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Increasing cesarean section rates have led to an increased awareness of associated complications such as the formation of cesarean scar niche, defined as an indentation at the site of the cesarean scar with a depth of at least 2 mm, diagnosed by ultrasound or magnetic resonance imaging. The precise prevalence of cesarean scar niche is unclear. The cause of a cesarean scar niche appears to be multifactorial and likely a combination of technical factors (low incision location), anatomical factors (uterine retroflexion), and patient factors, which might impair healing (body mass index, smoking, maternal age). Most patients with cesarean scar niche are asymptomatic; however, women can present with postmenstrual bleeding, pelvic pain, and subfertility. In pregnancy, cesarean scar niches have been associated with placenta accreta spectrum disorder and uterine rupture. Treatment should be reserved for symptomatic women. Hormonal treatment using either the combined oral contraceptive pill or a progesterone-containing intrauterine device may address irregular vaginal bleeding. Surgical management should be reserved for those in whom hormonal manipulation has failed or is contraindicated. The aim of this review was to summarize current literature pertaining to the cause, prevalence, diagnosis, and symptoms of cesarean scar niche and to make recommendations for managing this relatively new condition.

Fetal ventriculomegaly is associated with varying degrees of genetic and structural abnormalities. The objective was to present the experience of fetal ventriculomegaly in a large European center in relation to: 1. grade of ventriculomegaly; 2. additional chromosomal/structural abnormalities; and 3. perinatal survival rates.This was a prospective observational study of patients referred with fetal ventriculomegaly from January 2011 to July 2020. Data were obtained from the hospital database and analyzed to determine the rate of isolated ventriculomegaly, associated structural abnormalities, chromosomal/genetic abnormalities, and survival rates. Data were stratified into three groups; mild (Vp = 10-12 mm), moderate (Vp = 13-15 mm) and severe (Vp 15 mm) ventriculomegaly.There were 213 fetuses included for analysis. Of these 42.7% had mild ventriculomegaly, 44.6% severe and 12.7% had moderate ventriculomegaly. Initial ultrasound assessment reported isolated ventriculomegaly in 45.5% fetuses, with additional structural abnormalities in 54.5%. The rate of chromosomal/genetic abnormalities was high,16.4%. After all investigations, the true rate of isolated VM was 36.1%. The overall survival was 85.6%. Survival was higher for those with isolated VM across all groups (P 0.05).Ventriculomegaly is a complex condition and patients should be counselled that even with apparently isolated VM, there remains the possibility of additional genetic and/or structural problems being diagnosed in up to 10% of fetuses.

Severe fetal ventriculomegaly (VM) is defined as an enlargement of the atria of the lateral cerebral ventricles (Vp) of greater than 15 mm. While it is well established that it confers significant risk of morbidity and mortality to the neonate, there is limited information pertaining to the caesarean delivery rates and the obstetric management of these complex cases. The aim of this study was twofold: firstly, to determine survival rates in fetuses with severe VM, and secondly to determine the caesarean delivery rates in continuing pregnancies. We explore the obstetric challenges associated with these difficult cases.This was a prospective observational study of patients with antenatal severe VM, attending the Department of Fetal Medicine, National Maternity Hospital, Dublin, Ireland, from 1st January 2011 to 31st July 2020. Data were obtained from the hospital database and those with severe VM (Vp 15 mm) were identified. The rates of chromosomal abnormalities, the survival rates and the caesarean delivery (CD) rates for the overall group were then determined. The data were then further sub-divided into two groups: 1. Vp 20 mm and 2. Vp 20 mm, and the results compared. Statistical analysis was performed using the Chi-Square test.A total of N = 95 pregnancies with severe VM were included for analysis, of which additional structural abnormalities on ultrasound were apparent in 67/95 (70.5%) and 28/95 (29.5%) had isolated severe VM. Chromosomal abnormalities were diagnosed in 15/95 (15.8%) of cases, with (2/28) 7.1% in the isolated SVM group versus (13/67) 19.4% in the non-isolated SVM group. The overall survival rate (excluding TOP) was 53/74 (71.6%), with 20/23 (86.9%) in the isolated SVM group. The overall CD rate was 47/72 (65.3%), which was significantly higher than the CD for the hospital during the same time period of 25.4% (P 0.01). The data were subdivided into Vp 20 and Vp 20 and those with a Vp 20 had higher rates of additional intracranial findings on ultrasound (Vp 20 13/41 (31.7%) versus Vp 20 32/54 (59.3%) (P 0.05)) and macrocrania (Vp 20 14/41 (34.1%) versus Vp 20 35/54 (64.8%) (P 0.05)). No significant difference was observed in the overall survival or CD rates between the two groups.In conclusion this study reports significant fetal morbidity and mortality with severe VM with high CD rates observed in this cohort. Significant challenges exist in relation to the obstetric management and counseling of parents regarding an often uncertain neonatal prognosis. In continuing pregnancies with significant macrocrania delivery plans should be individualized to improve neonatal outcomes where possible and minimize harm to the mother.

