Perinatal outcome of monochorionic triamniotic triplet pregnancy: multicenter cohort study

OBJECTIVE

Monochorionic (MC) triplet pregnancies are extremely rare and information on these pregnancies and their complications is limited. We aimed to investigate the risk of early and late pregnancy complications, perinatal outcome and the timing and methods of fetal intervention in these pregnancies.

METHODS

This was a multicenter retrospective cohort study of MC triamniotic (TA) triplet pregnancies managed in 21 participating centers around the world from 2007 onwards. Data on maternal age, mode of conception, diagnosis of major fetal structural anomalies or aneuploidy, gestational age (GA) at diagnosis of anomalies, twin-to-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence (TAPS), twin reversed arterial perfusion (TRAP) sequence and or selective fetal growth restriction (sFGR) were retrieved from patient records. Data on antenatal interventions were collected, including data on selective fetal reduction (three to two or three to one), laser surgery and any other active fetal intervention (including amniodrainage). Data on perinatal outcome were collected, including numbers of live birth, intrauterine demise, neonatal death, perinatal death and termination of fetus or pregnancy (TOP). Neonatal data such as GA at birth, birth weight, admission to neonatal intensive care unit and neonatal morbidity were also collected. Perinatal outcomes were assessed according to whether the pregnancy was managed expectantly or underwent fetal intervention.

RESULTS

Of an initial cohort of 174 MCTA triplet pregnancies, 11 underwent early TOP, three had an early miscarriage, six were lost to follow-up and one was ongoing at the time of writing. Thus, the study cohort included 153 pregnancies, of which the majority (92.8%) were managed expectantly. The incidence of pregnancy affected by one or more fetal structural abnormality was 13.7% (21/153) and that of TRAP sequence was 5.2% (8/153). The most common antenatal complication related to chorionicity was TTTS, which affected just over one quarter (27.6%; 42/152, after removing a pregnancy with TOP < 24 weeks for fetal anomalies) of the pregnancies, followed by sFGR (16.4%; 25/152), while TAPS (spontaneous or post TTTS with or without laser treatment) occurred in only 4.6% (7/152) of pregnancies. No monochorionicity-related antenatal complication was recorded in 49.3% (75/152) of pregnancies. Survival was apparently associated largely with the development of these complications: there was at least one survivor beyond the neonatal period in 85.1% (57/67) of pregnancies without antenatal complications, in 100% (25/25) of those complicated by sFGR and in 47.6% (20/42) of those complicated by TTTS. The overall rate of preterm birth prior to 28 weeks was 14.5% (18/124) and that prior to 32 weeks' gestation was 49.2% (61/124).

CONCLUSION

Monochorionicity-related complications, which can impact adversely perinatal outcome, occur in almost half of MCTA triplet pregnancies, creating a challenge with regard to counseling, surveillance and management. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Non-Invasive Fetal K Status Prediction: 7 Years of Experience

Introduction

In the Kell blood group system, the K and k antigens are the clinically most important ones. Maternal anti-K IgG antibodies can lead to the demise of a K-positive fetus in early pregnancy. Intervention can save the fetus. Prenatal K status prediction of the fetus in early pregnancy is desirable and gives a good basis for pregnancy risk management. We present the results from 7 years of clinical experience in predicting fetal K status as well as some theoretical considerations relevant for design of the assay and evaluation of results.

Methods

Blood was collected from 43 women, all immunized against K, at a mean gestational age of 18 weeks (range 10–38). A total of 56 consecutive samples were tested. The KEL *01.01 /KEL *02 single nucleotide variant that determines K status was amplified from maternal plasma DNA by PCR without allele specificity. The PCR product was sequenced by NGS technology, and the number of sequenced KEL *01.01 and KEL *02 reads were counted. Prediction of the fetal K status was based on this count and was compared with the serologically determined K status of the newborns.

Results

All fetal K predictions were in accordance with postnatal serology where available (n = 34), using our current data analysis.

