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Medical informed consent is the process by which a 'competent', non-coerced individual receives sufficient information including risks of a medical procedure and gives permission for it to occur. The capacity to give an informed consent might be impaired during labour. This study aimed to examine women's abilities to understand and remember during labour. Women were prospectively recruited at 36 weeks of gestation and randomised to undertake questionnaires which assessed their ability to understand and remember information. They were randomised to: (1) information given in labour only, written format (2) information in labour, verbal (3) information at 36 weeks plus labour, written (4) information at 36 weeks plus labour, verbal. Immediate comprehension and retention was assessed at 36 weeks, in labour, and 24-72 hours after birth. Forty-nine women completed the questionnaires regarding understanding and retention of information at 36 weeks, six intrapartum, and five postpartum (90% attrition). Women receiving information at 36 weeks and in labour versus in labour had a higher comprehension of pregnancy-related information, its retention, and total score. Women receiving information in late pregnancy and labour may comprehend and retain it better than women only receiving information during labour. Given small sample size, further research is needed to support these preliminary findings. Impact statement What is already known on this subject? The evidence regarding the capacity of labouring women to give informed consent is largely based on women's self-reported experiences or expert opinions and has mixed findings. Existing guidelines recommend that an informed consent should be given antenatally for both clinical practice and research. Studies show that obtaining an informed consent antenatally is neither feasible nor widely implemented. What do the results of this study add? A novel approach to providing empirical evidence regarding women's capacity to comprehend and retain information during labour. Our study confirms the difficulty with antenatal recruitment for intrapartum research. What are the implications of these findings for clinical practice and/further research? This raises ethical concerns regarding the current intrapartum research in which consent is largely sought at the time of the study. Emphasises the need to explore the question 'Do labouring women have the capacity to consent to research?' in order to ensure that women are protected during labour. [ABSTRACT FROM AUTHOR]

Aims: Assess clinical utility of the foetal Myocardial Performance Index (MPI) in evaluation and management of monochorionic, diamniotic twin (MCDA) pregnancies. Methods: Prospective cohort of (a) initially uncomplicated MCDA (b) Complicated MCDA, including twin-twin transfusion syndrome (TTTS), selective intrauterine growth restriction (sIUGR), and liquor and/or growth discordance (L/GD) not meeting TTTS or sIUGR criteria. TTTS and sIUGR were case-control matched. Routine Dopplers and MPI were taken and correlated to diagnosis and final outcome. Results: Twenty-six always uncomplicated pairs, 51 always complicated pairs, and seven uncomplicated to pathological pairs were included. TTTS recipient (n = 25) left and right MPI and intertwin difference (ITD) were significantly elevated, however, were already elevated in Stage I (n = 10), and did not predict progression or pregnancy outcome. sIUGR MPI (n = 11) did not differ significantly from control. Of 15-L/GD pairs, two that progressed to TTTS had significantly higher left and right MPI values in the future recipient (0.61 and 0.72) versus future sIUGR larger twins (0.48 and 0.51) or stable L/GD (0.47 and 0.52): p < .01 for all comparisons. Conclusions: In this cohort, MPI did not add substantial diagnostic/prognostic information to current routine evaluation in established TTTS or sIUGR though potentially differentiated L/GD cases progressing to TTTS. [ABSTRACT FROM AUTHOR]

