Automated quantitative evaluation of fetal atrioventricular annular plane systolic excursion

OBJECTIVES

The primary aim of this study was to evaluate the feasibility of automated measurement of fetal atrioventricular (AV) plane displacement (AVPD) over several cardiac cycles using myocardial velocity traces obtained by color tissue Doppler imaging (cTDI). The secondary objectives were to establish reference ranges for AVPD during the second half of normal pregnancy, to assess fetal AVPD in prolonged pregnancy in relation to adverse perinatal outcome and to evaluate AVPD in fetuses with a suspicion of intrauterine growth restriction (IUGR).

METHODS

The population used to develop the reference ranges consisted of women with an uncomplicated singleton pregnancy at 18-42 weeks of gestation (n = 201). The prolonged-pregnancy group comprised women with an uncomplicated singleton pregnancy at ≥ 41 + 0 weeks of gestation (n = 107). The third study cohort comprised women with a singleton pregnancy and suspicion of IUGR, defined as an estimated fetal weight < 2.5^th centile or an estimated fetal weight < 10^th centile and umbilical artery pulsatility index > 97.5^th centile (n = 35). Cineloops of the four-chamber view of the fetal heart were recorded using cTDI. Regions of interest were placed at the AV plane in the left and right ventricular walls and the interventricular septum, and myocardial velocity traces were integrated and analyzed using an automated algorithm developed in-house to obtain mitral (MAPSE), tricuspid (TAPSE) and septal (SAPSE) annular plane systolic excursion. Gestational-age specific reference ranges were constructed and normalized for cardiac size. The correlation between AVPD measurements obtained using cTDI and those obtained by anatomic M-mode were evaluated, and agreement between these two methods was assessed using Bland-Altman analysis. The mean Z-scores of fetal AVPD in the cohort of prolonged pregnancies were compared between cases with normal and those with adverse outcome using Mann-Whitney U-test. The mean Z-scores of fetal AVPD in IUGR fetuses were compared with those in the normal reference population using Mann-Whitney U-test. Inter- and intraobserver variability for acquisition of cTDI recordings and offline analysis was assessed by calculating coefficients of variation (CV) using the root mean square method.

RESULTS

Fetal MAPSE, SAPSE and TAPSE increased with gestational age but did not change significantly when normalized for cardiac size. The fitted mean was highest for TAPSE throughout the second half of gestation, followed by SAPSE and MAPSE. There was a significant correlation between MAPSE (r = 0.64; P < 0.001), SAPSE (r = 0.72; P < 0.001) and TAPSE (r = 0.84; P < 0.001) measurements obtained by M-mode and those obtained by cTDI. The geometric means of ratios between AVPD measured by cTDI and by M-mode were 1.38 (95% limits of agreement (LoA), 0.84-2.25) for MAPSE, 1.00 (95% LoA, 0.72-1.40) for SAPSE and 1.20 (95% LoA, 0.92-1.57) for TAPSE. In the prolonged-pregnancy group, the mean ± SD Z-scores for MAPSE (0.14 ± 0.97), SAPSE (0.09 ± 1.02) and TAPSE (0.15 ± 0.90) did not show any significant difference compared to the reference ranges. Twenty-one of the 107 (19.6%) prolonged pregnancies had adverse perinatal outcome. The AVPD Z-scores were not significantly different between pregnancies with normal and those with adverse outcome in the prolonged-pregnancy cohort. The mean ± SD Z-scores for SAPSE (-0.62 ± 1.07; P = 0.006) and TAPSE (-0.60 ± 0.89; P = 0.002) were significantly lower in the IUGR group compared to those in the normal reference population, but the differences were not significant when the values were corrected for cardiac size. The interobserver CVs for the automated measurement of MAPSE, SAPSE and TAPSE were 28.1%, 17.7% and 15.3%, respectively, and the respective intraobserver CVs were 33.5%, 15.0% and 17.9%.

CONCLUSIONS

This study showed that fetal AVPD can be measured automatically by integrating cTDI velocities over several cardiac cycles. Automated analysis of AVPD could potentially help gather larger datasets to facilitate use of machine-learning models to study fetal cardiac function. The gestational-age associated increase in AVPD is most likely a result of increasing cardiac size, as the AVPD normalized for cardiac size did not change significantly between 18 and 42 weeks. A decrease was seen in TAPSE and SAPSE in IUGR fetuses, but not after correction for cardiac size. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

P–381 Deciphering the genetic cause of recurrent and sporadic pregnancy loss

Study question

To investigate the prevalence and effect of (mosaic) de novo genomic aberrations in recurrent pregnancy loss (RPL) and sporadic abortion (SA).

Summary answer

Prevalence of maternal uniparental disomies (UPDs) was high in both cohorts. While chromosomal UPDs were found in both cohorts, genome wide UPDs were RPL specific.

What is known already

Spontaneous abortion occurs in 10–15% of clinically recognized pregnancies and recurrent pregnancy loss in 1–3%. SA and RPL are associated with reduced quality of life. Multiple factors contribute to SA and RPL, such as uterine malformations and parental/fetal chromosomal abnormalities. However, in ∼60% of SA and RPL the cause remains unknown. UPD is defined as the presence of two homologues chromosomes originating from a single parent. This phenomenon can lead to imprinting disorders that are characterised by clinical features affecting growth, development and metabolism in liveborn offspring. However, it could also be responsible for pregnancy loss.

Study design, size, duration

We recruited 32 families with pregnancy loss (n = 16 RPL cohort, n = 16 SA cohort) with no known genetic predispositions and normal karyotyping results in both parents and the fetus. Average maternal age was 28.68 years (SD = 5.43), paternal age 30.3 years (SD = 5.53), and the gestational age at pregnancy loss was 8.65 weeks (SD = 2.47). The average number of miscarriages in the RPL group was 3.57 (SD = 0.84). We profiled the genomic landscape of both cohorts using SNP typing.

Participants/materials, setting, methods

We isolated DNA from blood of both parents and the placental tissues from the miscarried products of conception. The placenta tissues were sampled from two distinct extraembryonic and embryonic germ layers, the extraembryonic mesoderm and the chorionic villi cytotrophoblast. Subsequently, we performed SNP-genotyping using Illumina’s Global-Screening Array–24 v2.0 BeadChips and applied haplarithmisis to delineate allelic architecture of fetal tissues of both cohorts. This allowed us to detect large de novo copy-number and -neutral (&gt;10kb) changes.

Main results and the role of chance

In this pilot study, we have analyzed 132 DNA samples (n = 32 families), of which 16 families were in the RPL cohort and 16 in the SA cohort. Within the RPL cohort, we found: one family with mosaic genome wide hexaploidy both in the extraembryonic mesoderm and chorionic villi, one family with a non-mosaic genome wide hetero UPD of the chorionic villi tissue, one family with a mosaic UPD of chromosome 14 in both tissues and tetraploidy exclusively in the chorionic villi, one family with a mosaic UPD of chromosome 16 in both tissues, one family with a mosaic UPD of chromosome 6 in both tissues, and another family with a mosaic UPD of chromosome 5 in the extraembryonic mesoderm. Within the SA group, one family showed a UPD of chromosome 7 and another family showed a segmental UPD of chromosome 5 in both tissues. Strikingly, all the UPDs found in this study were maternal in origin.

Limitations, reasons for caution

The main limitation of this study is the resolution of detecting copy-neutral and copy-number variations, which is an inherent limiting factor of SNP-array technology. In addition, in the sample in which we observed non-mosaic genome wide UPD, maternal contamination is likely that can be investigated by other technologies.

Wider implications of the findings: Multiple genome wide UPDs are found in the RPL group but none in the SA group, indicating an association between genome wide mosaic UPD and RPL. These findings could lead to a better understanding of causative factors for SA and RPL and the need for a SNP-based non-invasive prenatal testing.

Trial registration number

Not applicable

Sex-specific reference ranges of cerebroplacental and umbilicocerebral ratios: longitudinal study

OBJECTIVES

Observational studies have shown that low cerebroplacental ratio (CPR) values predict an increased risk of adverse perinatal outcome. The inverse ratio, i.e. the umbilicocerebral ratio (UCR), has been suggested to be a better predictor as it rises with increasing degree of fetal compromise. However, longitudinal reference ranges for UCR have not been established, and whether gestational-age-dependent changes in CPR or UCR differ between male and female fetuses has not been studied. Thus, the aims of this study were to investigate sex-specific, gestational-age-associated serial changes in CPR and UCR during the second half of pregnancy and to establish longitudinal reference ranges.