Conclusion

We have developed an NGS-based method for the non-invasive prediction of fetal K status. This approach requires special considerations in terms of primer design, stringent preanalytical sample handling, and careful analytical procedures. We analyzed samples starting at GA 10 weeks and demonstrated the correct prediction of fetal K status. This assay enables timely clinical intervention in pregnancies at risk of hemolytic disease of the fetus and newborn caused by maternal anti-K IgG antibodies.

Laboratory Monitoring of Mother, Fetus, and Newborn in Hemolytic Disease of Fetus and Newborn

Background

Laboratory monitoring of mother, fetus, and newborn in hemolytic disease of fetus and newborn (HDFN) aims to guide clinicians and the immunized women to focus on the most serious problems of alloimmunization and thus minimize the consequences of HDFN in general and of anti-D in particular. Here, we present the current approach of laboratory screening and testing for prevention and monitoring of HDFN at the Copenhagen University Hospital in Denmark.

Summary

All pregnant women are typed and screened in the 1st trimester. This serves to identify the RhD-negative pregnant women who at gestational age (GA) of 25 weeks are offered a second screen test and a non-invasive fetal RhD prediction. At GA 29 weeks, and again after delivery, non-immunized RhD-negative women carrying an RhD-positive fetus are offered Rh immunoglobulin. If the 1st trimester screen reveals an alloantibody, antenatal investigation is initiated. This also includes RhD-positive women with alloantibodies. Specificity and titer are determined, the fetal phenotype is predicted by non-invasive genotyping based on cell-free DNA (RhD, K, Rhc, RhC, RhE, ABO), and serial monitoring of titer commences. Based on titers and specificity, monitoring with serial peak systolic velocity measurements in the fetal middle cerebral artery to detect anemia will take place. Intrauterine transfusion is given when fetal anemia is suspected. Monitoring of the newborn by titer and survival of fetal red blood cells by flow cytometry will help predict the length of the recovery of the newborn.

[Severe foetal anaemia caused by undetected alloimmunisation in a RhD-positive pregnant woman]

The incidence of haemolytic disease of the foetus or newborn (HDFN) has decreased considerably in Denmark since the introduction of routine administration of prophylactic anti-D immunoglobulin to RhD-negative pregnant women carrying a RhD-positive foetus. RhD-positive pregnant women are screened for irregular antibodies only in the first trimester of their pregnancy, as their risk of clinically relevant immunisation during pregnancy has been considered very low. This is a case report of severe undetected alloimmunisation causing fatal HDFN after the first trimester in a RhD-positive woman.

Prenatal prediction of fetal Rh C, c and E status by amplification of maternal cfDNA and deep sequencing

BACKGROUND

The Rh blood group system has considerable clinical importance. The C, c, and E antigens are targets of alloantibodies. Anti-C, anti-c or anti-E alloreactive antibodies produced in pregnant women can cause anemia of a fetus carrying the corresponding antigens.

AIMS

Based on NGS technology, we have developed a noninvasive diagnostic assay to predict the fetal blood group of C, c or E antigens by sequencing cell-free DNA (cfDNA) during pregnancy.

MATERIALS AND METHODS

The SNVs underlying either the C, c or E antigens were PCR amplified and sequenced using NGS on a MiSeq instrument. The DNA sequences encoding the C, c or E antigen were counted, as were the number of total sequences. Based on the percentage of fetally derived target SNVs inherited from the father, the fetal blood group could be predicted.

RESULTS

The results of 55 consecutive RHCE prenatal analyses with postnatal serological blood group determination of 30 newborns showed no discordant results. A threshold discerning positive from negative samples was set at 0.05% specific reads.

DISCUSSION

Noninvasive, prenatal prediction of fetal blood groups by sequencing cfDNA for the detection of low-level RHCE*C, RHCE*c and RHCE*E sequences was established as an accurate and robust assay applicable for use in clinical settings.

Why we succeed and fail in detecting fetal growth restriction: A population-based study

INTRODUCTION

The objective of this study was to explore the association between detection of fetal growth restriction and maternal-, healthcare provider- and organizational factors.

