Assessment of fetal cardiac function in early fetal life: feasibility, reproducibility, and early fetal nomograms

BACKGROUND

Fetal cardiology has shown a rapid development in the past decades. Fetal echocardiography is not only used for the detection of structural anomalies but also to assess fetal cardiac function. Assessment of the fetal cardiac function is performed mostly in the second and third trimesters. The study of fetal cardiac function at the end of first trimester has not been investigated properly, and there is a lack of reference values at early gestational weeks.

OBJECTIVE

This study aimed to assess if the measurement of time-related parameters of cardiac function in the left ventricle of the fetal heart is feasible and reproducible at the end of the first trimester. If possible, we provide nomograms of these parameters from 11 to 13+6 gestational weeks.

STUDY DESIGN

We conducted a prospective observational study from March to September 2022. The study was carried out in 2 hospitals (Hospital Universitari Dexeus, Barcelona, and Hospital VITAHS 9 Octubre, Valencia, Spain). The scans were performed by 3 specialists in fetal medicine. The exclusion criteria were fetal cardiac rhythm abnormalities, abnormal nuchal translucency, abnormal ductus venosus, fetal malformations, stillbirth, estimated fetal weight <10 percentile, diabetes, and gestational hypertensive disorders. The cardiac function parameters studied in the left ventricle were isovolumetric contraction time, isovolumetric relaxation time, ejection time, filling time, cycle time, myocardial performance index, ejection time fraction, and filling time fraction. We study the feasibility and intra- and interobserver reproducibility of these parameters using the interclass correlation coefficient. Nomograms were created and the percentiles of the values of the different parameters were calculated.

RESULTS

A total of 409 cases were recruited but only 296 could be included in the statistical analysis once the exclusion criteria were applied. The intraobserver reproducibility study was excellent (interclass correlation coefficient >0.900), and the interobserver reproducibility study was good (interclass correlation coefficient >0.700). The data regression analysis showed that cycle time, filling time, isovolumetric contraction time, and filling time fraction increased with gestational age, whereas ejection time fraction decreased with gestational age and myocardial performance index (mean, 0.43±0.08), isovolumetric relaxation time (mean, 0.04±0.01), and ejection time (mean, 0.16±0.01) remained constant from 11 to 13 weeks.

CONCLUSION

The study of fetal cardiac function is feasible and reproducible at 11 to 13+6 gestational weeks. Nomograms of the studied parameters are provided.

Prevalence of corpus callosum pathology in an unselected population. Should assessment of the corpus callosum be included in the routine 20 weeks scan?

OBJECTIVES

To determine the prevalence of abnormalities of the corpus callosum (AbnCC) in a non-selected population, to propose a systematic screening protocol for AbnCC in all populations through direct assessment, and to describe the follow-up and prognosis of all AbnCC cases diagnosed in our clinical setting.

METHODS

This was a retrospective review of the prevalence of AbnCC over 11 years. We included a sagittal assessment of the corpus callosum (CC) in the second-trimester scan. AbnCC was classified into complete agenesis of CC (ACC) and dysgenesis of CC (DCC; including small, partial agenesis, thick and with lipoma).

RESULTS

Of the 38,586 second-trimester scans performed during our screening, 43 cases of AbnCC were detected (prevalence of 0.8/1000). Of the AbnCC cases, 10 cases were identified as ACC (29.40%) and 24 as DCC (70.59%). Follow-up investigations showed that in the 43 cases with AbnCC, 76.5% had other associated ultrasound abnormalities, 26.5% had genetic abnormalities, 11.8% had other MRI abnormalities, and 25% of the children had neurodevelopmental delays (8.8% of the total), which were severe in only one case.

CONCLUSIONS

AbnCC is found in approximately 0.8/1000 of cases in an unselected population. The findings suggest that systematic and direct assessment of the CC as part of screening ultrasound in the second trimester of gestation should be recommended as a routine practice.

Prenatal screening after preimplantation genetic testing for aneuploidy: time to evaluate old strategies

RESEARCH QUESTION

How does first-trimester aneuploidy screening perform in pregnancies achieved through IVF with preimplantation genetic testing for aneuploidy (PGT-A) in a medical setting?

DESIGN

This retrospective cohort study was undertaken in a single tertiary care centre between January 2013 and June 2022. In total, 20,237 women had prenatal follow-up at the study centre and were included in the study. The women were divided into three groups: singleton pregnancies conceived through the transfer of a PGT-A-screened euploid embryo (n = 510); singleton pregnancies conceived through IVF without PGT-A (n = 3291); and singleton pregnancies conceived naturally (n = 16,436).

RESULTS

The conventional combined screening test for pregnancies conceived through IVF with PGT-A had specificity of 91%; sensitivity could not be calculated as there were no cases of fetal aneuploidy in this group. In 89.1% of pregnancies conceived through IVF with PGT-A with high risk for trisomy 21, 18 or 13, the result was related to advanced maternal age (>35 years at time of screening).

CONCLUSIONS

The current screening strategy for trisomies 21, 18 and 13 can generate unnecessary tests in pregnancies achieved through IVF with PGT-A. A new protocol is needed for these patients, with greater weight given to ultrasound markers.

Impact of a Successful Percutaneous Mitral Paravalvular Leak Closure on Long-term Major Clinical Outcomes

BACKGROUND

Percutaneous mitral paravalvular leak (PVL) closure techniques are an effective and safe alternative to surgical treatment, but data regarding long-term outcomes are scarce. We aim to describe the impact of successful percutaneous mitral PVL closure on long-term outcomes.

METHODS

All consecutive patients in whom a first-attempt percutaneous mitral PVL closure was performed in a single tertiary centre between January 2010 and October 2021 were included. Clinical variables, procedural details, and procedural success were collected. Patients were classified based on procedural success, defined as no more than mild residual leak. All-cause mortality was the primary endpoint. Cardiovascular death and heart failure hospitalizations (HFHs) were key secondary endpoints.

