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Data regarding effects of small-quantity-lipid-based nutrient supplements (SQ-LNS) on maternal serum zinc concentrations (SZC) in pregnancy and lactation are limited.

Cesarean section rates worldwide are rising, driven by medically unnecessary cesarean use. The new World Health Organization Labour Care Guide (LCG) aims to improve the quality of care for women during labor and childbirth. Using the LCG might reduce overuse of cesarean; however, its effects have not been evaluated in randomized trials. We conducted a stepped-wedge, cluster-randomized pilot trial in four hospitals in India to evaluate the implementation of an LCG strategy intervention, compared with routine care. We performed this trial to pilot the intervention and obtain preliminary effectiveness data, informing future research. Eligible clusters were four hospitals with >4,000 births annually and cesarean rates ≥30%. Eligible women were those giving birth at ≥20 weeks’ gestation. One hospital transitioned to intervention every 2 months, according to a random sequence. The primary outcome was the cesarean rate among women in Robson Group 1 (that is, those who were nulliparous and gave birth to a singleton, term pregnancy in cephalic presentation and in spontaneous labor). A total of 26,331 participants gave birth. A 5.5% crude absolute reduction in the primary outcome was observed (45.2% versus 39.7%; relative risk 0.85, 95% confidence interval 0.54–1.33). Maternal process-of-care outcomes were not significantly different, though labor augmentation with oxytocin was 18.0% lower with the LCG strategy. No differences were observed for other health outcomes or women’s birth experiences. These findings can guide future definitive effectiveness trials, particularly in settings where urgent reversal of rising cesarean section rates is needed. Clinical Trials Registry India number: CTRI/2021/01/030695.

BackgroundMaternal nutrition in preconception and early pregnancy influences fetal growth. Evidence for effects of prenatal maternal nutrition on early child development (ECD) in low-income and middle-income countries is limited.ObjectivesTo examine impact of maternal nutrition supplementation initiated prior to or during pregnancy on ECD, and to examine potential association of postnatal growth with ECD domains.DesignSecondary analysis regarding the offspring of participants of a maternal multicountry, individually randomised trial.SettingRural Democratic Republic of the Congo, Guatemala, India and Pakistan.Participants667 offspring of Women First trial participants, aged 24 months.InterventionMaternal lipid-based nutrient supplement initiated preconceptionally (arm 1, n=217), 12 weeks gestation (arm 2, n=230) or not (arm 3, n=220); intervention stopped at delivery.Main outcome measuresThe INTERGROWTH-21st Neurodevelopment Assessment (INTER-NDA) cognitive, language, gross motor, fine motor, positive and negative behaviour scores; visual acuity and contrast sensitivity scores and auditory evoked response potentials (ERP). Anthropometric z-scores, family care indicators (FCI) and sociodemographic variables were examined as covariates.ResultsNo significant differences were detected among the intervention arms for any INTER-NDA scores across domains, vision scores or ERP potentials. After adjusting for covariates, length-for-age z-score at 24 months (LAZ24), socio-economic status, maternal education and FCI significantly predicted vision and INTER-NDA scores (R2=0.11–0.38, p<0.01).ConclusionsPrenatal maternal nutrition supplementation was not associated with any neurodevelopmental outcomes at age 2 years. Maternal education, family environment and LAZ24predicted ECD. Interventions addressing multiple components of the nurturing care model may offer greatest impact on children’s developmental potential.Trial registration numberNCT01883193.

Preterm birth remains a common cause of neonatal mortality, with a disproportionately high burden in low-income and middle-income countries. Meta-analyses of low-dose aspirin to prevent pre-eclampsia suggest that the incidence of preterm birth might also be decreased, particularly if initiated before 16 weeks of gestation.

To overcome the three delays in triage, transport and treatment that underlie adverse pregnancy outcomes, we aimed to reduce all-cause adverse outcomes with community-level interventions targeting women with pregnancy hypertension in three low-income countries.

(Abstracted from Lancet2020;395:285–293)Preterm birth, or delivery before 37 weeks, is one of the most common causes of infant mortality. New evidence has shown that women who take low-dose aspirin (81 mg) may be at lower risk of preeclampsia.

Antenatal corticosteroids for pregnant women at risk of preterm birth are among the most effective hospital-based interventions to reduce neonatal mortality. We aimed to assess the feasibility, effectiveness, and safety of a multifaceted intervention designed to increase the use of antenatal corticosteroids at all levels of health care in low-income and middle-income countries.

Active management of the third stage of labour reduces the risk of post-partum haemorrhage. We aimed to assess whether controlled cord traction can be omitted from active management of this stage without increasing the risk of severe haemorrhage.