MATERIAL AND METHODS

A historical, observational, multicentre study. All women who gave birth to a child with a birthweight <2.3rd centile from 1 September 2012 to 31 August 2015 in Zealand, Denmark, were included. The population was identified through the Danish Fetal Medicine Database. Medical charts were reviewed to obtain data regarding maternal characteristics and information on the healthcare professionals. Date of authorization for the midwives and obstetricians involved was extracted from the Danish Health Authorization Registry. Multivariable Cox regression models were used to identify predictors of antenatal detection of fetal growth restriction, and analyses were adjusted for hospital, body mass index, parity, the presence of at least one risk factor and experience of the first midwife, number of midwife visits, number of visits to a doctor, the experience of the consultant midwife or the educational level of the doctor, the number of scans and gaps in continuity of midwife-care. Antenatal detection was defined as an ultrasound estimated fetal weight <2.3rd centile (corresponding to -2 standard deviations) prior to delivery.

RESULTS

Among 78 544 pregnancies, 3069 (3.9%) had a fetal growth restriction. Detection occurred in 31% of fetal growth-restricted pregnancies. Clinical experience (defined as years since graduation) of the first consultation midwife was positively associated with detection, with a hazard ratio [HR] of 1.15, 95% confidence interval [CI] 1.03-1.28), for every 10 years of additional experience. The hazard of detection increased with the number of midwife consultations (HR 1.15, 95% CI 1.05-1.26) and with multiparity (HR 1.28, 95% CI 1.03-1.58). After adjusting for all covariates, an unexplained difference between hospitals (P = .01) remained.

CONCLUSIONS

The low-risk nullipara may constitute an overlooked group of women at increased risk of antenatal non-detection of fetal growth restriction. Being screened by experienced midwives during early pregnancy and having access to multiple midwife consultations may improve future diagnosis.

Detection of growth-restricted fetuses during pregnancy is associated with fewer intrauterine deaths but increased adverse childhood outcomes: an observational study

OBJECTIVE

Exploring associations between antenatal detection of fetal growth restriction (FGR) and adverse outcome.

DESIGN

Retrospective, observational, register-based study.

SETTING

Zealand, Denmark.

POPULATION OR SAMPLE

Children born from 1 September 2012 to 31 August 2015.

METHODS

Diagnoses from birth until 1 January 2018 were retrieved from The National Patient Registry. Detection was defined as estimated fetal weight less than the 2.3rd centile. Cox regression was used to associate detection status with the hazard rate of adverse outcome, adjusted for fetal weight deviation, maternal age, ethnicity, body mass index and smoking.

MAIN OUTCOME MEASURES

Adverse neonatal outcome, adverse neuropsychiatric outcome, respiratory disorders, endocrine disorders, gastrointestinal/urogenital disorders.

RESULTS

A total of 2425 FGR children were included. An association was found for gastrointestinal/urogenital disorders (hazard ratio [HR] 1.68, 95% CI 1.26-2.23, P < 0.001) and respiratory disorders (HR 1.22, 95% CI 1.02-1.46, P = 0.03) in detected versus undetected infants. For adverse neuropsychiatric outcome, HR was 1.32 (95% CI 1.00-1.75, P = 0.05). There was no evidence of an association between detection and adverse neonatal outcome (HR 1.00, 95% CI 0.62-1.61, P = 0.99) and endocrine disorders (HR 1.39, 95% CI 0.88-2.19, P = 0.16). Detected infants were smaller (median -28% versus -25%, P < 0.0001), more often born preterm (odds ratio [OR] 4.15, 3.12-5.52, P < 0.0001) and more often born after induction or caesarean section (OR 5.19, 95% CI 4.13-6.51, P < 0.0001). Stillbirth risk was increased in undetected FGR fetuses (OR 2.63, 95% CI 1.37-5.04, P = 0.004).

CONCLUSIONS

We found an association between detection of FGR and risk of adverse childhood conditions, possibly caused by prematurity. Iatrogenic prematurity may be inevitable in stillbirth prevention, but is accompanied by a risk of long-term childhood conditions.

TWEETABLE ABSTRACT

Antenatal detection of growth-restricted fetuses is associated with adverse childhood outcomes but fewer intrauterine deaths.