Hemolytic disease of the fetus and newborn is characterized by fetal anemia, secondary to maternal alloantibody-mediated fetal erythrocyte destruction. Despite our reliance on intrauterine blood transfusion (IUT) to maintain severely affected pregnancies, it remains difficult to predict the fetal response to an infusion of donor blood. Our objective was to determine the daily rate of decline in fetal hemoglobin following one, two, and three transfusions. We also evaluated the relationship between the fetal hemoglobin level and the corresponding doppler measurement of the fetal middle cerebral artery peak systolic velocity (MCA-PSV).A prospective observational study of all singleton pregnancies treated with intrauterine transfusion for fetal anemia secondary to maternal alloimmunization at the National Maternity Hospital, a tertiary referral centre, was conducted over a 10-year period (2011-2020). Demographic and clinical data was obtained from the electronic patient records. Ethical approval was granted by the Ethics and Research Committee of the National Maternity Hospital.A total of 90 intrauterine blood transfusions were performed in 41 fetuses affected by maternal alloimmunization, of which 70% (n = 29), 34% (n = 14) and 15% (n = 6) required a 2nd, 3rdKnowledge of the expected rate of decline in fetal hemoglobin following an IUT aids in the determination of appropriate timing of subsequent transfusions in a fetus affected by red cell alloimmunization. We observed a reducing rate of daily decline in hemoglobin in fetuses requiring successive transfusions. Our findings suggest a reduced accuracy of the MCA-PSV threshold of 1.5 MoM in determining the optimal timing of 2nd, 3rd, and 4th transfusions.

Background Free Open-Access Medical education (FOAM) use among residents continues to rise. However, it often lacks quality assurance processes and residents receive little guidance on quality assessment. The Academic Life in Emergency Medicine Approved Instructional Resources tool (AAT) was created for FOAM appraisal by and for expert educators and has demonstrated validity in this context. It has yet to be evaluated in other populations. Objectives We assessed the AAT's usability in a diverse population of practicing emergency medicine (EM) physicians, residents, and medical students; solicited feedback; and developed a revised tool. Methods As part of the Medical Education Translational Resources: Impact and Quality (METRIQ) study, we recruited medical students, EM residents, and EM attendings to evaluate five FOAM posts with the AAT and provide quantitative and qualitative feedback via an online survey. Two independent analysts performed a qualitative thematic analysis with discrepancies resolved through discussion and negotiated consensus. This analysis informed development of an initial revised AAT, which was then further refined after pilot testing among the author group. The final tool was reassessed for reliability. Results Of 330 recruited international participants, 309 completed all ratings. The Best Evidence in Emergency Medicine (BEEM) score was the component most frequently reported as difficult to use. Several themes emerged from the qualitative analysis: for ease of use-understandable, logically structured, concise, and aligned with educational value. Limitations include deviation from questionnaire best practices, validity concerns, and challenges assessing evidence-based medicine. Themes supporting its use include evaluative utility and usability. The author group pilot tested the initial revised AAT, revealing a total score average measure intraclass correlation coefficient (ICC) of moderate reliability (ICC = 0.68, 95% confidence interval [CI] = 0 to 0.962). The final AAT's average measure ICC was 0.88 (95% CI = 0.77 to 0.95). Conclusions We developed the final revised AAT from usability feedback. The new score has significantly increased usability, but will need to be reassessed for reliability in a broad population.

OBJECTIVE Placenta accreta spectrum (PAS) is associated with significant maternal morbidity mainly related to blood loss. Pre-operative planning is aided by antenatal ultrasound and magnetic resonance imaging. We sought to assess whether three-dimensional (3D) models from MR images were accurate when compared with surgical and pathological findings. METHODS Digital Imaging and Communications in Medicine files containing MR images with varying severity of PAS (n = 4) were modeled using 3D Slicer. Placenta, bladder, and myometrial defects were modeled. Myometrial defects at three different uterine locations were included-anterior, lateral and inferior. 3D models were used to identify the relationship between the myometrial defect and the internal cervical os. Findings were validated in a larger series of PAS cases (n = 14) where patterns of invasion were compared with estimated blood loss and distance from defect to the internal os. RESULTS The defect illustrated in the four 3D models correlates to both surgical and pathological findings in terms of depth and pattern of invasion, location of defect, bladder involvement. Blood loss and topography of the defect from 3D modeling were examined in 14 further cases. Inferior defects were associated with increased blood loss compared with anterior defects. Increased distance from cervix was associated with reduced blood loss (R2 = 0.352, P = 0.01). CONCLUSION Three-dimensional models of PAS provide an accurate preoperative description of placental invasion and should be investigated as a tool for selecting patients for uterine-conserving surgery. Accurate 3D models of placenta accreta spectrum are achievable and may provide additional information, such as distance of the defect from the internal os.

A specialist fetal neurosurgical clinic was set up in order to improve patient care in a tertiary referral fetal medicine centre. The clinic provides a targeted clinical service for women diagnosed with fetal neurological abnormalities. The service consists of fetal MRI, fetal ultrasound and joint assessment and counselling from neurosurgery and fetal medicine teams. We aimed to review this service that provides MDT expertise directly to parents and record the cases and pregnancy outcomes involved. This is a prospective study of clinic data from Jan 2013 to Dec 2017. Information includes ultrasound scan findings, MRI results, karyotype results and pregnancy outcome data including post mortem results and data from the paediatric neurosurgery service at the affiliated children’s hospital. From 2013 to 2017, there were 1852 major fetal anomalies diagnosed antenatally at the tertiary referral fetal medicine service and n = 306/1852 [16%] were primarily neurological in origin. The neurosurgical clinic reviewed 125 patients since 2013. The most common reasons for referral were spina bifida, n = 60 [48%] and isolated ventriculomegaly n = 43 [34%]. Other reasons for referral include agenesis of the corpus callosum n = 4 [3%], encephalocoele n = 5 [4%] and intracranial mass lesions n = 3 [2.4%]. Cases with borderline ventriculomegaly and cases with known chromosomal or genetic abnormalities were not typically referred to the clinic. Full outcome data were available on 110 of 125 women seen. Thirty-two women [29%] underwent invasive testing and 14 women [12.7%] had a termination of pregnancy. Multidisciplinary antenatal counselling supported with in utero MRI provides families with optimum information to inform them of likely neonatal outcome.

