Male Baby Research Articles

Factors Associated with Infant Deaths in Indonesia: An Analysis of the 2012 and 2017 Indonesia Demographic and Health Surveys.

This exploratory study aimed to investigate factors related to infant deaths using a conceptual framework that explains the risk factors of infant deaths in developing countries. The study adopted a cross-sectional study design and used data from the 2012 and 2017 Indonesia Demographic and Health Surveys, with a sample of 3694 singleton live births in 2012 and 3413 in 2017. Female infants had a lower chance of mortality compared to male infants [adjusted odds ratio (aOR) = 0.51; 95% confidence interval (CI) = 0.34-0.77]. Infants with a smaller birth size had a higher risk of infant death compared to those with an average size (aOR = 5.66; 95% CI = 3.66-8.77). The risk of infant death with a preceding birth interval of ≥24 months was lower than that with a preceding birth interval of <24 months (aOR = 0.48; 95% CI = 0.26-0.90). An older maternal age was a risk factor for infant death compared to younger mothers (aOR = 3.61; 95% CI = 1.42-9.23). Infants who were born in Sumatra (aOR = 0.38; 95% CI = 0.16-0.89) and Java and Bali (aOR = 0.33; 95% CI = 0.14-0.78) were less likely to die than infants who were born in Papua and Maluku. A higher infant death risk was associated with male babies and a shorter birth interval (<24 months). Mothers who perceived their babies to be small and mothers who were older (35-49 years old) were high-risk factors for infant mortality. Mothers who lived in Java and Bali as well as Sumatera were less likely to experience infant mortality compared to those who lived in Papua and Maluku.

Maternal knowledge, attitudes and practices related to neonatal jaundice and associated factors in Shenzhen, China: a facility-based cross-sectional study

ObjectiveThis study aimed to assess knowledge, attitudes and practices related to neonatal jaundice among mothers in Shenzhen, China, and analyse associated factors.DesignA cross-sectional study.SettingThis study was conducted in Shenzhen Hospital,...

Athena: Speciality Certificate Examination case for Paediatrics and Genetics.

A four-month-old male baby presents in accident & emergency department with fever and respiratory distress. Parents report recurrent hospitalizations since birth due to chest infections. Antenatal and family history is unremarkable.

Severe autoimmune thrombocytopenia in a neonate secondary to maternal immune thrombocytopenia: a case report

&lt;p&gt;Neonatal thrombocytopenia is one of the common haematological problems encountered in neonatal intensive care unit. Severe neonatal thrombocytopenia is defined as a platelet count &amp;lt;50×10&lt;sup&gt;3&lt;/sup&gt;/µl and is relatively uncommon. Based on the time-of-onset, neonatal thrombocytopenia can be categorized into early-onset (&amp;lt;72 h after birth) and late-onset (&amp;gt;72 h after birth) thrombocytopenia. Neonatal autoimmune thrombocytopenia should be considered in any neonate who has early-onset thrombocytopenia and a maternal history of either immune thrombocytopenia (ITP) or an autoimmune disease (with or without thrombocytopenia). A term male baby, born to a 23-year-old primi-gravida with ITP was found to be thrombocytopenic at birth (platelets-85×10&lt;sup&gt;3&lt;/sup&gt;/µl) without any sign of neonatal sepsis. On serial monitoring, platelet counts kept falling and on day 3, the child developed severe thrombocytopenia (platelets-6.5×10&lt;sup&gt;3&lt;/sup&gt;/µl). No obvious signs of bleeding were present and the child was clinically well. Given the history of maternal thrombocytopenia (likely ITP), a possibility of neonatal autoimmune thrombocytopenia was considered. Owing to the risk of massive bleed, the baby was transfused random donor platelets and intravenous immunoglobulin (IVIg) was started on day 3. Thereafter, the platelets showed an increasing trend and child was discharged on day 7 with a platelet count of 170×10&lt;sup&gt;3&lt;/sup&gt;/µl. However, on follow-up platelet count was again found to be low (84×10&lt;sup&gt;3&lt;/sup&gt;/µl). It normalised subsequently, without any further requirement of IVIg. High index of suspicion, immediate work-up and diagnosis, with close monitoring and prompt management is required to prevent hemorrhagic complications in such children. Counselling for risk of thrombocytopenia in future pregnancies should be provided to parents.&lt;/p&gt;

