Normal Apgar Scores Research Articles

Endoscopic retrograde cholangiopancreatography results for the treatment of symptomatic choledocholithiasis in pregnant patients: A recent experience at a secondary care hospital in Mexico City

IntroductionEndoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for symptomatic choledocholithiasis during pregnancy. In pregnant patients, aside from the risks inherent in the procedure and sedation, there is the added concern of the potentially damaging effects of ionizing radiation on the fetus. AimTo describe the maternal and fetal results of ERCP performed to resolve symptomatic choledocholithiasis in pregnant patients. Materials and methodsA retrospective, descriptive, observational, and cross-sectional study was conducted. It included pregnant patients with choledocholithiasis that underwent ERCP within the time frame of June 2017 and June 2018. ResultsThe study included 9 pregnant patients, with a mean gestational age of 24.1 weeks, that underwent ERCP. There were no maternal or fetal complications associated with sedation, mean fluoroscopy time was 26.7s, and one patient (11.1%) presented with mild post-ERCP pancreatitis that was resolved through medical management. Pregnancy progression was normal in 100% of the cases, resulting in the birth of neonates with a normal Apgar score, a mean weight of 3120g, a mean length of 49.94cm, and a mean gestational age of 38.37 weeks. At follow-up at 6 months, the infants had a mean weight of 7.1kg and a mean length of 66.94cm. ConclusionsThe results from our hospital center were similar to those described in the international literature, showing that ERCP in our medical environment is a feasible, safe, and efficacious method for both the mother and fetus. When performed by an experienced endoscopist, it should be considered the treatment of choice for choledocholithiasis in pregnant patients.

Clinical Characteristics of Pregnant Women With Coronavirus Disease 2019 in Wuhan, China.

BackgroundCoronavirus disease 2019 (COVID-19) has become a pandemic. Despite the growing number of patients with COVID-19 infection, data on the clinical characteristics of pregnant patients are still limited.MethodsWe retrospectively included childbearing-age female patients with laboratory-confirmed COVID-19 at Renmin Hospital of Wuhan University from January 15 to February 23, 2020. Demographic, clinical, radiological, laboratory, and treatment data were reviewed. Clinical characteristics of pregnant and nonpregnant patients were compared.ResultsOne hundred eleven childbearing-age women with COVID-19 were included, including 16 patients (14.4%) with severe or critical disease. Compared with nonpregnant patients (n = 80), pregnant patients (n = 31) were less likely to have dyspnea (16.1% vs 37.5%), asthenia (3.2% vs 33.8%), and ≥3 symptoms (22.6% vs 45.0%); had a significantly higher neutrophil count (5.2 vs 2.5 ×109/L) and a higher percentage of CD3+ cells (76.7% vs 73.7%) and CD8+ cells (32.3% vs 28.4%); and had a dramatically lower percentage of lymphocytes (18.2% vs 31.8%), a lower CD4+/CD8+ ratio (1.2 vs 1.4), and a lower level of IgG (9.8 vs 11.9 g/L). Of note, pregnant patients had a significantly lower percentage of severe disease (3.2% vs 18.8%) and a substantially higher level of inflammation markers including neutrophil-to-lymphocyte ratio (4.4 vs 1.9) and systematic inflammatory index (812.8 vs 354.7) than nonpregnant patients. Seventeen live births were recorded, and all of these showed negative results of postnatal COVID-19 detection together with a normal Apgar score.ConclusionsPregnant patients with COVID-19 had a lower level of severity and an enhanced inflammatory response and cell immunity when compared with nonpregnant patients.