The purpose of this study is to compare maternal outcomes in patients with placenta accreta spectrum (PAS) when managed as part of a multi-disciplinary team (MDT) compared to standard care.Patients in the standard care group were retrospectively identified from pathology records, with patients in the MDT group prospectively collected on an electronic database. Data on maternal demographics, delivery, estimated blood loss (EBL), transfusion requirements, and morbidity were recorded.Sixty patients were diagnosed with PAS between 2006 and 2019, of whom 32 were part of the standard care group and 28 in the MDT group. Compared to standard care, MDT care was associated with an increase in antenatal diagnosis from 56.3 to 92.9% (p0.0001), a significant reduction in EBL (4150 mL (800-19500) vs 1975 (495-8500), p0.0001), and transfusion requirements (median 7 (0-30) units of RCC vs 1 (0-13), p0.0001).PAS is associated with significant maternal morbidity and warrants management in an MDT setting with specialist input, which is associated with improved outcomes.

Background Nasal cannula can achieve apneic oxygenation during emergency intubation. However, pre-procedure nasal cannula placement may be difficult in patients undergoing non-invasive positive pressure ventilation (NPPV) prior to intubation. Our objective was to compare mask leak during NPPV with versus without simultaneous application of nasal cannula. We hypothesized mask leak would be no worse with concomitant use of nasal cannula (non-inferiority design). Methods We performed a randomized crossover non-inferiority study of healthy volunteers. We randomized subjects undergoing 60 s trials of NPPV (10 cm H2O continuous positive airway pressure) to either NPPV alone (NPPV-a) or NPPV with nasal cannula at 15 L/min (NPPV-nc). After a brief rest period, all subjects underwent the alternative intervention. The primary outcome was time averaged mask leak over 60 s (L/min). We defined a non-inferiority margin of 5 L/min. Results We enrolled 64 subjects. Mean time-averaged mask leak was 2.2 L/min for NPPV-a versus 4.0 L/min for NPPV-nc for a difference of 1.7 L/min (one-sided 95% CI −∞ to 3.2 L/min). NPPV-a resulted in higher mean minute volume received (13.5 versus 12.2 L) and higher mean respiratory rates (14.8 versus 13.5 breaths per minute). Conclusion The addition of nasal cannula during NPPV does not significantly increase mask leak. The simultaneous application of nasal cannula with NPPV may be a useful strategy to streamline airway management among patients undergoing NPPV prior to intubation.

Study objective Online educational resources such as blogs are increasingly used for education by emergency medicine clinicians. The Social Media Index was developed to quantify their relative impact. The Medical Education Translational Resources: Indicators of Quality (METRIQ) study was conducted in part to determine the association between the Social Media Index score and quality as measured by gestalt and previously derived quality instruments. Methods Ten blogs were randomly selected from a list of emergency medicine and critical care Web sites. The 2 most recent clinically oriented blog posts published on these blogs were evaluated with gestalt, the Academic Life in Emergency Medicine Approved Instructional Resources (ALiEM AIR) score, and the METRIQ-8 score. Volunteer raters (including medical students, emergency medicine residents, and emergency medicine attending physicians) were identified with a multimodal recruitment methodology. The Social Media Index was calculated in February 2016, November 2016, April 2017, and December 2017. Pearson's correlations were calculated between the Social Media Index and the average rater gestalt, ALiEM AIR score, and METRIQ-8 score. Results A total of 309 of 330 raters completed all ratings (93.6%). The Social Media Index correlated moderately to strongly with the mean rater gestalt ratings (range 0.69 to 0.76) and moderately with the mean rater ALiEM AIR score (range 0.55 to 0.61) and METRIQ-8 score (range 0.53 to 0.57) during the month of the blog post's selection and for 2 years after. Conclusion The Social Media Index's correlation with multiple quality evaluation instruments over time supports the hypothesis that it is associated with overall Web site quality. It can play a role in guiding individuals to high-quality resources that can be reviewed with critical appraisal techniques.