RESULTS

Ninety patients (median age 72.5 years [66.0-78.4]; median EuroSCORE-II 8.2 [5.3-12.46]) were included. Although reduction of at least 1 degree in PVL severity was achieved in 82 (91.1%), procedural success was achieved in 47 (52.2%). Chronic kidney disease, previous surgery for PVL, and the presence of multiple jets were independently associated with procedural failure. After a median follow-up of 3.2 (1.2-5.2) years, mortality rate was higher in the procedural failure group (27.3 per 100 patients-years) compared with the group with successful closure (8.2 per 100 patient-years). Procedural failure was associated with all-cause death (adjusted hazard ratio [aHR], 2.59; 95% confidence interval [CI], 1.41-4.78), cardiovascular death (aHR, 3.53; 95% CI, 1.67-7.49) and HFH (aHR, 3.27; 95% CI,1.72-6.20).

CONCLUSIONS

A successful reduction in PVL to mild or absent is associated with improved rates of all-cause death, cardiovascular death, and HFHs.

Spontaneous reperfusion enhances succinate concentration in peripheral blood from stemi patients but its levels does not correlate with myocardial infarct size or area at risk

Succinate is enhanced during initial reperfusion in blood from the coronary sinus in ST-segment elevation myocardial infarction (STEMI) patients and in pigs submitted to transient coronary occlusion. Succinate levels might have a prognostic value, as they may correlate with edema volume or myocardial infarct size. However, blood from the coronary sinus is not routinely obtained in the CathLab. As succinate might be also increased in peripheral blood, we aimed to investigate whether peripheral plasma concentrations of succinate and other metabolites obtained during coronary revascularization correlate with edema volume or infarct size in STEMI patients. Plasma samples were obtained from peripheral blood within the first 10 min of revascularization in 102 STEMI patients included in the COMBAT-MI trial (initial TIMI 1) and from 9 additional patients with restituted coronary blood flow (TIMI 2). Metabolite concentrations were analyzed by ¹H-NMR. Succinate concentration averaged 0.069 ± 0.0073 mmol/L in patients with TIMI flow ≤ 1 and was significantly increased in those with TIMI 2 at admission (0.141 ± 0.058 mmol/L, p < 0.05). However, regression analysis did not detect any significant correlation between most metabolite concentrations and infarct size, extent of edema or other cardiac magnetic resonance (CMR) variables. In conclusion, spontaneous reperfusion in TIMI 2 patients associates with enhanced succinate levels in peripheral blood, suggesting that succinate release increases overtime following reperfusion. However, early plasma levels of succinate and other metabolites obtained from peripheral blood does not correlate with the degree of irreversible injury or area at risk in STEMI patients, and cannot be considered as predictors of CMR variables.Trial registration: Registered at www.clinicaltrials.gov (NCT02404376) on 31/03/2015. EudraCT number: 2015-001000-58.

Fetal Megacystis: Associated Structural Abnormalities and Obstetric Outcomes

Purpose: We evaluated the obstetrical outcomes, ultrasonographic characteristics, and final diagnosis in pregnancies with fetal megacystis (FM). Methods: We evaluated the obstetrical outcomes and associated structural abnormalities of fetuses with FM detected between FM between 2000 and 2021. Results: 17 FM were diagnosed, 16 had follow up. 16 were early megacystis. 14/16 (87.5%) of pregnancies were terminated, 1/16 (6.25%) resulted in intrauterine death, and 1/16 (6.25%) survived. FM was associated with 13 other abnormal sonographic findings in 12/16 (75%) pregnancies. The most common associated ultrasound abnormality was umbilical cord cyst in 3/16 (18.75%). Recognized etiologies included posterior urethral valves (2), trisomy 18 (2), trisomy 13 (1), Prune Belly syndrome (1), and Megacystis-Microcolon-Hypoperistalsis syndrome (1). Conclusion: Most FM are detected in the 2nd trimester, most are electively terminated, are associated with other ultrasonic abnormalities in 75%, most commonly umbilical cord cyst, and have an identifiable cause in 44%.

Angiogenic factors assessment in a preeclampsia high risk population for the prediction of small-for-gestational age neonates: a prospective longitudinal study

OBJECTIVE

Compare cross-sectional versus longitudinal models for prediction of small-for-gestational age (SGA) neonates among pregnancies with high risk of early preeclampsia (PE).

METHODS

A prospective longitudinal study was performed in Hospital Universitary Dexeus, Barcelona. Study population included 390 pregnancies with high risk of early PE according 1^st trimester algorithm. Cross-sectional models combining first trimester risk plus PlGF and sFlt-1/PlGF ratio, respectively, were created at 19-22, 24-26 and 27-30 weeks and compared with a model assessing longitudinal changes of these parameters. Models adding mean Uterine artery pulsatility index (UtA PI) and abdominal circumference (AC) were evaluated. SGA neonates were defined as birthweight less than the 10^th centile.

RESULTS

The predictive performance of a model assessing longitudinal changes of angiogenic factors was similar to that of single evaluations at second and early third trimester. The performance of the models combining angiogenic factors with mean UtA PI and AC was better than those using only biochemical markers. However, the longitudinal evaluation of biochemical and biophysical parameters did not perform better than cross-sectional evaluations.

CONCLUSIONS

Evaluation of angiogenic factors are useful for prediction of SGA neonates in a high-risk population of early PE. However, longitudinal models do not increase their predictive capacity.

Pulmonary vein isolation without fluoroscopy: results evaluation

Introduction

From the outset, the use of Xray (XR) has been a critical component in both the guidance and development of arrhythmia ablation procedures. At present however, due to the complex nature of electrophysiology procedures, the use of XR in isolation is not sufficient to ensure procedural success. Subsequently, the use of non-fluoroscopic virtual mapping systems is essential. Currently, given the evolution of this technology and its essential nature for procedural guidance, it is worth asking whether the use of XR is indeed still necessary in the modern era. The objective of this study was to demonstrate that “zero-XR” ablation of complex arrhythmias such as atrial fibrillation is both possible and safe.

Methods

Between 2020 and 2021, a total of 116 patients admitted for pulmonary vein ablation were included in the study. Amongst these, 41 patients were prospectively included at our centre, in a protocol for point-by-point ablation of pulmonary veins without fluoroscopy, “zero-XR”. In addition to the non-fluoroscopic mapping system, the transseptal puncture was monitored by intracardiac ultrasound in all cases. The objective of the ablation was the complete isolation of the pulmonary veins. In some patients, at the discretion of the operator, the ablation of other substrates was added. For the remaining 75 patients in the study, the ablation was performed using conventional techniques without the limitation of the use of XR. The mean follow up was 12 months.

