Ventriculitis after meningitis is a serious complication in the neonatal age group. The role of i... more Ventriculitis after meningitis is a serious complication in the neonatal age group. The role of intraventricular antibiotics in treatment is controversial. We present five such cases which were refractory to conventional intravenous antibiotic therapy, had persistent features of ventriculitis and in whom raised intracranial pressure (ICP) necessitated insertion of an external ventricular drain (EVD). Three of the five infants required intraventricular antibiotics but also developed EVD-related complications. Early diagnosis of ventriculitis and treatment is necessary to avoid a fatal outcome. Intravenous antibiotics are the treatment of choice, but intraventricular therapy may be considered in refractory cases. As the incidence of EVD-associated ventriculitis is high, proper care of EVDs and their early removal is mandatory.
After birth, separation of mothers and newborn is a common practice in many hospitals in our coun... more After birth, separation of mothers and newborn is a common practice in many hospitals in our country. After delivery, we take the normal newborn to the radiant warmer in the resuscitation area for routine care. This was the existing process of care at our hospital. The frontline delivery team undertook quality improvement initiative to understand and document factors creating challenges in delivering evidence-based practice of providing immediate skin-to-skin care (SSC), delayed cord clamp (DCC) and early breast feeding within 1 hour of birth. Some of the barriers identified were early newborn mother separation and late transfer of mother from delivery room to the observation area. Additionally, there was a challenge of high delivery load with variation in understanding and provision of SSC and drying on mother's abdomen. These made sustenance of improved care practices difficult. Using the Plan-Do-Study-Act (PDSA) approach some successful change ideas tested were pre-delivery counselling, avoiding separation of mother and newborn at birth by providing SSC and continuing it in the postdelivery observation area and getting family member's help in first breast feed. The delivery team adapted these successful change ideas by multiple iterations, group discussions and feedback. This resulted in improved and sustained compliance of pre-delivery counselling, SSC, DCC and initiating breast feed within 1 hour, from minimal compliance to a median compliance of 51%, 56%, 59% and 61%, respectively, over 36 months period. We undertook this quality improvement initiative at Delhi (India) at a tertiary care teaching hospital. The implementation of WHO recommended evidence-based practices benefitted more than 10 000 mother-newborn dyads annually over 2 years, using Point of Care Quality Improvement method. Implementation of evidence-based practice is possible in challenging situations using PDSA approach. The resultant contextualised processes are convenient and have better success at sustainability.
Moebius syndrome is a rare entity characterized by unilateral/ bilateral facial nerve palsy with ... more Moebius syndrome is a rare entity characterized by unilateral/ bilateral facial nerve palsy with or without other cranial nerve palsies and limb malformations. Etiology is largely unknown. We describe a case of Moebius syndrome who had bilateral facial and abducens nerve palsies and bilateral congenital talipes equino varus with possible cause being fetal misoprostol and mifepristone exposure. Introduction Moebius syndrome is a rare entity, characterized by congenital non-progressive complete/partial, unilateral/bilateral facial nerve palsy with/without other cranial nerve palsies and limb malformations (syndactyly, brachydactyly, absent digits or talipes), cleft palate, micrognathia, microtia, scoliosis, pectorals hypoplasia or other chest wall deformities. (1) Etiology is unknown, probably involving transient ischemia, infections, genetic etiologies and abortifacient (prostaglandin E1). (4) We present a case of Moebius syndrome due to failed abortion at 6 weeks of gestation due to use of misoprostol and mifepristone. Case Report A 1 year old female child presented with acute gastroenteritis. On examination, she was noticed to have failure to thrive (weight 3.8kg, length 60 cms and head circumference 48cms) with global developmental delay. She had bilateral facial palsy, left corneal opacity, bilateral convergent squint suggestive of bilateral sixth cranial nerve palsy, left eye microphthalmia and microcornea, and bilateral club-feet. On inquiry, it was found that mother had taken oral mifepristone 600 mg at 6-week gestation for elective abortion and 2 days later had taken misoprostol 400 μg. One month later, despite significant metrorrhagia, an ultrasound examination showed ongoing pregnancy, with no anomalies observed in the fetus. So, pregnancy was continued. Antenatal ultrasound (USG) at 37weeks gestation showed oligohydramnios with hydrocephalus. The child was born at term, and had a birth weight of 3.2kg. Parents had noticed bilateral congenital talipes equino varus (CTEV) at birth for which an orthopedic surgeon applied a cast. Parents also noticed that baby had feeding difficulty, poor development and facial dysmorphism but they did not seek medical attention for these. On presentation to us, we did MRI brain that showed communicating hydrocephalus. USG abdomen was normal. Chromosomal analysis could not be done because of financial concerns. Diarrhea subsided on oral rehydration therapy and patient was discharged and advised regular follow up. Discussion Moebius