The importance of collaboration in maternal medicine: A retrospective descriptive study of a maternal multidisciplinary team meeting.

OBJECTIVE: In the present study we aimed to review the evolution and function of the maternal medicine multidisciplinary team (MMMDT) meeting of a maternal medicine service of a tertiary level stand-alone maternity hospital. METHODS: We conducted a retrospective descriptive study of all minutes of MMMDT meetings from 2014 to 2020, with the aim of evaluating meeting characteristics and patient demographics. RESULTS: There were 575 multidisciplinary team (MDT) discussions of 486 women during 43 meetings in the 7 year period. On average, 13 (range 3-23; SD = 5.28) women were discussed at each meeting, attended by 17 (range: 11-27; SD = 4.26) attendees. There were 18 women discussed during successive pregnancies. When analyzing the 2017-2020 data, preconceptual discussions made up 7.3% (n = 42) of patients discussed, with 5.7% (n = 33) being postnatal. The mean maternal age was 32.5 years (range 15-48 years) and women were most likely to be discussed in the mid-trimester period (21-24 weeks gestation). The top five primary specialities involved were hematology, neurology, rheumatology, neurosurgery and gastroenterology; however, 22 specialities were represented overall when classified by the primary medical condition. When examining the MDT input, hematology input was required in 144 patients (25.0%), radiology in 161 (28.0%) patients, and 117 in anesthesiology (20.3%). When examining the number of teams required to manage the patient, 80 women required the input of three specialities, with 16 women requiring the input of four specialities. CONCLUSION: We demonstrate the value and role of the MDT in the management of complex patients, providing a forum to discuss care in all phases of the obstetric journey.

Acute colonic pseudo-obstruction post-cesarean section is not a benign entity: A case series and review of the literature.

Acute colonic pseudo-obstruction (ACPO) is an infrequent occurrence after cesarean section. Anecdotal evidence suggests that the clinical course of ACPO in the obstetric setting is different to that seen in non-pregnant adult patients with ACPO secondary to alternative causes, such as systemic illnesses, the use of certain medications, and after non-abdominal surgery. The risk of progression to ischemia and perforation, as well as the need for emergency surgery, appears to be higher after cesarean section. Here we describe the clinical course of ACPO in four patients after cesarean section from our institution, followed by a review of the literature and a discussion of the important issues surrounding this condition in the postpartum time period. The findings from our cohort of patients and the reports from the medical literature support a hands-on combined approach from a group of specialists including obstetricians, surgeons, radiologists, and enterostomal therapists. Immediate imaging followed by regular observation is mandatory for any patient being managed conservatively. Early use of endoscopic decompression should be considered for patients who are not resolving with a conservative approach. Clinical signs of peritonism or radiological signs of ischemia or perforation in patients with ACPO mandate immediate surgical intervention. Appropriate postoperative care is necessary to deal with the complex physiological and psychological consequences of emergency surgery and potential stoma formation so soon after cesarean section.

Radiomics-based prediction of FIGO grade for placenta accreta spectrum.

BACKGROUND: Placenta accreta spectrum (PAS) is a rare, life-threatening complication of pregnancy. Predicting PAS severity is critical to individualise care planning for the birth. We aim to explore whether radiomic analysis of T2-weighted magnetic resonance imaging (MRI) can predict severe cases by distinguishing between histopathological subtypes antenatally. METHODS: This was a bi-centre retrospective analysis of a prospective cohort study conducted between 2018 and 2022. Women who underwent MRI during pregnancy and had histological confirmation of PAS were included. Radiomic features were extracted from T2-weighted images. Univariate regression and multivariate analyses were performed to build predictive models to differentiate between non-invasive (International Federation of Gynecology and Obstetrics [FIGO] grade 1 or 2) and invasive (FIGO grade 3) PAS using R software. Prediction performance was assessed based on several metrics including sensitivity, specificity, accuracy and area under the curve (AUC) at receiver operating characteristic analysis. RESULTS: Forty-one women met the inclusion criteria. At univariate analysis, 0.64 sensitivity (95% confidence interval [CI] 0.0-1.00), specificity 0.93 (0.38-1.0), 0.58 accuracy (0.37-0.78) and 0.77 AUC (0.56-.097) was achieved for predicting severe FIGO grade 3 PAS. Using a multivariate approach, a support vector machine model yielded 0.30 sensitivity (95% CI 0.18-1.0]), 0.74 specificity (0.38-1.00), 0.58 accuracy (0.40-0.82), and 0.53 AUC (0.40-0.85). CONCLUSION: Our results demonstrate a predictive potential of this machine learning pipeline for classifying severe PAS cases. RELEVANCE STATEMENT: This study demonstrates the potential use of radiomics from MR images to identify severe cases of placenta accreta spectrum antenatally. KEY POINTS: • Identifying severe cases of placenta accreta spectrum from imaging is challenging. • We present a methodological approach for radiomics-based prediction of placenta accreta. • We report certain radiomic features are able to predict severe PAS subtypes. • Identifying severe PAS subtypes ensures safe and individualised care planning for birth.

