Comparing the outcomes of rheumatic heart disease in pregnancy complicated with and without atrial fibrillation: A propensity score matched analysis.

BACKGROUND: Atrial fibrillation (AF) may increase the risk of adverse maternal and fetal outcomes among pregnant with rheumatic valvular lesions (RHD). We aimed to assess the rate of occurrence of AF in pregnant with RHD and its impact on cardiac and maternal-fetal outcomes compared to those without it. METHODS: The study group consisted of pregnant women with RHD and AF (cases) and a matched comparison group of pregnant women with RHD but without AF (controls) was derived from the database of pregnant women with RHD receiving care at our center between 2011 and 2021. Incidence of composite adverse outcomes(maternal death, heart failure, or thrombo-embolic events) and pregnancy outcomes were compared between them. RESULTS: Seventy-one (5.1%; 95%CI 4.1%-6.4%) pregnant women with RHD had AF during pregnancy and childbirth, most occurring in the late second or early third trimester. New-onset AF was diagnosed in 34 (47.9%) of them. After matching, the incidence of composite outcome was higher in women with AF (77.5% (95%CI 66.3%-85.7%) compared to women without AF (17.3%(95%CI 13.3%-22.1%), P < .001), with seven (9.9%) maternal deaths among cases and two (0.7%) in controls. Heart failure was the most common adverse cardiac event (26.7% vs. 4.2%, P < .001, cases vs controls). Those with AF had higher odds (adjusted OR 56.6 (14.1-226.8)) of adverse cardiac outcomes after adjusting for other risk factors. The frequency of most non-cardiac pregnancy complications was similar in both groups. However, there was a trend towards a higher rate of miscarriage (16.9% vs. 9.9%), small-for-gestational-age babies(16.3 vs. 9.0%), and cesarean rates(31.9% vs. 18.3%) women with AF compared to those who did not experience AF. CONCLUSIONS: Atrial fibrillation in pregnancy among women with RHD was associated with an increased risk of maternal morbidity and mortality, with a trend towards an increase in some non-cardiac pregnancy complications compared to those pregnant women without AF. Our study results provide background data for developing and implementing a pregnancy-specific management strategy tailored to middle-income settings.

Factors Associated with Perinatal Mortality in Adult Pregnant Women with Hypertensive Disorders: A Case-Control Study.

Background: Hypertension complicates 5-10% of pregnancies and is a common cause of perinatal death. The perinatal mortality is estimated to be 3 to 5 times higher in hypertensive women compared to those without hypertension. Methods: A hypertensive mother either with a stillbirth or if baby died within 7 days of life was included as a case. Once a case was recognized, the next two consecutive hypertensive mothers who delivered a live baby, who survived up to 7 days of life, were taken as controls. Fetuses with congenital malformations incompatible with life and multiple pregnancies were excluded from the study. One hundred and twelve women in cases and 224 women in controls were studied. Results: Among 112 cases of perinatal death, 70% had died in utero before labor. Among the 33 fetuses alive, 50% were born still after labor and 50% died within 7 days of birth. We found that early onset hypertension (< 34 weeks) (p-< 0.001 (Chi2-23.819)), gestational age at termination of 28-32 weeks (OR 2.76), value of serum creatinine > 1.1 mg/dl (OR 10.1), abruption (OR 6.2) and birth weight < 1.5 kg was significantly associated with perinatal mortality (p-0.007, OR 5.7). Abnormal Doppler findings was a predictor of perinatal deaths. Conclusion: Severely growth retarded fetuses in association with early onset severe preeclampsia are likely to die in utero and need vigilant monitoring antenatally. Abnormal umbilical artery Dopplers predict perinatal mortality. Caesarean section at the gestational age of ≥ 32 weeks and an estimated fetal weight of ≥ 1.2 kg in our hospital resulted in favorable outcome.

Validation of Risk Stratification for Cardiac Events in Pregnant Women With Valvular Heart Disease.

