Publications
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Hafiz N, Allison BJ, Itani N, et al., 2020, Impaired Autonomic Control of Heart Rate Variability During Acute Stress in the Chronically Hypoxic Fetus., 67th Annual Scientific Meeting of the Society-for-Reproductive-Investigation (SRI), Publisher: SPRINGER HEIDELBERG, Pages: 322A-322A, ISSN: 1933-7191
Dall'Asta A, Girardelli S, Usman S, et al., 2020, Etiology and perinatal outcome in periviable fetal growth restriction associated with structural or genetic anomalies, Ultrasound in Obstetrics and Gynecology, Vol: 55, Pages: 368-374, ISSN: 0960-7692
OBJECTIVE: To investigate the aetiology and the perinatal outcome of fetuses diagnosed with periviable fetal growth restriction (FGR) associated with structural defects or genetic anomalies. METHODS: Retrospective study conducted at a referral Fetal Medicine unit. Singleton pregnancies seen between 2005 and 2018 in which FGR, defined by fetal abdominal circumference ≤3rd percentile for the gestational age, was diagnosed between 22+0 -25+6 weeks of gestation were enrolled. The study group included periviable FGR associated with genetic or structural anomalies ("anomalous FGR"), while the control group consisted in structurally and genetically normal FGR ("non-anomalous FGR"). The results of the genetic tests, of the TORCH screening and of the post-mortem examination as well as the perinatal outcomes were investigated. RESULTS: Of 255 cases, 188 fetuses were eligible, of whom 52 (28%) were anomalous FGR and 136 (72%) non-anomalous FGR. Confirmed genetic abnormalities accounted for 17/52 cases (33%) of anomalous FGR, with trisomy 18 constituting over 50% (9/17, 53%). The most common structural defects associated with FGR were CNS abnormalities (13/35, 37%). Overall, 12 cases survived the neonatal period. No differences were found in terms of perinatal survival between anomalous and non-anomalous FGR. CONCLUSIONS: Of anomalous FGR, most are associated with structural defects. The association of structural abnormality with a genetic defect and FGR at periviable gestation was invariably lethal, while the combination of periviable FGR and structural defect in the absence of a confirmed genetic abnormality was associated with survival into infancy in four out of five cases, with an overall chance of perinatal survival of one in three. These data can be used for the counselling of the prospective parents. This article is protected by copyright. All rights reserved.
Ganzevoort W, Thornton JG, Marlow N, et al., 2020, Comparative analysis of 2‐year outcomes in GRIT and TRUFFLE trials, Ultrasound in Obstetrics and Gynecology, Vol: 55, Pages: 68-74, ISSN: 0960-7692
OBJECTIVE: To explore the influence on perinatal outcome of different fetal monitoring strategies for preterm fetal growth restriction (FGR). DESIGN: Cohort analysis of individual participant data from the Growth Restriction Intervention Study (GRIT) and Trial of Umbilical and Fetal Flow in Europe (TRUFFLE) studies. SETTING: European multi-centre trials. POPULATION: All women from GRIT (n=238) and TRUFFLE (n=503), randomized between 26 and 32 weeks. METHODS: Women were categorized according to their monitoring-intervention method: A. immediate delivery (from GRIT), B. delayed delivery using conventional cardiotocography (CTG, from GRIT), C. delayed delivery using computerized CTG only (cCTG, from GRIT), D delayed delivery using cCTG only (from TRUFFLE) and E. delayed delivery using cCTG and ductus venosus (DV) Doppler (from TRUFFLE). PRIMARY OUTCOME MEASURE: Survival without impairment at two years. RESULTS: Gestational age at delivery and birth weight were similar in both studies. Fetal death rate was similar between GRIT and TRUFFLE, but neonatal and late death were more frequent in GRIT (18% vs. 6%; p<0.01). The primary outcome was least common in groups A (70%; 95% confidence interval [CI] 61-78), and B (69%; 95% CI 57-82), and increased with more advanced monitoring in C (80%; 95% CI 68-91) and D (77%; 95% CI 70-84) and was highest in E (84%; 95% CI 80-89); (p trend <0.01). CONCLUSIONS: This analysis supports that fetal monitoring for early FGR can best be performed by the combination of cCTG and DV Doppler assessment. TRIAL REGISTRATION: GRIT ISRCTN41358726 and TRUFFLE ISRCTN56204499.