The goal of our research was to quantify the placental vascularity in 3-D at 11-13 + 6 wk of pregnancy at precise distances from the utero-placental interface (UPI) using 3-D power Doppler ultrasound. With this automated image analysis technique, differences in vascularity between normal and pathologic pregnancies may be observed. The algorithm was validated using a computer-generated image phantom and applied retrospectively in 143 patients. The following features from the PD data were recorded: The number of spiral artery jets into the inter-villous space, total geometric and PD area. These were automatically measured at discrete millimeter distances from the UPI. Differences in features were compared with pregnancy outcomes: Pre-eclamptic versus normal, all small-for-gestational age (SGA) to appropriate-for-gestational age (AGA) patients and AGA versus SGA in normotensives (Mann-Whitney). The Benjamini-Hochberg procedure was used (false discovery rate 10%) for multiple comparison testing. Features decreased with increasing distance from the UPI (Kruskal-Wallis test; p <0.001). At 2- 3 mm from the UPI, all features were smaller in pre-eclamptic compared with normal patients and for some in SGA compared with AGA patients (p <0.05). For AGA versus SGA in normotensive patients, no significant differences were found. Number of jets measured at 2-5 mm from the UPI did not vary because of the position of the placenta in the uterus (ANOVA; p > 0.05). This method provides a new in-vivo imaging tool for examining spiral artery development through pregnancy. Size and number of entrances of blood flow into the UPI could potentially be used to identify high-risk pregnancies and may provide a new imaging biomarker for placental insufficiency. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether there is beat-to-beat (BTB) variability in the fetal left myocardial performance index (MPI), as evaluated by an automated system, and whether there is a correlation between MPI and fetal heart rate (FHR).Methods: This was a prospective cross-sectional study of uncomplicated, morphologically normal, singleton pregnancies at 20-38 weeks' gestation. Multiple cineloops for left MPI measurement were acquired during a single examination of each fetus. Raw cineloop data were analyzed by our automated MPI system (intraclass correlation coefficient of 1.0 for any given waveform) to produce a set of MPIs. The corresponding instantaneous FHR was measured for each individual cardiac cycle for which MPI was calculated.Results: Data from 29 fetuses were analyzed; mean MPI was 0.52, mean FHR was 150 beats per min and the median number of cardiac cycles examined per fetus was 70 (interquartile range, 31-115). Marked BTB variability was noted; median coefficient of variation was 10% (range, 5.5-13.9%). FHR was weakly correlated with absolute MPI (r = 0.22; P < 0.05). BTB variation in MPI as a percentage of the mean MPI was not significantly correlated with FHR (r = 0.031; P = 0.146). When standard error of the mean of all MPI values was divided by the mean for each case, it showed that at least four cardiac cycles should be averaged to reduce MPI variability to approximately ± 5%.Conclusion: There is significant BTB variability in fetal left MPI, which has an overall weak correlation with FHR. This could be a factor affecting the consistency of MPI values reported by different research groups. Variability would be reduced by averaging 4-5 cardiac cycles per fetus. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Objective: To undertake an observational study to see whether first trimester placental vascularity, measured with a standardized power Doppler index: 3D-FMBV, is different in pregnancies which either develop pre-eclampsia or lead to term, normotensive small for gestational age (SGA) babies. Methods: Women were scanned between 11 and 13+6 weeks. The placental volume (sPlaV) was estimated using our previously validated semi-automated tool. Estimates of 3D-FMBV were generated from the raw power Doppler signal for the whole utero-placental interface, UPI (FMBV-UPI) and 5mm into the placenta (FMBV-IVS). Differences in the placental volume and FMBV for pregnancies developing pre-eclampsia and resulting in term, normotensive SGA babies were compared with term, normotensive, appropriate for gestational age (AGA), controls. Results: Results were available for 143 women. The placental volume (sPlaV) was reduced in both pre-eclampsia (p = 0.007) and term, normotensive SGA (p = 0.001) when compared with term normotensive AGA controls. 3D-FMBV estimates were significantly lower for pregnancies developing pre-eclampsia (FMBV-UPI, p = 0.03, FMBV-IVS, p = 0.01) but not for the normotensive SGA pregnancies (FMBV-UPI, p = 0.16, FMBV-IVS, p = 0.27). Conclusion: Pregnancies destined to develop pre-eclampsia are more likely to have small placentas with significantly reduced vascularity at 11–13 weeks. Those pregnancies which were normotensive throughout but resulted in an SGA baby delivered at term, had significantly smaller placentas but with similar vascularity to normotensive AGA pregnancies. [ABSTRACT FROM AUTHOR]