Refractory Fetal Supraventricular Tachycardia with Hydrops Successfully Converted by Intraperitoneal Flecainide in the Fetus: A Case Report

INTRODUCTION

Supraventricular tachycardia is the most common fetal tachyarrhythmia and if persistent often associated with fetal hydrops which can cause intrauterine and neonatal death.

CASE PRESENTATION

We present a case of early second trimester supraventricular tachycardia in a hydropic fetus, initially refractory to transplacental treatment.

CONCLUSION

The supraventricular tachycardia was successfully treated when supplemented with intraperitoneal flecainide in the fetus.

Multicenter randomized trial exploring effects of simulation-based ultrasound training on obstetricians' diagnostic accuracy: value for experienced operators

OBJECTIVE

To explore the effects of simulation-based ultrasound training on the accuracy of fetal weight estimation in the third trimester among obstetricians with different levels of clinical experience.

METHODS

This was a multicenter, randomized pre-post-test practical trial conducted between March 2016 and January 2018. Obstetricians with different levels of clinical experience were randomized to either simulation-based ultrasound training focusing on fetal weight scans or no intervention. Participants completed two scans in pregnant women at term to establish baseline accuracy of fetal weight estimation. Another two scans were performed at follow-up. Accuracy was defined by the percentage difference between estimated fetal weight and actual birth weight. Ultrasound image quality was rated by two expert raters.

RESULTS

Seventy participants with different levels of clinical experience completed the study. Adjusting for clinical experience, the intervention group demonstrated an improvement in measurement accuracy of 31.9% (95% CI, 6.9-50.1%) (P = 0.02), whereas the control group did not improve (relative difference, 13.1% (95% CI, -17.9 to 55.9%); P = 0.45). The change in accuracy was significantly different between the groups (P = 0.02) and independent of clinical experience (P = 0.54). Image-quality scores improved by a mean of 1.2 (95% CI, 0.4-2.1) (P < 0.01) in the intervention group, with no change in the control group (mean difference, 0.1 (95% CI, -0.8 to 1.0); P = 0.78). There was a strong negative correlation between time spent using the simulator and clinical experience (r = -0.70, P = 0.0001).

CONCLUSION

Simulation-based ultrasound training improved accuracy and image quality when performing fetal weight estimation in women at term, independent of obstetricians' clinical experience. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Do chorionic villus samplings (CVS) or amniocenteses (AC) induce RhD immunisation? An evaluation of a large Danish cohort with no routine administration of anti-D after invasive prenatal testing

OBJECTIVE

To evaluate the risk of inducing RhD immunisation in pregnancies of RhD-negative mothers with an RhD-positive fetus undergoing chorionic villus samplings (CVS) or amniocenteses (AC).

DESIGN, SETTING AND POPULATION

Registry-based study in a Danish cohort which has not been given rhesus prophylaxis.

METHODS

Data were retrieved from the Department of Clinical Immunology at Rigshospitalet. All RhD-negative women carrying an RhD-positive fetus with screen test results from weeks 8-12 and weeks 25-29 were linked to data from the Danish Fetal Medicine Database. Data were divided into cases where no invasive prenatal diagnostic procedure was performed, cases that had AC performed, and cases that had CVS performed.

MAIN OUTCOME MEASURES

A comparison of the proportion of women who developed RhD immunisation between the two screen tests.

RESULTS

The cohort consisted of 10 085 women: 9353 had no invasive procedures performed, 189 had AC and 543 had CVS performed. No women were immunised spontaneously or due to the procedure between the first and second screen test in the group with no procedure performed, or in the AC group. One woman was immunised in the CVS group. When comparing the proportion of women who was immunised in the CVS group with the no invasive test group a non-significant difference was found (P = 0.055).

CONCLUSION

The RhD immunisation rate before gestational weeks 25-29 in RhD-negative women carrying an RhD-positive fetus is very low, even in women undergoing prenatal invasive testing without rhesus prophylaxis.

TWEETABLE ABSTRACT

The RhD immunisation rate during pregnancy is very low even in women undergoing prenatal invasive testing.

Short-Term Flow Changes in Monochorionic Survivor Twins after Ultrasound-Guided Umbilical Cord Occlusion

OBJECTIVE

To determine hemodynamic changes by Doppler ultrasound of the living fetus during 24 h after umbilical cord occlusion (UCO) in monochorionic diamniotic (MCDA) twin pregnancies.