MylreaFoley B, Shaw CJ, Harikumar N, et al., 2019, Early‐onset twin–twin transfusion syndrome: case series and systematic review, Australasian Journal of Ultrasound in Medicine, Vol: 22, Pages: 286-294, ISSN: 1836-6864
IntroductionData on the outcomes of early‐onset twin–twin transfusion syndrome (TTTS), diagnosed before 18 weeks gestational age (GA), are sparse. We aimed to review the diagnosis, management and outcomes of early‐onset TTTS.Material and methodsPregnancy records at a single referral unit 2010‐6 were reviewed. In early‐onset TTTS cases, data for pregnancy characteristics, interventions and outcomes were collected. PubMed and Scopus databases were searched for studies including pregnant women with early‐onset TTTS. The primary outcome measure was livebirths.ResultsCase series: 58 cases of early‐onset TTTS 2010‐6, with full outcome data in 44. Diagnostic criteria were variable. Median GA at intervention was 17+4 (range 15+0‐28+1); 67% of patients had laser therapy (39/58). Overall survival: 60% (53/88). At least one livebirth: 86% (38/44), Two livebirths: 34% (15/44); No survivors: 14% (6/44). GA at delivery was 32+1.5 (range 16+2‐37+4). Systematic review: 16 studies included (n = 171 pregnancies). Diagnostic criteria varied widely: 79% of studies used Quintero staging. Most offered laser (89%) at median 17+0 weeks (range 16+0‐21+6). GA at delivery was 23+0‐39+5 weeks. Overall survival: 69% (129/186). At least one livebirth: 74% (127/171). Two livebirths: 59% (55/93). No survivors: 26% (44/171).ConclusionsIn comparison with the commonly accepted overall survival for TTTS treated after 18 weeks of 60–90%, outcomes in early‐onset TTTS were at the lower bound of this range. Gestational age at intervention is similar to that of later onset TTTS, indicating a lack of therapeutic options when a diagnosis is made before 18 weeks.
Bourne T, Shah H, Falconieri N, et al., 2019, Burnout, well-being and defensive medical practice among obstetricians and gynaecologists in the UK: cross-sectional survey study, BMJ Open, Vol: 9, ISSN: 2044-6055
Objectives: To determine the prevalence of burnout in doctors practising obstetrics and gynaecology, and assess the association with defensive medical practice and self-reported wellbeing.Design: Nationwide online cross-sectional survey study; December 2017-March 2018. Setting: Hospitals in the United KingdomParticipants: 5661 practising Obstetrics and Gynaecology consultants, specialty and associate specialist doctors and trainees registered with the Royal College of Obstetricians and Gynaecologists Primary and Secondary Outcome Measures: Prevalence of burnout using the Maslach Burnout Inventory and defensive medical practice (avoiding cases or procedures, overprescribing, over-referral) using a 12-item questionnaire. The odds ratios of burnout with defensive medical practice and self-reported wellbeing.Results: 3102/5661 doctors (55%) completed the survey. 3073/3102 (99%) met the inclusion criteria (1462 consultants, 1357 trainees and 254 specialty and associate specialist doctors). 1116/3073 (36%) doctors met the burnout criteria, with levels highest amongst trainees (580/1357 [43%]). 258/1116 (23%) doctors with burnout reported increased defensive practice compared to 142/1957 (7%) without (adjusted odds ratio 4.35, 95% CI 3.46 to 5.49). Odds ratios of burnout with wellbeing items varied between 1.38 and 6.37, and were highest for anxiety (3.59, 95% CI 3.07 to 4.21), depression (4.05, 95% CI 3.26 to 5.04), and suicidal thoughts (6.37, 95% CI 95% CI 3.95 to 10.7). In multivariable logistic regression, being of younger age, white or ‘other’ ethnicity, and graduating with a medical degree from the UK or Ireland had the strongest associations with burnout.Conclusions: High levels of burnout were observed in obstetricians and gynaecologists and particularly amongst trainees. Burnout was associated with both increased defensive medical practice and worse doctor wellbeing. These findings have implications for the wellbeing and retention of doctors as well a
Stephens K, Al-Memar M, Beattie-Jones S, et al., 2019, Comparing the relationship between ultrasound-estimated fetal weight and birthweight in cohort of small for gestational age fetuses, Acta Obstetricia et Gynecologica Scandinavica, Vol: 98, Pages: 1435-1441, ISSN: 1600-0412
IntroductionSmall‐for‐gestational‐age (SGA) confers a higher perinatal risk of adverse outcomes. Birthweight cannot be accurately measured until delivery, therefore accurate estimated fetal weight (EFW) based on ultrasonography is important in identifying this high‐risk population. We aimed to establish the sensitivity of detecting SGA infants antenatally in a unit with a selective third‐trimester ultrasound policy and to investigate the association between EFW and birthweight in these babies.Material and methodsA retrospective cohort study was conducted on non‐anomalous singleton pregnancies delivered after 36 weeks of gestation where SGA (<10th percentile) was diagnosed at delivery. The EFW at the time of the third‐trimester ultrasound scan was recorded using standard Hadlock formulae.ResultsIn 2017, there were 8392 non‐anomalous singleton pregnancies live born after 36 weeks, excluding late bookers. 