Association between apgar score at 5 minutes and adverse outcomes among Low-Risk pregnancies

Objective Among low-risk pregnancies, we aimed to ascertain the association between 5-minute Apgar score and adverse outcomes of newborn-maternal dyad. Study design We conducted a retrospective cohort study using the U.S. vital statistics datasets (2012–2016), including live births from low-risk women with non-anomalous singleton gestations who delivered at 37–41 weeks. Apgar score was categorized as low (0–3), moderate (4–6), and normal (7–10). The primary outcome was composite neonatal adverse outcome (any of the following: assisted ventilation > 6 h, neonatal seizure, or neonatal death). The secondary outcomes were infant mortality and composite maternal adverse outcome (any of the following: admission to the intensive care unit, blood transfusion, uterine rupture, or unplanned hysterectomy). Multivariable Poisson regression analyses were used to estimate the association between 5-minute Apgar score and adverse outcomes (using adjusted relative risk [aRR] and 95% confidence intervals [CI]). Results Of 19.9 million live births delivered between 2012 and 2016, 11.7 million (58.7%) met inclusion criteria; 98.9% had a normal 5-minute Apgar score, 0.9% had a moderate score, and 0.2% had a low score. The overall composite neonatal adverse outcome was 3.2 per 1,000 live births and the rates were significantly higher among those with a moderate (aRR 20.8; 95% CI 20.2–21.4) or low score (aRR 43.1; 95% CI 41.6–44.5) than normal score. The overall composite maternal adverse outcome was 2.45 per 1,000 live births and it was significantly higher in deliveries with a moderate (aRR 3.1; 95% CI 2.9–3.3) and low (aRR 4.6; 95% CI 4.2–5.0) 5-minute Apgar score than those with a normal score. Infant mortality also showed a similar pattern. Conclusion Though approximate 1% of live births had a 5-minute Apgar score below 7 among low-risk pregnancies, a decreased score was associated with a significantly higher risk of neonatal and maternal adverse outcomes, as well as infant mortality.

Endoscopic retrograde cholangiopancreatography results for the treatment of symptomatic choledocholithiasis in pregnant patients: A recent experience at a secondary care hospital in Mexico City.

Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for symptomatic choledocholithiasis during pregnancy. In pregnant patients, aside from the risks inherent in the procedure and sedation, there is the added concern of the potentially damaging effects of ionizing radiation on the fetus. To describe the maternal and fetal results of ERCP performed to resolve symptomatic choledocholithiasis in pregnant patients. A retrospective, descriptive, observational, and cross-sectional study was conducted. It included pregnant patients with choledocholithiasis that underwent ERCP within the time frame of June 2017 and June 2018. The study included 9 pregnant patients, with a mean gestational age of 24.1 weeks, that underwent ERCP. There were no maternal or fetal complications associated with sedation, mean fluoroscopy time was 26.7seconds, and one patient (11.1%) presented with mild post-ERCP pancreatitis that was resolved through medical management. Pregnancy progression was normal in 100% of the cases, resulting in the birth of neonates with a normal Apgar score, a mean weight of 3,120g, a mean length of 49.94cm, and a mean gestational age of 38.37 weeks. At follow-up at 6 months, the infants had a mean weight of 7.1kg and a mean length of 66.94cm. The results from our hospital center were similar to those described in the international literature, showing that ERCP in our medical environment is a feasible, safe, and efficacious method for both the mother and fetus. When performed by an experienced endoscopist, it should be considered the treatment of choice for choledocholithiasis in pregnant patients.

Association Between Apgar Scores of 7 to 9 and Neonatal Mortality and Morbidity: A Population-based Cohort Study of Term Infants in Sweden

(BMJ. 2019;365:l1656) While low Apgar scores (<7) have been associated with increased risk of poor neonatal outcomes including mortality and morbidity, there have not been any investigations into whether the risks of these outcomes vary between normal Apgar scores of 7, 8, and 9 compared with a score of 10. This information could be useful in predicting the risk of conditions such as neonatal infection, respiratory distress, and hypoxic-ischemic encephalopathy, which have been associated with worse neurodevelopmental status later in childhood compared with children without these conditions. This population-based Swedish study examined the risks of neonatal mortality and morbidity associated with Apgar scores of 7, 8, and 9 (vs. 10) at 1, 5, and 10 minutes.

