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BACKGROUND: Severe acute respiratory syndrome-Corona Virus-2 (SARS-CoV2) has infected more than 500 million and has claimed the lives of more than 6.1 million people worldwide. CASE: We are presenting a 10-year-old girl who fulfilled the criteria of Multisystem inflammatory disease associated with COVID-19(MIS-C). She had fever of > 3 days, muco-cutaneous lesions, hypotension/shock, myocardial dysfunction, acute gastrointestinal symptoms, elevated markers of inflammation, coagulopathy without other microbial causes and positive COVID RT-PCR test. CONCLUSIONS: When pediatric patients present with the above symptoms and signs we should have a high index of suspicion of MIS-C for timely action and better outcome. [ABSTRACT FROM AUTHOR]

Introduction: Maternal mortality continues to be of great concern with most maternal deaths occurring in developing countries which accounts for about one in 180 deaths during childbirth as compared to 1 in 4,900 in developed nations. Aim: To determine the common causes of maternal deaths and to study their clinicopathological profile. Materials and Methods: The present study included series of 16 cases of maternal deaths from January 2018 to June 2020. The study was conducted at Indira Gandhi Medical College, Nagpur, Maharashtra, India. The post mortem examination in all these deaths was conducted as per institutional policy. The external, in-situ examination along with histological findings are studied in each case. Results: The study group comprised of 16 cases, in the range of 21 to 37 years with a mean age of 27 years. Seven deaths antepartum, 2 intrapartum while seven postpartum period and all the deliveries took place in hospital. Amongst these 16 deaths, 11 were brought dead while in rest five, deaths were hospital based. Conclusion: The autopsy provides an invaluable information and insights about pathophysiological changes and sequence of events leading to death. Usefulness of relevant clinical data in complementing the diagnosis cannot be overemphasized. Their in-depth analysis can certainly help to prevent future maternal deaths and also in early picking up of complications; which further can avoid this preventable and inevitable loss and reduces the national burden on maternal mortality. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID-19) pandemic is caused by a new coronavirus family member, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is linked with many disease manifestations in multiple organ systems on top of pulmonary manifestations. COVID-19 is also accompanied by several cardiovascular pathologies including myocarditis, acute myocardial infarction, stress cardiomyopathy, arterial and venous thromboembolism, pericarditis, and arrhythmias. The pathophysiological mechanisms explaining these clinical symptoms are multifactorial including systemic inflammation (cytokine storm), coagulopathy, direct viral invasion through angiotensin-converting enzyme 2, hypoxemia, electrolyte imbalance, and fever. Several case reports have shown the development of an unusual cardiovascular event after receiving SARS-CoV-2 vaccines. The current article aimed to review cardiovascular involvement in the COVID-19 pandemic with respect to clinical features, pathogenesis, long-term effects, and the adverse effects of treatments and vaccines based on the latest evidence. [ABSTRACT FROM AUTHOR]

The maintenance of coordinated powerful episodic contractions of the uterus is the crucial factor for normal labor. The uterine contractility is gradually enhanced with the progression of labor, which is related to the gene expression of the myometrium. Competing endogenous RNA (ceRNA) can also regulate the gene expression. To better understand the role of ceRNA network in labor, transcriptome sequencing was performed on the myometrium of 17 parturients at different labor durations (0–24 h). From this, expression levels of mRNA, long non-coding RNA (lncRNA), circular RNA (circRNA), and microRNA (miRNA) were correlated with labor duration. Then, targeting relationships between mRNAs, lncRNAs, circRNAs, and miRNAs were predicted, and the ceRNA regulatory network was established. The mRNA expression patterns associated with cervical dilation and postpartum bleeding were further investigated. This analysis identified 932 RNAs positively correlated with labor duration (859 mRNAs, 28 lncRNAs, and 45 circRNAs) and 153 RNAs negatively correlated with labor duration (122 mRNAs, 28 lncRNAs, and 3 miRNAs). These mRNAs were involved in protein metabolism, transport, and cytoskeleton functions. According to the targeting relationship among these ceRNAs and mRNAs, a ceRNA network consisting of 3 miRNAs, 72 mRNAs, 2 circRNAs, and 1 lncRNA was established. In addition, two mRNA expression patterns were established using time-series analysis of mRNA expression in different phases of cervical dilation. A ceRNA network analysis for blood loss was performed; postpartum bleeding was closely related to inflammatory response, angiogenesis, and hemostasis. This study identified human myometrial transcriptome and established the ceRNA regulatory network depending on labor duration and highlighted the dynamic changes that occur at ceRNAs during parturition, which need to be considered more in the future to better understand how changes in gene expression are relevant to functional changes in human myometrium at labor. [ABSTRACT FROM AUTHOR]

Spontaneous preterm delivery (<37 gestational weeks) has a multifactorial etiology with still incompletely identified pathways. Amniotic fluid is a biofluid with great potential for insights into the feto-maternal milieu. It is rich in metabolites, and metabolic consequences of inflammation is yet researched only to a limited extent. Metabolomic profiling provides opportunities to identify potential biomarkers of inflammatory conditioned pregnancy complications such as spontaneous preterm delivery. The aim of this study was to perform metabolomic profiling of amniotic fluid from uncomplicated singleton pregnancies in the mid-trimester to identify potential biomarkers associated with spontaneous preterm delivery and gestational duration at delivery. A secondary aim was to replicate previously reported mid-trimester amniotic fluid metabolic biomarkers of spontaneous preterm delivery in asymptomatic women. A nested case-control study was performed within a larger cohort study of asymptomatic pregnant women undergoing mid-trimester genetic amniocentesis at 14–19 gestational weeks in Gothenburg, Sweden. Medical records were used to obtain clinical data and delivery outcome variables. Amniotic fluid samples from women with a subsequent spontaneous preterm delivery (n = 37) were matched with amniotic fluid samples from women with a subsequent spontaneous delivery at term (n = 37). Amniotic fluid samples underwent untargeted metabolomic analyses using liquid chromatography-mass spectrometry. Multivariate random forest analyses were used for data processing. A secondary targeted analysis was performed, aiming to replicate previously reported mid-trimester amniotic fluid metabolic biomarkers in women with a subsequent spontaneous preterm delivery. Multivariate analysis did not distinguish the samples from women with a subsequent spontaneous preterm delivery from those with a subsequent term delivery. Neither was the metabolic profile associated with gestational duration at delivery. Potential metabolic biomarker candidates were identified from four publications by two different research groups relating mid-trimester amniotic fluid metabolomes to spontaneous PTD, of which fifteen markers were included in the secondary analysis. None of these were replicated. Metabolomic profiles of early mid-trimester amniotic fluid were not associated with spontaneous preterm delivery or gestational duration at delivery in this cohort. [ABSTRACT FROM AUTHOR]

Sudan ebolavirus (SUDV) is one of four members of the Ebolavirus genus known to cause Ebola Virus Disease (EVD) in humans, which is characterized by hemorrhagic fever and a high case fatality rate. While licensed therapeutics and vaccines are available in limited number to treat infections of Zaire ebolavirus, there are currently no effective licensed vaccines or therapeutics for SUDV. A well-characterized animal model of this disease is needed for the further development and testing of vaccines and therapeutics. In this study, twelve cynomolgus macaques (Macaca fascicularis) were challenged intramuscularly with 1000 PFUs of SUDV and were followed under continuous telemetric surveillance. Clinical observations, body weights, temperature, viremia, hematology, clinical chemistry, and coagulation were analyzed at timepoints throughout the study. Death from SUDV disease occurred between five and ten days after challenge at the point that each animal met the criteria for euthanasia. All animals were observed to exhibit clinical signs and lesions similar to those observed in human cases which included: viremia, fever, dehydration, reduced physical activity, macular skin rash, systemic inflammation, coagulopathy, lymphoid depletion, renal tubular necrosis, hepatocellular degeneration and necrosis. The results from this study will facilitate the future preclinical development and evaluation of vaccines and therapeutics for SUDV. [ABSTRACT FROM AUTHOR]