METHOD

We conducted a prospective observational study on fetuses undergoing UCO from 2015 to 2017. Doppler parameters peak systolic velocity (PSV) and umbilical pulsatility index (PI) were obtained in the middle cerebral artery (MCA), umbilical artery (UA) and ductus venosus (DV) before and right after UCO, and at 1, 3, 6, 12, and 24 h after. We used multiple of the median (MoM) to adjust for gestational age. Spaghetti plots visualized flow changes over time. Mixed model adjusting for paired longitudinal data compared the values at different time points.

RESULTS

A total of 16 women were included. MCA-PSV dropped within the first hour after surgery from 0.91 to 0.82 MoM (p = 0.08). MCA-PI and UA-PI increased in the first hour from 0.75 to 0.91 MoM (p = 0.02) and 0.94 to 0.98 MoM (p = 0.22), respectively. The DV-PIV increased to 1.14 MoM 3 h after surgery (p = 0.07). The spaghetti plots illustrated the small changes within the first hours and showed a stabilization of flow measurements near initial values 24 h after UCO.

CONCLUSION

Within the first hours after UCO the circulation of the survivor twin undergoes small hemodynamic changes.

Magnetic Resonance Imaging: A New Tool to Optimize the Prediction of Fetal Anemia?

INTRODUCTION

The false-positive rate in the prediction of fetal anemia is 10-15%. We investigated if a new, noninvasive MRI method used as a supplement to ultrasound could improve the prediction.

METHODS

Fetuses suspected of anemia and controls were scanned in a 1.5-tesla MRI scanner 1-4 times during pregnancy. Cases were scanned before and after intrauterine blood transfusion with a T1-mapping MRI sequence in a cross-section of the umbilical vein.

RESULTS

Inclusion of 8 cases and 11 controls resulted in 10 case scans (2 cases were included twice) and 33 control scans. In controls, the T1 relaxation time was 1,005-1,391 ms; in cases with severe anemia, 1,505-1,595 ms, moderate anemia 1,503-1,525 ms, and no/mild anemia 1,245-1,410 ms. After blood transfusions, values dropped to 1,123-1,288 ms. The mean value in moderate and severe anemic cases was 275 ms higher than in controls (95% CI 210-341 ms, p < 0.0001), and after blood transfusion it was comparable to controls (3 ms, 95% CI -62 to 68 ms, p = 0.934). A 1,450-ms cut-off would have identified all cases in need of blood transfusion with no false-positive cases.

CONCLUSIONS

Our findings indicate a potential for this new MRI method to improve the prediction of fetal anemia as a supplement to ultrasound.

OK-432 Treatment of Early Fetal Chylothorax: Pregnancy Outcome and Long-Term Follow-Up of 14 Cases

BACKGROUND

The treatment options for fetal chylothorax include thoracocentesis, thoracoamniotic shunting, and pleurodesis using OK-432. Knowledge on the long-term outcomes after treatment with OK-432 is limited.

OBJECTIVE

The aim of this study was to assess the long-term outcomes of children treated in utero with OK-432.

METHODS

We performed follow-up on pregnancies and children treated in utero with OK-432 between 2003 and 2009 at Copenhagen University Hospital Rigshospitalet for pleural effusions at gestational age (GA) 16+0-21+6 weeks. Anamnestic information, physical examination, pulmonary function test, neuropediatric examination, and intelligence testing using the Wechsler Intelligence Scale were used for evaluation.

RESULTS

Fourteen cases, all chylothorax, were treated with OK-432. None had preterm premature rupture of membranes (PPROM), and the median GA at delivery was 38+5 (24+4-41+5) weeks. Twelve children were eligible for follow-up. The median age at follow-up was 11.4 (7.8-13.8) years. Pulmonary function was normal in all children and the mean full-scale IQ did not differ from that of normal children. Four children had a diagnosed medical condition, attention deficit disorder, or genetic syndrome. The remaining children had normal follow-up.

