Etiology, Diagnosis and Management of Persistent Pulmonary Hypertension of the Newborn in Resource-limited Settings.

Persistent Pulmonary Hypertension of the Newborn (PPHN) is more common in Low and middle income countries (LMICs) due to high incidence of sepsis, perinatal asphyxia and meconium aspiration syndrome. Presence of hypoxic respiratory faillure and greater than 5% difference in preductal and post ductal saturation increases clinical sucipision for PPHN. The availability of Inhaled nitric oxide and extracorporaeal membrane oxygenation is limited but pulmonary vasodilators such as sildenafil are readily available in most LMICs.

[Clinical features of severe meconium aspiration syndrome (MAS) and early predicting factors for severe MAS in neonates with meconium-stained amniotic fluid]. / èƒŽç²ªæ±¡æŸ“ç¾Šæ°´æ–°ç”Ÿå„¿å‘ç”Ÿé‡åº¦èƒŽç²ªå¸å ¥ç»¼åˆå¾çš„ä¸´åºŠç‰¹å¾åŠé¢„è­¦å› ç´ åˆ†æž.

OBJECTIVES: To study the clinical features of severe meconium aspiration syndrome (MAS) and early predicting factors for the development of severe MAS in neonates with meconium-stained amniotic fluid (MSAF). METHODS: A total of 295 neonates who were hospitalized due to Ⅲ° MSAF from January 2018 to December 2019 were enrolled as subjects. The neonates were classified to a non-MAS group (n=199), a mild/moderate MAS group (n=77), and a severe MAS group (n=19). A retrospective analysis was performed for general clinical data, blood gas parameters, infection indicators, and perinatal clinical data of the mother. The respiratory support regimens after birth were compared among the three groups. The receiver operating characteristic (ROC) curve and multivariate logistic regression analysis were used to investigate predicting factors for the development of severe MAS in neonates with MSAF. RESULTS: Among the 295 neonates with MSAF, 32.5% (96/295) experienced MAS, among whom 20% (19/96) had severe MAS. Compared with the mild/moderate MAS group and the non-MAS group, the severe MAS group had a significantly lower 5-minute Apgar score (P<0.05) and a significantly higher blood lactate level in the umbilical artery (P<0.05). Compared with the non-MAS group, the severe MAS group had a significantly higher level of interleukin-6 (IL-6) in peripheral blood at 1 hour after birth (P<0.017). In the severe MAS group, 79% (15/19) of the neonates were born inactive, among whom 13 underwent meconium suctioning, and 100% of the neonates started to receive mechanical ventilation within 24 hours. Peripheral blood IL-6 >39.02 pg/mL and white blood cell count (WBC) >30.345×109/L at 1 hour after birth were early predicting indicators for severe MAS in neonates with MSAF (P<0.05). CONCLUSIONS: Meconium suctioning cannot completely prevent the onset of severe MAS in neonates with MSAF. The neonates with severe MAS may develop severe respiratory distress and require mechanical ventilation early after birth. Close monitoring of blood lactate in the umbilical artery and peripheral blood IL-6 and WBC at 1 hour after birth may help with early prediction of the development and severity of MAS.

Umbilical Cord Blood Acid-Base Parameters and Lactate as Predictors of Subsequent Meconium Aspiration Syndrome in Neonates.

Meconium aspiration syndrome (MAS) in neonates born through meconium-stained amniotic fluid (MSAF) causes significant morbidity and mortality. Early recognition of at-risk neonates could help optimize treatment. The aim was to determine predictive characteristics of cord blood pH, base deficit and lactate with subsequent MAS. Receiver operating characteristic (ROC) curves with area under curve (AUC) were estimated. Among 231 MSAF complicated pregnancies, 25 (10.8%) had MAS. Mean cord pH was significantly lower in neonates with MAS compared to those without MAS (7.15 ± 0.11 vs. 7.26 ± 0.07; p < 0.001). Median lactate between the two groups [5.6 (7.5, 3.7) vs. 2.7 (4.5, 2.0)] and base deficit [-10.6 (-13.2, -4.2) vs. -3.7 (-6.3, -2.6)] also differed significantly (p = 0.01). ROC curve area for cord lactate, pH, and base deficit were 0.81, 0.79, and 0.75, respectively. The predictive cutoff values for pH, lactate, and base deficit were 7.20, 3.55 mmol/L, and -5.3 mmol/L, respectively.