Results

The baseline characteristics of the patients, as well as the description of the procedure, are shown in the Table. There were no differences in the acute success rate or procedure time between the two groups. There was only one complication related to the procedure in the non-XR group consisting of pericardial effusion without cardiac tamponade. Regarding the recurrence rate at 12 months, it was higher in the group with fluoroscopy, without reaching statistical significance [n=0 in the group without fluoroscopy, n=2 (2.7%) in the group with fluoroscopy, p=0.15].

Conclusion

In our series, point-by-point ablation of atrial fibrillation without fluoroscopy proved to be a safe and feasible technique, with similar success rates when compared to conventional procedures using XR.

Funding Acknowledgement

Type of funding sources: None.

The use of antenatal corticosteroids for fetal maturation: clinical practice guideline by the WAPM-World Association of Perinatal Medicine and the PMF-Perinatal Medicine foundation

This practice guideline follows the mission of the World Association of Perinatal Medicine in collaboration with the Perinatal Medicine Foundation, bringing together groups and individuals throughout the world, with the goal of improving the use of antenatal corticosteroids (ACS) for fetal maturation. In fact, this document provides further guidance for healthcare practitioners on the appropriate use of ACS with the aim to increase the timely administration and avoid unnecessary or excessive use. Therefore, it is not intended to establish a legal standard of care. This document is based on consensus among perinatal experts throughout the world and serves as a guideline for use in clinical practice.

The use of antenatal corticosteroids for fetal maturation in COVID-19: clinical practice statement by WAPM-World Association of Perinatal Medicine and the PMF-Perinatal Medicine Foundation

This statement follows the mission of the World Association of Perinatal Medicine in collaboration with the Perinatal Medicine Foundation, bringing together groups and individuals throughout the world with the goal of improving the use of antenatal corticosteroids (ACS) for fetal maturation in Coronavirus Disease 2019 (COVID-19). Pregnant women with COVID-19 are at increased risk of hospitalization, admission to intensive care unit and mechanical ventilation compared to non-pregnant patients. Thus, obstetricians may face the dilemma of initiating maternal corticosteroid therapy for maternal indication while weighing its potential adverse effects on the fetus. As there is no evidence on the effect of betamethasone in pregnant women with COVID-19, dexamethasone should be preferably used for fetal maturation, if available. As a recommendation, for pregnant women with COVID-19 who are oxygen dependent or under mechanical ventilation and meet the criteria for ACS, the usual doses of dexamethasone should be administered, followed by oral prednisolone 40 mg OD or intravenous hydrocortisone 80 mg BD for up to 10 days.

The use of antenatal corticosteroids for fetal maturation: clinical practice guideline by the WAPM-World Association of Perinatal Medicine and the PMF-Perinatal Medicine Foundation

This practice guideline follows the mission of the World Association of Perinatal Medicine (WAPM) in collaboration with the Perinatal Medicine Foundation (PMF), bringing together groups and individuals throughout the world with the goal of improving the use of antenatal corticosteroids (ACS) for fetal maturation. In fact, this document provides further guidance for healthcare practitioners on the appropriate use of ACS with the aim to increase the timely administration and avoid unnecessary or excessive use. Therefore, it is not intended to establish a legal standard of care. This document is based on consensus among perinatal experts throughout the world and also serves as a guideline for use in clinical practice.

Cesarean rate in selected hospital network of private sector: A retrospective study

INTRODUCTION

In Spain over the last two decades, cesarean section (CS) rates have increased from 15 to 25% in the Public Health Sector and from 28 to 38% in the private sector. There are multiples causes for this rise, which are often unclear. The aim of our study is to collect and analyze all the CS rates data from a hospital network of the 42 Quirónsalud Hospitals (private sector) and to assess its distribution regarding the different types of hospitals and patient characteristics.

MATERIAL AND METHODS

An observational retrospective study between 2017 and 2018 was performed. Hospitals are classified into three groups: large hospitals (11), medium hospitals (17) and small hospitals (14). The cesarean section rate was measured by patient categorization into three groups: total deliveries, low risk cesarean sections and low risk cesarean sections without previous cesarean delivery.

RESULTS

We analyzed 62,685 deliveries: 42,987 were vaginal deliveries (68.6%) and 19,698 CS (31.4%). The mean age for the total number of deliveries was 34.18 years old, whilst the mean age for the low-risk group was 34.12. Of the 19,698 CS, 18.36% (3618) were in high-risk population and 81.63% (16,080) in low risk population. 69.54% (11,183) of the low-risk CS were in patients without a previous CS.

CONCLUSIONS

The overall rate of CS in the Quirónsalud group is slightly higher than the one from the Public Healthcare. The older maternal age as well as the hospital resources involved in the delivery attendance can explain this difference.

Présentation clinique, survie et facteurs associés à la mortalité: une étude prospective dans trois centres COVID-19 en Afrique de l’Ouest

Introduction

En Afrique, bien que le nombre total de décès dus a la COVID-19 semble plus faible quand dans les pays du nord, il existe peu de données sur la gravité de la maladie. Nous rapportons ici le tableau clinique et l’issue chez les malades infectés par le SARS-CoV-2 et suivis dans les centres de traitement COVID-19 (CTC) de deux pays d’Afrique de l’Ouest.

Matériels et méthodes

Le Burkina Faso et la Guinée ont mis en place trois CTC de référence pour hospitaliser tous les malades infectés par le SARS-CoV-2, quelle que soit leur gravité. Nous présentons les données recueillies auprès de ces patients symptomatiques hospitalisés dans ces trois CTC, entre mars et novembre 2020. Les données ont été collectées à l’aide du formulaire de déclaration des cas de COVID-19 de l’OMS. Une régression logistique a été réalisée pour analyser l’association entre l’évolution défavorable et les caractéristiques cliniques à l’admission.