METHODS

This was a secondary analysis of prospectively collected data from a dual-center longitudinal observational cohort study of low-risk singleton pregnancies. Doppler blood-flow velocity waveforms were obtained serially from the umbilical artery (UA) and fetal middle cerebral artery (MCA) from 19-41 weeks' gestation, and pulsatility indices (PIs) were determined. CPR and UCR were calculated as the ratios MCA-PI/UA-PI and UA-PI/MCA-PI, respectively. The course and outcome of pregnancies were recorded, and the sex of the fetus was determined after delivery. Reference intervals for CPR and UCR were constructed using multilevel modeling, and gestational-age-specific Z-scores in male and female fetuses were compared.

RESULTS

Of a total of 299 pregnancies enrolled, 284 (148 male and 136 female fetuses) were included in the final analysis, and 979 paired measurements of UA-PI and MCA-PI were used to construct sex-specific longitudinal reference intervals. The relationship of both CPR and UCR with gestational age was U-shaped, but in opposite directions. There was a small but significant difference in Z-scores of CPR and UCR between male and female fetuses throughout the second half of pregnancy (P = 0.007).

CONCLUSIONS

We have established longitudinal reference ranges for CPR and UCR suitable for serial monitoring, with the possibility of refining assessment by using fetal sex-specific ranges and conditioning by a previous measurement. The clinical significance of such refinements needs further evaluation. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Perinatal outcome of pregnancies complicated by placental chorioangioma: systematic review and meta-analysis

OBJECTIVE

To report the perinatal outcome of singleton pregnancies complicated by placental chorioangioma diagnosed on prenatal ultrasound.

METHODS

MEDLINE, EMBASE, CINAHL and ClinicalTrials.gov databases were searched for studies reporting the outcome of pregnancies complicated by placental chorioangioma. Inclusion criteria were singleton pregnancy diagnosed with placental chorioangioma on prenatal ultrasound, with no other associated structural anomaly. The primary outcome was perinatal mortality. Secondary outcomes included associated non-structural anomalies detected on prenatal ultrasound (including fetal hydrops, anemia, polyhydramnios, signs of hyperdynamic circulation and small-for-gestational-age (SGA) fetus), SGA at birth, composite neonatal morbidity and preterm birth. Outcome was assessed separately in pregnancies undergoing and those not undergoing fetal therapy. Subanalyses were performed according to the presence of hydrops and the size of the tumor in all pregnancies diagnosed with chorioangioma. Random-effects meta-analyses of proportions were used to analyze the data.

RESULTS

Twenty-eight studies (161 pregnancies) were included. In pregnancies complicated by chorioangioma that did not undergo intervention, intrauterine death occurred in 8.2% (95% CI, 3.8-15.0%), while neonatal death and perinatal death occurred in 3.8% (95% CI, 1.0-8.1%) and 11.1% (95% CI, 5.0-19.4%), respectively. SGA at birth was present in 24.0% (95% CI, 13.5-36.5%) of cases, while preterm birth < 37 weeks complicated 34.1% (95% CI, 21.1-48.3%) of pregnancies. Composite neonatal morbidity occurred in 12.0% (95% CI, 4.5-22.3%) of cases. On ultrasound, signs of fetal hyperdynamic circulation were present in 21.0% (95% CI, 9.6-35.3%) of cases, while peak systolic velocity in the fetal middle cerebral artery was increased in 20.6% (95% CI, 10.9-32.3%). Subanalysis according to the size of chorioangioma, including both pregnancies that did and those that did not undergo intervention, showed a progressive increase in the occurrence of most of the outcomes explored with increasing size of the tumor. Furthermore, the prevalence of adverse perinatal outcome was high in pregnancies complicated by chorioangioma presenting with fetal hydrops. There was no randomized controlled trial comparing intervention vs expectant management in pregnancies complicated by chorioangioma with signs of fetal compromise (hydrops or hyperdynamic circulation). Overall, perinatal mortality occurred in 31.2% (95% CI, 18.1-46.1%) of fetuses undergoing in-utero therapy, and 57.3% (95% CI, 39.2-74.4%) had resolution of hydrops or hyperdynamic circulation after treatment.

CONCLUSIONS

Placental chorioangioma is associated with adverse perinatal outcome. The size of the mass and presence of fetal hydrops are likely to be the main determinants of perinatal outcome in affected pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Outcome of twin-to-twin transfusion syndrome in monochorionic monoamniotic twin pregnancy: systematic review and meta-analysis

OBJECTIVES

To explore the outcome of monochorionic monoamniotic (MCMA) twin pregnancies affected by twin-to-twin transfusion syndrome (TTTS).

METHODS

MEDLINE and EMBASE databases were searched for studies reporting the outcome of MCMA twin pregnancies complicated by TTTS. The primary outcome was intrauterine death (IUD); secondary outcomes were miscarriage, single IUD, double IUD, neonatal death (NND), perinatal death (PND), survival of at least one twin, survival of both twins and preterm birth (PTB) before 32 weeks' gestation. Outcomes were assessed in MCMA twins affected by TTTS not undergoing intervention and in those treated with amniodrainage, laser therapy or cord occlusion. Subgroup analysis was performed including cases diagnosed before 24 weeks. Random-effects meta-analysis of proportions was used to analyze the data.

RESULTS

Fifteen cohort studies, including 888 MCMA twin pregnancies, of which 44 were affected by TTTS, were included in the review. There was no randomized trial comparing the different management options in MCMA twin pregnancies complicated by TTTS. In cases not undergoing intervention, miscarriage occurred in 11.0% of fetuses, while the incidence of IUD, NND and PND was 25.2%, 12.2% and 31.2%, respectively. PTB complicated 50.5% of these pregnancies. In cases treated by laser surgery, the incidence of miscarriage, IUD, NND and PND was 19.6%, 27.4%, 7.4% and 35.9%, respectively, and the incidence of PTB before 32 weeks' gestation was 64.9%. In cases treated with amniodrainage, the incidence of IUD, NND and PND was 31.3%, 13.5% and 45.7% respectively, and PTB complicated 76.2% of these pregnancies. Analysis of cases undergoing cord occlusion was affected by the very small number of included cases. Miscarriage occurred in 19.2%, while there was no case of IUD or NND of the surviving twin. PTB before 32 weeks occurred in 50.0% of these cases.

CONCLUSIONS

MCMA twin pregnancies complicated by TTTS are at high risk of perinatal mortality and PTB. Further studies are needed in order to elucidate the optimal type of prenatal treatment in these pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Fetal heart rate variability with hypoxemia in an instrumented sheep model

OBJECTIVE

To examine the effect of hypoxemia on fetal heart rate (FHR) variability, using an instrumented pregnant sheep model.

METHODS

In this prospective study, 19 pregnant sheep were instrumented under general anesthesia, at a mean gestational age of 127 days. After a 5-day recovery period, hypoxemia was induced by attaching the mother to a rebreathing circuit. Hypoxemia was sustained for 120 min, following which it was reversed until maternal and fetal partial pressure of oxygen (pO₂ ) returned to baseline. FHR recordings at baseline, after 30 and 120 min of hypoxemia and at recovery were analyzed to calculate short-term variation (STV) in 16 epochs of 3.75 s, every minute. Phase-rectified signal averaging (window length (L) = 10, time (T) = 2 and scale (S) = 2) was used to calculate FHR acceleration (AC) and deceleration (DC) capacities.

RESULTS

At baseline, mean ± SD fetal pO₂ was 2.90 ± 0.38 kPa. Acute hypoxemia was associated with a significant reduction in mean pO₂ at 30 (1.62 ± 0.37 kPa) and 120 (1.51 ± 0.16 kPa) min. Mean ± SD fetal pO₂ at recovery was 2.86 ± 0.32 kPa. At baseline, median STV, AC and DC were 1.307 (interquartile range (IQR), 0.515-2.508) ms, 1.295 (IQR, 0.990-2.685) beats per minute (bpm) and 1.197 (IQR, 0.850-1.836) bpm, respectively. At 30 min of hypoxemia, the values were 1.323 (IQR, 0.753-2.744) ms, 1.696 (IQR, 1.310-3.013) bpm and 1.584 (IQR, 1.217-4.132) bpm, respectively. At 120 min of hypoxemia, they were 1.760 (IQR, 0.928-4.656) ms, 3.098 (IQR, 1.530-5.163) bpm and 3.054 (IQR, 1.508-4.522) bpm, respectively. At recovery, they changed to 0.962 (IQR, 0.703-1.154) ms, 1.228 (IQR, 1.071-2.234) bpm and 1.086 (IQR, 0.873-1.568) bpm, respectively. Hypoxemia for 30 and 120 min was associated with a significant increase in DC compared to baseline (P = 0.014 and 0.017, respectively). The changes in STV and AC were not significant.

