Background Late-onset intrauterine growth restriction (IUGR) results from a failure of the placenta to supply adequate nutrients and oxygen to the rapidly growing late-gestation fetus. Limitations in ...current monitoring methods present the need for additional techniques for more accurate diagnosis of IUGR in utero. New magnetic resonance imaging (MRI) technology now provides a noninvasive technique for fetal hemodynamic assessment, which could provide additional information over conventional Doppler methods. Objective The objective of the study was to use new MRI techniques to measure hemodynamic parameters and brain growth in late-onset IUGR fetuses. Study Design This was a prospective observational case control study to compare the flow and T2 of blood in the major fetal vessels and brain imaging findings using MRI. Indexed fetal oxygen delivery and consumption were calculated. Middle cerebral artery and umbilical artery pulsatility indexes and cerebroplacental ratio were acquired using ultrasound. A score of ≥ 2 of the 4 following parameters defined IUGR: (1) birthweight the third centile or less or 20% or greater drop in the centile in estimated fetal weight; (2) lowest cerebroplacental ratio after 30 weeks less than the fifth centile; (3) ponderal index < 2.2; and (4) placental histology meets predefined criteria for placental underperfusion. Measurements were compared between the 2 groups (Student t test) and correlations between parameters were analyzed (Pearson’s correlation). MRI measurements were compared with Doppler parameters for identifying IUGR defined by postnatal criteria (birthweight, placental histology, ponderal index) using receiver-operating characteristic curves. Results We studied 14 IUGR and 26 non-IUGR fetuses at 35 weeks’ gestation. IUGR fetuses had lower umbilical vein ( P = .004) and pulmonary blood flow ( P = .01) and higher superior vena caval flow ( P < .0001) by MRI. IUGR fetuses had asymmetric growth but smaller brains than normal fetuses ( P < .0001). Newborns with IUGR also had smaller brains with otherwise essentially normal findings on MRI. Vessel T2s, oxygen delivery, oxygen consumption, middle cerebral artery pulsatility index, and cerebroplacental ratio were all significantly lower in IUGR fetuses, whereas there was no significant difference in umbilical artery pulsatility index. IUGR score correlated positively with superior vena caval flow and inversely with oxygen delivery, oxygen consumption, umbilical vein T2, and cerebroplacental ratio. Receiver-operating characteristic curves revealed equivalent performance of MRI and Doppler techniques in identifying IUGR that was defined based on postnatal parameters with superior vena caval flow area under the curve of 0.94 (95% confidence interval, 0.87–1.00) vs a cerebroplacental ratio area under the curve of 0.80 (95% confidence interval, 0.64–0.97). Conclusion MRI revealed the expected circulatory redistribution in response to hypoxia in IUGR fetuses. The reduced oxygen delivery in IUGR fetuses indicated impaired placental oxygen transport, whereas reduced oxygen consumption presumably reflected metabolic adaptation to diminished substrate delivery, resulting in slower fetal growth. Despite brain sparing, placental insufficiency limits fetal brain growth. Superior vena caval flow and umbilical vein T2 by MRI may be useful new markers of late-onset IUGR.
