Prevalence of vitamin D deficiency in Egyptian patients with pregnancy-induced hypertension.

Background Hypertensive disorders of pregnancy can cause severe maternal and fetal acute morbidity and mortality. Women with pre-eclampsia have been found to have alterations in calcium and vitamin D metabolism. There are conflicting results regarding the role of vitamin D deficiency in the development of pre-eclampsia. The aim was to compare 25 (OH) D level in patients with pre-eclampsia, eclampsia and normotensive pregnant women as well as to study the prevalence of Vitamin D deficiency among the 3 groups. Patients and methods Two hundred patients with pre-eclampsia, 100 with eclampsia and 200 normotensive pregnant controls were compared as regards vitamin D level. Results Mean 25(OH)D level was lower in the pre-eclampsia (14.8 ± 5.4 ng/mL) and in the eclampsia group (10.5 ± 1.6 ng/mL) than in the pregnant controls (19.5 ± 6.5 ng/mL) (P = 0.002). This difference was only significant between the eclampsia group and the pregnant controls (P = 0.02). All eclampsia cases had vitamin D insufficiency as compared to 17.5% in the pre-eclampsia group and 39.5% in the control group. Deficiency of vitamin D (<12 ng/mL) was 47.5% in the pre-eclampsia group, 80% in the eclampsia group and only 10.5% in the control group (P = 0.035). Conclusion Vitamin D deficiency is highly prevalent among Egyptian pregnant females. Our study supports the hypothesis that low vitamin D level can play a role in the development of pre-eclampsia and eclampsia. Thus, supplementation might prevent or delay the development of pre-eclampsia and eclampsia especially in patients at a high risk.

Fetal heart examination at the time of 13 weeks scan: a 5 years' prospective study.

Objective To evaluate our ability in classifying the fetal heart as normal or abnormal during the 1st trimester scan through fetal cardiac examination and determining the best time for this examination. Methods This was a prospective study performed on 3240 pregnant women to examine the fetal heart. Four chambers view and ventricular outflow tracts were mainly examined during the scan. We used grayscale and color mapping in the diagnosis. Color Doppler was used if additional information was needed, and all patients were rescanned during the 2nd trimester to confirm or negate our diagnosis. Results The cardiac findings were normal at both scans in 3108 pregnancies. The same cardiac abnormality was detected at both scans in 79 cases. In 36 cases there was false-positive diagnosis at the early scan; in 20 of these cases, there were mildly abnormal functional findings early in pregnancy with no abnormality found later. In 17 fetuses, there was discordance between the early and later diagnosis due to missed or incorrect diagnoses. The best time to do fetal heart examination during 1st trimester is between 13 and 13 + 6 weeks. Conclusion A high degree of accuracy in the identification of congenital heart disease (CHD) can be achieved by a 1st trimester fetal echocardiography.

Controversial ultrasound findings in mid trimester pregnancy. Evidence based approach.

Mid trimester fetal anatomy scan is a fundamental part of routine antenatal care. Some U/S soft markers or controversial U/S signs are seen during the scan and create some confusion regarding their relation to fetal chromosomal abnormalities. Example of these signs: echogenic focus in the heart, echogenic bowel, renal pyelectasis, ventriculomegaly, polydactely, club foot, choroid plexus cyst, single umbilical artery. We are presenting an evidence based approach from the literature for management of these controversial U/S signs.

Ultrasound in Africa: what can really be done?

Today we are living in a globalized world in which information on what is happening in one part of the world is easily communicated to other parts of the world. This happens thanks to advancement in science and technology. One area where technology has made the greatest impact is heath care provision. Ultrasound technology is now playing a critical role in health care provision particularly in Obstetrics and Gynaecology. This has significantly assisted in provision of quality health care to pregnant women and their unborn infants and in reducing maternal and neonatal morbidity and mortality in the developed world. Africa the continent with greatest health care challenges and with the highest maternal and neonatal mortalities is yet to fully utilize this important technology. The need for this technology is great as the conditions requiring its application abound. The effective application of Ultrasound however faces serious challenges in Africa. To successfully entrench Ultrasound in quality Obstetrics and Gynaecology care various approaches must be adopted to overcome the challenges. The aim of this paper is to identify the benefits and the challenges inimical to the application Ultrasound in Obstetrics and Gynecology in Africa. It also examines what needs to be done to achieve better application of Ultrasound in Obstetrics and Gynecology.

3D/4D sonography - any safety problem.

