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Abstract Amniotic fluid embolism (AFE) is a rare but potentially fatal complication of pregnancy. Prompt and aggressive resuscitative strategies are crucial in promoting survivability. We present a case of AFE resulting in cardiopulmonary collapse and subsequent cardiac arrest where we were able to safely deliver the baby and resuscitate the mother with veno‐arterial extracorporeal membrane oxygenation and Impella CP—a novel combination known as ECPELLA. We discuss the implications of this approach as a more efficacious strategy in resuscitating AFE‐induced cardiogenic shock and arrest.

Objective: This review provides a comprehensive intensive care unit (ICU) perspective on amniotic fluid embolism (AFE), encompassing its epidemiology, pathophysiology, diagnosis, and management. Mechanism: AFE is an abrupt and perilous condition. The enhancement of diagnostic criteria, starting from the understanding of pathologic physiology, can facilitate the development of more specialized disease management approaches and targeted interventions. Findings in Brief: Significant research advancements have improved the timeliness and accuracy of clinical diagnosis and treatment for AFE, leading to the development of several effective rescue procedures. Progress is expected to be made in various aspects including a comprehensive exploration of pathophysiological mechanisms, identification and utilization of biomarkers, innovation in treatment methods, enhancement of personnel training and collaboration within treatment teams, as well as the application of big data technology. Conclusions: The recent research has greatly contributed to substantial progress in the clinical diagnosis and treatment for AFE. However, further research holds potential to provide even greater benefits for patients.

Stroke in pregnancy is rare but is one of the leading causes of morbidity and mortality in developed countries. Pregnancy, as a prothrombotic state, acts as a precursor for stroke. Preeclampsia, eclampsia, amniotic fluid embolism, hypertension, diabetes, and many other factors predispose to the development of stroke. Endothelial cell injury leading to arteriosclerosis, causing a stroke, has been associated with raised homocysteine levels. Hereby, the authors present a case of a 26-year-old Gravida 3 Pregnancy 1 Live 1 Abortion 1 (G3P1L1A1) at 35 weeks gestation with a cephalic presentation who complained of a headache for two days, sudden onset of weakness in the right upper limb and lower limb with an inability to walk without support and inability to speak since 12 hours, associated with one episode of vomiting. Magnetic Resonance Imaging (MRI) brain showed acute infarcts in the left fronto-parietal lobes and capsule region with haemorrhagic transformation in the left frontal lobe. Serum vitamin B12 measured by Electroluminescence Assay (ECLA) was found to be low at 113pg/mL (normal range -191-771pg/mL). Serum homocysteine levels measured by enzymatic method were elevated at 46 umol/L (normal range 3-18 umol/L). A diagnosis at 34 weeks of pregnancy with acute cerebrovascular accident with right hemiparesis with Broca's aphasia due to hyperhomocysteinaemia secondary to vitamin B12 deficiency was made. Prompt diagnosis and treatment are known to decrease morbidity in women with cerebrovascular accidents. MRI brain with venogram is known to be the gold standard procedure in diagnosing stroke. Thrombolytic therapy has proven beneficial in the treatment of the disease and in preventing its progression. Prenatal and natal supplementation with folic acid/vitamin B12 in the first trimester of pregnancy prevents Vitamin B12 deficiency and raised homocysteine levels in the maternal serum, thereby decreasing the incidence of stroke. [ABSTRACT FROM AUTHOR]

BACKGROUND: Amniotic fluid embolism is an unpredictable and sometimes lethal complication of childbirth. Fibrinogen γ-chain peptide-coated, ADP-encapsulated Liposomes (H12-(ADP)-liposomes), which were developed as a platelet substitute, may be useful to control postpartum hemorrhage with consumptive coagulopathy. OBJECTIVE: This study aimed to establish a hemodynamically stable amniotic fluid embolism animal model and evaluate the efficacy of H12-ADP-liposome infusion in the initial management of postpartum hemorrhage complicated with amniotic fluid embolism–involved coagulopathy. STUDY DESIGN: Pregnant New Zealand white rabbits (28th day of pregnancy or normal gestation period of 29–35 days) underwent cesarean delivery, followed by intravenous administration of amniotic fluid (a total of 3.0 mL administered in 4 doses over 9 minutes). Thereafter, uncontrolled postpartum hemorrhage was induced by transecting the right midartery and concomitant vein in the myometrium. After initial bleeding for 5 minutes, rabbits received isovolemic fluid resuscitation through the femoral vein with an equivalent volume of blood loss every 5 minutes for 60 minutes. The transfusion regimens included platelet-rich plasma, platelet-poor plasma, and a bolus administration of H12-ADP-liposomes followed by platelet-poor plasma transfusion (8 rabbits per group). Moreover, 60 minutes after initiation of bleeding, rabbits received surgical hemostasis by ligation of bleeding vessels, except in cases with spontaneous hemostasis. RESULTS: The administration of amniotic fluid caused thrombocytopenia (56±3 × 103/μL) and prolonged both clotting time (before administration: 130.0±3.0 to 171.0±5.0 seconds) and prothrombin time (4.5±0.1 to 4.7±0.1 seconds). After the initial 5-minute bleeding in the rabbits, the mean arterial pressure fell to 43±2 mm Hg. Platelet-poor plasma transfusion alone further prolonged clotting time and prothrombin time at 60 minutes (192.0±10.0 and 5.2±0.1 seconds, respectively) with decreasing mean arterial pressure to 45 mm Hg throughout the experiment. H12-ADP-liposome infusion and platelet-poor plasma transfusion and platelet-rich plasma transfusion yielded spontaneous hemostasis in 4 of 8 rabbits, whereas platelet-poor plasma transfusion did not stop bleeding in any of the rabbits. The total blood loss was 59±17 mL in the H12-ADP-liposomes and platelet-poor plasma group, which was half of that in the platelet-poor plasma group (124±10 mL). CONCLUSION: H12-ADP-liposome infusion may be effective in the initial management of postpartum hemorrhage complicated with amniotic fluid embolism, resulting in mitigation of consumptive coagulopathy.

Background: Maternal body fluids contain abundant cell-free fetal RNAs which have the potential to serve as indicators of fetal development and pathophysiological conditions. In this context, this study aimed to explore the potential diagnostic value of maternal circulating long non-coding RNAs (lncRNAs) in ventricular septal defect (VSD). Methods: The potential of lncRNAs as non-invasive prenatal biomarkers for VSD was evaluated using quantitative polymerase chain reaction (qPCR) and receiver operating characteristic (ROC) curve analysis. The biological processes and regulatory network of these lncRNAs were elucidated through bioinformatics analysis. Results: Three lncRNAs (LINC00598, LINC01551, and GATA3-AS1) were found to be consistent in both maternal plasma and amniotic fluid. These lncRNAs exhibited strong diagnostic performance for VSD, with AUC values of 0.852, 0.957, and 0.864, respectively. The bioinformatics analysis revealed the involvement of these lncRNAs in heart morphogenesis, actin cytoskeleton organization, cell cycle regulation, and protein binding through a competitive endogenous RNA (ceRNA) network at the post-transcriptional level. Conclusion: The cell-free lncRNAs present in the amniotic fluid have the potential to be released into the maternal circulation, making them promising candidates for investigating epigenetic regulation in VSD. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has raised questions about indirect impact in pregnant women on the development of their future children. Investigating the characteristics of lipid metabolism in the "mother–placenta–fetus" system can give information about the pathophysiology of COVID-19 infection during pregnancy. A total of 234 women were included in study. Maternal plasma, cord blood, and amniotic fluid lipidome were analyzed using HPLC-MS/MS. Differences in lipid profile were searched by Mann–Whitney and Kruskall–Wallis test, and diagnostic model based on logistic regression were built by AIC. Elevated levels of lysophospholipids, triglycerides, sphingomyelins, and oxidized lipids were registered in patients' maternal and cord plasma after COVID-19 infection. An increase in maternal plasma sphingomyelins and oxidized lipids was observed in cases of infection during the second trimester. In amniotic fluid, compared to the control group, nine lipids were reduced and six were elevated. Levels of phosphoglycerides, lysophosphoglycerides, and phosphatidylinositols decreased during infection in the second and third trimesters of pregnancy. A health diagnostic model for newborns based on maternal plasma was developed for each group and exhibited good diagnostic value (AUC > 0.85). Maternal and cord plasma's lipidome changes during delivery, which are associated with COVID-19 infection during pregnancy, are synergistic. The most significant disturbances occur with infections in the second trimester of pregnancy. [ABSTRACT FROM AUTHOR]