Objective Fetal infection with human parvovirus B19 (hParvo-B19) has been associated mainly with fetal anemia, although data regarding other fetal hematologic effects are limited. Our aim was to ...assess the rate and consequences of severe fetal thrombocytopenia after fetal hParvo-B19 infection. Study Design We conducted a retrospective study of pregnancies that were complicated by fetal hParvo-B19 infection that underwent fetal blood sampling (FBS). The characteristics and outcomes of fetuses with severe thrombocytopenia (<50 × 109 /L) were compared with those of fetuses with a platelet concentration of ≥50 × 109 /L (control fetuses). Fetuses in whom 3 FBSs were performed (n = 4) were analyzed to assess the natural history of platelet levels after fetal hParvo-B19 infection. Results A total of 37 pregnancies that were affected by fetal hParvo-B19 infection were identified. Of the 29 cases that underwent FBS and had information regarding fetal platelets, 11 cases (38%) were complicated by severe fetal thrombocytopenia. Severely thrombocytopenic fetuses were characterized by a lower hemoglobin concentration (2.6 ± 0.9 g/dL vs 5.5 ± 3.6 g/dL; P = .01), lower reticulocyte count (9.1% ± 2.8% vs 17.3% ± 10.6%; P = .02), and lower gestational age at the time of diagnosis (21.4 ± 3.1 wk vs 23.6 ± 2.2 wk; P = .03). Both the fetal death rate within 48 hours of FBS (27.3% vs 0%; P = .02) and the risk of prematurity (100.0% vs 13.3%; P < .001) were higher in fetuses with severe thrombocytopenia. Fetal thrombocytopenia was more common during the second trimester but, in some cases, persisted into the third trimester. Intrauterine transfusion (IUT) of red blood cells resulted in a further mean decrease of 40.1% ± 31.0% in fetal platelet concentration. Conclusion Severe fetal thrombocytopenia is relatively common after fetal hParvo-B19 infection, can be further worsened by IUT, and may be associated with an increased risk of procedure-related fetal loss after either FBS or IUT.
To describe the role of ultrasound and MRI in defining the extent of disease and guiding perioperative and surgical management of abnormal invasive placentation (AIP).
We conducted a review of 65 ...cases of invasive placentation diagnosed antenatally with use of ultrasound and/or MRI in a single tertiary centre between January 2000 and December 2014. Cases were assigned a grade based on the depth of invasion and location of invasion within the uterus as described in ultrasound and MRI reports. These grades were then compared with grades assigned using a combination of pathology and dictated surgical reports.
Ultrasound correctly identified the presence of AIP in 91.9% of cases but was accurate in predicting the stage of invasion in only 38.7% of cases. Ultrasound identified only 6.3% of cases with parametrial involvement. MRI correctly identified the presence of AIP in 98.4% of cases and was accurate in predicting the stage of invasion in 61.3% of cases. MRI accurately detected parametrial involvement in 68.8% of cases.
Our results suggest that all women with signs of AIP on ultrasound scanning should be referred for MRI to assess the extent of placental invasion adequately and consequently to allow for adequate perioperative and surgical planning for delivery.
Objective The purpose of this study was to evaluate the prognostic role of placental ultrasound imaging at 19-23 weeks of gestation in clinically high-risk women with abnormal uterine artery Doppler ...(UTAD). Study Design Placentas of 60 women with abnormal UTAD were examined at 19-23 weeks of gestation for shape and texture abnormalities. Findings were correlated with clinical outcomes (preterm delivery at <32 weeks of gestation; birth weight <10th percentile small for gestational age; preeclampsia/hemolysis, elevated liver enzymes, low platelets; early-onset intrauterine growth restriction with abnormal umbilical artery Doppler; and intrauterine fetal death) and maternal serum screening data. Placental disease was reviewed by 2 perinatal pathologists. Results Women with abnormal placental shape at 19-23 weeks of gestation (n = 28) had higher odds of intrauterine fetal death (odds ratio, 4.5; 95% CI, 1.3-15.6), delivery at <32 weeks of gestation (odds ratio, 4.7; 95% CI, 1.6-14.1), and intrauterine growth restriction (odds ratio, 4.7; 95% CI, 1.4-15.1) than did the women with a normal placental shape. Thirty-two of 41 placentas (74%) weighed <10th percentile, and 36 of 43 placentas (83%) had ischemic-thrombotic pathologic condition. There was no association between abnormal placental shape at 19-23 weeks of gestation and placental weight, but 5 of 6 placentas that were <10 cm long were <10th percentile for weight at delivery. There was a poor correlation between measures of ultrasound texture at 19-23 weeks of gestation and the presence of specific lesions at delivery. Conclusion Combined abnormal UTAD and placental dysmorphologic condition before fetal viability identifies a subset of women who are at risk of adverse outcomes. Placental size is critical in the determination of the outcome in this situation because of the very high prevalence of destructive lesions, although present methods of placental imaging have significant limitations.
