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OBJECTIVES: To calculate 3D-segmented total lung volume (TLV) in fetuses with thoracic anomalies using deformable slice-to-volume registration (DSVR) with comparison to 2D-manual segmentation. To establish a normogram of TLV calculated by DSVR in healthy control fetuses. METHODS: A pilot study at a single regional fetal medicine referral centre included 16 magnetic resonance imaging (MRI) datasets of fetuses (22-32 weeks gestational age). Diagnosis was CDH (n = 6), CPAM (n = 2), and healthy controls (n = 8). Deformable slice-to-volume registration was used for reconstruction of 3D isotropic (0.85 mm) volumes of the fetal body followed by semi-automated lung segmentation. 3D TLV were compared to traditional 2D-based volumetry. Abnormal cases referenced to a normogram produced from 100 normal fetuses whose TLV was calculated by DSVR only. RESULTS: Deformable slice-to-volume registration-derived TLV values have high correlation with the 2D-based measurements but with a consistently lower volume; bias -1.44 cm3 [95% limits: -2.6 to -0.3] with improved resolution to exclude hilar structures even in cases of motion corruption or very low lung volumes. CONCLUSIONS: Deformable slice-to-volume registration for fetal lung MRI aids analysis of motion corrupted scans and does not suffer from the interpolation error inherent to 2D-segmentation. It increases information content of acquired data in terms of visualising organs in 3D space and quantification of volumes, which may improve counselling and surgical planning. ispartof: PRENATAL DIAGNOSIS vol:42 issue:5 pages:628-635 ispartof: location:England status: published

Key content Continuing financial constraints on the UK’s National Health Service means the need for clinicians to provide high-quality care in a cost-effective way has never been greater. While the medical education system equips doctors with skills to provide safe clinical care, it should also provide an understanding of healthcare costs and cost-effectiveness analysis. Value-based care is becoming a key paradigm in women’s health services, where clinicians must employ strategies for delivering value, rationalising costs and capitalising on the use of emerging technologies. The calculation of value of an intervention for providers and service users may differ; care must be taken to ensure this concept is adapted for, and not imposed on healthcare systems. Engaging trainees in systems transformation and embedding the concepts of ‘do no financial harm’ are essential to ensure sustainable healthcare services. Learning Objectives To understand the principles of value-based health care. To highlight the importance of adopting ‘cost-conscious’ care within daily clinical practice. To learn the differences between ‘cost’, ‘charge’, ‘price’ and ‘reimbursement. To encourage developing value-based competencies for future medical workforce through utilising out of programme placements and digital resources. Ethical Issues The ethical obligation of clinicians to consider cost may encompass justice and equity. However, the impact of practicing value-based health care is yet to be evaluated.

Measuring vascularization in uterine fibroids is important for their diagnosis, treatment and prognosis. Vascularization can be measured by power Doppler ultrasound. The power Doppler signal depends on fibroid characteristics and on a variety of ultrasound-machine settings. Literature describing which machine settings influence the power Doppler signal is limited. Each manufacturer names settings and presets at their own discretion, with little information available publicly. Consistency of machine settings is important for correct interpretation of images in daily practice and is essential in yielding reproducible data for research. The aims of this paper, drawing from both a literature search and semistructured interviews with ultrasound-machine engineers and clinical experts in gynecological ultrasound, were: (1) to provide comprehensive background information on ultrasound physics and fibroid characteristics; (2) to present an overview of machine settings relevant to both two- and three-dimensional power Doppler, including power Doppler frequency, pulse repetition frequency, gain, wall-motion filter, acoustic power, persistence and signal rise; and (3) to provide a step-by-step tutorial on the optimal settings for vascular evaluation of uterine fibroids using power Doppler. The step-by-step tutorial comprises six steps to optimize the power Doppler signal, create a preset and acquire a reliable three-dimensional volume. This step-by-step tutorial should help research groups and clinicians to use power Doppler correctly and reproducibly in the evaluation of uterine fibroids. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. ispartof: ULTRASOUND IN OBSTETRICS & GYNECOLOGY vol:60 issue:2 pages:277-283 ispartof: location:England status: published

A 20-year-old female patient presented with the complaint of pelvic pain. Radiological studies showed a cystic mass in the left ovary. Histological examination revealed a myxoid tumor with a chicken wire-like, thin vascularization. The diagnosis of the lesion, morphologically resembling myxoid liposarcoma was supported by demonstration of rearrangement of the DDIT3 gene by fluorescence in situ hybridization.

