Obstetric and gynecologic ultrasound curriculum and competency assessment in residency training programs: consensus report.

Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With increasing educational demands and limited hours in residency programs, dedicated time for training and achieving competency in ultrasound has diminished substantially. The American Institute of Ultrasound in Medicine assembled a multi-Society Task Force to develop a consensus-based, standardized curriculum and competency assessment tools for obstetric and gynecologic ultrasound training in residency programs. The curriculum and competency-assessment tools were developed based on existing national and international guidelines for the performance of obstetric and gynecologic ultrasound examinations and thus are intended to represent the minimum requirement for such training. By expert consensus, the curriculum was developed for each year of training, criteria for each competency assessment image were generated, the pass score was established at or close to 75% for each, and obtaining a set of five ultrasound images with pass score in each was deemed necessary for attaining each competency. Given the current lack of substantial data on competency assessment in ultrasound training, the Task Force expects that the criteria set forth in this document will evolve with time. The Task Force also encourages use of ultrasound simulation in residency training and expects that simulation will play a significant part in the curriculum and the competency-assessment process. Incorporating this training curriculum and the competency-assessment tools may promote consistency in training and competency assessment, thus enhancing the performance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Circulating cell-free fetal DNA for the detection of RHD status and sex using reflex fetal identifiers.

OBJECTIVE: To determine the sensitivity and specificity of circulating cell-free fetal DNA in determining the fetal RHD status and fetal sex. METHODS: Maternal blood was collected in each trimester of pregnancy from RhD negative nonalloimmunized women. Whole blood was centrifuged, separated into plasma and buffy coat, and frozen at -80°C. DNA analysis was conducted via allele-specific primer extensions for exons 4, 5, and 7 of the RHD gene and for a 37-base pair insertion in exon 4 (RHD pseudogene; psi) three Y-chromosome sequences (SRY, DBY, and TTY2), and an extraction control (TGIFL-like X/Y). RhD serotyping on cord blood and gender assessment of the newborns were entered into a Web-based database. RESULTS: One hundred twenty women were enrolled. The median gestational age at the first venipuncture was 12.4 (range: 10.6-13.9) weeks with 120 samples drawn; 118 samples were drawn at 17.6 (16-20.9) weeks; and 113 samples at 28.7 (27.9-33.9) weeks. Overall accuracy for RHD was 99.1%, 99.1%, and 98.1% for each trimester and was 99.1%, 99.1%, and 100% for fetal sex determination. CONCLUSIONS: Fetal RHD genotyping and sex can be very accurately determined in all three trimesters using circulating cell-free fetal DNA in the maternal circulation.

Maximal amniotic fluid index as a prognostic factor in pregnancies complicated by polyhydramnios.

OBJECTIVES: Polyhydramnios is present in approximately 2% of pregnancies and has been associated with a variety of adverse pregnancy outcomes. Our aim was to evaluate the association between the maximal amniotic fluid index (AFI) and the frequency of specific adverse outcomes. METHODS: This was a retrospective chart review of 524 singleton pregnancies diagnosed with polyhydramnios and delivered in a single tertiary referral center between 2003 and 2008. Polyhydramnios was defined as either AFI ≥ 25 cm or a maximum vertical pocket (MVP) ≥ 8 cm even in the presence of AFI < 25 cm. The cohort was stratified into four groups based on the maximal AFI noted during the pregnancy: < 25 cm but with MVP ≥ 8 cm; 25-29.9 cm; 30-34.9 cm; and ≥ 35 cm. Data were collected to determine the frequency of the following adverse pregnancy outcomes: prenatally diagnosed congenital anomalies, fetal aneuploidy, preterm delivery, Cesarean delivery, low birth weight, 5-min Apgar score < 7 and perinatal mortality. RESULTS: Higher AFI was associated with a statistically significant increase in the frequency of adverse pregnancy outcomes. The most severe form of polyhydramnios, as based on the maximal AFI (≥ 35 cm; n = 67), was associated with the highest rates of prenatally diagnosed congenital anomalies (79%), preterm delivery (46%), small-for-gestational-age neonate (16%), aneuploidy (13%) and perinatal mortality (27%). No significant association between degree of polyhydramnios and adverse outcome was demonstrated in cases of idiopathic polyhydramnios (n = 253). CONCLUSIONS: There is an association between the frequencies of a variety of adverse pregnancy outcomes and the severity of polyhydramnios as reflected by the maximal AFI.