CONCLUSION

Acute hypoxemia is associated with a significant increase in the DC of FHR in a fetal sheep model. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Effectiveness, safety and acceptability of self-assessment of the outcome of first-trimester medical abortion: a systematic review and meta-analysis

BACKGROUND

For many women, the need for multiple clinical visits is a barrier to medical abortion.

OBJECTIVES

We assessed the effectiveness, safety, and acceptability of self-assessment of the outcome of medical abortion completed at home versus routine clinic follow up after medical abortion.

SEARCH STRATEGY

We searched databases such as MEDLINE, Embase, and CENTRAL to find studies published in 1991-2018.

SELECTION CRITERIA

Eligible studies included women of reproductive age who had undergone a medical abortion that was completed at home. The intervention and self-assessment of the outcome of medical abortion done by urine pregnancy tests kits by women at home was compared with routine medical follow up at a clinic.

DATA COLLECTION AND ANALYSIS

Two researchers completed the study selection, data extraction, critical appraisal, and assessment of the evidence. The outcomes were successful complete abortions, side effects and complications, and acceptability. We performed meta-analyses when possible and GRADE to ascertain the certainty of the evidence. The protocol was registered in PROSPERO (CRD42017055316).

MAIN RESULTS

Four randomised controlled trials (RCTs; n = 5493) met our inclusion criteria. The pooled analysis from all studies showed no significant difference in complete abortion rates between self-assessment and routine clinic follow up: RR = 1.00, 95% CI 0.99-1.01. The ongoing pregnancy rates were similar and the pooled results for the safety outcomes showed no significant differences between the groups. There was a significantly greater preference for self-assessment as the follow-up method.

CONCLUSIONS

The effectiveness, safety, and acceptability of self-assessment of the outcome of medical abortion completed at home are not inferior to routine clinic follow up.

TWEETABLE ABSTRACT

The effectiveness, safety, and acceptability of self-assessment of the outcome of medical abortion are not inferior to routine clinic follow up.

Role of magnetic resonance imaging in fetuses with mild or moderate ventriculomegaly in the era of fetal neurosonography: systematic review and meta-analysis

OBJECTIVES

To report the rate of additional central nervous system (CNS) anomalies detected exclusively on prenatal magnetic resonance imaging (MRI) in fetuses diagnosed with isolated mild or moderate ventriculomegaly (VM) on ultrasound, according to the type of ultrasound protocol adopted (dedicated neurosonography vs standard assessment of the fetal brain), and to explore whether the diagnostic performance of fetal MRI in detecting such anomalies is affected by gestational age at examination and laterality and degree of ventricular dilatation.

METHODS

MEDLINE, EMBASE, CINAHL and Clinicaltrials.gov were searched for studies reporting on the prenatal MRI assessment of fetuses diagnosed with isolated mild or moderate VM (ventricular dilatation of 10-15 mm) on ultrasound. Additional anomalies detected only on MRI were classified as callosal, septal, posterior fossa, white matter, intraventricular hemorrhage, cortical, periventricular heterotopia, periventricular cysts or complex malformations. The rate of additional anomalies was compared between fetuses diagnosed on dedicated neurosonography, defined as a detailed assessment of the fetal brain, according to the International Society of Ultrasound in Obstetrics and Gynecology guidelines, and those diagnosed on standard fetal brain assessment. The rate of additional CNS anomalies missed on prenatal MRI and detected only at birth was calculated and compared between fetuses that had early (at or before 24 weeks' gestation) and those that had late (after 24 weeks) MRI. Subanalysis was performed according to the laterality (uni- vs bilateral) and degree (mild vs moderate, defined as ventricular dilatation of 10-12 and 13-15 mm, respectively) of ventricular dilatation. Whether MRI assessment led to a significant change in prenatal management was explored. Random-effects meta-analysis of proportions was used.

RESULTS

Sixteen studies (1159 fetuses) were included in the systematic review. Overall, MRI detected an anomaly not identified on ultrasound in 10.0% (95% CI, 6.2-14.5%) of fetuses. However, when stratifying the analysis according to the type of ultrasound assessment, the rate of associated anomalies detected only on MRI was 5.0% (95% CI, 3.0-7.0%) when dedicated neurosonography was performed compared with 16.8% (95% CI, 8.3-27.6%) in cases that underwent a standard assessment of the fetal brain in the axial plane. The overall rate of an additional anomaly detected only at birth and missed on prenatal MRI was 0.9% (95% CI, 0.04-1.5%) (I² , 0%). There was no difference in the rate of an associated anomaly detected only after birth when fetal MRI was carried out before, compared with after, 24 weeks of gestation (P = 0.265). The risk of detecting an associated CNS abnormality on MRI was higher in fetuses with moderate than in those with mild VM (odds ratio, 8.1 (95% CI, 2.3-29.0); P = 0.001), while there was no difference in those presenting with bilateral, compared with unilateral, dilatation (P = 0.333). Finally, a significant change in perinatal management, mainly termination of pregnancy owing to parental request, following MRI detection of an associated anomaly, was observed in 2.9% (95% CI, 0.01-9.8%) of fetuses undergoing dedicated neurosonography compared with 5.1% (95% CI, 3.2-7.5%) of those having standard assessment.

CONCLUSIONS

In fetuses undergoing dedicated neurosonography, the rate of a CNS anomaly detected exclusively on MRI is lower than that reported previously. Early MRI has an excellent diagnostic performance in identifying additional CNS anomalies, although the findings from this review suggest that MRI performed in the third trimester may be associated with a better detection rate for some types of anomaly, such as cortical, white matter and intracranial hemorrhagic anomalies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Automated analysis of fetal cardiac function using color tissue Doppler imaging in second half of normal pregnancy

OBJECTIVES

Color tissue Doppler imaging (cTDI) is a promising tool for the assessment of fetal cardiac function. However, the analysis of myocardial velocity traces is cumbersome and time-consuming, limiting its application in clinical practice. The aim of this study was to evaluate fetal cardiac function during the second half of pregnancy and to develop reference ranges using an automated method to analyze cTDI recordings from a cardiac four-chamber view.

METHODS

This was a cross-sectional study including 201 normal singleton pregnancies between 18 and 42 weeks of gestation. During fetal echocardiography, a four-chamber view of the heart was visualized and cTDI was performed. Regions of interest were positioned at the level of the atrioventricular plane in the left ventricular (LV), right ventricular (RV) and septal walls of the fetal heart, to obtain myocardial velocity traces that were analyzed offline using the automated algorithm. Peak myocardial velocities during atrial contraction (Am), ventricular ejection (Sm) and rapid ventricular filling, i.e. early diastole (Em), as well as the Em/Am ratio, mechanical cardiac time intervals and myocardial performance index (cMPI) were evaluated, and gestational age-specific reference ranges were constructed.

RESULTS

At 18 weeks of gestation, the peak myocardial velocities, presented as fitted mean with 95% CI, were: LV Am, 3.39 (3.09-3.70) cm/s; LV Sm, 1.62 (1.46-1.79) cm/s; LV Em, 1.95 (1.75-2.15) cm/s; septal Am, 3.07 (2.80-3.36) cm/s; septal Sm, 1.93 (1.81-2.06) cm/s; septal Em, 2.57 (2.32-2.84) cm/s; RV Am, 4.89 (4.59-5.20) cm/s; RV Sm, 2.31 (2.16-2.46) cm/s; and RV Em, 2.94 (2.69-3.21) cm/s. At 42 weeks of gestation, the peak myocardial velocities had increased to: LV Am, 4.25 (3.87-4.65) cm/s; LV Sm, 3.53 (3.19-3.89) cm/s; LV Em, 4.55 (4.18-4.94) cm/s; septal Am, 4.49 (4.17-4.82) cm/s; septal Sm, 3.36 (3.17-3.55) cm/s; septal Em, 3.76 (3.51-4.03) cm/s; RV Am, 6.52 (6.09-6.96) cm/s; RV Sm, 4.95 (4.59-5.32) cm/s; and RV Em, 5.42 (4.99-5.88) cm/s. The mechanical cardiac time intervals generally remained more stable throughout the second half of pregnancy, although, with increased gestational age, there was an increase in duration of septal and RV atrial contraction, LV pre-ejection and septal and RV ventricular ejection, while there was a decrease in duration of septal postejection. Regression equations used for the construction of gestational age-specific reference ranges for peak myocardial velocities, Em/Am ratios, mechanical cardiac time intervals and cMPI are presented.