Vaginal natural orifice transluminal endoscopic surgery (NOTES) is a novel technique for minimally invasive gynecological surgery. Adequate training and standardization are key elements to patient safety and quality of care. Based on consensus statements and expert opinion; we report a step-by-step guidance for hysterectomy via natural orifice transluminal endoscopy. A detailed description is presented of pre- and postoperative care, and the instruments and equipment used, and surgical steps are illustrated by photographic images. This report can guide surgeons in their training to perform a hysterectomy via NOTES. ispartof: ACTA OBSTETRICIA ET GYNECOLOGICA SCANDINAVICA vol:101 issue:6 pages:649-656 ispartof: location:United States status: published

Objective: The immune system of pregnant women undergoes several changes over the course of pregnancy. In the past, these changes have been associated with increased susceptibility to viral respiratory infections such as SARS-CoV-1 and influenza. Our primary objective was to investigate the differences in immune response to SARS-CoV-2 infection in pregnant women compared to non-pregnant women over time. Design: This was a prospective, laboratory-based longitudinal observational study of pregnant women who have been infected with SARS-CoV-2 to determine the effects of pregnancy on the serological response post infection compared to their matched non-pregnant women. Methods: Participants were recruited between September 2020 and June 2021 who all tested positive for SARS-CoV-2 infection using PCR or serology. Changes in the SARS-CoV-2-specific IgG titres were measured in blood samples that were collected from 51 pregnant and 52 non-pregnant women of reproductive age at approximately 7–14 days, 1-month (±7 days), 4 (±1 month), and 8 (±1 month) months post-infection, respectively. A chemiluminescent immunoassay was used to assess the IgG response to SARS-CoV-2 using serum from infected participants. Antibody levels to SARS-CoV-2 spike RBD (receptor binding domain) and nucleoprotein were measured as a relative light unit (RLU). Results: We found a reduction in seroconversion rate at 7–14 days post-infection in pregnant women compared to non-pregnant women with 63.33% compared to 100%, respectively. Longitudinal assessment highlighted a significant decline in anti-spike RBD IgG (20-fold reduction) at 151 days (or 5 months and 11 days; p

In view of the rapid spread of the Omicron variant of concern (VOC) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)1, the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) has decided to revise its position statements on use of personal protective equipment for the safe performance of obstetric and gynecological ultrasound2, 3, particularly in relation to the protection of healthcare workers. The World Health Organization (WHO) recommendation on mask use by healthcare workers, issued on 22 December 2021, states that ‘…the Omicron variant is spreading significantly faster than the Delta variant in countries with documented community transmission, with a doubling time between 1.5–3 days. Preliminary, unpublished data show a reduction in neutralizing titres against Omicron suggesting a level of immune evasion and an important reduction in vaccine effectiveness against infection and symptomatic disease for Omicron compared to Delta’4. ISUOG previously recommended the use of fit-approved masks or respirators (FFP2, FFP3, NIOSH-approved N95 or other equivalent or higher-level certified respirator) for the ultrasound examination of patients with suspected or confirmed SARS-CoV-2 infection3 or in the event of widespread community transmission2. The latest WHO recommendation on mask use by healthcare workers1 states that ‘A respirator… should be worn by health workers along with other personal protective equipment (PPE) – a gown, gloves and eye protection – before entering a room where there is a patient with suspected or confirmed COVID-19 … in care settings where ventilation is known to be poor or cannot be assessed or the ventilation system is not properly maintained…’. This applies to the rooms in which ultrasound scans are typically performed. In light of the growing number of SARS-CoV-2 infections and in particular the highly infectious Omicron VOC, the USA Centers for Disease Control and Prevention has predicted and provided strategies to limit the effects of healthcare staff shortages5. Patients do not undergo routinely polymerase chain reaction or lateral flow testing prior to ultrasound assessment for obstetric or gynecological indications, nonetheless, a high number of asymptomatic cases are to be expected in the context of the SARS-CoV-2 epidemic caused by the Omicron VOC6. On this basis, ISUOG now recommends that fit-approved masks or respirators should be worn routinely in ultrasound clinics and departments to limit the risk of infection for practitioners performing obstetric and gynecological ultrasound scans, in addition to preventive measures including hand hygiene, patient mask-wearing2-4 and vaccination7, 8. The recommendation can be adapted locally based on community prevalence and transmissibility of the current and future variants of SARS-CoV-2.

ispartof: OBSTETRICIAN & GYNAECOLOGIST vol:24 issue:1 pages:7-11 status: published

As the use of genomic sequencing (GS) in the prenatal setting becomes more widespread, laboratories and clinicians will be tasked with making decisions about whether to offer incidental and secondary findings to expectant parents and, if so, which ones. Unfortunately, few guidelines or position statements issued by professional bodies address the return of secondary findings specifically in the context of prenatal GS, nor do they offer clear guidance on whether, and which types of incidental findings should be reported. Laboratories and clinicians will also need to navigate other challenges, such as how to obtain sufficiently informed consent, workload burdens for both laboratories and clinicians, and funding. Here we discuss these, and other challenges associated with offering incidental and secondary findings in the context of prenatal GS. We outline existing guidelines for return of these findings, prenatally and in children. We review the existing literature on stakeholder perspectives on return of incidental and secondary findings and discuss the main practical and ethical challenges that require consideration. We then propose a framework to help guide decision-making, suggesting a baseline routine analysis, with additional layers of analysis that could be offered, according to local laboratory policy, with additional opt-in consent from the parents. ispartof: PRENATAL DIAGNOSIS vol:42 issue:6 pages:697-704 ispartof: location:England status: published