Obstetricians-gynecologists often have a special and long-term relationship with their patients and are ideally placed to assess their fracture risk and to institute appropriate therapy for osteoporosis. Assessment of risk factors according to the World Health Organization and more recent guidelines (e.g., age, smoking history, previous fracture, parental fracture, corticosteroid use, weight) enables the clinician to target patients for testing of bone mineral density by techniques such as dual-energy x-ray absorptiometry at the proximal femur. The current therapy of choice is an oral bisphosphonate, which has proven efficacy in increasing bone mineral density, reducing bone-turnover markers, and reducing fracture rates. Their main drawback is inconvenient dosing requirements, which necessitates taking the drug in the morning at least 30 minutes before the first meal or drink of the day; this may contribute to poor adherence with therapy and suboptimal outcomes. The availability of daily or weekly (alendronate and risedronate) or monthly (ibandronate) bisphosphonates means that patients can have therapy at their preferred frequency, and along with education regarding lifestyle issues such as nutrition, exercise, smoking, and alcohol use, and measures to reduce tripping in the home, should reduce the prevalence of osteoporotic fractures.

Barrier methods of contraception are among the oldest techniques of pregnancy prevention; their use dates back to ancient times. In the early twentieth century, barrier methods provided the only means of contraception for many women. More recently, their use has declined. In the 1995 National Survey of Family Growth, the use of female-controlled methods of barrier contraception was at its lowest rate ever. 29Nevertheless, one can argue that owing to the current high rates of unintended pregnancy and sexually transmitted diseases (STDs), barrier contraceptives with their dual role of pregnancy and STD prevention are exceedingly important.

Antenatal corticosteroids are 1 of the most effective hospital-based treatments to reduce neonatal mortality for pregnant women at risk of preterm birth. While studies have shown reductions in neonatal mortality in high- and middle-income countries, and the treatment has been recommended by national and international health organizations, less than 10 of women in low-income countries at risk of preterm birth receive antenatal corticosteroids. This cluster-randomized trial aimed to assess the feasibility, safety, and effectiveness of a multifaceted intervention to increase the use of these treatments in middle- and low- income countries.

Summary This report summarizes the course of a patient with asymptomatic chronic pancreatitis associated with hemorrhage into the pancreatic duct and metastatic fat necrosis. Retrograde cannulation of the pancreatic duct and superior mesenteric arteriography established the presence of a pseudocyst with a pancreatic duct-arteriovenous (DAV) fistula as the cause of the syndrome. Ligation of feeder vessels with external drainage of the cyst as the initial surgical procedure stopped the bleeding but failed to prevent recurrence of the pancreatic ductvenous fistula. A pancreaticoduodenectomy with resection of the cyst and fistula was required to arrest destruction of distant tissues. Although serum and urine amylase concentrations were markedly elevated, serum lipase levels were normal throughout the patient's course. Elevation of serum lipase does not seem to be a necessary condition for the development of the metastatic fat necrosis syndrome.

Introduction: A litany of recent evidence supports the morbidity of intra-natal iron-deficiency anemia and its prodrome, iron deficiency. Oral iron administered during second and third trimesters does not get to the developing fetus if the mother is iron deficient. This is especially concerning as the rapidly developing fetal brain is in particular need of iron sufficiency. Intra-natal iron deficiency is associated with autism, schizophrenia and abnormal brain structure. The obstetrical literature reports an unacceptably high incidence of gastrointestinal adverse events with oral iron. The time iron honored standard in the United States for intravenous iron replenishment in gravidas is iron sucrose. While safe and effective, four to seven visits are required to accomplish what newer formulations can achieve with one.Methods: Ferumoxytol is a superparamagnetic iron oxide linked to polyglucose sorbitol carboxymethylether-binding elemental iron tightly allowing administration of complete replacement doses in 15–30 min. Herein, we report the results of 131 consecutive, non-selected, iron-deficient second- and third-trimester pregnant women who received either 510 mg of intravenous (IV) ferumoxytol twice or 1020 mg once.Results: Hemoglobin and iron parameter increments were highly statistically significant. No adverse events were reported. We report how a single infusion is safe and effective as the same dose over two visits, saving an unnecessary visit and IV placement, while reducing cost.Conclusion: Ferumoxytol represents an efficacious and safe method of administration of IV iron which improves convenience for patients and practitioners, and is cost saving due to fewer visits.Plain language summary One or two infusions of intravenous iron for iron deficiency or iron-deficiency anemia of pregnancy simplifies care This study was conducted to highlight the inconvenience of multiple doses of IV iron and how administering the same dose in one or two infusions simplifies care. We report how a single infusion is as safe and effective as the same dose over two visits, saving an unnecessary visit and IV placement, while reducing cost. This study supports a growing body of evidence, to date, unreported, with ferumoxytol in pregnancy, reporting improved convenience and decreased costs with higher doses of IV iron in one or two visits.

