Effects of delayed cord clamping at different time intervals in late preterm and term neonates: a randomized controlled trial.

Delayed cord clamping (DCC) at delivery has well-recognized benefits; however, current scientific guidelines lack uniformity in its definition. This parallel-group, three-arm assessor-blinded randomized controlled trial compared the effects of three different timings of DCC at 30, 60, and 120 s on venous hematocrit and serum ferritin levels in late preterm and term neonates not requiring resuscitation. Eligible newborns (n = 204) were randomized to DCC 30 (n = 65), DCC 60 (n = 70), and DCC 120 (n = 69) groups immediately after delivery. The primary outcome variable was venous hematocrit at 24 ± 2 h. Secondary outcome variables were respiratory support, axillary temperature, vital parameters, incidences of polycythemia, neonatal hyperbilirubinemia (NNH), need and duration of phototherapy, and postpartum hemorrhage (PPH). Additionally, serum ferritin levels, the incidence of iron deficiency, exclusive breastfeeding (EBF) rate, and anthropometric parameters were assessed during post-discharge follow-up at 12 ± 2 weeks. Over one-third of the included mothers were anemic. DCC 120 was associated with a significant increase in the mean hematocrit by 2%, incidence of polycythemia, and duration of phototherapy, compared to DCC30 and DCC60; though the incidence of NNH and need for phototherapy was similar. No other serious neonatal or maternal adverse events including PPH were observed. No significant difference was documented in serum ferritin, incidences of iron deficiency, and growth parameters at 3 months even in the presence of a high EBF rate.   Conclusion: The standard recommendation of DCC at 30-60 s may be considered a safe and effective intervention in the busy settings of low-middle-income countries with a high prevalence of maternal anemia.   Trial registration: Clinical trial registry of India (CTRI/2021/10/037070). What is Known: • The benefits of delayed cord clamping (DCC) makes it an increasingly well-accepted practice in the delivery room. • However, uncertainty continues regarding the optimal timing of clamping; this may be of concern both in the neonate and the mother. What is New: • DCC at 120 s led to higher hematocrit, polycythemia and longer duration of phototherapy, without any difference in serum ferritin, and incidence of iron deficiency. • DCC at 30-60 s may be considered a safe and effective intervention in LMICs.

Effects of umbilical cord milking versus delayed cord clamping on systemic blood flow in intrauterine growth-restricted neonates: A randomized controlled trial.

Recommendations for umbilical cord management in intrauterine growth-restricted (IUGR) neonates are lacking. The present randomized controlled trial compared hemodynamic effects of umbilical cord milking (UCM) with delayed cord clamping (DCC) in IUGR neonates > 28 weeks of gestation, not requiring resuscitation. One hundred seventy IUGR neonates were randomly allocated to intact UCM (4 times squeezing of 20 cm intact cord; n = 85) or DCC (cord clamping after 60 s; n = 85) immediately after delivery. The primary outcome variable was superior vena cava (SVC) blood flow at 24 ± 2 h. Secondary outcomes assessed were anterior cerebral artery (ACA) and superior mesenteric artery (SMA) blood flow indices, right ventricular output (RVO), regional cerebral oxygen saturation (CrSO2) and venous hematocrit at 24 ± 2 h, peak total serum bilirubin (TSB), incidences of in-hospital complications, need and duration of respiratory support, and hospital stay. SVC flow was significantly higher in UCM compared to DCC (111.95 ± 33.54 and 99.49 ± 31.96 mL/kg/min, in UCM and DCC groups, respectively; p < 0.05). RVO and ACA/SMA blood flow indices were comparable whereas CrSO2 was significantly higher in UCM group. Incidences of polycythemia and jaundice requiring phototherapy were similar despite significantly higher venous hematocrit and peak TSB in UCM group. The need for non-invasive respiratory support was significantly higher in UCM group though the need and duration of mechanical ventilation and other outcomes were comparable. CONCLUSIONS:  UCM significantly increases SVC flow, venous hematocrit, and CrSO2 compared to DCC in IUGR neonates without any difference in other hemodynamic parameters and incidences of polycythemia and jaundice requiring phototherapy; however, the need for non-invasive respiratory support was higher with UCM. TRIAL REGISTRATION: Clinical trial registry of India (CTRI/2021/03/031864). WHAT IS KNOWN: • Umbilical cord milking (UCM) increases superior vena cava blood flow (SVC flow) and hematocrit without increasing the risk of symptomatic polycythemia and jaundice requiring phototherapy in preterm neonates compared to delayed cord clamping (DCC). • An association between UCM and intraventricular hemorrhage in preterm neonates < 28 weeks of gestation is still being investigated. WHAT IS NEW: • Placental transfusion by UCM compared to DCC increases SVC flow, regional cerebral oxygenation, and hematocrit without increasing the incidence of symptomatic polycythemia and jaundice requiring phototherapy in intrauterine growth-restricted neonates. • UCM also increases the need for non-invasive respiratory support compared to DCC.

