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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Case report
Full Version
Partial Exchange Transfusion in the Management of a Preterm Neonate with Severe Anaemia from Acute Foetomaternal Haemorrhage: A Case Report
Correspondence Address :
Basany Laxman,
Flat 301, B Block, Legend Galaxy Apartment, Kothapet, Hyderabad-500035, Telangana, India.
E-mail: laxmanbasani@yahoo.co.in
Foetomaternal Haemorrhage (FMH) refers to the passage of foetal blood into the maternal circulation. FMH is rarely diagnosed antenatally as clinical findings are subtle and non specific. Massive FMH is suspected when foetal movements are decreased, and Cardiotocographic (CTG) findings are abnormal with decreased heart rate variability, saw-tooth or a sinusoidal pattern. Massive FMH can lead to foetal demise, stillbirth, hydrops, or the birth of a severely anaemic infant with hypovolaemic shock. A 35-week pregnant woman presented with decreased foetal movements, and an emergency caesarean section was performed due to late deceleration on the cardiotocograph. The baby was very pale at birth and in shock. The Kleihauer-Betke (KB) test performed on the mother’s blood shortly after delivery showed 2.7% foetal red cells, suggesting 135 cc of FMH. The clinical features and outcome of FMH depend on the gestational age, volume, and rapidity of FMH, as well as, whether it is acute or chronic. Packed cell transfusion is recommended, but in babies with severe anaemia and cardiac failure, partial exchange transfusion is performed. The baby was managed with a fluid bolus, inotropic support, respiratory support, and partial exchange transfusion, resulting in a successful outcome. A high index of suspicion enables the obstetrician to undertake diagnostic tests, cordocentesis, plan for intrauterine transfusion or delivery, and alert the neonatal team for a better outcome.
Bleeding, Foetal movement, Hypovolaemic shock, Maternal circulation
A late preterm baby, born at 35 weeks of gestation, was retrieved from a private hospital at 30 minutes of age due to respiratory distress and pallor. This baby was born to a 26-year-old primigravida mother by emergency caesarean section done because of foetal distress. The antenatal period was uneventful until 12 hours prior to delivery when the mother noticed decreased foetal movements and the cardiotocograph showed late deceleration. There was no significant family or antenatal history.
There was no evidence of abruption, the placenta was pale, and the amniotic fluid was clear. The baby required positive pressure ventilation for one minute, and the Appearance, Pulse, Grimace, Activity and Respiration (APGAR) scores were 1, 3, and 8 at 1, 5, and 10 minutes, respectively. The baby was pale with a birth weight of 2100 grams. The baby developed respiratory distress soon after birth and was shifted to the Neonatal Intensive Care Unit. On examination, the vital signs were as follows: temperature 97.2°F, heart rate 162 beats per minute, respiratory rate 64 cycles per minute, blood pressure {Non invasive Blood Pressure (NIBP)} 42/26 mmHg (mean of 30 mmHg), and Saturation of Peripheral Oxygen (SPO2) of 92% in Fraction of Inspired Oxygen (FiO2) of 0.60. The baby exhibited clinical features of shock, including cold extremities, low volume pulses, and a delayed capillary refill time of 5-6 seconds.
Arterial Blood Gas (ABG) showed severe mixed acidosis, and a Complete Blood Picture (CBP) showed severe anaemia (Table/Fig 1). As the respiratory distress worsened, the baby was commenced on Synchronised Intermittent Mandatory Ventilation (SIMV) mode of mechanical ventilation. Due to severe anaemia, shock, and haemodynamic instability, a partial exchange transfusion was performed with 75 mL of O group Rhesus negative packed red blood cells at four hours of life. The post-transfusion Haemoglobin (Hb) level was 13.9 gm/dL with a Haematocrit (Hct) of 42%. Shock was managed with a saline bolus and inotrope (adrenaline cellsinfusion). The baby had mild jaundice, and the maximum bilirubin level was 11.2 mg/dL on day 5 of life, which required no specific management.
The thyroid profile was normal, and there was no blood group incompatibility in the baby. Serology for toxoplasma, rubella, cytomegalovirus, herpes and parvovirus B19 infections was negative, and the direct Coombs test was negative. The blood groups of the baby and mother were O Rhesus positive. The KB test performed on the mother’s blood sample shortly after delivery showed 2.7% foetal red cells, which corresponded to 135 cc of FMH.
The baby was extubated at 52 hours of life; however, the baby had feeding intolerance. The baby was on antibiotics for 72 hours, and subsequent sepsis screens were negative. The blood culture was found to be sterile. The baby reached full enteral feeds on day 9 of life, and the subsequent course was uneventful. The baby was discharged on day 10 of life, and growth and development were normal at six months of age on follow-up.
Spontaneous FMH is defined as the transfer of foetal blood into maternal circulation without trauma or placental abruption (1). The ability of foetal red cells to enter maternal circulation was first reported by Wiener in 1948 and later confirmed by Chown B in 1954 (2),(3). The majority of FMH cases are of low volume (<0.1 mL) and occur in 39-98% of pregnancies without haemodynamic significance, but they can cause alloimmunisation. FMH of >20 mL occurs in 4.6 per 1000 live births, and >80 mL occurs in 0.7 per 1000 live births. Massive FMH, defined as >150 mL of foetal haemorrhage, occurs in 1 per 5000 live births. FMH is associated with nearly 14% of foetal deaths and 12.5% of stillbirths (4).
