Association between first trimester platelet to lymphocyte ratio and stillbirth.

BACKGROUND: Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) have been investigated as inflammatory markers of malignancies, cardiovascular and autoimmune diseases. We explored the association between NLR, PRL, measured during pregnancy, and stillbirth (SB). METHODS: We conducted a retrospective case control study at a tertiary hospital center in New York City from May 2015 to July 2018. Cases were defined as SB pregnancies and controls as uncomplicated pregnancies. We calculated NLR and PLR using the complete blood count components routinely collected during prenatal care in the first trimester. The groups were matched by age, parity, body mass index (BMI) and race. We used receiver operating characteristic (ROC) curve analysis to evaluate the association of NLR and PLR to SB. RESULTS: We identified 28 patients with SB pregnancies and matched them with 28 controls. Age, parity, BMI, and race were equally distributed between the groups. The median gestational age of SB was 30 weeks (22-34). In the first trimester PLR was significantly lower in SB cases compared to controls (124.8 vs. 153.4, P=0.044) with an area under the curve (AUC) of 0.65. A PLR value higher than 156.4 accurately excluded SB with a sensitivity of 0.50, specificity of 0.89, positive predictive value of 0.013 and a negative predictive value of 0.998. NLR did not show a significant difference in the first trimester. CONCLUSIONS: A PLR higher than 156.4 in the first trimester appears to reliably exclude the occurrence of SB later during pregnancy. Lower platelet and higher lymphocyte levels may be related to an early inflammatory process. We speculate that pregnancies in which the initial myometrial invasion by the placental cells is dysfunctional and reflected by a high level of inflammation in the peripheral maternal blood, may contribute to fetal demise. Larger studies are needed to confirm our results.

Predictive value of preoperative complete blood count components on the occurrence of surgical site infection after elective cesarean section.

BACKGROUND: To analyze the predictive value of the preoperative complete blood count components on the occurrence of surgical site infection (SSI) after elective cesarean section. METHODS: We conducted a retrospective case control study in a tertiary care hospital located in New York City during the period of November 1, 2018, to October 30, 2020. We included patients who developed SSI after elective cesarean section as cases and patients who did not develop SSI as controls. We tested the ability of neutrophil, lymphocyte, platelet, hemoglobin, hematocrit, total white blood cells, neutrophil to lymphocyte ratio, hemoglobin to platelet ratio, platelet to lymphocyte ratio, platelet to neutrophil ratio, platelet to hemoglobin ratio and neutrophil to hemoglobin ratio to identify the occurrence of SSI after cesarean section. RESULTS: We compared ten cases and 20 controls. The median lymphocyte and lymphocyte to hemoglobin ratio were statistically significantly higher in cases compared to controls (P=0.049 and P=0.04, respectively). A lymphocyte value higher than 1.5 x103/µL was the best cut-off to exclude the occurrence of SSI, with a sensitivity of 95%, a specificity of 50%, a positive predictive value of 5.5% and a negative predictive value of >99%. A lymphocyte to hemoglobin ratio higher than 1.13 was the best cut off to exclude the occurrence of SSI, with a sensitivity of 95%, a specificity of 60%, a positive predictive value of 6.8% and a negative predictive value >99%. CONCLUSIONS: The preoperative lymphocyte and lymphocyte to hemoglobin ratio should be incorporated into patient counseling and preoperative algorithms to identify patients who will develop SSI. The biological mechanisms involved remain to be investigated and our data should be confirmed by further and larger studies.

Hispanic race is a risk factor for COVID-19 during pregnancy: data from an urban New York City hospital.