Objective This study aimed 1) to investigate the clinical characteristics of amniotic fluid embolism (AFE) cases clinically diagnosed by maternal fetal medicine (MFM) specialists in Korea, 2) to check the disagreement with 4 recently proposed criteria by the Society for Maternal-Fetal Medicine (SMFM) for research purpose, and 3) to compare maternal outcomes between cases satisfying all 4 criteria and cases with at least 1 missing criterion. Methods This study included 12 patients clinically diagnosed with AFE from 7 referral hospitals in Korea. We collected information, including maternal age, symptoms of AFE, the amount of transfusion, and maternal mortality. Results The median maternal age was 33 years (range, 28–40 years). Regarding symptoms, cardiovascular arrest, hypotension, respiratory compromise, clinical coagulopathy, and neurologic signs were observed in 41.7%, 83.3%, 83.3%, 100%, and 66.7% of the cases, respectively. Among the 12 cases, 5 women died and 2 suffered severe neurologic disability, showing an intact survival rate of 41.7%. Disagreement with all 4 criteria proposed by the SMFM was found in 66.7% of the cases, due to the lack of criteria for disseminated intravascular coagulation or strict onset time (

Karyotype analysis, fluorescence in situ hybridization (FISH) and microarray comparative genomic hybridization (array CGH) are currently the mainstay of invasive prenatal diagnosis of chromosomal abnormalities. Currently, array CGH is recommended by scientific organizations as a first-line test in the prenatal diagnosis of fetuses with sonographic abnormalities. The aim of this study was to present the results of array CGH in prenatal diagnosis. In this retrospective study, a total of 348 amniotic fluid samples from pregnant women with various indications were collected between 2018 and 2023. A total of 348 karyotypes were performed, together with 63 FISH and 43 array CGH analyses. The median maternal age was 33 range 21 – 44 years and the median gestational week was 19 range 13 – 37 weeks. The most common indication for array CGH was sonographic fetal anomaly, which was present in 84% (36/43) of cases. Soft ultrasound markers were observed in 19% (7/36) and hard markers in 81% (29/36) of cases. Abnormal molecular karyotype results were found in 18% (8/43) of the participants. Our results suggest that the use of the microarray method improves the detection rate of pathogenic single-copy losses in fetuses with sonographic abnormalities, although counselling prior to analysis is crucial. [ABSTRACT FROM AUTHOR]

We present the case of a postpartum woman presenting with acute dyspnoea and hypoxia. She was found to have liver enzyme derangement with evidence of synthetic dysfunction. Computed tomography of her chest showed ground-glass opacities. The causes of this phenomenon are discussed, including the difficulties in differentiating amniotic fluid embolism and acute fatty liver in pregnancy. Pulmonary fat embolism is also considered as a differential diagnosis. [ABSTRACT FROM AUTHOR]

Human envenoming from the bite of the abundant hump-nosed pit viper (Hypnale spp.) (HNPV) is a frequent occurrence with victims experiencing unpleasant and sometimes life-threatening consequences. Further, clinico-pathology, treatment and management measures in HNPV envenomed dogs are under recognized. Prospective investigations were performed to assess the clinico-pathology and management options for HNPV envenomed dogs brought to the University of Peradeniya's Veterinary Teaching Hospital from January, 2012 to March 2018. We recorded the local and systemic manifestations, hematological and urinary abnormalities of 78 dogs in which HNPV bite had been witnessed by the owner. Mild swelling, extensive swelling, hemorrhagic blistering and hemorrhagic bullae at the site of bite were observed in 59%, 31%, 6% and 4% of the dogs, respectively. Some dogs were subjected to surgical excision of necrotized tissue including limb amputation. We observed the following systemic clinical effects in envenomed dogs: neurotoxicity (13%), acute kidney injury (AKI) (14%) and coagulopathy (16%). All dogs showed leukocytosis with mean white blood cell count of 25.25 × 103/µL. Mild anemia and thrombocytopenia were detected in 29% of the dogs. There was a significant correlation between extent of local tissue injuries with length of hospitalization (LH). The mean time of coagulopathy observed was 21.3 h (IQR: 8–48 h). In coagulopathic dogs, there was a strong correlation between LH and extent of local tissue injury (rs = 0.7751, P < 0.0001); LH and whole blood clotting time(CT) (rs = 1.0, P < 0.0001); PT and aPTT (rs = 0.4712, P < 0.001). LH was significantly correlated with the development of AKI (p = 0.0013). Lack of specific antivenom (AVS) for HNPV envenoming provided an opportunity to study the remaining treatment options. Therefore, the study allowed the identification of local and systemic effects, hematological abnormalities, possible supportive treatments and drawbacks of management measures for envenomed dogs. [ABSTRACT FROM AUTHOR]

Amniotic fluid embolism (AFE) is a rare and often fatal complication of pregnancy that occurs during the puerperium. The low incidence of AFE has resulted in few large studies, which makes evidence-based management of AFE challenging. The use of extracorporeal membrane oxygenation (ECMO) has been reported but is limited by availability and challenges managing anticoagulation. In this report, we detail the case of a 29-year-old female who suffered from an AFE leading to cardiac arrest and disseminated intravascular coagulopathy. She was treated with protocolized A-OK (adenosine, ondansetron, and ketorolac), emergency c-section, cardiopulmonary resuscitation, massive blood transfusion, and rotational thromboelastometry-guided ECMO, allowing her to forgo initial anticoagulation. After a prolonged rehabilitation with initial poor neurological status, she made a complete recovery. In this report, we describe the protocols that contributed to her recovery and detail management of complicated AFE for other clinicians. [ABSTRACT FROM AUTHOR]

Immersion pulmonary edema is a rare, underrecognized, and potentially lethal pathology developing during scuba diving and other immersion-related activities (swimming or apnoea). Physiopathology is complex and not fully understood, but its mechanisms involve an alteration of the alveolo-capillary barrier caused by transcapillary pressure elevation during immersion, leading to an accumulation of fluid and blood in the alveolar space. Diagnosis remains a challenge for clinicians and forensic practionner. The symptoms begin during ascent, with cough, frothy sputum, and hemoptysis. Auscultation reveals signs of pulmonary edema. Pulmonary CT scan, which is the radiological exam of choice, shows ground glass opacities and interlobular thickening, eventually demonstrating a patterned distribution, likely in the anterior segments of both lungs. Apart from the support of vital functions, there is no specific treatment and hyperbaric oxygen therapy is not systematically recommended. We present a case of fatal IPE occurring in a recreational diver who unfortunately died shortly after his last dive. Diagnosis was made after complete forensic investigations including post-mortem-computed tomography, complete forensic autopsy, histological examination, and toxicological analysis. [ABSTRACT FROM AUTHOR]