BACKGROUND: Most risk stratification tools for pregnant patients with heart disease were developed in high-income countries and in populations with predominantly congenital heart disease, and therefore, may not be generalizable to those with valvular heart disease (VHD). OBJECTIVES: The purpose of this study was to validate and establish the clinical utility of 2 risk stratification tools-DEVI (VHD-specific tool) and CARPREG-II-for predicting adverse cardiac events in pregnant patients with VHD. METHODS: We conducted a cohort study involving consecutive pregnancies complicated with VHD admitted to a tertiary center in a middle-income setting from January 2019 to April 2022. Individual risk for adverse composite cardiac events was calculated using DEVI and CARPREG-II models. Performance was assessed through discrimination and calibration characteristics. Clinical utility was evaluated with Decision Curve Analysis. RESULTS: Of 577 eligible pregnancies, 69 (12.1%) experienced a component of the composite outcome. A majority (94.7%) had rheumatic etiology, with mitral regurgitation as the predominant lesion (48.2%). The area under the receiver-operating characteristic curve was 0.884 (95% CI: 0.844-0.923) for the DEVI and 0.808 (95% CI: 0.753-0.863) for the CARPREG-II models. Calibration plots suggested that DEVI score overestimates risk at higher probabilities, whereas CARPREG-II score overestimates risk at both extremes and underestimates risk at middle probabilities. Decision curve analysis demonstrated that both models were useful across predicted probability thresholds between 10% and 50%. CONCLUSIONS: In pregnant patients with VHD, DEVI and CARPREG-II scores showed good discriminative ability and clinical utility across a range of probabilities. The DEVI score showed better agreement between predicted probabilities and observed events.

Profile of cardiac lesions among laboratory confirmed congenital rubella syndrome (CRS) infants: a nationwide sentinel surveillance, India, 2016-22.

Background: The phenotypical profile of cardiovascular malformations in patients with congenital rubella syndrome (CRS) is varied. We aimed to describe the profile of cardiac defects among CRS patients detected in the sentinel CRS surveillance in India during 2016-22. Methods: Sentinel sites enrolled infants with suspected CRS based on presence of cardiac defects, hearing impairment, eye signs, or maternal history of febrile rash illness. Suspected CRS cases underwent detailed systemic examination, including echocardiography and serological investigation for rubella. Cardiac defects were categorized as 'Simple' or 'Complex' as per the National Heart, Lung, and Blood Institute classification. We compared the distribution of cardiac defects among laboratory confirmed CRS cases and seronegative discarded cases. Findings: Of the 4578 suspected CRS cases enrolled by 14 sites, 558 (12.2%) were laboratory confirmed. 419 (75.1%) laboratory confirmed cases had structural heart defects (simple defects: n = 273, 65.2%, complex defects: n = 144, 34.4%), with ventricular septal defect (42.7%), atrial septal defect (39.4%), patent ductus arteriosus (36.5%), and tetralogy of Fallot as the commonest defects (4.5%). Laboratory confirmed CRS cases had higher odds of left to right shunt lesions (OR = 1.58, 95% CI: 1.15-2.17). This was mainly on account of a significant association of PDA with CRS (OR = 1.77, 95% CI: 1.42-2.21). Mortality was higher among CRS patients with complex heart defects (HR = 2.04, 95% CI: 1.26-3.30). Interpretation: Three-fourths of the laboratory confirmed CRS cases had structural heart defects. CRS patients with complex cardiac defects had higher mortality. Detecting CRS infection early and providing timely intervention for cardiovascular defects is critical for the management of CRS patients. Funding: Ministry of Health and Family Welfare, Govt of India, through Gavi, the Vaccine Alliance.

Growth Pattern of Preterm Neonates with Fetal Growth Restriction: A Prospective Cohort Study.