Prediction of meconium aspiration syndrome by data available before delivery.

OBJECTIVE: To identify risk factors associated with the occurrence of meconium aspiration syndrome (MAS) among neonates. METHODS: A retrospective case-control study in a university affiliated tertiary medical center, including all neonates born with meconium stained amniotic fluid (MSAF) between March 2011 and March 2020. Patients were categorized by the occurrence of MAS. Demographic, pregnancy and delivery characteristics were compared between the two groups. Risk factors for MAS were analyzed. RESULTS: Of 90 579 singleton deliveries, a total of 11 856 with MSAF were included. Of these newborns, 78 (0.66%) were diagnosed with MAS Four factors were independently associated with MAS: delivery at <38 0/7 weeks (aOR [95% CI]: 3.48 (1.02-11.84), P = 0.046); higher body mass index (aOR [95% CI]: 1.09 (1.02-1.16), P = 0.003); lower amniotic fluid index (aOR [95% CI]: 0.99 (0.98-0.99), P = 0.032); higher white blood cell count (aOR [95% CI]: 1.11 (1.02-1.20), P = 0.009). The presence of one, two and three of the above-mentioned risk factors yielded a risk for MAS of 0.8%, 2.5% and 100%, respectively. CONCLUSION: We identified independent risk factors for MAS and developed a risk score calculator. This tool may assist physicians in the management of deliveries complicated by MSAF.

Clinical features of severe meconium aspiration syndrome (MAS) and early predicting factors for severe MAS in neonates with meconium-stained amniotic fluid / 中国当代儿科杂志

OBJECTIVES@#To study the clinical features of severe meconium aspiration syndrome (MAS) and early predicting factors for the development of severe MAS in neonates with meconium-stained amniotic fluid (MSAF).@*METHODS@#A total of 295 neonates who were hospitalized due to Ⅲ° MSAF from January 2018 to December 2019 were enrolled as subjects. The neonates were classified to a non-MAS group (n=199), a mild/moderate MAS group (n=77), and a severe MAS group (n=19). A retrospective analysis was performed for general clinical data, blood gas parameters, infection indicators, and perinatal clinical data of the mother. The respiratory support regimens after birth were compared among the three groups. The receiver operating characteristic (ROC) curve and multivariate logistic regression analysis were used to investigate predicting factors for the development of severe MAS in neonates with MSAF.@*RESULTS@#Among the 295 neonates with MSAF, 32.5% (96/295) experienced MAS, among whom 20% (19/96) had severe MAS. Compared with the mild/moderate MAS group and the non-MAS group, the severe MAS group had a significantly lower 5-minute Apgar score (P<0.05) and a significantly higher blood lactate level in the umbilical artery (P<0.05). Compared with the non-MAS group, the severe MAS group had a significantly higher level of interleukin-6 (IL-6) in peripheral blood at 1 hour after birth (P<0.017). In the severe MAS group, 79% (15/19) of the neonates were born inactive, among whom 13 underwent meconium suctioning, and 100% of the neonates started to receive mechanical ventilation within 24 hours. Peripheral blood IL-6 >39.02 pg/mL and white blood cell count (WBC) >30.345×109/L at 1 hour after birth were early predicting indicators for severe MAS in neonates with MSAF (P<0.05).@*CONCLUSIONS@#Meconium suctioning cannot completely prevent the onset of severe MAS in neonates with MSAF. The neonates with severe MAS may develop severe respiratory distress and require mechanical ventilation early after birth. Close monitoring of blood lactate in the umbilical artery and peripheral blood IL-6 and WBC at 1 hour after birth may help with early prediction of the development and severity of MAS.

Surfactant dysfunction disorder masquerading as meconium aspiration syndrome and persistent pulmonary hypertension of the newborn.