syndrome is a rare disorder first described by Von Graefe in 1880 and identified and defined in 1888 by Paul Julius Moebius. It consists of congenital unilateral or bilateral palsy of the abducens (VI) and facial (VII) cranial nerves. (1) It also involves abnormalities of the limbs, chest wall, spine, and soft tissues. Abramson et al actually classified and graded the syndrome on the basis of the clinical findings of cranial nerve palsies and musculoskeletal anomalies by using the acronym CLUFT (cranial nerve, lower limb, upper limb, face, and thorax). (3) This grading system included cranial nerve features of either partial or complete 6th or7th nerve palsies or both; lower extremity findings of talipes equino varus, ankylosis, longitudinal, or transverse deficits; upper extremity involvement with digital hypoplasia or failure of formation; structural facial findings of cleft palate, micrognathia, or microtia; and thoracic findings of scoliosis, pectoral hypoplasia, or other chest wall deformity. Mental retardation and autism were also observed by some authors in one-third of a population of 25 patients with Moebius syndrome. (4) Our patient had bilateral VI and VII nerve palsies with congenital talipes equino varus. Hydrocephalus and microphthalmia was also seen in our patient. Intense vasoconstriction and uterine contraction caused by misoprostol resulting in hypoxia may explain this finding. (5,6) The etiology of Moebius syndrome is multifactorial, and several theories have been proposed, with the most supported theory being that of transient ischemic or hypoxic insult to the fetus (3) Other infectious and genetic etiologies have also been proposed. In addition, the use of misoprostol, a prostaglandin-E1 analogue and abortifacient during pregnancy has also been implicated. (2) Use of oral or vaginal misoprostol during the first trimester of pregnancy significantly reduces uterine arterial blood flow. Doppler resistance indices are significantly increased 60–90 minutes after misoprostol administration (200 μg orally, or 200 μg intra-vaginally plus 200 μg orally) to pregnant women. (7) There are few case reports of Moebius syndrome secondary to the administration of misoprostol. (2,8-12). In several case reports, pregnancies not successfully aborted with mifepristone continued to full term with no adverse effects on the newborn. (13,14] Bernard et al (2013) conducted the first prospective study which found that the rate of major…
Therapeutic Advances in Vaccines and Immunotherapy, 2020
Background: As a part of a measles and rubella (MR) campaign, the MR vaccine replaced the two-dos... more Background: As a part of a measles and rubella (MR) campaign, the MR vaccine replaced the two-dose measles vaccine at 9–12 months and 16–24 months of age under the Universal Immunization Program (UIP). Although adverse events following immunization (AEFIs) following the measles and MMR vaccine at 9 months of age have been studied, AEFIs following the MR vaccine at 9 months of age have not been studied. As the MR vaccine a is very recent introduction in the UIP for routine immunization at 9 months of age, we intend to investigate the AEFI profile of MR vaccination at 9 months of age by active surveillance. Aim: We aimed to study the profile of the AEFIs with MR vaccine at 9-12 months of age in children vaccinated at the immunization clinic at the Pediatrics Department of a tertiary care hospital in East Delhi, India. Methods: Our study was a prospective observational study (telephonic survey). Children who attended Pediatrics OPD for the first dose of the MR vaccine at 9–12 months of...
After birth, separation of mothers and newborn is a common practice in many hospitals in our coun... more After birth, separation of mothers and newborn is a common practice in many hospitals in our country. After delivery, we take the normal newborn to the radiant warmer in the resuscitation area for routine care. This was the existing process of care at our hospital. The frontline delivery team undertook quality improvement initiative to understand and document factors creating challenges in delivering evidence-based practice of providing immediate skin-to-skin care (SSC), delayed cord clamp (DCC) and early breast feeding within 1 hour of birth. Some of the barriers identified were early newborn mother separation and late transfer of mother from delivery room to the observation area. Additionally, there was a challenge of high delivery load with variation in understanding and provision of SSC and drying on mother’s abdomen. These made sustenance of improved care practices difficult. Using the Plan-Do-Study-Act (PDSA) approach some successful change ideas tested were pre-delivery couns...
Ventriculitis after meningitis is a serious complication in the neonatal age group. The role of i... more Ventriculitis after meningitis is a serious complication in the neonatal age group. The role of intraventricular antibiotics in treatment is controversial. We present five such cases which were refractory to conventional intravenous antibiotic therapy, had persistent features of ventriculitis and in whom raised intracranial pressure (ICP) necessitated insertion of an external ventricular drain (EVD). Three of the five infants required intraventricular antibiotics but also developed EVD-related complications. Early diagnosis of ventriculitis and treatment is necessary to avoid a fatal outcome. Intravenous antibiotics are the treatment of choice, but intraventricular therapy may be considered in refractory cases. As the incidence of EVD-associated ventriculitis is high, proper care of EVDs and their early removal is mandatory.