CONCLUSION

Children treated with OK-432 have comparable survival rates and long-term neurodevelopmental outcomes to those treated with thoracoamniotic shunts. There seems to be a lower risk of procedure-related PPROM.

Long-Term Neurodevelopmental Outcome of Monochorionic Twins after Laser Therapy or Umbilical Cord Occlusion for Twin-Twin Transfusion Syndrome

INTRODUCTION

We sought to assess the incidence of severe neurodevelopmental impairment (NDI) in monochorionic twins treated for twin-twin transfusion syndrome (TTTS) and compare it to the incidence in uncomplicated monochorionic twins.

MATERIAL AND METHODS

We included TTTS pregnancies treated by fetoscopic selective laser coagulation (FSLC) or umbilical cord occlusion (UCO) in 2004-2015. Primary outcome was severe NDI defined as cerebral palsy, bilateral blindness or bilateral deafness (ICD-10 diagnoses), and severe cognitive and/or motor delay (assessed by the Ages and Stages Questionnaires [ASQ]).

RESULTS

A total of 124 children after TTTS and 98 controls were followed up at 25 months of age (SD 11.4). Severe NDI was found in 8.9% of the TTTS children (10.5% [9/86] after FSLC; 5.3% [2/38] after UCO) compared to 3.1% in the control group (p = 0.10). The odds ratio for severe NDI was 1.8 in cases versus controls (p = 0.37). The total ASQ score was significantly lower in the TTTS group than in controls (p = 0.03) after FSLC (p = 0.03) and after UCO (p = 0.14).

DISCUSSION

Children after TTTS appear to have a higher risk of severe NDI and score significantly lower on the ASQ compared to monochorionic twins from uncomplicated pregnancies.

[Mirror syndrome is a rare complication in pregnancy, characterized by oedema and hydrops fetalis]

We describe a case of mirror syndrome. A 41-year-old woman, para 4, was referred to hospital at 32 weeks of gestational age with excessive oedema. She developed oliguria, mild hypertension and proteinuria. Fetal ultrasound confirmed severe hydrops fetalis. Intrauterine pleural drainage was performed without improvement of the condition. Since maternal symptoms worsened, a caesarean section was performed at 34 weeks with delivery of a live hydropic girl who died after 17 hours. Maternal symptoms decreased four days after delivery with full recovery two weeks post-partum.

Collecting Validity Evidence for the Assessment of Mastery Learning in Simulation-Based Ultrasound Training

PURPOSE

To collect validity evidence for the assessment of mastery learning on a virtual reality transabdominal ultrasound simulator.

MATERIALS AND METHODS

We assessed the validity evidence using Messick's framework for validity. The study included 20 novices and 9 ultrasound experts who all completed 10 obstetric training modules on a transabdominal ultrasound simulator that provided automated measures of performance for each completed module (i. e., simulator metrics). Differences in the performance of the two groups were used to identify simulator metrics with validity evidence for the assessment of mastery learning. The novices continued to practice until they had attained mastery learning level.

RESULTS

One-third of the simulator metrics discriminated between the two groups. The median simulator scores from a maximum of 40 metrics were 17.5 percent (range 0 - 45.0 percent) for novices and 90.0 percent (range 85.0 - 97.5) for experts, p < 0.001. Internal consistency was high, with a Cronbach's alpha value of 0.98. The test/retest reliability gave an intra-class correlation coefficient (ICC) of 0.62 for novices who reached the mastery learning level twice. Novices reached the mastery learning level within a median of 4 attempts (range 3 - 8) corresponding to a median of 252 minutes of simulator training (range 211 - 394 minutes).

CONCLUSION

This study found that validity evidence for the assessment of mastery learning in simulation-based ultrasound training can be demonstrated and that ultrasound novices can attain mastery learning levels with less than 5 hours of training. Only one-third of the standard simulator metrics discriminated between different levels of competence.

Sustained effect of simulation-based ultrasound training on clinical performance: a randomized trial

OBJECTIVE

To study the effect of initial simulation-based transvaginal sonography (TVS) training compared with clinical training only, on the clinical performance of residents in obstetrics and gynecology (Ob-Gyn), assessed 2 months into their residency.