797 were live‐born SGA <10th percentile for birthweight and 464 <5th percentile, who met our inclusion criteria. The antenatal detection rate of SGA was 19.6% for babies with birthweight <10th percentile and 24.1% <5th percentile. There was a significant correlation between the EFW and birthweight of fetuses undergoing ultrasound assessment within 2 weeks of delivery (P < .001, r = 0.73 (Pearson correlation). For these cases, EFW was greater than the birthweight in 65% of cases. After adjusting all EFWs using the discrepancy between EFW and actual birthweight for those babies born within 48 hours of the scan, the mean difference between the birthweight and adjusted EFW 7 days before delivery was 111 g (95% CI 87‐136 g) and at 14 days was 200 g (95% CI 153‐248 g). Despite adjusting the EFW, 61/213 cases (28.6%) apparently lost weight between the ultrasound scan and delivery.ConclusionsSmall‐for‐gestational‐age infants with a birthweight <10th percentile are poorly identified antenatally with little improvement for those <5th percentile. In SGA b
Kahrs BH, Usman S, Ghi T, et al., 2019, Descent of fetal head during active pushing: secondary analysis of prospective cohort study investigating ultrasound examination before operative vaginal delivery, Ultrasound in Obstetrics and Gynecology, Vol: 54, Pages: 524-529, ISSN: 0960-7692
OBJECTIVES: To investigate if descent of the fetal head during active pushing was associated with duration of operative vaginal delivery, delivery mode and neonatal outcome in nulliparous women with prolonged second stage of labor. METHODS: We conducted a prospective cohort study between November 2013 and July 2016 in five European countries. Fetal head descent was measured with transperineal ultrasound. Head-perineum distance (HPD) was measured between contractions and at maximum contraction during active pushing, and the difference was calculated as delta-HPD. The main outcome was duration of operative vaginal delivery estimated with survival analyses as hazard rations (HRs) for a vaginal delivery, and values >1 show shorter duration. We differentiated delta-HPD into quartiles and compared delivery mode and neonatal outcome between groups. RESULTS: The study population comprised 204 women. Duration of vacuum extraction was shorter with increasing delta-HPD. Estimated mean duration was 10.0, 9.0, 8.8 and 7.5 minutes in quartile 1-4, and the adjusted hazard ratio for vaginal delivery using increasing delta-HPD as continuous variable was 1.04 (95% CI 1.01-1.08). Mean delta-HPD was 7 mm (-10 to 37). Delta-HPD was either negative or ≤2 mm in the lowest quartile. Overall, 7/50 (14%) were delivered with cesarean section in this group compared to 8/154 (5%) if delta-HPD was >2 mm (p <0.05). There was no significant association between umbilical artery pH or Apgar score <7 and delta-HPD groups. CONCLUSION: Lack of fetal head descent during active pushing was associated with longer duration of operative vaginal delivery and higher frequency of cesarean section.
Santhirakumaran S, Tay J, Lees C, 2019, The relationship between maternal characteristics and carotid intima-media thickness using an automated ultrasound technique, Hypertension in Pregnancy, Vol: 38, Pages: 252-259, ISSN: 1064-1955
Objective: To investigate CIMT and its relationship with maternal demographic characteristics in healthy pregnancy. Methods: CIMT was measured using an au. Results: CIMT showed no relationship with gestational age (rho=−0.124, p=0.335), parity (Z=−0.055, p=0.960) and MAP (rho=0.110, p=0.393). A relationship was found between CIMT and maternal age (rho=0.277, p=0.028), booking BMI (rho=0.278, p=0.027), and BMI at time of study (rho=0.287, p=0.023). CIMT ranged from 0.30-0.80mm, the 97.5th percentile was 0.63 mm. Conclusion: In healthy pregnancy, we reported CIMT was related to BMI and maternal age but not parity or gestational age.
Galjaard S, Ameye L, Lees CC, et al., 2019, Sex differences in fetal growth and immediate birth outcomes in a low-risk Caucasian population, Biology of Sex Differences, Vol: 10, ISSN: 2042-6410
BackgroundAccording to the WHO Multicentre Growth Reference Study Group recommendations, boys and girls have different growth trajectories after birth. Our aim was to develop gender-specific fetal growth curves in a low-risk population and to compare immediate birth outcomes.MethodsFirst, second, and third trimester fetal ultrasound examinations were conducted between 2002 and 2012. The data was selected using the following criteria: routine examinations in uncomplicated singleton pregnancies, Caucasian ethnicity, and confirmation of gestational age by a crown-rump length (CRL) measurement in the first trimester. Generalized Additive Model for Location, Scale and Shape (GAMLSS) was used to align the time frames of the longitudinal fetal measurements, corresponding with the methods of the postnatal growth curves of the WHO MGRS Group.ResultsA total of 27,680 complete scans were selected from the astraia© ultrasound database representing 12,368 pregnancies. Gender-specific fetal