Jezid Miranda

Comparison of severity-of-illness scores in critically ill obstetric patients: a 6-year retrospective cohort.

Objective:The purpose of this research was to evaluate the discrimination and calibration of mortality prediction of Simplified Acute Physiology Score 2, Simplified Acute Physiology Score 3, Mortality Probability Model II, and Mortality Probability Model III in peripartum women. Design:A retrospective cohort study. Setting:Rafael Calvo Maternity Hospital, a large teaching hospital in Cartagena (Colombia). Patients:All obstetric patients admitted to the ICU from 2006 to 2011. Interventions:None. Measurements and Main Results:Seven hundred twenty-six obstetric critical care patients were included. All scores showed good discrimination (area under the receiver operator characteristic curve > 0.86). Simplified Acute Physiology Score 2, Simplified Acute Physiology Score 3, and Mortality Probability Model III inaccurately estimated mortality. The only mortality prediction score that showed good calibration through mortality ratio and Hosmer-Lemeshow test was Mortality Probability Model II. Mortality ratio for Mortality Probability Model II was 0.88 (95% CI, 0.60–1.25). Hosmer-Lemeshow test was not significant (p = 0.571). Conclusions:Simplified Acute Physiology Score 2 and Simplified Acute Physiology Score 3 overestimate mortality in obstetric critical care patients. Mortality Probability Model III was inadequately calibrated. Mortality Probability Model II showed good fit to predict mortality in a developing country setting. Future studies in developed and developing countries are needed to further confirm our findings.

The effect of guideline variations on the implementation of active management of the third stage of labor

To determine whether healthcare providers performed active management of the third stage of labor (AMTSL) as defined by FIGO/ICM and WHO, and as described by the Cochrane Collaboration.

Long-term cardiovascular consequences of fetal growth restriction: biology, clinical implications, and opportunities for prevention of adult disease

In the modern world, cardiovascular disease is a leading cause of death for both men and women. Epidemiologic studies consistently have suggested an association between low birthweight and/or fetal growth restriction and increased rate of cardiovascular mortality in adulthood. Furthermore, experimental and clinical studies have demonstrated that sustained nutrient and oxygen restriction that are associated with fetal growth restriction activate adaptive cardiovascular changes that might explain this association. Fetal growth restriction results in metabolic programming that may increase the risk of metabolic syndrome and, consequently, of cardiovascular morbidity in the adult. In addition, fetal growth restriction is strongly associated with fetal cardiac and arterial remodeling and a subclinical state of cardiovascular dysfunction. The cardiovascular effects ocurring in fetal life, includes cardiac morphology changes, subclinical myocardial dysfunction, arterial remodeling, and impaired endothelial function, persist into childhood and adolescence. Importantly, these changes have been described in all clinical presentations of fetal growth restriction, from severe early- to milder late-onset forms. In this review we summarize the current evidence on the cardiovascular effects of fetal growth restriction, from subcellular to organ structure and function as well as from fetal to early postnatal life. Future research needs to elucidate whether and how early life cardiovascular remodeling persists into adulthood and determines the increased cardiovascular mortality rate described in epidemiologic studies.

Premature placental aging in term small‐for‐gestational‐age and fetal‐growth‐restricted fetuses

To perform a comprehensive assessment of the placental aging process in small term fetuses classified as being small‐for‐gestational age (SGA) or having fetal growth restriction (FGR) through analysis of senescence and apoptosis markers.

Metabolic profiling and targeted lipidomics reveals a disturbed lipid profile in mothers and fetuses with intrauterine growth restriction

Fetal growth may be impaired by poor placental function or maternal conditions, each of which can influence the transfer of nutrients and oxygen from the mother to the developing fetus. Large-scale studies of metabolites (metabolomics) are key to understand cellular metabolism and pathophysiology of human conditions. Herein, maternal and cord blood plasma samples were used for NMR-based metabolic fingerprinting and profiling, including analysis of the enrichment of circulating lipid classes and subclasses, as well as the number of sub-fraction particles and their size. Changes in phosphatidylcholines and glycoproteins were prominent in growth-restricted fetuses indicating significant alterations in their abundance and biophysical properties. Lipoprotein profiles showed significantly lower plasma concentrations of cholesterol-intermediate density lipoprotein (IDL), triglycerides-IDL and high-density lipoprotein (HDL) in mothers of growth-restricted fetuses compared to controls (p < 0.05). In contrast, growth-restricted fetuses had significantly higher plasma concentrations of cholesterol and triglycerides transporting lipoproteins [LDL, IDL, and VLDL, (p < 0.005; all)], as well as increased VLDL particle types (large, medium and small). Significant changes in plasma concentrations of formate, histidine, isoleucine and citrate in growth-restricted fetuses were also observed. Comprehensive metabolic profiling reveals that both, mother and fetuses of pregnancies complicated with fetal growth restriction have a substantial disruption in lipid metabolism.