To assess the effectiveness of a multidisciplinary team approach to reduce severe maternal morbidity in women with invasive placenta previa.
We conducted a prospective study of 33 women with placenta ...previa and increta-percreta (diagnosed by ultrasound and/or magnetic resonance imaging) delivering at Mount Sinai Hospital, Toronto, following the introduction in January 2008 of a team-based approach to women with this condition. We included women who delivered by June 2012. We reviewed antenatal outpatient and inpatient records for use of six pre-defined team components by the attending staff obstetrician: (1) antenatal maternal-fetal medicine consultation, (2) surgical gynaecology consultation, (3) antenatal MRI, (4) interventional radiology consultation and preoperative placement of balloon catheters in the anterior divisions of the internal iliac arteries, (5) pre-planned surgical date, and (6) surgery performed by members of the invasive placenta surgical team. Antenatal course, delivery, and postpartum details were recorded to derive a five-point composite severe maternal morbidity score based on the presence or absence of: (1) ICU admission following delivery, (2) transfusion > 2 units of blood, (3) general anaesthesia start or conversion, (4) operating time in highest quartile (> 125 minutes), and (5) significant postoperative complications (readmission, prolonged postpartum stay, and/or pulmonary embolism).
All 33 women survived during this time period. Two thirds (22/33) had either five or six of the six components of multidisciplinary care. Increasing use of multidisciplinary team components was associated with a significant reduction in composite morbidity (R2 = 0.228, P = 0.005).
Team-based assessment and management of women with invasive placenta previa is likely to improve maternal outcomes and should be encouraged on a regional basis.
AbstractPurposeThis study is the first description of hospital-wide anti-infective use according to clinical indication for a pediatric hospital. Children's Hospital Colorado (CHCO) is uniquely ...poised to examine its anti-infective use after the implementation of provider-selected order indications (PSOIs), which are distinct from Diagnosis Related Group classifications in that they are used for clinical treatment as opposed to final diagnosis codes for billing and thus are more granular. MethodsThis study used our institution's mandatory PSOIs to describe overall clinical indications for anti-infective use. For 2016, all anti-infective orders were extracted from the electronic medical record (Epic), including drug name, route, prescribing unit, and PSOI. We calculated the number of times each drug was associated with each indication and the number of times an indication was attributed to each drug, and then analyzed these data in Excel. FindingsThere were 29,258 orders at CHCO in 2016 with at least 1 indication. The most common clinical indication was “prophylaxis–medical/surgical,” accounting for 23% of all orders and commonly associated with cefazolin (42% of prophylaxis–medical/surgical orders). This was followed by the indications of “sepsis/bacteremia” and “pneumonia/sinusitis.” The most commonly prescribed anti-infectives for nonprophylactic clinical indications were IV vancomycin (14%), ceftriaxone (11%), and ampicillin (6%). ImplicationsKnowledge of the clinical reasons for hospital-wide anti-infective use enables hospitals to identify targets for improved use through education and guideline and policy development. This description provides better details than billing codes about the clinical reasons anti-infectives are used and offers a useful template for implementation at other hospitals.
Sonographic diagnosis of chronic abruption Walker, Melissa; Whittle, Wendy; Keating, Sarah ...
Journal of obstetrics and gynaecology Canada,
11/2010, Volume:
32, Issue:
11
Journal Article
Peer reviewed
placental abruption is usually an acute event in which clinical decision-making overrides the need for ultrasound imaging. By contrast, chronic abruption may present with vague or even confusing ...clinical findings. We describe a case in which the diagnosis of chronic abruption was established by ultrasound and the findings directly influenced clinical care.
a 30-year-old woman with asymptomatic preeclampsia was evaluated in our fetal medicine unit at 30 weeks' gestation. Despite normal fetal monitoring, a large, retroplacental sonolucent area was noted on ultrasound. A planned Caesarean section was performed two days later, despite normal daily fetal monitoring, because the mass had increased in size. Placental pathology confirmed the diagnosis of chronic abruption.
ultrasound may establish the diagnosis of a large chronic placental abruption that is relevant for clinical management.