The timing of umbilical cord and placental thrombosis in the third trimester intrauterine fetal death (TT-IUFD) may be fundamental for medico-legal purposes, when it undergoes medical litigation due to the absence of risk factors. Authors apply to human TT-IUFD cases a protocol, which includes histochemistry and immunohistochemistry (IHC) for the assessment of thrombi's chronology. A total of 35 thrombi of umbilical cord and/or placenta were assessed: 2 in umbilical artery, 6 in umbilical vein, 15 in insertion, 10 in chorionic vessels, 1 in fetal renal vein, 1 in fetal brachiocephalic vein. Thrombi's features were evaluated with hematoxylin–eosin, Picro-Mallory, Von Kossa, Perls, and immunohistochemistry for CD15, CD68, CD31, CD61, and Smooth Muscle Actin. The estimation of the age of the thrombi was established by applying neutrophils/macrophages ratio taking into consideration, according to literature, the presence of hemosiderophagi, calcium deposition, and angiogenesis. To estimate an approximate age of fresh thrombi (< 1 day), a non-linear regression model was tested. Results were compared to maternal risk factors, fetal time of death estimated at autopsy, mechanism, and cause of death. Our study confirms that the maternal risk factors for fetal intrauterine death and the pathologies of the cord, followed by those of the placental parenchyma, are the conditions that are most frequently associated with the presence of thrombi. Results obtained with histological stainings document that the neutrophile/macrophage ratio is a useful tool for determining placental thrombi's age. Age estimation of thrombi on the first day is very challenging; therefore, the study presented suggests the N/M ratio as a parameter to be used, together with others, i.e., hemosiderophagi, calcium deposition, and angiogenesis, for thrombi's age determination, and hypothesizes that its usefulness regards particularly the first days when all other parameters are negative. [ABSTRACT FROM AUTHOR]

Background: For a healthy parturient, a cardiopulmonary collapse that suddenly occurs shortly after an uneventful caesarean section is a relatively rare event and presents a significant challenge for the anesthesia provider.Case Presentation: Amniotic fluid embolism (AFE) is characterized by acute and rapid collapse and is well known to the obstetric team. Our patient experienced sudden cardiovascular collapse, severe respiratory difficulty and hypoxia, in the absence of other explanations for these findings at the time, and thus AFE was immediately become the focus of the consideration. However, there is no quick, standard laboratory test for AFE, therefore the diagnosis is one of exclusion based on presenting symptoms and clinical course. After given symptomatic treatment, the patient made an uneventful initial recovery in a short period and developed a rash. We recognized that the postpartum shock was associated with delayed anaphylaxis of antibiotics.Conclusions: These observations have implications for understanding whenever administering drugs in surgery, which may affect the anesthesiologist's judgment regarding the complications of anesthesia. Even though serious complications of common perioperative drugs may rarely occur, anesthesia providers should be aware of the consideration. Early recognition and effective treatment are more important than prompt diagnosis. [ABSTRACT FROM AUTHOR]

Background: Amniotic fluid embolism (AFE) is a rare but often catastrophic complication of pregnancy that leads to cardiopulmonary dysfunction and severe disseminated intravascular coagulopathy (DIC). Although few case reports have reported successful use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) with AFE, concerns can be raised about the increased bleeding risks with that device.Methods: This study included patients with AFE rescued by VA-ECMO hospitalized in two high ECMO volume centers between August 2008 and February 2021. Clinical characteristics, critical care management, in-intensive care unit (ICU) complications, and hospital outcomes were collected. ICU survivors were assessed for health-related quality of life (HRQL) in May 2021.Results: During that 13-year study period, VA-ECMO was initiated in 54 parturient women in two high ECMO volume centers. Among that population, 10 patients with AFE [median (range) age 33 (24-40), SAPS II at 69 (56-81)] who fulfilled our diagnosis criteria were treated with VA-ECMO. Pregnancy evolved for 36 (30-41) weeks. Seven patients had a cardiac arrest before ECMO and two were cannulated under cardiopulmonary resuscitation. Pre-ECMO hemodynamic was severely impaired with an inotrope score at 370 (55-1530) μg/kg/min, a severe left ventricular ejection fraction measured at 14 (0-40)%, and lactate at 12 (2-30) mmol/L. 70% of these patients were alive at hospital discharge despite an extreme pre-ECMO severity and massive blood product transfusion. However, HRQL was lower than age-matched controls and still profoundly impaired in the role-physical, bodily pain, and general health components after a median of 44 months follow-up.Conclusion: In this rare per-delivery complication, our results support the use of VA-ECMO despite intense DIC and ongoing bleeding. Future studies should focus on customized, patient-centered, rehabilitation programs that could lead to improved HRQL in this population. [ABSTRACT FROM AUTHOR]

Spontaneous hemoperitoneum in pregnancy (SHP) is an uncommon, but very critical complication when present in pregnancy, leading to important morbidity and mortality for both mother and fetus. The etiology includes a large spectrum of causes, not taking into consideration trauma or other pathologies not pregnancy related. One of the most frequent triggers is the rupture of the varicose veins around the uterus that can occur either spontaneously or during labor, that can be associated with the unfortunate event of delivery of a stillborn baby. Endometriosis has been suspected to be also implicated in the apparition of spontaneous hemoperitoneum in pregnant women due to the fragility of the tissues associated with endometriosis chronic inflammation (ruptured endometrioma, intraabdominal adhesions, decidualization at the site of endometriotic implants). Even the operative vaginal delivery can conduct to this complication, but the cases described in the literature were also associated with lesion of endometriosis at the bleeding site. Moreover, assisted reproductive procedures (IVF-ET) is incriminated as one of the possible etiologies. The improvements in the resuscitation, operative and anesthetic management of these cases have lowered the maternal mortality, but perinatal mortality still has a high value (31%). Symptoms as acute or subacute abdominal pain, that can be associated or not with hypovolemic shock and signs of fetal affliction, identified as heart decelerations, should raise a question mark regarding the possibility of a hemoperitoneum. Electronic research for subject related reviews and articles has been made, using PubMed, Medline, Cochrane Data Base and also the current international guidelines regarding the management of hemoperitoneum in pregnancy, recommended by Obstetrics and Gynecology Societies in United States and United Kingdom. Adequate case management as hematologic analysis, abdominal ultrasound, CT scan or MRI should reveal free intrabdominal fluid and estimate the blood loss, which can then be confirmed by paracentesis or by direct urgent laparotomy or laparoscopy. The aim of the current review is to raise awareness of this rare, but potentially fatal, complication in pregnancy and its most appropriate management, according to the current information presented in the medical literature. [ABSTRACT FROM AUTHOR]

Neural tube defects (NTDs) are the most severe birth defects and the main cause of newborn death; posing a great challenge to the affected children, families, and societies. Presently, the clinical diagnosis of NTDs mainly relies on ultrasound images combined with certain indices, such as alpha‐fetoprotein levels in the maternal serum and amniotic fluid. Recently, the discovery of additional biomarkers in maternal tissue has presented new possibilities for prenatal diagnosis. Over the past 20 years, "omics" techniques have provided the premise for the study of biomarkers. This review summarizes recent advances in candidate biomarkers for the prenatal diagnosis of fetal NTDs based on omics techniques using maternal biological specimens of different origins, including amniotic fluid, blood, and urine, which may provide a foundation for the early prenatal diagnosis of NTDs. [ABSTRACT FROM AUTHOR]

Background. Atrial fibrillation (AF) is the most common heart rhythm disorder that has been shown to be associated with a significant increase in stroke and systemic embolism risk. The left atrial appendage (LAA) is a finger-like extension originating from the left atrium; the formation of thrombus in LAA is the main reason of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF). This study is aimed at finding out the risk of left atrial appendage thrombus (LAAT) in patients with nonvalvular atrial fibrillation (NVAF). Method. We retrospectively examined the clinic and left atrial computer tomography angiography (CTA) features of patients assessed in Zhengzhou No. 7 People's Hospital between January 2020 and January 2021 derivation. Student's t -test, chi-square test, receiver operating characteristics (ROC) curves, and logistic regression analysis were used to identify predictors of LAAT. Result. Of 480 patients included in the analysis, LAAT was found in approximately 9.2% of all patients. Univariate demographic predictors of LAAT included left atrium top and bottom diameter (LTD), left atrial appendage depth (LAAD), CHA2DS2-VASc, tachycardia bradycardia syndrome (TBS), and nonparoxysmal atrial fibrillation (PAF). In a multiple logistic regression analysis, the independent predictors of thrombus were LAAD > 23.45 mm (odds ratio: 4.216, 95% CI: 1.869-9.510, P = 0.001), TBS (odds ratio: 4.076, 95% CI: 1.655-10.038, P = 0.002), and non-PAF (odds ratio: 2.896, 95% CI: 1.183-7.094, P = 0.02). Conclusion. In NVAF patients with LAAT, evidence suggested that larger LAAD, non-PAF, and TBS present a high risk of LAAT. This is the first report demonstrating that the LAAD and TBS are associated with LAAT in patients with NVAF. [ABSTRACT FROM AUTHOR]