Background: Thrombocytopenia is frequently found in malaria, but its prognostic value has not bee... more Background: Thrombocytopenia is frequently found in malaria, but its prognostic value has not been addressed in children. Bleeding with thrombocytopenia in malaria is not so common but can be a cause of mortality if left unattended. Objective: To study the occurrence and severity of thrombocytopenia with bleeding manifestations in children with malaria. Materials and Methods: This cross-sectional study was conducted in a pediatric hospital of north India. All positive cases of malaria <15 years of age admitted to the hospital between January 2008 and December 2013 were included in the study, and data were recorded on pre-designed pro forma. Patients were further assessed for thrombocytopenia and bleeding manifestations. Data were analyzed by Chi-square test and independent sample t-test using SPSS version 16. Results: Total 185 cases were included in the study with a median age of presentation of 4 years. Plasmodium vivax was identified in 142 (77%) patients, whereas Plasmodium falciparum in 31 (17%) and mixed infection in 12 (6%) patients. Thrombocytopenia was observed in 79 (43%) cases, of which 35 (44%) cases had mild, 30 (38%) cases moderate, and 14 (18%) cases had severe thrombocytopenia. Total 10 (5.4%) patients had bleeding manifestations, and all of these had thrombocytopenia. The most common bleeding manifestation was gastrointestinal bleeding presenting as malena. No significant association was found between bleeding and severity of thrombocytopenia (p=0.527) or species of malaria (p=0.682). Furthermore, no significant association was found between severity of malaria and thrombocytopenia (p=0.365). Conclusion: Thrombocytopenia and bleeding were not significantly associated with the type of malaria. In an endemic area, if a child presents with acute fever and thrombocytopenia with or without bleeding manifestation, diagnosis of malaria should be strongly suspected.
Objectives: Benefits of mother's only milk (MOM) for preterm infants are numerous. We realize... more Objectives: Benefits of mother's only milk (MOM) for preterm infants are numerous. We realized that usage of MOM in our unit is less and often delayed for days. The proportion of MOM usage as the first feed after birth of total feed, was only 19%. In view of this existing evidence and identified problem, we decided to start quality improvement (QI) initiative in our unit with the primary objective “To encourage the use of MOM as first feed in preterm (PT) and very low birth weight (VLBW) neonate from existing 19% to >50% over a period of 3 month.” Materials and Methods: This QI study involved the systematic implementation of evidence-based practices using Point of Care QI methodology developed by the WHO-SEARO. Results: After several Plan, Do, Study, Act, during the intervention phase, usage of MOM increases from baseline 19% to 91.3%. Postintervention, sustained usage of MOM after 6 months is at close to 80%. Conclusions: Effective implementation of comprehensive communication bundles (CCB) is feasible in resource-constraint setting and resulted in sustained increase in the usage of MOM in PT and VLBW neonates.
Background -Neonatal mortality contributes 70% to infant mortality rate which is disproportionate... more Background -Neonatal mortality contributes 70% to infant mortality rate which is disproportionately high. To decrease the neonatal mortality rate, government of India has launched a programme named facility based newborn care all over the India to provide care to the newborns at all levels. FBNC training programme has been started to enhance the knowledge and skills of the care givers. Objective -To evaluate the effectiveness of FBNC training programme in terms of knowledge of the participants in Uttar Pradesh. Methods-A retrospective analytical study has been carried out which analyzed the pretest and post-test scores of six FBNC training programmes conducted at Lucknow, Uttar Pradesh. Result-Overall score in NRP pre-test was 6.24 (±0.65) which increased to 14.32 (±0.85) in post test. The increase from pre-test to post test was 8.07 (±0.64) and this was statistically significant (p=0.0001 ). Similarly, overall score in FBNC pre-test was 2.80 (±0.31) which increased to 8.25 (±0.49) in post test. The increase from pre-test to post test was 5.30 (±0.33) and this was statistically significant (p=0 .0001 ). Conclusion -The written knowledge of the participants increased significantly after the training programmes thereby indicating the effectiveness of the training programme.
Journal of South Asian Federation of Obstetrics and Gynaecology, 2015
Objective To evaluate the effect of maternal oral hydration therapy in 3rd trimester pregnancies ... more Objective To evaluate the effect of maternal oral hydration therapy in 3rd trimester pregnancies with isolated oligohydramnios on amniotic fluid index (AFI) and maternal and perinatal outcome. Materials and methods A prospective study was conducted on 100 pregnant women in 3rd trimester with isolated oligohydramnios. Women were advised to drink 2 liters of fluids orally over 1 hour per day in the form of water, fruit juices, coconut water and to take rest in left lateral position. Amniotic fluid index was re-evaluated by ultrasonography done at 24 hours and then repeated at 48 hours of oral hydration therapy. Difference in prehydration and posthydration AFI was calculated for each selected cases at different intervals. Women were asked to continue the therapy of 2 liters per day orally in addition to routine fluid intake till delivery. All the women were followed till delivery and maternal and perinatal outcome was analyzed. Results The mean AFI increased from 6.23 ± 1.06 cm (pretre...
