Towards Accurate Search for Neonatal Heartbeat: Weighted Algorithm for Reliable ECG Analysis of Premature Infants.

Accurate identification of the QRS complex is critical to analyse heart rate variability (HRV), which is linked to various adverse outcomes in premature infants. Reliable and accurate extraction of HRV characteristics at a large scale in the neonatal context remains a challenge. In this paper, we investigate the capabilities of 15 state-of-the-art QRS complex detection implementations using two real-world preterm neonatal datasets. As an attempt to improve the accuracy and reliability, we introduce a weighted ensemble-based method as an alternative. Obtained results indicate the superiority of the proposed method over the state of the art on both datasets with an F1-score of 0.966 (95% CI 0.962-0.97) and 0.893 (95% CI 0.892-0.894). This motivates the deployment of ensemble-based methods for any HRV-based analysis to ensure robust and accurate QRS complex detection.

Development of an Interactive Dashboard to Analyse Physiological Signals in the Neonatal Intensive Care Unit.

Premature babies and those born with a medical condition are cared for within the neonatal intensive care unit (NICU) in hospitals. Monitoring physiological signals and subsequent analysis and interpretation can reveal acute and chronic conditions for these neonates. Several advanced algorithms using physiological signals have been built into existing monitoring systems to allow clinicians to analyse signals in real time and anticipate patient deterioration. However, limited enhancements have been made to interactively visualise and adapt them to neonatal monitoring systems. To bridge this gap, we describe the development of a user-friendly and interactive dashboard for neonatal vital signs analysis written in the Python programming language where the analysis can be performed without prior computing knowledge. To ensure practicality, the dashboard was designed in consultation with a neonatologist to visualise electrocardiogram, heart rate, respiratory rate and oxygen saturation data in a time-series format. The resulting dashboard included interactive visualisations, advanced electrocardiogram analysis and statistical analysis which can be used to extract important information on patients' conditions.Clinical Relevance- This will support the care of preterm infants by allowing clinicians to visualise and interpret physiological data in greater granularity, aiding in patient monitoring and detection of adverse conditions. The detection of adverse conditions could allow timely and potentially life-saving interventions for conditions such as sepsis and brain injury.

Conservative Management of Huge Symptomatic Endocervical Polyp in Pregnancy: A Case Report.

Cervical polyp is very rare in pregnancy, usually asymptomatic and small. There are several reports of different sizes of cervical polyp in pregnancy but, huge cervical polyp causing funnelling and shortening of cervical length was first reported in 2014. It was managed by polypectomy causing cervical length to return to normal value. We present the second case report in literature of a huge endocervical polyp in pregnancy that caused funnelling and shortening of cervical length. Unlike the earlier report this patient presented with preterm contractions and antepartum haemorrhage (APH). She was managed conservatively by polypectomy at 38 weeks of gestation without complications. This is the first case report in the literature of a huge symptomatic endocervical polyp in pregnancy presenting with preterm contractions and APH that was conservatively managed. The role of such management has been emphasized.

Spontaneous intraperitoneal hemorrhage in the third trimester of pregnancy: Clinical suspicion made the difference.

A case of spontaneous hemoperitoneum resulting from ruptured vessels in the uterine-ovarian plexus, in the third trimester of pregnancy is described. This is a rare and challenging obstetric emergency. Acute abdominal pain is the main presenting symptom. Clinical suspicion and rapid intervention consisting of emergency cesarean section with ligation of bleeding vessels resulted in favorable outcomes for both mother and baby. The importance of prompt action in the case of deteriorating vital signs is emphasized to achieve success in their management.

Multiple repeat cesarean sections: operative difficulties, maternal complications and outcome.