About 10% of term neonates present with respiratory distress at birth. The most common aetiologies include transient tachypnoea of the newborn, pneumonia and meconium aspiration syndrome (MAS). Hyaline membrane disease (HMD) in a term infant occurs either as primary HMD, secondary surfactant deficiency or congenital surfactant dysfunction. A detailed history supported with appropriate radiological and laboratory investigations can help a clinician reach a diagnosis. We report a case of surfactant dysfunction disorder which presented as severe MAS and persistent pulmonary hypertension of the newborn. In the infant described, the significant history of a sibling death with severe neonatal respiratory disease led us to think of diffuse developmental lung diseases especially surfactant dysfunction syndromes. Exome sequencing detected a heterozygous missense variation in exon 21 of the ATP binding cassette protein member 3 (ABCA3) gene. Based on the clinical picture supported with the exome sequencing, a diagnosis of surfactant dysfunction disorder (ABCA3 deficiency) was confirmed.

The prognostic value of the level of lactate in umbilical cord blood in predicting complications of neonates with meconium aspiration syndrome.

BACKGROUND: In spite of significant advances in therapeutic, diagnostic and even medical modalities, meconium management continues to be a concern for management. It has been recently assumed that trace of lactate in both serum and urine can be a sign of the asphyxia in neonates. However, no study has been done on the prognostic value of increasing lactate concentration in umbilical cord blood for predicting the outcomes of meconium aspiration syndrome (MAS), which was our aim in this study. METHODS: Thin cross-sectional study was performed on 150 neonates suffering meconium aspiration syndrome who were admitted to Akbar Abadi hospital in Tehran between 2016 and 2018. Samples of umbilical cord blood were extracted from neonates and sent to the reference laboratory to measure lactate level as well as arterial blood gas analysis. The neonatal characteristics as well as postdelivery complications were also collected by reviewing the hospital recorded files. RESULTS: Thick meconium stained amniotic fluid (TKMSF) was found in 40.0% and thin meconium stained amniotic fluid (TNMSF) in 60.0%. The mean level of lactate was significantly higher in those neonates with morbidities including pulmonary hemorrhage, persistent pulmonary hypertension of the neonate (PPHN), intraventricular hemorrhage (IVH), and respiratory failure requiring ventilation support. According to the ROC curve analysis, increasing lactate in umbilical cord blood could predict occurrence of pulmonary hemorrhage (AUC = 0.885), PPHN (AUC = 0.832), IVH (AUC = 0.898), and requiring ventilation (AUC = 0.833). Comparing the two groups with TKMSF and TNMSF showed higher gestational age, lower Apgar score, lower BE, higher PCO2, lower PO2, lower PH as well as higher serum lactate. In this regard and using the ROC curve analysis (Table 4), increased lactate could effectively discriminate TKMSF from TNMSF (AUC = 0.998) with the best cut-off value of 4.10. CONCLUSION: The increase in lactate in the umbilical cord blood (>4.1 mmol/L with high sensitivity and specificity) can distinguish between thick meconium and thin meconium forms in amniotic acid and thus can determine the severity of MAS. Also, increasing serum lactate levels is an accurate indicator for predicting complications such as pulmonary hemorrhage, PPHN, IVH, and need for ventilation in newborns with this syndrome. This diagnostic accuracy is even beyond the usual markers for arterial gas analysis, such as PH, PCO2, PO2 and BE.

Haematoma complicating subcutaneous fat necrosis of the newborn: a rare complication following therapeutic hypothermia.

A term, large for gestational age male newborn, was admitted to the neonatal intensive care unit with meconium aspiration syndrome and severe hypoxic-ischaemic encephalopathy. The baby was treated with therapeutic hypothermia using a total body cooling blanket. After 48 hours, the baby developed tender, indurated subcutaneous nodules consistent with subcutaneous fat necrosis (SCFN). The lesions started initially over the back but gradually spread to cover both shoulders, upper arms, chest area and both thighs. On day 19 of life, multiple small nodules on the back softened and coalesced to form one sizeable fluctuant swelling over the thoracolumbar area. Over a few hours, the swelling rapidly progressed to a large, tense mass with sloughing of the gangrenous overlying skin. This unusual complication of SCFN required surgical intervention for evacuation and debridement of the haematoma followed by graft repair of the skin defect.

Extra-Corporeal Membrane Oxygenation for Neonatal Respiratory Support.

