Ultrasound characteristics, serum biochemistry and outcome of ectopic pregnancies presenting during COVID-19 pandemic.

OBJECTIVE: To describe and compare the characteristics of ectopic pregnancies (EPs) in the year prior to vs during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This was a retrospective analysis of women diagnosed with an EP on transvaginal sonography conducted at a center in London, UK, providing early-pregnancy assessment, between 1 January 2019 and 31 December 2020. Women were identified via the Astraia ultrasound reporting system using coded and non-coded outcomes of EP or pregnancy outside the uterine cavity. Data related to predefined outcomes were collected using Astraia and Cerner electronic reporting systems. Main outcome measures included clinical, ultrasound and biochemical features of EP, in addition to reported complications and management. RESULTS: There were 22 683 consultations over the 2-year period. Following consultation, a similar number and proportion of EPs were diagnosed in 2019 (141/12 657 (1%)) and 2020 (134/10 026 (1%)). Both cohorts were comparable in age, ethnicity, weight and method of conception. Gestational age at the first transvaginal sonography scan and at diagnosis were similar, and no difference in location, size or morphology of EP was found between the two cohorts. Serum human chorionic gonadotropin (hCG) levels at the time of EP diagnosis were higher in 2020 than in 2019 (1005 IU/L vs 665 IU/L; P = 0.03). The proportions of women according to type of final EP management were similar, but the rate of failed first-line management was higher during vs before the pandemic (16% vs 6%; P = 0.01). The rates of blood detected in the pelvis (hemoperitoneum) on ultrasound (23% vs 26%; P = 0.58) and of ruptured EP confirmed surgically (9% vs 3%; P = 0.07) were similar in 2019 vs 2020. CONCLUSIONS: No difference was observed in the location, size, morphology or gestational age at the first ultrasound examination or at diagnosis of EP between women diagnosed before vs during the COVID-19 pandemic. Complication rates and final management strategy were also unchanged. However, hCG levels and the failure rate of first-line conservative management measures were higher during the pandemic. Our findings suggest that women continued to access appropriate care for EP during the COVID-19 pandemic, with no evidence of diagnostic delay or an increase in adverse outcome in our population. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

First-trimester intrauterine hematoma and pregnancy complications.

OBJECTIVE: To assess whether sonographic diagnosis of intrauterine hematoma (IUH) in the first trimester of pregnancy is associated with first-trimester miscarriage and antenatal, delivery and neonatal complications. METHODS: This was a prospective observational cohort study of women with an intrauterine singleton pregnancy between 5 and 14 weeks' gestation recruited at Queen Charlotte's and Chelsea Hospital, London, UK, between March 2014 and March 2016. Participants underwent serial ultrasound examinations in the first trimester, and the presence, location, size and persistence of any IUH was evaluated. First-trimester miscarriage was defined as pregnancy loss before 14 weeks' gestation. Clinical symptoms, including pelvic pain and vaginal bleeding, were recorded at each visit using validated symptom scores. Antenatal, delivery and neonatal outcomes were obtained from hospital records. Logistic regression analysis and the chi-square test were used to assess the association between the presence and features of IUH and the incidence of adverse pregnancy outcome. Odds ratios (OR) were first adjusted for maternal age (aOR) and then further adjusted for the presence of vaginal bleeding or pelvic pain in the first trimester. RESULTS: Of 1003 women recruited to the study, 946 were included in the final analysis and of these, 268 (28.3%) were diagnosed with an IUH in the first trimester. The presence of IUH was associated with the incidence of preterm birth (aOR, 1.94 (95% CI, 1.07-3.52)), but no other individual or overall antenatal, delivery or neonatal complications. No association was found between the presence of IUH in the first trimester and first-trimester miscarriage (aOR, 0.81 (95% CI, 0.44-1.50)). These findings were independent of the absolute size of the hematoma and the presence of vaginal bleeding or pelvic pain in the first trimester. When IUH was present in the first trimester, there was no association between its size, content or position in relation to the gestational sac and overall antenatal, delivery and neonatal complications. Diagnosis of a retroplacental IUH was associated with an increased risk of overall antenatal complications (P = 0.04). CONCLUSIONS: Our findings demonstrate that there is no association between the presence of IUH in the first trimester and first-trimester miscarriage. However, an association with preterm birth, independently of the presence of symptoms of pelvic pain and/or vaginal bleeding, is evident. Women diagnosed with IUH in the first trimester should be counseled about their increased risk of preterm birth and possibly be offered increased surveillance during the course of their pregnancy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Managing pregnancy of unknown location based on initial serum progesterone and serial serum hCG levels: development and validation of a two-step triage protocol.

