Crash Caesarean Delivery: How to Optimise Decision-to-Delivery Interval by Initiating a Novel Code? A Clinical Audit.

Background: Many resource-constrained centres fail to meet the international standard of 30 min of decision-to-delivery interval (DDI) of Category-1 crash caesarean deliveries. However, specific scenarios like acute foetal bradycardia and antepartum haemorrhage necessitate even faster interventions. Methods: A multidisciplinary team developed a "CODE-10 Crash Caesarean" rapid response protocol to limit DDI to 15 min. A multidisciplinary committee analysed a retrospective clinical audit of maternal-foetal outcomes over 15 months (August 2020-November 2021), and expert recommendations were sought. Results: The median DDI of twenty-five patients who underwent a "CODE-10 Crash Caesarean delivery" was 13 ± 6 min, with 92% (23/25) of DDIs falling below 15 min. Seven neonates required intensive care for more than 24 h with no maternal or neonatal mortality. DDIs during office and non-office hours were not significantly different (12.5 ± 6 min vs 13 ± 5 min, p = 0.911). Transport delays caused the two instances of DDI > 15 min. Conclusion: The novel "CODE-10 Crash Caesarean" protocol may be feasible for adoption in a similar tertiary-care setting with appropriate planning and training.

Arresting post-partum hemorrhage using the novel trans-vaginal uterine artery clamp.

OBJECTIVES: Post-partum hemorrhage (PPH) continues to be the leading cause of maternal mortality in low-resource settings. The commonest variant - Atonic PPH, is managed by additional pharmacological measures which may fail. Additional surgical interventions for hemostasis take time and are not universally available. Immediate arrest of bleeding was deemed essential and a novel Transvaginal Uterine Artery Clamp (TVUAC) was explored for its effectiveness in achieving immediate hemostasis in atonic and mixed post-partum hemorrhage. STUDY DESIGN: A retrospective chart review was performed for all patients, who underwent vaginal delivery and developed immediate post-partum atonic PPH, in a tertiary care center in South India, between 1st April 2015 and 31st December 2020. As soon as excess bleeding was observed, two TVUACs were applied trans-vaginally at 3' and 9'o clock position of the cervix to occlude the uterine arteries where it joins the isthmus of the uterus. RESULTS: Of 3999 vaginal deliveries, there were 251 patients who developed primary atonic PPH during the study period, of which 89 were managed by medical measures alone. Out of the remaining 162 patients, in 153 (94.4%) TVUAC helped to achieve hemostasis; with TVUAC alone in 120 patients (78.43%) and with an additional second line surgical intervention in 33 patients. In nine patients, TVUAC was not readily available and hence second line interventions alone were used. None required any third line surgical interventions (laparotomies) for hemostasis nor were there any incident of maternal mortality or consumptive coagulopathy. TVUAC was applied for a mean duration of 25 ± 10 min. Only 11.6% (29/251, 95% C.I 7.9-16.1%) of the patients required a blood transfusion with a median of 2 (1-4) units of packed RBC. No procedure related complications were reported up to a scheduled 6th week in-person follow-up. CONCLUSION: The novel TVUAC shows potential in limiting third line interventions, maternal morbidity and mortality. Its effectiveness and safety may be further explored as a first line surgical adjunct to medical measures, in PPH protocols in low-resource settings.

Comparative Study of Cesarean Myomectomy with Abdominal Myomectomy in Terms of Blood Loss in Single Fibroid.

OBJECTIVE: In this study, we evaluate the safety and feasibility of cesarean myomectomy and compare this procedure with abdominal myomectomy in single fibroid, in terms of blood loss and postoperative complications. METHODS: Thirty-three patients who underwent cesarean myomectomy from June 2006 to 2012 in Amrita Institute of Medical Sciences, were included in the study. Almost an equal number of patients who underwent abdominal myomectomy (32) in the same period were included. Women are divided into two groups: group 1-cesarean myomectomy, group 2-abdominal myomectomy. RESULTS: Mean age of the women was comparable; mean gestational age in group 1 was 37.97 +/- 1.57 weeks; and 60 % were primiparous. Hemoglobin (Hb) drop postoperatively was compared between the groups, and there was no significant difference. Though there was statistically significant difference among the groups regarding the size of fibroids, the main outcome measure of the study, the Hb drop was comparable between group 1 and 2. There is statistically significant difference in the Hb difference with increasing mean diameter of the fibroids. As the size increases, Hb drop also increases indicating the increasing blood loss. The measures used to reduce blood loss such as vasopressin instillation and stepwise devascularization influence the blood loss, and P value shows borderline significance. There was no difference in Hb drop among the groups according to the type of fibroids. But more subserous fibroids were removed in group 1, whereas more intramural fibroids were removed in group 2. CONCLUSION: Cesarean myomectomy can be safely done in single fibroids and is comparable to abdominal myomectomy in terms of blood loss.

Speciation of coagulase negative Staphylococcal isolates from clinically significant specimens and their antibiogram.