Introduction: Coronavirus disease 2019 (COVID-19) has infected millions of people worldwide, which is characterized by the manifestation of symptoms from coagulopathy to disseminated intravascular coagulation (DIC). This study aimed to investigated the correlation of D-dimer with lipoproteins values in COVID-19 patients. Methods: Observational cross-sectional analysis, using secondary data from medical records, based on the sample size formula it takes 78 samples, the data analysis method uses the SPSS program version 24. Results: From the results of the study, the number of patients with a D-dimer value of less than 0.5 ug/ml was 26%. While as many as 74% patients got the value of D-dimer increased by more than 0.5 ug/ml. Triglyceride and LDL levels were not associated with changes in D-dimer values. There is a correlation between the value of D-dimer with HDL (P = 0.024). High levels of D-dimer values are associated with the severity of symptoms and a poor prognosis. Excessive inflammatory processes will initiate coagulation via the extrinsic pathway, which progresses to disseminated intravascular coagulation (DIC) due to an imbalance between coagulation and fibrinolysis. Meanwhile, high HDL values reduce the risk of thrombotic events by initiating plasmin formation and are associated with low mortality rates. Conclusion: There is a statistically significant correlation between D-dimer values and HDL lipid levels. Suggestions, further research is needed to measure the correlation of D-dimer and HDL values in acute infection with the COVID-19 virus with a larger sample. [ABSTRACT FROM AUTHOR]

Background: SARS-CoV-2 infection in pregnant women may induce inflammation within the amniotic cavity and/or an increase in proinflammatory cytokines in fetal circulation. The aim was to investigate levels of IL-6 in maternal blood, umbilical cord blood, and amniotic fluid in pregnant women infected with SARS-CoV-2 at delivery. Methods: A single-center prospective observational case–control study of pregnant women diagnosed with SARS-CoV-2 infection at delivery was conducted. A total of 48 infected and 42 healthy women had IL-6 concentrations measured in their blood, amniotic fluid, and umbilical cord blood. Results: The concentrations of IL-6 in maternal blood and amniotic fluid were similar in the study and control groups, while umbilical cord blood concentrations were significantly higher in SARS-CoV-2-positive women. The umbilical cord blood IL-6 concentration was related to composite neonatal morbidity. Conclusions: Maternal SARS-CoV-2 infection in pregnant women at delivery increases umbilical cord blood IL-6 concentration. The correlation between maternal and umbilical blood concentrations indicates a possibility of passage of IL-6 through the placenta. Perinatal alterations resulting from maternal SARS-CoV-2 infection at delivery carry a risk of impacting the health of infants even in asymptomatic course of infection. [ABSTRACT FROM AUTHOR]

Objective: To identify the lessons learned from women who died during pregnancy or childbirth in Lebanon between 2018 and 2020. Method: This is a case series and synthesis of maternal deaths between 2018 and 2020 that were reported by healthcare facilities to the Ministry of Public Health in Lebanon. The notes recorded from the maternal mortality review reports were analyzed using the "Three Delays" model to identify preventable causes and lessons learned. Results: A total of 49 women died before, during, or after childbirth, with hemorrhage being the most frequent cause (n = 16). The possible factors that would have prevented maternal deaths included a prompt recognition of clinical severity, availability of blood for transfusion and magnesium sulfate for eclampsia, adequate transfer to tertiary care hospitals comprising specialist care, and involvement of skilled medical staff in obstetric emergencies. Conclusion: Many maternal deaths in Lebanon are preventable. Better risk assessment, use of an obstetric warning system, access to adequately skilled human resources and medications, and improved communication and transfer mechanisms between private and tertiary care hospitals may avoid future maternal deaths. Synopsis: Maternal mortality in Lebanon can be prevented by improving referral practices between healthcare facilities, ensuring availability of essential medicines and blood products, and prompt recognition of clinical deterioration. [ABSTRACT FROM AUTHOR]

Pregnancy on a rudimentary uterine horn is a rare condition that can lead to a catastrophic outcome when it ruptures. The majority of cases are diagnosed late, after the rupture has occurred. We present the case of a 29-year-old female G2 P1 who complained of abdominal pain. She consulted a medical practitioner who prescribed her analgesics. In the next day, she was found dead in her bedroom. The pregnancy was undiagnosed as she was not aware that she was in a gravid state. At autopsy, there was massive haemoperitoneum and a 24-week gestation foetus lying outside the uterus. The uterus revealed an anomaly in keeping with a non- communicating rudimentary horn. Forensic pathologists do encounter undiagnosed ectopic pregnancies in practice. However, abdominal ectopic pregnancy with a uterine anomaly remains uncommon. These cases are often associated with a high maternal and foetal mortality. [ABSTRACT FROM AUTHOR]

Objective The COVID-19 pandemic was declared a pandemic and a global health emergency by the World Health Organization (WHO) on March 11, 2020. COVID-19 infection is the most common cause of life-threatening acute respiratory tract infection in adults and older people but more mildly in the childhood age group. While the pandemic continues, there is no clear information about the vertical transmission of COVID-19 infection from the mother to the baby. Methods In our study, we aimed to examine vertical virus transmission (breast milk, amniotic fluid, placenta) in pregnant women with COVID-19 infection and to examine the demographic, clinical, and laboratory characteristics of these infants. Our prospective and observational study was conducted in our hospital between March 1, 2020 and July 31, 2021. Results During the study period, a total of 24 infants were included. All infants were admitted to the neonatal intensive care unit for postnatal follow-up. The virus was not detected in breast milk or amniotic fluids by the SARS-COV-2 reverse transcription polymerase chain reaction (RT-PCR) test, and no evidence of vertical transmission was found. Conclusion In our study, no life-threatening complication was found in the babies of mothers infected with COVID-19 at birth. Babies born to mothers with COVID-19 infection did not develop any system findings that required specific treatment. [ABSTRACT FROM AUTHOR]

Objective: Amniotic fluid embolism (AFE) is a rare entity that occurs during pregnancy, about which there is limited information currently. This study aimed to contribute to the literature by evaluating histopathologic findings, clinical data, and autopsy findings of the cases from a postmortem point of view. Methods: A 10-year retrospective study was designed to assess deaths during pregnancy. To address vascular structures and identify the squamous cells, immunohistochemical staining was performed on the lung specimens of individuals who underwent autopsy due to sudden death during this period and were diagnosed with amnion embolism. Demographic data and clinical findings of the cases were obtained from the institutional archive and evaluated together with autopsy and histopathologic findings. Results: During a 10-year period, 89 pregnant women were autopsied and five were diagnosed with amniotic fluid embolism. In all cases, macroscopic examination revealed subpleural petechial hemorrhages in the lungs, and hematoxylin-eosin (HE)-stained sections of the lungs showed scales and squamous cells in pulmonary vessel lumens. Immunohistochemical staining with CD34 in vascular structures and with pankeratin (PANCK) in scales and squamous cells was detected in all cases. There was no pathology in other organs on macroscopic and microscopic examination. No drugs or toxins were detected in the blood and body fluids in the toxologic analysis. Two decedents had symptoms before labor and two decedents had symptoms during labor. One decedent had symptoms just after she gave birth vaginally. Four of them had emergency c-sections. In three cases, uterine rupture followed by hysterectomy was observed, and in two cases, the fetus also died with the mother. Three fetuses whose mothers died due to amniotic fluid embolism were rescued alive. Conclusion: This study underlines uterine rupture and Cesarean sections as crucial risk factors for AFE, but no connection was found with older maternal age. Although AFE is such a devastating picture, there is still no agreed diagnostic definition currently. This study supports the reliability of the clinical parameters recommended in the Paris AFE framework, which was based on clinical findings. These criteria can also be used in our country in places with more limited conditions. This study emphasizes that it is critical to evaluate patients with echocardiography, which is available in many centers in Turkey, in cases of pregnancy with unstoppable vaginal bleeding that starts with hypotension and neurological findings. The postmortem data can contribute to the recognition of its unique clinical and histopathological manifestations, which can be used for maternal and infant survival. [ABSTRACT FROM AUTHOR]