OBJECTIVES: A uniform rationalized management protocol for pregnancies of unknown location (PUL) is lacking. We developed a two-step triage protocol to select PUL at high risk of ectopic pregnancy (EP), based on serum progesterone level at presentation (step 1) and the serum human chorionic gonadotropin (hCG) ratio, defined as the ratio of hCG at 48 h to hCG at presentation (step 2). METHODS: This was a cohort study of 2753 PUL (301 EP), involving a secondary analysis of prospectively and consecutively collected PUL data from two London-based university teaching hospitals. Using a chronological split we used 1449 PUL for development and 1304 for validation. We aimed to assign PUL as low risk with high confidence (high negative predictive value (NPV)) while classifying most EP as high risk (high sensitivity). The first triage step assigned PUL as low risk using a threshold of serum progesterone at presentation. The remaining PUL were triaged using a novel logistic regression risk model based on hCG ratio and initial serum progesterone (second step), defining low risk as an estimated EP risk of < 5%. RESULTS: On validation, initial serum progesterone ≤ 2 nmol/L (step 1) classified 16.1% PUL as low risk. Second-step classification with the risk model selected an additional 46.0% of all PUL as low risk. Overall, the two-step protocol classified 62.1% of PUL as low risk, with an NPV of 98.6% and a sensitivity of 92.0%. When the risk model was used in isolation (i.e. without the first step), 60.5% of PUL were classified as low risk with 99.1% NPV and 94.9% sensitivity. CONCLUSION: PUL can be classified efficiently into being either high or low risk for complications using a two-step protocol involving initial progesterone and hCG levels and the hCG ratio. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Ultrasound assessment of the peri-implantation uterus: a review.

Emerging evidence suggests that early embryo implantation is a more active maternal process than hitherto appreciated, involving active encapsulation of the implanting blastocyst by maternal decidual cells and coordinated changes in the underlying inner myometrium, known as the junctional zone. These concepts raise the possibility that early ultrasound markers predictive of adverse pregnancy outcome could be identified. In this review we assess the role of ultrasound in predicting the likelihood of different pregnancy outcomes and highlight potential novel markers that could be tested.

Embryo volume measurement: an intraobserver, intermethod comparative study of semiautomated and manual three-dimensional ultrasound techniques.

OBJECTIVE: To compare the reliability of our recently introduced technique for first-trimester embryo volume measurement, the 'semiautomated technique' using both Virtual Organ Computer-aided AnaLysis (VOCAL(™) ) and Sonography-based Automated Volume Count (SonoAVC) with a manual technique using VOCAL alone. METHODS: Seventy-four subjects with viable, singleton first-trimester in-vitro fertilization (IVF) pregnancies were recruited. Each subject underwent transvaginal sonography, at which a three-dimensional ultrasound dataset of the entire gestational sac was acquired. Each embryo volume was measured by two techniques, each performed twice. In the semiautomated technique VOCAL was used to calculate the volume of the gestational and yolk sacs, and SonoAVC was used to quantify the fluid volume within the amniotic and extra-amniotic cavities. Embryo volume was calculated by subtracting the sum of yolk sac, amniotic and extra-amniotic fluid volumes from gestational sac volume. In the manual technique, VOCAL was used to delineate the entire embryo using 9° rotations. Reliability was assessed using limits of agreement and intraclass correlation coefficient. RESULTS: Datasets were included from 52 eligible subjects. Median gestational age was 7 + 4 weeks; median crown-rump length (CRL) was 13 (range, 2-29) mm; and median embryo volume was 1.8 (range, 0.03-8.1) cm(3) using the semiautomated technique and 0.7 (range 0.009-3.6) cm(3) using the manual technique. There was a significant discrepancy in the volumes measured by the two different techniques. Assessment of the limits of agreement suggested that the semiautomated technique (-15.8% to 14.0% of the mean embryo volume) was more reliable than was the manual technique (-22.4% to 26.6%). CONCLUSION: The semiautomated technique is more reliable than is the manual technique for embryo volume measurement. However, the discrepancy in measurements between the two methods raises concerns over the validity of the semiautomated technique that require further investigation.

Prevalence of uterine anomalies and their impact on early pregnancy in women conceiving after assisted reproduction treatment.

