Manasi Patwardhan

Maternal death: Case definition and guidelines for data collection, analysis, and presentation of immunization safety data ☆

Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA Henry Jackson Foundation, Bethesda, MD, USA School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Johannesburg, Department of Science and Technology National Research oundation, Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Global Healthcare Consulting, India

Human β-defensin-1: A natural antimicrobial peptide present in amniotic fluid that is increased in spontaneous preterm labor with intra-amniotic infection

Human β‐defensins (HBDs) are antimicrobial peptides that participate in the soluble innate immune mechanisms against infection. Herein, we determined whether HBD‐1 was present in amniotic fluid during normal pregnancy and whether its concentrations change with intra‐amniotic inflammation and/or infection.

Management of Liddle Syndrome in Pregnancy: A Case Report and Literature Review

Liddle syndrome is an autosomal dominant genetic condition that causes hypertension and hypokalemia due to a gain-of-function mutation in the SCNN1B or SCNN1G genes which code for the epithelial sodium channel in the kidney. This leads to increased sodium and water reabsorption causing hypertension. We report a case of a 27-year-old pregnant woman who was admitted for hypertension and hypokalemia and later diagnosed and treated for Liddle syndrome using amiloride. Maintaining a high suspicion of Liddle syndrome in pregnancy is essential in such cases to be able to adequately and effectively treat the hypertension. Due to physiological effects of pregnancy, the dose of amiloride may need to be increased as gestational age progresses up to a maximum dose of 30 mg orally per day.

Intrahepatic Cholestasis of Pregnancy Leading to Severe Vitamin K Deficiency and Coagulopathy

Intrahepatic cholestasis of pregnancy is seldom associated with significant vitamin K deficiency. We report a case of a 16-year-old primigravid patient at 24 weeks and 3 days of gestation who presented with pruritus, hematuria, and preterm labor. Laboratory work-up showed severe coagulopathy with Prothrombin Time (PT) of 117.8 seconds, International Normalized Ratio (INR) of 10.34, and elevated transaminases suggestive of intrahepatic cholestasis of pregnancy. Her serum vitamin K level was undetectable (<0.1 nMol/L). Initial therapy consisted of intramuscular replacement of vitamin K and administration of fresh frozen plasma. Her hematuria and preterm labor resolved and she was discharged. She presented in active labor and delivered at 27 weeks and 1 day. Her bile acids (93 μ/L) and INR (2.32) had worsened. She delivered a male infant, 1150 grams with Apgar scores 7 and 9. The newborn received 0.5 mg of intramuscular vitamin K shortly after delivery but went on to develop bilateral grade III intraventricular hemorrhages by day 5. Intrahepatic cholestasis in pregnancy and nutrition issues were identified as the main risk factors for the severe coagulopathy of this patient. This case underlines the importance of evaluation of possible severe coagulopathy in patients with intrahepatic cholestasis of pregnancy in order to avoid serious maternal or fetal adverse outcomes.

Dynamic Changes in the Myometrium during the Third Stage of Labor, Evaluated Using Two-Dimensional Ultrasound, in Women with Normal and Abnormal Third Stage of Labor and in Women with Obstetric Complications

Objective: To investigate dynamic changes in myometrial thickness during the third stage of labor. Methods: Myometrial thickness was measured using ultrasound at one-minute time intervals during the third stage of labor in the mid-region of the upper and lower uterine segments in 151 patients including: women with a long third stage of labor (n = 30), postpartum hemorrhage (n = 4), preterm delivery (n = 7) and clinical chorioamnionitis (n = 4). Differences between myometrial thickness of the uterine segments and as a function of time were evaluated. Results: There was a significant linear increase in the mean myometrial thickness of the upper uterine segments, as well as a significant linear decrease in the mean myometrial thickness of the lower uterine segments until the expulsion of the placenta (p < 0.001). The ratio of the measurements of the upper to the lower uterine segments increased significantly as a function of time (p < 0.0001). In women with postpartum hemorrhage, preterm delivery, and clinical chorioamnionitis, an uncoordinated pattern among the uterine segments was observed. Conclusion: A well-coordinated activity between the upper and lower uterine segments is demonstrated in normal placental delivery. In some clinical conditions this pattern is not observed, increasing the time for placental delivery and the risk of postpartum hemorrhage.

Use of Fluorescence In Situ Hybridization Technology to Explain a Confusing Case of Vasa Previa

