WHO Recommendations for Prevention and Treatment of Maternal Peripartum Infections. September 2015

Key Messages

1. • Bacterial infections around the time of childbirth account for about one-tenth of maternal deaths    and contribute to severe morbidity and long-term disability for many affected women.
2. • Standard infection prevention and control measures are a cornerstone of peripartum infection prevention(e.g.,hand hygiene and use of clean equipment).
3. • WHO recommendations for prevention and treatment of maternal peripartum infections include both recommended and non-recommended interventions during labour, childbirth, and the postpartum period.
4. • Clinical monitoring, early detection, and prompt treatment of peripartum infection with an appropriate antibiotic regimen are essential for reducing death and morbidity in affected women.
5. • Recommendations for antibiotic prophylaxis/treatment for specific indications balance health benefits for the mother and newborn with safety concerns (e.g., adverse effects) and the public health imperative to control antibiotic resistance.

Good Clinical Practice:  
Observe Standard Infection Prevention and Control Measures and Judicious Use of Antibiotics to Control Antimicrobial Resistance 

1. • Identify and correct predisposing factors to infection (e.g., by providing nutritional advice and addressing nutritional deficiencies, anaemia, and other maternal medical conditions [e.g., diabetes]) during antenatal care. 
2. • Promote hand hygiene, use of clean products (e.g., blood products), use of clean equipment, and aseptic surgical practices (e.g., standard skin preparation techniques and proper use of antiseptic agents for surgical site preparation). 
3. • Maintain clean hospital environment (e.g., clean water, appropriate waste disposal, and sanitation).
4. • Develop and implement local protocols on infection prevention and control practices in accordance with existing WHO guidance.
5. • Promote judicious use of antibiotics (administer only for recommended indications; use narrowest antibacterial spectrum and simplest effective dose; verify woman’s history of drug intolerance; monitor local bacteria and antibiotic susceptibility and resistance patterns). 

Cardiac Arrest in Pregnancy AHA scientific statement on maternal resuscitation

October 19, 2015

The American Heart Association’s (AHA) scientific statement on maternal resuscitation includes up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. The statement is intended to help health care providers be prepared and provide the best possible care for a maternal cardiac arrest. Among the recommendations are:

• The newly developed in-hospital and out-of-hospital basic life support and advanced cardiovascular life support algorithms should be the backbone of the response plan to a maternal cardiac arrest.

• Special attention should be paid to manual left uterine displacement (LUD), the difficult airway, and appropriate use of perimortem cesarean delivery (PMCD).

• A maternal cardiac arrest committee must be formed at every institution.

• Emergency response plans specific to each institution must be developed and implemented.

Citation: Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac arrest in pregnancy: A scientific statement from the American Heart Association. [Published online ahead of print October 6, 2015]. Circulation. doi: 10.1161/CIR.0000000000000300. 

Prepare for emergent c-section as soon as cardiac arrest identified in the pregnant woman 

Quickly determine gestational age during initial resuscitation of mother 

Once procedure begins, ideally two teams now working independently 

 CPR is continued on mother Factors that increase the infant’s chance of survival 

 Short interval between arrest and delivery 

 No sustained prearrest hypoxia of mother 

 Minimal or no signs of fetal distress before arrest 

 Aggressive/effective resuscitation of mother 

 Procedure performed in center with neonatal ICU 

 Emergency C-section within rescuer’s procedural range of experience/skills

Katz and colleagues recommended 

 “initiation of C-section within 4 minutes of maternal arrest and fetal delivery within 5 minutes.” These recs have been supported by other studies and consensus panels 

Forms the basis of the “4 minute” rule 

Case reports of prolonged time (>20) do not make this “4 minute rule “ absolute

Vitamin D status is inversely associated with anemia and serum erythropoietin during pregnancy

Findings the STUDY by Thomas C, Guillet R, Queenan R, Cooper E, Kent T, Pressman E, Vermeylen F, Roberson M, O'Brien K; American Journal of Clinical Nutrition (Oct 2015) 

DESIGN The trial was a prospective longitudinal study of 158 pregnant adolescents (aged ≤18 y). Maternal circulating biomarkers of vitamin D and iron were determined at midgestation (∼25 wk) and delivery (∼40 wk). Linear regression was used to assess associations between vitamin D and iron status indicators. Bivariate and multivariate logistic regressions were used to generate the OR of anemia as a function of vitamin D status. A mediation analysis was performed to examine direct and indirect relations between vitamin D status, hemoglobin, and erythropoietin in maternal serum.