growth curves for biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) were derived. The HC and BPD were significantly larger in boys compared to girls from 20 weeks of gestation onwards (p < 0.001) equating to a 3-day difference at 20–24 weeks. Boys were significantly heavier, longer, and had greater head circumference than girls (p < 0.001) at birth. The Apgar score at 1 min (p = 0.01) and arterial cord pH (p < 0.001) were lower in boys.ConclusionsThese longitudinal fetal growth curves for the first time allow integration with neonatal and pediatric WHO gender-specific growth curves. Boys exceed head growth halfway of the pregnancy, and immediate birth outcomes are worse in boys than girls. Gender difference in intrauterine growth is sufficiently distinct to have a clinically important effect on fetal weight estimation but also on the second trimester d
Regan F, Lees CC, Jones B, et al., 2019, Prenatal management of pregnancies at risk of fetal neonatal alloimmune thrombocytopenia (FNAIT) scientific impact paper No. 61, BJOG: an International Journal of Obstetrics and Gynaecology, Vol: 126, Pages: E173-E185, ISSN: 1470-0328
What is it?Fetal neonatal alloimmune thrombocytopenia (FNAIT), also known as neonatal alloimmune thrombocytopenia (NAIT) or fetomaternal alloimmune thrombocytopenia (FMAIT), is a rare condition which affects a baby's platelets. This can put them at risk of problems with bleeding, particularly into the brain. One baby per week in the UK may be seriously affected and milder forms can affect one in every 1000 births.How is it caused?Platelets are blood cells that are very important in helping blood to clot. All platelets have natural proteins on their surface called human platelet antigens (HPAs). In babies, half of these antigens are inherited from the mother and half from the father. During pregnancy, some of the baby's platelets can cross into the mother's bloodstream. In most cases, this does not cause a problem. But in cases of FNAIT, the mother's immune system does not recognise the baby's HPAs that were inherited from the father and develops antibodies, which can cross the placenta and attack the baby's platelets. These antibodies are called anti‐HPAs, and the commonest antibody implicated is anti‐HPA‐1a, but there are other rarer antibody types. If this happens, the baby's platelets may be destroyed causing their platelet count to fall dangerously low. If the platelet count is very low there is a risk to the baby of bleeding into their brain before they are born. This is very rare but if it happens it can have serious effects on the baby's health.How is it inherited?A baby inherits half of their HPAs from its mother and half from its father. Consequently, a baby may have different HPAs from its mother. As the condition is very rare, and even if the baby is at risk of the condition we have no way of knowing how severely they will be affected, routine screening is not currently recommended.What can be done?FNAIT is usually diagnosed if a previous baby has had a low platelet count. The parents are offered blood tests and the condition can be confirmed or ruled out
Tay J, Lees C, 2019, RE: Tay et al, Uterine and fetal placental Doppler indices are associated with maternal cardiovascular function, American Journal of Obstetrics and Gynecology, Vol: 221, Pages: 291-292, ISSN: 0002-9378
Wilkinson M, Usman S, Barton H, et al., 2019, The views of pregnant women, midwives, and a women's panel on intrapartum ultrasound research: A pilot study, Australasian Journal of Ultrasound in Medicine, Vol: 22, Pages: 186-190, ISSN: 1836-6864
BackgroundUltrasound is increasingly used in labour; however, little data exist on attitudes to its use. We sought to analyse and compare the views of pregnant women, midwives, and a women's panel on the value and use of ultrasound in labour.MethodsFocus groups involving a short presentation on ultrasound, questionnaire, and a question and answer session were held with groups of pregnant women, midwives at 2 inner‐city maternity units, and a RCOG online Women's Panel. Data were collected on attitudes to vaginal examination, ultrasound, predicting Caesarean section, and the utility of a digital representation of labour.ResultsTwenty one midwives and 29 service users (19 pregnant women and 10 women's panel members) participated. Significantly more service users saw positive value in intrapartum ultrasound (P = 0.0005) and predicting Caesarean section (P = 0.03) than midwives. The majority of both groups – 72% (20/29) and 62% (13/21), respectively – thought women would want a digital representation of their labour, with the most popular format being on a mobile phone (56%, 20/36).ConclusionsService users were most and midwives least positive about ultrasound versus vaginal examination, indicating divergence between midwives' perspective of women's need to understand risk and desire to know about their labour. Women found the non‐intrusive nature and accuracy of ultrasound valuable while midwives were concerned about de‐skilling and medicalisation of birth. All groups felt a graphical representation of labour on a device would be helpful.