OBJECTIVE: To determine maternal/neonatal complications and outcome in patients with multiple repeat cesarean sections (CSs). STUDY DESIGN: A retrospective case-control study of 144 pregnant women with > or = 4 cesarean sections was compared with a control group of 288 women having 2-3 cesarean sections for maternal, operative and neonatal complications. RESULTS: The study patients had longer operating times (p = 0.0001) due to severe adhesions (p = 0.0005), with increased blood loss and blood transfusion (p = 0.0001). Rupture of the uterus (p = 0.0015), placenta previa (p = 0.0372), gestational age at delivery (p < 0.0002), preterm birth (p = 0.0497) and Apgar scores < 7 at 5 minutes (p = 0.0140) were significant in the study group. There was no significant difference of placenta accreta, bladder and bowel injury, cesarean hysterectomy, wound infection and postoperative pyrexia between the 2 groups. Among the neonates of the 2 groups, NICU admissions, small-for-gestational-age birth weights, large-for-gestational-age birth weights and perinatal mortality were similar. No mother died in the series. The incidence of a single major complication was higher in women with > or = 4 cesarean deliveries (p = 0.0011). CONCLUSION: Repeated CS increases the risk of uterine rupture and intraoperative complications, making these patients a high-risk group. No absolute upper limit for the number of repeat cesarean deliveries can be given. Patients must be informed of the risks of multiple CSs and encouraged to have tubal ligation.

Ovarian tumors in children and adolescents--a clinical study of 52 patients in a university hospital.

STUDY OBJECTIVE: To review the clinical presentation of ovarian tumors in children and adolescents treated at the University of Dammam and King Fahad University Hospital. DESIGN: Data of the patients was noted retrospectively from the hospital medical records regarding age, presentation, diagnosis, treatment, and outcome. SETTING: The study was carried out in the Ob/Gyn department at King Fahad Hospital of Dammam University, Saudi Arabia between January 1985 and December 2009. PARTICIPANTS: There were 52 patients between 6 and 20 years of age who presented with an ovarian tumor during the study period. INTERVENTION: Preoperative diagnostic approach included history, physical examination, ultrasonography, radiological examination, tumor markers, operative treatment, and histopathological examination of the tumor. Chemotherapy was given to patients where indicated. RESULTS: The main presenting symptom was abdominal pain in 30 (58%) patients. Of the neoplastic tumors, 87% were germ cell tumors, of which 73% were benign while 13% were malignant. Operative procedures included 48 (92%) exploratory laparotomies and 4 (8%) laparoscopic resections. Ovarian cystectomy was done in 23 (44%) patients and salpingoophorectomy in 28 (54%) patients. Of the 7 (13%) patients with malignant tumors, five received postoperative chemotherapy. Three patients with malignancy died in the series. CONCLUSION: Early diagnosis of ovarian masses in young girls is important. Since most of these masses are benign, operation should be designed to optimize future fertility, while the treatment of malignant tumors would involve complete staging, resection of the tumor, postoperative chemotherapy when indicated, to give the patient a chance for future childbearing.

Ovarian tumors associated with pregnancy: a 20-year experience in a teaching hospital.

OBJECTIVE: Pregnancy associated with ovarian tumors was reviewed over a 20-year period to determine the maternal and fetal outcome in patients undergoing surgery during pregnancy. METHOD: A retrospective study of 94 cases of ovarian tumors treated surgically during pregnancy was investigated for incidence, clinico-pathological features and outcome in a teaching hospital between June 1987 and May 2007. RESULTS: The overall incidence of ovarian tumor in pregnant women was 1 in 505 (0.2%) deliveries. Diagnosis of 69.2% tumors resulted in the first and second trimesters of pregnancy. Twenty-two (23.4%) patients presented as an emergency at different periods of gestation and 16 (17.1%) tumors were incidentally discovered at cesarean section which underlines the significance of examining the ovaries routinely at cesarean section. Benign teratoma (39.4%) and serous cystadenoma (24.5%) were the most common types of ovarian tumors found in the study. The incidence of malignant tumors was 5.3%. Tumors with low malignant potential comprised 40% of malignancy. The miscarriage rate after surgery was 44.4% in the first trimester compared with 16.6% in the second trimester. The preterm birth rate was 4.3% in the series. CONCLUSION: The value of clinical and ultrasound examinations in early pregnancy as a diagnostic aid is highlighted. Whenever an ovarian tumor is detected in pregnancy, malignancy should always be suspected. Treatment of an ovarian tumor in pregnancy should be tailored according to the age, parity, clinical presentation, gestational age and histopathology of the tumor. Removal of persisting or enlarging ovarian masses as soon as possible is important to obtain a final histologic diagnosis and rule out malignancy. Early diagnosis and appropriate treatment of malignant tumors offers the best prognosis for the patient.