When FMH is suspected, maternal blood is tested for foetal red cells, and the most common test performed is the acid elution or KB test. In this test, maternal blood is fixed, washed with acid, and stained. The maternal cells appear as ghost cells, which are manually counted, and FMH is calculated based on the percentage of foetal cells. The KB test is influenced by temperature, pH, staining, intrauterine transfusion, maternal Foetal Haemoglobin (HbF) level, and can overestimate blood volume, with FMH volumes of 400-700 mL reported in the literature (1),(5).
Other tests include the rosette test, flow cytometry, High-Performance Liquid Chromatography (HPLC), and serum alpha-foetoprotein (6). The rosette test is a qualitative test, and if positive, it warrants a quantitative test. Flow cytometry is more accurate than the KB test but is not widely available (7). Following FMH, α-fetoprotein levels increase in maternal serum, which helps estimate the volume of FMH (8).
The baby in this case was severely anaemic and required resuscitation, fluid bolus, inotrope, and respiratory support. Hence, a partial exchange transfusion was performed instead of a blood transfusion. Naulaers G et al., performed partial exchange transfusions in two neonates with severe anaemia due to massive FMH (9). Naulaers G et al., also reported 100 mL of FMH in a 34-week preterm neonate with an Hb of 5.6 gm/dL, similar to the index case, but the neonate was treated with Packed Red Blood Cell (PRBC) transfusion as they were stable (9). Miyahara J et al., performed a partial exchange transfusion with successful outcomes in a preterm neonate with severe anaemia (Hb-1.2 gm/dL) due to FMH (10). The volume of partial exchange transfusion is calculated according to the formula: Volume of packed cells to be transfused=blood volume×(Desired Hct-Observed Hct)/(Hct of packed cells-Observed Hct) (11).
Other rare causes of anaemia, such as intrauterine infections and maternal parvovirus infection, were ruled out by viral studies. FMH is calculated using the formula: Stained cells/unstained cells×maternal blood volume=FMH in mL. One foetal cell per 1000 maternal cells (0.1% foetal cells) corresponds to 5 mL of FMH (12). The index case had severe anaemia (Hb-5.6 gm/dL), and the KB test showed 2.7% foetal cells, which corresponds to 135 mL of FMH, representing a blood loss of 51.9 mL/kg.
The initial symptoms of acute FMH are often subtle and non specific. Occasionally, the mother presents with fever, chills, and nausea, which suggests a transfusion reaction. The triad of decreased foetal movement, sinusoidal heart rate and hydrops foetalis suggests massive FMH (13). Disruption of the maternal-foetal barrier leads to FMH, as the blood pressure in foetal blood vessels is higher than in the intervillous space. In the setting of ABO incompatibility, the maternal clotting system is activated, and placental clots limit FMH. FMH can occur following maternal abdominal trauma, chorioangioma, abruption, monozygotic twins, and as a result of obstetric procedures such as external cephalic version, amniocentesis, and manual removal of the placenta. Severe FMH can lead to hydrops, disseminated intravascular coagulation, hypoxic-ischaemic encephalopathy, cerebral infarction, intraventricular haemorrhage, and periventricular leukomalacia. The differential diagnosis of neonatal anaemia includes haemolytic anaemia, congenital viral infections, erythrocyte membrane defects, red cell enzyme defects, haemoglobinopathies, congenital hypoplastic anaemia and leukaemia (14).
The management of massive FMH depends on gestational age, the availability of facilities for cordocentesis, foetal transfusion, and neonatal care. FMH at ≥34 weeks gestation with foetal distress warrants immediate delivery. At ≤32 weeks of gestation, Intrauterine transfusion (IUT) can be considered, if facilities are available. If the haemorrhage continues, serial transfusions may be indicated. Exchange transfusion allows for rapid correction of anaemia without volume overload or cardiac compromise (9),(10),(11).
Literature search showed that neonates with Hb <4.5 g/dL are associated with a poor outcome, and babies with Hb >4.8 g/dL had a normal neurodevelopmental outcome. Christensen RD et al., reported a normal outcome in neonates with Hb >4 g/dL and adverse outcomes if Hb was <4 g/dL (15). The importance of foetal movement counts should be emphasised during counseling in the third trimester. Non stress tests, sonograms and doppler studies help assess foetal anaemia and guide obstetric management. The findings in the present study are compared with previous studies in (Table/Fig 2) (5),(9),(10),(14).
The FMH should be considered when a pregnant mother presents with decreased foetal movements, foetal distress, and a pale baby at birth. Although the symptoms of FMH can be subtle and non specific, reduced foetal movements, abnormal CTG, Coombsnegative anaemia, and the KB test can help diagnose FMH. Despite the limitations of the KB test, it helps quantify FMH. Partial exchange transfusion with PRBC is preferred over transfusion in unstable babies. Maintaining a high index of suspicion for FMH, monitoring CTG, considering emergency delivery, and providing resuscitation, stabilisation, and partial exchange transfusion in unstable babies improve outcomes without adverse effects.
DOI: 10.7860/JCDR/2024/64995.18941
Date of Submission: Apr 25, 2023
Date of Peer Review: Jul 15, 2023
Date of Acceptance: Oct 23, 2023
Date of Publishing: Jan 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 05, 2023
• Manual Googling: Aug 11, 2023
• iThenticate Software: Oct 20, 2023 (9%)
ETYMOLOGY: Author Origin
EMENDATIONS: 7
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
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