An adenoviral vector-based mucosal vaccine is effective in protection against botulism.

A replication-incompetent adenoviral vector encoding the heavy chain C-fragment (H(C)50) of botulinum neurotoxin type C (BoNT/C) was evaluated as a mucosal vaccine against botulism in a mouse model. Single intranasal inoculation of the adenoviral vector elicited a high level of H(C)50-specific IgG, IgG1 and IgG2a in sera and IgA in mucosal secretions as early as 2 weeks after vaccination. The antigen-specific serum antibodies were maintained at a high level at least until the 27th week. Immune sera showed high potency in neutralizing BoNT/C as indicated by in vitro toxin neutralization assay. The mice receiving single dose of 2 x 10(7) p.f.u. (plaque-forming unit) of adenoviral vector were completely protected against challenge with up to 10(4) x MLD(50) of BoNT/C. The protective immunity showed vaccine dose dependence from 10(5) to 2 x 10(7) p.f.u. of adenoviral vector. In addition, animals receiving single intranasal dose of 2 x 10(7) p.f.u. adenoviral vector could be protected against 100 x MLD(50) 27 weeks after vaccination. Animals with preexisting immunity to adenovirus could also be vaccinated intranasally and protected against lethal challenge with BoNT/C. These results suggest that the adenoviral vector is a highly effective gene-based mucosal vaccine against botulism.

Nationwide data confirms absence of 'July phenomenon' in obstetrics: it's safe to deliver in July.

OBJECTIVE(S): To determine whether operator-dependent obstetric complications occur at higher rates in July at teaching hospitals using a large, nationwide sample of deliveries. STUDY DESIGN: Data for this study were obtained from an administrative dataset, the Nationwide Inpatient Sample, for the years 1998 to 2002. Singleton deliveries and singleton livebirth admissions among Medicaid patients at teaching hospitals with OB/GYN residents working on the Labor and Delivery ward were identified. Outcomes for various complications for these patients in the month of July were compared to those occurring in the months from August to June. RESULTS: The 26,546 women in our cohort who delivered in July were compared to the 272,584 women delivering during August to June. There were no statistically significant differences in the rates of cesarean delivery, urethral/bladder injury, third or fourth degree lacerations, wound complications, postpartum hemorrhage, transfusion, shoulder dystocia, chorioamnionitis or anesthesia-related complications. The 26,175 singleton livebirth admissions in July were compared to 266,158 such admissions in August to June. There were no statistically significant differences in the rates of brachial plexus injury (0.2 vs 0.2%, P=0.824) or birth asphyxia (0.1 vs 0.1%, P=0.643). CONCLUSION(S): This study shows no increased rate of operator-dependent complications of delivery at teaching hospitals nationwide in the month of July.

The effect of behavioral stimulant doses of amphetamine on blood pressure.

Blood pressure responses to amphetamine have been studied both in humans and in rats. Blood pressure was monitored in patients who had experienced an adverse behavioral reaction to the drug. All of the patients had self-administereed amphetamine, and later sought medical attention for their adverse reaction. In a series of 14 patients, there was no evidence that amphetamine had evoked a sustained increase in blood pressure. In rats, experiments were conducted in two steps: (1) a determination of the doses of amphetamine that cause behavioral stimulation, and (2) an evaluation of the blood pressure effects of the same dose of amphetamine. In control animals, behavioral stimulant doses of amphetamine exerted only transient effects on blood pressure. In pithed animals, ie, animals devoid of all central mechanisms, amphetamine exerted a sustained effect on blood pressure. It is concluded that the potential ability of amphetamine to evoke sustained cardiovascular responses is damped by the central nervous system of intact animals.

Cloning and sequence analysis of a cDNA encoding human syntaxin 1A, a polypeptide essential for exocytosis.

A clone encoding human syntaxin 1A was isolated and sequenced from a human brain library. The deduced sequence encodes a 288-amino-acid (aa) protein that presumably plays a critical role in neurotransmitter exocytosis and is 98.0% identical to the aa sequence of rat syntaxin 1A.