Irregular erythrocyte antibodies among antenatal women and their neonatal outcome at a tertiary care hospital in Northern India.

BACKGROUND: Red blood cell alloimmunisation during the pregnancy is a significant cause for neonatal mortality and morbidity. This study was planned to determine the prevalence and specificity of irregular erythrocyte antibodies in antenatal mothers and their neonatal outcome. METHODS: In this observational study, blood grouping and red cell antibody screening of mothers were performed at first visit and after 28 weeks of gestation and positive cases were identified and followed up monthly till delivery by repeating antibody titre and middle cerebral artery-peak systolic velocity. After delivery of alloimmunised mothers, cord blood haemoglobin, bilirubin and direct antiglobulin tests (DAT) were analysed and further outcome of neonate was recorded. RESULTS: Among 652 registered antenatal cases, 18 multigravida women were found to be alloimmunised, accounting to prevalence of 2.8%. Most common alloantibody identified was anti D (>70%) followed by anti-Lea, anti-C, anti-Leb, anti-E and anti-Jka. Only 47.7% Rh D negative women received anti-D prophylaxis during previous pregnancies or whenever indicated. DAT was positive in 56.2% of neonates. Among nine DAT positive neonates, two early neonatal deaths due to severe anaemia were observed following birth resuscitation. Four antenatal mothers required intrauterine transfusion in view of fetal anaemia while three neonates received double volume exchange transfusion and top up transfusions after birth. CONCLUSIONS: This study emphasises importance of red cell antibody screening for all multigravida antenatal women at registration of pregnancy and additionally at 28 weeks or later in high-risk cases irrespective of RhD status.

Acute non-puerperal uterine inversion ascribed to malignant mixed Mullerian tumor of uterus: a rare presentation.

Non-puerperal uterine inversion is an extremely uncommon condition, and its occurrence due to malignant mixed Mullerian tumor (MMMT) of the uterus is quite exceptional. We report one such case of acute non-puerperal uterine inversion ascribed to MMMT in a 77-year-old postmenopausal woman. Such a case poses a diagnostic and management dilemma, and prior knowledge may result in a successful outcome.

Obstetric and perinatal outcomes in pregnant women with COVID-19: an interim analysis.

The coronavirus disease (COVID-19) has affected the health-care system worldwide. The effect of COVID-19 on obstetric and perinatal outcomes is yet to be completely ascertained. A hospital-based prospective observational study was conducted at the Department of Obstetrics & Gynecology, AIIMS Rishikesh from July to December 2020. A total of 60 COVID-positive pregnant women were included. Obstetric and perinatal outcomes were compared with 60 COVID-negative pregnant women. A subgroup comparison was also performed between symptomatic and asymptomatic pregnant women with COVID-19. Majority of COVID-positive pregnant women were asymptomatic (81.7%). Eleven patients were symptomatic, out of which 9 (15%) had mild disease and only 2 (3.3%) had severe pneumonia. There was an increased likelihood of early pregnancy loss (5%), oligohydramnios (21.7%), preterm birth (31.7%), and cesarean section (53.3%). The occurrence of preterm birth was significantly higher in symptomatic women than asymptomatic women (p = .01). Oligohydramnios was significantly more frequent in COVID-positive than COVID-negative pregnant women (p = .048). Preterm birth and cesarean rate were slightly higher in COVID-positive group but the difference was not statistically significant. Other obstetric outcomes were comparable in both groups. The majority of women with COVID-19 infection in pregnancy remain asymptomatic or have mild symptoms. Still, it may lead to maternal death and poor fetal outcomes in form of early pregnancy loss, prematurity, oligohydramnios, intrapartum fetal distress, and increased cesarean rate. Therefore, COVID-19 preventive measures should be strictly implemented and followed.

Effects of delayed cord clamping in intrauterine growth-restricted neonates: a randomized controlled trial.