This study aimed to characterize dietary protein patterns (DPPs) in a sample pool of 298 well-nourished pregnant women and explore potential associations between DPPs and neonatal anthropometrics. Maternal dietary data were collected using a validated food frequency questionnaire. Neonatal anthropometrics were abstracted from health booklets. A hierarchical cluster analysis identified three DPPs: "Dairy-focused", "Med-fusion", and "Traditional-inspired". The "Dairy-focused" DPP exhibited the highest protein intake (p < 0.001), predominantly animal protein (p < 0.001), while the "Traditional-inspired" DPP presented higher plant protein (p < 0.001) and fiber intakes (p < 0.001), and, therefore, a reduced carbohydrate-to-fiber quotient (p < 0.001). The "Med-fusion" DPP had the lowest protein-to-fat ratio (p < 0.001). Infants of women following the "Dairy-focused" DPP had the highest birth height centiles (p = 0.007) and the lowest ponderal index (p = 0.003). The NMR-metabolomics approach was implemented on a subset of women that provided amniotic fluid (AF) specimens (n = 62) to elucidate distinct metabolic signatures associated with DPPs. PCA and OPLS-DA models verified the adherence to three DPPs, revealing that the levels of several amino acids (AAs) were the highest in "Dairy-focused", reflecting its protein-rich nature. The "Traditional-inspired" DPP showed decreased AAs and glucose levels. This knowledge may contribute to optimizing maternal dietary recommendations. Further research is needed to validate these findings and better understand the relationships between maternal diet, AF metabolic signature, and neonatal anthropometrics. [ABSTRACT FROM AUTHOR]

Purpose: An emergency caesarean section (CS) has more complications than a planned CS. The arrest of labour is a major indication for an emergency CS. This study aimed to develop a prediction model for the arrest of labour to be used in regular check-ups at 36 or 37 gestational weeks for primiparas. Methods: This was a retrospective cohort study conducted at a single institution in Japan using data from January 2007 to December 2013. Primiparas attending regular check-ups during 36 or 37 gestational weeks, with live single foetuses in a cephalic presentation were included. The outcome was the incidence of labour arrest. Candidate predictors included 25 maternal and foetal findings. We developed a prediction model using logistic regression analysis with stepwise selection. A score was assigned to each predictor of the final model based on their respective β coefficients. Results: A total of 739 women were included in the analysis. Arrest of labour was diagnosed in 47 women (6.4%), and all of them delivered by emergency CS. The predictors in the final model were a Bishop score ≤ 1, maternal height ≤ 154 cm, foetal biparietal diameter ≥ 91 mm, pre-pregnancy weight ≥ 54 kg, maternal haemoglobin concentration ≥ 11.0 g/dl, and amniotic fluid index ≥ 13. The area under the receiver operating characteristic curve was 0.783. Conclusion: We have developed the first model to predict arrested labour before its onset. Although this model requires validation using external samples, it will help clinicians and pregnant women to control gestational conditions and make decisions regarding planned CS. [ABSTRACT FROM AUTHOR]

Objective: To identify predictors of adverse perinatal outcomes in pregnancies with fetal growth restriction (FGR) using a combination of maternal clinical factors and simple ultrasound parameters and develop a risk‐scoring model for predicting adverse perinatal outcomes. Methods: A retrospective study of 370 non‐anomalous singleton pregnancies with FGR was conducted. Multivariate logistic regression analysis was used to identify factors associated with adverse perinatal outcomes; P < 0.05 was considered statistically significant. The discriminative ability was measured with the area under the receiver operating characteristic curve (AUC). A weighted score for each predictor was calculated. Results: Adverse perinatal outcomes occurred in 165/370 (44.6%) cases. There were eight predictive factors, including a history of pregnancy‐induced hypertension (PIH) (score = 1), chronic hypertension (score = 3), PIH (score = 2), maternal weight gain less than 8 kg (score = 1), early‐onset FGR (score = 1), estimated fetal weight less than 5th percentile (score = 2), amniotic fluid index less than 5 cm (score = 3), and abnormal umbilical artery Doppler (score = 2), with total scores ranging from 0 to 15. AUC for the eight‐item predictive model was 0.799 (95% confidence interval 0.753–0.845). Conclusion: A combination of maternal clinical factors and simple ultrasound parameters showed acceptable predictive performance for adverse perinatal outcomes in FGR. Synopsis: A combination of maternal clinical factors and simple ultrasound parameters has acceptable predictive performance for adverse perinatal outcomes in fetal growth restriction. [ABSTRACT FROM AUTHOR]

Nowadays, people have relaxed their vigilance against COVID-19 due to its declining infection numbers and attenuated virulence. However, COVID-19 still needs to be concern due to its emerging variants, the relaxation of restrictions as well as breakthrough infections. During the period of the COVID-19 infection, the imbalanced and hyper-responsive immune system plays a critical role in its pathogenesis. Macrophage Activation Syndrome (MAS) is a fatal complication of immune system disease, which is caused by the excessive activation and proliferation of macrophages and cytotoxic T cells (CTL). COVID-19-related hyperinflammation shares common clinical features with the above MAS symptoms, such as hypercytokinemia, hyperferritinemia, and coagulopathy. In MAS, immune exhaustion or defective anti-viral responses leads to the inadequate cytolytic capacity of CTL which contributes to prolonged interaction between CTL, APCs and macrophages. It is possible that the same process also occurred in COVID-19 patients, and further led to a cytokine storm confined to the lungs. It is associated with the poor prognosis of severe patients such as multiple organ failure and even death. The main difference of cytokine storm is that in COVID-19 pneumonia is mainly the specific damage of the lung, while in MAS is easy to develop into a systemic. The attractive therapeutic approach to prevent MAS in COVID-19 mainly includes antiviral, antibiotics, convalescent plasma (CP) therapy and hemadsorption, extensive immunosuppressive agents, and cytokine-targeted therapies. Here, we discuss the role of the therapeutic approaches mentioned above in the two diseases. And we found that the treatment effect of the same therapeutic approach is different. [ABSTRACT FROM AUTHOR]

Objective As the awareness of the accompanying morbidity of placenta accreta spectrum (PAS) has increased over recent decades. We sought to analyze the precision and reliability of the currently available content regarding PAS on YouTube. Study Design A YouTube search was performed on June 17, 2019 by using the search terms "placenta accreta," "PAS," and "invasive placentation." Search results were sorted by relevance, and up to 200 videos per search term were systematically evaluated by four independent reviewers. A quality assessment checklist relating to aspects of PAS was developed with a Likert's scale from 0 to 12 points to quantify video content. Videos were classified as poor educational quality (grade 0 to ≤4), moderate quality (grade >4–8), and high quality (grade >8–12). Results Of the 318 videos identified, 99 videos met inclusion criteria. The majority of videos (61.6%) were produced by a professional source, that is, appearing to be from a hospital, university, or educational service. Of the remaining videos, 16.2% were classified as personal, that is, posted from personal YouTube accounts and depicting a personal or family member experience, and 22.2% were classified as other. The majority of the "other" category consisted of news segments and short clips from talk shows. Overall, 60.6% of videos were of poor educational quality, 32.3% were of moderate quality, and 7.1% were deemed high quality. All seven of the high-quality videos were produced by a professional source and intended for an audience of medical professionals. There were neither high-quality videos intended for the general public nor the likely affected and relevant patient population. Conclusion This study suggests that the currently available videos on YouTube regarding PAS are poor educational sources for patients seeking information, and demonstrates a need for high-quality content videos produced by medical professionals specifically focused on meeting the needs of patient population. Key Points Awareness of the accompanying morbidity of placenta accreta spectrum has increased over recent decades. YouTube videos are poor educational sources for patients seeking information regarding PAS. YouTube videos and all social media warrant improvements regarding patient's information. [ABSTRACT FROM AUTHOR]

Objective: To summarize the application value of copy number variant sequencing (CNV-seq) in the detection of fetal chromosome and cytomegalovirus load. Methods: The study analyzed the clinical basic data, relevant laboratory tests, treatment process, and outcomes of three patients with positive cytomegalovirus load detected by CNV-seq for fetal chromosomes and cytomegalovirus load, and literature review was done simutaneoubly. Results: In all three cases, the amniotic fluid cytomegalovirus load was less than 105 Copies/ml, and there were no significant neurological abnormalities observed during pregnancy or postpartum follow-up. There is no literature review on the application of CNV-seq technology in the detection of cytomegalovirus infection, only literature reports on genome analysis of CMV-DNA in confirmed patients were available. Conclusion: CNV-seq can be used to detect cytomegalovirus load, which may have a certain degree of predictive value for fetal outcome. CNV-seq can simultaneously detect fetal chromosomes and pathogenic microorganisms, which is of great significance for the prevention and control of birth defects. [ABSTRACT FROM AUTHOR]