Objective The aim of this study is to document the detection of fetal congenital heart defect (CHD) in relation to the following: (1) indication for referral, (2) chromosomal and (3) extracardiac abnormalities. Method All fetal echocardiograms performed in our institution from 2007 to 2011 were reviewed retrospectively. Indication for referral, cardiac diagnosis based on the World Health Organization International Classification of Diseases tenth revision criteria and the presence of chromosomal and extracardiac defects were recorded. Results Of 1262 echocardiograms, 287 (22.7%) had CHD. Abnormal anatomy scan in pregnancies originally considered to be at low risk of CHD was the best indicator for detecting CHD (91.2% of positive cardiac diagnoses), compared with other indications of family history (5.6%) or maternal medical disorder (3.1%). Congenital anomalies of the cardiac septa comprised the largest category (n = 89), within which atrioventricular septal defects were the most common anomaly (n = 36). Invasive prenatal testing was performed for 126 of 287 cases, of which 44% (n = 55) had a chromosomal abnormality. Of 232 fetuses without chromosomal abnormalities, 31% had an extracardiac defect (n = 76). Conclusions Most CHDs occur in pregnancies regarded to be at low risk, highlighting the importance of a routine midtrimester fetal anatomy scan. Frequent association of fetal CHD and chromosomal and extracardiac pathology emphasises the importance of thorough evaluation of any fetus with CHD. © 2015 John Wiley & Sons, Ltd.

The use of social media by health professionals and medical journals is increasing. The aim of this study was to compare online views of articles in press (AIPs) released by Annals of Emergency Medicine before and after a nine-person social media team started actively posting links to AIPs using their personal Twitter accounts.An observational before-and-after study was conducted. Web traffic data for Annals were obtained from the publisher (Elsevier), detailing the number of page views to annemergmed.com by referring websites during the study period. The preintervention time period was defined as January 1, 2013, to June 30, 2014, and the postintervention period as July 1, 2014, to July 31, 2015. The primary outcome was page views from Twitter per AIP released each month to account for the number of articles published each month. Secondary outcomes included page views from Facebook (on which there was no article-sharing intervention) and total article views per month.The median page views from Twitter per individual AIP released each month increased from 33 in the preintervention period to 130, for an effect size of 97 (95% confidence interval, 56-111; P.001). There was a smaller increase in median page views from Facebook per individual AIP of 21 (95% confidence interval, 10-32). There was no significant increase in these median values for total page views per AIP.Twitter sharing of AIPs increased the number of page views that came from Twitter but did not increase the overall number of page views.

Objective To determine the antenatal course of severe red cell alloimmunisation in pregnancies requiring intrauterine fetal transfusion. Study design A retrospective cohort study over 16 years in a single national quaternary fetal medicine centre. From 1996 to 2011, 242 red cell intrauterine transfusions (IUT) were performed in 102 alloimmunised pregnancies. Antibody type was categorized into Rh(D) and non-Rh(D) (including Rh(c), Kell and Rh(E)). Women with Rh(D) antibodies were further stratified into those with and without additional red cell antibodies. Data were compared using the Mann–Whitney U and Fisher's exact tests. Two-tailed P values at the 5% level were considered significant. Results Comparing Rh(D) and non-Rh(D) pregnancies, there were no differences in either gestational age or fetal haemoglobin at first IUT, number of transfusions required, gestation at delivery, caesarean delivery rates or perinatal losses. In women sensitized to Rh(D), the presence of additional antibodies did not influence the degree of fetal anaemia or the first transfusion-delivery interval, although rates of fetal hydrops were higher in the presence of multiple antibodies. The “procedure-related” loss rate was 1.7% per procedure in our institution. Conclusion Antibody status does not appear to influence clinical outcomes following fetal transfusion for alloimmunisation.

Study objective Open educational resources such as blogs are increasingly used for medical education. Gestalt is generally the evaluation method used for these resources; however, little information has been published on it. We aim to evaluate the reliability of gestalt in the assessment of emergency medicine blogs. Methods We identified 60 English-language emergency medicine Web sites that posted clinically oriented blogs between January 1, 2016, and February 24, 2016. Ten Web sites were selected with a random-number generator. Medical students, emergency medicine residents, and emergency medicine attending physicians evaluated the 2 most recent clinical blog posts from each site for quality, using a 7-point Likert scale. The mean gestalt scores of each blog post were compared between groups with Pearson's correlations. Single and average measure intraclass correlation coefficients were calculated within groups. A generalizability study evaluated variance within gestalt and a decision study calculated the number of raters required to reliably (>0.8) estimate quality. Results One hundred twenty-one medical students, 88 residents, and 100 attending physicians (93.6% of enrolled participants) evaluated all 20 blog posts. Single-measure intraclass correlation coefficients within groups were fair to poor (0.36 to 0.40). Average-measure intraclass correlation coefficients were more reliable (0.811 to 0.840). Mean gestalt ratings by attending physicians correlated strongly with those by medical students (r=0.92) and residents (r=0.99). The generalizability coefficient was 0.91 for the complete data set. The decision study found that 42 gestalt ratings were required to reliably evaluate quality (>0.8). Conclusion The mean gestalt quality ratings of blog posts between medical students, residents, and attending physicians correlate strongly, but individual ratings are unreliable. With sufficient raters, mean gestalt ratings provide a community standard for assessment.