CONCLUSION

Peak myocardial velocities increase with gestational age, while the mechanical time intervals remain more stable throughout the second half of pregnancy. Using an automated method to analyze cTDI-derived myocardial velocity traces, it was possible to construct reference ranges, which could be used in distinguishing between normal and abnormal fetal cardiac function. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Perinatal mortality, timing of delivery and prenatal management of monoamniotic twin pregnancy: systematic review and meta-analysis

OBJECTIVE

To quantify the rate of perinatal mortality in monochorionic monoamniotic (MCMA) twin pregnancies, according to gestational age, and to ascertain the incidence of mortality in pregnancies managed as inpatients compared with those managed as outpatients.

METHODS

MEDLINE, EMBASE and CINAHL databases were searched for studies on monoamniotic twin pregnancy. The primary outcomes explored were the incidence of intrauterine death (IUD), neonatal death (NND) and perinatal death (PND) in MCMA twins at different gestational-age windows (24-30, 31-32, 33-34, 35-36 and ≥ 37 weeks of gestation). The secondary outcomes were the incidence of IUD, NND and PND in MCMA twins according to the type of fetal monitoring (inpatient vs outpatient), and the incidence of delivery ahead of schedule. Random-effects model meta-analyses were used to analyze the data.

RESULTS

Twenty-five studies (1628 non-anomalous twins reaching 24 weeks of gestation) were included. Single and double intrauterine deaths occurred in 2.5% (95% CI, 1.8-3.3%) and 3.8% (95% CI, 2.5-5.3%) of cases, respectively. IUD occurred in 4.3% (95% CI, 2.8-6.2%) of twins at 24-30 weeks, in 1.0% (95% CI, 0.6-1.7%) at 31-32 weeks and in 2.2% (95% CI, 0.9-3.9%) at 33-34 weeks of gestation, while there was no case of IUD, either single or double, from 35 weeks of gestation. In MCMA twin pregnancies managed mainly as inpatients, the incidence of IUD was 3.0% (95% CI, 1.4-5.2%), while the corresponding figure for those managed mainly as outpatients was 7.4% (95% CI, 4.4-11.1%). Finally, 37.8% (95% CI, 28.0-48.2%) of MCMA pregnancies were delivered before the scheduled time, due mainly to spontaneous preterm labor or abnormal cardiotocographic findings.

CONCLUSIONS

MCMA twins are at high risk of perinatal loss during the third trimester of pregnancy, with the large majority of such losses occurring as apparently unexpected events. Inpatient management seems to be associated with a lower rate of mortality, although further studies are needed in order to establish the appropriate type and timing of prenatal assessment in these pregnancies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Automated analysis of fetal cardiac function using color tissue Doppler imaging

OBJECTIVE

To evaluate the feasibility of automated analysis of fetal myocardial velocity recordings obtained by color tissue Doppler imaging (cTDI).

METHODS

This was a prospective cross-sectional observational study of 107 singleton pregnancies ≥ 41 weeks of gestation. Myocardial velocity recordings were obtained by cTDI in a long-axis four-chamber view of the fetal heart. Regions of interest were placed in the septum and the right (RV) and left (LV) ventricular walls at the level of the atrioventricular plane. Peak myocardial velocities and mechanical cardiac time intervals were measured both manually and by an automated algorithm and agreement between the two methods was evaluated.

RESULTS

In total, 321 myocardial velocity traces were analyzed using each method. It was possible to analyze all velocity traces obtained from the LV, RV and septal walls with the automated algorithm, and myocardial velocities and cardiac mechanical time intervals could be measured in 96% of all traces. The same results were obtained when the algorithm was run repeatedly. The myocardial velocities measured using the automated method correlated significantly with those measured manually. The agreement between methods was not consistent and some cTDI parameters had considerable bias and poor precision.

CONCLUSIONS

Automated analysis of myocardial velocity recordings obtained by cTDI was feasible, suggesting that this technique could simplify and facilitate the use of cTDI in the evaluation of fetal cardiac function, both in research and in clinical practice. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Weight discordance and perinatal mortality in twin pregnancy: systematic review and meta-analysis

OBJECTIVES

The primary aim of this systematic review was to explore the strength of association between birth-weight (BW) discordance and perinatal mortality in twin pregnancy. The secondary aim was to ascertain the contribution of gestational age and growth restriction in predicting mortality in growth-discordant twins.

METHODS

MEDLINE, EMBASE, CINAHL and ClinicalTrials.gov databases were searched. Only studies reporting on the risk of mortality in twin pregnancies affected compared with those not affected by BW discordance were included. The primary outcomes explored were incidence of intrauterine death (IUD), neonatal death (NND) and perinatal death. Outcome was assessed separately for monochorionic (MC) and dichorionic (DC) twin pregnancies. Analyses were stratified according to BW discordance cut-off (≥ 15%, ≥ 20%, ≥ 25% and ≥ 30%) and selected gestational characteristics, including incidence of IUD or NND before and after 34 weeks' gestation, presence of at least one small-for-gestational age (SGA) fetus in the twin pair and both twins being appropriate-for-gestational age. Risk of mortality in the larger vs smaller twin was also assessed. Meta-analyses using individual data random-effects logistic regression and meta-analyses of proportion were used to analyze the data.

RESULTS

Twenty-two studies (10 877 twin pregnancies) were included in the analysis. In DC pregnancies, a higher risk of IUD, but not of NND, was observed in twins with BW discordance ≥ 15% (odds ratio (OR) 9.8, 95% CI, 3.9-29.4), ≥ 20% (OR 7.0, 95% CI, 4.15-11.8), ≥ 25% (OR 17.4, 95% CI, 8.3-36.7) and ≥ 30% (OR 22.9, 95% CI, 10.2-51.6) compared with those without weight discordance. For each cut-off of BW discordance explored in DC pregnancies, the smaller twin was at higher risk of mortality compared with the larger one. In MC twin pregnancies, excluding cases affected by twin-twin transfusion syndrome, twins with BW discordance ≥ 20% (OR 2.8, 95% CI, 1.3-5.8) or ≥ 25% (OR 3.2, 95% CI, 1.5-6.7) were at higher risk of IUD, compared with controls. MC pregnancies with ≥ 25% weight discordance were also at increased risk of NND (OR 4.66, 95% CI, 1.8-12.4) compared with those with concordant weight. The risk of IUD was higher when considering discordant pregnancies involving at least one SGA fetus. The overall risk of mortality in MC pregnancies was similar between the smaller and larger twin, except in those with BW discordance ≥ 20%.

CONCLUSION

DC and MC twin pregnancies discordant for fetal growth are at higher risk of IUD but not of NND compared with pregnancies with concordant BW. The risk of IUD in BW-discordant DC and MC twins is higher when at least one fetus is SGA. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis

OBJECTIVE

To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP).

METHODS

An electronic search of MEDLINE, EMBASE and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for 'Cesarean scar pregnancy' and 'outcome'. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: severe first-trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first- or second-trimester uterine rupture or hysterectomy; third-trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta-analyses of proportions using a random-effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis.

RESULTS

A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8-26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1-37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9-20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6-32.8%) of all cases. Forty (76.9% (95% CI, 65.4-86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4-66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0-92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two-thirds (69.7% (95% CI, 42.8-90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4-87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9-52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7-30.3%) of cases, but hysterectomy was not required in any case.

CONCLUSIONS

CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

First-trimester detection of abnormally invasive placenta in high-risk women: systematic review and meta-analysis

OBJECTIVES

The primary aim of this systematic review was to ascertain whether ultrasound signs suggestive of abnormally invasive placenta (AIP) are present in the first trimester of pregnancy. Secondary aims were to ascertain the strength of association and the predictive accuracy of such signs in detecting AIP in the first trimester.