Placental exosomes profile in maternal and fetal circulation in intrauterine growth restriction - Liquid biopsies to monitoring fetal growth

INTRODUCTION Placenta-derived exosomes may represent an additional pathway by which the placenta communicates with the maternal system to induce maternal vascular adaptations to pregnancy and it may be affected during Fetal growth restriction (FGR). The objective of this study was to quantify the concentration of total and placenta-derived exosomes in maternal and fetal circulation in small fetuses classified as FGR or small for gestational age (SGA). METHODS Prospective cohort study in singleton term gestations including 10 normally grown fetuses and 20 small fetuses, sub-classified into SGA and FGR accordingly to birth weight (BW) percentile and fetoplacental Doppler. Exosomes were isolated from maternal and fetal plasma and characterized by morphology, enrichment of exosomal proteins, and size distribution by electron microscopy, western blot, and nanoparticle tracking analysis, respectively. Total and specific placenta-derived exosomes were determined using quantum dots coupled with CD63+ve and placental-type alkaline phosphatase (PLAP)+ve antibodies, respectively. RESULTS Maternal concentrations of CD63+ve and PLAP+ve exosomes were similar between the groups (all p > 0.05). However, there was a significant positive correlation between the ratio of placental-derived to total exosomes (PLAP+ve ratio) and BW percentile, [rho = 0.77 (95% CI: 0.57 to 0.89); p = 0.0001]. The contribution of placental exosomes to the total exosome concentration in maternal and fetal circulation showed a significant decrease among cases, with lower PLAP+ve ratios in FGR compared to controls and SGA cases. DISCUSSION Quantification of placental exosomes in maternal plasma reflects fetal growth and it may be a useful indicator of placental function.

Predictors of Maternal Mortality and Prognostic Models in Obstetric Patients

Abstract The use of predictive models has been proposed as a potential tool to reduce maternal morbidity and mortality, by aiding in the timely identification of potential high‐risk patients. Prognostic models in critical care have been used to characterize the severity of illness of specific diseases. Physiological changes in pregnancy may result in general critical illness prediction models overestimating mortality in obstetric patients. Models that specifically reflect the unique characteristics of obstetric patients may have better prognostic value. Recently developed tools have focused on identifying at‐risk patients before they require intensive care unit (ICU) admission to target early interventions and prevent acute clinical decompensation. The aim of the newest scoring systems, specifically designed for groups of obstetric patients receiving non‐ICU care, is to reduce maternal morbidity and mortality by identifying early high‐risk patients and initiating prompt effective medical responses.

Pregnancy-Associated Exosomes Changes in Pregnancies Complicated by Small-for-Gestational-Age (SGA) Neonates and Intrauterine Growth Restriction (IUGR)

Figures will be available only online Underline represents presenting author; Asterisk represents senior author; Dagger represents an in-training author.

Long-term mechanical ventilation in a pregnant woman with amyotrophic lateral sclerosis: a successful outcome

Abstract Introduction: Amyotrophic lateral sclerosis (ALS) is a progressive degenerative motor neuron disease that is rarely encountered in the obstetric population. This report describes the successful use of long-term mechanical ventilation in a pregnant woman with ALS. Case presentation: A 37-year-old G3P2 woman with ALS was admitted to the emergency room with shortness of breath, tachypnea, and evidence of hypoxic and hypercapnic respiratory failure at 24 weeks of gestation, precipitated by bacterial pneumonia. Antibiotic therapy, intubation, and mechanical ventilatory support were initiated, followed by an early tracheostomy as soon as the need for prolonged airway access was identified. The mother remained with prolonged mechanical ventilation until spontaneous preterm birth occurred at 32 weeks of gestation, with the vaginal delivery of a healthy infant. The mother was discharged from the intensive care unit during puerperium to continue mechanical ventilation support in a home care facility. Conclusion: Long-term mechanical ventilation can be successfully performed during pregnancy. Goals of oxygenation and ventilation need to be modified and customized based on the underlying condition and the status of the mother.

O690 ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOR: ARE INTERNATIONAL GUIDELINES USED IN CLINICAL PRACTICE?

be made available through non-clinical settings might facilitate uptake. 2) Among young, married women in India, studies suggest that being married is the greatest HIV risk factor. Condom use is low in marriage, and the dominant method of family planning is female sterilization – leaving younger women with few options to prevent pregnancy or HIV/STIs. MPTs that are easy to use and provided through existing primary health or family planning channels may fill an important gap. 3) Among sex worker populations in several African contexts, clinical trials of topical and oral PrEP against HIV found high levels of acceptability; however, lack of effective contraceptive use was a problem. Careful attention is needed to ensure that high-risk women who use condoms effectively do not substitute them for a MPT that provides only partial HIV protection. Distribution through STI or primary care clinics may be the most effective means of making MPTs available to these most-at-risk groups. Conclusions: MPTs provide a compelling response to the multiple and reinforcing SRH risks faced by women globally. Nevertheless, careful planning will be needed to generate demand, provide effective counseling for proper use, and effectively integrate these new products in different geographic, sociocultural, and service delivery settings.