Cyclopia with shoulder dystocia leading to an obstetric catastrophe: a case report

<p>Abstract</p> <p>Introduction</p> <p>Cyclopia is a rare fetal malformation characterized by a single palpebral fissure and a proboscis associated with severe brain malformations. Approximately 1.05 in 100,000 births including stillbirths are identified as cyclopean. The prevalence is about one in 11,000 to 20,000 in live births and one in 250 during embryogenesis.</p> <p>Case presentation</p> <p>A 30-year-old Indian woman of Asian origin, sixth gravida, was referred to the labor room of our hospital. There were no ultrasound examinations performed during this pregnancy as our patient had not received regular antenatal care. We found out that the head of her baby was already outside the vulva but the remaining parts of the baby were not yet delivered. Further examination was carried out and a diagnosis of shoulder dystocia with intrauterine fetal demise was made. A stillborn baby boy of 3.5 kg was delivered using McRoberts' maneuver. The baby was suspected of having features of cyclopia and this was later confirmed by autopsy and anatomic correlation. The mother had a cervical tear which extended into the lower segment of her uterus, thus leading to the rupture of her uterus. There was a massive broad ligament hematoma on the left side of her uterus. A total abdominal hysterectomy was carried out.</p> <p>Conclusion</p> <p>Prenatal diagnosis by ultrasound examination might help in detecting cyclopia and preventing complications associated with this condition. However, in developing countries where women do not receive regular antenatal care and do not undergo prenatal diagnosis, such cases will go undetected. In our case report, the occurrence of shoulder dystocia could be coincidental, as no risk factors were previously noted.</p

Antenatal dexamethasone for early preterm birth in low-resource countries

BACKGROUND: The safety and efficacy of antenatal glucocorticoids in women in low-resource countries who are at risk for preterm birth are uncertain. METHODS: We conducted a multicountry, randomized trial involving pregnant women between 26 weeks 0 days and 33 weeks 6 days of gestation who were at risk for preterm birth. The participants were assigned to intramuscular dexamethasone or identical placebo. The primary outcomes were neonatal death alone, stillbirth or neonatal death, and possible maternal bacterial infection; neonatal death alone and stillbirth or neonatal death were evaluated with superiority analyses, and possible maternal bacterial infection was evaluated with a noninferiority analysis with the use of a prespecified margin of 1.25 on the relative scale. RESULTS: A total of 2852 women (and their 3070 fetuses) from 29 secondary- and tertiary-level hospitals across Bangladesh, India, Kenya, Nigeria, and Pakistan underwent randomization. The trial was stopped for benefit at the second interim analysis. Neonatal death occurred in 278 of 1417 infants (19.6%) in the dexamethasone group and in 331 of 1406 infants (23.5%) in the placebo group (relative risk, 0.84; 95% confidence interval [CI], 0.72 to 0.97; P=0.03). Stillbirth or neonatal death occurred in 393 of 1532 fetuses and infants (25.7%) and in 444 of 1519 fetuses and infants (29.2%), respectively (relative risk, 0.88; 95% CI, 0.78 to 0.99; P=0.04); the incidence of possible maternal bacterial infection was 4.8% and 6.3%, respectively (relative risk, 0.76; 95% CI, 0.56 to 1.03). There was no significant between-group difference in the incidence of adverse events. CONCLUSIONS: Among women in low-resource countries who were at risk for early preterm birth, the use of dexamethasone resulted in significantly lower risks of neonatal death alone and stillbirth or neonatal death than the use of placebo, without an increase in the incidence of possible maternal bacterial infection.Fil: Oladapo, Olufemi T.. Organizacion Mundial de la Salud; ArgentinaFil: Vogel, Joshua P.. Organizacion Mundial de la Salud; ArgentinaFil: Piaggio, Gilda. Organizacion Mundial de la Salud; ArgentinaFil: Nguyen, My-Huong. Organizacion Mundial de la Salud; ArgentinaFil: Althabe, Fernando. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Metin Gülmezoglu, A.. Organizacion Mundial de la Salud; ArgentinaFil: Bahl, Rajiv. Organizacion Mundial de la Salud; ArgentinaFil: Rao, Suman P.N.. Organizacion Mundial de la Salud; ArgentinaFil: de Costa, Ayesha. Organizacion Mundial de la Salud; ArgentinaFil: Gupta, Shuchita. Organizacion Mundial de la Salud; ArgentinaFil: Shahidullah, Mohammod. No especifíca;Fil: Chowdhury, Saleha B.. No especifíca;Fil: Ara, Gulshan. No especifíca;Fil: Akter, Shaheen. No especifíca;Fil: Akhter, Nasreen. No especifíca;Fil: Dey, Probhat R.. No especifíca;Fil: Abdus Sabur, M.. No especifíca;Fil: Azad, Mohammad T.. No especifíca;Fil: Choudhury, Shahana F.. No especifíca;Fil: Matin, M.A.. No especifíca;Fil: Goudar, Shivaprasad S.. No especifíca;Fil: Dhaded, Sangappa M.. No especifíca;Fil: Metgud, Mrityunjay C.. No especifíca;Fil: Pujar, Yeshita V.. No especifíca;Fil: Somannavar, Manjunath S.. No especifíca;Fil: Vernekar, Sunil S.. No especifíca;Fil: Herekar, Veena R.. No especifíca;Fil: Bidri, Shailaja R.. No especifíca;Fil: Mathapati, Sangamesh S.. No especifíca;Fil: Patil, Preeti G.. No especifíca;Fil: Patil, Mallanagouda M.. No especifíca;Fil: Gudadinni, Muttappa R.. No especifíca;Fil: Bijapure, Hidaytullah R.. No especifíca;Fil: Mallapur, Ashalata A.. No especifíca;Fil: Katageri, Geetanjali M.. No especifíca;Fil: Chikkamath, Sumangala B.. No especifíca;Fil: Yelamali, Bhuvaneshwari C.. No especifíca;Fil: Pol, Ramesh R.. No especifíca;Fil: Misra, Sujata S.. No especifíca;Fil: Das, Leena. No especifíca

