Computing Z-Score Equations for Clinical Use to Measure Fetal Umbilical Vein Size and Flow Using Six Independent Variables of Age and Size.

INTRODUCTION: Measurements of the umbilical vein diameter (UVD) and blood flow (mL/min) (UVF) have been demonstrated to be decreased in fetuses with growth restriction (FGR) using gestational age (GA) as the independent variable. However, no previous studies have used the biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL), and the estimated fetal weight (EFW) to create equations to be used for z-score computations when evaluating fetuses at risk foran abnormal UVD and UVF. METHODS: Two hundred and forty normal fetuses between 20 and 40 weeks of gestation were examined in which the UVD and time averaged maximal velocity (TAMX) were measured from which the UVF, UVF/HC, UVF/AC, and UVF/kg were computed. Fractional polynomial regression analysis was used to compute z-score equations using the above independent variables. Thirty-six fetuses with abnormal growth of the AC were examined to test the validity of the equations. RESULTS: The UVD, TAMX, UVF, UVF/HC, and UVF/AC all increased with gestatonal age and fetal growth except for the UVF/kg, which decreased with age and growth. From the regression equations, two z-score calculators were created using an Excel spreadsheet that can be used in clinical practice. Abnormal measurements of the UVD, UVF, UVF/HC, UVF/AC, and UVF/kg were observed in the 36 study fetuses, 21 with an AC < 10th centile and 15 with an AC > 90th centile. CONCLUSION: Using the equations generated from this study and the z-score calculators provides a clinical tool to measure the size and flow of the umbilical vein that may have clinical implications.

Web-based comparison of historical vs contemporary methods of fetal heart rate interpretation.

BACKGROUND: Contemporary interpretation of fetal heart rate patterns is based largely on the tenets of Drs Quilligan and Hon. This method differs from an older method that was championed by Dr Caldeyro-Barcia in recording speed and classification of decelerations. The latter uses a paper speed of 1 cm/min and classifies decelerations referent to uterine contractions as type I or II dips, compared with conventional classification as early, late, or variable with paper speed of 3 cm/min. We hypothesized that 3 cm/min speed may lead to over-analysis of fetal heart rate and that 1 cm/min may provide adequate information without compromising accuracy or efficiency. OBJECTIVE: The purpose of this study was to compare the Hon-Quilligan method of fetal heart rate interpretation with the Caldeyro-Barcia method among groups of obstetrics care providers with the use of an online interactive testing tool. STUDY DESIGN: We deidentified 40 fetal heart rate tracings from the terminal 30 minutes before delivery. A website was created to view these tracings with the use of the standard Hon-Quilligan method and adjusted the same tracings to the 1 cm/min monitoring speed for the Caldeyro-Barcia method. We invited 2-4 caregivers to participate: maternal-fetal medicine experts, practicing maternal-fetal medicine specialists, maternal-fetal medicine fellows, obstetrics nurses, and certified nurse midwives. After completing an introductory tutorial and quiz, they were asked to interpret the fetal heart rate tracings (the order was scrambled) to manage and predict maternal and neonatal outcomes using both methods. Their results were compared with those of our expert, Edward Quilligan, and were compared among groups. Analysis was performed with the use of 3 measures: percent classification, Kappa, and adjusted Gwet-Kappa (P < .05 was considered significant). RESULTS: Overall, our results show from moderate to almost perfect agreement with the expert and both between and within examiners (Gwet-Kappa 0.4-0.8). The agreement at each stratum of practitioner was generally highest for ascertainment of baseline and for management; the least agreement was for assessment of variability. CONCLUSION: We examined the agreement of fetal heart rate interpretation with a defined set of rules among a number of different obstetrics practitioners using 3 different statistical methods and found moderate-to-substantial agreement among the clinicians for matching the interpretation of the expert. This implies that the simpler Caldeyro-Barcia method may perform as well as the newer classification system.

Interobserver reliability of fetal heart rate pattern interpretation using NICHD definitions.

OBJECTIVE: To evaluate the interobserver reliability of fetal heart rate (FHR) pattern definition and interpretation assessed by physicians at various levels of training using standard Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) definitions and standard principles of interpretation. STUDY DESIGN: We conducted an interrater reliability study of the intrapartum FHR tracings of 32 singleton term pregnancies at Los Angeles County-University of Southern California (LAC + USC) Medical Center. Analysis included the 5 hours immediately preceding delivery, divided into 10- minute segments. A medical student, resident, and three attending physicians evaluated the same set of FHR tracings. Interobserver agreement was assessed using the free-marginal kappa coefficient. RESULTS: Reviewers demonstrated substantial to excellent agreement on baseline rate (κ = 0.97), moderate variability (κ = 0.80), accelerations (κ = 0.62), decelerations (κ = 0.63), category (κ = 0.68), and the ability to identify the presence of either moderate variability or accelerations (κ = 0.82). CONCLUSIONS: Interobserver agreement was significantly higher on all components of FHR definition and interpretation than previously expected. Standardization of FHR definitions and interpretation may improve interobserver reliability and patient safety.