Usman S, Kahrs BH, Wilhelm-Benartzi C, et al., 2019, Prediction of mode of delivery using the first ultrasound-based “intrapartum app”, American Journal of Obstetrics and Gynecology, Vol: 221, Pages: 163-166, ISSN: 0002-9378
Jaspal R, Prior T, Denton J, et al., 2019, The impact of cross-border IVF on maternal and neonatal outcomes in multiple pregnancies: Experience from a UK fetal medicine service, European Journal of Obstetrics and Gynecology and Reproductive Biology, Vol: 238, Pages: 63-67, ISSN: 0301-2115
Objectives: To determine whether women seeking NHS care for IVF multiple pregnancies were more likely to have sought IVF treatment overseas and whether this was associated with different maternal and neonatal outcomes. Study design: A single large tertiary centre, for perinatal care in northwest London. Sixty-five women were referred to our fetal medicine centre, between 2012–2016, with IVF conceived multiple pregnancies. Inclusion criteria: In Vitro fertilisation and conception of twins/ triplets/quadruplets. Exclusion criteria: Intra-uterine insemination, ovulation induction, Clomid-conception and singleton pregnancies. The primary outcome measure was the Country where IVF treatment was performed. The secondary outcomes measures included the specifics of IVF treatment (e.g. number of embryos transferred), subsequent pregnancy outcomes (e.g. live-births and prematurity) and neonatal outcomes (e.g. length and cost of care). Results and Conclusion: Thirty-eight women had IVF overseas; they were older and had more pre-existing medical conditions. Eleven pregnancies used donor embryos, of which ten were from overseas treatment. 75% of women treated overseas conceived a triplet or higher order pregnancy compared to fewer than 10% of women who conceived in the UK. Almost half of all women treated overseas had more than two embryos transferred. Overseas IVF pregnancies had poorer obstetric and neonatal outcomes: 24% of live born babies died in the neonatal period compared to 0% in the UK group. The average neonatal costs per baby born from overseas IVF were £20, 600: two-and-a-half times higher than for those whose mothers conceived in the UK. Higher order multiple pregnancies are greatly over-represented by those undergoing IVF in overseas clinics. These are associated with poorer obstetric and neonatal outcomes. Perhaps paradoxically, improving NHS provision of fertility services might improve outcomes for the mother and babies while reducing the long-term b
Bijl RC, Valensise H, Novelli GP, et al., 2019, Methods and considerations concerning cardiac output measurement in pregnant women: recommendations of the International Working Group on Maternal Hemodynamics, Ultrasound in Obstetrics and Gynecology, Vol: 54, Pages: 35-50, ISSN: 0960-7692
Cardiac output (CO), along with blood pressure and vascular resistance, is one of the most important parameters of maternal hemodynamic function. Substantial changes in CO occur in normal pregnancy and in most obstetric complications. With the development of several non‐invasive techniques for the measurement of CO, there is a growing interest in the determination of this parameter in pregnancy. These techniques were initially developed for use in critical‐care settings and were subsequently adopted in obstetrics, often without appropriate validation for use in pregnancy. In this article, methods and devices for the measurement of CO are described and compared, and recommendations are formulated for their use in pregnancy, with the aim of standardizing the assessment of CO and peripheral vascular resistance in clinical practice and research studies on maternal hemodynamics.
Bourne T, Shah H, Falconieri N, et al., 2019, Investigating burnout, wellbeing and defensive medical practice among obstetricians and gynaecologists in the United Kingdom, RCOG World Congress 2019, Publisher: WILEY, Pages: 121-122, ISSN: 1470-0328
Paramasivam G, Kumar S, Sanna E, et al., 2019, Selective reduction in complex triplet pregnancy by radiofrequency ablation: single-centre experience, RCOG world congress 2019, Publisher: WILEY, Pages: 52-53, ISSN: 1470-0328
Usman S, Barton H, Wilhelm-Benartzi C, et al., 2019, Ultrasound is better tolerated than vaginal examination in and before labour, Australian and New Zealand Journal of Obstetrics and Gynaecology, Vol: 59, Pages: 362-366, ISSN: 0004-8666
BACKGROUND: Intrapartum ultrasound has been proposed as a method of assessing labour progress but its acceptability has not been comprehensively assessed. AIMS: We evaluated the acceptability of intrapartum ultrasound in women having vaginal examination (VE) and ultrasound (US) assessment (transabdominal (TA) and transperineal (TP)) prior to delivery, with and without regional analgesia (RA). MATERIALS AND METHODS: Women at 24-42 weeks gestation were included in a prospective observational cohort study. The acceptability of digital VE and TP US were assessed pre- and post-examination using the modified validated Wijma Delivery Experience Questionnaire. Acceptability scores ranged 6-36 (6 being most and 36 being least positive) in six domains: positive-trust and relax, negative-harmful to baby, worrying, painful, intrusive. RESULTS: Of 119 women recruited, 104 completed both pre- and post-assessment questionnaires. Eighty-nine per cent of women were nulliparous with median gestation 40 + 2 weeks (25-42+1 ). Thirty-two per cent had RA before assessment, 91% in total. The combined acceptability scores of both negative and positive experiences (6 = most acceptable, 36 = least acceptable) for VE and US pre-assessment were 15 and 7 respectively (P < 0.0001: Mann-Whitney U-test). VE was associated with less positive / more negative domain scoring post-assessment 12 and 6, respectively (P < 0.0001). Although RA made no difference to the perceived experience pre-VE (P = 0.9), post-VE, women with RAs considered VEs more acceptable than those without RA (P = 0.0022). CONCLUSION(S): This is the first study to comprehensively assess the acceptability of VE and intrapartum US. US assessment prior to delivery is more acceptable than VE. RA ameliorated the negative experience of the VE post-assessment.