Introduction Twin reversed arterial perfusion ( TRAP) sequence occurs when there is one non-viable twin without cardiac structures and a viable pump twin that perfuses the acardiac mass. This study aims to investigate the management and immediate neonatal outcomes for monochorionic multiple pregnancies complicated by TRAP referred to the NSW Fetal Therapy Centre ( NSW FTC). Methods Retrospective cohort study of multiple pregnancies referred to NSW FTC between April 2006 and April 2014, reviewing data for cases of TRAP sequence (n = 19, including two triplet cases) compared to a timeframe matched sample of uncomplicated monochorionic diamniotic ( MCDA) twin pregnancies managed in the unit (n = 45). Results Primary management of the 19 TRAP cases was expectant management in 10 (53%), radiofrequency ablation ( RFA) in 6 (32%), and bipolar cord coagulation, amniodrainage and termination of pregnancy in 1 case each. 1 of 6 RFA cases had pump twin demise <1 week post-procedure. Average gestation at birth (35.1 ± 5.0 vs. 35.0 ± 2.8 weeks) and mean birthweight (2157 ± 1019 g vs. 2245 ± 537 g) were similar between TRAP pump fetuses and uncomplicated MCDA cases. Pump twin survival was 81% (twins only) compared to 98% for uncomplicated MCDA twins (P = 0.02), and in 5 of 19 (26%) TRAP pregnancies the pump fetus had a congenital anomaly. Conclusion Mean gestational age at birth and mean birthweight were similar for both TRAP and uncomplicated MCDA pregnancies. TRAP cases, however, had higher perinatal mortality, and high rates of congenital anomaly. The overall neonatal outcome at NSW FTC for TRAP cases is similar to reported international outcomes. [ABSTRACT FROM AUTHOR]

Objective: To compare automated measurements of the fetal left myocardial performance index (MPI) with manual measurements for absolute value, repeatability and waveform acceptability.Methods: This was a multicenter international online study using images from uncomplicated, morphologically normal singleton pregnancies (16-38 weeks' gestation). Single Doppler ultrasound cardiac cycle images of 25 cases were selected, triplicated and randomized (n = 75). Six senior observers, unaware of the repetition of images, manually calculated MPI for each waveform and the results were compared with automation. Intraobserver repeatability and interobserver reproducibility were assessed using intraclass correlation coefficients (ICCs) and 95% CI. The agreement between each observer's manual MPI measurements and corresponding automated measurements was evaluated using Bland-Altman plots and ICCs with 95% CI. The degree of variation between experts in the classification of fetal MPI waveform quality was assessed using individual cardiac cycle left MPI images previously classified by two authors as 'optimal', 'suboptimal' or 'unacceptable', with 30 images selected for each quality group. Ten images in each category were duplicated and the resulting 120 images were randomized and then classified online by five observers. The kappa statistic (κ) was used to demonstrate interobserver and intraobserver agreement and agreement of classifications by the five observers.Results: The automated measurement software returned the same value for any given image, resulting in an ICC of 1.00. Manual measurements had intraobserver repeatability ICC values ranging from 0.69 to 0.97, and the interobserver reproducibility ICC was 0.78. Comparison of automated vs manual MPI absolute measurements for each observer gave ICCs ranging from 0.77 to 0.96. Interobserver image quality classification agreement gave k = 0.69 (P < 0.001), and the intraobserver agreement was variable (κ ranging from 0.40 to 0.81).Conclusions: Automated fetal MPI provides superior repeatability and reproducibility to manual methodology. Additionally, experts vary significantly when classifying suitability of fetal MPI waveforms. Automated MPI may facilitate clinical translation by removing human subjectivity. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Background: Although specialised clinics for multiple pregnancies are recommended by several Obstetrics and Gynaecology governing bodies, studies examining outcome before and after introduction of such clinics remain few, were performed predominantly in North America in the 1990s, and either amongst dichorionic twin pregnancies only or where chorionicity was not specified. Our objective, in the modern setting with twins of known chorionicity, was to compare maternal and neonatal outcomes of twin pregnancies before and after commencement of a consultant-led, multidisciplinary twins clinic (TC).Methods: Retrospective cohort study of 513 women, with birth of twins at ≥20 weeks' gestation, January 2007 to November 2011, at a metropolitan tertiary maternity hospital, Sydney, Australia. Demographic, pregnancy, and outcome data were obtained from hospital databases. Women receiving TC care (2009-2011) were compared to those receiving general antenatal clinic (ANC) care (2007-2010) and private care (2009-2011). Other models of care were excluded. Main outcome measures were total maternal inpatient stay, mode of birth, gestational age at birth, and neonatal nursery admission.Results: 286 women were included in the main analyses: 84 attended ANC, 101 TC, and 101 a private obstetrician. TC women had similar demographics to ANC women and were slightly younger than private patients. TC women had lower Caesarean section rates (55% vs. 70% ANC and 76% private, p = 0.008) and fewer late preterm (34 + 0-36 + 6 weeks) births, (26%TC vs. 44% ANC and 41% private, p < 0.001). Median maternal inpatient stay was shorter in TC than ANC (7 vs. 8 days, p = 0.009) and similar to private (7 days). Nursery admission rates were higher in private patients (67% vs. 49% ANC and 47% TC, p = 0.001) and average birthweight lower (2283 g vs. 2501 g ANC and 2496 g TC, p < 0.001).Conclusions: Within a single centre, maternal and neonatal twin pregnancy outcomes varied significantly by model of care. Introducing a specialised twins clinic in our setting decreased Caesarean section rates, late preterm birth, and inpatient stay compared to ANC. [ABSTRACT FROM AUTHOR]