Recognizable neonatal clinical features of aplasia cutis congenita

BackgroundAplasia cutis congenita (ACC), classified in nine groups, is likely to be underreported, since milder isolated lesions in wellbeing newborns could often be undetected, and solitary lesions in the context of polymalformative syndromes could not always be reported. Regardless of form and cause, therapeutic options have in common the aim to restore the deficient mechanical and immunological cutaneous protection and to limit the risk of fluid leakage or rupture of the exposed organs. We aimed to review our institutional prevalence, comorbidities, treatment and outcome of newborns with ACC.MethodsWe conducted a retrospective study including all newborns affected by ACC and admitted at the University Mother-Child Department from October 2010 to October 2019. Anthropometric and clinical characteristics of ACC1 versus a non-isolated ACC group were analyzed.ResultsWe encountered 37 newborns, 16 with ACC1 versus 21 with non-isolated ACC. The incidence rate of 0.1% in ACC1 was higher than expected, while 19% of cases showed intrafamilial autosomal dominant transmission. Higher birth weight centile, though lower than reference population, being adequate for gestational age, normal Apgar score and euglycemia characterizing ACC1 resulted associated to a rapid tissue regeneration. Non-isolated ACC, in relation to concomitant congenital anomalies and higher prematurity rate, showed more surgical and medical complications along with the risk of neonatal death. Specifically, newborns with ACC4 were characterized by the frequent necessity of abdominal wall defect repair, responsible for the occurrence of an abdominal compartment syndrome.ConclusionPrompt carefully assessment of the newborn with ACC in order to exclude concomitant other congenital malformations, provides clues to the underlying pathophysiology, and to the short-term prognosis. Family should be oriented toward identification of other family members affected by similar pathology, while obstetric history should exclude initial multiple pregnancy with death of a co-twin, placental anomalies and drug assumption. Molecular-genetic diagnosis and genetic counseling are integrative in individualized disease approach.

Low Apgar score in term newborns and long-term infectious morbidity: a population-based cohort study with up to 18years of follow-up.

Since introduced, the Apgar score has remained the most widespread predictor for neonatal morbidity and mortality. We aimed to investigate the association between low 5-min Apgar score and long-term infectious pediatric morbidity. A population-based cohort analysis was performed comparing total and specific subtypes of infectious morbidity leading to hospitalization among term newborns with normal (≥ 7) and low (< 7) 5-min Apgar scores, born between 1999 and 2014 at a single tertiary regional hospital. Infectious morbidity included hospitalizations involving a pre-defined set of infection-related ICD-9 codes. A Kaplan-Meier survival curve was constructed to compare cumulative infectious morbidity incidence and a Cox proportional hazards model to adjust for confounders. The long-term analysis of 223,335 children (excluding perinatal death cases) yielded 585 (0.3%) infants with low 5-min Apgar scores. The rate of infection-related hospitalizations was 9.8% and 12.4% among newborns with normal and low 5-min Apgar scores, respectively (p = 0.06). Adjusting for maternal age, gestational age, hypertension, diabetes, cesarean delivery, and fertility treatments, the association proved to be statistically significant (adjusted HR = 1.28; 95% CI 1.01-1.61).Conclusion: Term infants with low 5-min Apgar scores may be at an increased risk for long-term pediatric infectious morbidity.What is Known:• Though not meant to be a prognostic tool for long-term morbidity, studies assessing the correlation between low Apgar score and long-term outcomes were and are being performed, reporting significant associations with many outcomes-such as cerebral palsy (CP), ophthalmic disorders, GI disorders, and several types of malignancies.• Yet, an association between low Apgar scores and future health remains a matter of controversy.What is New:• Our work shows that a low 5-min Apgar score is independently associated with long-term pediatric infection-related hospitalizations among term singleton newborns.

