Objective The objective of the study was to test whether ultrasound-measured fetal adrenal gland volume (AGV) and fetal zone enlargement (FZE) predicts preterm birth (PTB) better than cervical length ...(CL). Study Design Three-dimensional and 2-dimensional ultrasound were used prospectively to measure fetal AGV, FZE, and CL in women with preterm labor symptoms. We corrected AGV for fetal weight (cAGV). The ratio between whole gland depth (D) and central fetal zone depth (d) (d/D) was used to measure FZE. Ability of cAGV, d/D, and CL to predict PTB 7 days or less was compared. Results Twenty-seven of 74 women (36.5%) presenting between 21 and 34 weeks had PTB of 7 days or less. FZE greater than 49.5% was the single best predictor for PTB (sensitivity/specificity 100%/89%) compared with cAGV (81%/87%) and CL (56%/60%; P < .05). Prediction was independent of obstetrics history and tocolytic use. Conclusion The 2-dimensional measurement of the adrenal gland FZE is highly effective performing superior to CL in identifying women at risk for PTB within 7 days.
Proteomic analysis of amniotic fluid shows the presence of biomarkers characteristic of intrauterine inflammation. We sought to validate prospectively the clinical utility of one such proteomic ...profile, the Mass Restricted (MR) score.
We enrolled 169 consecutive women with singleton pregnancies admitted with preterm labor or preterm premature rupture of membranes. All women had a clinically indicated amniocentesis to rule out intra-amniotic infection. A proteomic fingerprint (MR score) was generated from fresh samples of amniotic fluid using surface-enhanced laser desorption ionization (SELDI) mass spectrometry. Presence or absence of the biomarkers of the MR score was interpreted in relationship to the amniocentesis-to-delivery interval, placental inflammation, and early-onset neonatal sepsis for all neonates admitted to the Newborn Special Care Unit (n = 104). Women with "severe" amniotic fluid inflammation (MR score of 3 or 4) had shorter amniocentesis-to-delivery intervals than women with "no" (MR score of 0) inflammation or even "minimal" (MR score of 1 or 2) inflammation (median range MR 3-4: 0.4 d 0.0-49.6 d versus MR 1-2: 3.8 d 0.0-151.2 d versus MR 0: 17.0 d 0.1-94.3 d, p < 0.001). Nonetheless, a "minimal" degree of inflammation was also associated with preterm birth regardless of membrane status. There was a significant association between the MR score and severity of histological chorioamnionitis (r = 0.599, p < 0.001). Furthermore, neonatal hematological indices and early-onset sepsis significantly correlated with the MR score even after adjusting for gestational age at birth (OR for MR 3-4: 3.3 95% CI, 1.1 to 9.2, p = 0.03). When compared with other laboratory tests routinely used to diagnose amniotic fluid inflammation and infection, the MR score had the highest accuracy to detect inflammation (white blood cell count > 100 cells/mm3), whereas the combination of Gram stain and MR score was best for rapid prediction of intra-amniotic infection (positive amniotic fluid culture).
High MR scores are associated with preterm delivery, histological chorioamnionitis, and early-onset neonatal sepsis. In this study, proteomic analysis of amniotic fluid was shown to be the most accurate test for diagnosis of intra-amniotic inflammation, whereas addition of the MR score to the Gram stain provides the best combination of tests to rapidly predict infection.
To estimate the relationship between histologic chorioamnionitis and four amniotic fluid proteomic biomarkers characteristic of inflammation (defensins 2 and 1, calgranulins C and A).
One hundred ...fifty-eight women with singleton pregnancies had a clinically indicated amniocentesis to rule out inflammation and infection in the context of preterm labor or preterm premature rupture of membranes. A proteomic fingerprint (Mass Restricted score) was generated from amniotic fluid using surface-enhanced laser desorption ionization time-of-flight mass spectrometry. The Mass Restricted score ranges from 0 to 4 (none to all four biomarkers present) in direct relationship with severity of intra-amniotic inflammation. Presence or absence of biomarkers was analyzed in relationship to placental pathology. Criteria for severity of histologic chorioamnionitis were 3 stages and 4 grades of inflammation of the amnion, choriodecidua and chorionic plate.
The prevalence of histologic chorioamnionitis was 64% (stage I 12%, stage II 16%, and stage III 37%). The Mass Restricted score significantly correlated with stages of histologic chorioamnionitis (r=0.539, P<.001), grades of choriodeciduitis (r=0.465, P<.001), and amnionitis (r=0.536, P<.001). African-American women were overrepresented in the group with severe inflammation (Mass Restricted score 3-4, P=.022). Of the four biomarkers of the Mass Restricted score, calgranulin C had the strongest relationship with presence of stage III chorioamnionitis, independent of race, amniocentesis-to-delivery interval, and gestational age.
Proteomic analysis of amniotic fluid provides an opportunity for early recognition of histologic chorioamnionitis. This methodology may in the future identify candidates for antenatal therapeutic interventions.
II.