Adverse Perinatal Outcomes of True Knot of the Umbilical Cord: A Case Series and Review of Literature

A true knot of the umbilical cord (TKUC) is an actual knot formed in pregnancy. It is seen in approximately 0.3%-1.2% of all pregnancies. True knots are of significance as they can cause a wide spectrum of adverse perinatal outcomes like small for gestational age (SGA) fetus, low appearance, pulse, grimace, activity, and respiration (Apgar) score at birth, fetal hypoxia, and even fetal demise.Here, we report a case series of three patients with TKUC and the varied adverse perinatal outcomes associated with them. A low-risk primigravida at term gestation had a suspicious non-stress test (NST). Repeat NST after maternal resuscitation became pathological. Emergency cesarean delivery was performed in view of pathological NST persisting despite intrauterine resuscitation. A healthy male baby weighing 2920 g was delivered, and the umbilical cord had a true knot.A multigravida at 33 + 3 weeks of gestation was referred with fetal growth restriction (FGR). Color Doppler examination showed absent end-diastolic flow (AEDF) in the umbilical artery (UA). Cesarean delivery was performed in view of FGR stage two with AEDF in the UA at 34 weeks of gestation as per the Barcelona criteria. A male baby weighing 1505 g was delivered. The umbilical cord had a true tight knot. The baby had an Apgar score of 7 at one minute after birth but was shifted to the neonatal intensive care unit (NICU) in view of low birth weight and prematurity. The baby slowly gained weight and was discharged from NICU after 15 days in stable condition.A multigravida at 32 weeks of gestation was referred with intrauterine fetal demise. Ultrasonography confirmed the presence of a single intrauterine dead fetus corresponding to 30 + 4 weeks of gestation with an estimated fetal weight (EFW) of 1633 g, amniotic fluid index (AFI) equal to nine, and presence of Spalding’s sign. Induction of labor was done, and she expelled a dead macerated male fetus weighing 1825 g. The infantogram was normal. A true umbilical cord knot was found.The umbilical cord is the source of fetal blood supply; therefore, any cord abnormality can have a significant impact on the fetal outcome. There are various factors that can predispose to TKUC, such as polyhydramnios, increased cord length, monoamniotic twins, male baby, grand multiparity, small fetus, and amniocentesis. TKUC can lead to various adverse outcomes in pregnancy and labor like SGA fetus, low Apgar score at birth, fetal hypoxia, and fetal demise. TKUC increases the risk of fetal demise by as much as four times.With the development of advanced techniques such as three-dimensional/four-dimensional color Doppler ultrasounds, TKUC can be diagnosed antenatally in the form of a four-leaf-clover, a “hanging-noose sign,” or by an unusual multicolor pattern in the cord. The prenatal detection rate of TKUC is only 12%. It mostly remains undetected unless visualized incidentally. Although TKUC is not rare and can have serious outcomes, the importance of its antenatal diagnosis has not been determined. It should be suspected in patients with risk factors, and emphasis should be placed on its antenatal diagnosis on ultrasonography to avoid obstetric disasters in otherwise low-risk females. Though there is no specific management of these cases, a good clinical outcome can be achieved if TKUC is diagnosed antenatally and monitored closely until fetal maturity is attained.

Achievement of a 136-day delayed-interval delivery of a second twin with minimum intervention