Incidence and outcome of vaginal birth after cesarean among women receiving counseling at El Manial University Hospital

Background Repeated cesarean section (CS) is the most significant factor contributing to overall increased CS rates. The primary indicator of repeated CS is a prior CS. Vaginal birth after cesarean (VBAC) is a trial to reduce CS rates. Aim The aim of study was to examine the effect of counseling on the incidence, maternal, and neonatal outcomes of VBAC. Design A quasi-experimental one-group posttest-only design was adopted for this study. Setting The study was conducted at the Outpatient Clinic and Casualty Department at Manial University Hospital affiliated to Cairo University. Sample A purposive sample of pregnant women was recruited through a period of 6 months from July to December 2019 based on certain criteria; the most important one is to have a previous CS. Tool A structured interviewing tool, labor progress record (Partograph), and neonatal Apgar score were used to collect the data. Results A total of 90 participants were enrolled into study. A total of 79 (87.8%) women agreed to have VBAC after counseling compared with only 11 (12.2%), who refused to have VBAC and chose CS. The trial of labor after cesarean (TOLAC) rate was 40.5%. The rate of VBAC was 31.6%. Success rate of TOLAC was 78.1%, whereas failed TOLAC was 21.9% owing to lack of labor progress and fetal distress. Overall, 68.4% had CSs lower segment cesarean section (LSCS). Among them, 37% had elective LSCS and 63% had emergency LSCS. Physician decision without any medical indication for CS was the most common indications of elective repeat CS, with a rate of 85%. Oligohydramnios was the most common cause for emergency CS delivery, with a rate of 44.5%. All women who delivered VBAC had normal progress of labor and their babies had normal Apgar score (8–10). No cases that underwent VBAC had any morbidity or mortality. Conclusion Counseling is needed for the selection of VBAC as a mode of delivery. Successful VBAC is associated with better fetomaternal and neonatal outcomes, so most women with one previous cesarean delivery with a low-transverse incision should be counseled and encouraged to undergo a trial of labor in her recurrent pregnancy. Recommendations A qualitative research study should be conducted to assess the satisfaction of women from VBAC and compare it with CS.

Uterine Torsion Diagnosed at the Time of Laparotomy for a Planned Cesarean Section at Term

Background: Uterine torsion is defined as the rotation of the uterus more than 45 degrees around its long axis. The angle of rotation is usually 180 degrees, although, in the literature, there are reported cases of uterine torsion up to 720 degrees. This is a rare complication of pregnancy but associated with significant mortality and morbidity. Etiology still remains unclear and clinical diagnosis may be challenging. Symptoms can be absent or few and nonspecific as in chronic conditions or catastrophic such in case of acute presentation associated with acute abdomen. Final diagnosis is usually made at the time of laparotomy or even after delivery. In the literature, bilateral plication of round ligaments is proposed to prevent recurrences. However, there are no validated guidelines for the management of uterine torsion in pregnancy. Case: We present a 33-year-old, gravida 2 para 1. She had a previous vaginal delivery and no medical known conditions. She was admitted for a planned caesarian section at 39 weeks of gestation for breech presentation. After a difficult delivery of a healthy female neonate with normal Apgar scores and cord pH levels, a spontaneous derotation of the uterus of 180 degrees was observed. Giving the absence of pelvic anomalies, we chose to not perform any additional preventive surgical procedure. The patient was discharged on 3rd postoperative day. Finally, no complications were observed at the two-months postpartum visit. Conclusion: Uterine torsion in pregnancy is an uncommon pathology but potentially life threatening that obstetrician should be aware of. Occasionally, imaging can be helpful, but diagnosis is mostly made during surgery. In case of irreducible torsion, delivery can be made with a transverse incision in the lower posterior uterine segment. Bilateral plication of round ligaments, as previously described by other authors, may be evaluated as a taylored treatment in case of extreme uterine torsion and other pelvic anomalies, in order to prevent the recurrence of the torsion.

599: Isolated neonatal acidemia: What is the long-term outcome?