Intrauterine growth restriction (IUGR), which complicates approximately 3% to 10% of all pregnancies leads to preferential hemodynamic changes in affected fetuses. Advanced ultrasound modalities ...allow reliable and reproducible assessment of the intrauterine fetal cardiac function. Among other methods, combined cardiac output, individual ventricular ejection forces, E/A ratio, and Tei index can be utilized to quantify fetal heart function. While systolic ejection forces significantly increase with advancing gestational age in normal fetuses, there is a significant decline in the systolic function in IUGR fetuses. From the diastolic cardiac function point, IUGR fetuses have significantly lower left and right ventricular diastolic filling without significant changes in diastolic function. Overall, IUGR fetuses demonstrate progressive hemodynamic changes. It appears that there is an earlier and more pronounced right than left and diastolic than systolic fetal cardiac function deterioration in growth-restricted fetuses.
We aim to test the hypothesis that two-dimensional (2-D) fetal adrenal gland volume (AGV) measurements offer similar volume estimates as volume calculations based on 3-D technique.
Fetal AGV was ...estimated by three-dimensional (3-D) ultrasound (VOCAL) in 93 women with signs/symptoms of preterm labor and 73 controls. Fetal AGV was calculated using an ellipsoid formula derived from 2-D measurements of the same blocks (0.523 × length × width × depth). Comparisons were performed by intraclass correlation coefficient (ICC), coefficient of repeatability, and Bland-Altman method. The corrected AGV (cAGV; AGV/fetal weight) was calculated for both methods and compared for prediction of preterm birth (PTB) within 7 days.
Among 168 volumes, there was a significant correlation between 3-D and 2-D methods (ICC = 0.979; 95% confidence interval CI: 0.971 to 0.984). The coefficient of repeatability for the 3-D was superior to the 2-D method (intraobserver 3-D: 30.8, 2-D:57.6; interobserver 3-D:12.2, 2-D: 15.6). Based on 2-D calculations, cAGV ≥ 433 mm3/kg was best for prediction of PTB (sensitivity: 75%, 95% CI = 59 to 87; specificity: 89%, 95% CI = 82 to 94). Sensitivity and specificity for the 3-D cAGV (cutoff ≥ 420 mm3/kg) was 85% (95% CI = 70 to 94) and 95% (95% CI = 90 to 98), respectively. In receiver-operating-curve curve analysis, 3-D cAGV was superior to 2-D cAGV for prediction of PTB (z = 1.99, p = 0.047).
2-D volume estimation of fetal adrenal gland using ellipsoid formula cannot replace 3-D AGV calculations for prediction of PTB.
Objective To determine preoperative predictive factors for donor and recipient death after laser ablation of placental vessels in twin-to-twin transfusion syndrome. Study Design Retrospective ...analysis of North American Fetal Therapy Network center laser procedures, 2002-2009. Factors associated with donor and recipient death were identified by regression analysis. Results There were 466 patients from 8 centers. Factors significantly associated with donor fetal death were low donor estimated fetal weight (odds ratio OR, 0.69; 95% confidence interval CI, 0.55–0.87) and reversed end diastolic velocity in the umbilical artery (OR, 4.0; 95% CI, 1.54–10.2); for recipient fetal death–low recipient estimated fetal weight (OR, 0.65; 95% CI, 0.44–0.95), recipient reversed “a” wave in the ductus venosus (OR, 2.39; 95% CI, 1.27–4.51) and hydrops (OR, 3.7; 95% CI, 1.1–12.7); for recipient neonatal death–low donor estimated fetal weight (OR, 0.54; 95% CI, 0.30–0.95), high recipient estimated fetal weight (OR, 1.55; 95% CI, 1.06–2.26) and recipient reversed end diastolic velocity in the umbilical artery (OR, 7.8; 95% CI, 1.03–59.3). Conclusion Preoperative findings predict fetal and neonatal demise in twin-to-twin transfusion syndrome treated with laser therapy.