Objective To determine whether the technique of fractional moving blood volume ( FMBV) is applicable to Virtual Organ Computer-aided AnaLysis II ( VOCAL II™)-based indices to quantify three-dimensional power Doppler ultrasound ( 3D-PDU) by investigating the effect of gain level on the indices measured at a possible reference point for standardization. Methods Ten women with singleton pregnancy between 33 + 3 and 37 + 5 weeks' gestation were recruited. The optimal position for 3D acquisition of cord insertion into the placenta was identified and static 3D-PDU volumes were acquired using consistent machine configurations. Without moving the probe or the participant changing position, successive 3D volumes were stored at −3, -5, -7 and −9 dB and at the individualized sub-noise gain ( SNG) level. Volumes were excluded if flash artifact was present, in which case all five volumes were reacquired. Using 4D View software, the cord insertion was magnified and the smallest sphere possible was used to measure vascularization index ( VI), flow index ( FI) and vascularization flow index ( VFI). The associations between VOCAL indices and gain level were assessed using Pearson's correlation coefficient. Results VOCAL indices for cord insertion correlated poorly with gain level, whether fundamental or relative to SNG level ( R2 = 0.07 and 0.04, respectively). VI was consistently 100% and mean FI and VFI were 99.5 ( SD, 0.57), with all values > 97 irrespective of gain level. Conclusions Whilst previous work has shown that gain correlates well with placental tissue VOCAL indices, the correlation between gain level and VOCAL indices in an area of 100% vascularity at the cord insertion is poor. Regions of 100% vascularity appear to be artificially assigned a value approaching 100% for all VOCAL indices irrespective of gain level. This precludes using the technique of VOCAL indices from large vessels to standardize power Doppler measurements and the FMBV index is therefore not applicable to image analysis using VOCAL. [ABSTRACT FROM AUTHOR]

Background Enhancing collaboration has been highlighted as a marker for future success in maternity care, although this suggestion comes with little methodological guidance. This study assessed the efficacy of a collaborative partnership between obstetric doctors and midwives providing Midwifery Group Practice ( MGP) care. Methods A retrospective analysis was undertaken with notes from weekly case review meetings held between the obstetricians and midwives over a 12-month period; audio recordings and a prospective analysis of 16 meetings with verbal contributions of the different professions; the number and types of cases discussed and referred, medical records kept at these meetings and a professional satisfaction questionnaire. Consistency of care was measured against the Australian National Midwifery Guidelines for Consultation and Referral. Results Of the 337 women booked with MGP, 50% were discussed at least once. Of these, 35% were referred for consultation with an obstetrician. Women as ' Patients' were most commonly discussed, followed by educational discussions and anecdotes with equal verbal contributions from midwives and doctors. Plans for each case were recorded 97% of the time, and adhered to 90% of the time. A high level of consistency of care between similar cases (75% of the time) and with the consultation and referral guidelines (85% of the time) were achieved. Professional satisfaction with this model of care rated highly for both groups. Conclusion Inter-professional collaboration between midwifery and obstetric staff is highly attainable within this model of care. This study reinforces the effectiveness of collaboration in the MGP model of care for women of all risk levels and should encourage other maternity care providers to consider adopting this collaborative model. [ABSTRACT FROM AUTHOR]