Résultats

Au total, 1805 patients (1151 [64 %] hommes, âge médian 41 ans, 22 % [388] ≥ 60) ont été admis avec un COVID-19 confirmé. La durée médiane entre le début des symptômes et l’admission en CTC était de 7 jours (IQR : 4–11). Les symptômes principaux à l’admission était l’asthénie (748, 41 %) et la toux (833, 46 %) et près de la moitié des patients (867, 48 %) présentaient une forme légère de la maladie. Au cours de l’hospitalisation, 443 (25 %) patients ont présenté au moins une fois une SpO₂ < 94 %, 237 (13 %) ont reçu une oxygénothérapie et 266 (15 %) ont été traités par des corticostéroïdes. La quasi-totalité (1697, 95 %) des patients a reçu un traitement dit spécifique (hydroxychloroquine ± azithromycine ± lopinavir/ritonavir). La mortalité globale était de 5 %, elle était de 1 %, 5 % et 14 % chez les patients de < 40, 40–59 et ≥ 60 ans. Trente et un pou cent des patients atteignaient un critère de composite d’évolution défavorable comportant le décès ou la désaturation (< 94 %) ou la mise sous oxygène. En analyse multivariée, le risque de décès était plus élevé chez les hommes (aOR : 2, IC95 % : 1,1–3,6), les personnes âgées ≥ 60 ans (aOR : 2,9, IC95 % : 1,7–4,8) et celles souffrant d’hypertension artérielle chronique (aOR : 2,1, IC95 % : 1,2–3,4). Le risque d’évolution défavorable était plus élevé chez les hommes (aOR : 1,6, IC95 % : 1,3–2,1), les personnes âgées ≥ 60 ans (aOR : 3,1, IC95 % : 2,4–4), celles souffrant d’hypertension artérielle chronique (aOR : 1,7, IC95 % : 1,3–2,2) ou de diabète (aOR : 2,3, IC95 % : 1,6–3,1).

Conclusion

La maladie à COVID-19 est aussi grave en Afrique qu’ailleurs et les facteurs de risque de décès sont identiques que dans les pays du nord.

"Screening for small-for-gestational age neonates at early third trimester in a high-risk population for preeclampsia"

BACKGROUND

Strategies to improve prenatal detection of small-for-gestational age (SGA) neonates are necessary because its association with poorer perinatal outcome. This study evaluated, in pregnancies with first trimester high risk of early preeclampsia, the performance of a third trimester screening for SGA combining biophysical and biochemical markers.

METHODS

This is a prospective longitudinal study on 378 singleton pregnancies identified at high risk of early preeclampsia according to a first trimester multiparametric algorithm with the cutoff corresponding to 15% false positive rate. This cohort included 50 cases that delivered SGA neonates with birthweight < 10th centile (13.2%) and 328 cases with normal birthweight (86.8%). At 27-30 weeks' gestation, maternal weight, blood pressure, estimated fetal weight, mean uterine artery pulsatility index and maternal biochemical markers (placental growth factor and soluble FMS-Like Tyrosine Kinase-1) were assessed. Different predictive models were created to evaluate their performance to predict SGA neonates.

RESULTS

For a 15% FPR, a model that combines maternal characteristics, estimated fetal weight, mean uterine artery pulsatility index and placental growth factor achieved a detection rate (DR) of 56% with a negative predictive value of 92.2%. The area under receiver operating characteristic curve (AUC) was 0.79 (95% confidence interval (CI), 0.72-0.86). The DR of a model including maternal characteristics, estimated fetal weight and mean uterine artery pulsatility index was 54% (AUC, 0.77 (95% CI, 0.70-0.84)). The DR of a model that includes maternal characteristics and placental growth factor achieved a similar performance (DR 56%, AUC 0.75, 95% CI (0.67-0.83)).

CONCLUSIONS

The performance of screening for SGA neonates at early third trimester combining biophysical and biochemical markers in a high-risk population is poor. However, a high negative predictive value could help in reducing maternal anxiety, avoid iatrogenic interventions and propose a specific plan for higher risk patients.

A new model for screening for early-onset preeclampsia

BACKGROUND

Early identification of women with an increased risk for preeclampsia is of utmost importance to minimize adverse perinatal events. Models developed until now (mainly multiparametric algorithms) are thought to be overfitted to the derivation population, which may affect their reliability when applied to other populations. Options allowing adaptation to a variety of populations are needed.

OBJECTIVE

The objective of the study was to assess the performance of a first-trimester multivariate Gaussian distribution model including maternal characteristics and biophysical/biochemical parameters for screening of early-onset preeclampsia (delivery <34 weeks of gestation) in a routine care low-risk setting.

STUDY DESIGN

Early-onset preeclampsia screening was undertaken in a prospective cohort of singleton pregnancies undergoing routine first-trimester screening (8 weeks 0/7 days to 13 weeks 6/7 days of gestation), mainly using a 2-step scheme, at 2 hospitals from March 2014 to September 2017. A multivariate Gaussian distribution model including maternal characteristics (a priori risk), serum pregnancy-associated plasma protein-A and placental growth factor assessed at 8 weeks 0/7 days to 13 weeks 6/7 days and mean arterial pressure and uterine artery pulsatility index measured at 11.0-13.6 weeks was used.

RESULTS

A total of 7908 pregnancies underwent examination, of which 6893 were included in the analysis. Incidence of global preeclampsia was 2.3% (n = 161), while of early-onset preeclampsia was 0.2% (n = 17). The combination of maternal characteristics, biophysical parameters, and placental growth factor showed the best detection rate, which was 59% for a 5% false-positive rate and 94% for a 10% false-positive rate (area under the curve, 0.96, 95% confidence interval, 0.94-0.98). The addition of placental growth factor to biophysical markers significantly improved the detection rate from 59% to 94%.

CONCLUSION

The multivariate Gaussian distribution model including maternal factors, early placental growth factor determination (at 8 weeks 0/7 days to 13 weeks 6/7 days), and biophysical variables (mean arterial pressure and uterine artery pulsatility index) at 11 weeks 0/7 days to 13 weeks 6/7 days is a feasible tool for early-onset preeclampsia screening in the routine care setting. Performance of this model should be compared with predicting models based on regression analysis.

First-trimester fasting glycemia as a predictor of gestational diabetes (GDM) and adverse pregnancy outcomes

AIMS

Studies to prevent gestational diabetes (GDM) have shown the best results when lifestyle measures have been applied early in pregnancy. We aimed to investigate whether first-trimester fasting plasma glucose (FPG) could predict GDM risk and adverse pregnancy outcomes.

