risk Pregnant Women

Resumo: Considerando o Diabetes Mellitus um problema de saúde pública e sendo um dos principais fatores de morbimortalidade no Brasil, torna-se relevante destacar o aumento de casos ocorridos do DMG em gestantes de alto risco. Esta pesquisa teve por objetivo: investigar o perfil clínico do diabetes mellitus gestacional (DMG) e como o mesmo pode levar a uma gravidez de alto risco, sua associação aos fatores de riscos e suas principais complicações. Quanto à metodologia é exclusivamente de caráter bibliográfico. Foi feita uma pesquisa de revisão bibliográfica, a qual utilizou fontes de internet, onde foram aplicados critérios de inclusão e exclusão, chegando a um total de 12 artigos selecionados. A partir desses artigos, a pesquisa verificou que os fatores de riscos associados ao DMG e suas complicações, fazem correlação com a gravidez de alto risco. Assim, se faz necessário o rastreamento e monitoramento, a prevenção, o diagnóstico e tratamento do DMG tanto para a mãe quanto para o feto. Logo é fundamental a atuação do farmacêutico na equipe multidisciplinar, pois contribui desde a gestão, aquisição até a dispensação eficiente dos medicamentos auxiliando de forma a reduzir os riscos, promovendo atenção, cuidado e uma saúde de qualidade às gestantes. Palavras Chave: Diabetes Mellitus. Diabetes Mellitus Gestacional. Gravidez de Alto Risco. Abstract: Considering Diabetes Mellitus a public health problem and one of the main morbidity and mortality factors in Brazil, it is relevant to highlight the increase in cases of GDM in high-risk pregnant women. This research aimed to: investigate the clinical profile of gestacional diabetes mellitus (GDM) and how it can lead to a high-risk pregnancy, its association with risk factors and its main complications. As for the methodology, it is exclusively bibliographic in nature. A bibliographic review research was carried out, using internet sources, where inclusion and exclusion criteria were applied, reaching a total of 12 selected articles. From these articles, the research found that the risk factors associated with GDM and its complications are correlated with high-risk pregnancy. Thus, it is necessary the tracking and monitoring, prevention, diagnosis and treatment of GDM for both mother and fetus. Therefore, the role of the pharmacist in the multidisciplinary team is essential, as he contributes from the management, acquisition to the efficient dispensing of medicines, helping to reduce risks, promoting attention, care and quality health for pregnant women. Keywords: Diabetes Mellitus. Gestational Diabetes Mellitus. High-risk Pregnancy.

HIGH RISK PREGNANCY DETECTION USING TELEHEALTH-BASED SCREENING

High-risk pregnancy is a pregnancy that is likely to cause harm or complications to the mother and fetus. Given the high rate of disease transmission, the use of telehealth technology can be an effective and efficient way to deal with the spread of the virus. Telehealth is one solution to overcome the problem of access to health, with telehealth it can perform screening to detect high-risk pregnancies early, so that pregnant women can get continuous monitoring. Telehealth can operate as a filter that is able to expand and facilitate access to services, especially in the examination and screening of risks in pregnancy and can apply high risk detection instruments in pregnancy in applications, so as to facilitate decision making. Telehealth can detect high-risk pregnancies early, so that pregnant women can get continuous monitoring. The purpose of this activity is to conduct and determine the effectiveness of telehealth-based high-risk detection in pregnant women. The method of activity is in the form of community service through webinars and screenings which are carried out within 6 months online. The result of the activity is an increase in the knowledge of webinar respondents with an average pre-test value of 120 and post-test 157 out of a total of 200. Based on the results of screening using the SIBIDAN application, from 25 pregnant women in trimesters 1,2, and 3 who became respondents, the results were 52%, low risk group, 32% high risk group, and 16% very high-risk group. Therefore, further assistance, monitoring, and referral are needed to minimize pregnancy complications.

High-risk pregnancy: effectiveness of personalized pregravid preparation and positive perinatal experience

Research objective: to study the possibilities of improving perinatal results by optimizing pergravid preparation in women with high perinatal risk.Materials and methods. The first stage – a cross-sectional study – consisted in determining the vitamin D (VD) status and assessing the course of pregnancy in 459 women in the II and III trimester; the second stage was a randomized controlled study of women with VD deficiency in group IIA (planning stage, 54 women) and IIB (I trimester, 60 women), who received the vitamin and mineral complex (VMC) Pregna-5 with a high calcitriol content and perinatal results were evaluated. VD in the blood was determined by the enzyme-linked immunosorbent assay.Results. VD level was optimal only in 30.7% of pregnant women (group ІА), in 69.3% of women its insufficiency or deficiency was found (group ІB). The frequency of threatened termination (9.9 vs. 45.6%; p < 0.01), preeclampsia (2.0 vs. 11%; p < 0.05), intrauterine growth retardation (7% only in group IIB, p < 0.01) was significantly higher against the background of BD deficiency. Normalization of the VD level (groups IIA and IIB) after VMC administration was observed within 1–3 months. Pregnancy complications value was higher in the group where the VMC was started in the first trimester: early gestosis (15 vs. 28.57%; p < 0.05), the threat of termination (22.2 vs. 36.7%; p < 0.05), bacterial vaginosis (7.4 vs. 31.7%; p < 0.05), placental dysfunction (18.5 vs. 40.0%; p <0.01), placental pathology in group IIB was detected 2–3 times more often. The differences between the preeclampsia (1.9 vs. 6.7%; p > 0.05) and anemia (16.6 vs. 28.3%; p > 0.05) were insignificant. Analysis of the childbirth results showed a significantly higher frequency of cesarean sections in group IIB (38.3 vs. 22.2%; p < 0.05), the average weight of newborns was less (3299.11 ± 128 g vs. 3643.24 ± 136 g; p < 0.01). The most effective was the VMC start at the stage of pregnancy planning (F = 13.35482; p = 0.000016); a significant difference was revealed in the course of pregnancy in the groups where VMC started in the first, second and third trimesters of pregnancy (Q = 4.67, p = 0.00458).Conclusions. Timely donation of VMC with a high content of cholecalciferol in women with high perinatal risk may lead to a positive course of pregnancy. Further research is required to obtain a convincing evidence base.