The rate of multiple pregnancies in the past three decades has increased dramatically. Twin pregnancies have a higher risk of pregnancy loss owing to premature birth. Although the premature delivery of the first twin is usually followed by spontaneous birth of the second twin, there are ways to delay the delivery of the second twin to enhance survival and neonatal outcomes. However, there is insufficient evidence to support the role of any interventions such as cerclage, hospitalization, tocolytics, and/or antibiotics. As a result, the management of delayed interval for the delivery of the second twin varies depending on each case. The purpose of this study was to report the obstetric components of a successful delayed-interval delivery, with an emphasis on the current conflicts around the active management of the delayed interval delivery of the second twin. A case of a 40-year-old, G5P4, woman who had three cesarean sections is presented. She got pregnant with a dichorionic diamniotic twin. At 17 weeks of gestation, she developed sudden severe lower abdominal pain, vaginal bleeding, and spontaneous expulsion of the first fetus weighing 179 g. After delivery of the first twin, the vaginal bleeding became minimal, and the cervix was reconstituted soon, so cervical cerclage was not offered. The umbilical cord of the first fetus was cut at the level of the external cervical os, and the placenta was retained. She received intravenous fluids, anti-D prophylaxis, paracetamol, and antibiotics. The patient was keen to continue with the pregnancy and was informed about the risks and benefits. The management was mainly an outpatient basis after an initial short hospital stay of 6 days before being discharged (upon her request); during the follow-up, she did not develop any clinical manifestations of maternal infection. She was subjected to ANC at the outpatient clinic every 2 weeks, where vaginal culture, complete blood count, prothrombin time, and C-reactive protein levels and serial ultrasonography were checked consistently. The fetus showed adequate growth. After 136 days, she delivered by elective cesarean section a male baby weighing 2850 g at 37 weeks of gestation with good recovery. In certain situations, delayed delivery of the second twin of diamniotic dichorionic twin pregnancy may be a safe, simple with less interventions, and effective option to improve pregnancy outcome.

PHOTOTHERAPY INDUCED HYPOCALCEMIA IN ICTERIC NEWBORNS ATTENDING BIRAT MEDICAL COLLEGE TEACHING HOSPITAL, MORANG, NEPAL

Background: Neonatal jaundice is the single most common abnormal physical finding and the cause of morbidity in the first week of life. It is commonly managed by phototherapy. A lesser known, but a potential complication of phototherapy is hypocalcemia. This study was done to determine the prevalence of phototherapy induced hypocalcemia in icteric newborn and to compare it between preterm and term babies. Methods: This was a hospital based cross sectional study carried out in the Department of Pediatrics, Birat Medical College Teaching Hospital from 1st September 2020 to 1st March 2021. This study was performed on 201 icteric newborn that were managed with phototherapy. Serum calcium level was estimated both before initiating phototherapy and after 24 hours of phototherapy. All the data were recorded in the structured proforma. Data was analysed using SPSS version 16. Results: This study was performed on 201 icteric newborn (121 term, 80 preterm). Male babies (n=133; 66.2%) outnumbered the female babies (n=68; 33.8%). The majority of neonates were in the age group of 1-5 days (n=156; 77.6%), with mean age of4.50± 3.39 days.7.9% (16 out of 201) neonates exhibited phototherapy induced hypocalcemia. The prevalence of hypocalcemia in preterm was 10%and term neonates was 6.6%. Conclusions: Hypocalcemia is a significant problem in icteric newborn treated with phototherapy. Hence there is a need for closed monitoring of serum calcium levels. Also the risk is greater in preterm neonates as compared to the term neonates.

Neonatal Facial Subcutaneous Abscess: A Case Report

Skin and soft-tissue infections (SSTIs) are a relatively common diagnosis in both the pediatric and adult populations and include abscesses and cellulitis. An abscess is a focal, contained, purulent infection with a clearly defined “cavity” and surrounding inflammation involving the deep subcutaneous tissues. Cellulitis is an infection of the skin, without an organized cavity, presenting with erythema, warmth, induration, and tenderness [1]. There has been a recent rise in the incidence of SSTIs, with up to 95% of this increase attributed to abscesses and cellulitis, with the largest change occurring in the pediatric (&lt;18 years) population [2]. In addition to an overall increase in SSTIs, there has been a concomitant rise in the incidence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) [3]. A 20 days old male full term baby born to a G2P1D1 mother via lower segment cesarean section in view of non progression of labor with birth weight of 2.8 kgs presented in our hospital with subcutaneous abscess diffusly present on the left side of the scalp &amp; face. Informant was father with good reliability. Patient presented with complaints of fever since 2 days and distension of abdomen since 2 days. Swelling over the scalp since birth. All relevant investigations sent &amp; IV antiobiotics like meropenem &amp; vancomycin started. Incision &amp; drainage done by pediatric surgeon &amp; 100 ml pus removed. IV antibiotics given for 14 days. Regular dressing done &amp; patient discharged on day 16 of admission. The gold standard treatment for subcutaneous abscesses remains incision and drainage (I&amp;D). The use of antibiotics for SSTIs after drainage is an area of great debate and variance. As a general guideline, the Infectious Disease Society of America (IDSA) recommends the use of antibiotics after I&amp;D only in the presence of systemic signs of infection. In summary, abscesses are a very common presentation in the pediatric ED. MRSA is the most common isolate of these abscesses, regardless of risk factors. History and physical exam combined with ultrasound should be used to diagnose abscesses. As upper &amp; lower limb skin abscess are more common, we here report facial abscess in neonate which was diffuse &amp; successfully treated.