METHODS

A retrospective analysis of prospectively collected data from singleton pregnancies who were attended at our hospital between 2008 and 2018 (n = 27,198) was performed. We included patients with a recorded first-trimester FPG and complete pregnancy data (n = 6845). Patients under 18, with pregestational diabetes or reproductive techniques, were excluded. First-trimester FPG was evaluated as a continuous variable and divided into quartiles. GDM was diagnosed by NDDG criteria. The relationship between first- and second-trimester glucose > 92 mg/dL was also investigated. The relationship between FPG and pregnancy outcomes was assessed in 6150 patients who did not have GDM.

RESULTS

Maternal age was 34.2 ± 3.9 years, BMI 23.1 ± 3.7 kg/m² and mean FPG 83.0 ± 7.3 mg/dL. Glucose quartiles were: ≤ 78, 79-83, 84-87 and ≥ 88 mg/dL. First-trimester FPG predicted the risk of GDM (7%, 8%, 10.2% and 16% in each quartile, p < 0.001) and the risk of second-trimester glucose > 92 mg/dL (2.6%, 3.8%, 6.3% and 11.4% in each quartile, p < 0.001). FPG was significantly associated with LGA (8.2%, 9.3%, 10% and 11.7% in each quartile, p = 0.011) but not with other obstetrical outcomes. In a multivariate analysis including age, BMI, tobacco use, number of pregnancies and weight gained during pregnancy, first-trimester FPG was an independent predictor of LGA.

CONCLUSIONS

First-trimester FPG is an early marker of GDM and LGA.

Delayed-onset paraparesis in Lassa fever: A case report

Lassa fever (LF) is an endemic viral hemorrhagic fever in West Africa. Among the serious complications of the disease are neurological manifestations whose spectrum is incompletely known. Here we report the case of a 61-year-old man who developed a delayed-onset paraparesis a few weeks after getting infected with Lassa virus, thereby suggesting a possible association between LF and spinal cord disorders.

Maternal fasting glycemia and adverse pregnancy outcomes in a Mediterranean population

AIMS

The hyperglycemia and adverse pregnancy outcome study demonstrated a continuous association between fasting plasma glucose (FPG) levels below those diagnostic of diabetes and adverse neonatal outcomes. We aimed to investigate whether the same association was found in a Mediterranean population.

METHODS

A retrospective analysis of singleton pregnancies attended at our Hospital between 2008 and 2015 (n = 5203). FPG was evaluated in the second trimester, and it was divided into 7 categories (1 < 75, 2 75-79, 3 80-84, 4 85-89, 5 90-94, 6 95-99 and 7 100-124 mg/dL). Pregnancy outcomes included elective cesarean delivery, gestational hypertensive disorders (GHD), large for gestational age (LGA), small for gestational age (SGA), macrosomia, prematurity, severe prematurity and APGAR at 1 min <7.

RESULTS

Maternal age was 33.8 ± 3.8 years, and BMI at first antenatal visit was 22.9 ± 3.5 kg/m²; mean FPG was 79 ± 7 mg/dL. A positive association was observed between FPG and LGA (p < 0.001), GHD (p = 0.004) and prematurity both <37 and <34 weeks of gestation (p = 0.001 and p = 0.004). FPG and SGA were inversely related (p = 0,038). FPG was not significantly related to rate of C-section or APGAR. Adjusted odds ratios associated with 1 standard deviation increase in the fasting plasma glucose (7 mg/dL) were 1.26 (1.15 to 1.37) for LGA, 1.28 (1.09 to 1.49) for GHD and 0.83 (0.74-0.93) for SGA. In a multivariate analysis controlling for confounders, FPG remained associated with LGA.

CONCLUSIONS

We found an association between FPG levels, below those diagnostic of gestational diabetes according to our guidelines, and adverse maternal and neonatal outcomes in a Mediterranean population.

The TITAN-AMI multicenter registry evaluating the usage of Titan2 stent in patients with ST segment elevation myocardial infarction. Final result at 12-month follow-up

AIM

Primary percutaneous coronary intervention with stent implantation is the recommended treatment for patients with ST elevation myocardial infarction (STEMI). Data from randomised trials showed good performance by a titanium-nitric-oxide coated stent in this context. The aim of this study was to confirm these data.

METHODS

A multicentre registry was compiled in 23 hospitals in Spain in an all-comers population. We selected patients with STEMI from a global Titan AMI registry that included patients with acute coronary syndrome. Primary endpoint was the composite of cardiac death, non-fatal myocardial infarction, stent thrombosis and target lesion revascularisation, at 12-month follow-up.

RESULTS

The study included 893 patients with STEMI. We included all possibilities for PCI: 86.6% primary, 5% facilitated after successful fibrinolysis and 8.4% rescue PCI after failed fibrinolysis. The primary endpoint was reached in 8.4% of the patients: cardiac death 2.7%, reinfarction 3.4%, target lesion revascularisation 3.5% and definite or probable stent thrombosis 2.8%. The majority of stent thromboses presented in the first 30 days after PCI.

CONCLUSION

A bioactive stent (titanium-nitric-oxide coated stent) is a possible alternative for the treatment of patients with STEMI. One-year follow-up showed better results than those presented by a regular bare-metal stent or first-generation drug-eluting stent in terms of stent thrombosis.

Initial experience with non-invasive prenatal testing of cell-free DNA for major chromosomal anomalies in a clinical setting

OBJECTIVE

To evaluate non-invasive prenatal testing (NIPT) of cell-free DNA (cfDNA) as a screening method for major chromosomal anomalies (CA) in a clinical setting.

METHODS

From January to December 2013, Panorama™ test or Harmony™ prenatal test were offered as advanced NIPT, in addition to first-trimester combined screening in singleton pregnancies.

RESULTS

The cohort included 333 pregnant women with a mean maternal age (MA) of 37 years who underwent testing at a mean gestational age of 14.6 weeks. Eighty-four percent were low-risk pregnancies. Results were provided in 97.3% of patients at a mean reporting time of 12.9 calendar days. Repeat sampling was performed in six cases and results were obtained in five of them. No results were provided in four cases. Four cases of Down syndrome were detected and there was one discordant result of Turner syndrome. We found no statistical differences between commercial tests except in reporting time, fetal fraction and MA. The cfDNA fraction was statistically associated with test type, maternal weight, BMI and log βhCG levels.