OBJECTIVES: To compare the growth of preterm neonates with fetal growth restriction (FGR) and preterm neonates born appropriate-for-gestational-age (AGA) from birth to 12-18 mo of corrected age (CA). METHODS: In this prospective cohort study, 85 preterm neonates with FGR and 85 gestation- and gender-matched AGA neonates were followed up from birth till 12-18 mo corrected age. Anthropometric indices were compared at specific time points and the risk factors for underweight status were analyzed. RESULTS: Mean gestational age of the cohort was 32.8 ± 2.1 wk. Mean birth weight was 1414 ± 248 g in the FGR and 1806 ± 416 g in AGA neonates. At 12-18 mo of corrected age, a significantly greater proportion of FGR infants were wasted (24.3% vs. 7.2%, P = 0.005). A greater proportion of FGR infants were underweight (27% vs. 17.4%, P = 0.11), stunted (41.9% vs. 36.2%, P = 0.30), and microcephalic (27% vs. 23.1%, P = 0.36), although the differences were not statistically significant. Significant catch-up growth from 40 wk postmenstrual age (PMA) to 12-18 mo corrected age in weight (52.8% vs. 13.1%, P <0.001) and length (37.9% vs. 8.7%, P <0.001) was observed in the FGR neonates. The z-score of weight for age at 3 mo (adjusted OR 0.65, 95% CI: 0.52-0.8; P <0.001), the median time to full feeds (aOR: 1.10, 95% CI: 1.04-1.15; P = 0.001), and hypothyroidism (aOR 2.44, 95% CI: 1.46-4.08; P = 0.001), were independent predictors of underweight status at 12-18 mo. CONCLUSIONS: At 12-18 mo of corrected age, a significantly greater proportion of preterm FGR neonates were wasted compared to AGA ones. The former also exhibited significantly greater catch-up growth than the latter.

Concurrent valve replacement and caesarean section for rheumatic mitral valve disease with refractory heart failure in late pregnancy.

Objective: To assess clinical characteristics and outcomes of women who underwent concurrent valve replacement with caesarean section for severe rheumatic mitral valve disease with refractory heart failure. Methods: All women admitted to a single centre from 2011 to 2020 with severe rheumatic mitral valve disease, having recurrent episodes of pulmonary edema on optimal medical therapy and contraindication to percutaneous balloon mitral valvotomy, who underwent concurrent valve replacement (for native valve disease) along with caesarean section, were included. Results: Among 1300 pregnancies with rheumatic heart disease, six underwent the concurrent procedure. All had replacement of mitral valve except one who had both aortic and mitral valve replacements, between 33 and 39 weeks of gestation. There were no maternal deaths, and there was one neonatal loss from late-onset sepsis. Conclusion: Pregnant women with severe rheumatic mitral valve disease with refractory heart failure, unsuitable for minimal access interventions, can be considered for a concurrent valve replacement with caesarean section.

Metabolic Bone Disease in Preterm Neonates With Fetal Growth Restriction (FGR): A Prospective Cohort Study.

OBJECTIVE: To study the association of fetal growth restriction (FGR) with metabolic bone disease in preterm neonates. METHODOLOGY: This prospective cohort study included 94 preterm neonates with FGR as cases and an equal number of gestation-matched appropriate for gestational age (AGA) neonates without FGR as controls. The incidence of metabolic bone disease, and serum biochemical markers at various time intervals till 6 months corrected age were compared. The risk factors for metabolic bone disease and its association with stunting at 6 months of corrected age were studied. RESULTS: The incidence of metabolic bone disease, though higher in the FGR neonates (15.5%), was not significantly different from AGA neonates (6.7%) [RR (95%CI) 0.92-5.82; P=0.06]. Birth weight [aOR (95%CI) 0.8 (0.64-0.98); P=0.03] and time to reach full feeds [aOR (95%CI) 1.17 (1.01-1.36); P=0.03] were significantly associated with an increased risk of metabolic bone disease after adjusting for FGR status. Mean (SD) levels of calcium, phosphorus, alkaline phosphatase, parathormone (PTH), and vitamin D were similar in both groups. No significant association existed between metabolic bone disease and stunting at 6 months of corrected age [RR (95%CI) 2 (0.75-5.4); P=0.16]. CONCLUSION: FGR was not found to be significantly associated with metabolic bone disease in preterm neonates.

Echocardiographic nomograms and Z-scores for term Indian neonates.

