External validation of prognostic models to predict stillbirth using the International Prediction of Pregnancy Complications (IPPIC) Network database: an individual participant data meta-analysis

Objective Stillbirth is a potentially preventable complication of pregnancy. Identifying women at high risk of stillbirth can guide decisions on the need for closer surveillance and timing of delivery in order to prevent fetal death. Prognostic models have been developed to predict the risk of stillbirth, but none has yet been validated externally. In this study, we externally validated published prediction models for stillbirth using individual participant data (IPD) meta-analysis to assess their predictive performance. Methods MEDLINE, EMBASE, DH-DATA and AMED databases were searched from inception to December 2020 to identify studies reporting stillbirth prediction models. Studies that developed or updated prediction models for stillbirth for use at any time during pregnancy were included. IPD from cohorts within the International Prediction of Pregnancy Complications (IPPIC) Network were used to validate externally the identified prediction models whose individual variables were available in the IPD. The risk of bias of the models and cohorts was assessed using the Prediction study Risk Of Bias ASsessment Tool (PROBAST). The discriminative performance of the models was evaluated using the C-statistic, and calibration was assessed using calibration plots, calibration slope and calibration-in-the-large. Performance measures were estimated separately in each cohort, as well as summarized across cohorts using random-effects meta-analysis. Clinical utility was assessed using net benefit. Results Seventeen studies reporting the development of 40 prognostic models for stillbirth were identified. None of the models had been previously validated externally, and the full model equation was reported for only one-fifth (20%, 8/40) of the models. External validation was possible for three of these models, using IPD from 19 cohorts (491 201 pregnant women) within the IPPIC Network database. Based on evaluation of the model development studies, all three models had an overall high risk of bias, according to PROBAST. In the IPD meta-analysis, the models had summary C-statistics ranging from 0.53 to 0.65 and summary calibration slopes ranging from 0.40 to 0.88, with risk predictions that were generally too extreme compared with the observed risks. The models had little to no clinical utility, as assessed by net benefit. However, there remained uncertainty in the performance of some models due to small available sample sizes. Conclusions The three validated stillbirth prediction models showed generally poor and uncertain predictive performance in new data, with limited evidence to support their clinical application. The findings suggest methodological shortcomings in their development, including overfitting. Further research is needed to further validate these and other models, identify stronger prognostic factors and develop more robust prediction models. (c) 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.Peer reviewe