CONCLUSIONS

NIPT has the potential to be a highly effective screening method for major CA in a clinical setting.

Buttock necrosis after hypogastric artery embolization for postpartum hemorrhage

Background: Uterine or hypogastric artery embolization is a useful alternative to hysterectomy in the treatment of postpartum hemorrhage.

Case: Puerpera requiring a bilateral hypogastric artery embolization for postpartum hemorrhage after cesarean section in a term twin pregnancy. Unexpected unilateral buttock necrosis appeared 5 days later. Treatment consisted of debridement, the use of vacuum-assisted closure therapy and skin grafting.

Conclusion: Buttock necrosis is a rare complication after hypogastric artery embolization in the treatment of postpartum hemorrhage.

Prenatal Diagnosis of Chromosome Abnormalities: A 13-Year Institution Experience

Objective: To analyze trends in screening and invasive prenatal diagnosis of chromosome abnormalities (CA) over a 13-year period and correlate them to changes in the national prenatal screening policy. Methods: We retrospectively reviewed Down syndrome (DS) screening tests and fetal karyotypes obtained by prenatal invasive testing (IT) in our fetal medicine unit between January 1999 and December 2011. Results: A total of 24,226 prenatal screening tests for DS and 11,045 invasive procedures have been analyzed. Over a 13-year period, utilization of non-invasive screening methods has significantly increased from 57% to 89%. The percentage of invasive procedures has declined from 49% to 12%, although the percentage of IT performed for maternal anxiety has increased from 22% to 55%. The percentage of detected CA increased from 2.5% to 5.9%. Overall, 31 invasive procedures are needed to diagnose 1 abnormal case, being 23 procedures in medical indications and 241 procedures in non-medical indications. Conclusions: Our experience on screening and invasive prenatal diagnostic practice shows a decrease of the number of IT, with a parallel decline in medical indications. There is an increasing efficiency of prenatal screening program to detect CA. Despite the increasing screening policies, our population shows a growing request for prenatal IT. The a priori low risk population shows a not negligible residual risk for relevant CA. This observation challenges the current prenatal screening strategy focused on DS; showing that the residual risk is higher than the current cut-off used to indicate an invasive technique.

4D Sonographic Assessment of Intertwin Contacts

Objective

To assess the onset and frequency of first interfetal contacts by 4D sonography.

Subjects and methods

Twenty twin pregnancies were scanned transvaginally between 56 (8 weeks) and 69 postmenstrual days (9+6 weeks) and onward transabdominally, at weekly intervals until 112 postmenstrual days (16 weeks). Scans were recorded on DVD and analyzed retrospectively. The moment of onset, type and frequency of intertwin contacts were assessed.

Results

First interhuman contacts were observed between 61 (8+5 weeks) and 68 (9+5 weeks) postmenstrual days. The frequency of different movements varied according to the gestational age. ‘Touch no reaction’ and ‘First reaction’ were common and frequent from 70 postmenstrual days (10 weeks) onward. ‘Slow body movements’ were more common than ‘Fast body movements’. ‘Complex contacts’ were more frequent at 94 postmenstrual days (13+3 weeks). Simple contacts diminished around 100 postmenstrual days (14+2 weeks). ‘Complex contacts’ and ‘diffuse interactions’ were more commonly observed between 105 (15 weeks) and 112 postmenstrual days (16 weeks). No significant differences were found when different gender combinations were compared.

Conclusion

Intertwin contacts start as soon as 8+5 weeks of gestation and complex or diffuse interactions are already seen at 15 to 16 weeks of gestation.

How to cite this article

Prats P, Serra B, Fournier S, Baulies S, Andonotopo W, Kurjak A. 4D Sonographic Assessment of Intertwin Contacts. Donald School J Ultrasound Obstet Gynecol 2012;6(2):154-159.

Analysis of quality of nuchal translucency measurements: its role in prenatal diagnosis

Objective. Quantitative analysis of the quality of nuchal translucency (NT) measurements. Methods. First-trimester combined screening for Down syndrome was performed to all pregnant women attended in our Department from October 2003 to November 2009. NT was measured according to the Fetal Medicine Foundation (FMF) criteria by 20 trained obstetricians. The performance of NT measurements was retrospectively analyzed with regard to several quality control standards. Accuracy according to experience, professional profile, crown rump length (CRL) values, and FMF certification was statistically tested. Results. A total of 14978 NT measurements were assessed. (1) The mean operator-specific median NT-MoM values was 0,98. (2) Mean percentage of cases >95th and <5th centiles were 5,0% and 4,2%, respectively. (3) Logarithmic mean and SD of the NT MoM values were 0,00 and 0,13, respectively. (4) The DR for trisomy 21 at screening time was 90,7% for a FPR of 6,7% for standard screening strategy. (5) According to Cumulative SUM (CUSUM) figures, the performance was more acceptable in FMF-certified operators. Conclusion. Overall, quality standards show optimal NT measurements in our unit. Operator experience, a dedicated profile to fetal medicine, CRL over 60 mm, and FMF certification have a significant positive impact on the quality standards.

Analysis of Quality of Nuchal Translucency Measurements

Objective

Quantitative analysis of the quality of nuchal translucency (NT) measurements.

Methods

This is a retrospective single-center study. NT was measured according to the Fetal Medicine Foundation (FMF) criteria by 20 trained obstetricians (October 2003-November 2009). The performance of NT measurements was analyzed with regard to several quality control standards. Accuracy according to experience, professional profile, crown-rump length (CRL) values and FMF certification was statistically tested.

Results

A total of 14,978 NT measurements were assessed. (1) The mean operator-specific median NT-MoM values was 0.98. (2) Mean percentage of cases >95th and <5th percentiles were 5.0 and 4.2% respectively. (3) Logarithmic mean and SD of the NT-MoM values were 0.00 and 0.13 respectively. (4) The DR for trisomy 21 at screening time was 90.7% for a FPR of 6.7% for standard screening strategy. (5) According to cumulative SUM (CUSUM) figures, the performance was more acceptable in FMF-certified operators. Operator experience, exclusive dedication to FM, FMF certification and a range of CRL values > 60 mm had a statistical impact improving these standards.