HUBUNGAN TINGKAT PENGETAHUAN DENGAN PENERAPAN MODEL DETEKSI DINI KEHAMILAN RESIKO TINGGI OLEH KADER POSYANDU DI DESA JATEN, KARANGANYAR

ABSTRAKSasaran pembangunan kesehatan yang akan dicapai pada tahun 2025 adalah meningkatnya derajat kesehatan masyarakat yang salah satunya ditunjukkan oleh menurunnya Angka Kematian Ibu dengan mengenalkan resiko tinggi pada ibu hamil dilakukan dengan skrining/deteksi dini berbagai faktor resiko secara pro aktif terhadap semua ibu hamil. Kader kesehatan memiliki peran yang besar dalam hal deteksi dini risiko tinggi kehamilan dan persalinan yang memerlukan pengetahuan dan penerapan model deteksi. Tujuan penelitian ini adalah Untuk mengetahui Hubungan Tingkat Pengetahuan Dengan Penerapan Model Deteksi Dini Kehamilan Resiko Tinggi Oleh Kader Posyandu Di Desa Jaten, Karanganyar. Metode penelitian observasional analitik dengan pendekatan cross sectional. Populasi dalam penelitian ini adalah 192 orang kader posyandu di desa Jaten, tehnik sampling yang digunakan adalah “Accidental Sampling” dimana yang mengisi kuesioner melalui goegle form sejumlah 54 orang. Hasil penelitian Tingkat Pengetahuan Responden Sebagian besar mempunyai Tingkat Pengetahuan Baik yaitu 42 responden (77,8%), penerapan model deteksi dini kehamilan resiko tinggi oleh kader posyandu sebagian besar responden mempunyai penerapan model deteksi dini yang baik yaitu 41 responden (75,8%), hasil analisis cros tabulasi dengan uji Fisher's Exact Test di dapatkan hasil nya nilai p = 0,001. Kesimpulan : ada hubungan antara tingkat pengetahuan dengan penerapan model deteksi dini kehamilan resiko tinggi oleh kader posyandu desa Jaten, Karanganyar. Kata Kunci : kader, model deteksi, kehamilan resiko tinggiTHE RELATIONSHIP OF KNOWLEDGE LEVEL WITH THE APPLICATION OF HIGH RISK PREGNANCY EARLY DETECTION MODELS BY POSYANDU CADRES IN JATEN VILLAGE, KARANGANYARABSTRACTThe health development target to be achieved in 2025 is to increase the degree of public health, one of which is indicated by a decrease in the Maternal Mortality Rate by introducing high risk to pregnant women through screening/early detection of various risk factors proactively for all pregnant women. Health cadres have a big role in terms of early detection of high risk pregnancy and childbirth which requires knowledge and application of detection models. The purpose of this study was to determine the relationship between the level of knowledge and the application of the early detection model of high risk pregnancy by Posyandu cadres in Jaten Village, Karanganyar. Analytical observational research method with a cross sectional approach. The population in this study were all posyandu cadres in the village of Jaten, the sampling technique used was "Accidental Sampling" as many as 54 people. The results of the study on the Knowledge Level of Respondents Most of the respondents had a good knowledge level, namely 42 respondents (77.8%), the application of the high risk pregnancy early detection model by posyandu cadres, most of the respondents had a good early detection model application, namely 41 respondents (75.8%) , the results of the cross tabulation analysis with the Fisher's Exact Test, the result is the p value = 0.000. Conclusion; there is a relationship between the level of knowledge and the application of the high-risk pregnancy early detection model by posyandu cadres in Jaten village, Karanganyar. Keywords: Cadre, Detection Model, High Risk Pregnant

Ultrasound Pitfalls in a Complex Fetal Cardiac Malformation—Case Report of a New Arteriovenous Central Communication

Cardiac and cardiovascular malformations are of real interest in terms of definition, epidemiology, and means of early diagnosis by imaging. Although ultrasound examination reaches exceptional performance nowadays, unusual pathologies are still exposed to the risk of either incorrect acquired image or misinterpretation by the specialist in a routine scan. Herein, we present a case of a 20-week-old fetus (from an apparently low-risk pregnancy) with complex cardiac and vascular abnormalities, including an arteriovenous malformation along with ventricular septal defect, ductal coarctation of the aorta, aneurysm of a brachiocephalic vein, and dilation of the entire neck and upper mediastinum venous system, and the limitations that were encountered in the process of diagnosis and management of the case.