Miracle Pregnancy: Management of Poor Responder in In-Vitro Fertilization

Background:: Patient-Oriented Strategy Encompassing IndividualizeD Oocyte Number (POSEIDON) 3 and 4 subgroup is common nowadays. We hereby report a case of successful management of POSEIDON 4 patient, who underwent an individualized GnRH antagonist protocol. Case Presentation:: A 36-year-old woman presented with primary infertility for 10 years. She had undergone multiple cycles of ovulation induction and intrauterine insemination previously. She had previous one IVF failure. Post COVID lockdown, patient was a POSEIDON 4 group patient who underwent second IVF cycle. Three grade 4 oocytes were retrieved after dual trigger. Two 8 celled grade B embryos were transferred on day 3. Patient conceived and had caesarean section at 37 weeks POG, 2.4 kg healthy male baby delivered. Conclusion:: IVF with self-oocyte can be tried along with proper counselling to decrease the psychological and financial burden on the patient and family, therefore, ruling out oocyte donation as the only treatment option in these patients.

Prevalence of Glucose-6-Phosphate Dehydrogenase Deficiency among hospitalized Children at tertiary care Hospital in Eastern Part of Nepal

Introduction: Glucose 6 phosphate dehydrogenase deficiency is the most significant enzyme defect. It is X linked inherited disorder that affects males and females are rarely affected by lyonization. Severe jaundice, anemia and hemolytic crisis following ingestion of fava beans and certain drugs are known to occur in children with G6PD deficiency. Therefore, routine neonatal and child screening programs to facilitate the identification and effective management of children with G6PD deficiency is paramount.&#x0D; Objective: The main objective of this study is to find out the hospital prevalence of G6PD deficiency in hospitalized children at Birat Medical College teaching Hospital.&#x0D; Methodology: This is a hospital based cross sectional study carried out in the Department of Paediatric, Birat Medical College Teaching Hospital from30th November 2020 to 30th May 2021. Three hundred children upto to ten years of age admitted in department of pediatrics were included in this study. This study was performed on hospitalized children who were screened for G6PD deficiency. The test was carried out using the Randox G6PD quantitative in vitro test to determine the prevalence of G6PD deficiency among the admitted children upto 10 years of age.Data was analysed using SPSS version 16.&#x0D; Results: This study was performed on 300 children, in which male babies (n=192; 64%) outnumbered the female babies (n=108; 36%). The majority of children were in the age group of &lt; 1 years (n=131; 43.7%).The overall prevalence of G6PD deficiency was 9.3% of which 96.4% were moderately deficient while 3.6% was severely deficient.The highest proportion was noted in the age group of 1 to 5 years. The frequency of this disorder in males and females were 13.5% and 1.9% respectively which was statistically significant (p=0.001).&#x0D; Conclusion: The present study confirms the high prevalence of G6PD deficiency in Eastern Region of Nepal. Therefore, we need to establish routine screening and educational programs in order to prevent grave complications in future.

Gauging the correlation between anthropometric measurements to birth weight in subjects of urban lower socioeconomic status in Mumbai

Background: Birth weight is largely influenced by the mother's parity, gender of the baby, conceptus number, and maternal environment. The heavier weight is seen for male babies at full-term compared to females, in singleton compared to twins, and in later-born compared to the first baby. Low-weight babies are seen in mothers of lower socioeconomic status. In urban lower socioeconomic group females, the closest correlation is seen with neonatal calf circumference. Aim: The present study was conducted to perceive the anthropometric parameters that have the best correlation with the birth weight in the urban lower socioeconomic population of Mumbai. Methods: From the post-natal ward of Sir JJ group of hospital and Cama hospital, 200 newborns who were normal-delivered, newborns, singletons, born to females with no history of infections like tuberculosis, hypertension, and diabetes mellitus were assessed. In 200 included subjects, anthropometric parameters and birth weight were assessed. Results: Good correlation was seen in both females and males between birth weight and calf circumference, thigh circumference, mid-arm circumference, and abdominal circumference. However, poor correlation in females and good correlation in males was seen in chest circumference, head circumference, and crown to heel length.