INTRODUCTION: There is no global agreement on how to best determine pregnancy of unknown location viability and location using biomarkers. Measurements of progesterone and β human chorionic gonadotropin (βhCG) are still used in clinical practice to exclude the possibility of a viable intrauterine pregnancy (VIUP). We evaluate the predictive value of progesterone, βhCG, and βhCG ratio cut-off levels to exclude a VIUP in women with a pregnancy of unknown location. MATERIAL AND METHODS: This was a secondary analysis of prospective multicenter study data of consecutive women with a pregnancy of unknown location between January 2015 and 2017 collected from dedicated early pregnancy assessment units of eight hospitals. Single progesterone and serial βhCG measurements were taken. Women were followed up until final pregnancy outcome between 11 and 14 weeks of gestation was confirmed using transvaginal ultrasonography: (1) VIUP, (2) non-viable intrauterine pregnancy or failed pregnancy of unknown location, and (3) ectopic pregnancy or persisting pregnancy of unknown location. The predictive value of cut-off levels for ruling out VIUP were evaluated across a range of values likely to be encountered clinically for progesterone, βhCG, and βhCG ratio. RESULTS: Data from 2507 of 3272 (76.6%) women were suitable for analysis. All had data for βhCG levels, 2248 (89.7%) had progesterone levels, and 1809 (72.2%) had βhCG ratio. The likelihood of viability falls with the progesterone level. Although the median progesterone level associated with viability was 59 nmol/L, VIUP were identified with levels as low as 5 nmol/L. No single βhCG cut-off reliably ruled out the presence of viability with certainty, even when the level was more than 3000 IU/L, there were 39/358 (11%) women who had a VIUP. The probability of viability decreases with the βhCG ratio. Although the median βhCG ratio associated with viability was 2.26, VIUP were identified with ratios as low as 1.02. A progesterone level below 2 nmol/L and βhCG ratio below 0.87 were unlikely to be associated with viability but were not definitive when considering multiple imputation. CONCLUSIONS: Cut-off levels for βhCG, βhCG ratio, and progesterone are not safe to be used clinically to exclude viability in early pregnancy. Although βhCG ratio and progesterone have slightly better performance in comparison, single βhCG used in this manner is highly unreliable. ispartof: ACTA OBSTETRICIA ET GYNECOLOGICA SCANDINAVICA vol:101 issue:1 pages:46-55 ispartof: location:United States status: published

OBJECTIVE: To develop a standardized sonographic evaluation and reporting system for Cesarean scar pregnancy (CSP) in the first trimester, for use by both general gynecology and expert clinics. METHODS: A modified Delphi procedure was carried out, in which 28 international experts in obstetric and gynecological ultrasonography were invited to participate. Extensive experience in the use of ultrasound to evaluate Cesarean section (CS) scars in early pregnancy and/or publications concerning CSP or niche evaluation was required to participate. Relevant items for the detection and evaluation of CSP were determined based on the results of a literature search. Consensus was predefined as a level of agreement of at least 70% for each item, and a minimum of three Delphi rounds were planned (two online questionnaires and one group meeting). RESULTS: Sixteen experts participated in the Delphi study and four Delphi rounds were performed. In total, 58 items were determined to be relevant. We differentiated between basic measurements to be performed in general practice and advanced measurements for expert centers or for research purposes. The panel also formulated advice on indications for referral to an expert clinic. Consensus was reached for all 58 items on the definition, terminology, relevant items for evaluation and reporting of CSP. It was recommended that the first CS scar evaluation to determine the location of the pregnancy should be performed at 6-7 weeks' gestation using transvaginal ultrasound. The use of magnetic resonance imaging was not considered to add value in the diagnosis of CSP. A CSP was defined as a pregnancy with implantation in, or in close contact with, the niche. The experts agreed that a CSP can occur only when a niche is present and not in relation to a healed CS scar. Relevant sonographic items to record included gestational sac (GS) size, vascularity, location in relation to the uterine vessels, thickness of the residual myometrium and location of the pregnancy in relation to the uterine cavity and serosa. According to its location, a CSP can be classified as: (1) CSP in which the largest part of the GS protrudes towards the uterine cavity; (2) CSP in which the largest part of the GS is embedded in the myometrium but does not cross the serosal contour; and (3) CSP in which the GS is partially located beyond the outer contour of the cervix or uterus. The type of CSP may change with advancing gestation. Future studies are needed to validate this reporting system and the value of the different CSP types. CONCLUSION: Consensus was achieved among experts regarding the sonographic evaluation and reporting of CSP in the first trimester. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. ispartof: ULTRASOUND IN OBSTETRICS & GYNECOLOGY vol:59 issue:4 pages:437-449 ispartof: location:England status: published