Gray-scale image data are processed in 3D ultrasound by repeated scans of multiple planes within a few seconds to achieve one surface rendering image and three perpendicular plane images. The 4D image is achieved by repeating 3D images in short intervals, i.e. 3D and 4D ultrasound are based on simple B-mode images. During 3D/4D acquisition, a fetus in utero is exposed by ultrasound beam for only a few seconds, and it is as short as real-time B-mode scanning. Therefore, simple 3D imaging is as safe as a simple B-mode scan. The 4D ultrasound is also as safe as a simple B-mode scan, but the ultrasound exposure should be shorter than 30 min. The thermal index (TI) and mechanical index (MI) should both be lower than 1.0, and the ultrasound study is regulated by the Doppler ultrasound if it is combined with simple 3D or 4D ultrasound. Recently, some articles have reported the functional changes of animal fetal brain neuronal cells and liver cell apoptosis with Doppler ultrasound. We discuss cell apoptosis by ultrasound in this report. Diagnostic ultrasound safety is achieved by controlling the output pulse and continuous ultrasound waves using thermal and mechanical indices, which should be <1.0 in abdominal and transvaginal scan, pulsed Doppler, as well as 3D and 4D ultrasound. The lowest spatial peak temporal average (SPTA) intensity of the ultrasound to suppress cultured cell growth is 240 mW/cm2, below which no ultrasound effect has been reported. An ultrasound user must be trained to recognize the ultrasound bioeffects; thermal and mechanical indices, and how to reduce these when they are higher than 1.0 on the monitor display; and guide the proper use of the ultrasound under the ALARA principle, because the user is responsible for ensuring ultrasound safety.

Fetal magnetic resonance imaging and ultrasound.

Magnetic resonance imaging (MRI) has been increasingly adopted in obstetrics practice in the past three decades. MRI aids prenatal ultrasound and improves diagnostic accuracy for selected maternal and fetal conditions. However, it should be considered only when high-quality ultrasound cannot provide certain information that affects the counseling, prenatal intervention, pregnancy course, and delivery plan. Major indications of fetal MRI include, but are not restricted to, morbidly adherent placenta, selected cases of fetal brain anomalies, thoracic lesions (especially in severe congenital diaphragmatic hernia), and soft tissue tumors at head and neck regions of the fetus. For fetal anatomy assessment, a 1.5-Tesla machine with a fast T2-weighted single-shot technique is recommended for image requisition of common fetal abnormalities. Individual judgment needs to be applied when considering usage of a 3-Tesla machine. Gadolinium MRI contrast is not recommended during pregnancy. MRI should be avoided in the first half of pregnancy due to small fetal structures and motion artifacts. Assessment of fetal cerebral cortex can be achieved with MRI in the third trimester. MRI is a viable research tool for noninvasive interrogation of the fetus and the placenta.

Is intrauterine surgery justified? Report from the working group on ultrasound in obstetrics of the World Association of Perinatal Medicine (WAPM).

Fetal surgery involves a large number of heterogeneous interventions that vary from simple and settled procedures to very sophisticated or still-in-development approaches. The overarching goal of fetal interventions is clear: to improve the health of children by intervening before birth to correct or treat prenatally diagnosed abnormalities. This article provides an overview of fetal interventions, ethical approaches in fetal surgery, and benefits obtained from antenatal surgeries.

Early administration of low-dose aspirin for the prevention of preterm and term preeclampsia: a systematic review and meta-analysis.

OBJECTIVE: To compare the effect of early administration of aspirin on the risk of preterm and term preeclampsia. METHOD: A systematic review and meta-analysis of randomized controlled trials were performed. Women who were randomized to low-dose aspirin or placebo/no treatment at or before 16 weeks of gestation were included. The outcomes of interest were preterm preeclampsia (delivery <37 weeks) and term preeclampsia. Pooled relative risks (RR) with their 95% confidence intervals (CI) were computed. RESULTS: The search identified 7,941 citations but only five trials on a combined total of 556 women fulfilled the inclusion criteria. When compared to controls, aspirin initiated ≤16 weeks of gestation was associated with a major reduction of the risk of preterm preeclampsia (RR 0.11, 95% CI 0.04-0.33) but had no significant effect on term preeclampsia (RR 0.98, 95% CI 0.42-2.33). CONCLUSION: Low-dose aspirin administrated at or before 16 weeks of gestation reduces the risk of preterm but not term preeclampsia.