Cardiac tumors are rare in neonates, most are benign hamartomas (rhabdomyomas) of the muscle cell... more Cardiac tumors are rare in neonates, most are benign hamartomas (rhabdomyomas) of the muscle cells. Due of large size, they may cause homodynamic instability and even death in neonatal period. They are rarely diagnosed prenatally and are found in multiple forms. In $50% of the cases, rhabdomyoma is associated with tuberous sclerosis.
Acta Obstetricia et Gynecologica Scandinavica, 2007
The patient was a 26-year-old primigravida who underwent routine ultrasound examination at gestat... more The patient was a 26-year-old primigravida who underwent routine ultrasound examination at gestational week 18 + 3 according to last menstrual period.The pregnancy had been uneventful with no signs...
n India, neonatal mortality rate (NMR) is 29 per 1000 live birth, and it contributes 56% to the u... more n India, neonatal mortality rate (NMR) is 29 per 1000 live birth, and it contributes 56% to the under 5 mortality (SRS 2012). As per the India Newborn Action Plan, it is expected that India will achieve the goals of "Single Digit NMR" by 2030 . Neonatal mortality reflects overall utilization of health-care services by the community, infrastructure, and involvement of health-care personnel in providing neonatal care. There is a huge gap between urban and rural mortality rates and geographical variation due to inequitable distribution of the health-care services . Previous studies done by Baqui et al. and Narang et al., showed prematurity (32%) as the most important cause of mortality while Aggarwal et al., and Sehgal et al., showed sepsis as the main cause of neonatal deaths. All these studies were conducted in a tertiary care center in urban area. Our aim was to find out the predictors of neonatal mortality among the neonates transported to a tertiary care center in rural area. A descriptive study was conducted in the department of pediatrics at Uttar Pradesh Rural Institute of Medical Sciences and Research, Saifai, India, from May 2015 to October 2015. A pretested pro forma was used to record data regarding birth details, modes of transport, stabilization before and during transport, and neonatal condition on admission. The study protocol was fully explained to parents/guardian and written informed consent was obtained. Ethical clearance was obtained from the Institutional Ethical Committee. During the study period, neonates delivered outside our hospital premises (at home, government, private hospitals) and referred to our neonatal intensive care unit were enrolled in the study. Birth details were noted in terms of mode of delivery (vaginal/cesarean section), place of delivery (home, government or private hospital), personnel who conducted the delivery (Dai/skilled birth attendants), stabilization before transport (in Objective: To assess the predictors of neonatal mortality transported to our institution from other hospitals. Methods: In this descriptive study, neonates who were delivered outside of the hospital premises and were referred to our tertiary care teaching institute were enrolled in the study and the following information were recorded -gestational ages in completed week, place of birth, stabilization of newborn before and during transportation, and clinical parameter on hospital arrival. Management of neonatal illness was performed as per the standard protocol. Predictors of neonatal mortality were assessed. Results: Out of 245 referred neonates included in the study, 45 expired. Number of babies delivered at home and conducted by unskilled birth attendant was 46 (18.8%) and at private hospitals was 82 (33.5%). Government ambulance facility for neonatal transport was used only in 80 (32.6%). Among the expired neonate, 73.3% of the babies were delivered by unskilled birth attendants (odds ratio [OR]: 16.60, 95% confidence interval [CI]: 4.57-60.19, p=0.0001). Neonatal mortality was significantly less when baby referred or admitted early, i.e. <24 h age at the time of admission (p=0.02) and total duration of transport <1 h (OR: 0.01, 95% CI: 0.001-0.05, p=0.001). Conclusions: Significant predictors of neonatal mortality were birth weight <1.5 kg, gestational age <28 weeks, duration of transport > 1 h, delivery by traditional birth attendants, oxygen saturation <90%, poor perfusion (capillary refill time), and cyanosis at the time of admission. The most common cause of mortality was birth asphyxia, followed by sepsis and prematurity.
Scimitar syndrome is a congenital anomaly characterized by anomalous drainage of the right lung i... more Scimitar syndrome is a congenital anomaly characterized by anomalous drainage of the right lung into inferior vena cava. This may be associated with other anomalies in the form of pulmonary hypoplasia, systemic arterial supply of right lung, and congenital heart diseases. We report an infant with recurrent pneumonia who turned out to be a case of scimitar syndrome on further workup. The patient was managed surgically by selective embolization of the artery from celiac trunk to sequestered lung. This case report highlights the fact that scimitar syndrome should be suspected in a patient with recurrent pneumonia with typical chest X-ray findings.