Seizure in a patient with a postdural puncture headache is uncommon; early consultation with an anesthesiologist for potential epidural blood patch therapy should be considered. If CT and MRI of the head do not show a cause of seizures, a magnetic resonance angiogram to assess for cerebral artery narrowing, as is seen in reversible cerebral vasoconstriction syndrome, should be considered.[3] An EEG can identify a primary seizure disorder; patients with epilepsy are prone to postpartum seizures due to sleep deprivation. If the patient is actively seizing, treatment should focus on termination of the seizure; magnesium sulfate is the first-line agent if eclampsia is the presumed cause. Initial assessment of seizure in a postpartum patient should include a broad differential with pregnancy-associated causes and other causes. [Extracted from the article]

Maternal mortality continues to be an issue globally despite advances in technology and pharmacotherapy. Pregnancy can lead to complications that necessitate immediate action to prevent severe morbidity and mortality. Patients may need escalation to the ICU setting for close monitoring and administration of advanced therapies not available elsewhere. Obstetric emergencies are rare but high‐stakes events that require clinicians to have prompt identification and management. The purpose of this review is to describe complications of pregnancy and provide a focused resource of pharmacotherapy considerations that clinicians may encounter. For each disease state, the epidemiology, pathophysiology, and management are summarized. Brief descriptions of non‐pharmacological (e.g., cesarean or vaginal delivery of the baby) interventions are provided. Mainstays of pharmacotherapy highlighted include oxytocin for obstetric hemorrhage, methotrexate for ectopic pregnancy, magnesium and antihypertensive agents for preeclampsia and eclampsia, eculizumab for atypical hemolytic uremic syndrome, corticosteroids, and immunosuppressive agents for thrombotic thrombocytopenic purpura, diuretics, metoprolol, and anticoagulation for peripartum cardiomyopathy, and pulmonary vasodilators for amniotic fluid embolism. [ABSTRACT FROM AUTHOR]

Amniotic Fluid Volume (AFV) is a crucial fetal biomarker when diagnosing specific fetal abnormalities. This study proposes a novel Convolutional Neural Network (CNN) model, AFNet, for segmenting amniotic fluid (AF) to facilitate clinical AFV evaluation. AFNet was trained and tested on a manually segmented and radiologist-validated AF dataset. AFNet outperforms ResUNet++ by using efficient feature mapping in the attention block and transposing convolutions in the decoder. Our experimental results show that AFNet achieved a mean Intersection over Union (mIoU) of 93.38% on our dataset, thereby outperforming other state-of-the-art models. While AFNet achieves performance scores similar to those of the UNet++ model, it does so while utilizing merely less than half the number of parameters. By creating a detailed AF dataset with an improved CNN architecture, we enable the quantification of AFV in clinical practice, which can aid in diagnosing AF disorders during gestation. [ABSTRACT FROM AUTHOR]

Introduction: Extracorporeal Membrane Oxygenation (ECMO) may be used in the setting of pregnancy or the peripartal period, however its utility has not been well-characterized. This study aims to give an overview on the prevalence of peripartel ECMO cases and further assess the indications and outcomes of ECMO in this setting across multiple centers and countries. Methods: A retrospective, multicenter, international cohort study of pregnant and peripartum ECMO cases was performed. Data were collected from six ECMO centers across three continents over a 10-year period. Results: A total of 60 pregnany/peripartal ECMO cases have been identified. Most frequent indications are acute respiratory distress syndrome (n = 30) and pulmonary embolism (n = 5). Veno-venous ECMO mode was applied more often (77%). ECMO treatment during pregnancy was performed in 17 cases. Maternal and fetal survival was high with 87% (n = 52), respectively 73% (n = 44). Conclusions: Various emergency scenarios during pregnancy and at time of delivery may require ECMO treatment. Peripartal mortality in a well-resourced setting is rare, however emergencies in the labor room occur and knowledge of available rescue therapy is essential to improve outcome. Obstetricians and obstetric anesthesiologists should be aware of the availability of ECMO resource at their hospital or region to ensure immediate contact when needed. [ABSTRACT FROM AUTHOR]

Amniotic fluid embolism (AFE) is a rare but deadly complication of pregnancy. First described in 1926, it remains a diagnosis of exclusion, without clear etiology or a specific test to confirm the diagnosis. Mortality remains high and neurological injury is common among survivors, although reported case fatality rates are decreasing over time. Hemodynamic instability appears to be caused by severe pulmonary vasospasm and subsequent right heart failure, followed by severe left ventricular failure. Presentation is often sudden with loss of consciousness and circulatory arrest, requiring immediate cardiopulmonary resuscitation, vasopressor and inotropic support, and endotracheal intubation. Disseminated intravascular coagulation commonly follows with severe coagulopathy and postpartum hemorrhage and may in some cases be the primary presenting feature. Management remains largely supportive, with the use of extracorporeal membrane oxygenation and inhaled pulmonary vasodilators assuming an increased role, in addition to advanced life support methods. Blood products and coagulation factor replacement are frequently required, sometimes in the form of a massive transfusion. This narrative review summarizes the past and current literature, emphasizing rapid identification of AFE and therapeutic options for its immediate management. [ABSTRACT FROM AUTHOR]

Aim This article determines the association and diagnostic effectiveness of abnormal Doppler and abnormal amniotic fluid volume (AFV) in the third trimester of pregnancy with preterm births. Methods The third trimester screening protocol of the Samrakshan program of the Indian Radiological and Imaging Association utilizes trimester-specific fetal Doppler studies and ultrasound assessments, estimation of the risk for preterm preeclampsia (PE), assessment of the fetal environment, growth, and structure, and staging of fetal growth restriction. A multivariate logistic regression model was used to explore associations of abnormal Doppler and AFV with preterm birth. The diagnostic effectiveness of Doppler and amniotic fluid measurements for preterm births was assessed. Results One hundred and sixty-one (25.6%) of the 630 women had a preterm birth before 37 gestational weeks. Eighty (21.1%) of the 379 women with normal AFV and normal fetal Doppler studies in the third trimester had a preterm birth. The proportion of preterm birth declined from 35.14% in 2019 to 19.53% in 2022 (chi-square test p = 0.009). Preterm birth was associated with preterm PE (adjusted odds ratio: 3.66, 95% confidence interval: 1.42, 9.44) in a multivariate logistic regression model. Both abnormal fetal Doppler and AFV did not have a good discriminatory ability for preterm births. Conclusion Integration of fetal Doppler studies helped reduce the preterm birth rate by providing an objective measure of fetal well-being, contrary to a common belief that the use of color Doppler in the third trimester may result in iatrogenic increased preterm birth. Preterm births are associated with preterm PE and early identification of high-risk women and early initiation of low-dose aspirin may have an added benefit on preterm birth rates. [ABSTRACT FROM AUTHOR]

Aims of the study: to determine the incidence of amniotic fluid embolism in the Czech Republic and the availability of immediate transthoracic echocardiography (TTE) examination in the departments performing obstetric anesthesia and intensive care. Study type: multicentre questionnaire study. Methods: All 87 anesthetics departments performing obstetric anesthesia in the Czech Republic were invited to complete an online questionnaire on the period 2018-2020. The data collection took place from September to December 2021. Results: 42 departments (collectively responsible for 52% of all births in the Czech Republic) responded to the invitation. In total, 8 cases of amniotic fluid embolism were recorded at these departments over the study period; of these, one patient died and seven survived without permanent sequelae. No immunological diagnostics was performed. Echocardiography was used for diagnosis in 25 % of cases. 23 % of the responding departments do have internal guidelines for the management of suspected amniotic fluid embolism ready and 50 % can provide emergency bedside TTE examination. Conclusions: The incidence of amniotic fluid embolism in the Czech Republic in 2018-2020 ranged between 1.7 and 6.7/100 000 labours in the respective years. In all, eight cases were recorded, one of which was fatal. [ABSTRACT FROM AUTHOR]