Maternal and fetal outcome of pregnancy complicated by HELLP syndrome.

OBJECTIVE: The study evaluated the maternal and fetal outcome in 64 pregnancies complicated by HELLP syndrome. METHODS: A retrospective analysis of the medical records was performed of patients with HELLP syndrome managed at this tertiary Obstetric unit between January 1996 and December 2005, who were admitted for preeclamsia/eclampsia and had documented evidence of hemolysis, elevated liver enzymes and low platelet count. Maternal and neonatal complications were recorded and analyzed. RESULTS: The incidence of HELLP syndrome in the study was 8.3%. Mean gestational age at delivery was 32.4 +/- 4.2 weeks and mean birth weight was 1851 +/- 810 g. Forty-two percent of the patients had deliveries <32 weeks and 28% IUGR. Respiratory distress syndrome was the main indication for NICU admissions (33.9%). The PNM rate was 20%. Maternal morbidity rate was 34%. The most common maternal complications were abruptio placentae (36.4%) and DIC (31.8%). There was no maternal death. CONCLUSION: Once the diagnosis of HELLP syndrome is confirmed, the management depends on several obstetric and maternal variables like gestational age, severity of laboratory abnormalities and fetal status. As soon as the maternal condition is stabilized and fetal assessment is obtained, prompt delivery of the fetus is indicated. It is not yet established whether expectant management in preterm pregnancies with HELLP syndrome would improve perinatal outcome.

Shoulder dystocia in a 16-year experience in a teaching hospital.

OBJECTIVE: To determine incidence of shoulder dystocia and evaluate associated maternal, obstetric and fetal risk factors. STUDY DESIGN: Records of patients and neonates with shoulder dystocia at delivery were studied for demography, labor complications and neonatal outcome. Two control cases who delivered vaginally following each patient were selected that matched the maternal demography of the patient group. Incidence of shoulder dystocia and related risk factors were analyzed and compared with controls. Maternal and fetal morbidity and mortality were determined. RESULTS: Among 32,312 singleton vaginal deliveries, 104 cases of shoulder dystocia were recorded. Several reported high-risk factors related to increased incidence of shoulder dystocia reported were confirmed by the study, although 26% of the neonates with shoulder dystocia weighed < 4,000 g. Postpartum hemorrhage and third-degree perineal tear were significant complications; neonatal brachial plexus injury occurred in 20%, clavicle and humerus fracture in 10.6% and neonate asphyxiation in 8.6%. No maternal death occurred; high perinatal mortality was no surprise. CONCLUSION: Training clinicians to manage shoulder dystocia is difficult because of rare occurrence and lack of standardized management; simulation training with mannequins is helpful. Obstetricians should formulate a management plan and act promptly and decisively when confronted with this complication.

Pregnancy outcome in patients with homozygous sickle cell disease in a university hospital, Eastern Saudi Arabia.

OBJECTIVE: To evaluate the maternal and fetal outcome in pregnant women with sickle cell disease and to highlight the complications encountered during pregnancy and delivery at a university hospital in the Eastern Saudi Arabia. STUDY DESIGN: A retrospective study of 255 pregnancies in 145 patients with sickle cell disease (SCD) over an 8-year-period analyzed the perinatal complications and maternal and fetal outcomes compared with a control group of 500 Saudi females with the normal hemoglobin phenotype selected randomly that matched for age, parity and delivered during the study period. RESULTS: The incidence of SCD was 1.3% of all deliveries with one maternal death (0.4%) and a perinatal mortality rate of 78.2/1,000 deliveries in the series. The major maternal complications in the 255 pregnancies were anemia 84.3%, sickle cell crisis 44.3% (26.6% painful and 17.7% hemolytic crises), infection 45.9%, fetal growth restriction 20.1%, preterm delivery 12.6%, and pregnancy-induced hypertension 10.6%. Blood transfusion was necessary in 34% pregnancies. Stillbirths accounted for 63% of the perinatal mortality. CONCLUSIONS: Saudi women with SCD are at a greater risk of morbidity and mortality in pregnancy than previously reported, with a high perinatal mortality rate. Early booking, meticulous antenatal care and supervised hospital delivery will improve the maternal and fetal outcomes in these patients.