Fetal acidemia has been associated with Hypoxic Ischemic Encephalopathy (HIE) and delayed development (DD). Criteria for pathologic acidemia have been primarily derived through consensus with little evidence to support routine measurement of cord gases at birth. Further, the appropriate management for full or near-term newborns who are clinically stable with normal APGAR scores but cord gas evidence of acidemia (pH< 7.10, base deficit (BD)< -11.0) is not known. We sought to determine whether isolated fetal acidemia is associated with DD milestones. We hypothesize that these neonates have a similar incidence of DD when compared to non-acidemic neonates. Retrospective case control study of newborns with acidemia (pH< 7.10, BD< -11.0), born 2015-2019, at ≥36 weeks gestational age (GA) at a tertiary referral center with universal cord gas collection. Cases were paired with controls matched by date of birth, birth weight, GA, and NICU or nursery admission. The primary outcome was DD milestones as defined by diagnosed speech/motor delay by a specialist up to 24 months after birth. 148 neonates were matched with controls of whom 46% were female, 38% non-Hispanic Caucasian, full or near term (39 ± 1.4w), and of normal weight (3270±560g). 80 were admitted to the newborn nursery. Eleven cases had DD. There was no significant difference in incidence of DD milestones between the acidemic and control groups (p=0.58 for nursery admission, p=0.69 for NICU admission). Neonates with DD did not have any significant difference in arterial or venous pH or BD (p≥0.16), however the 5 min Apgar scores were significantly lower for DD babies in both acidemic (7.3 vs 8.3) and control (7.7 vs 8.7) groups (p≤0.01). Category II/III Fetal Heart Tracings were significantly associated with incidence of acidemia (p≤0.01) but not DD (p≥0.33). Isolated fetal acidemia with a 5 min Apgar ≥7 is not associated with short term delayed developmental milestones. Future studies should include a prospective analysis of acidemic babies with later assessment of developmental data.

Guillain-Barre Syndrome following Cushing's Syndrome in a Pregnant Woman: A Case Report

Guillain-Barre syndrome is a neurological disorder that begins with weakness of the limbs and can cause respiratory and cardiac involvement. The subject of this report is a 30-year-old woman who was diagnosed with Cushing’s syndrome following recurrent bone fractures and receiving treatment for the Cushing’s syndrome. The patient was referred to a hospital during pregnancy because of generalized pain and weakness in the extremities. Abdominal ultrasound showed a mass in the left adrenal gland and so surgery was performed to remove the mass. However, the patient's symptoms did not improve after surgery. The patient was asked to consult a neurologist who made a diagnosis of Guillain-Barre syndrome after cerebrospinal fluid was examined. Patient was discharged with personal consent. Four months later, the baby was born with a normal Apgar score, and the general condition of mother and child were evaluated as good. This case demonstrates a rare coincidence of Cushing's disease and Guillain-Barre syndrome. Due to the increase in corticosteroids due to Cushing's syndrome, it is expected that symptoms of Guillain-Barre syndrome would not occur. This case could indicate that there are several mechanisms for development of Guillain-Barre syndrome and that animal models can be helpful in this context.

CCRN Across the Life Span.

CCRN Across the Life Span.

Maternal and perinatal outcomes in external cephalic version: prognostic factors for the success of the technique.

Background We aimed to analyze the success rate of external cephalic version (ECV) for breech presentations performed in our center between March 2011 and March 2016. We evaluated factors related to a successful ECV, delivery mode, complications and newborn status after ECV. Methods Analysis of assembled data of 327 consecutive ECVs in the third trimester was done. Results The total success rate was 56.6%. After a successful ECV, 85.9% of the fetuses were delivered vaginally. Logistic regression analysis of background factors leading to a successful ECV showed that tocolysis with ritodrine and anterior placenta were each significantly correlated with the rate of successful version. No severe complications were registered during the ECVs, and all babies had normal Apgar scores at delivery. Conclusion These findings suggest that attempting an ECV in breech presentations, once or even twice, seems to be an appropriate management given that a successful ECV decreases the rate of cesarean section in this group of patients and by doing so, it might also decrease the risk of cesarean sections in future pregnancies.