Background: Ultrasound (US) imaging is characterised by high levels of operator subjectivity and variability. Recent advances in artificial intelligence (AI) have demonstrated the potential to reduce both factors. This study pilots the end-to-end automation of multiple elements of the mid-trimester obstetric screening US scan using AI-enabled tools. Methods: A single centre, prospective method comparison study was conducted. Participants had both standard manual and AI-assisted US scans performed independently by different blinded sonographers. The AI-tools automated the acquisition of standard plane images, measurement of fetal biometrics and the production of a written clinical report with saved images available for review. A feedback survey captured the sonographers’ perception of scanning with both methods. Findings: Twenty-three subjects were studied. The average time saving per scan was 7.62 min (34.7%) when using the AI-assisted method (p

Endometrial cancer is the most common gynecological malignancy in high- and middle-income countries. Although the overall prognosis is relatively good, high-grade endometrial cancers have a tendency to recur. Recurrence needs to be prevented since the prognosis for recurrent endometrial cancer is dismal. Treatment tailored to tumor biology is the optimal strategy to balance treatment efficacy against toxicity. Since The Cancer Genome Atlas defined four molecular subgroups of endometrial cancers, the molecular factors are increasingly used to define prognosis and treatment. Standard treatment consists of hysterectomy and bilateral salpingo-oophorectomy. Lymphadenectomy (and increasingly sentinel node biopsy) enables identification of lymph node-positive patients who need adjuvant treatment, including radiotherapy and chemotherapy. Adjuvant therapy is used for Stage I-II patients with high-risk factors and Stage III patients; chemotherapy is especially used in non-endometrioid cancers and those in the copy-number high molecular group characterized by TP53 mutation. In advanced disease, a combination of surgery to no residual disease and chemotherapy with or without radiotherapy results in the best outcome. Surgery for recurrent disease is only advocated in patients with a good performance status with a relatively long disease-free interval. ispartof: INTERNATIONAL JOURNAL OF GYNECOLOGY & OBSTETRICS vol:155 issue:Suppl 1 pages:45-60 ispartof: location:United States status: published

OBJECTIVES: To describe and then compare the characteristics of ectopic pregnancies (EP) in the year prior to and then during the SARS-CoV-2 pandemic. METHODS: This was a retrospective analysis from 1st January 2019 to 31st December 2020 of women diagnosed with an EP (n=275) at a London dual center early pregnancy assessment service. Women were identified via the AstraiaTM ultrasound reporting system using coded and non-coded outcomes of 'EP' or 'pregnancy outside the uterine cavity'. Data relating to predefined outcomes were collected using AstraiaTM and CernerTM electronic reporting systems. Main outcome measures included clinical, ultrasound and biochemical features of EP, in addition to reported complications and management. Statistical analysis was carried out using GraphPad Prism v8.2.1. RESULTS: Similar numbers and proportions of EP were seen in 2019 (n=141, 1%) and 2020 (n=134, 1%). Both cohorts were comparable in age, ethnicity, weight and method of conception. Gestational age at first ultrasound and at diagnosis was similar, with no difference in EP location, size or morphology. Human chorionic gonadotrophin (hCG) levels at time of EP diagnosis were higher in 2020 than 2019 (1005 IU/L vs 665 IU/L, p=0.03). The type of final EP management was similar, but more failed first line management during the pandemic (16% vs 6%, p=0.01). Rates of blood visualized on ultrasound within the pelvis (hemoperitoneum) (23% vs 27%, p=0.58) and of rupture confirmed surgically (9% vs 3%, p=0.07) were both similar. CONCLUSIONS: No difference was observed in the location, size, morphology and gestational age of ectopic pregnancies. Complication rates and management were also unchanged. HCG levels were higher, and a greater proportion of conservative management measures failed during the pandemic. Our findings suggest women continued to access appropriate care for EP during the SARS-CoV-2 pandemic, with no evidence of diagnostic delay or increase in adverse outcomes in our population. This article is protected by copyright. All rights reserved.

Objective To investigate the relation between vaginal microbiota composition and outcome of rescue cervical cerclage. Design Prospective observational study. Setting Queen Charlotte's and Chelsea Hospital, London. Population Twenty singleton pregnancies undergoing a rescue cervical cerclage. Methods Vaginal microbiota composition was analysed in women presenting with a dilated cervix and exposed fetal membranes before and 10 days following rescue cervical cerclage and was correlated with clinical outcomes. Main outcome measures Composition of vaginal bacteria was characterised by culture‐independent next generation sequencing. Successful cerclage was defined as that resulting in the birth of a neonate discharged from hospital without morbidity. Unsuccessful cerclage was defined as procedures culminating in miscarriage, intrauterine death, neonatal death or significant neonatal morbidity. Results Reduced Lactobacillus spp. relative abundance was observed in 40% of cases prior to rescue cerclage compared with 10% of gestation age‐matched controls (8/20, 40% versus 3/30, 10%, P = 0.017). Gardnerella vaginalis was over‐represented in women presenting with symptoms (3/7, 43% versus 0/13, 0%, P = 0.03, linear discriminant analysis, LDA (log 10) and cases culminating in miscarriage (3/6, 50% versus 0/14, 0%, P = 0.017). In the majority of cases (10/14, 71%) bacterial composition was unchanged following cerclage insertion and perioperative interventions. Conclusions Reduced relative abundance of Lactobacillus spp. is associated with premature cervical dilation, whereas high levels of G. vaginalis are associated with unsuccessful rescue cerclage cases. The insertion of a rescue cerclage does not affect the underlying bacterial composition in the majority of cases. Tweetable abstract Preterm cervical dilatation associates with reduced Lactobacillus spp. Presence of Gardnerella vaginalis predicts rescue cerclage failure., Tweetable abstract Preterm cervical dilatation associates with reduced Lactobacillus spp. Presence of Gardnerella vaginalis predicts rescue cerclage failure.