The study was conducted on children upto 12 years of age from Pediatric ART Centre at a tertiary ... more The study was conducted on children upto 12 years of age from Pediatric ART Centre at a tertiary care teaching Hospital, New Delhi, India. Children were eligible for HAART based on clinical and immunologic parameters after a diagnosis of HIV infection was made by HIV antibody testing if they were older than
Ventriculitis after meningitis is a serious complication in the neonatal age group. The role of i... more Ventriculitis after meningitis is a serious complication in the neonatal age group. The role of intraventricular antibiotics in treatment is controversial. We present five such cases which were refractory to conventional intravenous antibiotic therapy, had persistent features of ventriculitis and in whom raised intracranial pressure (ICP) necessitated insertion of an external ventricular drain (EVD). Three of the five infants required intraventricular antibiotics but also developed EVD-related complications. Early diagnosis of ventriculitis and treatment is necessary to avoid a fatal outcome. Intravenous antibiotics are the treatment of choice, but intraventricular therapy may be considered in refractory cases. As the incidence of EVD-associated ventriculitis is high, proper care of EVDs and their early removal is mandatory.
After birth, separation of mothers and newborn is a common practice in many hospitals in our coun... more After birth, separation of mothers and newborn is a common practice in many hospitals in our country. After delivery, we take the normal newborn to the radiant warmer in the resuscitation area for routine care. This was the existing process of care at our hospital. The frontline delivery team undertook quality improvement initiative to understand and document factors creating challenges in delivering evidence-based practice of providing immediate skin-to-skin care (SSC), delayed cord clamp (DCC) and early breast feeding within 1 hour of birth. Some of the barriers identified were early newborn mother separation and late transfer of mother from delivery room to the observation area. Additionally, there was a challenge of high delivery load with variation in understanding and provision of SSC and drying on mother's abdomen. These made sustenance of improved care practices difficult. Using the Plan-Do-Study-Act (PDSA) approach some successful change ideas tested were pre-delivery counselling, avoiding separation of mother and newborn at birth by providing SSC and continuing it in the postdelivery observation area and getting family member's help in first breast feed. The delivery team adapted these successful change ideas by multiple iterations, group discussions and feedback. This resulted in improved and sustained compliance of pre-delivery counselling, SSC, DCC and initiating breast feed within 1 hour, from minimal compliance to a median compliance of 51%, 56%, 59% and 61%, respectively, over 36 months period. We undertook this quality improvement initiative at Delhi (India) at a tertiary care teaching hospital. The implementation of WHO recommended evidence-based practices benefitted more than 10 000 mother-newborn dyads annually over 2 years, using Point of Care Quality Improvement method. Implementation of evidence-based practice is possible in challenging situations using PDSA approach. The resultant contextualised processes are convenient and have better success at sustainability.
Moebius syndrome is a rare entity characterized by unilateral/ bilateral facial nerve palsy with ... more Moebius syndrome is a rare entity characterized by unilateral/ bilateral facial nerve palsy with or without other cranial nerve palsies and limb malformations. Etiology is largely unknown. We describe a case of Moebius syndrome who had bilateral facial and abducens nerve palsies and bilateral congenital talipes equino varus with possible cause being fetal misoprostol and mifepristone exposure. Introduction Moebius syndrome is a rare entity, characterized by congenital non-progressive complete/partial, unilateral/bilateral facial nerve palsy with/without other cranial nerve palsies and limb malformations (syndactyly, brachydactyly, absent digits or talipes), cleft palate, micrognathia, microtia, scoliosis, pectorals hypoplasia or other chest wall deformities. (1) Etiology is unknown, probably involving transient ischemia, infections, genetic etiologies and abortifacient (prostaglandin E1). (4) We present a case of Moebius syndrome due to failed abortion at 6 weeks of gestation due to use of misoprostol and mifepristone. Case Report A 1 year old female child presented with acute gastroenteritis. On examination, she was noticed to have failure to thrive (weight 3.8kg, length 60 cms and head circumference 48cms) with global developmental delay. She had bilateral facial palsy, left corneal opacity, bilateral convergent squint suggestive of bilateral sixth cranial nerve palsy, left eye microphthalmia and microcornea, and bilateral club-feet. On inquiry, it was found that mother had taken oral mifepristone 600 mg at 6-week gestation for elective abortion and 2 days later had taken misoprostol 400 μg. One month later, despite significant metrorrhagia, an ultrasound examination showed ongoing pregnancy, with no anomalies observed in the fetus. So, pregnancy was continued. Antenatal ultrasound (USG) at 37weeks gestation showed oligohydramnios with hydrocephalus. The child was born at term, and had a birth weight of 3.2kg. Parents had noticed bilateral congenital talipes equino varus (CTEV) at birth for which an orthopedic surgeon applied a cast. Parents also noticed that baby had feeding difficulty, poor development and facial dysmorphism but they did not seek medical attention for these. On presentation to us, we did MRI brain that showed communicating hydrocephalus. USG abdomen