Seizures in newborn infants without hypoxic ischemic encephalopathy – antenatal and labor-related risk factors: a case-control study

Objective: To identify antepartum and intrapartum risk factors for neonatal seizures in the absence of hypoxic ischemic encephalopathy (HIE).Methods: Population-based case-control study. Of 98 484 births, 40 newborns at 34 gestational weeks or later had seizures within the first 7 days of life. Cases (n = 40) and controls (n = 160) were retrieved from the University hospitals of Örebro for 1994–2013 and Uppsala for 2003–2013. Demographics and characteristics of pregnancy, labor, delivery, and neonatal data were analyzed. Crude odds ratio (OR) and adjusted odds ratios (AOR) with 95% confidence intervals (CIs) for antenatal and intrapartum factors were calculated using logistic regression analysis. Main outcome measure was neonatal seizures within the first 7 days of life.Results: The incidence of neonatal seizures without HIE was 0.41/1000 live births. Antenatal risk factors for neonatal seizures were as follows: short maternal stature (AOR: 5.4; 1.8–16.5); previous caesarean section (AOR: 4.8; 1.5–15.0); and assisted fertilization (AOR: 6.8; 1.3–35.2). Intrapartum risk factors were as follows: induction of labor (AOR: 5.7; 1.8–17.7); preterm birth (AOR: 13.5; 3.7–48.9); and head circumference >37 cm (AOR: 6.9; 1.4–34.8).Conclusions: Preterm birth was the strongest risk factor for neonatal seizures in the absence of HIE. The results also indicate that feto-pelvic disproportion is associated with the occurrence of seizures.Rationale: Antepartum and intrapartum risk factors for newborn seizures in the absence of HIE were investigated in a case-control study. Out of 98 484 births at 34 gestational weeks or more, 40 newborns had seizures without HIE. All had a normal Apgar score although they later presented with seizures. Preterm birth was the strongest risk factor (OR: 13.5; 95% CI: 3.7–48.9). Our results also indicate that feto-pelvic disproportion is of importance. Furthermore, a history of prior caesarean was associated with seizures. This is the first study to assess obstetric risk factors for newborn seizures separate from those with seizures and concomitant HIE. The distinction is of importance due to different etiologies, treatments, and preventive strategies.

Case 2: Coexisting Cystic Lesions of Lung in a Term Neonate: A Management Dilemma

A term, 38-week-gestation, small-for–gestational age female infant weighing 2,135 g is delivered vaginally by a primigravida woman with an antenatal history of deranged Doppler flows. Resuscitation is not required at birth because the infant has normal Apgar scores of 7 and 9 at 1 and 5 minutes, respectively. Prenatal ultrasonography reports the presence of congenital pulmonary airway malformation (CPAM) on the left side, which regressed after steroid treatment in the third trimester. Delivery room postnatal examination suggests that the heart sounds are prominent on the right side of the precordium with the infant maintaining target oxygen saturation on room air with no signs of respiratory distress. She is admitted to the NICU for observation and further evaluation of mediastinal shift. In the NICU, chest radiography reveals hyperinflated left lung with shifting of mediastinum to the right side (Fig 1). Computed tomographic (CT) imaging reveals left lower lobe CPAM with a posterior mediastinal cyst compressing the left main bronchus (Fig 2). Echocardiography and ultrasonography of the abdomen and cranium are performed to rule out other associated congenital anomalies, and are found to be normal. At 20 hours after delivery, she develops mild respiratory distress but does not require any respiratory support. Forty-eight hours after admission, the infant undergoes bronchoscopy to locate the site of airway obstruction, which reveals the presence of a bluish mass compressing the left main bronchus (Fig 3). This leads us to suspect a hemangioma or vascular malformation compressing the bronchus. However, CT pulmonary angiography rules out the presence of any such vascular malformation. The possibilities are thus narrowed down to …