BACKGROUND Vitamin D and iron deficiencies frequently co-exist. It is now appreciated that mechanistic interactions between iron and vitamin D metabolism may underlie these associations.
OBJECTIVE We examined interrelations between iron and vitamin D status and their regulatory hormones in pregnant adolescents, who are a group at risk of both suboptimal vitamin D and suboptimal iron status.
RESULTS Maternal 25-hydroxyvitamin D [25(OH)D] was positively associated with maternal hemoglobin at both midgestation and at delivery (P<0 .01="" 25="" 8="" a="" adjustment="" adolescents="" after="" age="" an="" and="" anemia="" associated="" at="" be="" between="" both="" by="" concentrations="" could="" delivery="" direct="" enrollment="" erythropoietin.="" erythropoietin="" explained="" for="" greater="" hemoglobin="" in="" indirect="" inversely="" maternal="" mediated="" midgestation="" nmol="" observed="" odds="" of="" p="" race="" relation="" significant="" than="" that="" the="" those="" times="" was="" with=""> CONCLUSIONS In this group of pregnant adolescents, suboptimal vitamin D status was associated with increased risk of iron insufficiency and vice versa. These findings emphasize the need for screening for multiple nutrient deficiencies during pregnancy and greater attention to overlapping metabolic pathways when selecting prenatal supplementation regimens.

Source: Am J Clin Nutr 

Polio death in Lao renews int'l effort to eradicate polio around world

VIENTIANE, Oct. 17 (Xinhua) -- The recent death of a polio-stricken 8-year-old Lao boy had refocused local and world attention to polio, an ailment which is now almost extinct in other parts of the world.
The death has drawn the attention of policymakers from the 10-member Association of South-East Asian Nations (ASEAN) as they gather in the nation's capital Vientiane for a five-day Ministerial Meeting on Rural Development and Poverty Eradication.
A personal tragedy for the boy's family and a deep concern for local and national Lao health authorities, the death also marks a setback in the global fight against the disease and the attainment of a "polio-free world."
The incident has also drawn attention to the plight of children in the developing country of some seven million, whose population is mostly young people and is set to surpass 10 million by the end of the decade.
One particularly passionate advocate of children in Laos and beyond is United Nations Children's Fund (UNICEF) Country Representative for Laos, China's Ms Hongwei Gao.
Speaking to Xinhua's Vientiane Bureau, Ms. Gao said the death was a reminder that every child must be immunized to prevent polio and other potentially fatal or debilitating illnesses.
"The polio virus can cause lifelong paralysis. There is no cure but it can be prevented by vaccine. We are now close to a polio-free world, but there is only one way to reach it: take action and immunize all children," she said.
Meanwhile, the launch of a national polio vaccination campaign by the country's Prime Minister Thongsing Thammavong Thursday was a demonstration of high level commitment to the cause.
"In the past two or three years the government of Laos has sharply increased this budget allocation to support national immunization program to buy good quality vaccines...this is evidence of action to concretely support child development," Ms. Gao said.
She said Laos had made great strides to achieve the Millennium Development Goals set for 2015, particularly in reducing extreme poverty and hunger, decreasing child and maternal mortality rates, and ensuring that more children are enrolled in schools.
However, Ms. Gao said the country's high rate of malnutrition or under nutrition among some 44 percent of Lao children remained an area requiring continued improvement, particularly in affected rural and remote areas.
"Nutrition is the one indicator where Lao is really lagging behind other countries and this is a huge challenge to national development. If not addressed properly, this would result in huge loss in human capital," she said.
Improved sanitation and food preparation practices and exclusive breastfeeding for the first six months of the child's life are among the remedies, she said.
"What does it take to ensure that a child has good nutritional status?"
It takes, of course, good and sufficient food, and good and efficient feeding practices by parents," Ms. Gao said.
According to Ms. Gao, a well coordinated effort to boost children's safety and their active participation in socio-economic development could particularly benefit countries with young populations such as Laos.        More

Positive Living With Sickle Cell Disease

If you or your child has sickle cell disease (SCD), you should learn as much as you can about the disease. Your health care providers are there to help you, and you should feel comfortable asking questions.