was normal. Chromosomal analysis could not be done because of financial concerns. Diarrhea subsided on oral rehydration therapy and patient was discharged and advised regular follow up. Discussion Moebius syndrome is a rare disorder first described by Von Graefe in 1880 and identified and defined in 1888 by Paul Julius Moebius. It consists of congenital unilateral or bilateral palsy of the abducens (VI) and facial (VII) cranial nerves. (1) It also involves abnormalities of the limbs, chest wall, spine, and soft tissues. Abramson et al actually classified and graded the syndrome on the basis of the clinical findings of cranial nerve palsies and musculoskeletal anomalies by using the acronym CLUFT (cranial nerve, lower limb, upper limb, face, and thorax). (3) This grading system included cranial nerve features of either partial or complete 6th or7th nerve palsies or both; lower extremity findings of talipes equino varus, ankylosis, longitudinal, or transverse deficits; upper extremity involvement with digital hypoplasia or failure of formation; structural facial findings of cleft palate, micrognathia, or microtia; and thoracic findings of scoliosis, pectoral hypoplasia, or other chest wall deformity. Mental retardation and autism were also observed by some authors in one-third of a population of 25 patients with Moebius syndrome. (4) Our patient had bilateral VI and VII nerve palsies with congenital talipes equino varus. Hydrocephalus and microphthalmia was also seen in our patient. Intense vasoconstriction and uterine contraction caused by misoprostol resulting in hypoxia may explain this finding. (5,6) The etiology of Moebius syndrome is multifactorial, and several theories have been proposed, with the most supported theory being that of transient ischemic or hypoxic insult to the fetus (3) Other infectious and genetic etiologies have also been proposed. In addition, the use of misoprostol, a prostaglandin-E1 analogue and abortifacient during pregnancy has also been implicated. (2) Use of oral or vaginal misoprostol during the first trimester of pregnancy significantly reduces uterine arterial blood flow. Doppler resistance indices are significantly increased 60–90 minutes after misoprostol administration (200 μg orally, or 200 μg intra-vaginally plus 200 μg orally) to pregnant women. (7) There are few case reports of Moebius syndrome secondary to the administration of misoprostol. (2,8-12). In several case reports, pregnancies not successfully aborted with mifepristone continued to full term with no adverse effects on the newborn. (13,14] Bernard et al (2013) conducted the first prospective study which found that the rate of major…
Therapeutic Advances in Vaccines and Immunotherapy, 2020
Background: As a part of a measles and rubella (MR) campaign, the MR vaccine replaced the two-dos... more Background: As a part of a measles and rubella (MR) campaign, the MR vaccine replaced the two-dose measles vaccine at 9–12 months and 16–24 months of age under the Universal Immunization Program (UIP). Although adverse events following immunization (AEFIs) following the measles and MMR vaccine at 9 months of age have been studied, AEFIs following the MR vaccine at 9 months of age have not been studied. As the MR vaccine a is very recent introduction in the UIP for routine immunization at 9 months of age, we intend to investigate the AEFI profile of MR vaccination at 9 months of age by active surveillance. Aim: We aimed to study the profile of the AEFIs with MR vaccine at 9-12 months of age in children vaccinated at the immunization clinic at the Pediatrics Department of a tertiary care hospital in East Delhi, India. Methods: Our study was a prospective observational study (telephonic survey). Children who attended Pediatrics OPD for the first dose of the MR vaccine at 9–12 months of...
After birth, separation of mothers and newborn is a common practice in many hospitals in our coun... more After birth, separation of mothers and newborn is a common practice in many hospitals in our country. After delivery, we take the normal newborn to the radiant warmer in the resuscitation area for routine care. This was the existing process of care at our hospital. The frontline delivery team undertook quality improvement initiative to understand and document factors creating challenges in delivering evidence-based practice of providing immediate skin-to-skin care (SSC), delayed cord clamp (DCC) and early breast feeding within 1 hour of birth. Some of the barriers identified were early newborn mother separation and late transfer of mother from delivery room to the observation area. Additionally, there was a challenge of high delivery load with variation in understanding and provision of SSC and drying on mother’s abdomen. These made sustenance of improved care practices difficult. Using the Plan-Do-Study-Act (PDSA) approach some successful change ideas tested were pre-delivery couns...
Ventriculitis after meningitis is a serious complication in the neonatal age group. The role of i... more Ventriculitis after meningitis is a serious complication in the neonatal age group. The role of intraventricular antibiotics in treatment is controversial. We present five such cases which were refractory to conventional intravenous antibiotic therapy, had persistent features of ventriculitis and in whom raised intracranial pressure (ICP) necessitated insertion of an external ventricular drain (EVD). Three of the five infants required intraventricular antibiotics but also developed EVD-related complications. Early diagnosis of ventriculitis and treatment is necessary to avoid a fatal outcome. Intravenous antibiotics are the treatment of choice, but intraventricular therapy may be considered in refractory cases. As the incidence of EVD-associated ventriculitis is high, proper care of EVDs and their early removal is mandatory.