Objective To evaluate the intra- and interobserver reliability of assessment of three-dimensional power Doppler (3D-PD) indices from single spherical samples of the placenta. Methods Women with singleton pregnancies at 24-40 weeks' gestation were included. Three scans were independently performed by two observers; Observer 1 performed the first and third scan, intercalated by the scan of Observer 2. The observers independently analyzed the 3D-PD datasets that they had previously acquired using four different methods, each using a spherical sample: random sample extending from basal to chorionic plate; random sample with 2 cm3 of volume; directed sample to the region subjectively determined as containing more color Doppler signals extending from basal to chorionic plate; or directed sample with 2 cm3 of volume. The vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were evaluated in each case. The observers were blinded to their own and each other's results. Additional evaluation was performed according to placental location: anterior, posterior and fundal or lateral. Intra- and interobserver reliability was assessed by intraclass correlation coefficients (ICC). Results Ninety-five pregnancies were included in the analysis. All three placental 3D-PD indices showed only weak to moderate reliability (ICC < 0.66 and ICC < 0.48, intra- and interobserver, respectively). The highest values of ICC were observed when using directed spherical samples from basal to chorionic plate. When analyzed by placental location, we found lower ICCs for lateral and fundal placentae compared to anterior and posterior ones. Conclusion Intra- and interobserver reliability of assessment of placental 3D-PD indices from single spherical samples in pregnant women greater than 24 weeks' gestation is poor to moderate, and clinical usefulness of these indices is likely to be limited. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives To demonstrate the influence of gain setting on the calculated Virtual Organ Computer-aided AnaLysis (VOCAL™) three-dimensional (3D) indices and define a point, the sub-noise gain (SNG), at which maximum information is available without noise artifact. Methods Pregnant women were recruited at the time of their pregnancy-dating scan. Five identical static 3D power Doppler volumes of the placenta were acquired using identical machine settings apart from altering the power Doppler gain setting. The gain settings included the individualized SNG setting (determined by increasing gain until noise artifact was visible, then reducing it until the artifact just disappeared). The data were analyzed using VOCAL II. Vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were calculated for the same sample at five different power Doppler gain levels. The relationship between the values calculated for the VOCAL indices and the gain value was explored using linear regression analysis. Results Results from 50 women were analyzed. The percentage difference in VI and VFI from that observed at the SNG level in each woman was significantly linearly related to the gain setting relative to that at the SNG point (VI: r2 = 0.68, P < 0.0001; VFI: r2 = 0.72, P < 0.0001), with the values produced for VI and VFI decreasing as the gain was turned down. There was a distinct 'turning point' at the SNG level with linear relationships above and below, but with significantly different gradients ( P ⩽ 0.001). This relationship was not demonstrated for FI. Conclusion The SNG setting appears to represent each individual's optimum gain level. Using this may improve meaningful comparisons of VI and VFI between patients. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

An abstract of the research paper "Delta-MPI in pathological versus uncomplicated pregnancy: a value-add to right and left mod-MPI?," by A. Henry and colleagues is presented.

Abstract: This study was aimed at assessing the intra-observer and inter-observer repeatability of selecting the sub-noise gain (SNG) level when acquiring placental volumes with 3-D power Doppler for analysis using virtual organ computer-aided analysis (VOCAL). Sixty women with uncomplicated singleton pregnancies between 20 and 38 wk of gestation were recruited. Two women were excluded for flash artifact noted during image analysis. Two blinded observers independently adjusted gain to their perceived SNG level before acquiring a static 3-D volume of the placenta at the cord insertion; observers alternated after each acquisition until each had acquired two volumes. A single observer operated the probe at all times. During offline analysis, SNG levels were recorded and VOCAL indices were calculated. SNG exhibited excellent intra-observer and inter-observer reliability. Intra-observer intra-class correlation coefficients (95% confidence intervals) were 0.98 (0.97–0.99) and 0.98 (0.98–0.99) for observers 1 and 2, respectively. The inter-observer intra-class correlation coefficient was 0.96 (0.93–0.98). Despite its perceived inherent subjectivity, the excellent intra-class correlation coefficients obtained in this study support SNG as a promising tool for future research using 3-D power Doppler. [Copyright &y& Elsevier]