Objective To predict birth weight at various potential gestational ages of delivery based on data routinely available at the first antenatal visit.Design Individual participant data meta-analysis.Data sources Individual participant data of four cohorts (237 228 pregnancies) from the International Prediction of Pregnancy Complications (IPPIC) network dataset.Eligibility criteria for selecting studies Studies in the IPPIC network were identified by searching major databases for studies reporting risk factors for adverse pregnancy outcomes, such as pre-eclampsia, fetal growth restriction, and stillbirth, from database inception to August 2019. Data of four IPPIC cohorts (237 228 pregnancies) from the US (National Institute of Child Health and Human Development, 2018; 233 483 pregnancies), UK (Allen et al, 2017; 1045 pregnancies), Norway (STORK Groruddalen research programme, 2010; 823 pregnancies), and Australia (Rumbold et al, 2006; 1877 pregnancies) were included in the development of the model.Results The IPPIC birth weight model was developed with random intercept regression models with backward elimination for variable selection. Internal-external cross validation was performed to assess the study specific and pooled performance of the model, reported as calibration slope, calibration-in-the-large, and observed versus expected average birth weight ratio. Meta-analysis showed that the apparent performance of the model had good calibration (calibration slope 0.99, 95% confidence interval (CI) 0.88 to 1.10; calibration-in-the-large 44.5 g, -18.4 to 107.3) with an observed versus expected average birth weight ratio of 1.02 (95% CI 0.97 to 1.07). The proportion of variation in birth weight explained by the model (R2) was 46.9% (range 32.7-56.1% in each cohort). On internal-external cross validation, the model showed good calibration and predictive performance when validated in three cohorts with a calibration slope of 0.90 (Allen cohort), 1.04 (STORK Groruddalen cohort), and 1.07 (Rumbold cohort), calibration-in-the-large of -22.3 g (Allen cohort), -33.42 (Rumbold cohort), and 86.4 g (STORK Groruddalen cohort), and observed versus expected ratio of 0.99 (Rumbold cohort), 1.00 (Allen cohort), and 1.03 (STORK Groruddalen cohort); respective pooled estimates were 1.00 (95% CI 0.78 to 1.23; calibration slope), 9.7 g (-154.3 to 173.8; calibration-in-the-large), and 1.00 (0.94 to 1.07; observed v expected ratio). The model predictions were more accurate (smaller mean square error) in the lower end of predicted birth weight, which is important in informing clinical decision making.Conclusions The IPPIC birth weight model allowed birth weight predictions for a range of possible gestational ages. The model explained about 50% of individual variation in birth weights, was well calibrated (especially in babies at high risk of fetal growth restriction and its complications), and showed promising performance in four different populations included in the individual participant data meta-analysis. Further research to examine the generalisability of performance in other countries, settings, and subgroups is required.Trial registration PROSPERO CRD42019135045

The association between endometriosis and infertility is well established and treatment is challenging. It is a chronic and debilitating disease with multiple pathophysiologic mechanisms. Treatment involves both surgical/medical interventions and ART for those with infertility. Evidence on the ideal approach is inadequate and guidelines vary. The patient’s symptomatology, age, fertility desires and prior surgical interventions are important factors to consider. Fertility preservation is paramount. We present an interesting case of a nulliparous patient who over four years has had recurrent ovarian endometriosis, underwent four laparoscopic surgical/medical interventions, and ultimately achieved a natural conception. Case A 32-year-old female presented in 2019 with symptoms of endometriosis confirmed on pelvic ultrasound. Laparoscopy, the gold standard was performed and the histology confirmed endometriosis. Postoperatively, she was on medical management to control symptoms. However, seven months later, she presented with worsening symptoms despite being on Leuprolide and later Visanne. Ultrasound showed recurrent ovarian endometriosis and uterine fibroids. A Laparoscopic myomectomy, adhesiolysis, and excision of ovarian endometriosis were done. She was then on Visanne but 6 months later her symptoms returned. A scan showed recurrent left ovarian endometriosis and she underwent laparoscopic excision. Her symptoms improved. Two years later she presented with worsening symptoms. A repeat ultrasound scan showed ovarian endometriosis. With a desire to conceive, laparoscopic excision of endometriosis, Adhesiolysis, and chromopertubation were performed. She conceived spontaneously four months later and is currently in her second trimester. Conclusion Treatment for endometriosis is an enigma and has to be individualized. Shared decision-making is important and repeated surgical/medical interventions with fertility preservation are a plausible approach for those keen on child-bearing.