To review our experience with Extra-Corporeal Membrane Oxygenation (ECMO) for respiratory support in neonates. From 1989 to 2018 2114 patients underwent respiratory ECMO support, with 764 (36%) neonates. Veno-Venous (V-V) cannulation was used in 428 (56%) neonates and Veno-Arterial (V-A) in 336 (44%). Historically V-V ECMO was our preferred modality, but due to lack of suitable cannula in the last 7 years V-A was used in 209/228 (92%) neonates. Mean and inter-quartile range of ECMO duration was 117 hours (inter-quartile range 90 to 164 hours). Overall 724 (95%) neonates survived to ECMO decannulation, with 640 (84%) hospital discharge. Survival varied with underlying diagnosis: meconium aspiration 98% (354/362), persistent pulmonary hypertension 80% (120/151), congenital diaphragmatic hernia 66% (82/124), sepsis 59% (35/59), pneumonia 86% (6/7), other 71% (43/61). Survival was 86% with V-V and 80% with V-A cannulation, better than ELSO Registry with 77% V-V and 63% V-A. Major complications: cerebral infarction/hemorrhage in 4.7% (31.1% survival to discharge), renal replacement therapy in 17.6% (58.1% survival to discharge), new infection in 2.9%, with negative impact on survival (30%). Following a circuit design modification and subsequent reduction in heparin requirement, intracerebral hemorrhage decreased to 9/299 (3.0%) radiologically proven cerebral infarction/hemorrhage. We concluded (1) outcomes from neonatal ECMO in our large case series were excellent, with better survival and lower complication rate than reported in ELSO registry. (2) These results highlight the benefits of ECMO service in high volume units. (3) The similar survival rate seen in neonates with V-A and V-V cannulation differs from the ELSO register; this may reflect the change in cannulation enforced by lack of suitable V-V cannula and all neonates undergoing V-A cannulation.

[ISOLATED OLIGOHYDRAMNIOS - THE DILEMMA OF PROPER MANAGEMENT].

INTRODUCTION: There are two methods to diagnose oligohydramnios: maximal vertical pocket (MVP) and amniotic fluid index (AFI). Following a recent large Cochrane review and other studies, MVP is being recommended as the method of choice by professional societies, after it was shown to result in fewer inductions of labor and C-sections (CS), without compromising neonatal outcome. There is controversy regarding the management of isolated oligohydramnios (IO). It is unclear whether this finding reflects an underlying pathological process, and therefore management protocols differ between different institutions. Studies have shown a higher rate of CS (RR of >2) in IO. Whether this is a true complication of IO or is a result of different confounders like labor inductions and primigravidity is unclear. The effects on neonatal outcomes are also unclear; whereas some authors did not show any adverse effects, others have shown higher rates of neonatal intensive care unit (NICU) admissions, lower Apgar scores and higher rate of Meconium aspiration syndrome. Some studies have shown a higher rate of undiagnosed small for gestational age (SGA) in IO pregnancies. There is no consensus regarding the optimal management and time of delivery. Until now, common practice was to induce labor at term, and some advocate induction in late preterm. Recently, the growing awareness to early term morbidity has led practitioners to question the benefit of early induction. There are several studies that have shown maternal hydration to improve AFI, but there is insufficient data to show the effect on outcomes. In conclusion, many questions regarding IO are still unanswered, and further research, specifically RCT studies, is needed.

Delivery room emergencies: Respiratory emergencies in the DR.

The majority of newborns transition to extra uterine life without support. However, respiratory emergencies in the delivery room are a common occurrence. Whilst some situations are predictable e.g. the anticipated birth of an extremely preterm infant, others are less so. In this chapter we address the most frequent scenarios that result in delivery room respiratory emergencies and discuss the latest recommendations for their management. We outline the need for a trained resuscitation team and appropriate equipment to provide respiratory support at every birth. We address the basic care that all infants should receive, the detailed application of non-invasive ventilation and the use of advanced airway techniques. We discuss the unique challenges presented by extreme prematurity including umbilical cord management, use of supplemental oxygen, initial modes of respiratory support and surfactant delivery. We will explore optimal techniques in the management of infants with lung hypoplasia, pneumothorax and meconium aspiration.