Background: Thrombocytopenia is frequently found in malaria, but its prognostic value has not bee... more Background: Thrombocytopenia is frequently found in malaria, but its prognostic value has not been addressed in children. Bleeding with thrombocytopenia in malaria is not so common but can be a cause of mortality if left unattended. Objective: To study the occurrence and severity of thrombocytopenia with bleeding manifestations in children with malaria. Materials and Methods: This cross-sectional study was conducted in a pediatric hospital of north India. All positive cases of malaria <15 years of age admitted to the hospital between January 2008 and December 2013 were included in the study, and data were recorded on pre-designed pro forma. Patients were further assessed for thrombocytopenia and bleeding manifestations. Data were analyzed by Chi-square test and independent sample t-test using SPSS version 16. Results: Total 185 cases were included in the study with a median age of presentation of 4 years. Plasmodium vivax was identified in 142 (77%) patients, whereas Plasmodium falciparum in 31 (17%) and mixed infection in 12 (6%) patients. Thrombocytopenia was observed in 79 (43%) cases, of which 35 (44%) cases had mild, 30 (38%) cases moderate, and 14 (18%) cases had severe thrombocytopenia. Total 10 (5.4%) patients had bleeding manifestations, and all of these had thrombocytopenia. The most common bleeding manifestation was gastrointestinal bleeding presenting as malena. No significant association was found between bleeding and severity of thrombocytopenia (p=0.527) or species of malaria (p=0.682). Furthermore, no significant association was found between severity of malaria and thrombocytopenia (p=0.365). Conclusion: Thrombocytopenia and bleeding were not significantly associated with the type of malaria. In an endemic area, if a child presents with acute fever and thrombocytopenia with or without bleeding manifestation, diagnosis of malaria should be strongly suspected.
Objectives: Benefits of mother's only milk (MOM) for preterm infants are numerous. We realize... more Objectives: Benefits of mother's only milk (MOM) for preterm infants are numerous. We realized that usage of MOM in our unit is less and often delayed for days. The proportion of MOM usage as the first feed after birth of total feed, was only 19%. In view of this existing evidence and identified problem, we decided to start quality improvement (QI) initiative in our unit with the primary objective “To encourage the use of MOM as first feed in preterm (PT) and very low birth weight (VLBW) neonate from existing 19% to >50% over a period of 3 month.” Materials and Methods: This QI study involved the systematic implementation of evidence-based practices using Point of Care QI methodology developed by the WHO-SEARO. Results: After several Plan, Do, Study, Act, during the intervention phase, usage of MOM increases from baseline 19% to 91.3%. Postintervention, sustained usage of MOM after 6 months is at close to 80%. Conclusions: Effective implementation of comprehensive communication bundles (CCB) is feasible in resource-constraint setting and resulted in sustained increase in the usage of MOM in PT and VLBW neonates.
Background -Neonatal mortality contributes 70% to infant mortality rate which is disproportionate... more Background -Neonatal mortality contributes 70% to infant mortality rate which is disproportionately high. To decrease the neonatal mortality rate, government of India has launched a programme named facility based newborn care all over the India to provide care to the newborns at all levels. FBNC training programme has been started to enhance the knowledge and skills of the care givers. Objective -To evaluate the effectiveness of FBNC training programme in terms of knowledge of the participants in Uttar Pradesh. Methods-A retrospective analytical study has been carried out which analyzed the pretest and post-test scores of six FBNC training programmes conducted at Lucknow, Uttar Pradesh. Result-Overall score in NRP pre-test was 6.24 (±0.65) which increased to 14.32 (±0.85) in post test. The increase from pre-test to post test was 8.07 (±0.64) and this was statistically significant (p=0.0001 ). Similarly, overall score in FBNC pre-test was 2.80 (±0.31) which increased to 8.25 (±0.49) in post test. The increase from pre-test to post test was 5.30 (±0.33) and this was statistically significant (p=0 .0001 ). Conclusion -The written knowledge of the participants increased significantly after the training programmes thereby indicating the effectiveness of the training programme.
Journal of South Asian Federation of Obstetrics and Gynaecology, 2015
Objective To evaluate the effect of maternal oral hydration therapy in 3rd trimester pregnancies ... more Objective To evaluate the effect of maternal oral hydration therapy in 3rd trimester pregnancies with isolated oligohydramnios on amniotic fluid index (AFI) and maternal and perinatal outcome. Materials and methods A prospective study was conducted on 100 pregnant women in 3rd trimester with isolated oligohydramnios. Women were advised to drink 2 liters of fluids orally over 1 hour per day in the form of water, fruit juices, coconut water and to take rest in left lateral position. Amniotic fluid index was re-evaluated by ultrasonography done at 24 hours and then repeated at 48 hours of oral hydration therapy. Difference in prehydration and posthydration AFI was calculated for each selected cases at different intervals. Women were asked to continue the therapy of 2 liters per day orally in addition to routine fluid intake till delivery. All the women were followed till delivery and maternal and perinatal outcome was analyzed. Results The mean AFI increased from 6.23 ± 1.06 cm (pretre...