Neurosurgical Mission to Ukraine.

Ukrainian health care before 2021 was like that in comparable middle-income countries. The conflict with Russia over the last 8 months has added significant burden to the already resource-constrained system. We describe the current neurosurgical situation in Ukraine as well as remote and in-person efforts to provide needed assistance to Ukrainian neurosurgical colleagues.

Putting Medical Boots on the Ground: Lessons from the War in Ukraine and Applications for Future Conflict with Near-Peer Adversaries.

In the past 20 years of the Global War on Terror, the US has seen substantial improvements in its system of medical delivery in combat. However, throughout that conflict, enemy forces did not have parity with the weaponry, capability, or personnel of the US and allied forces. War against countries like China and Russia, who are considered near-peer adversaries in terms of capabilities, will challenge battlefield medical care in many different ways. This article reviews the experience of a medical team, Global Surgical and Medical Support Group, that has been providing assistance, training, medical support, and surgical support to Ukraine since the Russian invasion began in February 2022. The team has extensive experience in medicine, surgery, austere environments, conflict zones, and building partner nation capacities. This article compares and contrasts the healthcare systems of this war against the systems used during the Global War on Terror. The lessons learned here could help the US anticipate challenges and successfully plan for the provision of medical care in a future conflict against an adversary with capabilities close to its own.

Effectiveness of the Global Surgical and Medical Support Group (GSMSG) activities in Ukraine.

OBJECTIVE: Targeting of healthcare infrastructures in Ukraine has served as a tactical warfare strategy. The goal of the Global Surgical and Medical Support Group (GSMSG) is to provide sustainable, high quality medical and surgical care in war zones. INTERVENTIONS: GSMSG deployed United States (US) Special Operations veterans and highly specialized licensed medical experts. Training of Ukrainian civilians was implemented. RESULTS: Over 20,000 Ukrainians trained and over 100 major surgeries performed with assistance of world experts. Specialized medical equipment was also provided. CONCLUSION: GSMSG lays the groundwork for effective, high quality, and sustainable surgical interventions into a nation in conflict.

PHLDA2 gene polymorphisms and risk of HELLP syndrome and severe preeclampsia.

OBJECTIVE: Pleckstrin homology-like domain, family A, member 2 (PHLDA2) is a maternally expressed imprinted gene. Loss of imprinting in PHLDA2 is associated with abnormal placental development and fetal growth restriction. Our objective was to determine whether genetic variation in PHLDA2 is also associated with risk of HELLP syndrome and preeclampsia (PE) with severe features. STUDY DESIGN: Case (n = 162) and control (n = 33) mother-father-child triads were recruited using an internet-based method. Medical records were reviewed to verify clinical diagnosis of self-reported cases. DNA was genotyped for three polymorphisms in the PHLDA2 gene using TaqMan assays: rs13390, rs1056819, rs2583435. MAIN OUTCOME MEASURES: To examine the association between minor alleles and haplotypes with HELLP syndrome and PE with severe features, relative risks and 95% confidence intervals were estimated using log-linear models, adjusting for the correlation between familial genotypes, using HAPLIN. RESULTS: There was no association identified between PHLDA2 gene polymorphisms or haplotypes and HELLP syndrome and PE with severe features. No parent-of-origin effects were observed. CONCLUSION: Genetic variation in the PHLDA2 gene is not associated with HELLP syndrome or PE with severe features.

Helicobacter pylori and thrombocytopenia in the pregnant hispanic population.

OBJECTIVE: An association between Helicobacter pylori (H. pylori) and thrombocytopenia has been demonstrated in the literature in a non-pregnant population. The purpose of this study was to determine whether or not there is a similar association in the third trimester of pregnancy in a Hispanic population. METHODS: This is a secondary analysis of 82 pregnant Hispanic women with and without hyperemesis gravidarum who underwent serologic evaluation for H. pylori IgG. Results of complete blood counts obtained in the third trimester were analysed for thrombocytopenia. RESULTS: Of the 82 subjects who had H. pylori testing, 54 subjects had both serum H. pylori IgG results and third trimester platelet levels. The prevalence of thrombocytopenia was 11.1% (6/54). Thirty-six subjects were seropositive for H. pylori IgG and 18 subjects were seronegative. Of the 36 subjects who were H. pylori seropositive, four (11.1%) developed thrombocytopenia compared to three of 18 (16.7%) H. pylori seronegative subjects (P = 0.67). There was no difference between the groups in their mean platelet values (205 K/cu mm vs. 212 K/cu mm, P = 0.69). CONCLUSIONS: In this limited study, we found no association between H. pylori and thrombocytopenia in the pregnant Hispanic population.