Objective. To examine the pattern and prospective risk of intrauterine fetal death (IUFD) in twin pregnancy by chorionicity. Design. Retrospective cohort analysis. Setting. Large national tertiary referral center. Population. All consecutive twin deliveries (1997–2006) ≥24 weeks. Methods. Retrospective review of all consecutive twin deliveries over 10 years to identify patterns of IUFD in twins and calculate gestation-specific prospective risks of IUFD. Fetal death was defined as intrauterine demise of a fetus ≥24weeks, intertwin birthweight discordance as ≥20% difference and growth restriction as birthweight

We set out to examine rates of perinatal mortality in twin pregnancies over a 17-year study period. Changes in mode of delivery were also examined as well as causes of death in twin mortalities.This retrospective cohort study was performed at three large tertiary referral centers from 1996 to 2012. It included all normally formed twin infants with a birth weight more than 500 g. All cases of perinatal mortality in twin pregnancies (infants more than 500 g who suffered an intrauterine or early neonatal (≤ 7 days of age) death were recorded. The changing rate of cesarean delivery as well as varying causes of death in twins over the course of the study were also examined.During the study period, there were 395,830 pregnancies across the three institutions, this included 6,727 twin gestations. The perinatal mortality rate was 21.5/1,000 twin infants. The perinatal mortality rate in twins decreased over the study period (p = 0.0006; R (2) = 0.55; slope = -1.2). Rates of cesarean delivery in twin gestations were found to have increased over the course of the study (p 0.0001; R (2) = 0.84; slope = 1.7). There were 288 intrauterine and early neonatal deaths in twin infants, 50% (147/288) occurred in twins born extremely premature (26 weeks). Prematurity was the leading cause of mortality in twins, followed by twin-to-twin transfusion syndrome (TTTS). TTTS was found to have a decreasing contribution to perinatal mortality during the study (p = 0.008; R (2) = 0.38; slope = -1.5).The perinatal mortality rate in twins improved during the study. The rate of cesarean delivery increased by 1.7% for each year of the study, culminating in a cesarean delivery rate of 62% in 2012. TTTS made a decreasing contribution to the mortality rate in twins during the study.

Our aims were to study the effect of birthweight growth discordance (≥20 %) on neuro-developmental outcome of monochorionic and dichorionic twins and to compare the relative effects of foetal growth discordance and prematurity on cognitive outcome. We performed a cross-sectional multicentre prospective follow-up study from a cohort of 948 twin pregnancies. One hundred nineteen birthweight-discordant twin pairs were examined (24 monochorionic pairs) and were matched for gestational age at delivery with 111 concordant control pairs. Participants were assessed with the Bayley Scales between 24 and 42 months of age. Analysis was by paired t test for intra-twin pair differences and by multiple linear regression. Compared to the larger twin of a discordant pair, the smaller twin performed significantly worse in cognition (mean composite cognitive score difference = −1.7, 95 % confidence interval (CI) = 0.3–3.1, p = 0.01) and also in language and motor skills. Prematurity prior to 33 weeks’ gestation, however, had a far greater impact on cognitive outcomes (mean cognitive composite score difference = −5.8, 95 % CI = 1.2–10.5, p = 0.008). Conclusion: Birthweight growth discordance of ≥20 % confers an independent adverse effect on long-term neuro-development of the smaller twin. However, prior to 33 weeks’ gestation, gestational age at birth adversely affects cognitive development to a greater extent than foetal growth discordance.

Objective With the recognition of the role of fetoscopic laser ablation for twin to twin transfusion syndrome (TTTS), there is a requirement for auditable standards for this technically challenging and specialized treatment. The purpose of this study is to report on the perinatal and medium-term neurodevelopmental outcomes following an 8-year national single center experience in the management of TTTS using the selective fetoscopic laser ablation technique. Study design An audit of all cases of TTTS treated with selective laser ablation by a single national fetal medicine team was performed. Overall perinatal survival and medium-term neurodevelopmental outcomes were reported and correlated with gestational age at diagnosis, placental location, volume of amnio-reduction, Quintero staging and percentage inter-twin growth discordance. Procedure-related complications were recorded. Results The overall fetal survival for the first 105 consecutive cases of TTTS was 61% (128/210 fetuses). Dual survival occurred in 47% (49/105) of cases, and with a single survival rate of 28% (30/105), perinatal survival of least one infant was achieved in 75% (79/105) of cases. No correlation was found between any clinical or sonographic marker and perinatal outcome, although dual survival was noted to be significantly decreased with increasing Quintero stage (p = 0.041). Currently, 86% of survivors have been reported to have a normal medium-term neurological outcome. Conclusion Fetoscopic laser ablation is the established optimal treatment for severe twin to twin transfusion syndrome (TTTS). We report comparable short and medium-term outcomes following the selective fetoscopic technique comparing results from our national program with internationally published single-center outcomes, supporting the efficacy and safety of this treatment at our center.

The aim of this study is to document the detection of fetal congenital heart defect (CHD) in relation to the following: (1) indication for referral, (2) chromosomal and (3) extracardiac abnormalities.All fetal echocardiograms performed in our institution from 2007 to 2011 were reviewed retrospectively. Indication for referral, cardiac diagnosis based on the World Health Organization International Classification of Diseases tenth revision criteria and the presence of chromosomal and extracardiac defects were recorded.Of 1262 echocardiograms, 287 (22.7%) had CHD. Abnormal anatomy scan in pregnancies originally considered to be at low risk of CHD was the best indicator for detecting CHD (91.2% of positive cardiac diagnoses), compared with other indications of family history (5.6%) or maternal medical disorder (3.1%). Congenital anomalies of the cardiac septa comprised the largest category (n = 89), within which atrioventricular septal defects were the most common anomaly (n = 36). Invasive prenatal testing was performed for 126 of 287 cases, of which 44% (n = 55) had a chromosomal abnormality. Of 232 fetuses without chromosomal abnormalities, 31% had an extracardiac defect (n = 76).Most CHDs occur in pregnancies regarded to be at low risk, highlighting the importance of a routine midtrimester fetal anatomy scan. Frequent association of fetal CHD and chromosomal and extracardiac pathology emphasises the importance of thorough evaluation of any fetus with CHD.