METHODS

An electronic search of MEDLINE, EMBASE, CINAHL and Cochrane databases (2000-2016) was performed. Only studies reporting on first-trimester diagnosis of AIP that was subsequently confirmed in the third trimester either during operative delivery or by pathological examination were included. Meta-analysis of proportions, random-effects meta-analysis and hierarchical summary receiver-operating characteristics curve analysis were used to analyze the data.

RESULTS

Seven studies, involving 551 pregnancies at high risk of AIP, were included. At least one ultrasound sign suggestive of AIP was detected in 91.4% (95% CI, 85.8-95.7%) of cases with confirmed AIP. The most common ultrasound feature in the first trimester of pregnancy was low implantation of the gestational sac close to a previous uterine scar, which was observed in 82.4% (95% CI, 46.6-99.8%) of cases. Anechoic spaces within the placental mass (lacunae) were observed in 46.0% (95% CI, 10.9-83.7%) and a reduced myometrial thickness in 66.8% (95% CI, 45.2-85.2%) of cases affected by AIP. Pregnancies with a low implantation of the gestational sac had a significantly higher risk of AIP (odds ratio, 19.6 (95% CI, 6.7-57.3)), with a sensitivity and specificity of 44.4% (95% CI, 21.5-69.2%) and 93.4% (95% CI, 90.5-95.7%), respectively.

CONCLUSIONS

Ultrasound signs of AIP can be present during the first trimester of pregnancy, even before 11 weeks' gestation. Low anterior implantation of the placenta/gestational sac close to or within the scar was the most commonly seen early ultrasound sign suggestive of AIP, although its individual predictive accuracy was not high. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Anti-Mullerian hormone (AMH) and embryo quality assessed by time-lapse imaging (TLI): a cross-sectional observational study

PURPOSE

Serum anti-Mullerian hormone shows a strong positive correlation to the quantitative ovarian reserve but its correlation to embryo quality is unclear. This study assessed the association between serum AMH as a marker of ovarian reserve and embryo quality, using the technology of time-lapse imaging of the embryos in women undergoing in vitro fertilisation (IVF) treatment.

METHODS

304 embryos from 198 women undergoing IVF were included in the study. Serum AMH was assessed for all women. Embryo quality was assessed with the known implantation data (KID) score generated by the time-lapse imaging system.

RESULTS

There was no statistically significant difference in mean serum AMH among different KID score categories (p = 0.135). This remained non-significant after controlling for confounding variables (p = 0.305).

CONCLUSIONS

The results of our study show no significant association between serum AMH and embryo quality in women undergoing IVF treatment when embryo quality was assessed using the KID scores generated by time-lapse imaging which is a better method of embryo assessment rather than conventional morphological assessment.

Outcome of fetal ovarian cysts diagnosed on prenatal ultrasound examination: systematic review and meta-analysis

OBJECTIVE

To explore the outcome of fetuses with a prenatal diagnosis of ovarian cyst.

METHODS

The electronic databases MEDLINE and EMBASE were searched using keywords and word variants for 'ovarian cysts', 'ultrasound' and 'outcome'. The following outcomes in fetuses with a prenatal diagnosis of ovarian cyst were explored: resolution of the cyst, change of ultrasound pattern of the cyst, occurrence of ovarian torsion and intracystic hemorrhage, need for postnatal surgery, need for oophorectomy, accuracy of prenatal ultrasound examination in correctly identifying ovarian cyst, type of ovarian cyst at histopathological analysis and intrauterine treatment. Meta-analyses using individual data random-effects logistic regression and meta-analyses of proportions were performed. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale.

RESULTS

Thirty-four studies (954 fetuses) were included. In 53.8% (95% CI, 46.0-61.5%) of cases for which resolution of the cyst was evaluated (784 fetuses), the cyst regressed either during pregnancy or after birth. The likelihood of resolution was significantly lower in complex vs simple cysts (odds ratio (OR), 0.15 (95% CI, 0.10-0.23)) and in cysts measuring ≥ 40 mm vs < 40 mm (OR, 0.03 (95% CI, 0.01-0.06)). Change in ultrasound pattern of the cyst was associated with an increased risk of ovarian loss (surgical removal or autoamputation) (pooled proportion, 57.7% (95% CI, 42.9-71.8%)). The risk of ovarian torsion was significantly higher for cysts measuring ≥ 40 mm compared with < 40 mm (OR, 30.8 (95% CI, 8.6-110.0)). The likelihood of having postnatal surgery was higher in patients with cysts ≥ 40 mm compared with < 40 mm (OR, 64.4 (95% CI, 23.6-175.0)) and in complex compared with simple cysts, irrespective of cyst size (OR, 14.6 (95% CI, 8.5-24.8)). In cases undergoing prenatal aspiration of the cyst, rate of recurrence was 37.9% (95% CI, 14.8-64.3%), ovarian torsion and intracystic hemorrhage were diagnosed after birth in 10.8% (95% CI, 4.4-19.7%) and 12.8% (95% CI, 3.8-26.0%), respectively, and 21.8% (95% CI, 0.9-40.0%) had surgery after birth.

CONCLUSION

Size and ultrasound appearance are the major determinants of perinatal outcome in fetuses with ovarian cysts. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Systematic review and meta-analysis of persistent left superior vena cava on prenatal ultrasound: associated anomalies, diagnostic accuracy and postnatal outcome

OBJECTIVES

To quantify the prevalence of chromosomal anomalies in fetuses with persistent left superior vena cava (PLSVC), assess the strength of the association between PLSVC and coarctation of the aorta and ascertain the diagnostic accuracy of antenatal ultrasound in correctly identifying isolated cases of PLSVC.

METHODS

MEDLINE, EMBASE, CINHAL and the Cochrane databases were searched from the year 2000 onwards using combinations of keywords 'left superior vena cava' and 'outcome'. Two authors reviewed all abstracts independently. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for cohort studies. The rates of the following outcomes were analyzed: chromosomal abnormalities; associated intracardiac anomalies (ICAs) and extracardiac anomalies (ECAs) diagnosed prenatally; additional ICAs and ECAs detected only at postnatal imaging or clinical evaluation but missed at prenatal imaging; and association of PLSVC and coarctation of the aorta. Meta-analyses of proportions were used to combine data.

RESULTS

In total, 2708 articles were identified and 13 (n = 501) were included in the systematic review. Associated ICAs and ECAs were detected at the prenatal ultrasound examination or at a follow-up assessment in 60.7% (95% CI, 44.2-75.9%) and 37.8% (95% CI, 31.0-44.8%) of cases, respectively. Chromosomal anomalies occurred in 12.5% (95% CI, 9.0-16.4%) of cases in the overall population of fetuses with PLSVC and in 7.0% (95% CI, 2.7-13.0%) of isolated cases. Additional ICAs and ECAs were detected only after birth and missed at ultrasound in 2.4% (95% CI, 0.5-5.8%) and 6.7% (95% CI, 2.2-13.2%) of cases, respectively. Coarctation of the aorta was associated with isolated PLSVC in 21.3% (95% CI, 13.6-30.3%) of cases.

CONCLUSIONS

PLSVC is commonly associated with ICAs, ECAs and chromosomal anomalies. Fetuses with isolated PLSVC should be followed up throughout pregnancy in order to rule out coarctation of the aorta. As most of the data in this review were derived from high-risk pregnancies, the rate of associated abnormalities is likely to be higher than that in the general population of fetuses with PLSVC, for which more data are needed. Revisión sistemática y metaanálisis de la persistencia de la vena cava superior izquierda en la ecografía prenatal: anomalías asociadas, precisión del diagnóstico y resultado postnatal RESUMEN OBJETIVOS: Cuantificar la prevalencia de anomalías cromosómicas en fetos con vena cava superior izquierda persistente (VCSIP), evaluar la solidez de la asociación entre la VCSIP y la coartación aórtica, y determinar la precisión del diagnóstico de la ecografía prenatal como método para identificar correctamente casos aislados de VCSIP. MÉTODOS: Se buscó en las bases de datos de MEDLINE, EMBASE, CINHAL y Cochrane artículos publicados desde el año 2000 en adelante, usando combinaciones de las palabras clave "vena cava superior izquierda" y "resultado". Dos de los autores revisaron de forma independiente todos los resúmenes encontrados. La evaluación de calidad de los estudios incluidos se realizó mediante la escala Newcastle-Ottawa para estudios de cohortes. Se analizaron las tasas de los siguientes resultados: anomalías cromosómicas; anomalías intracardíacas (AIC) y anomalías extracardíacas (AEC) asociadas diagnosticadas prenatalmente; AIC y AEC adicionales detectadas sólo en ecografías postnatales o mediante evaluación clínica, pero no observadas en ecografías prenatales; y la asociación entre la VCSIP y la coartación aórtica. Se utilizó un meta-análisis de proporciones para combinar los datos.