Bladder injuries during cesarean section in a University Hospital: a 25-year review.

OBJECTIVES: The objective was to determine the prevalence of bladder injury during cesarean section (CS) and identify the risk factors causing these injuries, their management and the outcome. METHODS: We retrospectively reviewed the medical records of all the patients who had bladder injury during CS over a period of 25 years (1983-2007) at the King Fahad Hospital, Al-Khobar, Saudi Arabia. Demographic data, obstetric, surgical details, mechanism of injury, anatomic location, diagnosis, management and outcome were assessed. RESULTS: Thirty-four cases of bladder injury were identified among 7,708 cesarean deliveries performed during this period with an overall incidence of 0.44%. Primary CS was found in 41.2% of the patients and 58.8% had repeat CS giving an incidence of 0.27 and 0.81%, respectively. Bladder injury occurred when surgical difficulties were encountered during opening of the peritoneal cavity and while developing the bladder flap over the lower uterine segment, mainly due to adhesions and scar tissue resulting from previous abdominal surgery. All the bladder injuries were recognized intraoperatively and repaired with an overall satisfactory outcome. Repeat CS and presence of adhesions were found to be statistically significant risk factors in the study, while operator experience and emergency nature of the CS were considered risk factors in a few cases of bladder injury. CONCLUSIONS: Data presented in this study indicates that bladder injury when adequately repaired is rarely associated with any complications. Multiple cesarean deliveries is a significant risk factor for bladder injury at the time of repeat CS and patients should be counseled regarding this risk before surgery.

Progression of retinopathy during pregnancy in type 1 diabetes mellitus.

PURPOSE: The incidence and risk factors for progression of retinopathy during pregnancy in women with type 1 diabetes mellitus were retrospectively evaluated. METHODS: Fifty-four insulin-dependent diabetic patients at a teaching hospital in Saudi Arabia were followed throughout the pregnancy/puerperium with serial ophthalmic examination. Dilated fundus examination was performed in each trimester and puerperium. RESULTS: Progression of diabetic retinopathy in the study occurred in 13/54 (24%) patients--2/22 (9.1%) patients had no diabetic retinopathy initially, 4/20 (20%) had non-proliferative diabetic retinopathy (NPDR) and 7/12 (58.3%) had proliferative diabetic retinopathy (PDR). Of the eight patients with PDR who had no laser treatment before pregnancy, six (75%) showed progression but only one of the four patients who had PDR and laser treatment prior to pregnancy experienced progression of retinopathy. Eight patients in total received panretinal photocoagulation to arrest the progression of retinal disease during pregnancy and only one of them had laser treatment prior to pregnancy. CONCLUSION: Laser photocoagulation for severe NPDR or early PDR prior to pregnancy may protect against rapid progression of PDR. Visual impairment resulting from progression of PDR can be prevented by aggressive laser treatment during pregnancy. Duration of diabetes>15 years, poor glycaemic control and hypertension are high-risk factors in the progression of diabetic retinopathy in pregnancy.

Obstetric admissions to the intensive care unit: a 12-year review.

OBJECTIVE: The objective was to ascertain the prevalence, causes and outcome of critically ill obstetric patients admitted to the intensive care unit (ICU). DESIGN: The design was a retrospective collection of data. SETTINGS: The setting was a multidisciplinary ICU in a University hospital. PATIENTS: All obstetric patients admitted to the ICU over a 12-year period from May 1992 to April 2004 were reviewed. METHODS: Data collected included demographic characteristics of the patients, pre-existing medical conditions, obstetric complications, invasive procedures required in the ICU and outcome of the patients. RESULTS: The incidence of obstetric admissions to the ICU represented 0.22% of all deliveries during the study period. The majority (84.4%) of patients were admitted to the ICU postpartum. Obstetric haemorrhage (32.8%) and pregnancy-induced hypertension (17.2%) were the two main obstetrical reasons for admission. The remainder included medical disorders (37.5%) and other causes (6.2%). Associated major complications included adult respiratory distress syndrome (ARDS) and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome. The perinatal mortality rate was 20% and the maternal mortality rate 9.4%. CONCLUSIONS: A team approach consisting treatment by obstetricians, intensive care specialists and anaesthesiologists provided optimal care for the patients. Improved management strategies for obstetric haemorrhage and hypertension may significantly reduce maternal morbidity.