Background: The availability of nomograms is crucial for the correct interpretation of pediatric and neonatal echocardiograms. Echocardiographic Z-score applications/websites use Western nomograms as reference, which may not be an appropriate standard for gauging Indian neonates. Currently available Indian pediatric nomograms either have not included neonates or have not been specifically designed for neonates. This gross underrepresentation of neonates renders available nomograms unreliable for use as standards for comparison. Objectives: The objective of this study was to collect normative data for the measurement of various cardiac structures using M-Mode and two-dimensional (2D) echo in healthy Indian neonates and to derive Z-scores for each measured parameter. Methods: Echocardiograms were performed on healthy term neonates (within first 5 days of life). Birth weight and length were recorded, and body surface area was calculated using Haycock's formula. Twenty M-mode and 2D-echo parameters were measured (including left ventricular dimensions, atrioventricular valves, and semilunar valves' annuli sizes, pulmonary artery and branches, aortic root, and arch). Results: We studied 142 neonates (73 males) with a mean age of 1.83 ± 1.12 days and mean birth weight of 2.89 ± 0.39 Kg. Regression equations with linear, logarithmic, exponential and square root models were tested to select the best model of fit for the relationship between birth weight and each echocardiographic parameter. Scatter plots and nomogram charts with Z-scores were prepared for each echocardiographic parameter. Conclusions: Our study provides nomograms with Z-scores for term Indian neonates weighing between 2 kg and 4 kg at birth, within first 5 days of life, for a set of echocardiographic parameters that are frequently used in clinical practice. This nomogram has poor predictability for babies at extremes of birth weight. There is a need for further indigenous studies to include neonates at extremes of weight, both term, and preterm.

Patterns of antibiotic use, pathogens, and prediction of mortality in hospitalized neonates and young infants with sepsis: A global neonatal sepsis observational cohort study (NeoOBS).

BACKGROUND: There is limited data on antibiotic treatment in hospitalized neonates in low- and middle-income countries (LMICs). We aimed to describe patterns of antibiotic use, pathogens, and clinical outcomes, and to develop a severity score predicting mortality in neonatal sepsis to inform future clinical trial design. METHODS AND FINDINGS: Hospitalized infants <60 days with clinical sepsis were enrolled during 2018 to 2020 by 19 sites in 11 countries (mainly Asia and Africa). Prospective daily observational data was collected on clinical signs, supportive care, antibiotic treatment, microbiology, and 28-day mortality. Two prediction models were developed for (1) 28-day mortality from baseline variables (baseline NeoSep Severity Score); and (2) daily risk of death on IV antibiotics from daily updated assessments (NeoSep Recovery Score). Multivariable Cox regression models included a randomly selected 85% of infants, with 15% for validation. A total of 3,204 infants were enrolled, with median birth weight of 2,500 g (IQR 1,400 to 3,000) and postnatal age of 5 days (IQR 1 to 15). 206 different empiric antibiotic combinations were started in 3,141 infants, which were structured into 5 groups based on the World Health Organization (WHO) AWaRe classification. Approximately 25.9% (n = 814) of infants started WHO first line regimens (Group 1-Access) and 13.8% (n = 432) started WHO second-line cephalosporins (cefotaxime/ceftriaxone) (Group 2-"Low" Watch). The largest group (34.0%, n = 1,068) started a regimen providing partial extended-spectrum beta-lactamase (ESBL)/pseudomonal coverage (piperacillin-tazobactam, ceftazidime, or fluoroquinolone-based) (Group 3-"Medium" Watch), 18.0% (n = 566) started a carbapenem (Group 4-"High" Watch), and 1.8% (n = 57) a Reserve antibiotic (Group 5, largely colistin-based), and 728/2,880 (25.3%) of initial regimens in Groups 1 to 4 were escalated, mainly to carbapenems, usually for clinical deterioration (n = 480; 65.9%). A total of 564/3,195 infants (17.7%) were blood culture pathogen positive, of whom 62.9% (n = 355) had a gram-negative organism, predominantly Klebsiella pneumoniae (n = 132) or Acinetobacter spp. (n = 72). Both were commonly resistant to WHO-recommended regimens and to carbapenems in 43 (32.6%) and 50 (71.4%) of cases, respectively. MRSA accounted for 33 (61.1%) of 54 Staphylococcus aureus isolates. Overall, 350/3,204 infants died (11.3%; 95% CI 10.2% to 12.5%), 17.7% if blood cultures were positive for pathogens (95% CI 14.7% to 21.1%, n = 99/564). A baseline NeoSep Severity Score had a C-index of 0.76 (0.69 to 0.82) in the validation sample, with mortality of 1.6% (3/189; 95% CI: 0.5% to 4.6%), 11.0% (27/245; 7.7% to 15.6%), and 27.3% (12/44; 16.3% to 41.8%) in low (score 0 to 4), medium (5 to 8), and high (9 to 16) risk groups, respectively, with similar performance across subgroups. A related NeoSep Recovery Score had an area under the receiver operating curve for predicting death the next day between 0.8 and 0.9 over the first week. There was significant variation in outcomes between sites and external validation would strengthen score applicability. CONCLUSION: Antibiotic regimens used in neonatal sepsis commonly diverge from WHO guidelines, and trials of novel empiric regimens are urgently needed in the context of increasing antimicrobial resistance (AMR). The baseline NeoSep Severity Score identifies high mortality risk criteria for trial entry, while the NeoSep Recovery Score can help guide decisions on regimen change. NeoOBS data informed the NeoSep1 antibiotic trial (ISRCTN48721236), which aims to identify novel first- and second-line empiric antibiotic regimens for neonatal sepsis. TRIAL REGISTRATION: ClinicalTrials.gov, (NCT03721302).