Background: Amniotic fluid embolism (AFE) is one of the main causes of maternal mortality in developed countries. The most critical AFE variants may be considered from the perspective of systemic inflammation (SI), a general pathological process that includes high levels of systemic inflammatory response, neuroendocrine system distress, microthrombosis, and multiple organ dysfunction syndrome (MODS). This research work aimed to characterize the dynamics of super-acute SI using four clinical case studies of patients with critical AFE. Methods: In all the cases, we examined blood coagulation parameters, plasma levels of cortisol, troponin I, myoglobin, C-reactive protein, IL-6, IL-8, IL-10, and TNF-α, and calculated the integral scores. Results: All four patients revealed the characteristic signs of SI, including increased cytokine, myoglobin, and troponin I levels, changes in blood cortisol, and clinical manifestations of coagulopathy and MODS. At the same time, the cytokine plasma levels can be characterized not only as hypercytokinemia, and not even as a “cytokine storm”, but rather as a “cytokine catastrophe” (an increase of thousands and tens of thousands of times in proinflammatory cytokine levels). AFE pathogenesis involves rapid transition from the hyperergic shock phase, with its high levels of a systemic inflammatory response over to the hypoergic shock phase, characterized by the mismatch between low systemic inflammatory response values and the patient’s critical condition. In contrast to septic shock, in AFE there is a much more rapid succession of SI phases. Conclusion: AFE is one of the most compelling examples for studying the dynamics of super-acute SI.

Abstract Background Placenta mesenchymal dysplasia (PMD) is a rare placental anomaly associated with various fetal and maternal complications. Whether close ultrasound surveillance can prevent intrauterine fetal demise (IUFD) in patients with PMD is still under investigation. Amniotic fluid embolism (AFE) is a rare, lethal, and unpredictable maternal complication that has never been described in association with PMD. Here, we report a case of PMD, in which the fetus eventually demised in utero despite weekly color Doppler monitoring, and the mother subsequently encountered AFE during delivery. Case presentation A 43-year-old woman who had received three frozen embryo transfer, was found to have a singleton pregnancy with an enlarged multi-cystic placenta at 8 weeks’ gestation. Fetal growth restriction (FGR) was noted since the 21stweek. The fetus eventually demised in-utero at 25 weeks despite weekly color Doppler surveillance. Cesarean section was performed under general anesthesia due to placenta previa totalis and antepartum hemorrhage. During surgery, the patient experienced a sudden blood pressure drop and desaturation followed by profound coagulopathy. AFE was suspected. After administration of inotropic agents and massive blood transfusion, the patient eventually survived AFE. PMD was confirmed after pathological examination of the placenta. Conclusions While FGR can be monitored by color Doppler, our case echoed previous reports that IUFD may be unpreventable even under intensive surveillance in PMD cases. Although AFE is usually considered unpredictable, PMD can result in cumulative risk factors contributing to AFE. Whether a specific link exists between the pathophysiology of PMD and AFE requires further investigation.

Objective: We described a unique case of near-negative chromosome mosaicism in chorionic villi but complete monosomy X in amniotic fluid. Methods: Chorionic villus sampling and amniocentesis were performed separately in the first and second trimesters. Chromosomal microarray (CMA) and rapid aneuploidy detection (QF-PCR and FISH) were performed on placental villi and uncultured amniotic fluid. After pregnancy termination, the placenta, umbilical cord, and fetal muscle tissues were sampled for FISH detection. Results: The CMA revealed a lower signal from chromosome X in chorionic villi, with a copy number of 1.85, implying the presence of mosaic monosomy X. However, the QF-PCR and FISH results were nearly normal. In uncultured amniotic fluid, CMA and rapid aneuploidy detection indicated complete monosomy X. Across different sampling points on the aborted fetus, the FISH results varied from normal, to mosaic, and then complete monosomy X. Conclusion: This case presents a rare and complex situation where sampling from uncultured chorionic villi indicated low-level chromosome mosaicism, while sampling from amniotic fluid revealed complete monosomy X. Although some of these discordant outcomes may be due to methodological limitations, we conclude that prenatal consultation should be combined with fetal ultrasound phenotype and genetic testing for a comprehensive evaluation of fetal genetic abnormalities. [ABSTRACT FROM AUTHOR]

Amniotic fluid embolism (AFE) is a potentially fatal pregnancy complication in which amniotic fluid, foetal hair, cells, or other debris enters the maternal pulmonary circulation, generating a cascade of clinical events that culminate in cardiovascular collapse. The understanding of the aetiology is still in it's infancy, but possible historical reasoning suggests that any breach in the membrane separating amniotic fluid from maternal blood causes amniotic fluid to enter the systemic circulation, which causes a physical obstruction of the pulmonary circulation It can develop in healthy women during labour, or up to 48 hours after delivery. It can also develop during or after an abortion, caesarean section, irregular vaginal delivery, abdominal trauma, or amnio-infusion. AFE's initial warning signs and symptoms touch on numerous organ systems. Acute dyspnea, coughing, hypotension, cyanosis, foetal bradycardia, encephalopathy, acute pulmonary hypertension, coagulopathy etc. are the typical clinical signs and symptoms. Although care is mostly supportive, a multidisciplinary strategy to preventing failing organs and systems is the linchpin of treatment. Despite a virtuous infant survival rate, the prognosis for mothers sustaining an amniotic fluid embolism is very dismal. [ABSTRACT FROM AUTHOR]

Introduction: Placental abruption is a serious complication, especially when accompanied by intrauterine fetal death. The optimal delivery route for placental abruption with intrauterine fetal death for reducing maternal complications is still unclear. In this study we aimed to compare the maternal outcomes between cesarean delivery and vaginal delivery in women with placental abruption with intrauterine fetal death. Material and methods: Using the Japan Society of Obstetrics and Gynecology nationwide perinatal registry database, we identified pregnant women with placental abruption with intrauterine fetal death between 2013 and 2019. The following women were excluded: those with multiple pregnancies, placenta previa, placenta accreta spectrum, amniotic fluid embolism, or whose delivery route was missing data. The association between delivery routes (cesarean delivery and vaginal delivery) and the maternal outcome was examined using a linear regression model with inverse probability weighting. The primary outcome was the amount of bleeding during delivery. Missing data were imputed using multiple imputation. Results: The number of women with placental abruption with intrauterine fetal death was 1218/1601932 (0.076%). Of 1134 women analyzed, 608 (53.6%) underwent cesarean delivery. Bleeding during delivery (median [interquartile range]) was 1650.00 (950.00-2450.00) (mL) and 1171.00 (500.00-2196.50) (mL) in cesarean and vaginal delivery, respectively. Bleeding during delivery (mL) was significantly greater in cesarean delivery than in vaginal delivery (regression coefficient, 1086.39; 95% confidence interval, 130.96-2041.81; p = 0.026). Maternal death and uterine rupture occurred in four (0.4%) and five (0.4%) women, respectively. The four maternal deaths were noted in the vaginal delivery group. Conclusions: Bleeding during delivery was significantly greater in cesarean delivery than that in vaginal delivery in women with placental abruption with intrauterine fetal death. However, severe complications, including maternal death and uterine rupture, occurred in vaginal delivery-related cases. The management of women with placental abruption with intrauterine fetal death should be cautious regardless of the delivery route. [ABSTRACT FROM AUTHOR]

Purpose: Pregnant patients present a unique challenge to cancer therapy. Due to the potential catastrophic implications related to teratogenic effects or pregnancy loss, oncologic management of this vulnerable patient group must be strategic and personalized. Methods: This article will discuss the unique treatment approach to the pregnant cancer patient. This includes discussion of the role of imaging during staging, treatment, and follow-up with an emphasis on avoiding ionizing radiation when possible. Results and Conclusion: Specific considerations and modifications to standard cancer treatments, including surgery and systemic therapies such as chemotherapy, immunotherapy, targeted and hormone therapies are crucial components of providing oncologic care to minimize negative effects to the mother and developing fetus. Radiation and proton therapy are also options that may be employed in specific circumstances. Finally, this article will address the long-term treatment effects of these therapies on future fertility. [ABSTRACT FROM AUTHOR]