The time of cord clamping in intrauterine growth-restricted (IUGR) neonates remains an area of uncertainty. This assessor-blinded randomized controlled trial compared the effects of delayed cord clamping (DCC) with early cord clamping (ECC) on the systemic blood flow (SBF) and cerebral hemodynamics in IUGR neonates of gestational age ≥28 weeks, not requiring resuscitation. Eligible newborns were randomized to DCC (cord clamping after 60 s; n=55) or ECC (cord clamping within 30 s; n=55) group immediately after delivery. The primary outcome variable was superior vena cava (SVC) blood flow at 24±2 h. The secondary outcome variables were right ventricular output (RVO), anterior cerebral artery (ACA) blood flow velocity (BFV), superior mesenteric artery (SMA)-BFV and venous hematocrit at 24±2 h, peak total serum bilirubin (TSB), incidences of polycythemia, intraventricular hemorrhage, respiratory distress, feeding intolerance, and necrotizing enterocolitis, outcome, duration of hospital stay, screening audiometry, and serum ferritin levels at the postnatal age of 3 months. Compared to ECC, DCC was associated with significantly higher SVC flow (101.22±21.02 and 81.27±19.12 mL/kg/min, in DCC and ECC groups, respectively; p<0.0001), and significantly increased RVO, SMA-BFV, venous hematocrit, and serum ferritin levels. Though peak TSB was significantly higher with DCC, duration of phototherapy was comparable. ACA-BFV, incidence of polycythemia, and other outcomes were comparable between the groups.Conclusions: DCC was a safe and beneficial intervention in IUGR infants with an improved SBF and SMA-BFV and an increased hematocrit and serum ferritin levels without higher incidences of polycythemia and requirement of phototherapy for significant hyperbilirubinemia.Trial registration: Clinical Trials Registry of India (CTRI/2019/05/018904) What is Known: • Delayed cord clamping (DCC) increases superior vena cava (SVC) blood flow in preterm neonates. • DCC increases hematocrit and serum ferritin in intrauterine growth-restricted (IUGR) neonates, but there may be an associated risk of polycythemia and neonatal hyperbilirubinemia. What is New: • DCC increases SVC blood flow, right ventricular output, superior mesenteric artery blood flow velocity, venous hematocrit, and serum ferritin in IUGR neonates. • Incidences of polycythemia and duration of phototherapy for significant neonatal hyperbilirubinemia do not increase with DCC.

Hospital admissions for dental disorders in patients with severe mental illness in Southeast London: A register-based cohort study.

In people with mental disorders, adverse general health is well recognized but dental diseases remain underinvestigated. The objective of this study was to investigate risk factors for hospital admissions for dental disorders in patients with severe mental illness (SMI) and/or depressive disorder. De-identified electronic mental health records from the South London and Maudsley NHS Foundation Trust (SLaM) were linked to national Hospital Episode Statistics (HES) data for analysis. Data were extracted for adults with a diagnosis of SMI (schizophrenia, schizoaffective disorder, bipolar disorder) and/or depression, who had received care at SLaM between 1 January 2010 and 31 March 2017. In the cohort of 18,999 patients thus obtained, the following factors were independently associated with hospital admission for dental disorders: female gender [odds ratio (OR) = 1.48, 95% CI: 1.31-1.68)], Health of the Nation Outcome Scales (HoNOS) problem drinking/drug taking (OR = 1.12, 95% CI: 1.05-1.19), HoNOS physical illness/disability (OR = 1.18, 95% CI: 1.12-.25), diabetes (OR = 1.24, 95% CI: 1.06-1.43), recorded current/past smoking (OR = 1.35, 95% CI: 1.06-1.43), treatment with antidepressant medication (OR = 1.48, 95% CI: 1.31-1.68), and depressive disorder (OR = 1.36, 95% CI: 1.11-1.68). Building on previous research in this population, which indicated a relatively high risk of acute care hospitalizations with dental disorders as discharge diagnoses, a number of demographic and clinical characteristics were found to be independent predictors over a 7-yr period. Further research into these predictors would facilitate a better understanding of how adverse dental outcomes might be prevented.

Irregular erythrocyte antibodies among antenatal women and their neonatal outcome at a tertiary care hospital in Northern India.

BACKGROUND: Red blood cell alloimmunisation during the pregnancy is a significant cause for neonatal mortality and morbidity. This study was planned to determine the prevalence and specificity of irregular erythrocyte antibodies in antenatal mothers and their neonatal outcome. METHODS: In this observational study, blood grouping and red cell antibody screening of mothers were performed at first visit and after 28 weeks of gestation and positive cases were identified and followed up monthly till delivery by repeating antibody titre and middle cerebral artery-peak systolic velocity. After delivery of alloimmunised mothers, cord blood haemoglobin, bilirubin and direct antiglobulin tests (DAT) were analysed and further outcome of neonate was recorded. RESULTS: Among 652 registered antenatal cases, 18 multigravida women were found to be alloimmunised, accounting to prevalence of 2.8%. Most common alloantibody identified was anti D (>70%) followed by anti-Lea, anti-C, anti-Leb, anti-E and anti-Jka. Only 47.7% Rh D negative women received anti-D prophylaxis during previous pregnancies or whenever indicated. DAT was positive in 56.2% of neonates. Among nine DAT positive neonates, two early neonatal deaths due to severe anaemia were observed following birth resuscitation. Four antenatal mothers required intrauterine transfusion in view of fetal anaemia while three neonates received double volume exchange transfusion and top up transfusions after birth. CONCLUSIONS: This study emphasises importance of red cell antibody screening for all multigravida antenatal women at registration of pregnancy and additionally at 28 weeks or later in high-risk cases irrespective of RhD status.