Objective The best screening strategy for gestational diabetes mellitus (GDM) remains a topic of debate. Several organizations made a statement in favor of universal screening, but the volume of oral glucose tolerance tests (OGTT) required may burden healthcare systems. As a result, many countries still rely on selective screening using a checklist of risk factors, but reported diagnostic characteristics vary. Moreover, women's discomfort due to an OGTT is often neglected. Since 2017, obstetric healthcare professionals in a Dutch region assessed women's GDM risk with a prediction model and counseled those with an increased risk regarding an OGTT. Methods From 2017 to 2018, 865 women were recruited in a multicenter prospective cohort. Results In total, 385 women (48%) had an increased predicted GDM risk. Of all women, 78% reported that their healthcare professional discussed their GDM risk. Predicted GDM risks were positively correlated with conducting an OGTT. Conclusion Implementation of a GDM prediction model resulted in moderate rates of OGTTs performed in general, but high rates in high‐risk women. As 25% of women experienced discomfort from the OGTT, a selective screening strategy based on a prediction model with a high detection rate may be an interesting alternative to universal screening. Study cohort registration Netherlands Trial Register: NTR4143; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4143., Synopsis Implementing a gestational diabetes mellitus prediction model resulted in a majority of high‐risk women receiving an oral glucose tolerance test within the recommended gestational window.

There has been a recent explosion in the use of artificial intelligence (AI), which is now part of our everyday lives. Uptake in medicine has been more limited, although in several fields there have been encouraging results showing excellent performance when AI is used to assist in a well‐defined medical task. Most of this work has been performed using retrospective data, and there have been few clinical trials published using prospective data. This review focuses on the potential uses of AI in the field of fetal cardiology. Ultrasound of the fetal heart is highly specific and sensitive in experienced hands, but despite this there is significant room for improvement in the rates of prenatal diagnosis of congenital heart disease in most countries. AI may be one way of improving this. Other potential applications in fetal cardiology include the provision of more accurate prognoses for individuals, and automatic quantification of various metrics including cardiac function. However, there are also ethical and governance concerns. These will need to be overcome before AI can be widely accepted in mainstream use. It is likely that a familiarity of the uses, and pitfalls, of AI will soon be mandatory for many healthcare professionals working in fetal cardiology., Key Points What's already known about this topic? Artificial intelligence (AI) is rapidly becoming part of everyday life, and interest is growing in its use in improving medical outcomes.AI may be a useful tool in fetal cardiology to improve rates of antenatal diagnosis of congenital heart disease, as well as other potential benefits.Potential pitfalls exist however, and future clinicians will likely need to have a thorough understanding of the risks and benefits of AI. What does this study add? This review article summarizes the fundamentals of AI, the potential uses of AI in fetal cardiology, and what the future may hold.

OBJECTIVE: We examined whether peptide amphiphiles functionalised with adhesive, migratory or regenerative sequences could be combined with amniotic fluid (AF) to form plugs that repair fetal membrane (FM) defects after trauma and co-culture with connexin 43 (Cx43) antisense. METHODS: We assessed interactions between peptide amphiphiles and AF and examined the plugs in FM defects after trauma and co-culture with the Cx43antisense. RESULTS: Confocal microscopy confirmed directed self-assembly of peptide amphiphiles with AF to form a plug within minutes, with good mechanical properties. SEM of the plug revealed a multi-layered, nanofibrous network that sealed the FM defect after trauma. Co-culture of the FM defect with Cx43 antisense and plug increased collagen levels but reduced GAG. Culture of the FM defect with peptide amphiphiles incorporating regenerative sequences for 5 days, increased F-actin and nuclear cell contraction, migration and polarization of collagen fibers across the FM defect when compared to control specimens with minimal repair. CONCLUSIONS: Whilst the nanoarchitecture revealed promising conditions to seal iatrogenic FM defects, the peptide amphiphiles need to be designed to maximize repair mechanisms and promote structural compliance with high mechanical tolerance that maintains tissue remodeling with Cx43 antisense for future treatment. ispartof: PRENATAL DIAGNOSIS vol:41 issue:1 pages:89-99 ispartof: location:England status: published