Percutaneous Internal Ring Suturing (Pirs): A Minimally Invasive Procedure in Pediatric Inguinal Hernia Repair

Objective Percutaneous internal ring suturing (PIRS) is a single port laparoscopic technique used to repair pediatric indirect inguinal hernia. Unlike the open method, which is the gold standard of the hernia repair, this technique is still new in the fraternity and not many centers practiced it. We applied this technique on our patients and we found that the duration of surgery was shortened, smaller surgical incision, lesser complications and early discharges. Methods Patient selection was done based on several criteria, term baby with no anomalies, indirect inguinal hernia, and male baby with a thin abdominal wall. The baby was put under general anesthesia via endotracheal intubation. One-centimeter infraumbilical incision was made and a 3mm 70◦ scope is inserted after a pneumoperitoneum achieved. With the guidance of the scope, a spinal needle with a Prolene 2-0 was punctured and threaded in on the medial edge of the internal inguinal ring (Figure 1-3). Once the sutures in, the needle is withdrawn. Similarly, another Prolene 2-0 is punctured and threaded in on the lateral edge of the internal inguinal ring (Figure 4). This time, the needle is looped into the first suture (Figure 5). After the withdrawal of the needle, the sutures were tightened and ligated (Figure 6). Laparoscopy is used to inspect that the internal ring is snugly closed without the entrapment of the vas or the cord structures. Once ligated, the scope is removed and the port site is sutured using a purse-string suture. The patient is extubated, observed in the general ward till afternoon and was discharged home after passing flatus, stool, and urine.

Uterine torsion as an elusive obstetrical emergency in pregnancy: is there an association between gravid uterus torsion and Ehlers–Danlos syndrome?: a case report

BackgroundTimely diagnosis of uterine torsion can lead to acceptable maternal and fetal outcomes. This article presents the case of a 42-year-old pregnant woman, diagnosed with a rare 270° uterine torsion, in whom proper management led to good maternal outcomes but, unfortunately, severe prematurity and metabolic acidosis led to neonatal death. Moreover, the mother was clinically suspected for Ehlers–Danlos syndrome.Case presentationIn December 2020, a 42-year-old pregnant Iranian woman, Gravid 3 para2 live2, at 30 weeks of gestation presented to the obstetric emergency department of Vali-Asr Hospital (Birjand, Iran) suffering from acute severe generalized abdominal pain, nausea, vomiting, and dizziness while she was hemodynamically unstable. After resuscitation, owing to persistent fetal bradycardia on fetal heart rate monitoring, she underwent an emergency cesarean section. Infra-umbilical midline skin incision was made, and when the abdominal cavity was opened, owing to abnormal appearance of the uterus, we further investigated the abdominopelvic cavity. Surprisingly, the uterus was dextrorotated by 270°. After uterine detorsion through a Kerr incision, a nonvigorous male baby was born with severe metabolic acidosis that led to his death soon after birth. Interestingly, we could find no predisposing factors such as pelvic abnormalities during surgery. Nevertheless, as her postoperative detailed physical examination revealed skin hyperextensibility, joint laxity, pelvic organ prolapse, and trivial exophthalmos, connective tissue disorders, mainly Ehlers–Danlos syndrome, were suspected. Unfortunately, for significant financial, cultural, and religious reasons, the patient refused to undergo further investigations. Additionally, despite severe congested uterus and subsequent uterine atony, timely diagnosis and anatomical correction of the gravid uterus before uterine incision prevented iatrogenic complications. The mother was discharged 2 days later without any postpartum complications.ConclusionAlthough uterine torsion is an extremely rare condition during pregnancy, based on severe associated maternal and perinatal complications, it is important to take this diagnosis into consideration as an differential diagnosis. Moreover, connective tissue disorders seem to be a potential risk factor for uterine torsion, although further studies on this subject are required.