Isolated thrombocytopenia in childhood: what if it is not immune thrombocytopenia?

INTRODUCTION: Childhood immune thrombocytopenia (ITP) remains a diagnosis of exclusion when isolated thrombocytopenia is not part of another disease process. In practice, the diagnosis of ITP can only be confirmed when thrombocytopenia resolves or is excluded after the recognition of a primary cause. METHODS: The records of 87 consecutive children with isolated thrombocytopenia seen over a nine-year period in a private paediatric haematology practice were reviewed retrospectively. Children in whom a primary cause was eventually found were the subjects of a further descriptive study. RESULTS: 9 (10%) children with isolated thrombocytopenia were not diagnosed with ITP because a primary disease was found. Of these nine cases, four had thrombocytopenia recognised during the neonatal period, consisting of perinatal cytomegalovirus infection (n = 2), meconium aspiration pneumonia (n = 1) and transient abnormal myelopoiesis associated with Down syndrome (n = 1). The remaining five children were each found to have familial thrombocytopenia, portal hypertension, cutaneous mastocytosis, May-Hegglin anomaly and systemic lupus erythematosus. Two of them had a history of failure of response to corticosteroid therapy. CONCLUSION: Secondary thrombocytopenia is not uncommon in a tertiary paediatric specialty practice with adequate evaluation. Thrombocytopenia occurring during the newborn period and failure of steroid therapy are predictive of secondary cases.

Clinico-radiological Observations in Meconium Aspiration Syndrome.

INTRODUCTION: To understand and report the prevalence of meconium aspiration syndrome and the clinico-radiological features in a tertiary care hospital of western Nepal. METHODS: An observational study carried out for a year in 2014-15 in all babies with MAS. Clinical and radiological profiles of MAS in relation to gender, gestational age, mode of delivery, birth weight, Apgar score, thickness of meconium, age at admission and the immediate outcome were studied. RESULTS: Out of 584 admitted newborns (male=389; female=186) during the study period, 78 (13.4%) had meconium aspiration syndrome with male: female ratio of 1.2:1. Majority of babies admitted to NICU had thick meconium [n=52 (66.7%)]. There was no statistical significant difference in various parameters such as Apgar score at 1 and 5 minutes, respiratory distress, birth asphyxia, duration of oxygen use, MAS severity and chest x-ray in those with thick MAS compared to thin. Among all newborns with MAS, 59% (n=46) had abnormal radiological findings with over two-folds in those with thick MAS (71.7%)] compared to thin (28%). Hyperinflation (47.8%), diffuse patchy infiltration (37%), consolidation (21.7%) collapse (8.7%), right lung fissure (6.5%) and pneumothorax (8.7%) were the abnormal radiological findings seen in MAS babies. The odds of having APGAR score at 1 minute at least 7 or more was twice unlikely in those having thick meconium compared to thin (P=0.02) Conclusions: Thick meconium is relatively common with more significant abnormal radiological findings and low Apgar score.

Management of Meconium-Stained Newborns in the Delivery Room.

The approach to the management of meconium-stained newborns in the delivery room has been changing for over 40 years. The goal is to prevent meconium aspiration syndrome (MAS) and complications related to MAS. For decades, airway obstruction was believed to be a major component of MAS and, consequently, suction maneuvers to remove meconium from the airways were recommended to decrease the frequency and severity of MAS. Initial recommendations were based on observational studies. However, the incidence of MAS and mortality related to MAS has declined since the 1970s, mostly because of a decrease in the number of postterm deliveries. Recently updated guidelines by the American Heart Association and the Neonatal Resuscitation Program have reflected the strength of evidence supporting tracheal intubation and suctioning for nonvigorous, meconium-stained newborns. This article examines practice change since the 1970s in the delivery room management of meconium-stained newborns and evaluates evidence behind the changes.

Pulmonary Hypertension Associated with Hypoxic-Ischemic Encephalopathy-Antecedent Characteristics and Comorbidities.