The purpose of this study was to assess the value of the middle cerebral artery time-averaged mean velocity for the detection of anemia as the cause of fetal hydrops.We examined 17 pregnant women with fetuses with hydrops (with ascites as the main component of hydrops) and who were considered at risk for anemia because there was no obvious explanation for the hydrops on the initial scan. Assessment included the measurement of the middle cerebral artery time-averaged mean velocity by color flow Doppler scan, followed by fetal blood sampling for investigations that included fetal hemoglobin. We investigated the correlation between increased middle cerebral artery time-averaged mean velocity (2 SDs for gestational age) and fetal anemia (2 SDs for gestational age).Eleven fetuses had anemia; 3 of the fetuses had red cell antibodies, and 6 of the fetuses had normal hemoglobin. There was a strong negative correlation between the middle cerebral artery time-averaged mean velocity and the hemoglobin values (r = -.9; P.0001). The mean (z score) of middle cerebral artery time-averaged mean velocity for fetuses with normal hemoglobin was 1.1 +/- 0.81 and for the fetuses with anemia was 4.71 +/- 2.16 (P.001). The sensitivity for the increased middle cerebral artery time-averaged mean velocity to predict fetal anemia was 91%, and the specificity was 100%.The middle cerebral artery time-averaged mean velocity is significantly increased in cases of hydrops caused by anemia, including cases other than red-cell alloimmunization. These findings can be useful for counseling and treatment and allow the investigation of the cause of hydrops without awaiting blood for intrauterine transfusion in patients who are very unlikely to be anemic and often avoids 2 procedures in those patients who require transfusion. Larger studies are required to further confirm these findings.

Objectives To examine the association between fetal talipes and other defects, and outcome in relation to postnatal surgery. Methods All cases of talipes presenting to the fetal medicine unit between 1993 and 1998 and cases of isolated talipes presenting to the ultrasound department between 1991 and 1998 were examined. The infants were followed-up to determine the number of cases that had structural or positional talipes and the number of cases requiring surgery. Results There were 76 cases, 59 of which attended the fetal medicine unit and 17 the ultrasound department. Postnatal follow-up details were available in 31 of the 40 live births. There were three neonates with unilateral talipes at birth who were thought to have bilateral talipes on prenatal ultrasound and one neonate had bilateral talipes at birth who had been thought to have unilateral talipes prenatally. In two (6.4%) neonates in whom talipes was not confirmed at birth the abnormality was diagnosed prenatally. Of the 29 neonates with confirmed talipes at birth, the defect was structural in 26 (90%) cases and positional in three. Surgery was necessary in 21 (72%) of the 29 cases and 18 (86%) of those undergoing surgery required only one operation. When live births with associated anomalies were excluded, there were 24 cases with confirmed isolated talipes and 18 (75%) required surgery. Conclusions This study provides long-term outcome data which can be used to complement current prenatal counseling and shows that in cases of fetal talipes diagnosed prenatally, 90% have a structural rather than a positional deformity. For isolated talipes three quarters of children will require surgery and in the majority of cases only one operation on the foot is necessary. Parents should be made aware of the small possibility of a false-positive diagnosis and discrepancy between the ultrasound and postnatal diagnoses of laterality. Copyright © 2001 International Society of Ultrasound in Obstetrics and Gynecology

This report of four cases shows that fetal vesicocentesis at 10-14 weeks of gestation is a useful treatment option in some cases with megacystis. Although megacystis at this gestation has been reported, there are few studies examining the role of early vesicocentesis. The natural history of the condition and outcome following treatment is reviewed with reference to the literature.

Objective. To examine fetal outcome in hydrops fetalis in relation to gestational age at diagnosis and following investigation and treatment. Methods. All cases of hydrops fetalis presenting to the Fetal Medicine Unit during the last seven years, between 1993 and 1999, were identified from the Fetal Medicine Database. During this time 87 of 13,980 patients who attended the Fetal Medicine Unit had hydrops fetalis. The cases were examined for gestational age at presentation according to etiology and fetal survival following investigation and treatment. The fetal survival rates for non-immune cases of hydrops before and after 24 weeks were compared. Results. The cause of hydrops was determined antenatally in 71 of the 87 (82%) cases. Of the 51 cases presenting before 24 weeks' gestation, 23 (45%) were due to chromosomal abnormality. After 24 weeks, fetal tachyarrhythmias and hydrothorax were the most common causes and accounted for 14 (38%) of the 36 cases. Thirty-four cases (39%) of hydrops received intraut...