Cali G, Forlani F, Lees C, et al., 2019, Proposal for ultrasound staging of placenta accreta spectrum disorders, Ultrasound in Obstetrics and Gynecology, Vol: 53, Pages: 752-760, ISSN: 0960-7692
OBJECTIVE: To develop an ultrasound (US) staging system for placenta accreta spectrum disorders (PAS) and to ascertain whether it may stratify the risk of surgical outcome before birth. METHODS: Secondary retrospective analysis of a prospective collected data on women with placenta previa. We propose the following classification of PAS based upon the distribution of the different ultrasound signs in women with placenta previa: PAS0: Placenta previa with no US signs of invasion or placenta previa with placental lacunae but no evidence of abnormal uterine-bladder interface PAS1: Presence of at least two ultrasound signs among: placental lacunae, loss of the clear zone or bladder wall interruption. PAS2: PAS1 + uterovescical hypervascularity PAS3: PAS1/PAS2 + evidence of increased vascularity in the inferior part of the lower uterine segment potentially extending in the parametrial region. We explored whether this ultrasound staging system was correlated with surgical outcomes [estimated blood loss (EBL, ml), units of packed red blood cells (PRBC), fresh frozen plasma (FFP) and platelets (PLT) transfused, operative times (minutes), surgical complications, defined as the occurrence to any damage in either bladder, ureters or bowel, length of in hospital stay (days) and admission to intensive care unit (ICU)], and depth of placental invasion. Finally, we assessed the correlation between the present ultrasound staging and the clinical grading system proposed by the International Federation of Gynaecology and Obstetrics (FIGO). Prenatal and surgical management were not based on such prenatal ultrasound staging of PAS disorders. Linear and multiple regression models were used to analyse the data. RESULTS: Two-hundred and fifty-nine women were included in the analysis. Mean EBL was 516±151 ml in women with PAS0, 609±146 in PAS1, 950±190 in PAS2 and 1323±53 in PAS3 and significantly increased with increasing severity of ultrasound PAS staging. Mean
Sanna E, Loukogeorgakis S, Prior T, et al., 2019, Fetal abdominal cysts: antenatal course and postnatal outcomes, Journal of Perinatal Medicine, Vol: 47, Pages: 418-421, ISSN: 0300-5577
Background There is little information on which to base the prognostic counselling as to whether an antenatally diagnosed fetal abdominal cyst will grow or shrink, or need surgery. This study aims to provide contemporary data on prenatally diagnosed fetal abdominal cysts in relation to their course and postnatal outcomes. Methods Fetal abdominal cysts diagnosed over 11 years in a single centre were identified. The gestational age at diagnosis and cyst characteristics at each examination were recorded (size, location, echogenity, septation and vascularity) and follow-up data from postnatal visits were collected. Results Eighty abdominal cysts were identified antenatally at 28+4 weeks (range 11+0-38+3). Most (87%) were isolated and the majority were pelvic (52%), simple (87.5%) and avascular (100%). Antenatally, 29% resolved spontaneously; 29% reduced in size; 9% were stable and 33% increased in size. Forty-one percent of cysts under 20 mm diameter increased in size, while only 20% of cysts with a diameter of over 40 mm increased in size. The majority of cysts were ovarian in origin (n=45, 56%), followed by intestinal (n=15, 18%), choledochal (n=3, 4%), liver (n=2, 3%) and renal/adrenal origins (n=2, 3%), respectively. In 16% (n=13), the antenatal diagnosis was not obvious. Seventy-five percent of the cysts that persisted postnatally required surgical intervention. Conclusions Most antenatally diagnosed fetal abdominal cysts were ovarian in origin. Though most disappeared antenatally, nearly three quarters required surgical intervention when present after birth. Cysts of intestinal origin are more difficult to diagnose antenatally and often require surgery.
Shaw CJ, Rivens I, Civale J, et al., 2019, Maternal and fetal cardiometabolic recovery following ultrasound-guided high-intensity focused ultrasound placental vascular occlusion, Journal of the Royal Society Interface, Vol: 16, ISSN: 1742-5662
High-intensity focused ultrasound (HIFU) is a non-invasive method of selective placental vascular occlusion, providing a potential therapy for conditions such as twin-twin transfusion syndrome. In order to translate this technique into human studies, evidence of prolonged fetal recovery and maintenance of a healthy fetal physiology following exposure to HIFU is essential. At 116 ± 2 days gestation, 12 pregnant ewes were assigned to control ( n = 6) or HIFU vascular occlusion ( n = 6) groups and anaesthetized. Placental blood vessels were identified using colour Doppler ultrasound; HIFU-mediated vascular occlusion was performed through intact maternal skin (1.66 MHz, 5 s duration, in situ ISPTA 1.8-3.9 kW cm-2). Unidentifiable colour Doppler signals in targeted vessels following HIFU exposure denoted successful occlusion. Ewes and fetuses were then surgically instrumented with vascular catheters and transonic flow probes and recovered from anaesthesia. A custom-made wireless data acquisition system, which records continuous maternal and fetal cardiovascular data, and daily blood sampling were used to assess wellbeing for 20 days, followed by post-mortem examination. Based on a comparison of pre- and post-treatment colour Doppler imaging, 100% (36/36) of placental vessels were occluded following HIFU, and occlusion persisted for 20 days. All fetuses survived. No differences in maternal or fetal blood pressure, heart rate, heart rate variability, metabolic status or oxygenation were observed between treatment groups. There was evidence of normal fetal maturation and no evidence of chronic fetal stress. There were no maternal injuries and no placental vascular haemorrhage. There was both a uterine and fetal burn, which did not result in any obstetric or fetal complications. This study demonstrates normal long-term recovery of fetal sheep from exposure to HIFU-mediated placental vascular occlusion and underlines the potential of HIFU as a potential non-invasive th
Dall'Asta A, Paramasivam G, Lees C, et al., 2019, The brain shadowing sign: a clue finding for early suspicion of craniosynostosis?, Fetal Diagnosis and Therapy, Vol: 45, Pages: 357-360, ISSN: 1015-3837
Antenatal imaging of craniosynostosis mainly relies on the demonstration with 2D ultrasound of the abnormal contour of the calvarium and of the loss of hypoechogenicity of the synostotic sutures and on indirect signs of premature closure of the skull sutures; however, isolated craniosynostosis is detected only sporadically at prenatal ultrasound. In this article, we present the first case to our knowledge in which the "brain shadowing sign," a recently described indirect sign of craniosynostosis, noted at 24 weeks in a structurally normal fetus, was the first clue for the diagnosis of isolated bilateral coronal craniosynostosis, which became evident at late gestation.