METHODS

In a randomized study, new Ob-Gyn residents (n = 33) with no prior ultrasound experience were recruited from three teaching hospitals. Participants were allocated to either simulation-based training followed by clinical training (intervention group; n = 18) or clinical training only (control group; n = 15). The simulation-based training was performed using a virtual-reality TVS simulator until an expert performance level was attained, and was followed by training on a pelvic mannequin. After 2 months of clinical training, one TVS examination was recorded for assessment of each resident's clinical performance (n = 26). Two ultrasound experts blinded to group allocation rated the scans using the Objective Structured Assessment of Ultrasound Skills (OSAUS) scale.

RESULTS

During the 2 months of clinical training, participants in the intervention and control groups completed an average ± SD of 58 ± 41 and 63 ± 47 scans, respectively (P = 0.67). In the subsequent clinical performance test, the intervention group achieved higher OSAUS scores than did the control group (mean score, 59.1% vs 37.6%, respectively; P < 0.001). A greater proportion of the intervention group passed a pre-established pass/fail level than did controls (85.7% vs 8.3%, respectively; P < 0.001).

CONCLUSION

Simulation-based ultrasound training leads to substantial improvement in clinical performance that is sustained after 2 months of clinical training. © 2015 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

[Life-threatening extrauterine pregnancy after in vitro fertilization and bilateral salpingectomy]

A woman with a history of bilateral salpingectomy achieved pregnancy after in vitro fertilization. At the gestational age of six weeks she experienced fatigue, haematemesis and abdominal pain. She was hospitalized on suspicion of a peptic ulcer. Several physicians rejected the possibility of an ectopic pregnancy due to the history of salpingectomy. The patient had intraabdominal bleeding and went through emergency surgery because of a ruptured interstitial pregnancy. The purpose of this case report is to recall the risk of interstitial pregnancy in pregnant women with a history of salpingectomy.

Assessment of performance measures and learning curves for use of a virtual-reality ultrasound simulator in transvaginal ultrasound examination

OBJECTIVE

To assess the validity and reliability of performance measures, develop credible performance standards and explore learning curves for a virtual-reality simulator designed for transvaginal gynecological ultrasound examination.

METHODS

A group of 16 ultrasound novices, along with a group of 12 obstetrics/gynecology (Ob/Gyn) consultants, were included in this experimental study. The first two performances of the two groups on seven selected modules on a high-fidelity ultrasound simulator were used to identify valid and reliable metrics. Performance standards were determined and novices were instructed to continue practicing until they attained the performance level of an expert subgroup (n = 4).

RESULTS

All 28 participants completed the selected modules twice and all novices reached the expert performance level. Of 153 metrics, 48 were able to be used to discriminate between the two groups' performance. The ultrasound novices scored a median of 43.8% (range, 17.9-68.9%) and the Ob/Gyn consultants scored a median of 82.8% (range, 60.4-91.7%) of the maximum sum score (P < 0.001). The ultrasound novices reached the expert level (88.4%) within a median of five iterations (range, 5-6), corresponding to an average of 219 min (range, 150-251 min) of training. The test/retest reliability was high, with an intraclass correlation coefficient of 0.93.

CONCLUSIONS

Competence in the performance of gynecological ultrasound examination can be assessed in a valid and reliable way using virtual-reality simulation. The novices' performance improved with practice and their learning curves plateaued at the level of expert performance, following between 3 and 4 h of simulator training.

[Array-comparative genomic hybridization is a new and promising method for prenatal chromosomal diagnosis]

Array-comparative genomic hybridization (array-CGH) is a very sensitive method for identifying chromosomal imbalances and is now used on a clinical basis for prenatal diagnosis. This article reviews the advantages and disadvantages of the method, the ethical considerations and the current recommendations for prenatal use in Denmark according to a new national guideline from The Danish Society of Foetal Medicine and the Danish Society of Medical Genetics.

Water immersion and changes in the foetoplacental and uteroplacental circulation: an observational study with the case as its own control

OBJECTIVE

To evaluate the effect of immersion into water on maternal blood pressure, amount of amniotic fluid and on the foetoplacental- and uteroplacental circulation in healthy women with an uncomplicated singleton pregnancy.