Based on WHO data, there is about 14% average of patients who suffer from a severe level of Covid-19 disease and 5% of patients admitted to the ICU (Intensive Care Unit) are known to have symptoms of thromboembolism and coagulopathy disorders. The current management of Covid-19 therapy requires heparin. This research aims to find out the accuracy of the heparin regimen, to determine the improvement of the patient's clinical condition, the side effects of heparin based on clinical response, to analyze the relationship between the accuracy of the therapeutic regimen and the improvement of the patient's clinical condition, and also to know the incidence of side effects after heparin use. The type of this research was descriptive-analytic with a cohort design with retrospective data collection. The data were collected by taking medical records at PKU Muhammadiyah Gamping Hospital Yogyakarta. Moreover, the data were collected including heparin therapy regimens with subjective condition and patient objective during the therapy. The data obtained were analyzed by using univariate analysis technique and bivariate analysis technique. The results showed there were 61 patients who fulfilled the inclusion criteria. The evaluation of the accuracy the heparin therapy regimen obtained 95.08% correct results and 4.92% incorrect results. The analysis result of the accuracy the therapeutic regimen showed a significant relationship with clinical improvement with parameters APTT number (p=0.006; RR=0.155; CI = 0.085-0.283). Whereas, there was not found a significant relationship between the accuracy of the therapeutic regimen with the incidence of side effects (p>0.05). [ABSTRACT FROM AUTHOR]

Neurological complications in pregnancy and the puerperium deserve particular attention from specialists due to the worsening of the clinical picture for both the mother and the fetus. This narrative review of existing data in the literature aims to analyze the most common "red flag symptoms" attributable to neurological complications such as pre-eclampsia (PE), eclampsia, HELLP syndrome, posterior reversible encephalopathy syndrome (PRES), cerebral vasoconstriction syndrome (RCVS), stroke, CVS thrombosis, pituitary apoplexy, amniotic fluid embolism and cerebral aneurysm rupture, with the aim of providing a rapid diagnostic algorithm useful for the early diagnosis and treatment of these complications. The data were derived through the use of PubMed. The results and conclusions of our review are that neurological complications of a vascular nature in pregnancy and the puerperium are conditions that are often difficult to diagnose and manage clinically. For the obstetrics specialist who is faced with these situations, it is always important to have a guide in mind in order to be able to unravel the difficulties of clinical reasoning and promptly arrive at a diagnostic hypothesis. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to estimate the incidence of fatal amniotic fluid embolism, describe its risk factors, and analyze perinatal outcomes. Methods: Maternity cases and newborn records of amniotic fluid embolism were collected from the Zhejiang Maternal Surveillance System from October 2006 to October 2019. This study strictly limited the diagnostic criteria for AFE and excluded suspicious cases in order to minimize false-positive AFE cases. The risk factors of fatal amniotic fluid embolism and the relationship between perinatal prognosis and AFE were investigated using logistic regression analysis, estimating the adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results: 149 cases of amniotic fluid embolism were registered, of which 80 cases were fatal. The estimated fatal AFE incidence was 0.99 per 100,000. The occurrence of fatal AFE was significantly correlated with spontaneous vaginal delivery (aOR 12.3, 95% CI 3.3–39.2) and cardiac arrest (aOR 64.8, 95% CI 14.6–287.8). The average diagnosis time of fatal AFE is 85.51 min, and the peak period of female death is 1–12 h after the onset of the disease, accounting for 60% (48/80) of cases. Fatal amniotic embolism is a cause of intrauterine fetal death and fetal death during delivery (aOR 11.957, 95% CI 1.457–96.919; aOR 13.152, 95% CI 1.636–105.723). Of the 149 confirmed AFE cases, 11 cases of stillbirth occurred, 12 cases were stillborn, and 7 cases of neonatal death were reported. The perinatal mortality rate was 202 per 1000. Conclusions: Early detection, diagnosis, and treatment of amniotic fluid embolism are essential to avoiding fatal AFE. Clinicians should fully evaluate the pros and cons of choosing the delivery method for pregnant women. When cardiac arrest occurs in women with amniotic fluid embolism, obstetricians should be particularly careful and provide timely and effective treatment to minimize the fatality rate. The outcome of AFE is not only related to maternal survival but also plays a decisive role in the prognosis of the infant over the perinatal period. [ABSTRACT FROM AUTHOR]

We report on the case of prenatal detection of trisomy 2 in placental biopsy and further algorithm of genetic counseling and testing. A 29-year-old woman with first-trimester biochemical markers refused chorionic villus sampling and preferred targeted non-invasive prenatal testing (NIPT), which showed low risk for aneuploidies 13, 18, 21, and X. A series of ultrasound examinations revealed increased chorion thickness at 13/14 weeks of gestation and fetal growth retardation, a hyperechoic bowel, challenging visualization of the kidneys, dolichocephaly, ventriculomegaly, increase in placental thickness, and pronounced oligohydramnios at 16/17 weeks of gestation. The patient was referred to our center for an invasive prenatal diagnosis. The patient's blood and placenta were sampled for whole-genome sequencing-based NIPT and array comparative genomic hybridization (aCGH), respectively. Both investigations revealed trisomy 2. Further prenatal genetic testing in order to confirm trisomy 2 in amniocytes and/or fetal blood was highly questionable because oligohydramnios and fetal growth retardation made amniocentesis and cordocentesis technically unfeasible. The patient opted to terminate the pregnancy. Pathological examination of the fetus revealed internal hydrocephalus, atrophy of brain structure, and craniofacial dysmorphism. Conventional cytogenetic analysis and fluorescence in situ hybridization revealed chromosome 2 mosaicism with a prevalence of trisomic clone in the placenta (83.2% vs. 16.8%) and a low frequency of trisomy 2, which did not exceed 0.6% in fetal tissues, advocating for low-level true fetal mosaicism. To conclude, in pregnancies at risk of fetal chromosomal abnormalities that refuse invasive prenatal diagnosis, whole-genome sequencing-based NIPT, but not targeted NIPT, should be considered. In prenatal cases of trisomy 2, true mosaicism should be distinguished from placental-confined mosaicism using cytogenetic analysis of amniotic fluid cells or fetal blood cells. However, if material sampling is impossible due to oligohydramnios and/or fetal growth retardation, further decisions should be based on a series of high-resolution fetal ultrasound examinations. Genetic counseling for the risk of uniparental disomy in a fetus is also required. [ABSTRACT FROM AUTHOR]

Amniotic fluid embolism (AFE) is a rare but potentially fatal complication of pregnancy. Prompt and aggressive resuscitative strategies are crucial in promoting survivability. We present a case of AFE resulting in cardiopulmonary collapse and subsequent cardiac arrest where we were able to safely deliver the baby and resuscitate the mother with veno‐arterial extracorporeal membrane oxygenation and Impella CP—a novel combination known as ECPELLA. We discuss the implications of this approach as a more efficacious strategy in resuscitating AFE‐induced cardiogenic shock and arrest. [ABSTRACT FROM AUTHOR]

Keywords: Fibrinogen concentrate; Placental abruption; Postpartum hemorrhage EN Fibrinogen concentrate Placental abruption Postpartum hemorrhage 820 822 3 10/04/23 20231001 NES 231001 Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s00540-023-03247-8. Fibrinogen was consumed rapidly in large quantities in these patients; their minimum fibrinogen levels (which were unmeasurable in two patients, i.e., < 40 mg/dL) were lower than those in patients with non-consumption coagulopathy. To the Editor In Japan, fibrinogen concentrate (FC) was approved for insurance coverage in 2021 for the treatment of hypofibrinogenemia associated with massive postpartum hemorrhage (PPH). [Extracted from the article]

This article, published in the journal Ultrasound in Obstetrics & Gynecology, examines the impact of Twin-twin transfusion syndrome (TTTS) on maternal circulation in twin pregnancies. The study analyzed data from three groups: singleton pregnancies, uncomplicated mono-chorionic diaphragmatic twin pregnancies, and TTTS cases. The results showed that TTTS cases had smaller left ventricular end-diastolic volume and end-systolic volume compared to the uncomplicated twin pregnancies, but no significant difference compared to singleton pregnancies. Additionally, TTTS cases had a higher left ventricular ejection fraction and heart rate. The study suggests that TTTS may decrease circulating blood volume and that maternal cardiac function may adapt to compensate for cardiac output in these cases. [Extracted from the article]

