A Case of Umbilical Cord Prolapse With Intact Membranes Managed Successfully With Conservative Measures.

Umbilical cord prolapse with ruptured membranes is an obstetric emergency with management consisting of delivery via emergent cesarean delivery. If the umbilical cord prolapses beyond the internal os with intact membranes, there is an opportunity to intervene and reduce the risk of fetal morbidity and mortality. A healthy 30-year-old, gravida 1 para 0 was incidentally found to have a short cervical length at 25 weeks five days on routine anatomy ultrasound evaluation. On evaluation via ultrasound by the maternal-fetal medicine service, the umbilical cord was noted to be prolapsing through the cervix with membranes intact. The cord prolapse with intact membranes resolved after placing the patient in the Trendelenburg position and nifedipine was administered for tocolysis given the uterus was noted to be contracting. For the remainder of the pregnancy, the patient underwent close follow-up and serial ultrasound scans with confirmation of the fetal head as the presenting part. The patient ultimately delivered vaginally at term. Cord prolapse with intact membranes, when identified via ultrasound, can be managed conservatively via Trendelenburg positioning and tocolysis to avoid premature cesarean delivery.

Defining malaria risks among forest workers in Aceh, Indonesia: a formative assessment.

BACKGROUND: Following a dramatic decline of malaria cases in Aceh province, geographically-based reactive case detection (RACD) was recently evaluated as a tool to improve surveillance with the goal of malaria elimination. While RACD detected few cases in households surrounding index cases, engaging in forest work was identified as a risk factor for malaria and infections from Plasmodium knowlesi-a non-human primate malaria parasite-were more common than expected. This qualitative formative assessment was conducted to improve understanding of malaria risk from forest work and identify strategies for targeted surveillance among forest workers, including adapting reactive case detection. METHODS: Between June and August, 2016, five focus groups and 18 in-depth interviews with forest workers and key informants were conducted in each of four subdistricts in Aceh Besar and Aceh Jaya districts. Themes included: types of forest activities, mobility of workers, interactions with non-human primates, malaria prevention and treatment-seeking behaviours, and willingness to participate in malaria surveys at forest work sites and using peer-referral. RESULTS: Reported forest activities included mining, logging, and agriculture in the deep forest and along the forest fringe. Forest workers, particularly miners and loggers, described often spending weeks to months at work sites in makeshift housing, rarely utilizing mosquito prevention and, upon fever, self-medicating and seeking care from traditional healers or pharmacies rather than health facilities. Non-human primates are frequently observed near work sites, and most forest work locations are within a day's journey of health clinics. Employers and workers expressed interest in undertaking malaria testing and in participating in survey recruitment by peer-referral and at work sites. CONCLUSIONS: Diverse groups of forest workers in Aceh are potentially exposed to malaria through forest work. Passive surveillance and household-based screening may under-estimate malaria burden due to extended stays in the forest and health-seeking behaviours. Adapting active surveillance to specifically target forest workers through work-site screening and/or peer-referral appears promising for addressing currently undetected infections.

Where There Is No Trauma System: A Successful Patient Evacuation in the Republic of Kiribati.

Research is lacking around how best to approach trauma care in resource poor settings, particularly in remote areas such as the islands of the South Pacific. Without examples of successful treatment of high-risk cases in these settings, countries are unable to move forward with developing policies and standardized procedures for emergency care.The Republic of Kiribati is a Pacific Island nation composed of 33 islands spanning over 2,000 miles in the central Pacific Ocean. With the only hospital located on Kiritimati Island and inadequate boat transportation, the government recently committed to providing an aircraft for patients to receive appropriate medical care. In 2016, a 20-year-old female, primigravida, on a neighboring island, failed to progress in labor for 24 hours and needed an emergency cesarean section. A radio call was made to Kiritimati, and a team consisting of a general surgeon, nurse, and a laboratory technician was dispatched. The patient was brought to the local clinic and flown to Kiritimati where a team was prepared to perform the cesarean section.The successful patient evacuation emphasizes the importance of a dedicated health care team, government commitment, and the constant quality communication when approaching feasibility of trauma and emergency care. (Disaster Med Public Health Preparedness. 2019;13:774-776).