Adopt Healthy Lifestyle

Like all people, you or your child should strive to maintain a healthy lifestyle that includes:

• A nourishing diet
• Enough sleep
• Regular physical activity

People with SCD often tire easily, so be careful to pace yourself and to avoid very strenuous activities.
Don’t smoke and try to avoid second-hand smoke. If you drink alcohol, try to quit and drink extra water to avoid dehydration.

Prevent and Control Complications

Avoid situations that may set off a crisis. Extreme heat or cold, as well as abrupt changes in temperature, are often triggers. When swimming, ease into the pool rather than jumping right in.
Avoid overexertion and dehydration. Take time out to rest and drink plenty of fluids.
Do not travel in an aircraft cabin that is unpressurized.
Take your medicines as your doctor prescribes. Get any medical and lab tests or immunizations that your doctor orders.
See a doctor right away if you have any of the following danger signs:

• Fever
• Stroke symptoms
• Problems breathing
• Symptoms of splenic enlargement
• Sudden loss of vision
• Symptoms of severe anemia

If your child attends daycare, preschool, or school, speak to his or her teacher about the disease. Teachers need to know what to watch for and how to accommodate your child.

Get Ongoing Care

Make and keep regular appointments with your SCD doctor or medical team. These visits will help to reduce the number of acute problems that need immediate care. Avoid seeing your doctor only when you or your child has an urgent problem that needs care right away.
Your SCD medical team can help prevent complications and improve your quality of life.

Coping With Pain

Every person experiences pain differently. Work with your doctor to develop a pain management plan that works for you. This often includes over-the-counter medicines, as well as stronger medicines that you get with a prescription.
You may find other methods that help your pain, such as:

• A heating pad
• A warm bath
• A massage
• Physical therapy
• Acupuncture
• Distracting and relaxing activities, such as listening to music, talking on the phone, or watching TV

Mental Health

Living with SCD can be very stressful. At times, you may feel sad or depressed. Talk to your doctor or SCD medical team if you or your child is having any emotional problems. Tell your doctor right away if you or your child is feeling very depressed. Some people find counseling or antidepressant medicines helpful.
You may find that speaking to a counselor or psychiatrist, or participating in a support group is helpful. When families and friends provide love and support to people with SCD, they can help to relieve stress and sadness. Let your loved ones know how you feel and what you need.

Patients in India With Sickle Cell Anemia Suffer Due To Insufficient Healthcare Services

World Sickle Cell Day with the theme strengthening the primary health services for sickle cell patients is commemorated on June 19 every year. World Health Organization (WHO) estimates that 5% of the world's population is afflicted by genetic blood disorders like sickle cell anemia.

In India, Nagpur is in the center of sickle cell belt and the health services in the city cater to patients from all over Central India. These services, however, leave a lot of scope for improvement.

Maharashtra fares poorly in this regard. Patients depend on tertiary care hospitals for treatment and management of the disease as the primary health centers, rural hospitals and even district hospitals in the state do not provide much.

"Primary health is a secondary issue for the authorities. The benefits of most schemes don't trickle down to the lowest levels at all. When it comes to sickle cell disease, even patients in Nagpur don't have many facilities. A huge number of people suffering from sickle cell disease (SCD) are from rural areas. They are even more helpless, as they cannot afford to run to Mumbai for every little episode or flare up of the condition, which is pretty common," said Sampat Ramteke, President of NGO Sickle Cell Society of India (SCSI).

The situation is so bad that there is just one government-run center in the entire state that conducts a prenatal test for detection of SCD. This center, National Institute of Immuno-haematology at KEM Hospital of Mumbai, is run by Indian Council of Medical Research (ICMR), and not by the state government.

"Conducting prenatal tests is the easiest way to eradicate the disease. There should be more government-run centers as private centers are too expensive for the economically backward classes. Traveling to bigger cities to consult doctors at higher centers is an expensive affair. We often have parents who decide to stop treatment and leave the children to their fate due to lack of funds," said Sanjeevani Satpute, district sickle cell counselor.

Source: Medindia