Bowel injury in gynecologic operations: analysis of 110 cases.

The incidence, risk factors, and morbidity were retrospectively reviewed of 110 intestinal injuries that occurred during gynecologic operations from January 1984 through December 2003 performed for benign and malignant conditions. The incidence of bowel injury was 0.54% in this series. Of the 110 bowel injuries, 37.3% occurred during opening of the peritoneal cavity, 38.2% during adhenolysis and pelvic dissection, 9% during laparoscopy, 9.1% sustained at vaginal operations, and 8.2% during dilatation and curettage. The small intestine was injured in 75.5% and large bowel in 24.5% of cases; 76.4% of all the injuries were minor, and 23.6% major. Standard surgical repair procedure of the bowel injury produced satisfactory results. It is recommended that gynecologists acquire a basic knowledge in the prevention and principles of management of intestinal injuries. Adherence to the standard surgical techniques during gynecologic operations and anticipation of bowel injury in high-risk patients will contribute to minimize the occurrence of such injuries.

Pregnancy outcome in lupus nephropathy.

METHODS: The maternal and fetal outcomes of 55 pregnancies in 24 patients with pre-existing lupus nephritis (LN) were retrospectively analysed. The risk factors for poor fetal outcome were evaluated. The patients were divided into two groups. Patients in Group A had quiescent LN and those in Group B showed clinical evidence of active LN at conception. RESULTS: In Group A, of the 36 pregnancies in 16 patients, 11 resulted in term deliveries without complications, 9 in spontaneous abortions, 6 in preterm deliveries, 3 in intrauterine growth retardation (IUGR) and in 2 stillbirths. In Group B, of the 19 pregnancies in 8 patients, there were 6 spontaneous abortions, 3 uncomplicated term deliveries and 10 pregnancies were complicated by hypertension. Gross IUGR occurred in 3 pregnancies. There were 3 stillbirths and 1 neonatal death in the study. Total fetal loss was 38.2% and the perinatal mortality (PNM) rate, 150/1,000 deliveries. Two mothers, both from Group B died in the series, 1 from multisystem failure of systemic lupus erythematosus, 3 days after delivery and the second died from irreversible renal failure 2 months after caesarean section. CONCLUSIONS: Pregnant women with long-standing LN are at high risk of spontaneous abortions and increased PNM. However, the outlook of pregnancy in patients with stable LN at conception is relatively favourable. The risk of obstetric complications and maternal mortality is high in patients with active lupus nephropathy associated with pre-existing hypertension. Pregnant women with LN require intense fetal and maternal surveillance for the best outcomes of pregnancy.

Maternal mortality: a twenty-year survey at the King Faisal University Hospital, Al-Khobar, Eastern Saudi Arabia.

This was an institutional study of all maternal deaths that occurred among 56422 total births at the King Faisal University Hospital, Al-Khobar, Saudi Arabia, between 1983 and 2002. The underlying cause of each maternal death and potentially avoidable factors were analysed. There were 16 maternal deaths in the hospital during the study period, giving a maternal mortality rate of 28.4/100,000 births. The leading cause of death was haemorrhage in seven (43.75%) patients, followed by pulmonary embolism in four (25%) and general anaesthesia in two (12.5%) mothers. The risk factors noted were maternal age 35 years and parity 5 coupled with iron deficiency anaemia. The main avoidable factors were failure of the patients to seek timely medical care and to follow medical advice. More than half the number of direct obstetrical causes of death was thought to be preventable. A rapidly changing attitude of women towards childbirth is occurring through progressively increasing female education and community health programmes in the region. Further reduction of maternal mortality rates in the community is envisaged through greater patient acceptance of medical advice, family spacing and proficient obstetric services.

Surgical treatment of rectovaginal fistula of obstetric origin: a review of 15 years' experience in a teaching hospital.