Congenital rubella syndrome surveillance in India, 2016-21: Analysis of five years surveillance data.

Background: In India, facility-based surveillance for congenital rubella syndrome (CRS) was initiated in 2016 to estimate the burden and monitor the progress made in rubella control. We analyzed the surveillance data for 2016-2021 from 14 sentinel sites to describe the epidemiology of CRS. Method: We analyzed the surveillance data to describe the distribution of suspected and laboratory confirmed CRS patients by time, place and person characteristics. We compared clinical signs of laboratory confirmed CRS and discarded case-patients to find independent predictors of CRS using logistic regression analysis and developed a risk prediction model. Results: During 2016-21, surveillance sites enrolled 3940 suspected CRS case-patients (Age 3.5 months, SD: 3.5). About one-fifth (n = 813, 20.6%) were enrolled during newborn examination. Of the suspected CRS patients, 493 (12.5%) had laboratory evidence of rubella infection. The proportion of laboratory confirmed CRS cases declined from 26% in 2017 to 8.7% in 2021. Laboratory confirmed patients had higher odds of having hearing impairment (Odds ratio [OR] = 9.5, 95% confidence interval [CI]: 5.6-16.2), cataract (OR = 7.8, 95% CI: 5.4-11.2), pigmentary retinopathy (OR = 6.7, 95 CI: 3.3-13.6), structural heart defect with hearing impairment (OR = 3.8, 95% CI: 1.2-12.2) and glaucoma (OR = 3.1, 95% CI: 1.2-8.1). Nomogram, along with a web version, was developed. Conclusions: Rubella continues to be a significant public health issue in India. The declining trend of test positivity among suspected CRS case-patients needs to be monitored through continued surveillance in these sentinel sites.

Growth and Neurodevelopmental Outcomes of Very Low Birth Weight Infants From Southern India at Corrected Age of One Year.