Use of an aortic balloon to achieve uterine conservation in a case of placenta accreta spectrum: A case report.

Placenta accreta spectrum (PAS) is a rare complication of pregnancy associated with a high risk of massive haemorrhage and caesarean hysterectomy. This is a case report of abdominal aortic balloon occlusion, using intravascular ultrasound, to achieve uterine conservation in a case of severe PAS. The patient was a 34-year-old woman, G2P1, with one prior caesarean section. Antenatal imaging, consisting of transabdominal and transvaginal ultrasound, and magnetic resonance imaging, showed features of PAS. The risk of caesarean hysterectomy with PAS was explained, but the patient declared a desire to retain fertility. Following multi-disciplinary discussion, it was considered appropriate to attempt uterine conservation using en-bloc myometrial and placental resection. An elective caesarean delivery was performed at 36 weeks of gestation. An aortic balloon was inserted prior to surgery using intravascular ultrasound, which allowed for radiation-free, point-of-surgery, accurate balloon sizing, by measuring the aortic diameter, and correct placement of the balloon in the abdominal aorta below the renal vessels. Intraoperative findings confirmed PAS, and a myometrial resection was performed. There were no intraoperative complications. Estimated blood loss was 1000 mL and the patient had an uncomplicated postoperative course. This case demonstrates how the use of an intravascular intraoperative aortic balloon can facilitate uterine conservation in a case of severe PAS.

MRI remains highly accurate in the diagnosis of appendicitis in pregnancy when read by radiologists of mixed specialty training and experience.

PURPOSE: To audit the accuracy of magnetic resonance imaging (MRI) abdominal studies performed in the diagnosis of appendicitis in pregnant patients when read by radiologists of mixed experience. METHODS: MRI reports from 45 pregnant women presenting to our emergency department for the investigation of appendicitis between 2009 and 2020 were retrospectively reviewed. Where available, these reports were correlated with surgical and pathology reports as well as follow-up clinical information. Following a review of literature, accuracy targets were set. Statistical analyses including sensitivity, specificity, positive, and negative predictive values were calculated. RESULTS: A total of 18 radiology consultants read 45 MRI abdominal studies in the assessment of appendicitis during pregnancy with 62% (n = 28) of these read by specialist radiologists and the remainder by general radiologists. This yielded an accuracy in diagnosis of 99.8%, sensitivity of 80% (95% CI: 49-94.3%), and specificity of 100% (95% CI: 90-100%). The calculated negative predictive value was 94.6% (95% CI: 82.3-98.5%), and positive predictive value was 100% (95% CI: 90-100%). The appendix was not identified in 19 patients (42%). A statistically significant relationship between the presence of right iliac fossa stranding of the fat OR free fluid was associated with appendicitis (p = 0.01). Alternate diagnoses were identified in 8% (n = 4) of cases. CONCLUSION: MRI is a highly accurate imaging modality for the assessment of appendicitis in pregnancy. Even with variable reader MRI experience, MRI demonstrates an accuracy of 99.8% and a positive predictive value for acute appendicitis of 100%. Double reading and the possible inclusion of DWI may help further improve accuracy and minimise false-negative rates.