Vasa previa is defined as unprotected fetal vessels coursing within the membranes overlying or in close proximity to the cervix. The incidence is approximately 1 per 1300 to 2500 singleton pregnancies, with major fetal and neonatal morbidity and mortality occurring. The rate of vasa previa in twin pregnancies is higher, estimated at 1 per 135 cases. Velamentous cord insertion and a succenturiate lobe are the conditions reported to lead to vasa previa. Vasa previa in the absence of a velamentous cord or succenturiate lobe has not been reported. We describe a case of antenatally identified vasa previa in a dichorionic twin gestation with 2 early separated placental masses. Although there are speculations in the literature that vascular anastomoses can occur between dichorionic placentas, they have been reported only under the circumstances in which the placentas are fused. After delivery, macroscopic examination of the placentas in our case seemed to confirm this event of separate placentas without the evidence of the presence of velamentous cord insertion or a succenturiate lobe until fluorescence in situ hybridization was used to clarify the findings. A 36-year-old woman, gravida 2, para 0010, presented at 9 weeks with an ultrasound-confirmed diamniotic dichorionic pregnancy. Ultrasound scanning at 19 weeks’ gestation showed twin A to be a female fetus with a posterior placenta. Twin B was a male fetus with a separate anterior placenta (Figure 1A). A follow-up transvaginal ultrasound scan at 22 weeks’ gestation suggested the diagnosis of vasa previa (Figure 1B). The free fetal vessel appeared to be communicating between the 2 separate placental masses, traversing across the endocervical canal. These ultrasound findings persisted at 27 and 34 weeks’ gestation. At 34 weeks 2 days, the patient

Gestational diabetes mellitus: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data.

https://doi.org/10.1016/j.vaccine.2017.01.043 0264-410X/ 2017 Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). ⇑ Corresponding author. E-mail addresses: NChescheir@greenjournal.org, contact@brightoncollaboration. org (N. Chescheir). 1 Present address: University of Washington, Seattle, USA. 2 Brighton Collaboration homepage: http://www.brightoncollaboration.org. Alisa Kachikis , Linda O. Eckert , Christie Walker , Eugene Oteng-Ntim , Rama Guggilla , Manish Gupta , Manasi Patwardhan , Ronald Mataya , Tamala Mallett Moore , Ana Maria Alguacil-Ramos , Cheryl Keech , Michael Gravett , Helen Murphy , Sonali Kochhar , Nancy Chescheir p,⇑, The Brighton Collaboration Gestational Diabetes Mellitus Working Group 2

Fetal growth restriction: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data

http://dx.doi.org/10.1016/j.vaccine.2017.01.042 0264-410X/ 2017 Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). ⇑ Corresponding author. E-mail address: contact@brightoncollaboration.org (T. McElrath). 1 Brighton Collaboration homepage: http://www.brightoncollaboration.org. 2 Present address: University of Washington, Seattle USA. Sarah Rae Easter , Linda O. Eckert , Nansi Boghossian , Rebecca Spencer , Eugene Oteng-Ntim , Christos Ioannou , Manasi Patwardhan , Margo S. Harrison , Asma Khalil , Michael Gravett , Robert Goldenberg , Alastair McKelvey , Manish Gupta , Vitali Pool , Stephen C. Robson, Jyoti Joshi , Sonali Kochhar , Tom McElrath a,⇑, The Brighton Collaboration Fetal Growth Restriction Working Group 1

Early Evaluation of the Fetal Heart

Evaluation of the fetal heart at 11-13 + 6 weeks of gestation is indicated for women with a family history of congenital heart defects (CHD), a previous child with CDH, or an ultrasound finding associated with cardiac anomalies. The accuracy for early detection of CHD is highly related to the experience of the operator. The 4-chamber view and outflow tracts are the most important planes for identification of an abnormal heart, and can be obtained in the majority of fetuses from 11 weeks of gestation onward. Transvaginal ultrasound is the preferred route for fetal cardiac examination prior to 12 weeks of gestation, whereas, after 12 weeks, the fetal heart can be reliably evaluated by transabdominal ultrasound. Cardiac defects, such as ventricular septal defects, tetralogy of Fallot, Ebsteins anomaly, or cardiac tumors, are unlikely to be identified at ≤14 weeks of gestation. Additional ultrasound techniques such as spatiotemporal image correlation and the evaluation of volumes by a fetal-heart expert can improve the detection of congenital heart disease. The evaluation of the fetal cardiac function at 11-13 + 6 weeks of gestation can be useful for early identification of fetuses at risk of anemia due to hemoglobinopathies, such as hemoglobin Barts disease.

The Fetal Heart in Early Pregnancy

Early evaluation of the fetal heart at 11–13 + 6 weeks of gestation is indicated in women with family history of congenital heart defects or with a previous child with a cardiac defect, increased nuchal translucency, tricuspid regurgitation, abnormal Doppler waveform in the ductus venous, cystic hygroma, or any other anatomical defect in the fetus. The effectiveness of early evaluation of the fetal heart, either as a screening or as an indicated method, is related to technological resources and experience of the operators. With state-of-the art ultrasound systems and adequately trained operators, a 40–50 % identification rate might be achieved at this gestational age. The 4-chamber view and outflow tracts are the most important planes for identification of a normal/abnormal heart and can be obtained from 11 weeks of gestation onwards in the majority of fetuses. At or before 12 weeks of gestation transvaginal ultrasound can provide adequate images for cardiac examination; whereas transabdominal ultrasound provides reliable cardiac images from 13 weeks of gestation. Several cardiac defects might not be recognized before 14 weeks, such as ventricular septal defects, Tetralogy of Fallot, Ebstein’s anomaly, or cardiac tumors. Additional US techniques, such as color directional Doppler and spatiotemporal image correlation (STIC) can contribute in improving the detection rate of congenital heart defects in early pregnancy.