Conclusion

Overall quality standards show optimal NT measurements in our unit. Experience a dedicated profile to fetal medicine ultrasound, CRL over 60 mm and FMF certification has a significant positive impact on the quality standards.

Rapid aneuploidy testing versus traditional karyotyping in amniocentesis for certain referral indications

OBJECTIVE

(1) To determine the suitability of replacing full karyotype analysis with quantitative fluorescent polymerase chain reaction (QF-PCR) for prenatal diagnosis in amniotic fluid samples obtained by amniocentesis. (2) To evaluate an indication-based classification of cases at risk of missing clinically relevant chromosomal disorders by QF-PCR.

METHODS

We reviewed all fetal karyotypes obtained by amniocentesis between January 2004 and December 2008. We compared the cytogenetic findings obtained through conventional karyotype with those that would have been theoretically obtained using QF-PCR.

RESULTS

Of the 4007 karyotypes obtained, 110 abnormal karyotypes were found (2.8%). Out of these, 30 (27%) were chromosomal abnormalities (CA) which would not have been detected by PCR alone. These included 16 cases (53%) predicted to confer no increased risk, 9 (30%) predicted to have a low risk, and 5 (17%) with an uncertain or high risk of fetal abnormality. A policy of QF-PCR alone would have identified 80 of 85 (94%) clinically significant CA. When QF-PCR shows a normal result, the overall residual risk is 0.75% for any CA and 0.12% for a clinical significant CA.

CONCLUSION

In our population, a policy of QF-PCR alone would miss 0.12% clinically relevant CA. QF-PCR directed to common aneuploidies can be considered as an economically and clinically acceptable prenatal diagnosis policy, offering full karyotype only for specific indications.

Integrated electrochemical gluconic acid biosensor based on self-assembled monolayer-modified gold electrodes. Application to the analysis of gluconic acid in musts and wines

An integrated amperometric gluconic acid biosensor constructed using a gold electrode (AuE) modified with a self-assembled monolayer (SAM) of 3-mercaptopropionic acid (MPA) on which gluconate dehydrogenase (GADH, 0.84 U) and the mediator tetrathiafulvalene (TTF, 1.5 micromol) were coimmobilized by covering the electrode surface with a dialysis membrane is reported. The working conditions selected were Eapp=+0.15 V and 25+/-1 degrees C. The useful lifetime of one single TTF-GADH-MPA-AuE was surprisingly long. After 53 days of continuous use, the biosensor exhibited 86% of the original sensitivity. A linear calibration plot was obtained for gluconic acid over the 6.0x10(-7) to 2.0x10(-5) M concentration range, with a limit of detection of 1.9x10(-7) M. The effect of potential interferents (glucose, fructose, galactose, arabinose, and tartaric, citric, malic, ascorbic, gallic, and caffeic acids) on the biosensor response was evaluated. The behavior of the biosensor in a flow-injection system in connection with amperometric detection was tested. The analytical usefulness of the biosensor was evaluated by determining gluconic acid in wine and must samples, and the results obtained were validated by comparison with those provided by using a commercial enzyme test kit.

Molecularly imprinted polymer solid-phase extraction coupled to square wave voltammetry at carbon fibre microelectrodes for the determination of fenbendazole in beef liver

A molecularly imprinted polymer was developed and used for solid-phase extraction (MISPE) of the antihelmintic fenbendazole in beef liver samples. Detection of the analyte was accomplished using square wave voltammetry (SWV) at a cylindrical carbon fibre microelectrode (CFME). A mixture of MeOH/HAc (9:1) was employed both as eluent in the MISPE system and as working medium for electrochemical detection of fenbendazole. The limit of detection was 1.9x10(-7) mol L-1 (57 microg L-1), which was appropriate for the determination of fenbendazole at the maximum residue level permitted by the European Commission (500 microg kg-1 in liver). Given that the SW voltammetric analysis could not be directly performed in the sample extract as a consequence of interference from some sample components, a sample clean-up with a MIP for selectively retaining fenbendazole was performed. The MIP was synthesized using a 1:8:22 template/methacrylic acid/ethylene glycol dimethacrylate ratio. A Britton-Robinson Buffer of pH 9.0 was selected for retaining fenbendazole in the MIP cartridges, and an eluent volume of 5.0 mL at a flow rate of 2.0 mL min-1 was chosen in the elution step. Cross-reactivity with the MIP was observed for other benzimidazoles. The synthesized MIP exhibited a good selectivity for benzimidazoles with respect to other veterinary drugs. The applicability of the MISPE-SWV method was tested with beef liver samples, spiked with fenbendazole at 5,000 and 500 microg kg-1. Results obtained for ten different liver samples yielded mean recoveries of (95+/-12)% and (96+/-11)% for the upper and lower concentration level, respectively.

Prenatal ultrasound diagnosis of vasa praevia and analysis of risk factors

OBJECTIVE

To evaluate the role of ultrasound in prenatal diagnosis of vasa praevia (VP) and to asses the risk of VP associated with different causal factors.

MATERIAL AND METHODS

A retrospective study of the incidence of VP in a series of 12,063 deliveries between January 2000 and March 2005. We also studied the factors that predisposed for VP and the perinatal outcome of pregnancies.

RESULTS

The prevalence of VP in our centre during this period was 0.07% (9 cases). All cases were prenatally diagnosed. The mean gestational age at diagnosis was 26 weeks. Multivariate analysis revealed the following associated factors: IVF pregnancies, bilobate or succenturiate placenta, and second-trimester placenta praevia, with an odds ratio of 7.75, 22.11 and 22.86, respectively.

CONCLUSIONS

In our series, the prenatal diagnosis of all cases of VP achieved during the second-trimester scan allowed us to avoid any prenatal death related to this condition.

[Lipid lowering goals in high risk and very high cardiovascular risk patients: a reasonable challenge?]

OBJECTIVE

The last modifications of the National Cholesterol Education Program (NCEP) indicate some lower therapeutic targets of low density protein cholesterol (LDL-c) in patients with very high vascular risk. Our study aims to establish the degree of compliance of the therapeutic targets defined by these modifications.