Background: Amniotic fluid embolism (AFE) is a rare disease that can lead to profound coagulopathy and hemorrhage, especially when combined with the laceration and bleeding of other organs. Intraoperative cell salvage (ICS) has been widely used for treating obstetric hemorrhage, but it remains unclear whether ICS can be used in the treatment of AFE.Case Presentation: We report the case of a 27-year-old woman at 39 weeks' gestation who suddenly developed severe abdominal pain, convulsions, loss of consciousness, and decreased vital signs during labor. Despite an emergency cesarean section being performed, the parturient experienced sudden cardiac arrest. Fortunately, the heart rate spontaneously recovered after effective cardiopulmonary resuscitation (CPR). Further abdominal exploration revealed right hepatic laceration with active bleeding. ICS was performed and the salvaged blood was promptly transfused back to the patient. Subsequently, the patient was diagnosed with AFE based on hypotension, hypoxia, coagulopathy, and cardiac arrest. The patient was transfused with 2899 mL salvaged blood during surgery with no adverse effects. At 60- and 90-day follow-ups, no complaints of discomfort or abnormal laboratory test results were observed in the mother or the baby.Conclusion: ICS was used to rescue patient with AFE, and ICS did not worsen the condition of patients with AFE. For pregnant women who received CPR, clinicians should explore the presence of hepatic laceration which can be fatal to patients. [ABSTRACT FROM AUTHOR]

To investigate the changes of serum levels of PLA2 and PAF in pregnant rats with amniotic fluid embolism. Methods The 30 healthy pregnant rats were divided into normal saline group (group A), amniotic fluid group (group B) and amniotic fluid meconium mixture group (group C). Healthy pregnant rats were anesthetized. After the anesthesia effect was generated, the left com-mon carotid artery was isolated from the posterior closure of the uterus, and the two channels of physiological recorder were connected with it to continuously monitor the hemodynamic indicators. The rats were then intravenously injected with saline, amniotic fluid and a mixture of amniotic fluid and meconium. The rat lung tissue was taken 1 hour later. HE and APK staining and CK16 immunohistochemistry were used to detect the success of the model. At two blood points 1 hour before and after the experiment, 1mL of blood was taken from the left carotid artery cannula of the prepared amniotic fluid embolization model rats. The contents of PLA2 and PAF in serum, amniotic fluid and amniotic fluid meconium mixture were determined by enzyme-linked immunoassay. The obtained data were processed by SPSS 20.0 software, and serum PLA2 and PAF concentrations were analysed by paired t test, covariance analysis and correlation regression analysis. Results The 3 hemodynamic indexes (systolic, diastolic and mean arterial pressure) of group B and group C were significantly lower than that of group A (P<0.05), while the 4 hemodynamic indexes of group B and group C were not significantly different(P>0.05). Meanwhile, there was no significant difference in heart rate between group A, group B and group C (P>0.05). In HE staining, the lung interstitium of the rats in group B and C was significantly widened, with hyperemia, edema and inflammatory cell infiltration, while that of group A was not observed. In AMP staining, the lung tubules of group B and C showed blue amorphous material and pink keratinized squamous epithelium, while those of group A did not. In CK16 staining, yellow particles and squamous epithelium could be seen in the lung tubules of rats in group B and C, but not in group A. After 1 hour of experiment, the PLA2 and PAF content in group Band C was significantly higher than that in group A (P<0.05), and the elevation was greater in group C. PLA2 and PAF were detected in both the amniotic fluid and the amniotic fluid meconium mixture of pregnant rats, and both were high in the amniotic fluid meconium mixture. There was no correlation between PLA2 and PAF concentrations in the blood taken 1 hour before the experiment (P=0.762,R=0.012), while there was a positive correlation between PLA2 and PAF concentrations in the blood taken 1 hour after the experiment(P=0.002, R=0.437). The results of HE and APK combined with CK16 staining showed that the model of amniotic fluid embolization was successfully made. Both PLA2 and PAF were present in the amniotic fluid and meconium of the rats, and the levels ofPLA2 and PAF in the blood taken 1 hour after the experiment were significantly higher in group B combination C than in group A. This suggests that amniotic fluid and meconium contain stimulants that increase PLA2 and PAF levels. [ABSTRACT FROM AUTHOR]

Coronavirus Disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is frequently complicated by thrombosis. In some cases of severe COVID-19, fibrinolysis may be markedly enhanced within a few days, resulting in fatal bleeding. In the treatment of COVID-19, attention should be paid to both coagulation activation and fibrinolytic activation. Various thromboses are known to occur after vaccination with SARS-CoV-2 vaccines. Vaccine-induced immune thrombotic thrombocytopenia (VITT) can occur after adenovirus-vectored vaccination, and is characterized by the detection of anti-platelet factor 4 antibodies by enzyme-linked immunosorbent assay and thrombosis in unusual locations such as cerebral venous sinuses and visceral veins. Treatment comprises high-dose immunoglobulin, argatroban, and fondaparinux. Some VITT cases show marked decreases in fibrinogen and platelets and marked increases in D-dimer, suggesting the presence of enhanced-fibrinolytic-type disseminated intravascular coagulation with a high risk of bleeding. In the treatment of VITT, evaluation of both coagulation activation and fibrinolytic activation is important, adjusting treatments accordingly to improve outcomes. [ABSTRACT FROM AUTHOR]

Although COVID-19 coagulopathy typically manifests with thrombotic complications, hemorrhagic complications also occur and must be considered when making decisions about anticoagulation in these patients. Here, we report a case of massive hemoptysis occurring in a recently post-partum woman via Cesarean section with COVID-19 who was managed via bronchial artery embolization while on extracorporeal membrane oxygenation. • Although COVID-19 coagulopathy typically manifests with thrombotic complications, hemorrhagic complications can occur and must be considered when making decisions about anticoagulation • Pulmonary hemorrhage is an uncommon manifestation of COVID-19 infection, occurring in 0.9-3% of cases • Bronchial artery embolization for pulmonary hemorrhage seems safe and effective in the setting of COVID-19 infection [ABSTRACT FROM AUTHOR]

The epidemiology features and clinical symptoms associated with 121 cases of snakebite requiring admission to 24 hospitals in Jordan, during 2018–2020, are discussed. Ninety-six of them (79%) brought with them to the hospital the snake that bit them or a photograph of it. Echis coloratus was responsible for 68 of the bites and 6 fatalities. Sex ratio was 3.2 males: 1 female, with an overall average age of 27 ± 14.36 years. The highest incidence of bites was reported in September. Bites were most common on hands and legs. The period of hospitalization ranged from 1 to 36 days. Irbid and Karak governorates had the highest number of snakebites, most cases being reported from agricultural areas and among farmers. Clinical symptoms associated with five species of venomous snakes are described along with illustrative case histories. Symptoms associated with Echis coloratus bites included local swelling and necrosis, coagulopathy and bleeding, microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury (AKI) and chronic renal failure. Daboia palaestinae victims exhibited ecchymoses, local swelling and necrosis, with one case of angioedema. Other symptoms included thrombocytopenia, coagulopathy, microangiopathic hemolysis and local and systemic bleeding, as well as AKI. A single case of envenoming by Macrovipera lebetinus developed the following symptoms; swelling, severe pain, extensive ecchymoses, neutrophil leukocytosis, normochromic normocytic anemia and aggregated platelets with thrombocytopenia. Symptoms associated with two cases of Pseudocerastes fieldi included swelling that spread from bitten hands, and mild abnormalities of platelet count and bleeding time. Four cases of envenoming by Atractaspis engaddensis exhibited severe pain, local swelling, erythema, numbness and tissue necrosis. One of them developed acute systemic symptoms. The only antivenom currently available in Jordan, is VINS "Snake venom antitoxin (Biosnake)", manufactured in India using venoms of three African snakes that do not occur in Jordan. It proved clinically ineffective against envenoming by Jordanian Viperidae, failing to correct coagulopathy and life-threatening hemorrhage, and to prevent AKI. • This study is intended to serve public health providers in Jordan concerning snake bites. • The epidemiology and clinical symptoms associated with snake bites and current treatments with antivenoms is discussed. • Antivenoms used Jordan is not effective based on clinical outcomes. [ABSTRACT FROM AUTHOR]