Maternal nutrition and newborn health outcome

Early life nutrition is one of the most substantial environmental factors that shapes future health. This extends from the women’s nutritional status prior to conception and during pregnancy to the offspring’s nutritional conditions during infancy and early childhood. During this critical period, various body organs are undergone growth and development at incredible rates and programming of body systems take place. This thesis basically provides evidence on the associations between nutritional circumstances early in life, particularly during preconception and gestation period, with newborn health outcomes. We outlined this thesis into three parts. The first part (chapters 2, 3, 4, and 5) mainly focuses on in utero Ramadan exposure as nutritional determinants that may influence newborn health outcome. The second part (chapters 6 and 7) provides evidence about the effect of maternal nutrition status early in pregnancy on the development of pregnancy complications and newborn outcome. In the third part of this thesis (chapter 8), we described a protocol of a randomized trial on breastfeeding which is aimed to investigate the effect of breastfeeding on health outcomes during the first years of life. Part 1 begins with a description of various factors that predict women’s adherence to Ramadan fasting during pregnancy (Chapter 2). Although the health effects of Ramadan fasting during pregnancy are still unclear, it is important to identify various factors behind women’s adherence to Ramadan fasting. The results of our cross sectional study among Indonesian women showed that demographic factors such as age, income, education, or employment do not influence fasting adherence, but higher pre-pregnancy body mass index (BMI), earlier gestational age, opposition from husband and fear of adverse fasting effects on their own or the baby’s health do. These factors need to be addressed properly during counseling. In Chapter 3, we present the association between Ramadan exposure and fasting during pregnancy with newborn’s birth weight and the risk of gestational hypertension. In our Indonesian cohort of pregnant women, we found that birth weight was generally higher with Ramadan exposure as compared to without exposure. Analyses among women with Ramadan exposure revealed that although women who fasted had significantly lower nutrient intake in Ramadan, no different in the newborn’s birth weight nor in the risk of gestational hypertension was found. These findings suggest that a transient life style modification that occurs with Ramadan does not seem to affect pregnancy outcomes investigated. In Chapter 4, we show that among women of Moroccan and Turkish background living in The Netherlands, Ramadan fasting during the first trimester of pregnancy was associated with lower birth weight. No difference of birth weight was found if the fasting took place later in pregnancy. This suggests that the effect of Ramadan fasting on newborn’s birth weight may depend on the timing exposure. Furthermore, differences in finding as compared to the study in Indonesian women indicate that the effects may (partially) be influenced by culture or dietary habits as well as the length of fasting duration. Chapter 5 addresses the association between in-utero Ramadan exposure with various birth outcomes. We analyzed 1,987,124 newborns from 11 birth cohorts of the Perinatal Registry of the Netherlands (Perined), 139,322 of these were classified as Muslims. No clinically relevant effect of Ramadan exposure was found, including on birth weight, Apgar score, congenital anomalies, sex ratio, gestational duration and perinatal mortality. In Part 2, we focus on the effects of maternal nutrition status early in pregnancy on pregnancy outcomes. We present the associations between hyperemesis gravidarum, as a model of nutritional disturbance, on the development of placental dysfunction disorders in Chapter 6. Using the data from our prospective cohort study in Jakarta, Indonesia, we found that women who experienced severe hyperemesis had significantly lower birth weight newborns. Hyperemesis did not affect the development of placental dysfunction disorders (gestational hypertension, preeclampsia, stillbirth, and miscarriage), other newborn health measures (SGA, low birth weight, Apgar score, and gestation length), nor the placental dimension (placental weight and placental-weight-to-birth-weight ratio). In Chapter 7, we elaborate the effect of women’s prepregnancy body mass index (BMI) on their blood pressure during pregnancy. Using the data from our prospective cohort study in Jakarta, Indonesia, we showed that pre-pregnancy BMI determined women’s systolic and diastolic blood pressure level during pregnancy. Higher prepregnancy BMI was also associated with higher risk of gestational hypertension and preeclampsia. These associations imply that pre-pregnancy (cardiovascular) risk factors strongly influence women’s blood pressure. This finding also suggests the importance of prevention of pregnancy complications which should be done prior to pregnancy. Part 3 (Chapter 8), we described a study protocol of a randomized trial on breastfeeding optimization (BRAVO) that is on going in Jakarta, Indonesia. This study is aimed to provide evidence about the short and long term health effects of breastfeeding, mainly on the children’s cardiovascular and metabolic risks. Pregnant women with low intention to breastfeed are randomly allocated into either usual care or receiving an add-on breastfeeding optimization program which includes antenatal, perinatal, postnatal intervention, and special support for working mothers. Primary outcomes include breastfeeding rate, lung function, and blood pressure during the first year of life and vascular/cardiac characteristics which will be measured when the children are between 4 to 5 years old. So far, BRAVO has been successfully conducted with satisfactory completeness of follow up. Finally in Chapter 9 (general discussion), we discuss our findings in light of implementable intervention measures, both in the context of maternal and child health and in the prevention of later health consequences. Findings from the etiologic studies described in this thesis about maternal nutrition, including Ramadan (fasting) exposure in pregnancy, hyperemesis gravidarum, pre-pregnancy BMI, and breastfeeding, although may not directly translatable to practice, could provide indications for prevention and directions future research in this area