Combined use of molindone and guanethidine in patients with schizophrenia and hypertension.

Human sympathetic nerves have a high-affinity norepinephrine uptake system. This uptake system is inhibited competitively by chlorpromazine but not by molindone, which suggests that molindone will not interact adversely with guanethidine, an antihypertensive drug that enters sympathetic nerves via the high-affinity uptake system. Accordingly, patients with concomitant schizophrenia and hypertension were treated simultaneously with molindone and guanethidine; there was no evidence of an adverse drug interaction. The data indicate that molindone and guanethidine can be used in combination safely and effectively.

Identification of the characteristics that underlie botulinum toxin potency: implications for designing novel drugs.

Botulinum toxin is a uniquely potent substance whose natural site of action is the peripheral cholinergic nerve ending. A substantial amount of information on the cellular, subcellular and molecular aspects of toxin action has been accumulated, and as a result a sound understanding of the basis for toxin potency has been developed. The principal characteristics of the toxin molecule that account for its potency are its ability: a) to be absorbed from the gut with minimal degradation; b) to bind to receptors that maximize the prospects of a pathophysiologic outcome; c) to act by a multiplicative (viz., enzymatic) mechanism; and d) to modify a substrate that is essential for neuronal function. Interestingly, the same properties that account for potency can also be exploited to utilize the toxin as a research tool and as a therapeutic agent. Several specific examples of ways to use the toxin advantageously are presented, including: a) development of oral medications and vaccines; b) analysis of subcellular mechanisms that govern transcytosis; c) identification of cell surface markers characteristic of cholinergic nerve endings; and d) analysis of specific aspects of exocytosis, such as spontaneous quantal release and synchronous quantal release. In all likelihood, further studies on the mechanism of botulinum toxin action will reveal yet further opportunities for utilizing it as a research tool or therapeutic agent.

Respiratory effects of cyclic AMP following injection into the nucleus tractus solitarius of rats.

Rats were anesthetized with urethane and a limited occipital craniotomy was performed to expose the caudal medulla in the region of the obex. Injections were made into sites in the brainstem of spontaneously-breathing rats through glass micropipettes. Tidal volume, respiratory frequency, minute volume, blood pressure and heart rate were recorded before and after the administration of 8-bromoadenosine 3',5'-cyclic monophosphate (Br-cAMP), an analog of cyclic AMP. Injections of Br-cAMP into the ventromedial portion of the caudal nucleus tractus solitarius (NTS) produced dose-related decreases in pulmonary ventilation due to effects on both respiratory frequency, as well as minute volume. In larger doses, Br-cAMP produced periodic apnea and irregular breathing. The respiratory depression was accompanied by transient hypotension and bradycardia. The data indicate that cyclic AMP may function as a second messenger in respiratory control regions in the brainstem.

The effect of prostaglandin E2 on the arterial blood pressure of normotensive and spontaneously hypertensive rats.

1 In anaesthetized rats, injection of prostaglandin E(2) (0.5-5.0 mug/kg i.v.) caused a dose-dependent vasodepressor response. The magnitude of response was significantly greater in spontaneously hypertensive rats than in normotensive rats.2 In spontaneously hypertensive rats, the magnitude of the prostaglandin-induced depressor response was closely correlated with blood pressure. The higher the blood pressure, the greater was the response evoked by prostaglandin.3 In spontaneously hypertensive rats, a combination of guanethidine plus hydralazine reduced both blood pressure and prostaglandin-induced depressor responses.4 Spontaneously hypertensive rats and normotensive rats did not differ in the magnitude of their vasodepressor responses to intravenously administered acetylcholine or isoprenaline.

Cardiac dysfunction in twin-twin transfusion syndrome: a prospective, longitudinal study.