Objective We hypothesized that nitric oxide (NO) inhibition has synergistic effects with chronic hypoxia in altering maternal serum levels of soluble fms-like tyrosine kinase 1 (sFlt-1), vascular ...endothelial growth factor (VEGF), and placental growth factor (PlGF). We tested our hypothesis in a rodent model of intrauterine growth restriction induced by chronic hypoxia and NO inhibition with NG -nitro-L-arginine methyl ester (L-NAME). Study design Timed pregnant adult Sprague-Dawley rats were assigned to the following groups: (1) 20% (oxygen) O2 + saline (n = 7); (2) 20% O2 + L-NAME (n = 8); (3) 14% O2 + saline (n = 5); (4) 14% O2 + L-NAME (n = 5); (5) 10% O2 + saline (n = 6); and (6) 10% O2 + L-NAME (n = 6). Seven nulliparous females served as nonpregnant controls. L-NAME (50 mg/rat/day) or saline was administered via subcutaneous osmotic pumps, inserted on day 17 of gestation. A hypoxic chamber was used to assure mild (14% O2 ) or severe (10% O2 ) hypoxic environment after surgical placement of the minipumps and until the animals were killed on day 21 of gestation before the onset of labor. Maternal blood was collected preceding death. Free serum levels of VEGF, PlGF, and sFlt-1 were measured by highly specific immunoassays. Two composite indices were calculated (sFV: log (sFlt-1)/VEGF and sFP: log (sFlt-1)/PlGF and compared among groups. Results Fetal growth restriction was induced by both severe hypoxia (10% O2 ) and L-NAME infusion (2-way analysis of variance, P = .02 O2 levels, P < .001 L-NAME), whereas their combination proved to be the most damaging ( P < .001). Pregnancy was characterized by higher maternal serum concentrations of VEGF ( P < .001) and PlGF ( P < .001), but lower levels of sFlt-1 ( P = .037) compared with nonpregnant controls. Serum VEGF levels were not altered by either hypoxia or L-NAME infusion ( P = .348 O2 levels, P = .205 L-NAME). In contrast, L-NAME significantly increased sFlt-1 serum levels independent of O2 levels ( P = .032, L-NAME treatment, P = .991 O2 levels). Chronic hypoxia significantly decreases the circulating levels of PlGF ( P < .001) independent of L-NAME treatment. The sFV ratio was neither altered by hypoxia nor by L-NAME infusion. In contrast, the sFP ratio was significantly increased by both L-NAME ( P < .001) and severe hypoxia ( P < .001), but the effect was not synergistic ( P = .655). Conclusion Chronic NO inhibition as well as hypoxia induce fetal growth restriction and significantly change maternal circulating levels of sFlt-1 and PlGF, but not of VEGF. The primary effect of chronic hypoxia is in decreasing circulating levels of PlGF that contrasts with that of NO inhibition, which selectively increases sFlt-1 levels. Their effect is thus not synergistic, suggesting independent pathways.
This study aimed to synthesize the qualitative literature on parental experiences of fetal care to reflect events that happened across the continuum of care and to better understand parents’ positive ...and negative experiences with care delivery.
Eligible studies published until June 2020 were retrieved from MEDLINE, Embase, Cochrane Central Register of Controlled Trials, EBSCO CINAHL, Web of Science, and ProQuest.
Studies must have been: (1) published in English in a peer-reviewed journal or in ProQuest, (2) available in full text, (3) contained a qualitative component, and (4) focused on expectant parents’ experiences of tertiary, coordinated, multidisciplinary prenatal diagnosis and care related to a fetal anomaly.
Researchers used the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. A metastudy and an interpretive description approach was taken to synthesize the events that happened across the continuum of care and the themes associated with a positive care experience.
The metasynthesis included 13 studies and 217 patients from 11 different multidisciplinary fetal diagnosis and intervention practices across North America and Europe. We identified key events that influenced parental experience of fetal care across the continuum. The themes associated with a positive care experience are parents (1) gaining understanding and feeling understood, (2) realizing agency and control, and (3) finding hope and meaning. We identified aspects of healthcare delivery that served as barriers or facilitators to these positive experiences.
Understanding the commonalities of the parental experience of fetal care across diverse settings creates a foundation for improving care and better meeting the needs of parents undergoing a painful and life-defining event. Although health outcomes are not always positive, a positive experience of care is possible and can assist parents to cope with their grief, manage their expectations, and engage in their care. The findings of this study illustrate the ways in which healthcare delivery can facilitate or obstruct a positive care experience.
The only definitive treatment for twin-to-twin transfusion syndrome is minimally invasive fetoscopic surgery for the selective coagulation of placental blood vessels. Fetoscopic surgery is a ...technically challenging operation, mainly due to the poor visibility conditions in the uterine environment. We present the design of an algorithm for the computerized enhancement of fetoscopic video and show that the enhanced video increases the ability of human users to identify blood vessels within fetoscopic video rapidly and accurately.
A computer algorithm for the enhancement of fetoscopic video frames was created. First, optical fiber artifacts were removed via a modification of unsharp masking. Second, image contrast was increased via Contrast Limited Adaptive Histogram Equalization (CLAHE). Third, the effect of contrast enhancements on stationary features was removed by normalizing to a windowed mean of the video frames. Fourth, color information was reincorporated by combining the mean-normalized result with the unnormalized contrast enhanced image using the soft light blending algorithm. Medical trainees (n = 16) were recruited into a study to validate the algorithm. Subjects were shown enhanced or unenhanced fetoscopic video frames on a screen and were asked to identify whether a randomly placed marker fell on a blood vessel or on background. The accuracy of their responses was recorded.
On the subset of images where subjects had the lowest mean accuracy in identifying the placement of the marker, subjects performed better when viewing video frames enhanced by the computer (accuracy 74.27%; SE 0.97) than when viewing unenhanced video frames (accuracy 63.78%; SE 2.79). This result was statistically significant (p < 0.01).
Real-time computerized enhancement of fetoscopic video has the potential to ease the readability of video in poor lighting conditions, thus providing a benefit to the surgeon intraoperatively.
PDF