Establishing biotinidase reference interval: A foundation stone for newborn screening of biotinidase deficiency in Pakistan.

To determine the reference interval of biotinidase activity in healthy neonates. The cross-sectional study was conducted at the Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from May to November 2019, and comprised blood samples collected from healthy neonates aged 2-6 days. The samples were collected on filter paper and analysed on genetic screening processor based on dissociation-enhanced lanthanide flouroimmunoassay. Data was analysed using SPSS 21. Of the 120 dried blood spot specimens, 81(67.5%) were from male babies and 39(32.5%) from female babies. Reference interval for biotinidase activity, based on 2.5th and 97.5th percentiles, was from 3.0 to 11.0 nmol/ml/min. Screening of newborns for biotinidase deficiency is crucial to prevent irreversible neurological damage.

A rare presentation of OEIS variant with a recto-bladder neck fistula: A case report and literature review.

IntroductionOmphalocele, bladder extrophy, imperforate anus and spinal defect (known as OEIS) is a very rare congenital anomaly with an unknown etiology. In this report we describe a case of an OEIS variant associated with a wide pubic diastasis, bladder extrophy with a recto-bladder neck fistula and a high ano-rectal malformation. This work has been reported in line with the SCARE 2020 criteria.Presentation of the caseA 30-year-old mother delivered a male baby at 39 weeks through a normal vaginal delivery. Examination revealed multiple congenital anomalies in the form of an Omphalocele, extrophied bladder, imperforate anus, ambiguous genitalia and a large pelvic diastasis. Fecal matter was noted at the most inferior point of the extrophied bladder, raising the suspicion of a recto- vesical fistula.An exploratory laparotomy showed a fistula between the rectum and the neck of the extrophied bladder. A sigmoid colostomy was carried out in addition to a mucous fistula. The fascial defect of the Omphalocele was approximated to the upper border of the extrophied bladder.At the age of 2 years, the baby underwent a bladder extrophy repair, a posterior sagittal anorectoplasty and bilateral osteotomies.DiscussionOEIS complex has been reported to occur with a wide variety of associated anomalies, and this necessitates a thorough investigation in order to formulate an appropriate treatment plan. A prenatal diagnosis of OEIS complex can be made by ultrasound stressing the importance of antenatal follow up and a multidisciplinary approach in management.ConclusionWe described a rare variant of an OEIS complex and management of such anomalies requires a multidisciplinary input.

Cystic fibrosis and alpha-1 antitrypsin deficiency: case report and review of literature

BackgroundThis case report describes a child born with both cystic fibrosis (CF) and alpha-1 antitrypsin deficiency (A1ATD). Both are autosomal recessive inherited diseases, mainly affecting the lungs and the liver. The combination of both diseases together is rare and may lead to a fulminant disease with limited life span. To the best of our knowledge, no case has been reported of a patient born with both diseases.Case presentationAfter an uneventful pregnancy, a male baby was born with meconium ileus. The suspected diagnosis of CF was confirmed based on the sweat test and genetic analysis. The child developed persisting cholestasis, too severe to be likely caused by CF alone and indicating an associated problem. The diagnosis of A1ATD was established based on clinical suspicion (persisting cholestasis), decreased serum alpha-1 antitrypsin and genetic analysis. Supportive therapy was started, however the boy evolved to rapidly progressive liver disease leading to liver failure which necessitated an infant liver transplantation.ConclusionsThis case illustrates the complexity of care in case of two severe inherited diseases as well as post solid organ transplant care.