Objective To generate guidance for detailed uterine niche evaluation by ultrasonography in the non‐pregnant woman, using a modified Delphi procedure amongst European experts. Methods Twenty gynecological experts were approached through their membership of the European Niche Taskforce. All experts were physicians with extensive experience in niche evaluation in clinical practice and/or authors of niche publications. By means of a modified Delphi procedure, relevant items for niche measurement were determined based on the results of a literature search and recommendations of a focus group of six Dutch experts. It was predetermined that at least three Delphi rounds would be performed (two online questionnaires completed by the expert panel and one group meeting). For it to be declared that consensus had been reached, a consensus rate for each item of at least 70% was predefined. Results Fifteen experts participated in the Delphi procedure. Consensus was reached for all 42 items on niche evaluation, including definitions, relevance, method of measurement and tips for visualization of the niche. A niche was defined as an indentation at the site of a Cesarean section with a depth of at least 2 mm. Basic measurements, including niche length and depth, residual and adjacent myometrial thickness in the sagittal plane, and niche width in the transverse plane, were considered to be essential. If present, branches should be reported and additional measurements should be made. The use of gel or saline contrast sonography was preferred over standard transvaginal sonography but was not considered mandatory if intrauterine fluid was present. Variation in pressure generated by the transvaginal probe can facilitate imaging, and Doppler imaging can be used to differentiate between a niche and other uterine abnormalities, but neither was considered mandatory. Conclusion Consensus between niche experts was achieved regarding ultrasonographic niche evaluation. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology., This article's abstract has been translated into Spanish and Chinese. Follow the links from the abstract to view the translations. This article has been selected for Journal Club. Click here to view slides and discussion points.

OBJECTIVE To develop a set of core outcomes to be minimally reported in trials on induction of labour. DESIGN Two-round Delphi survey and consensus meeting. POPULATION Four stakeholder groups: midwives, obstetricians, neonatologists, and women's representatives. METHODS Protocol registered with COMET (Registration Number: 695). Stakeholders rated reported outcomes for importance (1-limited to 9-critical). The median rating of each outcome was calculated. The consensus criteria to include outcomes were as follows: ≥70% participants rated outcomes as critical and

Background Intrapartum ultrasound has been proposed as a method of assessing labour progress but its acceptability has not been comprehensively assessed. Aims We evaluated the acceptability of intrapartum ultrasound in women having vaginal examination (VE) and ultrasound (US) assessment (transabdominal (TA) and transperineal (TP)) prior to delivery, with and without regional analgesia (RA). Materials and Methods Women at 24–42 weeks gestation were included in a prospective observational cohort study. The acceptability of digital VE and TP US were assessed pre‐ and post‐examination using the modified validated Wijma Delivery Experience Questionnaire. Acceptability scores ranged 6–36 (6 being most and 36 being least positive) in six domains: positive‐trust and relax, negative‐harmful to baby, worrying, painful, intrusive. Results Of 119 women recruited, 104 completed both pre‐ and post‐assessment questionnaires. Eighty‐nine per cent of women were nulliparous with median gestation 40 + 2 weeks (25–42+1). Thirty‐two per cent had RA before assessment, 91% in total. The combined acceptability scores of both negative and positive experiences (6 = most acceptable, 36 = least acceptable) for VE and US pre‐assessment were 15 and 7 respectively (P < 0.0001: Mann‐Whitney U‐test). VE was associated with less positive / more negative domain scoring post‐assessment 12 and 6, respectively (P < 0.0001). Although RA made no difference to the perceived experience pre‐VE (P = 0.9), post‐VE, women with RAs considered VEs more acceptable than those without RA (P = 0.0022). Conclusion(s) This is the first study to comprehensively assess the acceptability of VE and intrapartum US. US assessment prior to delivery is more acceptable than VE. RA ameliorated the negative experience of the VE post‐assessment.

BACKGROUND: Lutenising hormone (LH) and human chorionic gonadotropin (hCG) hormone are useful biochemical markers to indicate ovulation and embryonic implantation, respectively. We explored "point-of-care" LH and hCG testing using a digital home-testing device in a cohort trying to conceive. OBJECTIVE: To determine conception and spontaneous pregnancy loss rates, and to assess whether trends in LH-hCG interval which are known to be associated with pregnancy viability could be identified with point-of-care testing. METHODS: We recruited healthy women aged 18-44 planning a pregnancy. Participants used a home monitor to track LH and hCG levels for 12 menstrual cycles or until pregnancy was conceived. Pregnancy outcomes (viable, clinical miscarriage, or biochemical pregnancy loss) were recorded. Monitor data were analysed by a statistician blinded to pregnancy outcome. RESULTS: From 387 recruits, there were 290 pregnancies with known outcomes within study timeline. Adequate monitor data for analysis were available for 150 conceptive cycles. Overall spontaneous first-trimester pregnancy loss rate was 30% with clinically recognised miscarriage rate of 17%. The difference to LH-hCG interval median had wider spread for biochemical losses (0.5-8.5 days) compared with clinical miscarriage (0-5 days) and viable pregnancies (0-6 days). Fixed effect hCG profile change distinguished between pregnancy outcomes from as early as day-2 post-hCG rise from baseline. CONCLUSIONS: The risk of first-trimester spontaneous pregnancy loss in our prospective cohort is comparable to studies utilising daily urinary hCG collection and laboratory assays. A wider LH-hCG interval range is associated with biochemical pregnancy loss and may relate to late or early implantation. Although early hCG changes discriminate between pregnancies that will miscarry from viable pregnancies, this point-of-care testing model is not sufficiently developed to be predictive. ispartof: PAEDIATRIC AND PERINATAL EPIDEMIOLOGY vol:34 issue:5 pages:495-503 ispartof: location:England status: published