MR imaging of acute abdominal pain in pregnancy.

Abdominal pain in pregnancy is a diagnostic challenge with many potential aetiologies. Diagnostic imaging is a valuable tool in the assessment of these patients, with ultrasound commonly employed first line. MRI is an excellent problem-solving adjunct to ultrasound and has many advantages in terms of improved spatial resolution and soft tissue characterisation. This pictorial review aims to outline the role of MRI in the work up of acute abdominal pain in pregnancy and provide imaging examples of pathologies which may be encountered.

Comparing three-dimensional models of placenta accreta spectrum with surgical findings.

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.

Natural growth pattern of sporadic renal angiomyolipoma.

BACKGROUND: Surveillance of sporadic renal angiomyolipomas is a growing issue for physicians and radiologists. Current treatment recommendations favor active surveillance. However, the evidence underlying these is based on small case series, which also typically include angiomyolipomas associated with tuberous sclerosis. PURPOSE: To evaluate the natural growth pattern of sporadic renal angiomyolipomas in patients without tuberous sclerosis. MATERIAL AND METHODS: A retrospective review was performed in three separate tertiary referral centers. A keyword search of each institutions PACS history was performed. Inclusion criteria were angiomyolipomas > 1 cm in size, three years of follow-up, and lesions requiring treatment before reaching three years of follow-up. Exclusion criteria included a diagnosis of tuberous sclerosis, pregnancy, prior treatment with embolization without any prior imaging, and lesions which were treated on presentation. Growth of the angiomyolipomas was evaluated on the basis of maximum dimension on initial and follow-up images. RESULTS: Sixty-three patients were identified in total, with 64 lesions eligible for inclusion. The majority of patients were women (55/63). The mean age at which the angiomyolipomas discovered was 56.4 years. Mean total growth was 0.085 mm and mean follow-up was 65.5 months. At initial measurement, the mean maximum dimension of the lesions in our cohort was 2.08 cm. After follow-up, this was 2.16 cm. The average rate of growth was 0.015 cm per year. CONCLUSION: Sporadic angiomyolipomas exhibit minimal, if any, natural growth. Current surveillance strategies could be relaxed.

Outcomes of Patients Treated With Upfront Cholecystostomy for Severe Acute Cholecystitis.

INTRODUCTION: Percutaneous cholecystostomy tube (PCT) placement is a treatment method for acute cholecystitis, both in adult patients unsuitable for surgery and those failing to improve with conservative management. The purpose of this study was to assess the outcomes of patients undergoing cholecystostomy. MATERIALS AND METHODS: A review of consecutive patients who underwent PCT insertion over a 10-year period was performed. Outcomes assessed included cholecystostomy dwell time, tubogram requirement, cholecystostomy reinsertion, cholecystectomy, bile leaks, and mortality. RESULTS: One hundred eight patients (77 male individuals, 31 female individuals) were included. The mean age was 70 years (range: 29 to 93 y). A total of 89 transhepatic and 19 transperitoneal PCTs were inserted. Fifty-nine patients (55%) had a subsequent tubogram to assess cystic duct patency or catheter position. Mean catheter dwell time was 17 days (range: 1 to 154 d). Eleven (10%) required PCT reinsertion. Time to reinsertion ranged from 2 to 163 days (mean=38 d). Fifty-three patients (50%) had no further biliary intervention after removal of the cholecystostomy catheter. One patient required subsequent drainage of a hepatic abscess, and another developed a biloma. Thirty-two patients (30%) underwent cholecystectomy (66% laparoscopic, 34% open). Thirty-day mortality after PCT insertion was 8.3%. Twenty patients (19%) died of non-cholecystostomy-related illness during the 10-year follow-up period. CONCLUSIONS: Cholecystostomy is an important treatment method of acute cholecystitis as a bridge to cholecystectomy or as an alternative definitive treatment option in those unsuitable for surgery. A tubogram is not always necessary before tube removal. Cholecystostomy tubes can be removed safely with little risk of bile leak if patients are clinically well, and clean-appearing bile is draining.

Single-institution experience with selective internal radiation therapy (SIRT) for the treatment of unresectable colorectal liver metastases.