Background: Maternal mortality remains a major health problem in Ethiopia. To generate contextual evidence on the burden and distribution of existing causes and contributing factors for programmatic and individual-level decision-making, the Maternal Death Surveillance and Response System was introduced in 2013. This assessment describes the Ethiopian health system's readiness to avail evidence for decision-making through the MDSR system. Method: A cross-sectional study designed using the WHO framework for evaluating surveillance systems was used. By employing a multistage sampling, 631 health facilities and 539 health posts were included. ODK collect data entry software was used to collect data from September 2019 to April 2020. Findings are presented in text descriptions, graphs, maps, and tables. Findings: Four hundred (77.1%) health facilities (332 (74.6%) health centers and 68 (91.9%) hospitals) and 264 (71.5%) health posts reported implementing the MDSR system. Of the implementing health facilities, 349 (87.3%) had a death review committee, and only 42 (12.4%) were functional. About 89.4% of health centers and 79.4% of hospitals had sub-optimal maternal death identification and notification readiness. Only 23 (6.96%) and 18 (26.47%) MDSR-implementing health centers and hospitals had optimal readiness to investigate and review maternal deaths, respectively. Moreover, only 39 (14.0%) health posts had locally translated case definitions and 28 (10.6%) had verbal autopsy format to investigate maternal deaths. Six (1.5%) facility officers and 24 (9.1%) health extension workers were engaged in data analysis and evidence generation at least once during 2019/20. Regional variation is observed in system implementation. Conclusions and recommendations: Sub-optimal MDSR system implementation is recorded. Revitalizing the system by addressing all system components is critical. Having a national-level roadmap for MDSR system implementation and mobilizing all available resources and stakeholders to facilitate this is vital. Establishing a system for routine data quality monitoring and assurance by integrating with the existing PHEM structure, having a system for routine capacity building, advocacy, and monitoring and evaluating the availability and functionality of MDSR committees at health facilities are all critical. Digitalization, designing a system to fit emerging regions' health service delivery, and availing required resources for the system is key. [ABSTRACT FROM AUTHOR]

Background: Amniotic fluid embolism (AFE) is one of the main causes of maternal mortality in developed countries. The most critical AFE variants may be considered from the perspective of systemic inflammation (SI), a general pathological process that includes high levels of systemic inflammatory response, neuroendocrine system distress, microthrombosis, and multiple organ dysfunction syndrome (MODS). This research work aimed to characterize the dynamics of super-acute SI using four clinical case studies of patients with critical AFE. Methods: In all the cases, we examined blood coagulation parameters, plasma levels of cortisol, troponin I, myoglobin, C-reactive protein, IL-6, IL-8, IL-10, and TNF-α, and calculated the integral scores. Results: All four patients revealed the characteristic signs of SI, including increased cytokine, myoglobin, and troponin I levels, changes in blood cortisol, and clinical manifestations of coagulopathy and MODS. At the same time, the cytokine plasma levels can be characterized not only as hypercytokinemia, and not even as a "cytokine storm", but rather as a "cytokine catastrophe" (an increase of thousands and tens of thousands of times in proinflammatory cytokine levels). AFE pathogenesis involves rapid transition from the hyperergic shock phase, with its high levels of a systemic inflammatory response over to the hypoergic shock phase, characterized by the mismatch between low systemic inflammatory response values and the patient's critical condition. In contrast to septic shock, in AFE there is a much more rapid succession of SI phases. Conclusion: AFE is one of the most compelling examples for studying the dynamics of super-acute SI. [ABSTRACT FROM AUTHOR]

Background: A growing number of cytogenetic techniques have been used for prenatal diagnosis. This study aimed to demonstrate the usefulness of karyotyping, BACs-on-Beads (BoBs) assay and single nucleotide polymorphism (SNP) array in prenatal diagnosis during the second trimester based on our laboratory experience. Methods: A total of 10,580 pregnant women with a variety of indications for amniocentesis were enrolled in this retrospective study between January 2015 and December 2020, of whom amniotic fluid samples were analysed in 10,320 women. The main technical indicators of participants in the three different technologies were summarized, and cases of chromosome abnormalities were further evaluated. Results: The overall abnormality detection rate of karyotyping among all the amniotic fluid samples was 15.4%, and trisomy 21 was the most common abnormality (20.9%). The total abnormality detection rate of the BoBs assay was 5.6%, and the diagnosis rate of microdeletion/microduplication syndromes that were not identified by karyotyping was 0.2%. The detection results of the BoBs assay were 100.0% concordant with karyotyping analysis in common aneuploidies. Seventy (87.5%) cases of structural abnormalities were missed by BoBs assay. The total abnormality detection rate of the SNP array was 21.6%. The detection results of common aneuploidies were exactly the same between SNP array and karyotyping. Overall, 60.1% of structural abnormalities were missed by SNP array. The further detection rate of pathogenic significant copy number variations (CNVs) by SNP was 1.4%. Conclusions: Karyotyping analysis combined with BoBs assay or SNP array for prenatal diagnosis could provide quick and accurate results. Combined use of the technologies, especially with SNP array, improved the diagnostic yield and interpretation of the results, which contributes to genetic counselling. BoBs assay or SNP array could be a useful supplement to karyotyping. [ABSTRACT FROM AUTHOR]

Nontrombotic pulmonary embolism represents the embolization of different types of materials (cells, organisms, gas, foreign material) into pulmonary circulation. The disease is uncommon, and clinical presentation together with laboratory findings are nonspecific. Its pathology is usually misdiagnosed based on imaging findings as pulmonary thromboembolism, but the correct diagnosis is essential because different therapeutic approaches are required. In this context, knowledge of the risk factors associated with nontrombotic pulmonary embolism and specific clinical symptoms is fundamental. Our objective was to discuss the specific features of the most common etiologies of nontrombotic pulmonary embolism, gas, fat, amniotic fluid, sepsis and tumors, to provide assistance for a rapid and correct diagnosis. Because the most common etiologies are iatrogenic, knowledge of the risk factors could be an important tool for prevention or rapid treatment if the disease develops during different procedures. The diagnosis of nontrombotic pulmonary embolisms represent a laborious challenge, and endeavors should be made to prevent development and increase awareness of this disease. [ABSTRACT FROM AUTHOR]

Objective: To determine the significance of tumor necrosis factor‐α (TNF‐α) and matrix metalloproteinase‐8 (MMP‐8) in vaginally obtained amniotic fluid predicting fetal inflammatory response syndrome (FIRS) after preterm premature rupture of membranes (PPROM). Methods: In this prospective case–control study, TNF‐α and MMP‐8 concentrations were evaluated in vaginally obtained amniotic fluid from women with PPROM at 22–34 weeks of pregnancy. Biomarkers' concentrations were determined using an enzyme‐linked immunosorbent assay. Patients were divided into two groups: the FIRS group (cord blood interleukin‐6 > 11 pg/ml or histological funisitis) and the non‐FIRS group (without these findings). The data were analyzed using R package (R–4.0.5). Results: The median TNF‐α and MMP‐8 concentrations in amniotic fluid from the 145 women included in the study were higher in the FIRS group than in the non‐FIRS group. The area under the curve of TNF‐α and MMP‐8 was 0.77 and 0.75, respectively. The TNF‐α concentration cut‐off predicting FIRS was 89.20 pg/ml and was 170.76 pg/ml for MMP‐8. In regression analysis, MMP‐8 concentration was an independent predictor for FIRS. An MMP‐8 concentration greater than 170 ng/ml and a TNF‐α concentration greater than 89 pg/ml increased the odds of FIRS 7.62 and 14.92 times, respectively. Conclusions: MMP‐8 and TNF‐α concentrations in vaginally obtained amniotic fluid may be good predictors for FIRS after PPROM before 34 weeks of pregnancy. The non‐invasive amniotic fluid analysis could be an alternative method to invasive amniocentesis. Synopsis: MMP‐8 and TNF‐α in vaginally obtained amniotic fluid are significant predictors for FIRS after PPROM; non‐invasive analysis could be an alternative to invasive amniocentesis. [ABSTRACT FROM AUTHOR]