Fifty-two women with a rectovaginal fistula were managed over a period of 15 years. All the fistulae were caused by obstetric injury commonly resulting from breakdown of the repair of complete perineal tears or from unrecognised injury during forceps or precipitate delivery. In five patients the fistula healed spontaneously within 12 weeks of the injury. Thirty-nine patients underwent transvaginal purse-string repair by standard technique and eight patients had perineoproctotomy and sphincteroplasty for large fistulae associated with anal incontinence. Surgical repair was successful in all the 47 patients including two patients who had previous failed repair elsewhere. The routine postoperative follow-up period of the patients ranged between 6 months and 8 years. There were no residual symptoms of anal sphincter weakness in the patients treated with transvaginal purse-string repair. Two of the patients who underwent perineoproctotomy and sphincteroplasty complained of varying degrees of postoperative incontinence of flatus that resolved by 8 weeks postoperation. In our experience the transvaginal purse-string method of repair for small, low rectovaginal fistulae proved highly satisfactory with 100% cure rate. Perineoproctotomy and sphincteroplasty for larger fistulae associated with anal incompetence was equally successful with minimal postoperative morbidity.

Obstetric and gynecologic complications in women with Marfan syndrome.

OBJECTIVE: To analyze the maternal and fetal outcomes of pregnancy and gynecologic problems in women with Marfan syndrome. STUDY DESIGN: The outcomes of 14 pregnancies in 4 women with Marfan syndrome were prospectively observed between January 1988 and December 2000. The cardiovascular and obstetric complications were analyzed. During pregnancy all the patients were carefully monitored with serial echocardiography and close attention to symptoms. RESULTS: Of the 14 pregnancies, 5 (35.7%) ended in abortion, and 3 of them occurred in the early second trimester due to cervical incompetence. Premature onset of labor occurred in 2 pregnancies at 31 and 34 weeks. Postpartum hemorrhage complicated 3 deliveries, and inversion of the uterus occurred in 1 patient. Significant cardiovascular complications occurred in 2 patients, who required surgical correction of the aortic aneurysm and replacement of the aortic valve. In one patient the operation was performed within hours of vaginal delivery, and the other patient underwent surgery 8 weeks postpartum. No maternal death occurred in the study. One infant in the series was diagnosed as having Marfan syndrome. A premature infant delivered at 31 weeks died on the second day of life. CONCLUSION: Women with Marfan syndrome are at high risk of aortic dissection in pregnancy even in the absence of preconceptional aortic root dilatation. Obstetric complications in patients with this condition have been underreported in the past. Women with aortic root dilatation of < 40 mm usually tolerate pregnancy well, with good maternal and fetal outcomes. Women with Marfan syndrome should be counseled regarding the risk of pregnancy to both mother and fetus. Patients who have cardiac decompensation or aortic dilatation > 40 mm are advised to avoid pregnancy.

Ovarian carcinoma associated with pregnancy. A review of 9 cases.

BACKGROUND: The purpose of this study was to review patients with ovarian cancer in pregnancy, the effectiveness of the available methods of treatment and their prognosis. METHODS: A retrospective review of all women diagnosed to have cancer of the ovary associated with pregnancy who delivered at the authors' hospitals between January 1976 and December 2000. The demography, clinical presentation, time and mode of diagnosis, treatment, pregnancy outcome and maternal survival were noted. RESULTS: The incidence of ovarian carcinoma in pregnancy in the series was 0.08/1000 deliveries. Of the 9 patients, 7 had epithelial cancers; 4 serous cystadenocarcinoma, 2 mucinous cystadenocarcinomas and one undifferentiated cancer. One patient each had dysgerminoma and granulosa cell tumor. Six patients were in FIGO stage Ia, one Ic, one IIa. One patient was in stage III. Five patients were treated by unilateral salpingo-oophorectomy during pregnancy. Three patients had total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy followed by chemotherapy. Debulking of the tumor was done in a patient in stage III with subsequent chemotherapy. This patient died 13 months from the time of diagnosis of the tumor. The overall 5-year survival rate in the series was 78% and 100% for stage Ia. CONCLUSIONS: Association of ovarian cancer with pregnancy is a rare occurrence. Early diagnosis and appropriate treatment offers the best prognosis for the patient. The higher survival rates in the series was attributed to a larger number of patients in stage I of the disease and 2 patients with a germ cell tumor and dysgerminoma which have the best prognosis. Aggressive postoperative chemotherapy also contributed to the better outcome.