BACKGROUND: Liver metastases are the commonest cause of death for patients with colorectal cancer. Growing evidence supports the use of selective internal radiation therapy (SIRT) in combination with conventional chemotherapy regimens for liver-only or liver-dominant unresectable metastatic colorectal cancer. AIMS: To measure and evaluate outcomes of the first 20 consecutive patients with unresectable colorectal liver metastasis selected for SIRT in addition to their chemotherapy at a single Irish institution. METHODS: Retrospective case series was performed. Patient charts and medical records were reviewed. RESULTS: All 20 patients (100%) selected for angiographic workup were subsequently successfully treated with radioembolization. All patients were discharged 1 day post-SIRT. At initial imaging evaluation, 12 (60%) had a partial response in their liver, 2 (10%) had stable disease, and 6 (30%) had liver-specific progressive disease. Median follow up was 10 months (range 6-26). At last follow up, 14 (70%) patients were alive and 6 (30%) deceased. Most recent imaging demonstrated 2 (10%) with a complete response, 7 (35%) had a partial response, 2 (10%) had stable disease, and 9 (45%) had progressive disease within their liver. One patient was downstaged to hepatic resection, and one with a complete hepatic response had his primary sigmoid tumor resected 11 months post-SIRT. CONCLUSIONS: SIRT is a safe and effective therapy for certain patients with unresectable colorectal liver metastases. This case series supports our opinion that selected patients should be offered SIRT in concert with their medical oncologist, concomitant with their chemotherapy. Larger multi-center studies are required to more clearly define the patient groups that will derive most benefit from SIRT.

What Are the Indications for Prophylactic Embolization of Renal Angiomyolipomas? A Review of the Current Evidence in the Literature.

Renal angiomyolipomas (AMLs) are benign tumours that may occur sporadically in the general population or in patients with tuberous sclerosis complex. The concern with AMLs is that of retroperitoneal hemorrhage, which can be fatal. Classically the trigger for prophylactic intervention was thought to be an AML diameter of ≥4 cm. However, this value is largely based on data from case series and heterogeneous retrospective studies. The PICO (patient, intervention, comparison, outcome) paradigm was used to systematically search the Cochrane database, TRIP database, and PubMed. The quality of evidence in the literature is poor regarding the indications for prophylactic embolization of AMLs (level 4). There are no prospective studies that adequately assess embolization vs other treatment modalities. However, using the available evidence we have produced recommendations for when intervention should be considered. We have also made recommendations regarding the direction of future research.

Incidental Thoracic Findings on Routine Computed Tomography in Epithelial Ovarian Cancer.

INTRODUCTION: Multidetector computed tomography (MDCT) is routinely used in the surveillance of epithelial ovarian cancer. The aim of this study was to determine the incidence of thoracic findings on routine MDCT surveillance imaging in patients with ovarian carcinoma. MATERIALS AND METHODS: Retrospective evaluation of 100 MDCT studies of patients with a diagnosis of epithelial ovarian cancer was performed at a university teaching hospital. The cross-sectional studies were reviewed by a consultant radiologist with subspeciality training in cross-sectional imaging. RESULTS: Intrathoracic findings were identified in 35% of patients. Pleural effusions were identified in 40%, pulmonary nodules in 37%, mediastinal adenopathy in 17%, and thyroid nodules in 6% of patients. Thirty-five (35%) patients were found to have thoracic findings on computed tomography. Pleural effusions developed in 14 (40%) of these patients. Small lung nodules (<1 cm) were present in 13 (37%) patients. Mediastinal lymphadenopathy was seen in 6 (17%) patients. Two patients (6%) had thyroid nodules of unknown significance. Pleural effusions and small lung nodules were present at a similar level to that of the general population. CONCLUSIONS: This retrospective study supports the imaging recommendations of the European Society of Urogenital Radiology that MDCT protocols for the initial staging and evaluation of recurrent disease in epithelial ovarian carcinoma require only inclusion of the lung bases to the inguinal region reducing exposure to ionizing radiation, alleviating patient anxiety, and offering a cost-benefit to hospitals.