Amniotic fluid embolism (AFE) is a rare yet devastating complication of pregnancy. The outcomes are often poor, proving fatal for both mother and neonate. The incidence and mortality rate due to AFE is quite high even in developed countries and may be much higher in developing countries. Data from developing countries are unavailable. There is no uniform internationally accepted diagnostic criterion for AFE. No single diagnostic test has been found sufficient to suspect AFE in the early stages. Recently, complement system activation and an anaphylactoid reaction in the uterine tissue have been proposed in relation to its pathophysiology. In few cases, the use of complement C1 inhibitor with tranexamic acid, atropine, ondansetron, ketorolac therapy, and extracorporeal membrane oxygenation was observed to be very effective for early management. The studies on the pathophysiology of AFE are still limited. Further research is required to know the mechanism of this disease. Reliable rapid diagnostic tests are much needed at this stage. It is important to investigate the histopathology of tissues affected by AFE and find the origin of the disease in the maternal system. This review intends to highlight the best known and the unknown aspects of AFE relevant for future research purposes to minimize the fatality/mortality rate due to AFE, which remains an undiagnosed cause.

Serum phosphorus concentration reflects body energy equilibrium and functions of the kidney and the coagulation system. It is regulated by serum calcium concentration and parathyroid hormone (PTH). We present a case of constant low concentrations of serum phosphorus in a 34-year-old female who was diagnosed with amniotic fluid embolism (AFE) and was continuously treated with extracorporeal membrane oxygenation (ECMO), continuous renal replacement therapy (CRRT) and blood component transfusion during an observational period of 11 days. This case highlights that the release of inorganic phosphorus from platelets and plasma into the blood prompts PTH secretion. The administration of active vitamin D supplement and PTH antagonism should be considered to neutralize the negative regulatory effect of PTH on serum phosphorus and to benefit patients' recovery in the intensive care unit. [ABSTRACT FROM AUTHOR]

Objective: This study was conducted in order to investigate whether non-assisted hatching trophectoderm (TE) biopsy increases the risks of adverse perinatal outcomes in livebirths following elective single cryopreserved-thawed blastocyst transfer. Patients and Methods: A total of 5,412 cycles from 4,908 women who achieved singleton livebirths between 2013 and 2019 were included in this retrospective cohort study. All embryos in this study were fertilized by intracytoplasmic sperm injection (ICSI) and cryopreserved through vitrification. The main intervention is to open the zona pellucida (ZP) of day 5/6 blastocyst immediately for biopsy without pre-assisted hatching. The main outcome measures are the common maternal and neonatal outcomes, including hypertensive disorders of pregnancy (HDPs), gestational diabetes mellitus (GDM), abnormal placentation, abnormalities in umbilical cord and amniotic fluid, preterm birth, cesarean section, low birth weight, postpartum hemorrhage, and prolonged hospital stay (both mothers and infants). The generalized estimation equation (GEE) was used to control the effects of repeated measurements. The non-conditional logistic regression model was used to examine the associations between embryo biopsy status and each adverse perinatal event. Given that the selection bias and changes in learning curve might affect the results, we selected 1,086 similar (matching tolerance = 0.01) cycles from the ICSI group via propensity score matching (PSM) for second comparisons and adjustment (conditional logistic regression). Results: After adjusting for confounders, we confirmed that the non-assisted hatching protocol did not increase the risks of most adverse maternal and neonatal outcomes. Despite this, there were increased risks of GDM (aOR: 1.522, 95% CI: 1.141–2.031) and umbilical cord abnormalities (aOR: 11.539, 95% CI: 1.199–111.067) in the biopsy group. In the second comparisons after PSM, GDM incidence in the biopsy group was still higher (7.26% vs. 5.16%, P = 0.042), yet all measurement outcomes were equally likely to occur in both groups after the second adjustment. Conclusions: The non-assisted hatching TE biopsy does not increase the risks of most adverse perinatal outcomes. However, there is a higher GDM incidence in the biopsy group, and this association warrants further study. Considering its safety and simplicity, the non-assisted hatching protocol has the potential to become the preferred option for TE biopsy, especially in busy clinics and IVF laboratories. [ABSTRACT FROM AUTHOR]

Background: Amniotic fluid embolism (AFE) is a rare but potentially dangerous severe obstetrics complication, which is accompanied by an incidence between 1.9 and 6.1 per 100,000 births. Case presentation: Here, we report an AFE case after cesarean delivery diagnosed on a cardiac arrest complicated by acute respiratory distress syndrome and coagulopathy. Diagnosis, risk factors and pathophysiology for AFE have been fully discussed, besides, extracorporeal membrane oxygenation in the early management of cardiac arrest was used, describing the indication, efficacy and successful performed of open-chest cardiopulmonary resuscitation for the patient. Conclusion: In AFE with cute cardiovascular collapse, extracorporeal membrane oxygenation support can be considered as the alternative therapies. Highlights: The rare but dangerous amniotic fluid embolish after cesarean delivery was diagnosed. A cardiac arrest accompanied by acute respiratory distress syndrome and coagulopathy was recorded. Diagnosis, risk factors and pathophysiology for amniotic fluid embolish in this case were detailly discussed. [ABSTRACT FROM AUTHOR]

Introduction: Diabetes mellitus is a heterogeneous disorder of metabolism which results hyperglycemic-related atherothrombotic complications. These complications are the leading cause of death in diabetes mellitus patients. Therefore, this study was aimed to determine the prevalence of coagulopathy and associated factors among adult type II diabetes mellitus patients attending at University of Gondar comprehensive specialized hospital. Methods: A facility-based cross-sectional study was conducted among 357 study participants. A questionnaire and a data collection sheet were used to collect the sociodemographic and clinical data, respectively. About 6mL of venous blood samples were collected for coagulation tests and complete blood count. For prolonged coagulation tests, a mixing test was performed. Data were entered into EpiInfo and exported to SPSS for statistical analysis. Then, descriptive statistics were done. A binary and multivariable logistic regression model was used to identify the associated factors. P-value < 0.05 was considered as statistically significant. Results: In this study, 357 study participants were included. Of them, 52.1% (186) and 80.7% (288) were females and urban residences, respectively. The prevalence of coagulopathy was 26.6% (95% CI: 22.1, 31.5%). Out of this, 12.3% and 8.7% showed shortened PT and aPTT, respectively. In addition, the prevalence of prolonged PT and aPTT were 5.6% and 3.9%, respectively. From the prolonged PT and aPTT, the prevalence of factor deficiency was 95% and 92.8%, respectively. Being female (AOR = 2.06; 95% CI: 1.11– 3.85%), abnormal BMI (AOR = 1.94; 95% CI: 1.08– 3.50), and educational status of high school (AOR = 0.26; 95% CI: 0.10– 0.83%) were significantly associated with hypercoagulation. Conclusion: Coagulopathy is an important public health problem among type II diabetes mellitus patients. Being female and having abnormal BMI were associated with hypercoagulation. Therefore, regular monitoring of coagulation parameters is vital to reduce the consequence of coagulopathy. [ABSTRACT FROM AUTHOR]