Usman S, Kahrs B, Barton H, et al., 2019, Time to delivery based on sonographic assessment prior to forceps and vacuum, Australasian Journal of Ultrasound in Medicine, Vol: 22, Pages: 111-117, ISSN: 1836-6864
IntroductionTo compare the duration of vacuum and forceps delivery in relation to ultrasound assessment of fetal head position and station.MethodsA prospective single‐centre cohort study in nulliparous women at term with prolonged second stage of labour. Fetal head position was determined using transabdominal ultrasound and station as head‐perineum distance (HPD) from transperineal ultrasound prior to an instrument. The primary outcome was duration of vacuum and forceps to vaginal delivery and was analysed as survival expressed by hazard ratio (HR). Secondary outcomes were delivery mode and immediate neonatal outcome.ResultsIn the study population of 54 women, the primary instrument was vacuum for 36 and forceps for 18. Four women were delivered by Caesarean section. Estimated median duration for forceps deliveries was 5 min (95% CI 4.0–6.0) vs. 9 min (95% CI 7.3–10.6) for vacuum deliveries (P = 0.17; Log‐rank test). The HR for vaginal delivery was 2.02 (95% CI 1.04–3.91, P = 0.038) after adjusting for HPD, maternal age and BMI. OP position had minor influence on the primary outcome (HR changed from 2.02 to 2.08). The first instrument failed in 11/31 (35.5%) where HPD > 35 mm vs. 2/21 (9.5%) where HPD ≤ 35 mm (P < 0.05). There were no cases of Apgar score <7 at 5 min or umbilical artery pH < 7.1.ConclusionIn prolonged second stage, delivery with forceps was achieved more quickly than by vacuum when matched for ultrasound determined head station. Irrespective of which was the primary instrument, the failure rate was greater at higher head stations.
Masini G, Foo LF, Cornette J, et al., 2019, Cardiac output changes from prior to pregnancy to post partum using two non-invasive techniques, Heart, Vol: 105, Pages: 715-720, ISSN: 1355-6037
OBJECTIVES: We aimed to describe cardiac output (CO) trend from prepregnancy to post partum using an inert gas rebreathing (IGR) device and compare these measurements with those obtained by a pulse waveform analysis (PWA) technique, both cross-sectionally and longitudinally. METHODS: Non-smoking healthy women, aged 18-44 years, with body mass index <35 were included in this prospective observational study. CO measurements were collected at different time points (prepregnancy, at four different gestational epochs and post partum) using IGR and PWA. A linear mixed model analysis tested whether the longitudinal change in CO differed between the techniques. Bland-Altman analysis and intraclass correlation coefficient (ICC) were used for cross-sectional and a four-quadrant plot for longitudinal comparisons. RESULTS: Of the 413 participants, 69 had a complete longitudinal assessment throughout pregnancy. In this latter cohort, the maximum CO rise was seen at 15.2 weeks with IGR (+17.5% from prepregnancy) and at 10.4 weeks with PWA (+7.7% from prepregnancy). Trends differed significantly (p=0.0093). Cross-sectional analysis was performed in the whole population of 413 women: the mean CO was 6.14 L/min and 6.38 L/min for PWA and IGR, respectively, the percentage of error was 46% and the ICC was 0.348, with similar results at all separate time points. Longitudinal concordance was 64%. CONCLUSIONS: Despite differences between devices, the maximum CO rise in healthy pregnancies is more modest and earlier than previously reported. The two methods of CO measurement do not agree closely and cannot be used interchangeably. Technique-specific reference ranges are needed before they can be applied in research and clinical settings.