RESULTADOS

En total, se identificaron 2708 artículos y se incluyeron 13 (n = 501) en la revisión sistemática. En la ecografía prenatal o en una revisión de seguimiento se detectaron AIC y AEC asociadas en el 60,7% (IC 95%, 44,2-75,9%) y el 37,8% (IC 95%, 31,0-44,8%) de los casos, respectivamente. Se produjeron anomalías cromosómicas en el 12,5% (IC 95%, 9,0-16,4%) de los casos en la población general de fetos con VCSIP y en el 7,0% (IC 95%, 2,7-13,0%) de casos aislados. Las AIC y AEC adicionales sólo se detectaron después del nacimiento y en el 6,7% (IC 95%, 2,2-13,2%) de los casos, respectivamente. La coartación aórtica se encontró asociada con la VCSIP aislada en un 21,3% (IC 95%, 13,6-30,3%) de los casos.

CONCLUSIONES

La VCSIP está comúnmente asociada a AIC, AEC y anomalías cromosómicas. Los fetos con VCSIP aislada deben ser objeto de seguimiento durante todo el embarazo, con el fin de descartar la coartación aórtica. Como la mayoría de los datos de esta revisión proceden de embarazos de alto riesgo, es probable que la tasa de anomalías asociadas sea más alta que la de la población general de fetos con VCSIP, por lo que se necesitan más datos.

Nasal intubation: A comprehensive review

Nasal intubation technique was first described in 1902 by Kuhn. The others pioneering the nasal intubation techniques were Macewen, Rosenberg, Meltzer and Auer, and Elsberg. It is the most common method used for giving anesthesia in oral surgeries as it provides a good field for surgeons to operate. The anatomy behind nasal intubation is necessary to know as it gives an idea about the pathway of the endotracheal tube and complications encountered during nasotracheal intubation. Various techniques can be used to intubate the patient by nasal route and all of them have their own associated complications which are discussed in this article. Various complications may arise while doing nasotracheal intubation but a thorough knowledge of the anatomy and physics behind the procedure can help reduce such complications and manage appropriately. It is important for an anesthesiologist to be well versed with the basics of nasotracheal intubation and advances in the techniques. A thorough knowledge of the anatomy and the advent of newer devices have abolished the negative effect of blindness of the procedure.

Atrial dominance in the human embryonic heart: a study of cardiac function at 6-10 weeks of gestation

OBJECTIVE

To investigate the difference in forces developed by atrial and ventricular myocardium during contraction in human embryos using a novel method.

METHODS

This was a cross-sectional study of 115 pregnancies examined at 6-10 weeks of gestation. Ventricular inflow and outflow velocities were obtained by Doppler echocardiography and the relative force development was evaluated by calculating the ratio between atrial and ventricular ejection force (EF).

RESULTS

Data from 97 embryos with monophasic ventricular filling were analyzed. Both inflow and outflow cardiac velocities increased with advancing gestational age (P < 0.001). The mean peak inflow velocity (31.7 ± 10.2 cm/s) was significantly higher (P < 0.0001) than the outflow velocity (19.6 ± 6.1 cm/s). The EFinflow /EFoutflow ratio was more than 1.0 in all but four (96%) cases.

CONCLUSION

Our study indicates the possibility of atrial dominance in the embryonic period of heart development, which may have clinical implications, as deviations from this normal pattern may indicate human embryonic cardiac dysfunction.

Gene expression profile in cardiovascular disease and preeclampsia: a meta-analysis of the transcriptome based on raw data from human studies deposited in Gene Expression Omnibus

INTRODUCTION

Cardiovascular disease (CVD) and preeclampsia (PE) share common clinical features. We aimed to identify common transcriptomic signatures involved in CVD and PE in humans.

METHODS

Meta-analysis of individual raw microarray data deposited in GEO, obtained from blood samples of patients with CVD versus controls and placental samples from women with PE versus healthy women with uncomplicated pregnancies. Annotation of cases versus control samples was taken directly from the microarray documentation. Genes that showed a significant differential expression in the majority of experiments were selected for subsequent analysis. Hypergeometric gene list analysis was performed using Bioconductor GOstats package. Bioinformatic analysis was performed in PANTHER.

RESULTS

Seven studies in CVD and 5 studies in PE were eligible for meta-analysis. A total of 181 genes were found to be differentially expressed in microarray studies investigating gene expression in blood samples obtained from patients with CVD compared to controls and 925 genes were differentially expressed between preeclamptic and healthy placentas. Among these differentially expressed genes, 22 were common between CVD and PE.

DISCUSSION

Bioinformatic analysis of these genes revealed oxidative stress, p-53 pathway feedback, inflammation mediated by chemokines and cytokines, interleukin signaling, B-cell activation, PDGF signaling, Wnt signaling, integrin signaling and Alzheimer disease pathways to be involved in the pathophysiology of both CVD and PE. Metabolism, development, response to stimulus, immune response and cell communication were the associated biologic processes in both conditions. Gene set enrichment analysis showed the following overlapping pathways between CVD and PE: TGF-β-signaling, apoptosis, graft-versus-host disease, allograft rejection, chemokine signaling, steroid hormone synthesis, type I and II diabetes mellitus, VEGF signaling, pathways in cancer, GNRH signaling, Huntingtons disease and Notch signaling.

CONCLUSION

CVD and PE share same common traits in their gene expression profile indicating common pathways in their pathophysiology.

Bacteriological profile and associated risk factors of neonatal sepsis in Paropakar Maternity and Women's Hospital Thapathali, Kathmandu

Neonatal Sepsis is one of the most common reasons for admission to neonatal units in developing countries. It is also a major cause of mortality in both developed and developing countries. Identification of the common bacteria and risk factors causing such infections and their susceptibility patterns will provide necessary information for timely intervention. This study was carried out to determine the bacteriological profile and associated risk factors of neonatal sepsis in Paropakar Maternity and Women's hospital. A cross-sectional prospective study was conducted among neonates suspected of neonatal sepsis. Blood culture was performed and organisms were identified and antibiotic susceptibility was carried out with standard microbiological methods. Data were analysed by using SPSS. Ver. 16 software. The positive yield of blood culture was 21%. The most common isolates were Staphylococcus epidermidis, E. coli, Staphylococcus aureus, Klebsiella pneumoniae and Pseudomonas spp. In Antibiotic susceptibility pattern Gentamycin showed the highest sensitivity to all types of isolated organisms. Vancomycin sensitivity was highest for Gram positive organism and Ciprofloxacin was most effective for Gram negative organisms isolated. Ampicillin and Amoxycillin were the least effective drug. Multiple drug resistance was observed in 77.15% of isolates. Prematurity, low birth weight and maternal pyrexia before delivery were found to be strongly associated with neonatal sepsis. Gram positive organisms were more prevalent than gram negative organisms.

Differences in gene expression between first and third trimester human placenta: a microarray study

BACKGROUND

The human placenta is a rapidly developing organ that undergoes structural and functional changes throughout the pregnancy. Our objectives were to investigate the differences in global gene expression profile, the expression of imprinted genes and the effect of smoking in first and third trimester normal human placentas.

MATERIALS AND METHODS

Placental samples were collected from 21 women with uncomplicated pregnancies delivered at term and 16 healthy women undergoing termination of pregnancy at 9-12 weeks gestation. Placental gene expression profile was evaluated by Human Genome Survey Microarray v.2.0 (Applied Biosystems) and real-time polymerase chain reaction.

RESULTS

Almost 25% of the genes spotted on the array (n = 7519) were differentially expressed between first and third trimester placentas. Genes regulating biological processes involved in cell proliferation, cell differentiation and angiogenesis were up-regulated in the first trimester; whereas cell surface receptor mediated signal transduction, G-protein mediated signalling, ion transport, neuronal activities and chemosensory perception were up-regulated in the third trimester. Pathway analysis showed that brain and placenta might share common developmental routes. Principal component analysis based on the expression of 17 imprinted genes showed a clear separation of first and third trimester placentas, indicating that epigenetic modifications occur throughout pregnancy. In smokers, a set of genes encoding oxidoreductases were differentially expressed in both trimesters.