Obstetrical hemorrhage and especially DIC (disseminated intravascular coagulation) is a leading cause for maternal mortality across the globe, often secondary to underlying maternal and/or fetal complications including placental abruption, amniotic fluid embolism, HELLP syndrome (hemolysis, elevated liver enzymes and low platelets), retained stillbirth and acute fatty liver of pregnancy. Various obstetrical disorders can present with DIC as a complication; thus, increased awareness is key to diagnosing the condition. DIC patients can present to clinicians who may not be experienced in a variety of aspects of thrombosis and hemostasis. Hence, DIC diagnosis is often only entertained when the patient already developed uncontrollable bleeding or multi-organ failure, all of which represent unsalvageable scenarios. Beyond the clinical presentations, the main issue with DIC diagnosis is in relation to coagulation test abnormalities. It is widely believed that in DIC, patients will have prolonged prothrombin time (PT) and partial thromboplastin time (PTT), thrombocytopenia, low fibrinogen, and raised D-dimers. Diagnosis of DIC can be elusive during pregnancy and requires vigilance and knowledge of the physiologic changes during pregnancy. It can be facilitated by using a pregnancy specific DIC score including three components: 1) fibrinogen concentrations; 2) the PT difference – relating to the difference in PT result between the patient's plasma and the laboratory control; and 3) platelet count. At a cutoff of ≥ 26 points, the pregnancy specific DIC score has 88% sensitivity, 96% specificity, a positive likelihood ratio (LR) of 22, and a negative LR of 0.125. Management of DIC during pregnancy requires a prompt attention to the underlying condition leading to this complication, including the delivery of the patient, and correction of the hemostatic problem that can be guided by point of care testing adjusted for pregnancy. [ABSTRACT FROM AUTHOR]

Introduction: Human cytomegalovirus (HCMV) is the most common congenital infection, especially severe after a maternal primary infection; sequelae in neonates born to mothers experiencing a nonprimary infection have been already reported. Hereby, two cases of severe fetal HCMV disease in seroimmune gravidas referred to our Unit are described. Cases Presentation: Case 1: A fetus at 21 weeks' gestation with signs of anemia and brain abnormalities at ultrasound, described at magnetic resonance (MR) imaging as ependymal irregularity and bilateral asymmetric parenchymal thinning; amniotic fluid sample was positive for HCMV although the woman had a previous immunity; after termination of pregnancy, autopsy demonstrated a thicken layer of disorganized neurons on the right cortical plate, while on the left, there was a morphological pattern coherent with polymicrogyria. Case 2: A fetus at 20 weeks' gestation with anemia, moderate atrioventricular insufficiency, hepatosplenomegaly but no major cerebral lesions. Fetal blood was positive for HCMV, although unexpected for prepregnancy maternal immunity, and intrauterine transfusion was needed. A cesarean section at 34 weeks' gestation was performed due to worsening condition of the fetus, who had a birthweight of 2,210 g and needed platelet transfusions, but MR examination and clinical evaluation were normal. Conclusion: The impact of nonprimary maternal infection on pregnancy outcome is unknown and fetal brain damage in HCMV seroimmune transmitter-mothers can occur as a consequence of maternal reinfection or reactivation for a hypotetic different role of HCMV-primed CD4+ or CD8+ T-cells in fetal brain, with progressive brain lesions coexistent in the first case and with severe unexpected anemia in the second case. A previous maternal HCMV immunity should not exempt to test anemic fetuses for such infection, nor to consider a potential transplacental transmission. [ABSTRACT FROM AUTHOR]

Background: Hemorrhagic shock in horses may be classified in several ways. Hemorrhage may be considered internal versus external, controlled or uncontrolled, or described based on the severity of hypovolemic shock the patient is experiencing. Regardless of the cause, as the severity of hemorrhage worsens, homeostatic responses are stimulated to ameliorate the systemic and local effects of an oxygen debt. In mild to moderate cases of hemorrhage (<15% blood volume loss), physiological adaptations in the patient may not be clinically apparent. As hemorrhage worsens, often in the uncontrolled situation such as a vascular breach internally, the pathophysiological consequences are numerous. The patient mobilizes fluid and reserve blood volume, notably splenic stored and peripherally circulating erythrocytes, to preferentially supply oxygen to sensitive organs such as the brain and heart. When the global and local delivery of oxygen is insufficient to meet the metabolic needs of the tissues, a cascade of cellular, tissue, and organ dysfunction occurs. If left untreated, the patient dies of hemorrhagic anemic shock. Clinical importance: An understanding of the pathophysiological consequences of hemorrhagic shock in horses and their clinical manifestations may help the practitioner understand the severity of blood volume loss, the need for referral, the need for transfusion, and potential outcome. In cases of severe acute uncontrolled hemorrhage, it is essential to recognize the clinical manifestations quickly to best treat the patient, which may include humane euthanasia. Key Points: Uncontrolled hemorrhage may be defined as the development of a vascular breach and hemorrhage that cannot be controlled by interventional hemostasis methods such as external pressure, tourniquet, or ligation.Causes of uncontrolled hemorrhage in horses may be due to non‐surgical trauma, surgical trauma, invasive diagnostic procedures including percutaneous organ biopsy, coagulopathy, hypertension, cardiovascular anomaly, vascular damage, neoplasia such as hemangiosarcoma, toxicity, or idiopathic in nature.When a critical volume of blood is lost, the respondent changes in heart rate, splenic blood mobilization, and microcirculatory control can no longer compensate for decreasing oxygen delivery to the tissuesIn spite of organ‐specific microvascular responses (eg, myogenic responses, local mediator modulation of microvasculature, etc), all organs experience decreases in blood flow during severe hypovolemiaAcute, fatal hemorrhagic shock is characterized by progressive metabolic acidosis, coagulopathy, and hypothermia, often termed the "triad of death," followed by circulatory collapse [ABSTRACT FROM AUTHOR]

Abstract Background Amniotic fluid embolism (AFE), also known as anaphylactoid syndrome of pregnancy (ASP), typically occurs during labor and may result in cardiorespiratory collapse and disseminated intravascular coagulation (DIC). There are reports describing less typical presentations of AFE/ASP in which patients do not necessarily have the classic triad of hypoxia, hypotension, and coagulopathy. AFE/ASP rarely occurs in the absence of labor, but such cases may involve medical or surgical abortion, spontaneous miscarriage, or obstetrical procedures including amniocentesis and amnioinfusion. There are, however, no previously reported cases of AFE/ASP with sudden loss of consciousness and disseminated intravascular coagulation occurring during early pregnancy, in the absence of any intervention or obstetric event. Case presentation A 32-year-old G3P2 Japanese woman had sudden-onset syncope at 14 weeks’ gestation. On arrival at our hospital, her level of consciousness was severely disturbed as determined by the Glasgow Coma Scale. Although her vital signs were initially stable, blood samples collected intravenously and by femoral artery puncture did not coagulate. A subchorionic hematoma with active extravasation of blood was apparent on contrast-enhanced computed tomography. Two hours after her arrival, she developed hypovolemic shock with progression of DIC, presumably due to intrauterine and retroperitoneal bleeding. After transfusion of blood products; treatments for DIC including the use of recombinant human soluble thrombomodulin, ulinastatin, and corticosteroids; and hysterectomy, her level of consciousness and physical condition improved remarkably. Later investigation of preoperative blood samples revealed that serum levels of AFE/ASP-associated markers were elevated. Immunohistochemical studies on the excised, unruptured uterus showed that amniotic fluid components were present inside a uterine blood vessel. Conclusions This is the first reported patient with sudden-onset syncope and DIC, but without apparent cardiorespiratory collapse, with the highly likely etiology of AFE/ASP occurring at the beginning of the second trimester of pregnancy and in the absence of intervention or delivery. Maternal collapse with DIC during any stage of pregnancy should be considered an AFE/ASP-associated event, even in the absence of labor or obstetric procedures. This event may occur in the presence of subchorionic hematoma alone.

