Performance of a Maternal Risk Stratification System for Predicting Low Apgar Scores.

OBJECTIVE: Maternal risk stratification systems are increasingly employed in predicting and preventing obstetric complications. These systems focus primarily on maternal morbidity, and few tools exist to stratify neonatal risk. We sought to determine if a maternal risk stratification score was associated with neonatal morbidity. STUDY DESIGN: Retrospective cohort study of patients with liveborn infants born at ≥24 weeks at four hospitals in one health system between January 1, 2020, and December 31, 2020. The Expanded Obstetric Comorbidity Score (EOCS) is used as the maternal risk score. The primary neonatal outcome was 5-minute Apgar <7. Logistic regression models determined associations between EOCS and neonatal morbidity. Secondary analyses were performed, including stratifying outcomes by gestational age and limiting analysis to "low-risk" term singletons. Model discrimination assessed using the area under the receiver operating characteristic curves (AUC) and calibration via calibration plots. RESULTS: A total of 14,497 maternal-neonatal pairs were included; 236 (1.6%) had 5-minute Apgar <7; EOCS was higher in 5-minute Apgar <7 group (median 41 vs. 11, p < 0.001). AUC for EOCS in predicting Apgar <7 was 0.72 (95% Confidence Interval (CI) 0.68, 0.75), demonstrating relatively good discrimination. Calibration plot revealed that those in the highest EOCS decile had higher risk of neonatal morbidity (7.6 vs. 1.7%, p < 0.001). When stratified by gestational age, discrimination weakened with advancing gestational age: AUC 0.70 for <28 weeks, 0.63 for 28 to 31 weeks, 0.64 for 32 to 36 weeks, and 0.61 for ≥37 weeks. When limited to term low-risk singletons, EOCS had lower discrimination for predicting neonatal morbidity and was not well calibrated. CONCLUSION: A maternal morbidity risk stratification system does not perform well in most patients giving birth, at low risk for neonatal complications. The findings suggest that the association between EOCS and 5-minute Apgar <7 likely reflects a relationship with prematurity. This study cautions against intentional or unintentional extrapolation of maternal morbidity risk for neonatal risk, especially for term deliveries. KEY POINTS: · EOCS had moderate discrimination for Apgar <7.. · Predictive performance declined when limited to low-risk term singletons.. · Relationship between EOCS and Apgar <7 was likely driven by prematurity..

External Validation of a Prediction Model for External Cephalic Version Success.

External cephalic version (ECV) success correlates with numerous maternal and pregnancy factors. A prior study developed an ECV success prediction model based on body mass index, parity, placental location, and fetal presentation. We performed external validation of this model using a retrospective cohort of ECV procedures from a separate institution between July 2016 and December 2021. Four hundred thirty-four ECV procedures were performed, with a 44.4% success rate (95% CI 39.8-49.2%), which was similar to the derivation cohort (40.6%, 95% CI 37.7-43.5%, P =.16). There were significant differences in patients and practices between cohorts, including the rate of neuraxial anesthesia (83.5% derivation cohort vs 10.4% our cohort, P <.001). The area under the receiver operating characteristic curve (AUROC) was 0.70 (95% CI 0.65-0.75), which was similar to that in the derivation cohort (AUROC 0.67, 95% CI 0.63-0.70). These results suggest the published ECV prediction model's performance is generalizable outside the original study institution.

Testicular Relapse of Primary Diffuse Large B-cell Lymphoma of the Central Nervous System - a Rare Occurrence.

Among diffuse large b-cell lymphoma (DLBCL) subtypes, primary testicular lymphoma (PTL) has one of the highest risks of central nervous system (CNS) relapse. The converse, primary CNS lymphoma (PCNSL) relapse outside the CNS is rare. Molecular analysis has illustrated a genetic similarity between PTL and PCNSL. Here we present a case of a 64-year-old man with testicular relapse of PCNSL 20 months after a complete response to high dose methotrexate-based chemotherapy. His tumor demonstrated a molecular profile similar to both PCNSL and PTL on next generation sequencing, and molecular analysis confirmed common clonal origin of his CNS and testicular lesions. We review prior cases of testicular relapse of PCNSL, which lacked molecular investigations, and discuss the implications of the genomic findings in our patient, including future treatment options.

Case series of tubo-ovarian abscesses after saline infusion sonohysterography: reconsidering antibiotic prophylaxis.

Saline infusion sonohysterography (SIS) is useful for evaluating intrauterine pathology, particularly for patients with abnormal uterine bleeding and during assessment of infertility. Infectious complications are relatively rare, and tubo-ovarian abscess (TOA) after SIS has only been reported once in the literature. We present two additional cases of TOA after SIS that presented to our institution. First, a 40-year-old female with known endometriosis and bilateral tubal occlusion, presented with ruptured TOA fifteen days after SIS during fertility evaluation. The second, a 45-year-old female with endometriomas and a hydrosalpinx identified on SIS, diagnosed with TOAs four days after SIS for abnormal uterine bleeding evaluation. While hysterosalpingogram has defined antibiotic prophylaxis criteria, and despite likely similar mechanisms for ascending infections, current guidelines do not recommend prophylaxis after SIS. These cases suggest infectious complications, such as TOA, after SIS may be more common than previously reported, and as demonstrated by these cases can have serious clinical consequences for patients. Furthermore, by comparing to a technically similar procedure as HSG, it may be reasonable to consider if certain patients at high risk of complication may benefit from antibiotic prophylaxis to prevent serious clinical infections.