OBJECTIVE: To assess the growth and neurodevelopmental outcome of very low birth weight (VLBW) infants at corrected age of one year. METHODS: This prospective cohort study enrolled VLBW infants delivered in a tertiary care hospital, and followed up till one-year corrected age. The WHO Anthropo version 3.2.2 software was used to calculate weight for age, length for age, and head circumference z-score during follow up. Neuro-developmental assessment was done using Developmental Assessment Scale for Indian Infants (DASII) at the age of one year. RESULTS: The mean (SD) z-scores at one-year for weight for age, length for age and head circumference were -2.1 (1.1), -1.4 (1.03) and -2.2 (1.2), respectively. The mean (SD) DASII motor and mental scores were 90.8 (13.4) and 96.5 (13.2), respectively. Major and minor developmental abnormalities were noted in 9.4% and 18.2%, infants, respectively. Cerebral palsy was noted in 5.8% infants. CONCLUSION: VLBW infants showed impaired growth and significant developmental abnormalities at the corrected age of one year.

Clinical Profile and Outcome of Newborns Discharged Against Medical Advice From a Tertiary Care Centre.

OBJECTIVE: To determine the clinical profile and outcome of neonates discharged against medical advice (DAMA) from the neonatal intensive care unit (NICU) of a tertiary care public hospital. METHODS: We retrieved information from hospital records of infants who had been discharged against medical advice from the NICU between January, 2016 and December, 2020. This was followed by a telephonic interview to document the infant's outcome. RESULTS: Out of the 187 (7.7%) neonates that had left DAMA, 165 case records were available, and 65 (39%) families could be contacted telephonically. Congenital malformations accounted for 96 (58%) of the cases; cardiac malformations accounting for 42 (43.7%). 52 (80%) out of the 65 infants had died after median (IQR) 11 (5-35) days of DAMA, and 13 (20%) were alive at a median (IQR) age of 31 (18.5-31.5) months. Post-DAMA medical care was continued at another health facility in 12 (18%). CONCLUSION: One out of every five infants was alive for a median age of 31 months after having left DAMA. Mechanisms to ensure continuation of care after DAMA need to be explored.

Predictive validity of ESSENCE Q screening tool for early detection of neurodevelopmental disorder in children.

INTRODUCTION: Neurodevelopmental disorders (NDD) are a group of conditions that typically manifest early during the child's development with lifelong consequences. Early identification using efficient screening tools can positively modify the natural history of the disorder. ESSENCE Q is a simple questionnaire to detect ESSENCE (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations to reflect the co-existence of NDDs in children less than five years). There are limited studies on the validity of ESSENCE Q in detecting NDDs in young children in India. METHODS: We did a cross-sectional study in a tertiary care hospital to evaluate the validity of ESSENCE Q in detecting neurodevelopmental disorders. We translated the ESSENCE Q and subsequently used it to screen for NDD in 100 children aged 12-60 months. Clinical consensus diagnosis by two experienced experts was taken as the gold standard. RESULTS: 23% were diagnosed as having NDD as per the clinical consensus diagnosis. Around half the children (46%) were "at-risk for NDD" based on the ESSENCE Q scale. We found an optimal cut-off for ESSENCE Q of more than or equal to 4 with a sensitivity of 96%, a specificity of 82%, and a Youden index of 0.77. CONCLUSION: ESSENCE Q has good predictive validity to be used as a quick and easy screening tool to detect NDDs in young children under the age of 5 years.

Prenatal grading of fetal congenital heart disease and its influence on decision making during pregnancy and postnatal period: a prospective study.

BACKGROUND: Congenital heart defects(CHDs) are an important cause of neonatal mortality and morbidity. With advances in diagnosis and treatment, many defects are now amenable to correction. There is a need for individualized approach to prenatally detected lesions to predict the likely prognosis. Assigning them into risk category helps in prenatal counseling, decision making, referrals and formulation of management plan to improve the outcome. OBJECTIVE: To grade the fetal CHDs according to severity and study its usefulness in decision making. METHODS: A prospective study at a tertiary care institute between 2016 and 18, including pregnant women with antenatal diagnosis of fetal CHD. Detailed fetal echocardiography was followed by classification of lesions into four risk categories using modified grading system: (A) extremely high risk; (B) high risk (C) moderate risk (D) low risk. Appropriate counseling was provided to facilitate decision making and further management. The grading was reviewed and revised again postpartum/post-mortem for correlation. RESULTS: Of the total 137 cases, almost half (45.53%) were Category B, while Category D, C and A had 24.1%, 20.4% and 10.2% of cases respectively. The mean gestation age at diagnosis was 26.5 weeks. Termination of pregnancy was done in 21 cases, mostly in Category B (71.4%) and of the 116 continued pregnancies, there were 16 intrauterine deaths. Prenatal and postnatal findings were available in 109 cases and kappa analysis for agreement between antenatal and postnatal grading showed good agreement (0.82). CONCLUSION: Prenatal grading of congenital heart disease is a reliable, structured and simplified tool that can be used for providing counseling and facilitate decision making.

Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study.

Objective: To compare cardiac complications and pregnancy outcomes in women with mechanical heart valves (MHVs) on two different anticoagulation regimens in a middle-income country. Methods: We conducted a retrospective cohort study comparing outcomes in pregnant women with MHVs that received vitamin K antagonists (VKAs) throughout pregnancy versus sequential anticoagulation (heparins in the first trimester and peripartum period and VKAs for the remainder of pregnancy), at a tertiary centre in South India, from January 2011 to August 2020. Results: We identified 138 pregnancies in 121 women, of whom 32 received VKAs while 106 were on sequential anticoagulation. There were no differences between groups with regard to maternal deaths [0 vs. 6 (5.7%), p = 0.34], thromboembolic events [2 (6.3%) vs. 15 (14.2%), p = 0.36], haemorrhagic complications [4 (12.5%) vs. 12 (11.3%), p = 0.85], cardiac events [1 (3.1% vs. 17 (16%), p = 0.07], spontaneous miscarriages [5 (15.6%) vs. 13 (12.3%), p = 0.62], stillbirths [0 vs. 5 (5.4%), p = 0.581] or neonatal deaths [2 (8.7%) vs. 1 (1.1%), p = 0.11]. Both cases of warfarin embryopathy received >5 mg warfarin in the first trimester. Thromboembolic events were associated with subtherapeutic doses of heparin in the first and third trimesters and the early postpartum period. Fetal growth restriction and preterm birth complicated 34 (29.3%) and 26 (22.4%) pregnancies respectively. Conclusion: Pregnancy complications associated with MHVs in middle-income countries may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if daily doses >5 mg and ensuring therapeutic levels of heparin during bridging in the first and third trimesters and peripartum period. Administration of low-dose aspirin should be considered as this may prevent placentally-mediated complications of pregnancy. Highlights: Pregnancy complications associated with MHVs in LMICs may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if the daily dose is >5 mg, ensuring therapeutic levels of heparin in the first trimester and peripartum period.Placentally-mediated complications of pregnancy can be prevented by administering low-dose aspirin.Vitamin K antagonists or sequential regimen can be used as suitable alternatives to LMWH for anticoagulation in pregnant women with MHVs.

Diagnostic Accuracy of Point-of-care Nitrite and Leukocyte Esterase Dipstick Test for the Screening of Pediatric Urinary Tract Infections.

Our study aimed to evaluate the diagnostic performance of point-of-care nitrite and leukocyte esterase (LE) dipsticks in the diagnosis of suspected urinary tract infection (UTI) in infants <6 months (young infants) versus older children. The secondary objectives were to study the dipstick efficacy in children with congenital anomalies of the kidney and urinary tract (CAKUT) versus those without CAKUT; in children with simple UTI versus complicated UTI; and to evaluate the clinico-microbiological profile of children presenting with UTI. In this prospective observational study, cases with suspected UTI were enrolled from pediatric emergency or outpatient departments. Urine was collected for performing the urine dipstick and culture. Descriptive data regarding CAKUT, age, gender, etc., were recorded in a predesigned pro forma. We screened 506 children with suspected UTI, of whom 221 had urine culture positive. Approximately 38.4% of the children with UTI had underlying CAKUT, while 7.6% had renal scars. The most common CAKUT was vesicoureteric reflux (VUR). About 12 patients (2.3%) were known to have CAKUT at the time of enrollment in the study. In infants <6 months, LE dipstick had sensitivity 92%, specificity 89.7%, positive predictive value (PPV) 86.7%, negative predictive value (NPV) 93.8%, likelihood ratio (LR) + 8.9, LR- 0.09. In infants <6 months, nitrite dipstick had sensitivity 38%, specificity 97%, PPV 90.4%, NPV 68%, LR+ 12.6 and LR-0.63. In the age group 6 months to 12 years, the efficacy was better for both dipsticks. In age group more than 6 months to 12 years, LE dipstick had sensitivity 96.4%, specificity 95.8%, PPV 94.8 %, NPV 97.2%, LR+ 22.9, LR- 0.04. In age group more than six months to 12 years, nitrite dipstick had sensitivity 94.7%, specificity 99.5%, PPV 99.3%, NPV 96%, LR+ 189.4, and LR-0.05.