Objective: This article aims to review and provide more understanding of current knowledge of amniotic fluid embolism regarding pathophysiology, diagnostic criteria, risk factors, indicating biomarkers, treatment strategies and outcomes of some case reports. Study design: A systematic literature review was performed using the PubMed database, restricted to articles published in English from 1992 to 2018. Original research, case reports, guideline recommendations, and review articles were reviewed in this study. Summary: Amniotic fluid embolism (AFE) is a rare catastrophic obstetric condition defined by clinical manifestations of pregnancy with sudden onset of cardiopulmonary arrest, consumptive coagulopathy or neurological deficits without other explainable illnesses. The incidence varies from 1.7-14.8 cases per 100,000 worldwide. The current understanding of AFE pathophysiology includes fetal components obstructing maternal microvessels with subsequent anaphylactoid reaction. Maternal pulmonary vasospasm and hematologic activation occur later, followed by heart failure and sudden cardiovascular collapse. Some of the possible risk factors for AFE include; 1) Maternal risk: age over 35 years, hypertensive disorder and diabetes mellitus; 2) Fetal risk: polyhydramnios, multiparity, non-vertex at delivery, fetal distress and fetal macrosomia; 3) Obstetric risks: amniocentesis, artificial amniotic fluid injection, oxytocin infusion, and placental abruption. Some of the useful biomarkers have been proposed including zinc coproporphyrin-1, squamous cell carcinoma antigen, carcinoembryonic antigen, cancer antigen 125, Siatyl Tn, monoclonal antibody TKH-2, C3, C4, tryptase, insulin-like growth factor binding protein-1, C1 esterase inhibitor. Management of AFE requires immediate basic life support and advanced cardiac life support. Adequate oxygenation, ventilation, coagulopathy correction, and appropriate vasopressors are recommended. However, the outcome prediction of AFE remains challenging.

Abstract Background Amniotic fluid embolism (AFE) is a rare, life threatening obstetric complication, often associated with severe coagulopathy. Induced abortions are extremely safe procedures however complications including AFE can occur. Case presentation A 29-year-old previously healthy woman, gravida 1 para 0, presented for a scheduled second trimester induced abortion via dilation and evacuation at 22-weeks gestation. The case was complicated by a suspected AFE with associated profound coagulopathy. Viscoelastic point-of-care coagulation analysis was used to successfully and swiftly guide management of her coagulopathy. Conclusion AFE can occur in the setting of induced abortion. This case report suggests viscoelastic point-of-care coagulation analyzers may aid in the management of pregnancy-related coagulopathy by providing faster coagulation assessment than laboratory testing, and facilitating timely, targeted management of coagulopathy.

Amniotic fluid embolism (AFE) is a rare obstetric emergency with a high mortality rate despite treatment. The pathogenesis likely involves inflammatory cytokines reacting to amniotic fluid in the bloodstream, causing rapid multi-organ failure and coagulopathy. Prompt recognition and supportive, multidisciplinary treatment are vital for enhancing patient outcomes. This report presents the case of a 27-year-old female with acute decompensation due to AFE. Our patient was scheduled for cesarean delivery due to high-risk placental anomalies and began demonstrating signs of AFE and severe hemorrhage shortly after delivery. She was transferred to our tertiary care center and was treated with coil embolization of the hemorrhaging uterine, iliac, and epigastric arteries, ultimately stabilizing her and saving her life. This case highlights the successful management of AFE with interventional radiological (IR) techniques., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Sun et al.)

Amniotic fluid embolism (AFE) is a potentially fatal maternal condition demanding awareness from obstetricians and anesthesiologists regarding its different manifestations. The typical presentation involves maternal respiratory distress, cardiovascular collapse, neurological changes, and coagulopathy followed by fetal distress. This unusual case study emphasizes that fetal compromise may precede maternal decompensation as the initial sign of AFE. Fetal distress is a known symptom of AFE and is typically seen due to cardiorespiratory issues that lead to reduced uteroplacental perfusion, resulting in fetal hypoxia. In the case presented, fetal bradycardia occurred before any visible maternal symptoms, suggesting that fetal distress could be induced by factors independent of the mother's cardiopulmonary status. A 34-year-old healthy G4P2012 at 41 weeks and 2 days gestation who was initially laboring on the floor was emergently taken to the operating room for a cesarean delivery due to fetal bradycardia. Around the time the fetus was delivered, the patient displayed seizure activity, followed by a complete loss of consciousness and cardiac arrest. The patient was intubated and underwent cardiopulmonary resuscitation and defibrillation, subsequently converting to a wide complex tachycardia. In the operating room, there was evidence of heavy vaginal bleeding, uterine atony, and a fulminant form of disseminated intravascular coagulopathy (DIC), which required aggressive management over the next four hours. After achieving hemodynamic stability, the patient was transferred to the surgical intensive care unit (SICU), extubated on day 3, and discharged home on day 8., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Wang et al.)

Amniotic fluid embolism (AFE) is a rare but potentially catastrophic complication during pregnancy. The most common presenting symptoms of AFE are cardiac arrest, hemodynamic instability, and profound hemorrhage. Here, we present a case of a 28-year-old female with a past medical history of anemia, gestational diabetes, hypothyroidism, anxiety, and depression, presenting for induction of labor for cholestasis of pregnancy. The labor course was complicated by sudden cardiac arrest and resuscitation, followed by an emergent bedside peri-cardiac arrest cesarean section. Subsequently, the patient developed coagulopathy, uterine atony, and bleeding from the vagina and cervix. The AFE protocol was initiated, and the care team proceeded with a hysterectomy. Supportive treatment correcting for metabolic acid-base disturbances and coagulopathies was maintained. The patient was stabilized for air transport to a higher level of care., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Parenteau et al.)

A 33-year-old woman, gravida 3 para 2, at 39 weeks of gestation, undergoing induction of labor, had a seizure. She was transferred to the operating room and underwent a cesarean delivery for non-reassuring fetal status. An amniotic fluid embolism (AFE) was suspected given her cardiovascular collapse, disseminated intravascular coagulation, and early right heart failure. Early mobilization of resources (e.g., blood bank, gynecology oncology, extracorporeal membrane oxygenation) was necessary as the hospital was in a stand-alone building. Biomarkers were sent during the acute event. The creation of an AFE order set is discussed., Competing Interests: Paloma Toledo, M.D., M.P.H. is supported by a grant from the 10.13039/100000080Anesthesia Patient Safety Foundation and has received speaker fees from Paciri Biosciences, Int. The other authors declare that they have no conflict of interest regarding the publication of this case report., (© 2024 The Authors. Published by Elsevier B.V.)