CONCLUSIONS

Differences in global gene expression profile between first and third trimester human placenta reflect temporal changes in placental structure and function. Epigenetic rearrangements in the human placenta seem to occur across gestation, indicating the importance of environmental influence in the developing feto-placental unit.

IFPA Meeting 2011 workshop report I: Placenta: Predicting future health; roles of lipids in the growth and development of feto-placental unit; placental nutrient sensing; placental research to solve clinical problems--a translational approach

Workshops are an important part of the IFPA annual meeting as they allow for discussion of specialized topics. At IFPA meeting 2011 there were twelve themed workshops, four of which are summarized in this report. These workshops related to both basic science and clinical research into placental growth and nutrient sensing and were divided into 1) placenta: predicting future health; 2) roles of lipids in the growth and development of feto-placental unit; 3) placental nutrient sensing; 4) placental research to solve clinical problems: a translational approach.

A new non-invasive method for measuring uterine vascular resistance and its relationship to uterine artery Doppler indices: a longitudinal study

OBJECTIVES

To describe a new method for measuring uterine vascular resistance (R(uta) ), establish longitudinal reference ranges and explore the relationship between uterine artery (UtA) Doppler indices and R(uta) .

METHODS

This was a longitudinal study of 53 low-risk pregnancies. Doppler ultrasonography was used to measure UtA velocities, and the pulsatility index (PI), resistance index (RI) and systolic/diastolic velocity (S/D) ratio were calculated. R(uta) was calculated as a ratio between maternal mean arterial pressure and UtA time-averaged maximum velocity.

RESULTS

At 22 + 0 to 39 + 6 weeks of gestation, the mean R(uta) decreased from 1628 to 1180 dyne.s/cm(3) (P < 0.0001). UtA velocities increased (P < 0.0001), whereas the PI (0.79-0.56), RI (0.51-0.40) and S/D ratio (2.0-1.7) decreased (P < 0.0001). R(uta) and the UtA Doppler indices were positively associated (P = 0.003-0.001).

CONCLUSION

We describe a non-invasive method for measuring R(uta) and provide reference ranges for serial evaluation of UtA velocities, Doppler indices and R(uta) .

Pregnancy protects against antiangiogenic and fibrogenic effects of angiotensin II in rat hearts

AIM

To investigate the difference between physiological and pathological cardiac remodelling induced, respectively, by pregnancy and angiotensin (Ang) II, and to test the hypothesis that pregnancy protects against Ang II effects.

METHODS

Female Wistar rats, pregnant (n = 12) and non-pregnant (n = 12), were implanted with mini-pumps containing saline (sham) or 150 ng kg(-1) min(-1) Ang II. Ten days later echocardiography and blood pressure measurement were performed. Expression of 22 genes was assessed using RT-PCR. Microscopic sections of LV were prepared to determine collagen content (Sirius Red staining), vessel density (β-actin immunolabelling) and myocytes diameter (Toluidine Blue).

RESULTS

Heart weight (HW) was increased in Ang II treated groups compared with their controls. Furthermore, HW of Ang II treated pregnant rats (1.0 ± 0.03 g) was higher than that in non-pregnant sham (0.7 ± 0.02 g), pregnant (0.8 ± 0.01 g) and Ang II treated non-pregnant (0.8 ± 0.02 g) rats. Relative LV wall thickness showed similar pattern. Aortic pressure was significantly increased in Ang II groups. Collagen content was increased in Ang II (4.0 ± 0.5%) compared with sham (1.5 ± 0.1%) but reduced again when treated rats were pregnant (2.8 ± 0.4%). Vessel density was reduced by 47.8% after Ang II treatment in non-pregnant and by only 13.9% in pregnant rats. Gene expression analysis showed increased expression of atrial natriuretic factor (ANF), brain natriuretic peptide (BNP), anykrin repeat domain-containing protein 1 (Ankrd-1), protein kinase C-α and -δ and tumour suppressor gene TP53 (p53) in Ang II treated groups and upregulation of ANF, BNP and Ankrd-1 remained when pregnancy was combined with Ang II. Pregnancy reduced expression of: α-myosin heavy chain, tumour necrosis factor-α, p53, endothelial nitric oxide synthase and inducible nitric oxide synthase.

CONCLUSION

Pregnancy seems to counteract the detrimental effects of Ang II on fibrosis and angiogenesis in heart. In addition, pregnancy and Ang II lead to partly opposite changes in the expression of some genes important for heart function.

A comparative clinical trial of Chincha kshara and Kadali kshara on Amlapitta

A clinical trial was carried out on 30 patients of Amlapitta aged between 20 to 35 years with complaints of Avipaka, hrit-kanthadaha, tikta-amlodgara, utklesa, udarasula, adhmana and aruchi, who were registered from OPD and IPD of Gopabandhu Ayurveda Mahavidyalaya, Puri. They were equally divided into three groups Chincha kshara, Kadali kshara and placebo (who were administered with fresh wheat powder) for 30 days in a dose of 500 mg thrice daily with water. Investigations was done in order to exclude upper gastrointestinal tract ulcer, carcinoma in stomach, cholecystitis, carcinoma gall bladder, and heart diseases. The clinical assessments were carried out on the 30^th day by subjective and objective parameters and it was inferred that both Chincha kshara and Kadali kshara were effective and reduced the symptoms of amlapitta. Chincha kshara was found to be more effective than Kadali kshara. The study shows the effect of Chincha and Kadali kshara which led to cure in 4(40%) and 3(30%) patients respectively, and maximum improvement in 4(40%) and 5(50%) patients affected with amlapitta disease, respectively. No untoward effect was noticed due to administration of ksharas during the clinical trial period.

Longitudinal reference ranges for umbilical vein blood flow at a free loop of the umbilical cord

OBJECTIVE

To establish longitudinal reference ranges for the umbilical vein (UV) diameter, velocities and volume blood flow (Q(uv)) at a free loop of the umbilical cord and estimate the UV spatial velocity profile at this site.

METHODS

This was a prospective study of 53 low-risk pregnancies. The UV diameter and blood flow velocities were measured at 4-weekly intervals from 22 + 0 to 39 + 6 weeks of gestation (232 observations) using B-mode ultrasonography and pulsed-wave Doppler. Multilevel regression modeling was used to estimate the reference percentiles.

RESULTS

The mean UV diameter, velocities and Q(uv) increased with advancing gestation, whereas the Q(uv) normalized for estimated fetal weight decreased. The UV spatial velocity profile coefficient was 0.62.

CONCLUSION

We have established reference ranges for serial measurements of Q(uv) at a free loop of the umbilical cord during the second half of pregnancy. The spatial velocity profile of the UV is not completely parabolic at this site.

Reference values for variables of fetal cardiocirculatory dynamics at 11-14 weeks of gestation

OBJECTIVE

Despite the increasing popularity of first-trimester fetal echocardiography, the evaluation of fetal heart function during this period remains challenging. The parameters of normal cardiac function at 11-14 weeks' gestation are not well defined and appropriate reference values have not yet been established. The purpose of this study was to evaluate the fetal cardiocirculatory dynamics during routine first-trimester screening and establish cross-sectional reference ranges for 11-14 weeks' gestation.

METHODS

Fetal echocardiography was performed on 202 women with singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation. Global cardiac function was evaluated using the heart : chest area ratio and Tei index of the left (LV) and right (RV) ventricles. The proportion of isovolumic contraction (ICT%) and ejection (ET%) times of the cardiac cycle, and the outflow velocities described the systolic function. Diastolic function was evaluated by the proportion of relaxation (IRT%) and filling (FT%) times, the ratio of the blood velocity through the atrioventricular valves during early filling (E) and atrial contraction (A) phases of the cardiac cycle, and ductus venosus pulsatility index for veins (DV-PIV). All participants had additional fetal echocardiography in the second trimester and neonatal clinical examination after birth to confirm normality.