Congenital cardiac masses: a case report

BackgroundCardiac tumors in infants and children are rare. The most common cardiac tumor is rhabdomyoma, which may be associated with tuberous sclerosis. However, not all cardiac rhabdomyomas are pathognomonic for tuberous sclerosis, and not all congenital cardiac tumors are rhabdomyomas. During the prenatal period, early cardiac tumor detection provides important information about fetal wellbeing, delivery planning, and necessary postnatal care.Case presentationWe report a 36-year-old African American pregnant women. At 32 weeks 5 days gestational age, the male fetus had a fetal echocardiogram due to fetal arrhythmia. The fetal echocardiogram showed two small echogenic, RV apex and septal masses, suspicious of rhabdomyomas. After a routine pregnancy and a normal spontaneous vaginal delivery (39 weeks 1 day), the male baby was admitted to the neonatal intensive care unit for further monitoring and postnatal evaluation.ConclusionsRhabdomyomas are extremely rare and unique tumors. These tumors are very dangerous, but they usually regress after birth. During the prenatal period, early cardiac tumor detection provides important information about fetal wellbeing, delivery planning, and necessary postnatal care. We present this case to share our findings with our pediatric colleagues. Although a rarely reported case, we hope this cardiac rhabdomyoma case report and literature review can increase cardiac tumor awareness.

Factor XIII Deficiency in a Mother-Baby Dyad

Background: Factor XIII deficiency is a rare autosomal recessive coagulation disorder with varied presentations including prolonged bleeding from the umbilical cord stump, defective wound healing, recurrent miscarriages, or life-threatening intracranial hemorrhage. Clinical Description: A male baby was born at term gestation to a fourth gravida mother with a history of two abortions in the past. He was born out of a third-degree consanguineous marriage, with smooth perinatal transition, but developed multiple episodes of seizures associated with poor feeding and lethargy after 24 h of life. Management: On evaluation, septic screen, metabolic screen (serum electrolytes, calcium, and blood sugar), and coagulation assays were normal. Ultrasonogram revealed a hyperechoic lesion restricted to the left cerebral hemisphere, suggestive of an intraparenchymal hemorrhage. Magnetic resonance imaging brain showed left intraparenchymal hemorrhage with significant mass effect and midline shift. In view of intracranial bleed with normal coagulation assay and other causes being ruled out, factor XIII clot solubility assay was sent and found to have undetectable levels. Factor XIII levels of the mother were also found low (5.5%) though the levels in the father were normal. The baby was managed conservatively with supportive measures in the form of anticonvulsant and anti-edema measures. He recovered successfully and is under close follow-up. Conclusion: A high index of suspicion of factor XIII deficiency should be kept in any neonate presenting with intraparenchymal hemorrhage and recurrent abortions in the mother. This case is being reported to highlight factor XIII deficiency in recurrent pregnancy loss and neonatal intracranial bleeding. Prenatal screening for factor XIII deficiency in these circumstances will help in effective management of future pregnancies.

Anaesthetic implications of right atrial myxoma in a premature infant.