Usefulness of aspirin therapy in high-risk pregnant women with abnormal uterine artery Doppler ultrasound at 14-16 weeks pregnancy: randomized controlled clinical trial.

AIM: To assess the effectiveness of low-dose aspirin in the prevention of preeclampsia and intrauterine growth restriction (IUGR) in high-risk pregnant women with abnormal findings at uterine artery Doppler velocimetry performed at 14-16 weeks. DESIGN: Randomized controlled clinical trial. SETTING: Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Egypt. METHODS: The trial enrolled 139 women at risk of preeclampsia or IUGR, with abnormal uterine artery Doppler findings that included the presence of unilateral or bilateral diastolic notch, high resistance index (RI), or high pulsatility index (PI) at 14-16 weeks of gestation. The women were randomly allocated into two groups, one receiving aspirin since admission to hospital (n=74) and the other serving as control (n=65). All women were followed up until delivery to assess maternal and perinatal outcomes. T-test was used for comparison of quantitative variables, and categorical variables were compared by chi2 test. OUTCOME CRITERIA: Development of mild or severe preeclampsia, time of onset of preeclampsia, preterm delivery, and the development of IUGR. RESULTS: Preeclampsia developed in 35% of women receiving aspirin and 62% of women in the control group (P=0.003), with severe preeclampsia developing in 8% and 23% of women (P=0.215), respectively. Preeclampsia before 37 weeks of gestation was recorded in only 4% of women receiving aspirin as opposed to 83% of controls (P<0.001). In the group of women receiving aspirin, 19% of newborns suffered from IUGR as opposed to 32%of newborns in the control group (P=0.106). There was no significant difference between the two groups in the rate of preterm delivery (P=0.080), mode of delivery (P=0.971), Apgar score <5 after one minute (P=0.273) and after 5 minutes (P=0.941), maternal or neonatal bleeding (P=0.948), and neonatal birth weight (P=0.399). CONCLUSION: Low-dose aspirin administered as early as 14-16 weeks of gestation to pregnant women at high risk of preeclampsia with abnormal uterine Doppler findings may reduce or modify the course of severe preeclampsia. Its effects on the prevention of IUGR need further evaluation.

Middle cerebral/umbilical artery resistance index ratio as sensitive parameter for fetal well-being and neonatal outcome in patients with preeclampsia: case-control study.

AIM: To evaluate the accuracy of middle cerebral/umbilical artery resistance index (C/U RI) ratio in predicting acidemia and low Apgar score at 5 minutes after birth in the infants of women with preeclampsia. METHODS: This prospective case-control study performed at Kasr El Aini University Hospital included 50 pregnant women with preeclampsia with or without intrauterine growth restriction (IUGR). Thirty women with uneventful pregnancies, matched for age, parity, and gestational age, served as controls. Ultrasound and Doppler studies were carried out to estimate fetal weight (EFW) and determine fetal biophysical profile and resistance indices of the middle cerebral and umbilical arteries. C/U RI <1.0 was considered abnormal. Apgar scores were assessed at 5 minutes after birth, and fetal cord blood sampling to determine blood pH was done immediately after delivery. Apgar score <6 at 5 minutes, neonatal acidemia (pH<7.2), and/or neonatal admission to neonatal intensive care unit (NICU) indicated neonatal morbidity. RESULTS: There were no significant differences in fetal biophysical profile, middle cerebral artery RI, or umbilical artery RI between the fetuses of women with preeclampsia and those in the control group. C/U RI <1.0 was found in significantly more fetuses of women with preeclampsia than in their controls (0.7-/+0.3 and 1.3-/+0.7, respectively; P<0.001). In the preeclampsia group, C/U RI was abnormal in 32 out of 38 fetuses with IUGR, and in only 5 out of 12 of fetuses without IUGR. Neonatal acidemia was found in 30 out of 38 newborns with IUGR and in 3 out of 12 of newborns without IUGR. Preeclampsia and C/U RI <1.0 carried a relative risk of 1.4 for neonatal morbidity (neonatal academia pH<7.2, 5-minute Apgar score <6, and/or admission to NICU). C/U RI had 64.1% sensitivity, 72.7% specificity, 89.2% positive predictive value, and 36.3% negative predictive value for neonatal morbidity. CONCLUSION: There was a strong correlation between the C/U RI and neonatal outcome in women with preeclampsia. C/U RI <1.0 may be helpful in the identification of newborns at risk of morbidity, irrespective of whether they are small or appropriate for their gestational age.