A common prophylactic intervention used in the third stage of labor to reduce postpartum hemorrhage (PPH) can be labeled as active management. In the full management package used for active management, oxytocin is administered soon after delivery in combination with controlled cord traction. However, because the proper use of controlled cord traction requires manual skills, this procedure has been recommended only for skilled birth attendants. Unfortunately, a substantial proportion of maternal deaths from hemorrhage occur in settings in which skilled birth attendants are not available. Some evidence suggests that a simplified active package omitting controlled cord traction may have a similar effect on preventing blood loss, indicating that the uterotonic component in active management may be effective on its own. The contribution of controlled cord traction to blood loss is largely unknown.

The commonest cause of maternal deaths worldwide is postpartum bleeding, and the great majority of such deaths take place in developing countries such as India where women frequently do not deliver their children in a hospital setting. The major cause is uterine atony, which can be prevented by administering a uterotonic agent such as oxytocin. Such treatment remains impractical for much of the developing world, where women giving birth are cared for by untrained attendants. In addition, injected uterotonic agents must be stored in the cold and require active management of the third stage of labor. Orally administered misoprostol, a prostaglandin E1analogue, is a comparatively inexpensive alternative to oxytocin that has proved to be effective and safe, does not need to be refrigerated, and has a long shelf life.

Three-dimensional echo measurement of right ventricular (RV) volume has recently been validated in experimental models using automated voxel acquisition from rotated 2D echo views. This technique conveniently provides rapid and animated spatial appreciation from multiple perspectives. However, its feasibility and reliability for reconstructing and quantitating RV volume and function in humans is not known, given limitations of acoustic access and the need for ECG and respiratory gating; also, no other method for RV volume by 3D echo has been tested quantitatively in patients. We therefore imaged the RV from a parasternal or subcostal rotation in 18 normal subjects (6–19 years old) in order to compare calculated stroke volumes with an independent noninvasive measure in subjects not undergoing catheterization. Endocardial borders in parallel cross-sections derived from the voxel data set were traced and volumes calculated as σ (cavity area x slice height). Stroke volumes were compared with Doppler values (mean of mitral inflow and aortic outflow in the absence of regurgitation).

The aim of our study was to investigate the applicability of the 3D reconstruction for evaluating color Doppler regurgitant jet imaging compared to conventional 20 color Doppler flow mapping.

To investigate 3-D reconstruction imaging of dynamically accelerating flow convergence (FC) phenomena for quantitating regurgitant flow rates, we used an in vitro pulsatile flow model (Harvard piston pump, model 1423) for two types of regurgitant orifices: rectangular (RECl length=8 x width, orifice area=0.24cm2), and an oblique mitral valve prolapse (MVP, orifice area=0.28 cm2). Four different dynamic flows were imaged using a Interspec echo system with 3 Nyquist limits (9, 17, 35 cm/sec). These color Doppler FC images were three dimensionally reconstructed with a TomTech computer for each flow. Simulated ECG signals were obtained from an electromagnetic devise attached to the pulsatile pump to synchronize echo Doppler images and TomTech ECG gating (16 gates/beat). Instantaneous peak flow rates were measured using a transonic flow probes and meters attached to the flow models and these reference data were compared with FC data. Over peak flow rates 4.0–18 I/min, the FC method using the 3D measured hemispherical isovelocity assumption showed variable underestimation for both RECT and MVP, especially for low flow rates and higher Nyquist limits (up to 78%, r=0.56). Hemielliptical FC data derived from three 3D reconstructed orthogonal axes demonstrated a good correlation with actual flow rates with slight underestimation for RECT (18%, r=0.92) but for MVP showed more variable underestimation for all conditions (27%, r=0.86). Three dimensional reconstruction of dynamic FC estimated with a hemielliptic model showed better estimation of flow rates for a flat RECT orifice compared to the simple hemispherical model but for more geometrically complicated orifices with flow changing dynamically and variable constraint effects, projection axis measurements are insufficient for the accurate flow rate estimation and surface reconstruction and direct 3D implemented surface area measurements are required.

Recent computational advances have permitted 3-dimensional (3D) reconstruction of echo intensities over the cardiac volume from rotated 2D echo views gated to ECG and respiration. Unlike approaches using selected 2D views, such automated voxel acquisitions conveniently provide rapid spatial appreciation in animated views from multiple perspectives. However, only limited data are available regarding theaccuracyof such reconstructions in patients, particularly using thetransthoracicapproach without the need for TEE. We therefore reconstructed the left ventricles of 10 consecutive patients referred for cardiac gated blood pool scan (GBPS) by transthoracic apical rotation, 5 with abnormal wall motion. LV volume was calculated by summing endocardial areas in parallel cross-sections derived from the voxel data, and compared to GBPS values by validated techniques to normalize counts for attenuation and countstvolume of blood sample.