OBJECTIVE: To use serial echocardiography to evaluate prospectively the cardiac dysfunction in twin-twin transfusion syndrome and determine its clinical course and outcome. METHODS: Twin pregnancies presenting in the second trimester with sonographic evidence of twin-twin transfusion syndrome were managed with therapeutic reduction amniocenteses. Gestational age at diagnosis and delivery, number of amniocenteses performed, volume of amniotic fluid withdrawn, placentation, birth weight, hemoglobin at delivery, and perinatal outcome were recorded. Serial fetal echocardiography was carried out in a single tertiary center. Echocardiographic assessments included cardiac anatomy, chamber size, cardiothoracic ratio, interventricular septal thickness, ventricular systolic function, and the presence and severity of atrioventricular valve regurgitation. Postnatal echocardiograms were obtained on the surviving twins. RESULTS: Twelve cases of twin-twin transfusion syndrome were evaluated with serial echocardiography. Evidence of cardiac dysfunction was present prenatally in 10 recipient twins. All of the donor twins had normal fetal echocardiographic assessments. The most common abnormalities detected prenatally in recipient twins were decreased ventricular function, tricuspid regurgitation, and cardiac chamber enlargement. A deterioration of cardiac function was observed in seven recipient twins with increasing gestational age. Four of the eight surviving recipient twins had persistent postnatal echocardiographic abnormalities on follow-up examinations after the first 28 days of life. CONCLUSION: Prenatal cardiac dysfunction is common in recipient twins and can be transient, progressive, or persistent beyond the neonatal period.

Acute fatty liver of pregnancy in triplet gestation.

BACKGROUND: Acute fatty liver is reported to be more common in twin than in singleton pregnancies. We report three cases of biopsy-proven acute fatty liver in triplet gestations. CASES: In all three cases of acute fatty liver complicating triplet pregnancies, the presenting features were vague abdominal complaints with elevated hepatic aminotransferase levels. A liver biopsy was performed in each case, and cesareans were performed immediately after the diagnosis was confirmed histologically. Clinical resolution occurred in all cases, and all infants did well in the neonatal period. CONCLUSION: Patients with triplet gestations should be monitored closely for the early signs of acute fatty liver. Triplet gestations may contribute to the onset of acute fatty liver by further stressing the fatty acid oxidation capabilities of the susceptible woman.

Validation of first-trimester telemedicine as an obstetric imaging technology: a feasibility study.

OBJECTIVE: To establish whether first-trimester obstetric ultrasonography interpreted by a live video telemedicine link is comparable to an established videotape review network in a low-risk patient population. METHODS: An integrated services digital network was established from three satellite offices to our central prenatal diagnostic center. All patients had a sonographic evaluation of the uterus, adnexa, and gestational sac recorded onto videotape by a trained sonographer. A live, interactive video telemedicine link was established, and a perinatologist directed the sonographer through the scan. Subsequently, a different perinatologist, blinded to the telemedicine interpretation, reviewed the original videotaped examination. The reports generated from both modalities then were compared by means of a score of 12 sonographic characteristics. RESULTS: The first 100 patients were included. The mean gestational age (+/-standard deviation) was 8.9 +/- 2.3 weeks (range 5.7-14.4), and the mean duration for telemedicine scans was 7.8 +/- 2.9 minutes (range 3.8-20.1). Telemedicine and videotape review scores were the same in 95 cases, and the final diagnosis was identical in 98 cases. This study had 80% power to detect a 10% difference in diagnosis at a significance level of .05. The ability to detect abnormalities was equivalent using both systems. CONCLUSION: The interpretation of first-trimester obstetric ultrasonography using live video telemedicine is equivalent to a system of videotape review. Obstetric telemedicine may prove to be a useful tool for providing sonographic imaging for low-risk obstetric patients.

Botulinum toxin and tetanus toxin recognize similar membrane determinants.

The binding fragment of tetanus toxin (50,000 dalton carboxy-terminus of heavy chain) does not block neuromuscular transmission, but it does antagonize the ability of native tetanus toxin to block neuromuscular transmission. The binding fragment of tetanus toxin also antagonizes certain botulinum toxins, including types C and E. Antagonism is at the cell surface, suggesting that the various molecules compete for a similar membrane binding site. The data indicate that the binding site is specific for botulinum toxin rather than tetanus toxin.

Cardiorespiratory function is altered by picomole injections of 5'-N-ethylcarboxamidoadenosine into the nucleus tractus solitarius of rats.