OBJECTIVE: To determine the characteristics of term infants with persistent pulmonary hypertension of the newborn (PPHN) associated with moderate or severe hypoxic ischemic encephalopathy (HIE). METHODS: We compared infants with and without PPHN enrolled in 2 randomized trials of therapeutic hypothermia: the induced hypothermia trial of cooling to 33.5°C for 72 hours vs normothermia, and the "usual-care" arm (33.5°C for 72 hours) of the optimizing cooling trial. RESULTS: Among 303 infants with HIE from these 2 studies, 67 (22%) had PPHN and 236 (78%) did not. We compared infants with PPHN with those without PPHN. The proportion of patients treated with therapeutic hypothermia was similar in PPHN and no-PPHN groups (66% vs 65%). Medication use during resuscitation (58% vs 44%), acidosis after birth (pH: 7.0 ± 0.2 vs 7.1 ± 0.2), severe HIE (43% vs 28%), meconium aspiration syndrome (39% vs 7%), pulmonary hemorrhage (12% vs 3%), culture-positive sepsis (12% vs 3%), systemic hypotension (65% vs 28%), inhaled nitric oxide therapy (64% vs 3%), and extracorporeal membrane oxygenation (12% vs 0%) were more common in the PPHN group. Length of stay (26 ± 21 vs 16 ± 14 days) and mortality (27% vs 16%) were higher in the PPHN group. CONCLUSIONS: PPHN is common among infants with moderate/severe HIE and is associated with severe encephalopathy, lung disease, sepsis, systemic hypotension, and increased mortality. The prevalence of PPHN was not different between those infants receiving therapeutic hypothermia at 33.5°C in these 2 trials (44/197 = 22%) compared with infants receiving normothermia in the induced hypothermia trial (23/106 = 22%).

Combined maternal-associated risk factors with intrapartum fetal heart rate classification systems to predict peripartum asphyxia neonates.

OBJECTIVE: To improve the predictive ability for identification of peripartum asphyxia neonates by using the 3-tier and 5-tier fetal heart rate (FHR) classification systems. STUDY DESIGN: A retrospective case-control study comparing peripartum asphyxia neonates and no asphyxia neonates was conducted. The FHR tracings were classified into the 3-tier and 5-tier systems by the two reviewers. Pearson's X2 or Fisher's exact tests was used for comparisons between the groups. Logistic regression models were used to identify factors associated with peripartum asphyxia neonates. Odds Ratios (OR) and Likelihood Ratios (LR) with 95% confidence intervals (CI) were calculated from the regression coefficients. RESULTS: A total of 36 peripartum asphyxia fetuses (5.0%) were enrolled. Overall, the performance of category II and suspicious tracings to detect peripartum asphyxia neonates was higher than the yellow and orange tracings with 61% and 67% sensitivity, respectively. The 5-tier FHR classification had higher specificity than the 3-tier system (82-99%). The predictive ability to detect peripartum asphyxia neonates by the 5-tier FHR classification was highest when combined with maternal-associated risk factors (AUC 0.67-0.72). CONCLUSION: Maternal-associated risk factors combined with an abnormal 5-tier FHR classification had high predictive ability and specificity to detect peripartum asphyxia neonates.

Meconium "aspiration" (or respiratory distress associated with meconium-stained amniotic fluid?).

The designation meconium aspiration syndrome (MAS) reflects a spectrum of disorders in infants born with meconium-stained amniotic fluid, ranging from mild tachypnea to severe respiratory distress and significant mortality. The frequency of MAS is highest among infants with post-term gestation, thick meconium, and birth asphyxia. Pulmonary hypertension is an important component in severe cases. Prenatal hypopharyngeal suctioning and postnatal endotracheal intubation and suctioning of vigorous infants are not effective. Intubation and suctioning of non-breathing infants is controversial and needs more investigation. Oxygen, mechanical ventilation, and inhaled nitric oxide are the mainstays of treatment. Surfactant is often used in infants with severe parenchymal involvement. High-frequency ventilation and extracorporeal membrane oxygenation are usually considered rescue therapies.

A case report of an asymptomatic late term abdominal pregnancy with a live birth at 41 weeks of gestation.