BACKGROUND: Despite their frequency as contaminants, coagulase-negative Staphylococci (CONS) have become important nosocomial pathogens, accounting for 9% of all nosocomial infections. These infections are difficult to treat because of the risk factors and the multiple drug resistance nature of these organisms. MATERIALS AND METHODS: One hundred and two consecutive CONS were isolated from various clinical samples like blood, pus, urine, urine catheter tip and gastric lavage. Most of the blood samples were from patients with risk factors (immunocompromised or on medical devices). After confirming the isolates as CONS, species-level identification was performed by simple, non-expensive conventional methods and antibiotic sensitivity testing was also carried out. RESULTS: Of 102 CONS isolates, 100 isolates could be identified to the species level. Among the 100 isolates, epidermidis was the most common species isolated, seen in 32%, followed by S. hemolyticus (18%), S. lugdunensis (12%), S. hominis (10%), S. saprophyticus (8%), S. capitis (6%), S. caprae (4%), S. xylosus (4%), S. cohni and S. warneri (3% each). In the present study, 56% of the isolates were methicillin-resistant CONS. Most of the isolates showed resistance to ampicillin and amoxyclav (89% each), followed by ceftriaxone (52%), cotrimoxazole (46%), cefotaxime (32%), gentamicin (25%), amikacin (21%). CONCLUSION: The increased pathogenic potential and multiple-drug resistance demonstrates the need to adopt simple, reliable and non-expensive methods for identifying and determining the antibiotic sensitivity of CONS.

Laparoscopic Resection of Unruptured Rudimentary Horn Pregnancy.

A non-communicating rudimentary horn is an uncommon site for ectopic pregnancy. Rudimentary horn pregnancy (RHP) is a rare entity but associated with grave clinical consequences. Majority of these cases if not detected timely end up in uterine rupture and present as an obstetrical emergency. We present this case of a 32-year-old, third gravida with a 12 weeks live gestation in the right rudimentary horn, which was successfully managed with laparoscopic resection. Early diagnosis is the key stone in the management of such cases. Laparoscopic resection is a safe and viable option in the surgical management of unruptured RHP.

Herlyn-Werner-Wunderlich Syndrome Complicated with Pyocolpos: An Unusual Cause of Postabortal Sepsis.

Obstructive mullerian anomalies give rise to a spectrum of clinical presentations and are uncommon in routine gynecologic practice. The patient usually becomes symptomatic in early reproductive years. Recurrent pelvic pain, dysmenorrhea, enlarging abdominopelvic mass, and abnormal vaginal discharge are the common presenting symptoms. We describe a rare case of a mullerian anomaly getting diagnosed 13 years after attaining menarche during the evaluation of postabortal sepsis. Patient presented 2 weeks following evacuation carried out for missed abortion, with acute abdominal pain, fever and foul smelling discharge per vaginum. The anomaly was identified as uterus didelphys with obstructed left hemivagina and ipsilateral renal agenesis (Herlyn-Werner-Wunderlich syndrome) complicated by pyocolpos. She was successfully managed by single-stage transvaginal septum resection under laparoscopic control.

Backbone motions in a crystalline protein from field-dependent 2H-NMR relaxation and line-shape analysis.

We have used 2H-nmr to study backbone dynamics of the 2H-labeled, slowly exchanging amide sites of fully hydrated, crystalline hen egg white lysozyme. Order parameters are determined from the residual quadrupole coupling and values increase from S2 = 0.85 at 290 K to S2 = 0.94 at 200 K. Dynamical rates are determined from spin-lattice relaxation at three nmr frequencies (38.8, 61.5, and 76.7 MHz). The approach used here is thus distinct from solution nmr studies where dynamical amplitudes and rates are both determined from relaxation measurements. At temperatures below 250 K, relaxation is independent of the nmr frequency indicating that backbone motions are fast compared to the nmr frequencies. However, as the temperature is increased above 250 K, relaxation is significantly more efficient at the lowest frequency, which shows, in addition, the presence of motions that are slow compared to the nmr frequencies. Using the values of S2 determined from the residual quadrupole coupling and a model-free relaxation formalism that allows for fast and slow internal motions, we conclude that these slow motions have correlation times in the range of 0.1 to 1.0 microsecond and are effectively frozen out at 250 K where fast motions of the amide planes with approximately 15 ps effective correlation times and 9 degrees rms amplitudes dominate relaxation. The fast internal motions increase slightly in amplitude as the temperature rises toward 290 K, but the correlation time, as is also observed in solution nmr studies of RNase H, is approximately constant. These findings are consistent with hypotheses of dynamic glass transitions in hydrated proteins arising from temperature-dependent damping of harmonic modes of motion above the transition point.

17O NMR and crystalline hydrates.