Objective To determine the degree of agreement between prenatal ultrasound diagnosis of brain abnormalities and subsequent pathologic findings. Methods Between August 1993 and August 1999 there were 62 cases where a fetus with a prenatal ultrasound diagnosis of a brain abnormality other than neural tube defects underwent autopsy at the Regional Department of Pediatric Pathology. The cerebral diagnosis at ultrasound was compared with the findings at autopsy in all cases. Results In 47 of 61 (77%) cases the same defects were seen on ultrasound and at autopsy. The most common disparity was with the Dandy–Walker malformation or variant, where only six of the 14 (43%) cases prenatally diagnosed with this condition showed the same abnormality at autopsy. When fetuses with the Dandy–Walker malformation or variant were excluded, the scan findings correlated with autopsy in 41 of 47 (87%). In the main group with discordant findings, five of the seven cases where termination of pregnancy was undertaken had other fetal anomalies on ultrasound examination which were confirmed at autopsy. In the sixth case there was autolysis of brain tissue which affected detailed autopsy. Conclusions A very high level of agreement between prenatal ultrasound and autopsy findings was found for all abnormalities of the fetal brain, except for the Dandy–Walker malformation or variant. Potential discrepancy in findings between ultrasound and autopsy should be explained to patients who are considering termination of pregnancy for the Dandy–Walker type of abnormality. Copyright © 2000 International Society of Ultrasound in Obstetrics and Gynecology

Objectives: To assess the relationship between the volume of amniotic fluid removed and the change in amniotic fluid index (AFI) and calculate an equation describing this association. Materials and Methods: A retrospective analysis of 19 amnioreduction procedures performed in our unit. Multiple regression analysis was used to assess the effect of gestational age and pre-procedure AFI on the change in AFI (ΔAFI) after adjusting for the volume removed. Results: As expected, a significant linear relationship was found between the change in AFI and the volume removed (r = 0.82, n = 19, p < 0.0001). ΔAFI was not dependent on the gestational age or the pre-procedure AFI. The equation describing the association between the volume removed and ΔAFI was: volume = (ΔAFI – 2.26)/0.008, which is close to 1 cm ΔAFI for every 100 ml removed. Discussion: Using the described equation, it is possible to predict the required volume to be removed in order to achieve a particular ΔAFI, which may reduce the need to interrupt the procedure to measure the AFI. However, the limitation of AFI as a semiquantitative assessment of the liquor volume, together with its inter- and intra-observer variations mean this equation should be used only as a guide.

To compare the outcomes of twin pregnancies conceived by artificial reproductive techniques (ART) with those of spontaneous conception.In this multicenter prospective trial, comparisons were made between methods of conception in twin pregnancies, for maternal and perinatal outcomes.Of 1001 twin pairs, 763/1001 (72.7%) were spontaneously conceived and 238/1001(27.3%) were conceived by ART. There were no significant differences between the two groups with respect to obstetric complications. There were 13 per 1000 (20/1504; 1%) perinatal deaths in the spontaneously conceived group and 6 per 1000 (3/466; 0.6%) in the ART group (p = 0.8141). We found no differences in gestational age at delivery (median 36.9 versus 37.0 weeks), birth weight (median 2520 g versus 2538 g), or in a composite measure of adverse perinatal outcome (17% versus 15%) between the groups.There were no differences in the rate of adverse obstetric or perinatal outcomes between twins conceived naturally compared with twins conceived by assisted conception.

Infection-mediated inflammation may be responsible for premature delivery in cases of preterm prelabour amniorrhexis. Histological examination of the cord and placenta was performed in 54 such pregnancies, in addition to amniocentesis and cordocentesis at presentation. Histological chorioamnionitis was more likely in those with positive amniotic fluid and/or fetal blood cultures, and in those cases with histological evidence of inflammation, the interval to delivery was short regardless of the culture results. Inflammation rather than infection per se may he the best indicator of preterm delivery in preterm prelabour amniorrhexis.

OBJECTIVE: To determine the optimum timing for planned delivery of uncomplicated monochorionic and dichorionic twin pregnancies. METHODS: Unselected twin pregnancies were recruited for this prospective cohort study (N=1,028), which was conducted in eight tertiary referral perinatal centers in Ireland. Perinatal mortality and a composite measure of perinatal morbidity (respiratory distress, necrotizing enterocolitis, hypoxic ischemic encephalopathy, periventricular leukomalacia, or sepsis) were compared between uncomplicated twins that underwent planned preterm delivery compared with monochorionic twins that continued in utero beyond 34 weeks of gestation, and dichorionic twins who continued beyond 36 weeks. RESULTS: Perinatal outcome data were recorded for 100% of the 1,001 twin pairs that completed the study (n=200 monochorionic and n=801 dichorionic). Overall perinatal mortality was 30 per 1,000 in monochorionic twins and 3.8 per 1,000 among dichorionic twins. The prospective risk of in utero death was 1.5% after 34 weeks of gestation for uncomplicated monochorionic pregnancies, with no deaths among dichorionic twins after 33 weeks. The risk of a composite measure of perinatal morbidity for uncomplicated monochorionic twins fell from 41% (13/32 neonates, 3/6 among elective deliveries) at 34 weeks to 5% (4/84) at 37 weeks (P