Maternal nutrition and newborn health outcome

Early life nutrition is one of the most substantial environmental factors that shapes future health. This extends from the women’s nutritional status prior to conception and during pregnancy to the offspring’s nutritional conditions during infancy and early childhood. During this critical period, various body organs are undergone growth and development at incredible rates and programming of body systems take place. This thesis basically provides evidence on the associations between nutritional circumstances early in life, particularly during preconception and gestation period, with newborn health outcomes. We outlined this thesis into three parts. The first part (chapters 2, 3, 4, and 5) mainly focuses on in utero Ramadan exposure as nutritional determinants that may influence newborn health outcome. The second part (chapters 6 and 7) provides evidence about the effect of maternal nutrition status early in pregnancy on the development of pregnancy complications and newborn outcome. In the third part of this thesis (chapter 8), we described a protocol of a randomized trial on breastfeeding which is aimed to investigate the effect of breastfeeding on health outcomes during the first years of life. Part 1 begins with a description of various factors that predict women’s adherence to Ramadan fasting during pregnancy (Chapter 2). Although the health effects of Ramadan fasting during pregnancy are still unclear, it is important to identify various factors behind women’s adherence to Ramadan fasting. The results of our cross sectional study among Indonesian women showed that demographic factors such as age, income, education, or employment do not influence fasting adherence, but higher pre-pregnancy body mass index (BMI), earlier gestational age, opposition from husband and fear of adverse fasting effects on their own or the baby’s health do. These factors need to be addressed properly during counseling. In Chapter 3, we present the association between Ramadan exposure and fasting during pregnancy with newborn’s birth weight and the risk of gestational hypertension. In our Indonesian cohort of pregnant women, we found that birth weight was generally higher with Ramadan exposure as compared to without exposure. Analyses among women with Ramadan exposure revealed that although women who fasted had significantly lower nutrient intake in Ramadan, no different in the newborn’s birth weight nor in the risk of gestational hypertension was found. These findings suggest that a transient life style modification that occurs with Ramadan does not seem to affect pregnancy outcomes investigated. In Chapter 4, we show that among women of Moroccan and Turkish background living in The Netherlands, Ramadan fasting during the first trimester of pregnancy was associated with lower birth weight. No difference of birth weight was found if the fasting took place later in pregnancy. This suggests that the effect of Ramadan fasting on newborn’s birth weight may depend on the timing exposure. Furthermore, differences in finding as compared to the study in Indonesian women indicate that the effects may (partially) be influenced by culture or dietary habits as well as the length of fasting duration. Chapter 5 addresses the association between in-utero Ramadan exposure with various birth outcomes. We analyzed 1,987,124 newborns from 11 birth cohorts of the Perinatal Registry of the Netherlands (Perined), 139,322 of these were classified as Muslims. No clinically relevant effect of Ramadan exposure was found, including on birth weight, Apgar score, congenital anomalies, sex ratio, gestational duration and perinatal mortality. In Part 2, we focus on the effects of maternal nutrition status early in pregnancy on pregnancy outcomes. We present the associations between hyperemesis gravidarum, as a model of nutritional disturbance, on the development of placental dysfunction disorders in Chapter 6. Using the data from our prospective cohort study in Jakarta, Indonesia, we found that women who experienced severe hyperemesis had significantly lower birth weight newborns. Hyperemesis did not affect the development of placental dysfunction disorders (gestational hypertension, preeclampsia, stillbirth, and miscarriage), other newborn health measures (SGA, low birth weight, Apgar score, and gestation length), nor the placental dimension (placental weight and placental-weight-to-birth-weight ratio). In Chapter 7, we elaborate the effect of women’s prepregnancy body mass index (BMI) on their blood pressure during pregnancy. Using the data from our prospective cohort study in Jakarta, Indonesia, we showed that pre-pregnancy BMI determined women’s systolic and diastolic blood pressure level during pregnancy. Higher prepregnancy BMI was also associated with higher risk of gestational hypertension and preeclampsia. These associations imply that pre-pregnancy (cardiovascular) risk factors strongly influence women’s blood pressure. This finding also suggests the importance of prevention of pregnancy complications which should be done prior to pregnancy. Part 3 (Chapter 8), we described a study protocol of a randomized trial on breastfeeding optimization (BRAVO) that is on going in Jakarta, Indonesia. This study is aimed to provide evidence about the short and long term health effects of breastfeeding, mainly on the children’s cardiovascular and metabolic risks. Pregnant women with low intention to breastfeed are randomly allocated into either usual care or receiving an add-on breastfeeding optimization program which includes antenatal, perinatal, postnatal intervention, and special support for working mothers. Primary outcomes include breastfeeding rate, lung function, and blood pressure during the first year of life and vascular/cardiac characteristics which will be measured when the children are between 4 to 5 years old. So far, BRAVO has been successfully conducted with satisfactory completeness of follow up. Finally in Chapter 9 (general discussion), we discuss our findings in light of implementable intervention measures, both in the context of maternal and child health and in the prevention of later health consequences. Findings from the etiologic studies described in this thesis about maternal nutrition, including Ramadan (fasting) exposure in pregnancy, hyperemesis gravidarum, pre-pregnancy BMI, and breastfeeding, although may not directly translatable to practice, could provide indications for prevention and directions future research in this area

ASUHAN KEPERAWATAN PADA KLIEN PRE DAN POST OPERASI APENDISITIS DENGAN DIAGNOSA KEPERAWATAN NYERI AKUT DI PAVILIUN MAWAR RSUD JOMBANG