17O NMR is complementary to 2H NMR for studies of hydrate structure and dynamics in solids, insofar as the quadrupole coupling parameters can be accurately determined. At a Larmor frequency of 34.2 MHz, the effects of a large 17O quadrupole coupling (e2qQ/h approximately 7 MHz) on both the orientational dependence of the central transition resonance frequency and its observation by cross-polarization are examined in powders and a single crystal of oxalic acid dihydrate. Comparison with the exact energies shows that the variation of the central transition frequency with tensor orientation is accurately described as a second-order perturbation, even when e2qQ/h and the Larmor frequency are comparable. The combined chemical and quadrupole-induced shifts of the central transition frequency are separated by their distinct transformation properties, and we report the H2(17)O quadrupole coupling tensor in alpha-oxalic acid dihydrate, which is compared with the hydrogen bonding structure. Excitation of the central transition by cross-polarization is examined in terms of the 17O nutation frequency. Distortions in powder patterns and the loss of lines in single-crystal spectra owing to the orientational dependence of the first-order quadrupole coupling are verified, and simple methods for mitigating the problem in single-crystal and powder experiments are presented.

Deuterium quadrupole coupling in N-acetylglycine and librational dynamics in solid poly(gamma-benzyl-L-glutamate).

To study the dynamics of peptide groups in solid proteins, we have accurately determined the principal components and molecular orientation of the electric field gradient tensor for the exchangeable deuterons in monoclinic N-acetylglycine by single-crystal deuterium nuclear magnetic resonance. These results are compared with the principal components of the amide deuterons in solid poly(gamma-benzyl-L-glutamate) measured in powder samples over a wide temperature range (140-400 K). The comparison indicates that in the solid polypeptide the N-D bonds undergo a small-amplitude torsional reorientation (libration) perpendicular to the peptide plane. To estimate dynamic rates, longitudinal relaxation times (T1 values) are reported for N-acetylglycine and poly(gamma-benzyl-L-glutamate). T1 values for the carboxyl and amide deuterons in N-acetylglycine are approximately 100 s, whereas for the amide deuterons in the polypeptide T1 approximately 1 s, also indicating that the N-D bonds are not stationary in the polypeptide. We determine from the reduced quadrupole coupling tensor the mean-square amplitude for the libration and show that it increases linearly with temperature. A simple qualitative theory for the relaxation times is presented on the basis of the assumption that the N-D reorientation is described either as a diffusion process in a square well or as a damped Langevin oscillator with a harmonic restoring force. The conclusion is that the short relaxation times of the polypeptide amide deuterons result from substantial frictional effects on reorientation that increase with temperature.

Orientational ordering and dynamics of the hydrate and exchangeable hydrogen atoms in crystalline crambin.

Deuterium nuclear magnetic resonance studies of crambin crystals grown from deuterated solvent (2H2O/CH3CH2O2H or H2O/C2H3CH2OH) are reported. The extent to which the hydrate and exchangeable hydrogen atoms are dynamically disordered are then determined from the size of the residual deuterium quadrupole couplings, qcc. Rapid molecular reorientation (tau c-1 greater than 10(5) s-1) reduces the magnitude of the quadrupole coupling from its static value (216 kHz for solid water). We find that the room temperature spectrum of crambin is dominated by two features: a sharp line with very small residual quadrupolar coupling less than 3 kHz, and a broad pattern with a quadrupolar coupling in the range 185 to 195 kHz. The former is indicative of very nearly isotropically reorienting deuterons, whereas the latter is somewhat narrower than that observed for the amide deuterons of poly-gamma-benzyl-L-glutamate and thus indicative of deuterons that are almost but not completely stationary. By considering the nuclear magnetic resonance spectrum intensities along with the amino acid sequence, X-ray structure and the manner in which quadrupole couplings are reduced by dynamics, we conclude that the nuclear magnetic resonance signal from most of the water molecules of hydration are contained in the sharp line, i.e. reorient nearly isotropically in the crystalline protein. Unlike bulk water, which freezes abruptly in the manner of a phase transition, the water of hydration in crambin has a broad freezing range from 180 to 250K, as evidenced by the decreasing intensity of the sharp line that disappears at 180K. At temperatures between 150 and 200K, a typical hydrate molecule reorients at a rate comparable to the quadrupole coupling, 10(4) s-1 to 10(5) s-1, a process that occurs in hexagonal ice in the range of 240 to 270K. At 140K, the hydrate is stationary, tau c-1 less than 10(3) s-1. Studies of the protein crystallized from solvent deuterated only at the non-exchangeable methyl group of ethanol confirm that ethanol is in the lattice and show that this solvate behaves in much the same way as the hydrate. The refined X-ray structure has identified four ethanol solvate molecules. The deuterium spectrum at room temperature has a well-defined residual pattern with qcc = 2.2 kHz, i.e. a small-order parameter consistent with nearly isotropically reorienting molecules. The spectrum width broadens substantially only at temperatures below 200K and achieves the characteristic spectrum of a rotating methyl group with stationary C-C axis at 140K.(ABSTRACT TRUNCATED AT 400 WORDS)