With interest we read the correspondence of Bamberg et al.1 and Scioscia et al.2 about the randomized controlled trial of the first authors concerning the uterine niche after caesarean section (CS).3 They state that at the time of the trial it was not established which technique should be used in the evaluation of a caesarean scar or niche in daily practice and future research. Both authors underline the need for a uniform evaluation of the CS scar establishing an internationally accepted definition of a niche. In their study a niche was defined as an anechogenic area at the site of the uterine scar with a depth of at least 1 mm. This article is protected by copyright. All rights reserved. ispartof: ACTA OBSTETRICIA ET GYNECOLOGICA SCANDINAVICA vol:98 issue:10 pages:1351-1352 ispartof: location:United States status: published

KEY CONTENT: Spina bifida is a congenital neurological condition with lifelong physical and mental effects.Open fetal repair of the spinal lesion has been shown to improve hindbrain herniation, ventriculoperitoneal shunting, independent mobility and bladder outcomes for the child and, despite an increased risk of prematurity, does not seem to increase the risk of neurodevelopmental impairment.Open fetal surgery is associated with maternal morbidity.Surgery at our institution is offered and performed according to internationally agreed criteria and protocols.Further evidence regarding long-term outcomes, fetoscopic repair and alternative techniques is awaited. LEARNING OBJECTIVES: To understand the clinical effects, potential prevention and prenatal diagnosis of spina bifida.To understand the rationale and evidence supporting the benefits and risks of fetal repair of open spina bifida.To understand the criteria defining those who are likely to benefit from fetal surgery. ETHICAL ISSUES: The concept of the fetus as a patient, and issues surrounding fetal death or the need for resuscitation during fetal surgery.The associated maternal morbidity in a procedure performed solely for the benefit of the fetus/child.The financial implications of new surgical treatments. ispartof: OBSTETRICIAN & GYNAECOLOGIST vol:21 issue:4 pages:271-282 ispartof: location:England status: published

AIM: To evaluate the cardiotocography (CTG) features observed in suspected intrapartum chorioamnionitis in term fetuses according to the recently suggested criteria for the pathophysiological interpretation of the fetal heart rate and their correlation with perinatal outcomes. METHODS: Retrospective analysis of nonconsecutive CTG traces. 'CTG chorioamnionitis' was diagnosed either based on a persistent rise in the baseline for the given gestation or on a persistent increase in the baseline fetal heart rate during labor >10% without preceding CTG signs of hypoxia and in the absence of maternal pyrexia. Perinatal outcomes were compared among cases with no sign of chorioamnionitis, in those with only CTG features suspicious for chorioamnionitis and in those who developed clinical chorioamnionitis. RESULTS: Two thousand one hundred and five CTG traces were analyzed. Of these, 356 fulfilled the criteria for "CTG chorioamnionitis". Higher rates of Apgar

OBJECTIVES: this prospective observational study compared the value of magnetic resonance imaging (MRI) complementary to transvaginal ultrasonography (TV-US) to our standard preoperative assessment of patients with endometriosis referred for surgery in a tertiary care academic center. Based on the extent to which endometriosis affects reproductive organs, bowel, ureters, bladder or other abdominal organs, the surgery will be carried out by gynecologists only or by a multidisciplinary team involving abdominal surgeons and/or urologists. METHODS: In 74 women with clinically suspected deep endometriosis (DE) the standard preoperative imaging, i.e. an expert transvaginal ultrasonography (TV-US), complemented by an intravenous urography (IVU) for the evaluation of the ureters, and a double contrast barium enema (DCBE) for the evaluation of the rectum, sigmoid and caecum was compared with an expert TV-US complemented by a 'one-stop' abdominal and pelvic magnetic resonance imaging (MRI). The findings of the laparoscopy were the reference standard to provide an answer to the question if a 'one-stop' abdominal/pelvic MRI is equally reliable as our standard radiological imaging as a complement to transvaginal ultrasonography for preoperative triaging of patients with suspected urological and intestinal involvement by DE in tertiary care centers. RESULTS: The standard preoperative imaging as well as the combined findings of the TV-US and the MRI allowed a correct stratification for a monodisciplinary approach by gynecologists or a multidisciplinary approach in 90.5% of the patients. Both TV-US and DCBE underestimated the severity of the rectal involvement in 2.7%, whereas TV-US and/or DCBE overestimated it in 6.8% of the patients. CONCLUSIONS: In conclusion, complementary to an expert transvaginal ultrasound (TV-US) a 'one-stop' magnetic resonance imaging (MRI) predicts the intra-operative findings equally well as the standard radiological imaging (IVU and DCBE) in patients referred for endometriosis surgery in a tertiary care academic center.