There are limited studies on predisposing factors for COVID-19 positivity in asymptomatic pregnant women. The literature published to date on asymptomatic COVID-19 pregnant carriers does not focus on pregnancy or pre-pregnancy comorbidities. We wanted to identify risk factors for COVID-19 in asymptomatic pregnant women. We performed a retrospective chart review of 263 asymptomatic pregnant women admitted to labour and delivery at New York City Health + Hospitals/Lincoln.We analysed the association between race, body mass index (BMI), smoking, indication for admission, gravidity, parity, pre-pregnancy comorbidity, pregnancy comorbidity via uni- and multivariate statistical tests. Only Hispanic race was significant in the univariate analysis (p = .049). At the post-hoc analysis, Hispanics had a higher proportion of COVID-19 cases compared to non-Hispanic Blacks (p = .019). No variables were significantly associated with COVID-19 positivity in the multivariate analysis.Hispanic race appears to be a risk factor for asymptomatic COVID-19 infection during pregnancy. We speculate that the cultural and socioeconomic reality of Hispanic women living in our community leads to more exposure opportunities and therefore, a higher infection rate.Impact statementWhat is already known on this subject? Little is known on the role of comorbidities and risk factors that can favour COVID-19 infection during pregnancy.What do the results of this study add? We found that Hispanic pregnant asymptomatic women had a higher rate of COVID-19 in comparison to non-Hispanic Black women. Pre-pregnancy comorbidities such as pregestational diabetes, hypertension and asthma were not associated with COVID-19 positivity.What are the implications of these findings for clinical practice and/or further research? The reasons why the Hispanic race is more affected by COVID-19 during pregnancy is unclear. The social environment of Hispanic women living in our community, such as their tendency to live in multigenerational and multi-family households, might contribute to a higher infection rate. More resources might be dedicated in the future to Hispanic-dense neighbourhoods.

Utilization of platelet count in prediction of post-embolization syndrome after uterine artery embolization.

OBJECTIVE: To analyze the predictive value of neutrophils, lymphocytes, platelets, neutrophils to lymphocytes ratio (NLR), platelets to lymphocytes ratio (PLR) in identifying the occurrence of post-embolization syndrome (PES) after uterine artery embolization (UAE). METHODS: We conducted a retrospective observational study in a single tertiary care center located in New York City during period of November 2014 - December 2018, for patients who underwent UAE. PES was defined as the occurrence of pelvic pain, nausea or fever within one week after the procedure. RESULTS: We enrolled 62 patients: 12 of them had PES and 50 served as controls. Platelets were statistically significantly higher in patients with PES (p=0.036). Specifically, a platelet count greater than 336×103/uL was identified as cut-off with a specificity of 91.8 %, a sensitivity of 33.3 %, a positive predictive value of 46 % and a negative predictive value of 85 %. The area under the curve (AUC) was 0.721 (CI 0.536-0.907). CONCLUSION: Patients with a preprocedural platelet count less than 336×103/uL were less likely to have PES. If confirmed by larger studies, the platelet count could be incorporated into patient counseling and preoperative algorithms to identify the ideal UAE candidates.

Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio and Complete Blood Count Components in the First Trimester Do Not Predict HELLP Syndrome.

Background and Objectives: Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), mean platelet volume (MPV), and other components of the routine complete blood count (CBC) were found to be sensitive biomarkers of preeclampsia and other inflammatory obstetric conditions in previous studies, with conflicting results. We speculated that the same associations existed with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome in the first trimester of pregnancy. Materials and Methods: We conducted a retrospective case-control study at a tertiary care hospital in NY (USA), in the time frame between January 2016 and December 2018. Our population consisted of pregnant women in the first trimester: We compared patients with HELLP syndrome (cases) with healthy patients (controls) matched by age, body mass index (BMI), parity, and race. Patients with preeclampsia, infection, and fever were excluded. Venous blood samples were obtained as part of the routine work-up during the first prenatal visit in the first trimester, which includes a CBC. The main outcomes were NLR and PLR, and the secondary outcomes were hemoglobin, RDW, platelet count, MPV, neutrophils, and lymphocytes. Results: There were 10 patients in each group (Table 1). There were no differences in NLR and PLR levels and other CBC components between the two groups (Table 2). Conclusions: In our study NLR, PLR, and other CBC components did not predict HELLP syndrome. We speculate that HELLP syndrome has a sudden increase of tissue inflammation in the third trimester that is not manifested during the early phases of placentation. Larger studies are needed to evaluate the true ability of NLR, PLR, and CBC components to predict HELLP syndrome in the first trimester.

Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio, and Routine Complete Blood Count Components in HELLP Syndrome: A Matched Case Control Study.