RESULTS

The mean heart : chest area ratio (0.203 +/- 0.04) and the Tei indices of both ventricles did not vary significantly during weeks 11-14, but the mean Tei index of the LV (0.375 +/- 0.092) was significantly higher than that of the RV (0.332 +/- 0.079) (P = 0.001). The fetal heart rate (FHR) decreased with increasing crown-rump length (CRL) (P < 0.00001). The LV-ICT% did not vary significantly (P = 0.27), LV-IRT% (P = 0.03) and LV-ET% decreased (P = 0.01), whereas the LV-FT% increased (P = 0.02) with CRL. The RV-ET% (P = 0.84) and RV-FT% (P = 0.60) remained relatively stable. The LV-ET% was lower than the RV-ET% (P = 0.0001). The LV (P = 0.004) and RV (P < 0.00001) outflow velocities and E : A ratios of both ventricles (P < 0.0001) increased with advancing gestation. The E-velocity of the LV (P = 0.003) and RV (P = 0.002) increased significantly but the increase in A-velocity was not significant. The outflow velocity (P = 0.008) and E-velocity (P = 0.005) of the RV were higher than that of the LV but the A-velocities were similar (P = 0.066). The mean DV-PIV was 0.97 +/- 0.23 and did not change significantly (P = 0.95) during weeks 11-14. The FHR and DV-PIV did not correlate with the Tei index of either ventricle.

CONCLUSION

We have established reference ranges for the noninvasive evaluation of fetal cardiocirculatory dynamics at 11-14 weeks' gestation.

A longitudinal study of the relationship between maternal cardiac output measured by impedance cardiography and uterine artery blood flow in the second half of pregnancy

OBJECTIVE

To study serial changes in maternal systemic and uterine artery haemodynamics and establish reference ranges for the second half of pregnancy.

DESIGN

Prospective longitudinal observational study.

SETTING

University hospital in Norway.

POPULATION

Low-risk pregnant women.

METHODS

Fifty-three low-risk pregnancies were evaluated at approximately 4-weekly intervals. Maternal systemic haemodynamics was assessed with impedance cardiography. Uterine artery blood velocity and diameter were measured using Doppler ultrasonography and uterine artery volume blood flow (Q(uta)) was calculated as the product of mean velocity and cross-sectional area of the uterine artery. The fraction of cardiac output (CO) distributed to the uterine circulation was calculated as: Q(uta)/CO x 100.

MAIN OUTCOME MEASURES

CO, Q(uta), uterine vascular resistance (R(uta)) and the fraction of CO distributed to the uterine circulation.

RESULTS

The CO increased (P = 0.0063) until 34 weeks and remained stable until term. Total Q(uta) increased from 299 to 673 ml/minute and R(uta) halved from 0.26 to 0.13 mmHg/ml/minute (P < 0.0001). The fraction of CO distributed to the uterine circulation increased from 5.6% to 11.7% (P < 0.0001).

CONCLUSION

During the second half of pregnancy, Q(uta) and the fraction of maternal CO distributed to the uterine circulation increase approximately two-fold, mainly as a result of decrease in R(uta).

Agreement between umbilical vein volume blood flow measurements obtained at the intra-abdominal portion and free loop of the umbilical cord

OBJECTIVE

The umbilical vein (UV) is a single vessel and theoretically the volume of blood flowing through it should be equal whether it is measured at the intra-abdominal portion (IA) or a free loop of the umbilical cord (FL). However, the reported values vary considerably depending on the technique and site of measurement. Our objective was to investigate the correlation and agreement between UV volume blood flows (Q(uv)) measured at the IA and FL.

METHODS

Blood flow velocities and inner diameter of the UV were measured cross-sectionally at the IA and FL in 131 pregnant women at 22-24 weeks' gestation, and in 53 of them longitudinally at 4-weekly intervals until delivery. For each sampling site, the Q(uv) was calculated as: 0.5 x time-averaged maximum velocity x pi x (UV diameter/2)(2).

RESULTS

The mean Q(uv) measured at the IA (61.5 +/- 23.3 mL/min) and FL (60.7 +/- 17.6 mL/min) cross-sectionally in 131 fetuses at 22-24 weeks of gestation were similar, but the bivariate correlation between them was not strong (r = 0.38; P < 0.0001) and the intraclass correlation coefficient (ICC) was 0.37 (95% CI, 0.21-0.51). When the agreement between 131 pairs of Q(uv) measurements was tested with Bland-Altman analysis, the mean of the ratio IA-Q(uv)/FL-Q(uv) was found to be 1.05 (i.e. IA-Q(uv) exceeded FL-Q(uv) on average by 5%) with 95% limits of agreement of 0.31-1.78. In the longitudinal analysis of 232 pairs of Q(uv) measurements from 53 fetuses at 22-40 weeks, the mean Q(uv) obtained at the IA and FL were similar, i.e. 164 +/- 87 (range, 25-484) mL/min vs. 159 +/- 82 (range, 30-470) mL/min, and the correlation between them, assessed after grouping the observations in five different gestational age groups of 4-week intervals, was slightly better (r = 0.45-0.62; P < 0.0001). The ICC for the Q(uv) measurements obtained at the two sites ranged from 0.38 to 0.54. The mean of the ratio IA-Q(uv)/FL-Q(uv) was 1.07 (i.e. IA-Q(uv) exceeded FL-Q(uv) on average by 7%), with 95% limits of agreement of 0.39-1.75.

CONCLUSION

Average Q(uv) measured at the IA and FL was similar, but the agreement between individual pairs of measurements was not good enough to be able to use them interchangeably. Therefore, any clinical application of Q(uv) measurement would require standardization of the technique, strict adherence to methodology and use of appropriate reference ranges for it to be useful.

Fetal aortic isthmus blood flow and the fraction of cardiac output distributed to the upper body and brain at 11-20 weeks of gestation

OBJECTIVE

To measure serial changes in fetal aortic isthmus (AI) blood flow and estimate the fraction of fetal cardiac output distributed to the upper body, including the brain, at 11-20 weeks of gestation.

METHODS

Using pulsed-wave Doppler and two-dimensional ultrasound, blood flow velocities and inner diameter of the AI, aortic valve (AV) and pulmonary valve (PV) were measured longitudinally in 143 fetuses and volume blood flows (Q) were calculated for each site using the formula: Q (mL/min) = pix (diameter/2)(2) x velocity time integral x heart rate x 60. The sum of Q(av) and Q(pv) constituted the combined cardiac output (CCO) and the fraction (%) of the upper body (including brain) blood flow was calculated as: (Q(av)-Q(ai))x100/CCO.

RESULTS

AI blood velocities as well as the vessel diameter increased with advancing gestation, resulting in a significant increase in Q(ai) from 1.9 to 40.5 mL/min during weeks 11 to 20. The AI peak systolic velocity increased from 29 to 63 cm/s, end-diastolic velocity from 1.2 to 5.2 cm/s, and the time-averaged maximum velocity from 11 to 22 cm/s, resulting in a fairly stable pulsatility index (PI) of 2.4-2.6 and resistance index (RI) of 0.91-0.94. On average, 75% of blood ejected by the left ventricle (which represented about 35% of the CCO) passed through the AI to the descending aorta. The fraction of CCO distributed to the upper body, including the brain, was estimated as approximately 13%.

CONCLUSION

We have established longitudinal reference ranges for fetal AI diameter, blood flow velocities, PI, RI and volume blood flow at 11-20 weeks of gestation. The human fetus appears to direct a relatively small fraction (13%) of its CCO to the upper body, including the brain, during this period of pregnancy.

Diagnosis of spatiotemporal chaos in wave envelopes of a nematic electroconvection pattern

In this paper we report and analyze complex spatiotemporal dynamics recorded in electroconvection in the nematic liquid crystal I52, driven by an ac voltage slightly above the onset value. The instability mechanism creating the pattern is an oscillatory (Hopf) instability, giving rise to two pairs of counterpropagating rolls traveling in oblique directions relative to the unperturbed director axis. If a system of nonlinear partial differential equations shows the same set of unstable modes, the pattern above the onset is represented in a weakly nonlinear analysis as a superposition of the traveling rolls in terms of wave envelopes varying slowly in space and time. Motivated by this procedure, we extract slowly varying envelopes from the space-time data of the pattern, using a four-wave demodulation based on Fourier analysis. In order to characterize the spatiotemporal dynamics, we apply a variety of diagnostic methods to the envelopes, including the calculation of mean intensities and correlation lengths, global and local Karhunen-Loève decompositions in Fourier space and physical space, the location of holes, the identification of coherent vertical structures, and estimates of Lyapunov exponents. The results of this analysis provide strong evidence that our pattern exhibits extensive spatiotemporal chaos. One of its main characteristics is the presence of coherent structures of low and high intensities extended in the vertical (parallel to the director) direction.