A limited occipital craniotomy was conducted on urethane-anesthetized, spontaneously breathing rats to expose the caudal medulla in the region of the obex. Microinjections of 5'-N-ethylcarboxamidoadenosine (NECA), an adenosine analog, were made into the medial region of the caudal nucleus tractus solitarius (NTS) at the level of the caudal tip of the area postrema, an area of the NTS in which there is known to be a functional co-existence of cardiovascular and respiratory-related neuronal elements. Cardiorespiratory responses were subsequently recorded for a 60 min test period. Microinjections of NECA, in the dose range of 0.35-350 pmol per rat, produced significant dose-related reductions in respiratory rate which were accompanied by dose-dependent increases in tidal volume and these pronounced effects on respiration persisted throughout the test period. In contrast, the effects of NECA microinjections on cardiovascular parameters in this region of the NTS were bidirectional and elicited considerably more complex responses during the test period. During the initial period (2-5 min) following injection, NECA elicited significant hypotension (at lower doses) and pressor responses (at higher doses) in addition to significant bradycardia (at lower doses) whereas by the end of the 60 min test period, almost all doses of NECA had resulted in hypertension and tachycardia. Multivariate analysis of variance (MANOVA) and correlation statistics indicated that the effects of NECA on blood pressure during the initial 2-5 min were dose-dependent and unlikely related to depression of respiratory frequency. A further examination of the data by MANOVA indicated that the pharmacological effects of NECA during the 60 min test period exhibited a highly significant and specific dose-dependent and time-related response pattern for the respiratory, but not the cardiovascular, parameters. Taken together, these manifold response patterns suggest that the respiratory effects of NECA may be mediated by different intrinsic mechanisms in the NTS than are the cardiovascular effects of NECA. At the end of the 60 min test period following the administration of NECA, the respiratory rate remained profoundly depressed. In view of previous studies showing that microinjections of cyclic AMP analogs, forskolin, isoproterenol and adenosine into the same NTS sites elicit a similar depression of respiration, the results with NECA in the present study further support the notion that cyclic AMP may serve as a second messenger in NTS respiratory control regions and these respiratory depressant effects may be mediated by a single adenosine receptor subtype.(ABSTRACT TRUNCATED AT 400 WORDS)

Cardiorespiratory effects of inositol hexakisphosphate following microinjections into the nucleus tractus solitarii.

Microinjections of inositol hexakisphosphate (IP6), a metabolite of inositol recently found to occur in high concentrations in the brainstem, were made into the caudal portion of the nucleus tractus solitarii (NTS) of spontaneously breathing rats and cardiorespiratory parameters recorded for a 30 min test period. Microinjections of IP6, in the dose range of 100-500 pmol/rat, produced significant dose-related reductions in mean arterial blood pressure and respiratory rate. The onset for hypotensive action and respiratory depression following microinjections of IP6 was very rapid and a transient apnea could be elicited at the higher doses. Moreover, the sodium and calcium salts of IP6 were relatively equipotent in depressing cardiorespiratory parameters, with the exception of heart rate wherein the sodium salt elicited a much more pronounced bradycardia. These results confirm and extend the findings of a previous study suggesting that IP6 and closely related metabolites may act on extracellular receptors. Taken together, these data provide further support to the notion that inositol lipid signalling pathways may generate both intracellular and extracellular signals in the brain.

Fetal supraventricular tachycardias: diagnosis and management.

In the majority of cases, the diagnosis of an isolated fetal tachyarrhythmia results in a favorable perinatal outcome. Although there is general consensus on the management of fetal extrasystoles, refractory supraventricular tachycardia, and atrial flutter and fibrillation, the optimal approach to supraventricular tachycardia without hemodynamic compromise remains uncertain. The benefits of conservative management without antiarrhythmic therapy must be weighed carefully against the lack of reliable predictors for the development of fetal hydrops and associated neurologic complications.

Nuchal translucency and its relationship to congenital heart disease.

Nuchal translucency refers to the normal subcutaneous space, observed on first trimester ultrasound evaluation, between the skin and cervical spine. Increased nuchal translucency is known to be associated with an increased risk of aneuploidy, particularly Trisomy 21, and recent studies have also identified increased nuchal translucency as a nonspecific marker for various genetic syndromes and multiple structural anomalies, to include congenital heart disease. This increased risk applies to euploid and aneuploid pregnancies and is directly related to the degree of nuchal translucency thickening. This article reviews the role of nuchal translucency as a screening tool for congenital heart disease.