Background and objective: Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are new readily available inflammatory markers that have been analyzed in pregnancy-induced hypertensive disorders such as preeclampsia. Studies on the NLR/PLR ratio in hemolysis, elevated liver enzymes, low-platelet count (HELLP) syndrome are limited in the current literature. We compared NLR/PLR and other complete blood count (CBC) components between women with HELLP syndrome and women with healthy pregnancies. Methods: We conducted a retrospective matched case-control study at a tertiary care hospital in NY (USA) in the time frame between January 2016 and December 2018. The study compared pregnant women with HELLP syndrome (cases) to women with healthy pregnancies in the third trimester (controls), matched by age, body mass index (BMI), parity, and race. Patient with preeclampsia, infection, and fever were excluded. Venous blood samples were obtained as part of the routine work-up at admission for delivery, which included a CBC. The main outcomes were NLR and PLR. The secondary outcomes were hemoglobin, red cell distribution width (RDW), platelet count, mean platelet volume (MPV), neutrophils, lymphocytes. Results: There were 14 patients in each group. They were matched by age, race, BMI, and parity. NLR (5.8 vs. 3.6, p-value = 0.002) and neutrophil count (10.7 vs. 6.8, p-value = 0.001) were higher in women with HELLP compared to controls. PLR (34 vs. 130.2, p-value < 0.001) and platelet count (71 vs. 223, p-value < 0.001) were lower in the study group compared to controls. Conclusions: NLR was higher, and PLR was lower in women with HELLP syndrome. These inflammatory markers can be incorporated into the diagnostic algorithm for HELLP syndrome. Future studies are needed to evaluate their ability to predict HELLP syndrome.

Amniotic Band Syndrome, Perinatal Hospice, and Palliative Care versus Active Management.

Introduction. Amniotic band syndrome and sequence are a relatively rare condition in which congenital anomalies occur as a result of the adherence and entrapment of fetal parts with coarse fibrous bands of the amniotic membrane. A large percentage of reported cases have an atypical gestational history. The frequency of this obstetric complication is not affected by fetal gender, genetic abnormality, or prenatal infection. Case. A 21-year-old, G1P0 female parturient at 18 weeks and 5 days with a single intrauterine gestation during a routine ultrasound evaluation was noted to have amniotic band sequence. The pregnancy was subsequently complicated by preterm premature rupture of membranes with oligohydramnios, resulting in a surviving neonate scheduled for rehabilitative treatment. Conclusion. Amniotic band syndrome is an uncommon congenital anomaly resulting in multiple disfiguring and disabling manifestations. Several theories are proposed with most involving early rupture of the amnion and entanglement of fetal parts by amniotic bands. This syndrome can be manifested by development of multiple malformations, with the majority of the defects being limb abnormalities of a disorganized nature, as in the case we present. In the absence of a clear etiology of consequential congenital abnormalities, obstetric management guidelines should use shared decision models to focus on the quality of life for the offspring.

Triple Negative Breast Cancer in Pregnancy and Postpartum: Two Case Reports in Hispanic Women.

Objective. Despite studies suggesting that triple negative breast cancer is more often seen in women of African ancestry, we report here two cases of pregnancy associated triple negative breast cancer in Hispanic women. Cases. Case one is a 37-year-old female para 2-0-0-2, who presented with a left breast mass, at 19 weeks of gestation, the biopsy of which reported an invasive ductal carcinoma, found to be triple receptor negative. The patient underwent chemotherapy during the pregnancy and was delivered with a cesarean at 37 weeks for obstetric indication. After delivery, the patient completed her chemotherapy that was followed by radical mastectomy and radiotherapy. Case two is a 28-year-old female para 6-0-1-5, who presented while breast-feeding with signs and symptoms of mastitis, and an engorged and tender right breast, five months postpartum. However, the sonogram revealed a fluid filled cavity. Aspiration and cytology did not reflect an infection and were negative for malignancy. High suspicion and lack of improvement led to biopsy that identified an invasive ductal carcinoma, found to be triple negative. The patient underwent chemotherapy followed by modified radical mastectomy. Conclusions. Triple negative breast cancer, during pregnancy or postpartum, poses a unique challenge and requires a multidisciplinary team to optimize treatment for these women.

Didelphys Uterus: A Case Report and Review of the Literature.

Background. Mullerian duct anomalies (MDAs) are congenital defects of the female genital system that arise from abnormal embryological development of the Mullerian ducts. A didelphys uterus, also known as a "double uterus," is one of the least common amongst MDAs. This report discusses a case of didelphys uterus that successfully conceived, carried her pregnancy to term, and delivered vaginally without any significant complications. Case. Patient is a 29-year-old G2P0010 from Bangladesh, initially came a year prior in her first pregnancy, with spontaneous abortion (SAB). Pelvic Sonogram at that time showed a diagnosis of bicornuate versus didelphys uterus. There were no renal anomalies on subsequent abdominal CT scan. Patient presented with the second pregnancy and had uncomplicated prenatal care and did not have signs of preterm labor; fetus showed appropriate growth and the pregnancy was carried in the left uterus. Patient presented at 38 4/7 wks with Premature Rupture of Membrane and underwent induction of labor with Cytotec. Antibiotics were started for chorioamnionitis. Patient had a vaginal delivery with left mediolateral episiotomy and complete tear of vaginal septum. Third stage of labor was complicated with retained placenta, which was removed manually in the operating room with total EBL of 600 cc.