Apendisitis merupakan suatu peradangan apendiks yang mengenai semua lapisan dinding organ tersebut. Faktor yang menyebabkan terjadinya apendisitis,di antaranya sumbatan lumen apendisitis, hyperplasia jaringan limfe, tumor appendisitis, erosi mukosa oleh cacing askaris dan E.Histolytica. Metodologi dalam penulisan karya tulis ilmiah ini menggunakan metode studi kasus dengan melakukan asuhan keperawatan pada dua klien dengan kasus apendisitis, dengan menggunakan pendekatan tahapan proses keperawatan. Pelaksanaan asuhan keperawatan pada kedua pasien 1 dilakukan 6 hari sedangkan pada pasien ke 2 dilakukan selama 4 hari, ditemukan masalah prioritas pada kedua pasien, pre operasi ditemukan masalah nyeri akut dan post operasi ditemukan masalah nyeri akut, diagnosa ini merupakan diagnosa kolaboratif. Pada penatalaksanaan terapi kedua pasien mendapat terapi ranitidin dan ceftriaxone. Diagnosa pre operasi yaitu : nyeri akut yang muncul pada pasien apendisitis yang ditandai dengan nyeri perut kanan bawah yang disebabkan berbagai faktor. Pada pasien 1 apendisitis terjadi karena adanya bakteri dalam makanan, dan pada pasien 2 disebabkan karena kurangnya konsumsi serat. Sedangkan pada diagnosa post operasi yaitu : nyeri akut pada luka bekas operasi dikarenakan prosedur tindakan insisi. Didapatkan dengan data obyektif pada pre operasi: nyeri perut kanan bawah dan pada data obyektif post op: nyeri akut pada area luka operasi dengan luas area luka pada pasien 1=6 cm dan pasien 2 =4cm. Diagnosa yang muncul kedua kasus yaitu diagnosa pada pre operasi dengan nyeri akut berhubungan dengan agen cidera biologis, dan pada post operasi nyeri akut berhubungan dengan agen cidera fisik. Kata kunci : asuhan keperawatan, apendisitis pre dan post operasi, nyeri aku

Kompilasi strategi-strategi dalam tes TOEFL

Buku ini disusun oleh beberapa mahasiswa jurusan psikologi UIN Malang, angkatan 2019. Beberapa strategi pembelajaran dalam tes TOEFL atau TEP, tes kemampuan berbahasa Inggris disajikan ke dalam masing-masing skil atau keterampilan berbahasa Inggris yang mencakup: listening, structure & written expression serta reading. Terdapat 28 strategi yang mencakup listening serta reading yang bisa dijadikan referensi dalam mempersiapkan tes kemampuan berbahasa Inggris, baik untuk keperluan evaluasi akademik serta keperluan syarat beasiswa yang juga membutuhkan skor atau nilai Toefl/ TEP

Kompilasi strategi-strategi dalam tes TOEFL

Buku ini disusun oleh beberapa mahasiswa jurusan psikologi UIN Malang, angkatan 2019. Beberapa strategi pembelajaran dalam tes TOEFL atau TEP, tes kemampuan berbahasa Inggris disajikan ke dalam masing-masing skil atau keterampilan berbahasa Inggris yang mencakup: listening, structure & written expression serta reading. Terdapat 28 strategi yang mencakup listening serta reading yang bisa dijadikan referensi dalam mempersiapkan tes kemampuan berbahasa Inggris, baik untuk keperluan evaluasi akademik serta keperluan syarat beasiswa yang juga membutuhkan skor atau nilai Toefl/ TEP

The effect of Ramadan fasting during pregnancy on perinatal outcomes: a systematic review and meta-analysis

Abstract Background Although exempt, many pregnant Muslim women partake in the daily fast during daylight hours during the month of Ramadan. In other contexts an impoverished diet during pregnancy impacts on birth weight. The aim of this systematic review was to determine whether Ramadan fasting by pregnant women affects perinatal outcomes. Primary outcomes investigated were perinatal mortality, preterm birth and small for gestational age (SGA) infants. Secondary outcomes investigated were stillbirth, neonatal death, maternal death, hypertensive disorders of pregnancy, gestational diabetes, congenital abnormalities, serious neonatal morbidity, birth weight, preterm birth and placental weight. Methods Systematic review and meta-analysis of observational studies and randomised controlled trials was conducted in EMBASE, MEDLINE, CINAHL, Web of Science, Google Scholar, the Health Management Information Consortium and Applied Social Sciences Index and Abstracts. Studies from any year were eligible. Studies reporting predefined perinatal outcomes in pregnancies exposed to Ramadan fasting were included. Cohort studies with no comparator group or that considered fasting outside pregnancy were excluded, as were studies assuming fasting practice based solely upon family name. Quality of included studies was assessed using the ROBINS-I tool for assessing risk of bias in non-randomised studies. Analyses were performed in STATA. Results From 375 records, 22 studies of 31,374 pregnancies were included, of which 18,920 pregnancies were exposed to Ramadan fasting. Birth weight was reported in 21 studies and was not affected by maternal fasting (standardised mean difference [SMD] 0.03, 95% CI 0.00 to 0.05). Placental weight was significantly lower in fasting mothers (SMD -0.94, 95% CI -0.97 to  -0.90), although this observation was dominated by a single large study. No data were presented for perinatal mortality. Ramadan fasting had no effect on preterm delivery (odds ratio 0.99, 95% CI 0.72 to 1.37) based on 5600 pregnancies (1193 exposed to Ramadan fasting). Conclusions Ramadan fasting does not adversely affect birth weight although there is insufficient evidence regarding potential effects on other perinatal outcomes. Further studies are needed to accurately determine whether Ramadan fasting is associated with adverse maternal or neonatal outcome