Comparison of respiratory distress syndrome amongst preterm twins (28-34 Weeks) born within and after two weeks of completion of single antenatal corticosteroid course: A bidirectional cohort study.

BACKGROUND: The literature on neonatal outcomes in preterm twins delivered before 34 weeks but within and after 14 days of a single initial steroid course is limited. MATERIAL AND METHODS: This bidirectional (226 prospective and 42 retrospectives) cohort study was performed at a tertiary care teaching hospital in South India. We compared the respiratory distress syndrome and neonatal death amongst preterm twins from 28 to 34 weeks born < 14 days (Group A, n=268) and after 14 days (Group B, n=268) of completion of a single course of antenatal steroids. We used multivariable regression analysis (log-binomial model) to adjust for confounding variables. We generated a propensity-matched score with probit regression to analyse outcomes (respiratory distress and neonatal deaths). RESULTS: The two groups had significant differences in the distribution of birthweight, gestation period and mode of delivery. On adjusted analysis, the period of gestation below 33 weeks and weight below 1.5 kg had the maximum influence on respiratory and other morbidities, and weight less than 1 kg on neonatal death. [adjusted relative risk (ARR) 26.06, (95%CI=2.37-285.5), p=0.008]. On propensity scoring after matching all these variables, we found an [ARR of 2.0 (95% CI: 1.03-3.88), P=0.017] for neonatal death after 14 days of steroid injection. The ARR for respiratory distress syndrome was 1.13 in those born after 14 days of steroids, though it did not reach statistical significance. CONCLUSION: On propensity scoring, the steroid-delivery interval more than 14 days was associated with a significantly increased risk (ARR of 2) of neonatal death.

Neurodevelopmental Outcome of Preterm Newborns with Abnormal Umbilical Artery Doppler - A Prospective Cohort Study.

OBJECTIVE: To assess the neurodevelopmental outcome of preterm neonates with absent/reversed end diastolic flow (A/REDF) in umbilical artery Doppler at 1 year of corrected age. METHODS: A cohort of 70 preterm newborns with fetal growth restriction (FGR), defined as estimated fetal weight (EFW) <10th centile, confirmed by birthweight <10th centile, along with A/REDF in the umbilical artery Doppler was followed up till 1 year of corrected age (CA). An equal number of gestation and gender matched preterm newborns with birthweight >10th centile [appropriate for gestational age (AGA)] and normal antenatal ultrasound were taken as controls. Primary outcome was a composite of death or major neurodevelopmental disability (NDD) at 1 year of corrected age. Matched analysis was performed. RESULTS: A total of 140 newborns were enrolled, of which, 20 expired and 8 were lost to follow-up. The primary outcome (death/major NDD) occurred in 26.8% of the FGR (A/REDF) newborns as compared to 9.3% of their AGA counterparts (RR-2.83, p = 0.02, 95% CI:1.11-7.18). Mean motor quotient in Development Assessment Scale for Indian Infants (DASII) at 1 year of corrected age was significantly lower in FGR (A/REDF) infants (91 ± 13.6 vs. 96.3 ± 7.1, p < 0.05). Multiple other co-morbidities were also significantly more among these newborns. CONCLUSIONS: Preterm newborns with FGR and A/REDF are at significantly increased risk of death/major NDD at 1 year of corrected age.