Leptospirosis in Pregnancy: A Rare Condition Mimicking HELLP Syndrome

We report a case of leptospirosis in pregnancy. A 37-year-old woman of para 1, normal vaginal delivery (NVD) presented at 33 weeks with 3 days of jaundice and diarrhea and no history of fever, abdominal pain, itch or pale stools. Her pregnancy was uneventful except for gestational diabetes. On examination she had jaundice otherwise unremarkable. Investigations revealed proteinuria, hemolysis, low platelets, raised transaminases and bilirubin. Working diagnosis was of atypical hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome owing to absence of hypertension. She progressed into labour 1 day later after preterm premature rupture of membranes (PPROM), had thick meconium and pathological cardiotocography (CTG). She delivered a baby weighing 1,736 g and normal Apgar scores. Arterial cord pH was 7.275, lactate 3.04, base excess of -8.8 and venous pH was 7.316, lactate 2.93, BE -10.6. Leptospirosis EIA IgM antibody was positive and placenta histology showed focus increased perivillous fibrinoid deposits with acute intervillositis and meconium staining. Baby showed no signs of congenital leptospirosis and was discharged on day 15 of life. Patient’s symptoms resolved within 2 weeks and her biochemistry normalized within 1 month. Owning to unusual presentation and rarity, leptospirosis in pregnancy is often misdiagnosed and underreported. It mimics HELLP syndrome, viral hepatitis, obstetric cholestasis and acute fatty liver of pregnancy. It has severe implications of early miscarriages, stillbirths and neonatal leptospirosis requiring high index of suspicion, need for increased awareness, early diagnosis and treatment. J Med Cases. 2018;9(7):198-200 doi: https://doi.org/10.14740/jmc3073w

Associations Between State-Level Policies Regarding Alcohol Use Among Pregnant Women, Adverse Birth Outcomes, and Prenatal Care Utilization: Results from 1972 to 2013 Vital Statistics.

Policies regarding alcohol use during pregnancy continue to be enacted and debated in the United States. However, no study to date has examined whether these policies are related to birth outcomes-the outcomes they ultimately aim to improve. Here, we assessed whether state-level policies targeting alcohol use during pregnancy are related to birth outcomes, which has not been done comprehensively before. The study involved secondary analyses of birth certificate data from 148,048,208 U.S. singleton births between 1972 and 2013. Exposures were indicators of whether the following 8 policies were in effect during gestation: Mandatory Warning Signs (MWS), Priority Treatment for Pregnant Women, Priority Treatment for Pregnant Women/Women with Children, Reporting Requirements for Data and Treatment Purposes, Prohibitions Against Criminal Prosecution, Civil Commitment, Reporting Requirements for Child Protective Services Purposes, and Child Abuse/Child Neglect. Outcomes were low birthweight (<2,500g), premature birth (<37weeks), any prenatal care utilization (PCU), late PCU, inadequate PCU, and normal (≥7) APGAR score. Multivariable fixed-effect logistic regressions controlling for both maternal- and state-level covariates were used for statistical analyses. Of the 8 policies, 6 were significantly related to worse outcomes and 2 were not significantly related to any outcomes. The policy requiring MWS was related to the most outcomes: specifically, living in a state with MWS was related to 7% higher odds of low birthweight (p<0.001); 4% higher odds of premature birth (p<0.004); 18% lower odds of any PCU (p<0.001); 12% higher odds of late PCU (p<0.002); and 10% lower odds of a normal APGAR score (p<0.001) compared to living in a state without MWS. Most policies targeting alcohol use during pregnancy do not have their intended effects and are related to worse birth outcomes and less PCU.

Estimated glomerular filtration rate in apparently healthy term neonates in Nigeria

Background: Glomerular filtration rate (GFR) is the best measure of renal function. However, the ideal exogenous markers are not routinely used to estimate GFR in clinical settings. Outside Africa, GFR estimates for neonates have been calculated from formulae using creatinine as well as cystatin C. There is a paucity of data on estimated GFR in neonates in Africa. This study was conducted to estimate GFR in healthy term African neonates using cystatin C-based equations. Methods: One hundred and thirteen apparently healthy term babies with normal Apgar scores were recruited at birth. Cystatin C was measured in cord blood at birth and in venous samples from neonates on the third day of life. GFR was estimated using the Filler and Lepage as well as the Zappitelli et al. cystatin C-based equations. These estimates were compared with a reference GFR estimate of 41 ± 15 mL/min/1.73 m 2 . Results: The median (interquartile range) estimated GFR values based on cord blood and day 3 venous samples using the Filler and Lepage equation were 44.67 (36.35–72.44) and 51.29 (38.90–72.44) mL/min/1.73 m 2 , respectively. When the Zappitelli equation was applied, the estimates were 38.18 (31.84–61.34) and 43.82 (33.75–61.34) mL/min/1.73 m 2 , respectively. The GFR estimates derived from both equations did not differ in respect of the gestational age, sex and postnatal ages of the babies. Conclusions: GFR estimates using the Zappitelli equation had values that were closely related to reference GFR measures for neonates whereas the GFR estimates using the Filler and Lepage equation had higher values.