Sir, Cardiac myxoma is a benign tumour and the most common primary cardiac tumour in adults; however, it is unusual in paediatric patients, with only 20% constituting right atrial myxomas (RAMs).[1] A 3-month-old male baby, weighing 1.7 kg, presented to our hospital with tachypnoea while feeding and failure to thrive. The baby was born prematurely after 29 weeks of gestation. On examination, the baby looked emaciated [Figure 1]. A pansystolic murmur was present at the left lower sternal border on auscultation. Transthoracic echocardiography (TTE) revealed a large, homogenous, pedunculated mass (19 mm × 10 mm) attached to the interatrial septum (IAS) and protruding into the tricuspid valve (TV) causing tricuspid regurgitation (TR) [Figure 2]. Blood investigations revealed haemoglobin of 9.8 g/dL and platelet count of 78000/mm3. Surgical removal of the RAM was planned because of the inability to gain weight.Figure 1: Intraoperative image showing an emaciated look of the child. Fr: FrenchFigure 2: Apical four-chamber view on TTE showing RA myxoma. RA: right atrium, RV: right ventricle, LA: left atrium, LV: left ventricleOn the day of surgery, the baby was shifted to the operating room, and a multiparameter monitor was attached. All preparations were done before induction of anaesthesia to go on emergent cardiopulmonary bypass (CPB) if required. General anaesthesia with endotracheal intubation was induced with intravenous midazolam 0.1 mg/kg, fentanyl 5 μg/kg and vecuronium 0.1 mg/kg through an already placed peripheral cannula. Induction agents were given slowly while constantly monitoring the haemodynamics. Right radial arterial cannulation was done, and central venous catheter (CVC) was inserted carefully in the right internal jugular vein. Anaesthesia was maintained with 1.5% (v/v %) isoflurane and intermittent boluses of fentanyl and vecuronium. After midline sternotomy and full heparinisation, CPB was instituted through aorto-bicaval cannulation. Superior vena cava (SVC) cannulation was done through a higher approach, and other manipulations near the right atrium (RA) were done gently to avoid embolisation of the tumour. Under deep hypothermic circulatory arrest (DHCA), the RA was opened, and the mass was excised completely. The baby was weaned off CPB with inotropic support of intravenous milrinone 0.5 μg/kg/min. After completion of the surgery, the patient was shifted to the paediatric intensive care unit and was extubated after 8 hours. Postoperative TTE showed an intact IAS with no TR or residual mass in RA. RAMs usually present with breathlessness, cyanosis, feeding difficulty, and constitutional symptoms like fever, fatigue, anaemia, thrombocytopenia, malnourishment, and weight loss because of the release of interleukin-6 by RAM.[2] RAM can obstruct the TV causing jugular venous distension, peripheral oedema, hepatic congestion, ascites, and syncope.[3] Our patient looked malnourished, weighed only 1.7 kg along with low haemoglobin and platelet count. Arrhythmias commonly occur due to conduction defects caused by myxoma. Anaesthetic considerations in RAMs include hypoxaemia, low cardiac output, and potential pulmonary emboli due to their mobile nature. Aggravation of the patient’s symptoms and hypotension can occur at certain positions due to intermittent obstruction of TV by a mobile RAM along with a change in the character of the murmur. Evaluation of these positions must be done preoperatively, and induction should be done with careful positioning, with the administration of titrated doses of anaesthetic drugs, which avoid myocardial depression while maintaining the preload and preparation to go on emergent CPB. Placing a CVC and SVC cannulation can be difficult in the presence of a tumour in the RA and may result in its fragmentation and dislodgement. Hence, utmost care should be taken to avoid entering the RA. Intraoperative transoesophageal echocardiography (TOE) monitoring helps in the detection and diagnosis of tumour fragmentation or dislodgement, and in assessing volume status as TR caused by RAM renders CVP measurement unreliable for evaluation of volume status.[4] However, in our case, TOE examination was not done because of non-availability of a neonatal probe. DHCA provides excellent surgical exposure for tumour removal, but the duration of circulatory arrest must be limited to prevent complications.[5] Perioperative care in premature neonates also includes preventing hypoglycaemia, hypoxia and hypothermia.[6] Anaesthetic concerns range from difficult airways, risk reduction for adverse events and adequate pain management.[7] Thus, neonates with RAMs require early diagnosis, meticulous anaesthetic management and multidisciplinary approach to perioperative care. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Effect of Nitya virechana before intrauterine insemination

In modern medical science, diagnosis and treatment are based on a direct vision which is made by a number of diagnostic tests. When infertility evaluation failed to detect any cause of infertility, it is called “Unexplained Infertility.” Intra-uterine insemination (IUI) is a basic treatment option in such unexplained cases. In Ayurvedic classics, Ritu (~menstruation), Kshetra (~uterus), Ambu (~nutrition), and Beeja (~ovum and/or sperm) are described as essential factors for conception. Adequate physiological functioning of these factors is also necessary with the absence of causative factors to achieve conception. Along with that normal psychology is also described as an important aspect for conception. A 35-year-old female presented to Stree Roga Evum Prasuti Tantra OPD, on December 2019 with chief complaints of long-standing unexplained infertility. The patient was advised IUI along with Ayurvedic management. Vata is a principle Dosha in Vandhyatva (~infertility) and Mridu sanshodhana (~mild purification) described as a line of treatment to treat vitiated Vata dosha. Virechana is also maintained for “Agarbha” Stree (~infertile woman). Hence, the patient was treated with Nitya virechana (~daily therapeutic purgation) by Eranda sneha (~castor oil). Eranda sneha maintains Agni (~digestive power) and normalizes Vata dosha by Vata anulomana karma (~carminatives). It also affects the psychological status of the patient by Medhya (~intellect power) and Smritikara (~improving memory) properties. This concept was followed in this case to manage infertility. After the second cycle of IUI, urine pregnancy was achieved in April 2020, and delivered a healthy male baby in November 2020.