Aspirin delays the onset of hypertensive disorders of pregnancy among nulliparous pregnant women: A secondary analysis of the ASPIRIN trial

Objective: To assess the impact of low-dose aspirin (LDA) starting in early pregnancy on delaying preterm hypertensive disorders of pregnancy.Design: Non-prespecified secondary analysis of a randomised masked trial of LDA.Setting: The study was conducted among women in the Global Network for Women\u27s and Children\u27s Health\u27s Maternal and Newborn Health Registry (MNHR) clusters, a prospective, population-based study in Kenya, Zambia, the Democratic Republic of the Congo (DRC), Pakistan, India (two sites-Belagavi and Nagpur) and Guatemala.Population: Nulliparous singleton pregnancies between 6+0 weeks and 13+6 weeks in six low-middle income countries (Democratic Republic of Congo, Guatemala, India, Kenya, Pakistan, Zambia) enrolled in the ASPIRIN Trial.Methods: We compared the incidence of HDP at delivery at three gestational age periods (\u3c28, \u3c34 and \u3c37 weeks) between women who were randomised to aspirin or placebo. Women were included if they were randomised and had an outcome at or beyond 20 weeks (Modified Intent to Treat).Main outcome measures: Our primary outcome was pregnancies with HDP associated with preterm delivery (HDP@delivery) before \u3c28, \u3c34 and \u3c37 weeks. Secondary outcomes included small for gestational age (SGA) \u3c10th percentile, \u3c5th percentile, and perinatal mortality.Results: Among the 11 976 pregnancies, LDA did not significantly lower HDP@delivery \u3c28 weeks (relative risk [RR] 0.18, 95% confidence interval [CI] 0.02-1.52); however, it did lower HDP@delivery \u3c34 weeks (RR 0.37, 95% CI 0.17-0.81) and HDP@delivery \u3c37 weeks (RR 0.66, 95% CI 0.49-0.90). The overall rate of HDP did not differ between the two groups (RR 1.08, 95% CI 0.94-1.25). Among those pregnancies who had HDP, SGA \u3c10th percentile was reduced (RR 0.81, 95% CI 0.67-0.99), though SGA \u3c5th percentile was not (RR 0.84, 95% CI 0.64-1.09). Similarly, perinatal mortality among pregnancies with HDP occurred less frequently (RR 0.55, 95% CI 0.33-0.92) in those receiving LDA. Pregnancies randomised to LDA delivered later with HDP compared with those receiving placebo (median gestational age 38.5 weeks vs. 37.9 weeks; p = 0.022).Conclusions: In this secondary analysis of a study of low-risk nulliparous singleton pregnancies, early administration of LDA resulted in lower rates of preterm HDP and delivery before 34 and 37 weeks but not in the overall rate of HDP. These results suggest that LDA works in part by delaying HDP