Occipital condyle fracture in a patient with neck pain.

BACKGROUND: Occipital condyle fractures (OCF) are rare traumatic injuries and are of critical clinical importance because of the anatomic considerations of the occipitoatlantoaxial joint complex. OCF can be a diagnostic challenge because of the inability to diagnose this injury with plain radiographs. This is especially true in the emergency department (ED) setting. A high degree of clinical suspicion and careful investigation of the craniocervical junction is warranted in patients presenting to the ED with head and cervical trauma. FINDINGS: We present a case of a 45-year-old male who presented to the ED with complaints of neck pain and headache four days after an assault. The classification, clinical presentation, diagnosis, and management of his injury are discussed, and pertinent literature is reviewed. CONCLUSIONS: OCF can be easily overlooked due to multiple factors; including the conscious state of the patient or the inability to diagnose it through plain radiographs. Early recognition and diagnosis of OCF is crucial to prevent neurological involvement.

Intrasphenoidal encephalocele: an incidental finding in emergency department.

BACKGROUND: Basal encephaloceles are rare clinical entities. Intrasphenoidal encephalocele (ISE) is a rare form of basal encephalocele. The clinical presentation is often subtle and may remain undetected. Only a limited number of cases of ISE have been reported, mostly in middle-aged patients who presented with symptoms. Clinical diagnosis and management remain a challenge. Our case reports ISE as an incidental finding in a very elderly male patient. FINDINGS: We present a case of ISE discovered as an incidental finding in a 99-year-old male who presented to the emergency department (ED) after a fall from bed. The encephalocele was discovered in the evaluation of the computed tomography (CT) scan of the head. CONCLUSION: This is an incidental manifestation of a rare disease. It demonstrates that these encephaloceles may not manifest clinically or symptomatically as other reports have suggested.

Fracture of the penis: an atypical presentation.

BACKGROUND: Fracture of the penis is an uncommon injury presenting to the emergency department (ED). Personal embarrassment and social scenarios associated with this condition may result in underreporting. Patients often delay seeking medical attention, and even when they do, as in our case report, they may withhold the condition for a significant time. ED physicians need to be aware of the social inhibitions and the need for early diagnosis and prompt treatment. A delay in treatment increases the risk of complications such as ischemia, necrosis and penile deformity.Fracture of the penis is caused by rupture of the tunica albuginea of one or both corpora cavernosa by a blunt trauma to the erect penis. Diagnosis is usually clinical as evident by the characteristic history and clinical presentation. Diagnostic modalities aid in the management of the fracture and associated injuries if present. But promptness in the recognition and initiation of treatment can significantly reduce the chances of post-injury complications. FINDINGS: We present a case of penile fracture in a young male who presented to the ED with abdominal pain, but careful history and physical examination revealed penile fracture. A delay in diagnosis could have led to complications. CONCLUSION: Our case report is an attempt to emphasize the need to suspect injury to the penis in a young adult who might present to the emergency department with an entirely different complaint and also to treat any penile trauma as an emergency. This report provides evidence of an uncommon and underreported clinical entity. A review of the pertinent literature is included.

The nutcracker syndrome: an underrecognized cause of hematuria.

UNLABELLED: Nutcracker syndrome (NCS) is an uncommon cause of hematuria. It refers to the compression of the left renal vein between the aorta and superior mesenteric artery. It can cause both microscopic and gross hematuria. Hematuria may be associated with left flank pain. The diagnosis of NCS is often delayed. Most patients may have symptoms for many years and non-diagnostic evaluations before accurate diagnosis can be established. It should be included in the differential diagnosis of unexplained hematuria. The diagnosis and treatment of nutcracker syndrome are discussed. CONCLUSION: NCS is a rare but treatable clinical condition. An inclusion of this entity in the differential diagnosis of patients with unknown cause of hematuria and flank pain can achieve efficient management of this condition.