METHODS

Twenty-five healthy women were included. Recordings of blood pressure, deepest vertical pocket of amniotic fluid and pulsatility index (PI) measured by Doppler in the umbilical and uterine arteries were obtained. The participants were immersed into water and the measurements were repeated after 5 and 25 min in water and again 15 and 30 min post immersion.

RESULTS

The amount of amniotic fluid increased significantly (p < 0.001), and the maternal blood pressure decreased significantly during immersion (p < 0.001). There was no significant effect of immersion on either umbilical- or uterine artery PI. All changes returned toward baseline-level within 30 min after immersion.

CONCLUSIONS

Immersion into water increases the amount of amniotic fluid and decreases the maternal blood pressure. Immersion into water has no significant effect on either the foetoplacental or uteroplacental circulation. Further studies are needed in order to explore the effect of immersion in pregnancies complicated by a dysfunctional placenta.

Fetal growth in pregnancies conceived after gastric bypass surgery in relation to surgery-to-conception interval: a Danish national cohort study

OBJECTIVE

To describe early and late fetal growth in pregnancies conceived after gastric bypass surgery in relation to time from surgery to conception of pregnancy.

METHODS

National cohort study on 387 Danish women, who had laparoscopic or open gastric bypass surgery prior to a singleton pregnancy in which first trimester screening was performed between January 2008 and June 2011. Data were derived from national registers (Danish National Registry of Patients and Danish National Birth Registry, Pregnancy Complications and Abortion-clinical quality database (PreCAb) and the Danish Fetal Medicine Database). Main outcome measures were early and late fetal growth in relation to time from bariatric surgery to conception of the pregnancy. Early fetal growth was expressed as "Fetal Growth Index": the ratio between the estimated number of days from first trimester ultrasound to second trimester ultrasound biometries and the actual calender time elapsed in days. Late fetal growth was expressed as the observed versus expected birthweight according to gestational age (GA).

RESULTS

The surgery-to-conception interval ranged from 3 to 1851 days with a mean value of 502 (SD, 351) days. The mean "fetal growth index" was 0.99 (SD, 0.02) days/day and thus significantly lower than in the background population (mean, 1.04 (SD, 0.09) days/day, p<0.0001). The proportion of infants being small for gestational age was 18.8% and the proportion of large for gestational age infants was 6.7%. The correlation coefficients between surgery-to-conception time and "fetal growth index" and birthweight according to GA were 0.01 (p = 0.8) and 0.04 (p = 0.4), respectively.

CONCLUSION

Fetal growth index was lower than reported in the background population. No correlation was found between the surgery-to-conception interval and early or late fetal growth in pregnancies conceived after gastric bypass surgery.

[Treatment of placenta percreta requires a multidisciplinary approach]

Placenta percreta is a rare life-threatening obstetrical condition, often resulting in severe haemorrhage and hysterectomy. The incidence seems to be increasing, probably secondary to the increase in caesarean section rates. We present a protocol for an elective multidisciplinary approach with proactive management to reduce haemorrhage and allow appropriate surgery, which imply a low maternal and fetal morbidity as well as maintained fertility.

[A younger patient with peripheral emboli from massive aortic thrombi detected by transesophageal echocardiography]

A case report of a 55-year-old man with massive aortic thrombus detected by transesophageal echocardiography as a cause of peripheral and brain emboli causing sudden death.

[Prolonged pregnancy. Labor induction versus intensified monitoring]

This study was made in order to evaluate the effect of a policy of induction of labour at 42 weeks of gestation in post-term pregnancies. A group of 139 women with uncomplicated post-term pregnancies, who gave birth at the maternity ward at Herlev Hospital in 1993 was compared to a group of 145 women, who gave birth in 1996 at the same location. In 1993 spontaneous labour was awaited with twice weekly surveillance tests, and labour was only induced if there was evidence of foetal or maternal compromise, while in 1996 labour was induced at 42 weeks of gestation. There were at 20.1% inductions of labour in 1993 compared to 44.8% in 1996. The perinatal morbidity and birth complication rates were similar in the two groups.