To examine the pattern and prospective risk of intrauterine fetal death (IUFD) in twin pregnancy by chorionicity.Retrospective cohort analysis.Large national tertiary referral center.All consecutive twin deliveries (1997-2006) ≥24 weeks.Retrospective review of all consecutive twin deliveries over 10 years to identify patterns of IUFD in twins and calculate gestation-specific prospective risks of IUFD. Fetal death was defined as intrauterine demise of a fetus ≥24weeks, intertwin birthweight discordance as ≥20% difference and growth restriction as birthweight5(th) centile. Chorionicity was confirmed by postnatal placental examination.Fetal death.1094 twin pairs including 276 monochorionic-diamniotic (MCDA) (25.3%) and 818 dichorionic-diamniotic (DCDA) twin pregnancies (74.7%) were studied. Twenty-nine fetal deaths occurred affecting 22 twin pregnancies. The incidence of IUFD (death of one or both fetuses) in MCDA twin pregnancies was three times that in DCDA pregnancies [11/276 (3.9)% vs. 11/818 (1.3%) p0.001]. The majority of deaths in MCDA twins were associated with twin-twin transfusion syndrome (TTTS) prior to 30 weeks. In normally grown twins the prospective risk of IUFD was similarly low in MCDA and DCDA pregnancies after 34 weeks but in pregnancies complicated by abnormal growth, the prospective risk of IUFD was 3.4 in MCDA and 2.0 in DCDA pregnancies.Twin pregnancies complicated by growth restriction or growth discordance were associated with a high risk of IUFD, particularly in affected MCDA twins. Conversely, in normally grown twins the risk was similarly low in MCDA and DCDA pregnancies after 34 weeks.

The purpose of this study was to evaluate the impact of noncentral placental cord insertion on birthweight discordance in twins.We performed a multicenter, prospective trial of twin pregnancies. Placental cord insertion was documented as central, marginal, or velamentous according to a defined protocol. Association of the placental cord insertion site with chorionicity, birthweight discordance, and growth restriction were assessed.Eight hundred sixteen twin pairs were evaluated; 165 pairs were monochorionic, and 651 pairs were dichorionic. Monochorionic twins had higher rates of marginal (P = .0068) and velamentous (P.0001) placental cord insertion. Noncentral placental cord insertion was more frequent in smaller twins of discordant pairs than control pairs (29.8% vs 19.1%; P = .004). Velamentous placental cord insertion in monochorionic twins was associated significantly with birthweight discordance (odds ratio, 3.5; 95% confidence interval, 1.3-9.4) and growth restriction (odds ratio, 4; 95% confidence interval, 1.1-14.3).Noncentral placental cord insertion contributes to birthweight discordance in monochorionic twin pregnancies. Sonographic delineation of placental cord insertion may be of value in antenatal assessment of twin pregnancies.

Telecommunications network operators face the dual challenges of powering remote equipment while controlling both operating costs and energy consumption. As a means to help meet these challenges, this paper describes the functionality and performance of an Alternative Power Analyzer tool specially made for remote base station applications which models the outputs of renewably generated power based on location and user inputs. It combines these results with economic inputs to produce a business plan for the implementation of the preferred system. An important factor affecting economic viability is the various incentives for sustainable power generation. These can vary greatly by value, duration, equipment eligibility, location, and other constraints. To manage these complex datasets, a dynamic ontological information framework has been developed which is designed to iteratively interface with the APA tool. The outputs of the work indicate that a techno-economic systems approach can be applied both to assess the viability of location-specific system configurations under current incentives frameworks and to inform policy makers in terms of future incentives optimization.

We report a case of fetal parvovirus B19 infection which appears to have resulted in hydrops in the first trimester. An ultrasound scan performed at the booking visit of a woman in the first trimester showed generalised oedema. Karyotyping to exclude a fetal abnormality was normal. Maternal radioimmunoassay serological investigations showed parvovirus B19 IgG and IgM. Post-mortem analysis revealed intranuclear inclusion bodies typical of parvovirus in the erythroid cells in the liver and in the myocardium.

544 Background: The American Cancer Society (ACS) supports 80% by 2018. We have an innovative solution to address barriers: compliance and capacity without diluting quality. Methods: The “gold standard” test is a high-quality colonoscopy. To improve compliancewe leverage the primary care physician (PCP) through navigators. The existing colonoscopists are saturated while screening only half. Quality, as reflected in the protective benefit, is called into question by large-scale studies. An estimated 7% of CRCs are diagnosed as “interval cancers.” occurring in patients compliant with screening. Results: First, when the PCP invites the patient, their “butts” show up! Compliance in our study more than doubled and exceeded the ACS 80% by 2018 goal. We present an update to the initial study (de Groen, NEJM 2014) adding 15,000 more consecutive cases and 4 years to the database; incidence dropped (83%) as did mortality (89%). This is the first large study to demonstrate no diminution of protection in the right colon! Our hypothesis is that the two-man technique simplifies visualizing the mucosal surface. The continual availability of an “expert” to “mentor and monitor” was sufficient to supervise 30 PCPs and thus augment capacity (4,000 cases rather than 1,000 cases per year per expert). With the average cost of $250,000 per case of advanced CRC, the savings are more than double the screening costs. Conclusions: The inclusion of the PCP in CRC screening addresses the barriers: enhanced compliance, augmented capacity without any diminution in quality. The PCP provides capacity needed to screen the underserved (more than half of the at risk population not “up to date” with screening colonoscopy). Rather than taking patients from traditional providers, the model has excelled in identifying the underserved. To achieve 80% by 2018 will require 6,000,000 additional annual screening colonoscopies but would prevent 100,000 cases of CRC and 25,000 deaths. At the current rate, 30,000 PCP colonoscopists could meet this demand. Utilizing PCPs using the team colonoscopy approach could one day result in near elimination of deaths from “the preventable cancer.”