PATIENTS AND METHOD

Descriptive and cross sectional study of patients from a cardiovascular clinic. Low-density lipoprotein cholesterol (LDL-c) was calculated and targets were established according the new update of NCEP-ATP III.

RESULTS

836 patients, 625 (75%) with HR and 211(25%) with VHR were studied 45% of HR and 67% of VHR were receiving treatment with statins (p < 0.001) but only 38% of HR and 15% of VHR achieved target LDL-c levels. The percentage of patients who could achieve LDL-goals using the maximum approved dose of the statins plus other lipid lowering drug was calculated: The 31% of HR and 51% of VHR were unable to achieve the LDL-c targets.

CONCLUSIONS

Only 15% of very high risk patients achieve target levels of LDL-c according to the new NCEP-ATP III recommendations. Even using maximum dose of statins in combination with other lipid lowering drugs, less than half of the patients will be able to achieve LDL-c goal (< 70 mg/dl).

[Evolution over time in over perceivers of dyspnea in asthma]

OBJECTIVE

In previous studies we identified a subgroup of patients whose perception of breathlessness was exaggerated during acute bronchoconstriction and who were termed "over perceivers" or "hyperperceivers". In this study we aimed to determine whether such over perception is sporadic or stable over time. We also examined whether there is an association between over perception of dyspnea and hyperventilation syndrome.

PATIENTS AND METHODS

The subjects were 22 stable asthmatics (11 men, 11 women) who had been over perceivers of dyspnea in a study 9 years earlier. After a medical history was taken, a patient performed forced spirometry and a severity classification was made according to the criteria of the Global Initiative for Asthma (GINA). A bronchial histamine challenge was then administered to measure dose-related perception of dyspnea on a Borg scale, according to a procedure that was similar to the one used 9 years earlier by the same investigator. The patients were also asked for a subjective assessment of the severity of their asthma (scale, 0-10) and to respond to items on the Nijmegen hyperventilation questionnaire and the trait form of the State-Trait Anxiety Inventory.

RESULTS

The overall perception of severity of disease, level of anxiety, and perception of dyspnea at rest were lower after 9 years (P<.001). No change was observed in bronchial hyperresponsiveness (dose of inhaled histamine required to provoke a 20% decline in forced expiratory volume in the first second [FEV1]-PD20) or objective parameters of severity (FEV1 and GINA classification). Fourteen asthmatics (64%) were still over perceivers and the other patients had changed: 6 were normal perceivers and 2 were "poor perceivers". Only subjective perception of disease severity improved for the patients who were still over perceivers; the other patients, on the other hand, showed improvements in subjective assessments, objective ones (except PD20), and anxiety. Finally, those who remained over perceivers had higher scores for anxiety (24 vs 15; P<.05) and hyperventilation (18 vs 13; P= not significant).

CONCLUSIONS

Most over perceivers of dyspnea remain so over the years and this trait is related to anxiety. We have been unable to demonstrate an association with hyperventilation syndrome.

[Uncommon etiology of gastrointestinal bleeding: duodenal metastases from renal cell carcinoma]

Because of its unpredictable behavior, renal cell carcinoma is one of the most controversial neoplasms. On the one hand, patients frequently show metastases at diagnosis because of its slight manifestations, while on the other, the neoplasm can remain stable after nephrectomy and can then metastasize many years later. When this happens, the metastases usually involve more than 2 organs. The most frequent sites of metastases are the lung and lymph nodes, followed by the bones and liver, while duodenal involvement is rare. Indeed, intestinal metastases are found in only 2% of autopsies and of these, renal cell carcinoma metastases account for 7.1%. We present a case of a solitary late recurrence presenting as upper gastrointestinal bleeding 19 years after nephrectomy for clear cell renal carcinoma.

Rapid and highly sensitive electrochemical determination of alkaline phosphatase using a composite tyrosinase biosensor

The use of an amperometric graphite-Teflon composite tyrosinase biosensor for the rapid monitoring of alkaline phosphatase (ALP), with no need of an incubation step and using phenyl phosphate as the substrate, is reported. Phenol generated by the action of ALP is monitored at the tyrosinase composite electrode through the electrochemical reduction of the o-quinone produced to catechol, which produces a cycle between the tyrosinase substrate and the electroactive product, giving rise to the amplification of the biosensor response and to the sensitive detection of ALP. The current was measured at -0.10 V 5 min after the addition of ALP. As a compromise between high ALP activity and high sensitivity for the detection of phenol, a pH of 8.5 was chosen. The substrate concentration was also optimized. A linear calibration plot was obtained for ALP between 2.0 x 10(-13) and 2.5 x 10(-11), with a detection limit of 6.7 x 10(-14) M. Different types of milk were analyzed with good results, using an extremely simple and rapid procedure.

Candidiasis sistémica y tratamiento con infliximab

The use of infliximab in patients with luminal or fistulizing Crohn's disease refractory to medical treatment (steroids and immunomodulatory drugs) is increasingly widespread. Although the incidence of serious infections in patients undergoing infliximab treatment is not higher than that of controls, systemic fungal infections in patients treated with this antibody have been anecdotally described. We report a case of systemic candidiasis in a patient with refractory Crohn's disease who was treated with infliximab associated with corticosteroids and azathioprine and discuss the role that infliximab could have played in the development of this complication.

Enfermedad de Wilson con afectación neurológica grave: respuesta al tratamiento combinado con trientina y acetato de cinc

In patients with Wilson's disease and neurological manifestations, treatment with D-penicillamine can cause worsening of neurological symptoms, usually in the first few weeks of treatment. Because the neurological damage can be severe and irreversible, the use of D-penicillamine is controversial, and several authors believe that it should be avoided. Studies of the use of ammonium tetrathiomolybdate as an alternative chelating agent for the initial treatment of neurologic Wilson's disease are still in the experimental phase. Published experience on the simultaneous use of trientine, another chelating agent, and zinc, which blocks intestinal absorption of copper, is promising but limited. We present the case of a 17 year-old boy with severe neurologic Wilson's disease that had first presented six years previously. The patient showed a complete recovery after six months of treatment with a combination of trientine and zinc acetate.