Most studies of severe maternal morbidity (SMM) include only cases that occur during birth hospitalizations. We examined the increase in cases when including SMM during antenatal and postpartum (within 42 days of discharge) hospitalizations, using longitudinally linked data from 1,010,250 births in California from September 1, 2016, to December 31, 2018. For total SMM, expanding the definition resulted in 22.8% more cases; for nontransfusion SMM, 45.1% more cases were added. Sepsis accounted for 55.5% of the additional cases. The increase varied for specific indicators, for example, less than 2% for amniotic fluid embolism, 7.0% for transfusion, 112.9% for sepsis, and 155.6% for acute myocardial infarction. These findings reiterate the importance of considering SMM beyond just the birth hospitalization and facilitating access to longitudinally linked data to facilitate a more complete understanding of SMM. [ABSTRACT FROM AUTHOR]

Prostaglandins are thought to be important mediators in the initiation of human labour, however the evidence supporting this is not entirely clear. Determining how, and which, prostaglandins change during pregnancy and labour may provide insight into mechanisms governing labour initiation and the potential to predict timing of labour onset. The current study systematically searched the existing scientific literature to determine how biofluid levels of prostaglandins change throughout pregnancy before and during labour, and whether prostaglandins and/or their metabolites may be useful for prediction of labour. The databases EMBASE and MEDLINE were searched for English-language articles on prostaglandins measured in plasma, serum, amniotic fluid, or urine during pregnancy and/or spontaneous labour. Studies were assessed for quality and risk of bias and a qualitative summary of included studies was generated. Our review identified 83 studies published between 1968–2021 that met the inclusion criteria. As measured in amniotic fluid, levels of PGE2, along with PGF2α and its metabolite 13,14-dihydro-15-keto-PGF2α were reported higher in labour compared to non-labour. In blood, only 13,14-dihydro-15-keto-PGF2α was reported higher in labour. Additionally, PGF2α, PGF1α, and PGE2 were reported to increase in amniotic fluid as pregnancy progressed, though this pattern was not consistent in plasma. Overall, the evidence supporting changes in prostaglandin levels in these biofluids remains unclear. An important limitation is the lack of data on the complexity of the prostaglandin pathway outside of the PGE and PGF families. Future studies using new methodologies capable of co-assessing multiple prostaglandins and metabolites, in large, well-defined populations, will help provide more insight as to the identification of exactly which prostaglandins and/or metabolites consistently change with labour. Revisiting and revising our understanding of the prostaglandins may provide better targets for clinical monitoring of pregnancies. This study was supported by the Canadian Institutes of Health Research. [ABSTRACT FROM AUTHOR]

Background: Despite the benefits of extracorporeal cardiopulmonary resuscitation (ECPR) in cohorts of selected patients with cardiac arrest (CA), extracorporeal membrane oxygenation (ECMO) includes an artificial oxygenation membrane and circuits that contact the circulating blood and induce excessive oxidative stress and inflammatory responses, resulting in coagulopathy and endothelial cell damage. There is currently no pharmacological treatment that has been proven to improve outcomes after CA/ECPR. We aimed to test the hypothesis that administration of hydrogen gas (H2) combined with ECPR could improve outcomes after CA/ECPR in rats.Methods: Rats were subjected to 20 min of asphyxial CA and were resuscitated by ECPR. Mechanical ventilation (MV) was initiated at the beginning of ECPR. Animals were randomly assigned to the placebo or H2 gas treatment groups. The supplement gas was administered with O2 through the ECMO membrane and MV. Survival time, electroencephalography (EEG), brain functional status, and brain tissue oxygenation were measured. Changes in the plasma levels of syndecan-1 (a marker of endothelial damage), multiple cytokines, chemokines, and metabolites were also evaluated.Results: The survival rate at 4 h was 77.8% (7 out of 9) in the H2 group and 22.2% (2 out of 9) in the placebo group. The Kaplan-Meier analysis showed that H2 significantly improved the 4 h-survival endpoint (log-rank P = 0.025 vs. placebo). All animals treated with H2 regained EEG activity, whereas no recovery was observed in animals treated with placebo. H2 therapy markedly improved intra-resuscitation brain tissue oxygenation and prevented an increase in central venous pressure after ECPR. H2 attenuated an increase in syndecan-1 levels and enhanced an increase in interleukin-10, vascular endothelial growth factor, and leptin levels after ECPR. Metabolomics analysis identified significant changes at 2 h after CA/ECPR between the two groups, particularly in D-glutamine and D-glutamate metabolism.Conclusions: H2 therapy improved mortality in highly lethal CA rats rescued by ECPR and helped recover brain electrical activity. The underlying mechanism might be linked to protective effects against endothelial damage. Further studies are warranted to elucidate the mechanisms responsible for the beneficial effects of H2 on ischemia-reperfusion injury in critically ill patients who require ECMO support. [ABSTRACT FROM AUTHOR]

Objective: To assess the contribution of maternal blood detection of IGFBP‐1 for the diagnosis of amniotic‐fluid embolism in clinical daily practice. Design: A retrospective multicentre cohort study. Setting: Three tertiary care obstetric units in France. Sample: Data of 86 women for whom amniotic‐fluid embolism had been suspected and maternal serum detection of IGFBP‐1 had been performed between 2011 and 2019 were analysed. Methods: The criteria defined by the United Kingdom Obstetric Surveillance System (UKOSS) were used for the retrospective diagnosis of amniotic‐fluid embolism. The more structured definition proposed by the Society for Maternal‐Fetal Medicine and the Amniotic Fluid Embolism Foundation (SMFM) was also used as secondary endpoint. Main outcome measures: Agreements between biological and clinical assessments were tested. The performance of blood detection of IGFBP‐1 for the diagnosis of amniotic‐fluid embolism according to the UKOSS criteria, and to the SMFM definition, was also assessed. Results: There was only slight agreement between clinical and laboratory diagnosis of amniotic‐fluid embolism (Cohen's Kappa coefficient: 0.04). Blood detection of IGFBP‐1 had a sensitivity of 16%, a specificity of 88%, a positive and a negative likelihood ratio of 1.3 and 0.95, respectively, and a positive and a negative predictive value of 58 and 50%, respectively, for the diagnosis of amniotic‐fluid embolism based on the UKOSS criteria. The use of the more structured SMFM definition of amniotic‐fluid embolism did not substantially change the results. Conclusion: These results question the usefulness of blood detection of IGFBP‐1 for the early diagnosis of amniotic‐fluid embolism in daily clinical practice. This retrospective multicentre study questions the contribution of IGFBP‐1 detection for the diagnosis of AFE. This retrospective multicentre study questions the contribution of IGFBP‐1 detection for the diagnosis of AFE. [ABSTRACT FROM AUTHOR]

To utilize noninvasive collection of amniotic fluid in the setting of preterm premature rupture of membranes (PPROMs) to report the time concentration profile of azithromycin in amniotic fluid over 7 days from a single dose, and evaluate the correlation between azithromycin concentration and inflammatory markers in amniotic fluid. Prospective cohort study of five pregnant patients admitted with PPROMs and treated with a single 1 g oral azithromycin dose. Amniotic fluid was collected from pads and used to quantify azithromycin concentration as well as TNFa, IL‐1a, IL‐1b, IL‐6, IL‐8, and IL‐10 concentrations. Primary outcome was time/concentration profile of azithromycin in amniotic fluid. Secondary outcome included correlation between azithromycin concentration and cytokine concentrations. Five patients were enrolled. Mean gestational age on admission with PPROM was 27.5 ± 2.3 weeks with a median latency of 7 days (interquartile range [IQR] = 4–13). A median of two samples/day (IQR = 1–3) were collected per participant. Azithromycin was quantified in duplicate; intra‐assay coefficient of variation was 17%. Azithromycin concentration was less than 60 ng/ml after day 3. Azithromycin concentration was positively correlated with IL‐8 (r = 0.38, p = 0.03), IL1a (r = 0.39, p = 0.03), and IL‐1b (r = 0.36, p = 0.04) in amniotic fluid. Azithromycin is detectable in amniotic fluid over 7 days from a single 1 g maternal dose, however, it is not sustained over the range of minimum inhibitory concentration for common genitourinary flora. Based on correlation with specific cytokines, azithromycin penetration in amniotic fluid may relate to maternal monocyte concentration in amniotic fluid in the setting of PPROM. [ABSTRACT FROM AUTHOR]