Dall'Asta A, Paramasivam G, Shaw C, et al., 2019, EP.135 Surface vascular placental mapping with virtual endoscopy (sonofetoscopy): qualitative comparison of singleton and monochorionic twin pregnancies, British Maternal & Fetal Medicine Society (BMFMS) 21st Annual Conference 2019, Publisher: Wiley, Pages: 64-64, ISSN: 1470-0328
Dall'Asta A, Girardelli S, Usman S, et al., 2019, EP.137 Aetiology and short term outcome in periviable fetal growth restriction associated with structural and chromosomal abnormalities, British Maternal & Fetal Medicine Society (BMFMS) 21st Annual Conference 2019., Publisher: Wiley, Pages: 65-65, ISSN: 1470-0328
Vieira MC, Relph S, Copas A, et al., 2019, The DESiGN trial (DEtection of small for gestational age neonate), evaluating the effect of the Growth Assessment Protocol (GAP): study protocol for a randomised controlled trial, Trials, Vol: 20, ISSN: 1745-6215
BackgroundStillbirth rates in the United Kingdom (UK) are amongst the highest of all developed nations. The association between small-for-gestational-age (SGA) foetuses and stillbirth is well established, and observational studies suggest that improved antenatal detection of SGA babies may halve the stillbirth rate. The Growth Assessment Protocol (GAP) describes a complex intervention that includes risk assessment for SGA and screening using customised fundal-height growth charts. Increased detection of SGA from the use of GAP has been implicated in the reduction of stillbirth rates by 22%, in observational studies of UK regions where GAP uptake was high. This study will be the first randomised controlled trial examining the clinical efficacy, health economics and implementation of the GAP programme in the antenatal detection of SGA.Methods/designIn this randomised controlled trial, clusters comprising a maternity unit (or National Health Service Trust) were randomised to either implementation of the GAP programme, or standard care. The primary outcome is the rate of antenatal ultrasound detection of SGA in infants found to be SGA at birth by both population and customised standards, as this is recognised as being the group with highest risk for perinatal morbidity and mortality. Secondary outcomes include antenatal detection of SGA by population centiles, antenatal detection of SGA by customised centiles, short-term maternal and neonatal outcomes, resource use and economic consequences, and a process evaluation of GAP implementation. Qualitative interviews will be performed to assess facilitators and barriers to implementation of GAP.DiscussionThis study will be the first to provide data and outcomes from a randomised controlled trial investigating the potential difference between the GAP programme compared to standard care for antenatal ultrasound detection of SGA infants. Accurate information on the performance and service provision requirements of the GAP protoc
Dall'Asta A, Paramasivam G, Basheer SN, et al., 2019, How to obtain diagnostic planes of the fetal central nervous system using three-dimensional ultrasound and a context-preserving rendering technology, American Journal of Obstetrics and Gynecology, Vol: 220, Pages: 215-229, ISSN: 0002-9378
The antenatal evaluation of the fetal central nervous system (CNS) is among the most difficult tasks of prenatal ultrasound (US), requiring technical skills in relation to ultrasound and image acquisition as well as knowledge of CNS anatomy and how this changes with gestation. According to the International Guidelines for fetal neurosonology, the basic assessment of fetal CNS is most frequently performed on the axial planes, whereas the coronal and sagittal planes are required for the multiplanar evaluation of the CNS within the context of fetal neurosonology. It can be even more technically challenging to obtain “nonaxial” views with 2-dimensional (2D) US. The modality of 3-dimensional (3D) US has been suggested as a panacea to overcome the technical difficulties of achieving nonaxial views. The lack of familiarity of most sonologists with the use of 3D US and its related processing techniques may preclude its use even where it could play an important role in complementing antenatal 2D US assessment. Furthermore, once a 3D volume has been acquired, proprietary software allows it to be processed in different ways, leading to multiple ways of displaying and analyzing the same anatomical imaging or plane. These are difficult to learn and time consuming in the absence of specific training. In this article, we describe the key steps for volume acquisition of a 3D US volume, manipulation, and processing with reference to images of the fetal CNS, using a newly developed context-preserving rendering technique.
Ferrazzi E, Lees C, Acharya G, 2019, The controversial role of the Ductus Venosus in hypoxic human fetuses., Acta Obstet Gynecol Scand
The ductus venosus plays a critical role in circulatory adaptation to hypoxia in fetal growth restriction, but the mechanisms still remain controversial. Increased shunting of blood through the ductus venosus under hypoxic conditions has been shown in animal and human studies. The hemodynamic laws governing the accelerated flow in this vessel suggest that any dilatation at its isthmus, which increases the blood flow shunting to the heart, is associated with a low, absent or reversed a-wave, and a high pulsatility index. Cardiac dysfunction associated with increased atrial pressure as well as reduced ventricular compliance might be predominant mechanisms determining the profile of ductus venosus velocity waveforms in severe fetal growth restriction with signs of hypoxic compromise. Understanding the pathophysiology of the ductus venosus will underpin translation of the hypotheses developed through biostatistics towards explaining with more confidence Doppler changes in the fetal circulation in predicting clinical outcomes. This article is protected by copyright. All rights reserved.
Graupner O, Ortiz JU, Haller B, et al., 2019, Performance of computerized cardiotocography-based short-term variation in late-onset small-for-gestational-age fetuses and reference ranges for the late third trimester, ARCHIVES OF GYNECOLOGY AND OBSTETRICS, Vol: 299, Pages: 353-360, ISSN: 0932-0067
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