The in utero microbiome hypothesis has been long debated. This hypothesis will change our comprehension of the pioneer human microbiome if proved correct. In 60 uncomplicated pregnancies, we profiled the microbiome of chorionic villi (CV) and amniotic fluids (AF) in relation to maternal saliva, rectum, and vagina and the soluble cytokines cascade in the vagina, CV and AF. In our series, 12/37 (32%) AF and 10/23 (44%) CV tested positive for bacterial DNA. CV and AF harbored bacterial DNA of Streptococcus and Lactobacillus, overlapping that of the matched oral and vaginal niches, which showed a dysbiotic microbiome. In these pregnant women, the immune profiling revealed an immune hyporesponsiveness in the vagina and a high intraamniotic concentration of inflammatory cytokines. To understand the eventual role of bacterial colonization of the CV and AF and the associated immune response in the pregnancy outcome, further appropriate studies are needed. In this context, further studies should highlight if the hematogenous route could justify the spread of bacterial DNA from the oral microbiome to the placenta and if vaginal dysbiosis could favor the likelihood of identifying CV and AF positive for bacterial DNA. [ABSTRACT FROM AUTHOR]

Background: Pregnant women often experience the fatal outcome of their pregnancy both in developed and impoverished countries. Due to strong health systems and services, factual and historical data are available from developed countries. However, the prevalence trend and risk factors of a fatal termination of pregnancy in developing countries like Bangladesh are still lacking. Objective: The objective of the current study was to determine the 20 years trend of prevalence and risk factors of fatal pregnancy termination from 1997 to 2018 in Bangladesh. Method: This study utilised the publicly available seven consecutive cross-data on Bangladesh Demographic and Health Surveys data since 1997 following identical methods among women of reproductive age. Respondent was asked if they had had a fatal pregnancy termination ever. A Generalised Linear model with a log-Poisson link was used to estimate the relative risk of different predictors for four survey time points (1998, 2004, 2011, 2018). Results: The proportions of fatal pregnancy termination in urban and rural areas were 24% vs. 19% and 24% vs. 22% in 1997 and 2018, respectively. In multivariable analysis, maternal age 30 years and above and obesity were strongly associated in all survey time points. The richest wealth index had a weak association in 1997 but was strongly associated in 2011 and 2018. A significant modest association with secondary complete education level was only observed in 2018. Conclusion: The overall proportions of fatal pregnancy termination in Bangladesh remain nearly static; however, its risk factors differed across different survey time points. [ABSTRACT FROM AUTHOR]

Canadian stillbirth data are limited, and a significant proportion of pregnancies resulting in stillbirth have no attributable cause. The objective of this study was to characterize stillbirth case investigations and management at a tertiary care hospital in Ontario, Canada. This was a retrospective chart review study of all cases of singleton stillbirth at The Ottawa Hospital between 1 January 2012 and 31 December 2017. Terminations and multiples stillbirths were excluded. Chart reviews were conducted to extract maternal sociodemographic, obstetrical, and fetal characteristics, including results from antenatal ultrasounds, autopsy, placenta pathology, and laboratory investigations. A total of 155 eligible cases of stillbirth were identified, resulting in a 6-year stillbirth rate of 4.2 per 1000 total births. The median maternal age was 31.0 years (IQR: 29.0, 35.0) and the median gestational age at delivery was 28 weeks (IQR: 24, 35). A total of 9 (5.8%) pregnant individuals had a history of previous stillbirth. Of the 155 stillbirths, 35% underwent the full suite of post-loss laboratory, placental, and fetal autopsy investigations. 63.2% of cases had post-loss laboratory investigations completed. 76% and 71% of cases had fetal autopsy and placenta pathology evaluations completed, respectively. Antenatal characteristics associated with stillbirth included fetal anomalies/genetic markers (27.1%), umbilical cord and placental anomalies (24.5%), fetal growth abnormalities (27.7%), cervical/uterine abnormalities (11.6%), and amniotic fluid abnormalities (25.1%). The most common autopsy findings included evidence of infection (22.7%), fetal anomalies (12.6%), and fetal hypoxia (10%). The most common placental pathology findings included features of placental insufficiency (21.8%), retroplacental abnormalities (16.3%), and umbilical cord accident/infarct (15.4%). Our findings demonstrate that as many as two-thirds of singleton stillbirth cases at our center did not receive the post-perinatal loss investigations recommended by clinical practice guidelines. More thorough collection of post-stillbirth data at all levels (institutional, provincial, national) is warranted to improve our understanding of stillbirth epidemiology, etiology, and management in Canada. [ABSTRACT FROM AUTHOR]

The Crumbs homolog‐2 (CRB2)‐related syndrome (CRBS‐RS) is a rarely encountered condition initially described as a triad comprising ventriculomegaly, Finnish nephrosis, and elevated alpha‐fetoprotein levels in maternal serum and amniotic fluid. CRB2‐related syndrome is caused by biallelic, pathogenic variants in the CRB2 gene. Recent reports of CRB2‐RS have highlighted renal disease with persistent proteinuria and steroid‐resistant nephrotic syndrome (SRNS). We report six new and review 28 reported patients with pathogenic variants in CRB2. We compare clinical features and variant information in CRB2 in patients with CRB2‐RS and in those with isolated renal disease. The kidneys were the most frequently involved body system and 11 patients had only renal manifestations with SRNS or nephrotic syndrome. Central nervous system involvement was the next most common manifestation, followed by cardiac findings that included Scimitar syndrome. There was a significant clustering of pathogenic variants for CRB2‐RS in exons 8 and 10, whereas pathogenic variants in exons 12 and 13 were associated with isolated renal disease. Further information is needed to determine optimal management but monitoring for renal and ocular complications should be considered. [ABSTRACT FROM AUTHOR]

Objective: To investigate the role of fetal brain magnetic resonance imaging (MRI) in detecting associated anomalies in fetuses with congenital cytomegalovirus (CMV) infection and normal neurosonography. Methods: This was a multicenter, retrospective cohort study of patients examined between 2012 and 2021 in 11 referral fetal medicine centers in Italy. Inclusion criteria were fetuses with congenital CMV infection diagnosed by polymerase chain reaction analysis of amniotic fluid, pregnancies that underwent detailed multiplanar ultrasound assessment of the fetal brain as recommended by the International Society of Ultrasound in Obstetrics and Gynecology, maternal age ≥ 18 years, normal fetal karyotype and MRI performed within 3 weeks after the last ultrasound examination. The primary outcome was the rate of central nervous system (CNS) anomalies detected exclusively on MRI and confirmed after birth or autopsy in fetuses with a prenatal diagnosis of congenital CMV infection and normal neurosonography at diagnosis. Additional CNS anomalies were classified into anomalies of the ventricular and the periventricular zone, intracranial calcifications in the basal ganglia or germinal matrix, destructive encephalopathy in the white matter, malformations of cortical development, midline anomalies, posterior fossa anomalies and complex brain anomalies. We evaluated the relationship between the incidence of structural CNS malformations diagnosed exclusively on fetal MRI and a number of maternal and gestational characteristics. Univariate and multivariate logistic regression analyses were used to identify and adjust for potential independent predictors of the MRI diagnosis of fetal anomalies. Results: The analysis included 95 fetuses with a prenatal diagnosis of congenital CMV infection and normal neurosonography referred for prenatal MRI. The rate of structural anomalies detected exclusively at fetal MRI was 10.5% (10/95). When considering the type of anomaly, malformations of cortical development were detected on MRI in 40.0% (4/10) of fetuses, destructive encephalopathy in 20.0% (2/10), intracranial calcifications in the germinal matrix in 10.0% (1/10) and complex CNS anomalies in 30.0% (3/10). On multivariate logistic regression analysis, only CMV viral load in the amniotic fluid, expressed as a continuous variable (odds ratio (OR), 1.16 (95% CI, 1.02–1.21); P = 0.02) or categorical variable (> 100 000 copies/mL) (OR, 12.0 (95% CI, 1.2–124.7); P = 0.04), was independently associated with the likelihood of detecting fetal anomalies on MRI. Associated anomalies were detected exclusively at birth and missed by both prenatal neurosonography and fetal MRI in 3.8% (3/80) of fetuses with congenital CMV infection. Conclusions: Fetal brain MRI can detect additional anomalies in a significant proportion of fetuses with congenital CMV infection and negative neurosonography. Viral load in the amniotic fluid was an independent predictor of the risk of associated anomalies in these fetuses. The findings of this study support a longitudinal evaluation using fetal MRI in congenital CMV infection, even in cases with negative neurosonography at diagnosis. © 2022 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]