Background: Abruptio placenta refers to premature placental detachment from the uterus. Couvelaireuterus is a rare complication of abruptio placenta marked by blood infiltration of the myometrium followinghemorrhage into the decidua basalis. This is a case of severe early-onset preeclampsia with rapiddeterioration.Case presentation: A 35-year-old primigravida presented at 26 weeks 4 days with frontal headache andelevated blood pressure. On admission, with severe preeclampsia and type 1 fetal growth restriction, thepatient received labetalol, nifedipine, magnesium sulfate, and antenatal steroids. After two days ofhospitalization, she was discharged home to be closely monitored as an outpatient. She was readmittedwith severe hypertension and developed abruptio placenta with fetal death. Following labor induction, thepatient had significant antepartum hemorrhage necessitating an emergency hysterotomy.Intraoperatively, she had postpartum hemorrhage refractory to uterotonics with a Couvelaire uterus.Hemostasis was achieved using B-Lynch brace sutures. She developed hemolysis, elevated liverenzyme and low platelet count (HELLP) syndrome and acute kidney injury. She was transfused withpacked red cells, fresh frozen plasma, and platelets. Hemodynamically unstable, she was admitted to thecritical care unit and later stepped down to ward status and allowed home.Conclusion: Abruptio placenta is a clinical diagnosis, and a high index of suspicion is required becauseprompt action may be lifesaving. Complications such as Couvelaire uterus pose a significant challenge inmanagement and may lead to hysterectomy. However, in select cases, the uterus can be preserved byapplying B-lynch brace sutures.

There is a high association between umbilical cord hemangiomas or cysts with fetal mortality. However, favorable outcome is possible with proper prenatal monitoring and care

Background Takotsubo cardiomyopathy is rare in pregnancy and is characterized by left ventricular dysfunction with apical ballooning. This transient cardiac dysfunction may affect women of childbearing age in the antepartum, intrapartum or postpartum period. Most patients respond well to medical management with resolution of cardiac dysfunction within weeks. Case presentation A 35-year-old female in her second pregnancy presented with severe preeclampsia at 31 weeks of gestation. She subsequently developed severe substernal chest pain and workup showed a stress induced cardiomyopathy prior to her delivery via caesarean section. She had full recovery of her cardiac function by 12 weeks postpartum after medical management. Conclusions Stress induced cardiomyopathy, though rare, should be considered after acute myocardial infarction has been ruled out in gravid females presenting with acute chest pain. Management should involve a multidisciplinary team. Cardiac function recovery is common within 4 weeks although some patients may require long term heart failure management.

International Journal of Case Reports and Images (IJCRI)International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties.Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations.

OBJECTIVE:To assess the accuracy of angiogenic biomarkers to predict pre-eclampsia. DESIGN:Prospective multicentre study. From 2006 to 2009, 5121 pregnant women with risk factors for pre-eclampsia (nulliparity, diabetes, previous pre-eclampsia, chronic hypertension) from Argentina, Colombia, Peru, India, Italy, Kenya, Switzerland and Thailand had their serum tested for sFlt-1, PlGF and sEng levels and their urine for PlGF levels at ⩽20, 23-27 and 32-35weeks' gestation (index tests, results blinded from carers). Women were monitored for signs of pre-eclampsia, diagnosed by systolic blood pressure ⩾140mmHg and/or diastolic blood pressure ⩾90mmHg, and proteinuria (protein/creatinine ratio ⩾0.3, protein ⩾1g/l, or one dipstick measurement ⩾2+) appearing after 20weeks' gestation. Early pre-eclampsia was defined when these signs appeared ⩽34weeks' gestation. MAIN OUTCOME MEASURE:Pre-eclampsia. RESULTS:Pre-eclampsia was diagnosed in 198 of 5121 women tested (3.9%) of whom 47 (0.9%) developed it early. The median maternal serum concentrations of index tests were significantly altered in women who subsequently developed pre-eclampsia than in those who did not. However, the area under receiver operating characteristics curve at ⩽20weeks' gestation were closer to 0.5 than to 1.0 for all biomarkers both for predicting any pre-eclampsia or at ⩽34weeks' gestation. The corresponding sensitivity, specificity and likelihood ratios were poor. Multivariable models combining sEng with clinical features slightly improved the prediction capability. CONCLUSIONS:Angiogenic biomarkers in first half of pregnancy do not perform well enough in predicting the later development of pre-eclampsia.

Background: Universal screening strategy for gestational diabetes mellitus offers biochemical screening to all women irrespective of risk factor status while selective strategy screens only those with risk factors. The Aga Khan University Hospital adopted a selective screening protocol by consensus. This study compares both strategies and the prevalence of risk factors for gestational diabetes. Objectives: To compare screening strategies for gestational diabetes mellitus and determine the risk factors associated with gestational diabetes mellitus at The Aga Khan University Hospital, Nairobi. Methods: A cross-sectional study of 185 participants recruited at ≤ 28 weeks of pregnancy at Aga Khan University Hospital, Nairobi. All had risk factor assessment, a two-step screening with 50 g 1 hour glucose challenge test then a 2 hour 75 g OGTT for those with abnormal 50g 1 hour challenge test. Results: Prevalence of an abnormal screening test in a group with risk factors was 12.0% (95% CI: 6.0% to 17.9%) and in the group without risk factors it was 19.1% (95% CI: 9.5% to 28.7%). GDM prevalence was 1.08% and impaired glucose tolerance 8.65%. Obesity was the commonest risk factor (35.7% with BMI > 30). The data suggests negative correlations though not statistically significant for fasting glucose levels (Pearson correlation coefficient, r = -0.06, p-value = 0.42) and one hour post glucose load (Pearson correlation coefficient, r = -0.11, p-value = 0.58) with BMI. A positive correlation between BMI and blood glucose levels at 2 hours was also not statistically significant (Pearson correlation coefficient, r = 0.07, p-value = 0.36). Conclusion: There was no evidence of a difference between the screening strategies. Obesity was the commonest risk factor in the screened population. There was no significant positive correlation of BMI to measured fasting, 1hr and 2hour glucose levels. This defies known expectations and may be a subject for future research. Keywords: Gestational diabetes mellitus, Universal, Selective, Screening, Obesity