ispartof: BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY vol:126 issue:11 pages:1402-1403 ispartof: location:England status: published

OBJECTIVE: To investigate the aetiology and the perinatal outcome of fetuses diagnosed with periviable fetal growth restriction (FGR) associated with structural defects or genetic anomalies. METHODS: Retrospective study conducted at a referral Fetal Medicine unit. Singleton pregnancies seen between 2005 and 2018 in which FGR, defined by fetal abdominal circumference ≤3rd percentile for the gestational age, was diagnosed between 22+0 -25+6 weeks of gestation were enrolled. The study group included periviable FGR associated with genetic or structural anomalies ("anomalous FGR"), while the control group consisted in structurally and genetically normal FGR ("non-anomalous FGR"). The results of the genetic tests, of the TORCH screening and of the post-mortem examination as well as the perinatal outcomes were investigated. RESULTS: Of 255 cases, 188 fetuses were eligible, of whom 52 (28%) were anomalous FGR and 136 (72%) non-anomalous FGR. Confirmed genetic abnormalities accounted for 17/52 cases (33%) of anomalous FGR, with trisomy 18 constituting over 50% (9/17, 53%). The most common structural defects associated with FGR were CNS abnormalities (13/35, 37%). Overall, 12 cases survived the neonatal period. No differences were found in terms of perinatal survival between anomalous and non-anomalous FGR. CONCLUSIONS: Of anomalous FGR, most are associated with structural defects. The association of structural abnormality with a genetic defect and FGR at periviable gestation was invariably lethal, while the combination of periviable FGR and structural defect in the absence of a confirmed genetic abnormality was associated with survival into infancy in four out of five cases, with an overall chance of perinatal survival of one in three. These data can be used for the counselling of the prospective parents. This article is protected by copyright. All rights reserved.

INTRODUCTION Small-for-gestational-age (SGA) confers a higher perinatal risk of adverse outcomes. Birthweight cannot be accurately measured until delivery, therefore accurate estimated fetal weight (EFW) based on ultrasonography is important in identifying this high-risk population. We aimed to establish the sensitivity of detecting SGA infants antenatally in a unit with a selective third-trimester ultrasound policy and to investigate the association between EFW and birthweight in these babies. MATERIAL AND METHODS A retrospective cohort study was conducted on non-anomalous singleton pregnancies delivered after 36 weeks of gestation where SGA (

Objective To compare the birth characteristics of Syrian refugees with those of Turkish citizens. Methods In a retrospective study, data were obtained for singleton live births that occurred at a hospital in Bursa, Turkey, between June 1 and December 31, 2015. All Syrian refugees were eligible for inclusion; one Turkish citizen was included for each refugee. Results Overall, 545 Syrian refugees and 545 Turkish citizens were included. Cesarean delivery was undertaken for 176 (32.3%) Syrians and 235 (43.1%) Turks (P

Made available in DSpace on 2019-09-12T16:53:24Z (GMT). No. of bitstreams: 0 Previous issue date: 2019 [Cortes, M. Sanz; Belfort, M.] Texas Childrens Hosp, Baylor Coll Med, Dept Obstet & Gynecol, 6621 Fannin St, Houston, TX 77030 USA [Lapa, D. A.] Hosp Israelita Albert Einstein, Fetal Therapy Program, Sao Paulo, Brazil [Acacio, G. L.] Universidade de Taubaté (Unitau), Dept Obstet, Sao Paulo, Brazil [Belfort, M.] Texas Childrens Hosp, Baylor Coll Med, Dept Neurosurg, Houston, TX 77030 USA [Carreras, E.; Maiz, N.] Univ Autonoma Barcelona, Hosp Univ Vall dHebron, Dept Obstet & Gynecol, Barcelona, Spain [Peiro, J. L.; Lim, F. Y.] Cincinnati Childrens Hosp Med Ctr, Dept Pediat Surg, Cincinnati, OH 45229 USA [Miller, J.; Baschat, A.] Johns Hopkins Ctr Fetal Therapy, Dept Gynecol & Obstet, Baltimore, MD USA [Sepulveda, G.; Davila, I.] Hosp Christus Muguerza Alta Especialidad, Med Perinatal Alta Especialidad, Monterrey, NL, Mexico [Gielchinsky, Y.] Hadassah Hebrew Univ, Med Ctr, Dept Obstet & Gynecol, Jerusalem, Israel [Gielchinsky, Y.] Rabin Med Ctr, Dept Obstet & Gynecol, Petah Tiqwa, Israel [Benifla, M.] Rambam Hlth Care Campus, Pediat Neurosurg Unit, Haifa, Israel [Stirnemann, J.; Ville, Y.] Necker Enfants Malades Hosp, Dept Obstet & Gynecol, Paris, France [Yamamoto, M.; Figueroa, H.] Univ Los Andes, Santiago, Chile [Simpson, L.] Columbia Univ, New York Presbyterian Hosp, Med Ctr, Dept Obstet & Gynecol, New York, NY USA [Nicolaides, K. H.] Fetal Med Fdn, London, England