Novel Use of a Pneumatic Compression Device for Haemostasis of Haemodialysis Fistula Access Catheterisation Sites.

PURPOSE: Transradial pneumatic compression devices can be used to achieve haemostasis following radial artery puncture. This article describes a novel technique for acquiring haemostasis of arterio-venous haemodialysis fistula access sites without the need for suture placement using one such compression device. MATERIALS AND METHODS: A retrospective review of fistulograms with or without angioplasty/thrombectomy in a single institution was performed. 20 procedures performed on 12 patients who underwent percutaneous intervention of failing or thrombosed arterio-venous fistulas (AVF) had 27 puncture sites. Haemostasis was achieved using a pneumatic compression device at all access sites. Procedure details including size of access sheath, heparin administration and complications were recorded. RESULTS: Two diagnostic fistulograms, 14 fistulograms and angioplasties and four thrombectomies were performed via access sheaths with an average size (±SD) of 6 Fr (±1.12). IV unfractionated heparin was administered in 11 of 20 procedures. Haemostasis was achieved in 26 of 27 access sites following 15-20 min of compression using the pneumatic compression device. One case experienced limited bleeding from an inflow access site that was successfully treated with reinflation of the device for a further 5 min. No other complication was recorded. CONCLUSIONS: Haemostasis of arterio-venous haemodialysis fistula access sites can be safely and effectively achieved using a pneumatic compression device. This is a technically simple, safe and sutureless technique for acquiring haemostasis after AVF intervention.

Asymptomatic Renal Pseudoaneurysm Following Laparoscopic Partial Nephrectomy.

A 66-year-old-woman underwent a laparoscopic left partial nephrectomy for a 3 cm partially exophytic tumor arising from the posterior interpolar region of the left kidney. Follow-up surveillance computed tomography 6 months following the surgery found an incidental 4 cm lesion in the left kidney that is avidly enhanced in the arterial phase, consistent with a renal pseudoaneurysm. She was completely asymptomatic. Renal pseudoaneurysm is a rare complication following minimally invasive nephron-sparing surgery and typically presents in the early postoperative period with gross hematuria. However, a large renal pseudoaneurysm may also present as an asymptomatic incidental finding and is amenable to angioembolization.

Fabrication and assessment of 3D printed anatomical models of the lower limb for anatomical teaching and femoral vessel access training in medicine.

For centuries, cadaveric dissection has been the touchstone of anatomy education. It offers a medical student intimate access to his or her first patient. In contrast to idealized artisan anatomical models, it presents the natural variation of anatomy in fine detail. However, a new teaching construct has appeared recently in which artificial cadavers are manufactured through three-dimensional (3D) printing of patient specific radiological data sets. In this article, a simple powder based printer is made more versatile to manufacture hard bones, silicone muscles and perfusable blood vessels. The approach involves blending modern approaches (3D printing) with more ancient ones (casting and lost-wax techniques). These anatomically accurate models can augment the approach to anatomy teaching from dissection to synthesis of 3D-printed parts held together with embedded rare earth magnets. Vascular simulation is possible through application of pumps and artificial blood. The resulting arteries and veins can be cannulated and imaged with Doppler ultrasound. In some respects, 3D-printed anatomy is superior to older teaching methods because the parts are cheap, scalable, they can cover the entire age span, they can be both dissected and reassembled and the data files can be printed anywhere in the world and mass produced. Anatomical diversity can be collated as a digital repository and reprinted rather than waiting for the rare variant to appear in the dissection room. It is predicted that 3D printing will revolutionize anatomy when poly-material printing is perfected in the early 21st century.

Loss of renal India ink artifact-a useful radiological sign for obstructive hydronephrosis in pregnancy.

Magnetic resonance imaging is a useful tool for investigating causes of abdominal pain in pregnancy. Differentiating between physiologic hydronephrosis of pregnancy and pathologic hydronephrosis can be challenging for clinicians and radiologists. This report describes loss of the India ink artifact around the obstructed kidney as a novel and potentially useful radiological sign, which may be of value in the evaluation of abdominal pain and hydronephrosis in pregnancy.