Introduction Propylthiouracil-induced severe hepatotoxicity is a relatively rare occurrence, with very few cases reported in the literature. The management of this complication in pregnancy can be a challenge because of the effects of the various treatment options on the fetus. Case presentation We report a rare case of fulminant hepatic failure in a 36-year-old gravida 2 black woman of African descent that occurred at 17 weeks gestation following propylthiouracil treatment for Graves' disease. Her liver failure was managed by liver transplantation and thyroidectomy. Her pregnancy was continued to term, though with not so favorable early childhood sequelae. Conclusion This case illustrates a very rare complication of treatment with a presumed safe drug during pregnancy followed by adverse neonatal outcomes due to the extensive treatment.

BACKGROUND:Depot medroxyprogesterone acetate (DMPA) may have other noncontraceptive effects that could impact on the quality of life. The objective of this study was to assess the health-related quality of life changes associated with the use of DMPA for contraception.STUDY DESIGN:A prospective, observational study using the Short Form-36 quality of life questionnaire.RESULTS:After 6 months of use, the participants had an improved physical summary score, mean change [5.64 (95% confidence interval [CI], 1.87-9.4), p=.054]. There was no significant change in sexual function [5.33 (95% CI, -2.15 to 12.81), p=.0858] and mental summary score [-0.51 (95% CI, -1.90 to 2.92), p=.432]. The main side effect of DMPA was menstrual irregularity (32.5%); 17.2% of the participants found amenorrhea desirable.CONCLUSION:Besides its contraceptive efficacy, DMPA is associated with an improvement in perceived physical health with no apparent adverse effect on mental health and sexual function.

Objective: To review the histopathologic diagnosis of biopsies taken following visualization of endometriosis at laparoscopy and to correlate visual with microscopic diagnoses. Methods: A retrospective review was undertaken of medical charts with a diagnosis of endometriosis at Aga Khan University Hospital, Nairobi, Kenya, between January 2001 and October 2010. Eligibility included visual diagnosis of endometriosis at laparoscopy, with a clear record of site, size, morphology, and number of lesions. The histopathologic diagnosis of the biopsies sampled was sought. Correlation was undertaken using K statistics for diagnostic variability. Results: Of the 204 relevant records, 152 (74.5%) met the eligibility criteria; from these cases, 239 specimens were submitted for histology. The most common symptom was chronic pelvic pain (108[71.1%]). Most biopsies were obtained from the ovary and posterior cul-de-sac. Histopathologic diagnosis was confirmed in (152 [63.8%]) specimens and correlated with Asian race, multiparity, and chronic pelvic pain. Neither the site of the lesion nor the stage of disease influenced the histopathologic diagnosis. Conclusion: Laparoscopic visualization of endometriosis does not always correlate with histopathologic diagnosis; several other lesions may mimic endometriosis on histopathologic examination. (C) 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Background : Health related quality of life tools have been utilized in assessing many medical conditions; however, there has been minimal use in reproductive health research locally. Objectives : To evaluate the utility of the short form (SF)-36 health survey questionnaires among contraceptive users. Methodology : This was a cross sectional study which formed part a longitudinal observation study conducted over a 6-month period at the Aga Khan University Hospital and the Family Health Options clinics in Nairobi, Kenya among users of depot medroxyprogesterone acetate for contraception. The main outcome measures were the eight scales within the SF 36 health profile. Kline’s criterion of 0.4 was used to test for inter scale correlations while the internal consistency was measured by the Cronbach’s alpha using the Nunnally’s criterion of 0.7. Results : The SF-36 questionnaire was administered to 107 consenting clients. The mean scores for the eight scale SF-36 questionnaire were: physical functioning 81.4 (SD 22.4), social functioning 77.3 (SD 19.4), role limitation attributed to physical problem 81.6 (SD 31.6), role functioning attributed to emotional problems 76.3 (SD 35.5), energy and fatigue 66.9 (SD 16.4), mental health 71.4 (SD 17.5), general health 74.1 (SD 14.5) and pain 79.7 (SD 22.1). The SF-36 questionnaire satisfied rigorous psychometric criteria for reliability and internal consistency for 6 of the 8 scales. The item scale correlation persistently exceeded 0.4 for all variables. Conclusion : These results provide support for use of SF-36 and other medical outcome survey tools as potential measures of quality of life among contraceptive users in the local population. Keywords : Health related quality of life, contraceptives, depot-medroxyprogesterone acetate, RAND SF-36