A presentation of adenovirus with hypokalemia and rhabdomyolysis in pregnancy.

Background: Adenovirus infection is usually mild in presentation. However during pregnancy, the course can be more severe. Case: A 21-year-old woman in her second pregnancy presented with abdominal pain, vomiting, and fevers at 34 weeks and 4 days of gestation. Her respiratory pathogen panel on nasopharyngeal secretions was positive for adenovirus. Electrolytes were notable for hypomagnesaemia and persistent hypokalemia (nadir of 2.6 mmol/L) despite repletion but otherwise unremarkable. During her course, she developed rhabdomyolysis. During routine fetal monitoring at 35 weeks and 6 days of gestation, prolonged fetal bradycardia was identified, and an emergency caesarean delivery was performed. The infant had no clinical or laboratory evidence of adenovirus infection. The patient had a protracted clinical course but recovered with supportive care. Conclusion: Adenovirus can present with severe complications in a pregnant woman including hypokalemia and rhabdomyolysis. The mainstay of treatment is supportive care and monitoring of electrolyte abnormalities and renal function.

Countering COVID-19 Vaccine Hesitancy in Pregnancy: the "4 Cs".

Despite evidence to support the safety and efficacy of COVID-19 vaccination in pregnancy, and clear recommendations from professional organizations and the Centers for Disease Control and Prevention (CDC) for pregnant people to get vaccinated, COVID-19 vaccine hesitancy in pregnancy remains a significant public health problem. The emergence of the highly transmissible B.1.617.2 (Delta) variant among primarily unvaccinated people has exposed the cost of vaccine hesitancy. In this commentary, we explore factors contributing to COVID-19 vaccine hesitancy in pregnancy and potential solutions to overcome them. KEY POINTS: · Low COVID-19 vaccination coverage in pregnant people is a major public health problem in the United States.. · COVID-19 vaccine hesitancy in pregnancy is multifactorial.. · The "4 Cs" framework may be useful in countering COVID-19 vaccine hesitancy..

Tracking Calcium Dynamics and Immune Surveillance at the Choroid Plexus Blood-Cerebrospinal Fluid Interface.

The choroid plexus (ChP) epithelium is a source of secreted signaling factors in cerebrospinal fluid (CSF) and a key barrier between blood and brain. Here, we develop imaging tools to interrogate these functions in adult lateral ventricle ChP in whole-mount explants and in awake mice. By imaging epithelial cells in intact ChP explants, we observed calcium activity and secretory events that increased in frequency following delivery of serotonergic agonists. Using chronic two-photon imaging in awake mice, we observed spontaneous subcellular calcium events as well as strong agonist-evoked calcium activation and cytoplasmic secretion into CSF. Three-dimensional imaging of motility and mobility of multiple types of ChP immune cells at baseline and following immune challenge or focal injury revealed a range of surveillance and defensive behaviors. Together, these tools should help illuminate the diverse functions of this understudied body-brain interface.

Association between age and outcomes following thrombectomy for anterior circulation emergent large vessel occlusion is determined by degree of recanalisation.

BACKGROUND: Older patients undergoing thrombectomy for emergent large vessel occlusion have worse outcomes. However, complete or near-complete reperfusion (modified Thrombolysis in Cerebral Ischemia (mTICI) score of 2 c/3) is associated with improved outcomes compared with partial recanalisation (mTICI 2b). OBJECTIVE: To examine the relationship between outcomes and age separately for the mTICI 2c/3, 2b and 0-2a groups in patients undergoing thrombectomy for anterior circulation emergent large vessel occlusion. METHODS: Retrospective review of 157 consecutive patients undergoing thrombectomy at a single centre with an occlusion of the internal carotid artery (ICA), M1 or proximal M2 segments of the middle cerebral artery (MCA). Angiograms were graded in a blinded fashion. Patients were divided into three groups: mTICI 0-2a, mTICI 2b, and mTICI 2c/3. Demographics and workflow parameters were compared. Outcomes at 90 days were compared as a function of age, using both the conventional modified Rankin scale (mRs) and utility weighted mRs (UWmRs). RESULTS: There were 72, 61 and 24 patients in the mTICI 2c/3, 2b and 0-2a groups, respectively. Outcomes were significantly worse with increasing age for the mTICI 2b group, but not for the mTICI 0-2a and 2c/3 groups (P=0.0002). With increasing age, outcomes of the mTICI 2b group approached those of the mTICI 0-2a group. However, outcomes of the mTICI 2c/3 groups were similar for all ages. This association was present for both the original mRs and UWmRs. CONCLUSION: Increasing age was associated with worse outcomes for those with partial (mTICI 2b) recanalisation, not in patients with complete (mTICI 2c/3) recanalisation.