Leptospirosis in Pregnancy: A Rare Condition Mimicking HELLP Syndrome

We report a case of leptospirosis in pregnancy. A 37-year-old woman of para 1, normal vaginal delivery (NVD) presented at 33 weeks with 3 days of jaundice and diarrhea and no history of fever, abdominal pain, itch or pale stools. Her pregnancy was uneventful except for gestational diabetes. On examination she had jaundice otherwise unremarkable. Investigations revealed proteinuria, hemolysis, low platelets, raised transaminases and bilirubin. Working diagnosis was of atypical hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome owing to absence of hypertension. She progressed into labour 1 day later after preterm premature rupture of membranes (PPROM), had thick meconium and pathological cardiotocography (CTG). She delivered a baby weighing 1,736 g and normal Apgar scores. Arterial cord pH was 7.275, lactate 3.04, base excess of -8.8 and venous pH was 7.316, lactate 2.93, BE -10.6. Leptospirosis EIA IgM antibody was positive and placenta histology showed focus increased perivillous fibrinoid deposits with acute intervillositis and meconium staining. Baby showed no signs of congenital leptospirosis and was discharged on day 15 of life. Patient’s symptoms resolved within 2 weeks and her biochemistry normalized within 1 month. Owning to unusual presentation and rarity, leptospirosis in pregnancy is often misdiagnosed and underreported. It mimics HELLP syndrome, viral hepatitis, obstetric cholestasis and acute fatty liver of pregnancy. It has severe implications of early miscarriages, stillbirths and neonatal leptospirosis requiring high index of suspicion, need for increased awareness, early diagnosis and treatment. J Med Cases. 2018;9(7):198-200 doi: https://doi.org/10.14740/jmc3073w

Low Apgar scores in term newborns and long-term gastro-intestinal morbidity: a population-based cohort study with up to 18 years of follow-up

Introduction: Low Apgar scores (<7) measured at age 5 minutes can predict short-term infant morbidity and mortality. Although an association exists between low Apgar scores and neuropsychological disorders, other childhood disorders were not thoroughly studied. We aimed to study the possible association between low 5-minute Apgar scores in term newborns and their long-term childhood gastrointestinal (GI) morbidity.Methods: A population-based cohort analysis was performed comparing total and different subtypes of GI-related pediatric hospitalizations among newborns with normal (≥7) and low (<7) 5-minute Apgar scores. The analysis included all term singletons born between the years 1999 and 2014 at a single tertiary regional medical center. Infants with congenital malformations, multiple gestations, and all perinatal deaths were excluded from the analysis. GI-related morbidities included hospitalizations involving a predefined set of ICD-9 codes, as recorded in the hospital computerized files. A Kaplan–Meier survival curve was constructed to compare the cumulative GI morbidity, and a Cox proportional hazards model was used to adjust for confounders.Results: The study population, including 223 244 term singletons, was followed for an average of 10.02 ± 6.0 years (0–18 years, median 10.25) following discharge from birth hospitalization. Low 5-minute Apgar scores were recorded in 585 (0.3%) newborns. Incidence of GI-related hospitalizations was higher among the low versus the normal 5-minute Apgar score group (7.4 versus 5.2%; 8.6/1000 person years (PY) versus 5.2/1000 PY, respectively; p = .02; odds ratio =1.66, 95%CI 1.36–1.96). The association remained significant and independent while adjusting for gestational age, fetal weight, offspring gender, maternal age, maternal smoking, hypertension, and diabetes (Adjusted HR =1.57, 95%CI 1.16–2.12, p = .003).Conclusions: Low 5 minutes Apgar score is associated with an increased risk for long-term pediatric GI morbidity of the offspring. Our results suggest that Apgar scores can be used as a possible predictor for long-term pediatric morbidities and thus may necessitate appropriate surveillance in this vulnerable group of children.