A population-based, multifaceted strategy to implement antenatal corticosteroid treatment versus standard care for the reduction of neonatal mortality due to preterm birth in low-income and middle-income countries: The ACT cluster-randomised trial

Background Antenatal corticosteroids for pregnant women at risk of preterm birth are among the most effective hospital-based interventions to reduce neonatal mortality. We aimed to assess the feasibility, effectiveness, and safety of a multifaceted intervention designed to increase the use of antenatal corticosteroids at all levels of health care in low-income and middle-income countries. Methods In this 18-month, cluster-randomised trial, we randomly assigned (1:1) rural and semi-urban clusters within six countries (Argentina, Guatemala, India, Kenya, Pakistan, and Zambia) to standard care or a multifaceted intervention including components to improve identification of women at risk of preterm birth and to facilitate appropriate use of antenatal corticosteroids. The primary outcome was 28-day neonatal mortality among infants less than the 5th percentile for birthweight (a proxy for preterm birth) across the clusters. Use of antenatal corticosteroids and suspected maternal infection were additional main outcomes. This trial is registered with ClinicalTrials.gov, number NCT01084096. Findings The ACT trial took place between October, 2011, and March, 2014 (start dates varied by site). 51 intervention clusters with 47 394 livebirths (2520 [5%] less than 5th percentile for birthweight) and 50 control clusters with 50 743 livebirths (2258 [4%] less than 5th percentile) completed follow-up. 1052 (45%) of 2327 women in intervention clusters who delivered less-than-5th-percentile infants received antenatal corticosteroids, compared with 215 (10%) of 2062 in control clusters (p<0·0001). Among the less-than-5th-percentile infants, 28-day neonatal mortality was 225 per 1000 livebirths for the intervention group and 232 per 1000 livebirths for the control group (relative risk [RR] 0·96, 95% CI 0·87-1·06, p=0·65) and suspected maternal infection was reported in 236 (10%) of 2361 women in the intervention group and 133 (6%) of 2094 in the control group (odds ratio [OR] 1·67, 1·33-2·09, p<0·0001). Among the whole population, 28-day neonatal mortality was 27·4 per 1000 livebirths for the intervention group and 23·9 per 1000 livebirths for the control group (RR 1·12, 1·02-1·22, p=0·0127) and suspected maternal infection was reported in 1207 (3%) of 48 219 women in the intervention group and 867 (2%) of 51 523 in the control group (OR 1·45, 1·33-1·58, p<0·0001). Interpretation Despite increased use of antenatal corticosteroids in low-birthweight infants in the intervention groups, neonatal mortality did not decrease in this group, and increased in the population overall. For every 1000 women exposed to this strategy, an excess of 3·5 neonatal deaths occurred, and the risk of maternal infection seems to have been increased. Funding Eunice Kennedy Shriver National Institute of Child Health and Human Development.Fil: Althabe, Fernando. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Belizan, Jose. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: McClure, Elizabeth M.. Rti International;Fil: Hemingway Foday, Jennifer. Rti International;Fil: Berrueta, Amanda Mabel. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Mazzoni, Agustina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Ciganda, Alvaro. Unicem; Uruguay. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Goudar, Shivaprasad S.. Jawaharlal Nehru Medical College Belgaum; IndiaFil: Kodkany, Bhalachandra S.. Jawaharlal Nehru Medical College Belgaum; IndiaFil: Mahantshetti, Niranjana S.. Jawaharlal Nehru Medical College Belgaum; IndiaFil: Dhaded, Sangappa M.. Jawaharlal Nehru Medical College Belgaum; IndiaFil: Katageri, Geetanjali M.. S. Nijalingappa Medical College; IndiaFil: Metgud, Mrityunjay C.. Jawaharlal Nehru Medical College Belgaum; IndiaFil: Joshi, Anjali M.. Jawaharlal Nehru Medical College Belgaum; IndiaFil: Bellad, Mrutyunjaya B.. Jawaharlal Nehru Medical College Belgaum; IndiaFil: Honnungar, Narayan V.. Jawaharlal Nehru Medical College Belgaum; IndiaFil: Derman, Richard J.. Christiana Health Care Services; Estados UnidosFil: Saleem, Sarah. The Aga Khan University; PakistánFil: Pasha, Omrana. The Aga Khan University; PakistánFil: Ali, Sumera. The Aga Khan University; PakistánFil: Hasnain, Farid. The Aga Khan University; PakistánFil: Goldenberg, Robert L. Columbia University; Estados UnidosFil: Esamai, Fabian. Moi University; KeniaFil: Nyongesa, Paul. Moi University; KeniaFil: Ayunga, Silas. University of Alabama at Birmingahm; Estados UnidosFil: Liechty, Edward A. Indiana University; Estados UnidosFil: Garces, Ana L. Francisco Marroquin University; Guatemala. Fundacion Para la Alimentacion y Nutricion de Centro America y Panama; GuatemalaFil: Figueroa, Lester. Fundacion Para la Alimentacion y Nutricion de Centro America y Panama; GuatemalaFil: Hambidge, K Michael. State University of Colorado - Fort Collins; Estados UnidosFil: Krebs, Nancy F. State University of Colorado - Fort Collins; Estados UnidosFil: Patel, Archana. Government Medical College Nagpur; India. Lata Medical Research Foundation; IndiaFil: Bhandarkar, Anjali. Lata Medical Research Foundation; IndiaFil: Waikar, Manjushri. Lata Medical Research Foundation; IndiaFil: Hibberd, Patricia L. Massachusetts General Hospital; Estados UnidosFil: Chomba, Elwyn. University Teaching Hospital Lusaka; ZambiaFil: Carlo, Waldemar A. University of Alabama at Birmingahm; Estados UnidosFil: Mwiche, Angel. University Teaching Hospital Lusaka; ZambiaFil: Chiwila, Melody. Centre For Infectious Disease Research; ZambiaFil: Manasyan, Albert. University of Alabama at Birmingahm; Estados UnidosFil: Pineda, Sayury. Fundacion Para la Alimentacion y Nutricion de Centro America y Panama; GuatemalaFil: Meleth, Sreelatha. Rti International; Estados UnidosFil: Thorsten, Vanessa. Rti International; Estados UnidosFil: Stolka, Kristen. Rti International; Estados UnidosFil: Wallace, Dennis D. Rti International; Estados UnidosFil: Koso-Thomas, Marion. National Instituto Of Child Health & Human Developm.; Estados UnidosFil: Jobe, Alan H. Cincinnati Children's Hospital Medical Center; Estados UnidosFil: Buekens, Pierre M. Tulane University School Of Public Health And Tropical Medicine; Estados Unido