The effect of intrauterine misoprostol on blood loss during caesarean section.

Excessive bleeding during and after caesarean section is a major cause of maternal morbidity and mortality, especially in low resource countries. This study evaluates the effect of intrauterine misoprostol with oxytocin in comparison with oxytocin alone on blood loss during caesarean section. A retrospective data analysis of 160 women who underwent lower segment caesarean section was conducted. Eighty-five out of 160 (53%) women received tablet misoprostol 800 µg by intrauterine route after delivery of a baby in addition to routine oxytocin infusion (group A), while 75 women (47%) received only oxytocin (group B). Blood loss, Haemoglobin (Hb) difference (pre-operative Hb - post-operative Hb) and need of any other oxytocic were compared in both the groups. Demographic variables such as mean age, parity, and an indication of caesarean section were comparable in both the groups. Mean blood loss during caesarean section was lower in group A (680 ± 202 mL) than group B (740 ± 228 mL) (p = .08). Higher Hb difference was noted in group B (1.03 ± 0.83 gm%) than group A (0.93 ± 0.68 gm%) (p = .41). No patient required additional oxytocic and no patient had postpartum haemorrhage in both the groups. The use of misoprostol by the intrauterine route in addition to routine oxytocin infusion during caesarean section is associated with a clinically significant reduction in intra-operative and post-operative blood loss. IMPACT STATEMENT What is already known on this subject? The role of misoprostol in the prevention and treatment of haemorrhage during and after caesarean section is well known and well studied. It is a better alternative to oxytocin in low resource settings. Various routes of misoprostol, with or without oxytocin, and its effect on intrapartum and postpartum haemorrhage are described in the literature. Misoprostol is an autocoid substance and acts better if it is close to the target organ (uterus). The use of misoprostol by the intrauterine route during caesarean section has not been well explored. What do the results of this study add? The use of misoprostol by intrauterine route in addition to routine oxytocin infusion during caesarean section is associated with decreased intra-operative and post-operative -blood loss. What are the implications of these findings for clinical practice and/or further research? The findings of this study reveal that misoprostol is also effective by the intrauterine route. It is a convenient way to insert misoprostol during caesarean section and it can be considered to prevent intrapartum and postpartum haemorrhage. More studies including randomised controlled trials with bigger sample size are needed to reach to any firm conclusion.

Identifying Mentions of Pain in Mental Health Records Text: A Natural Language Processing Approach.

Pain is a common reason for accessing healthcare resources and is a growing area of research, especially in its overlap with mental health. Mental health electronic health records are a good data source to study this overlap. However, much information on pain is held in the free text of these records, where mentions of pain present a unique natural language processing problem due to its ambiguous nature. This project uses data from an anonymised mental health electronic health records database. A machine learning based classification algorithm is trained to classify sentences as discussing patient pain or not. This will facilitate the extraction of relevant pain information from large databases. 1,985 documents were manually triple-annotated for creation of gold standard training data, which was used to train four classification algorithms. The best performing model achieved an F1-score of 0.98 (95% CI 0.98-0.99).

Distributions of recorded pain in mental health records: a natural language processing based study.