Summary Background Zika virus is an arthropod-borne virus that is a member of the family Flaviviridae transmitted mainly by mosquitoes of the genus Aedes . Although usually asymptomatic, infection ...can result in a mild and self-limiting illness characterised by fever, rash, arthralgia, and conjunctivitis. An increase in the number of children born with microcephaly was noted in 2015 in regions of Brazil with high transmission of Zika virus. More recently, evidence has been accumulating supporting a link between Zika virus and microcephaly. Here, we describe findings from three fatal cases and two spontaneous abortions associated with Zika virus infection. Methods In this case series, formalin-fixed paraffin-embedded tissue samples from five cases, including two newborn babies with microcephaly and severe arthrogryposis who died shortly after birth, one 2-month-old baby, and two placentas from spontaneous abortions, from Brazil were submitted to the Infectious Diseases Pathology Branch at the US Centers for Disease Control and Prevention (Atlanta, GA, USA) between December, 2015, and March, 2016. Specimens were assessed by histopathological examination, immunohistochemical assays using a mouse anti-Zika virus antibody, and RT-PCR assays targeting the NS5 and envelope genes. Amplicons of RT-PCR positive cases were sequenced for characterisation of strains. Findings Viral antigens were localised to glial cells and neurons and associated with microcalcifications in all three fatal cases with microcephaly. Antigens were also seen in chorionic villi of one of the first trimester placentas. Tissues from all five cases were positive for Zika virus RNA by RT-PCR, and sequence analyses showed highest identities with Zika virus strains isolated from Brazil during 2015. Interpretation These findings provide strong evidence of a link between Zika virus infection and different congenital central nervous system malformations, including microcephaly as well as arthrogryposis and spontaneous abortions. Funding None.
Pulmonary metastasectomy is widely accepted for many tumor types because it may prolong survival and potentially cure some patients. However, intraoperative localization of pulmonary metastases can ...be technically challenging. We propose that intraoperative near-infrared (NIR) molecular imaging can be used as an adjunct during disease localization.
We inoculated 50 C57BL/6 mice with Lewis lung carcinoma (LLC) flank tumors. After flank tumor growth, mice were injected through the tail vein with indocyanine green (ICG) before operation, and intraoperative imaging was used to detect pulmonary metastases. On the basis of these experiments, we enrolled 8 patients undergoing pulmonary metastasectomy into a pilot and feasibility clinical trial. Each patient received intravenous ICG 1 day before operation, followed by wedge or segmental resection. Samples were imaged on the back table with an NIR camera to confirm disease presence and margins. All murine and human tumors and margins were confirmed by pathologic examination.
Mice had an average of 4 ± 2 metastatic tumors on both lungs, with an average size of 5.1 mm (interquartile range IQR 2.2 mm to 7.6 mm). Overall, 200 of 211 (95%) metastatic deposits were markedly fluorescent, with a mean tumor-to-background ratio (TBR) of 3.4 (IQR 3.1 to 4.1). The remaining tumors had a TBR below 1.5. In the human study, intraoperative NIR imaging identified six of the eight preoperatively localized lesions. Intraoperative back table NIR imaging identified all metastatic lesions, which were confirmed by pathologic examination. The average tumor size was 1.75 ± 1.4 cm, and the mean ex vivo TBR was 3.3 (IQR 3.1 to 3.7). Pathologic examination demonstrated melanoma (n = 4), osteogenic sarcoma (n = 2), renal cell carcinoma (n = 2), chondrosarcoma (n = 1), leiomyosarcoma (n = 1), and colorectal carcinoma (n = 1).
Systemic ICG identifies subcentimeter tumor metastases to the lung in murine models, and this work provides proof of principle in humans. Future research is focused on improving depth of penetration into the lung parenchyma.
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