Cardiac tumors are rare in neonates, most are benign hamartomas (rhabdomyomas) of the muscle cell... more Cardiac tumors are rare in neonates, most are benign hamartomas (rhabdomyomas) of the muscle cells. Due of large size, they may cause homodynamic instability and even death in neonatal period. They are rarely diagnosed prenatally and are found in multiple forms. In $50% of the cases, rhabdomyoma is associated with tuberous sclerosis.
Acta Obstetricia et Gynecologica Scandinavica, 2007
The patient was a 26-year-old primigravida who underwent routine ultrasound examination at gestat... more The patient was a 26-year-old primigravida who underwent routine ultrasound examination at gestational week 18 + 3 according to last menstrual period.The pregnancy had been uneventful with no signs...
n India, neonatal mortality rate (NMR) is 29 per 1000 live birth, and it contributes 56% to the u... more n India, neonatal mortality rate (NMR) is 29 per 1000 live birth, and it contributes 56% to the under 5 mortality (SRS 2012). As per the India Newborn Action Plan, it is expected that India will achieve the goals of "Single Digit NMR" by 2030 . Neonatal mortality reflects overall utilization of health-care services by the community, infrastructure, and involvement of health-care personnel in providing neonatal care. There is a huge gap between urban and rural mortality rates and geographical variation due to inequitable distribution of the health-care services . Previous studies done by Baqui et al. and Narang et al., showed prematurity (32%) as the most important cause of mortality while Aggarwal et al., and Sehgal et al., showed sepsis as the main cause of neonatal deaths. All these studies were conducted in a tertiary care center in urban area. Our aim was to find out the predictors of neonatal mortality among the neonates transported to a tertiary care center in rural area. A descriptive study was conducted in the department of pediatrics at Uttar Pradesh Rural Institute of Medical Sciences and Research, Saifai, India, from May 2015 to October 2015. A pretested pro forma was used to record data regarding birth details, modes of transport, stabilization before and during transport, and neonatal condition on admission. The study protocol was fully explained to parents/guardian and written informed consent was obtained. Ethical clearance was obtained from the Institutional Ethical Committee. During the study period, neonates delivered outside our hospital premises (at home, government, private hospitals) and referred to our neonatal intensive care unit were enrolled in the study. Birth details were noted in terms of mode of delivery (vaginal/cesarean section), place of delivery (home, government or private hospital), personnel who conducted the delivery (Dai/skilled birth attendants), stabilization before transport (in Objective: To assess the predictors of neonatal mortality transported to our institution from other hospitals. Methods: In this descriptive study, neonates who were delivered outside of the hospital premises and were referred to our tertiary care teaching institute were enrolled in the study and the following information were recorded -gestational ages in completed week, place of birth, stabilization of newborn before and during transportation, and clinical parameter on hospital arrival. Management of neonatal illness was performed as per the standard protocol. Predictors of neonatal mortality were assessed. Results: Out of 245 referred neonates included in the study, 45 expired. Number of babies delivered at home and conducted by unskilled birth attendant was 46 (18.8%) and at private hospitals was 82 (33.5%). Government ambulance facility for neonatal transport was used only in 80 (32.6%). Among the expired neonate, 73.3% of the babies were delivered by unskilled birth attendants (odds ratio [OR]: 16.60, 95% confidence interval [CI]: 4.57-60.19, p=0.0001). Neonatal mortality was significantly less when baby referred or admitted early, i.e. <24 h age at the time of admission (p=0.02) and total duration of transport <1 h (OR: 0.01, 95% CI: 0.001-0.05, p=0.001). Conclusions: Significant predictors of neonatal mortality were birth weight <1.5 kg, gestational age <28 weeks, duration of transport > 1 h, delivery by traditional birth attendants, oxygen saturation <90%, poor perfusion (capillary refill time), and cyanosis at the time of admission. The most common cause of mortality was birth asphyxia, followed by sepsis and prematurity.
Scimitar syndrome is a congenital anomaly characterized by anomalous drainage of the right lung i... more Scimitar syndrome is a congenital anomaly characterized by anomalous drainage of the right lung into inferior vena cava. This may be associated with other anomalies in the form of pulmonary hypoplasia, systemic arterial supply of right lung, and congenital heart diseases. We report an infant with recurrent pneumonia who turned out to be a case of scimitar syndrome on further workup. The patient was managed surgically by selective embolization of the artery from celiac trunk to sequestered lung. This case report highlights the fact that scimitar syndrome should be suspected in a patient with recurrent pneumonia with typical chest X-ray findings.
The study was conducted on children upto 12 years of age from Pediatric ART Centre at a tertiary ... more The study was conducted on children upto 12 years of age from Pediatric ART Centre at a tertiary care teaching Hospital, New Delhi, India. Children were eligible for HAART based on clinical and immunologic parameters after a diagnosis of HIV infection was made by HIV antibody testing if they were older than
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