BACKGROUND: Despite advances in diagnostic imaging and focused antenatal care, cases of undiagnosed abdominal pregnancies at term are still reported in obstetric practice. It is atypical and very rare for a patient to be asymptomatic late in pregnancy and for the pregnancy to result in a live birth with no evidence of intrauterine growth restriction despite the unfavourable implantation site. This late term asymptomatic presentation despite routine antenatal care demonstrates a diagnostic challenge. CASE PRESENTATION: We report a case of a 26 year old Primigravida with an asymptomatic and undiagnosed abdominal pregnancy carried beyond 41 weeks of gestation espite routine antenatal care and serial ultrasound reports. She presented for a routine antenatal care visit at 41 weeks of gestation. Induction of labour was initiated due to the late term gestation but was unsuccessful. At this point the fetus developed severe tachycardia and CTG confirmed persistent non-reassuring foetal heart rate patterns. The mother was then prepared for an emergency caesarean delivery. Abdominal pregnancy was only diagnosed at laparotomy where a term male baby weighing 3108 g was delivered with an Apgar Score of 7 and 8 at 1 and 5 min respectively. The placenta which was implanted into the omentum, ileal mesentery and extending to the pouch of Douglas was removed following active bleeding from its detached margins. She was transfused with two units of blood and four units of fresh frozen plasma. Postoperative morbidity was minimal with transient paralytic ileus on the second post-operative day. Her recovery was otherwise uneventful and she was discharged on the seventh post-operative day in good condition. The neonate developed meconium aspiration syndrome and passed away on the 2nd day of life despite having undergone standard care. A post-mortem examination was not performed because the family did not consent to the procedure. Follow up of the mother at 2, 6 weeks and 6 months postpartum was uneventful. CONCLUSIONS: This atypical presentation of an asymptomatic abdominal pregnancy carried tolate term and only diagnosed at laparotomy despite routine antenatal care demonstrates a significant lapse in diagnosis. Clinicians and radiologists must always bear this possibility in mind during routine client evaluation. Skills training in Obstetric ultrasound and in the clinical assessment of obstetric patients should emphasize features suggestive of abdominal pregnancy. This will improve diagnosis, ensure appropriate management and minimise complications. Immediate termination of pregnancy can be offered if the diagnosis is made before 20 weeks of gestation. Patients diagnosed with advanced abdominal pregnancies and are stable can be monitored under close surveillance and delivered at 34 weeks of gestation after lung maturity is achieved. Although removal of the placenta carries a higher risk of haemorrhage, a partially detached placenta can be delivered with minimal morbidity and a good maternal outcome. Given the documented low survival rates of neonates in such cases, neonatal units must be adequately equipped and staffed to support them. Post-mortem examination is important to confirm cause of death and exclude other complications and congenital anomalies. Communities need to be educated about the importance of this procedure.

Pulse Oximetry Screening for Critical Congenital Heart Disease after Home Birth and Early Discharge.

OBJECTIVES: To assess the feasibility of pulse oximetry (PO) screening in settings with home births and very early discharge. We assessed this with an adapted protocol in The Netherlands. STUDY DESIGN: PO screening was performed in the Leiden region in hospitals and by community midwives. Measurements were taken ≥ 1 hour after birth and on day 2 or 3 during the midwife visit. Primary outcome was the percentage of screened infants with parental consent. The time point of screening, oxygen saturation, false positive (FP) screenings, critical congenital heart defects (CCHDs), and other detected pathology were registered. RESULTS: In a 1-year period, 3625 eligible infants were born. Parents of 491 infants were not approached for consent, and 44 refused the screening. PO screening was performed in 3059/3090 (99%) infants with obtained consent. Median (IQR) time points of the first and second screening were 1.8 (1.3-2.8) and 37 (27-47) hours after birth. In 394 infants with screening within 1 hour after birth, the median pre- and postductal oxygen saturations were 99% (98%-100%) and 99% (97%-100%). No CCHD was detected. The FP prevalence was 1.0% overall (0.6% in the first hours after birth). After referral, important noncritical cardiac and other noncardiac pathology was found in 62% of the FP screenings. CONCLUSIONS: PO screening for CCHD is feasible after home births and very early discharge from hospital. Important neonatal pathology was detected at an early stage, potentially increasing the safety of home births and early discharge policy.