OBJECTIVE: The objective of this study is to determine demographic and diagnostic distributions of physical pain recorded in clinical notes of a mental health electronic health records database by using natural language processing and examine the overlap in recorded physical pain between primary and secondary care. DESIGN, SETTING AND PARTICIPANTS: The data were extracted from an anonymised version of the electronic health records of a large secondary mental healthcare provider serving a catchment of 1.3 million residents in south London. These included patients under active referral, aged 18+ at the index date of 1 July 2018 and having at least one clinical document (≥30 characters) between 1 July 2017 and 1 July 2019. This cohort was compared with linked primary care records from one of the four local government areas. OUTCOME: The primary outcome of interest was the presence of recorded physical pain within the clinical notes of the patients, not including psychological or metaphorical pain. RESULTS: A total of 27 211 patients were retrieved. Of these, 52% (14,202) had narrative text containing relevant mentions of physical pain. Older patients (OR 1.17, 95% CI 1.15 to 1.19), females (OR 1.42, 95% CI 1.35 to 1.49), Asians (OR 1.30, 95% CI 1.16 to 1.45) or black (OR 1.49, 95% CI 1.40 to 1.59) ethnicities, living in deprived neighbourhoods (OR 1.64, 95% CI 1.55 to 1.73) showed higher odds of recorded pain. Patients with severe mental illnesses were found to be less likely to report pain (OR 0.43, 95% CI 0.41 to 0.46, p<0.001). 17% of the cohort from secondary care also had records from primary care. CONCLUSION: The findings of this study show sociodemographic and diagnostic differences in recorded pain. Specifically, lower documentation across certain groups indicates the need for better screening protocols and training on recognising varied pain presentations. Additionally, targeting improved detection of pain for minority and disadvantaged groups by care providers can promote health equity.

Comparison of vaginoscopic hysteroscopy and traditional hysteroscopy: A systematic review and meta-analysis.

BACKGROUND: Outpatient hysteroscopy is a safe, feasible, and optimum procedure for the diagnosis and management of intrauterine pathologies. OBJECTIVE: To determine the best approach of outpatient hysteroscopy (vaginoscopic vs traditional) in terms of pain, duration of procedure, feasibility, safety, and acceptability. SEARCH STRATEGY: PubMed, Embase, Google Scholar, and Scopus were searched from January 2000 to October 2021. No filters or restrictions were applied. SELECTION CRITERIA: Randomized controlled trials comparing vaginoscopic hysteroscopy with traditional hysteroscopy in an outpatient setting. DATA COLLECTION AND ANALYSIS: Two authors independently performed a comprehensive literature search and collected and extracted data. The summary effect estimate was determined using both fixed effects and random-effects models. RESULTS: Seven studies with 2723 patients (vaginoscopic [n = 1378] and traditional hysteroscopy [n = 1345]) were included. Vaginoscopic hysteroscopy was associated with a significant reduction in intraprocedural pain (standardized mean difference, -0.05 [95% confidence interval (CI), -0.33 to -0.23], I2 = 0%), procedural time (standardized mean difference, -0.45 [95% CI, -0.76 to -0.14], I2 = 82%), and fewer side effects (relative risk, 0.37 [95% CI, 0.15-0.91], I2 = 0%). The procedure failure rate was similar in both approaches (relative risk, 0.97 [95% CI, 0.71-1.32], I2 = 43%). Complications were mostly documented with traditional hysteroscopy. CONCLUSION: Vaginoscopic hysteroscopy reduces the pain and duration compared with traditional hysteroscopy.

Laparoscopic Excision of Cesarean Scar Ectopic Pregnancy: An Optimum Management Option.

Cesarean scar ectopic pregnancy is a leading cause of life-threatening complications in the first trimester. It poses a diagnostic and management challenge; if not diagnosed and adequately treated in early pregnancy, it may lead to considerable maternal morbidity and mortality. We report a case series of cesarean scar ectopic pregnancies managed successfully by laparoscopy. Laparoscopic excision is the gold standard management approach for cesarean scar ectopic pregnancy.

Development and content validation of yoga module for the mental health of NICU mothers.

BACKGROUND: Postnatal yoga has been found to be effective for maternal mental health management. But a validated yoga module for the mental health of early postpartum mothers with infants admitted to the Neonatal Intensive Care Unit (NICU) is lacking. AIM: To design and validate a yoga module for the mental health of early postpartum mothers having infants admitted to the NICU. MATERIALS AND METHODS: First phase: A yoga module was designed through a review of published research articles and yogic texts for NICU mothers. Second phase: thirty-eight yoga experts validated the yoga module. Lawshe's formula was used to calculate each item's content validity ratio (CVR). The intra-class correlation coefficient was determined for the validated yoga module. Third phase: The validated yoga module was pilot-tested with a sample size of 20 NICU mothers. RESULTS: Thirty-eight yoga experts validated the yoga module for NICU mothers. Thirteen practices included in the module indicated good content validity (cutoff value: 0.316). The module's content validity index (CVI) and intra-class correlation coefficient were 0.672 and 0.924, respectively. Ten days of practicing the yoga module resulted in a significant reduction in maternal stress levels in the yoga group (p < 0.001) compared to the control group (p = 0.427). CONCLUSION: The present study suggests good content validity of the yoga module for the mental health of NICU mothers. However, future randomized controlled trials must be carried out to determine both the feasibility and clinical efficacy of the Yoga Module for NICU mothers.