OBJECTIVE: To estimate the prevalence of congenital uterine anomalies in subfertile women and to evaluate their influence on early pregnancy following assisted reproduction treatment (ART). METHODS: We prospectively recruited 1402 subjects undergoing ART over a period of 5 years from 2005 to 2009. Three-dimensional transvaginal sonography was performed in the early follicular phase of the menstrual cycle (days 2-5) and repeated in the late follicular phase (days 10-14) if the shape of the uterine cavity could not be assessed at the first scan. All subjects who conceived following ART were followed up to 12 weeks' gestation. Chi-square test was used to compare the pregnancy rates and miscarriage rates between women shown to have uterine anomalies and those with a normal uterus. RESULTS: One thousand three hundred and eighty-five subjects were included for final analysis after excluding 17 subjects in whom a definitive diagnosis could not be made. While 1201 (86.7%) subjects had a normal uterine cavity, uterine anomalies were demonstrated in 184 (13.3%) subjects. Arcuate uteri represented the commonest anomaly (n = 164 (11.8%)) followed by septate (n = 7 (0.5%)), unicornuate (n = 6 (0.4%)), subseptate (n = 5 (0.4%)), bicornuate (n = 1 (0.1%)) and T-shaped uteri (n = 1 (0.1%)). A total of 440 subjects who underwent ART were followed up. The pregnancy rates in women with arcuate uteri (36/66 (54.5%)) and major uterine anomalies (7/10 (70.0%)) were statistically similar (P = 0.09 and P = 0.11, respectively) to that of the matched controls with normal uteri (158/364 (43.4%)). While first-trimester miscarriage rates were similar (P = 0.81) between the control group (20/158 (12.7%)) and women with arcuate uteri (5/36 (13.9%)), women with major uterine anomalies experienced a higher miscarriage rate (3/7 (42.9%); P = 0.05). CONCLUSIONS: Women who are referred for ART have a high prevalence of congenital uterine anomalies, the most common anomaly being an arcuate uterus. These anomalies are not associated with a reduction in pregnancy rates following ART. However, while the arcuate uterus was not associated with an increase in first-trimester miscarriage, major uterine anomalies seemed to increase the risk of first-trimester miscarriage.

Delivery after caesarean section: consultant obstetricians' professional advice and personal preferences.

The objective of this study was to determine how obstetricians would wish to be managed in their own pregnancy and their advice to patients delivering after a caesarean section. A questionnaire was sent to 219 consultant obstetricians in two large UK medical deaneries investigating their personal preferences for delivery and management of spontaneous, augmented and induced labour after a caesarean section and how they advise their patients related to the indication for the previous caesarean section. Responses were analysed according to age and gender. The questionnaire yielded a 68% response rate. None would counsel against labour unless there were contraindications. The majority would recommend labour for all indications for the previous caesarean section, although personal preferences were lower (p<0.04): 56% would recommend labour to their patients after a failed instrumental delivery, but only 36% would personally choose that option (p<0.002). Female obstetricians would contemplate and recommend labour more readily than males. Labour augmentation and induction was more frequently recommended (66% and 57%, respectively) than opted for personally (57% and 52%). Reluctance for labour augmentation and induction was greatest among younger consultants. While the majority of consultants favour labour for themselves and recommend this for their patients, it was reassuring to note that patients are encouraged to make the final decision. Informed patient choice is paramount and it is therefore important that full information about risks and benefits is available.

Knowledge, attitude and practices about zoonoses with reference to Campylobacteriosis in a rural area of West Bengal.

Campylobacteriosis is a leading cause of zoonotic diarrhoea in the developed as well as developing countries. Domestic animals particularly the poultry act as a source of human infections. Domestic animal rearing is a very common practice in India particularly in rural areas. The present study of KAP of Zoonosis showed 68.2 % of 500 families interviewed did not have knowledge about zoonotic diseases in rural Bengal and not a single family had any idea of Campylobacter infections.

Primary trisomics of rice: origin, morphology, cytology and use in linkage mapping.

Twelve primary trisomics of Oryza sativa L. were isolated from the progenies of spontaneous triploids and were transferred by backcrossing to the genetic background of IR36, a widely grown high yielding rice variety. Eleven trisomics can be identified morphologically from one another and from diploids. However, triplo 11 is difficult to distinguish from diploid sibs.-The extra chromosome of each trisomic was identified cytologically at pachytene stage of meiosis, and the chromosomes were numbered according to their length at this stage. The major distinguishing features of each pachytene chromosome were redescribed.-The female transmission rates varied from 15.5% for triplo 1, the longest chromosome, to 43.9% for triplo 12, the shortest chromosome. Seven of the 12 primary trisomics transmitted the extra chromosome through the male. The low level of chromosomal imbalance tolerated by rice and other evidence are interpreted to indicate that this species is a basic diploid.-Genetic segregation for 22 marker genes in the trisomic progenies was studied. Of a possible 264 combinations, involving 22 genes and 12 trisomics, 120 were examined. Marker genes for each of the 12 chromosomes were identified. The results helped establish associations between linkage groups and cytologically identifiable chromosomes of rice for the first time. Relationships between various systems of numbering chromosomes, trisomics, linkage groups and marker genes are described, and a revised linkage map of rice is presented.

Localization of eosinophil-derived neurotoxin and eosinophil cationic protein in neutrophilic leukocytes.

Eosinophil-derived neurotoxin (EDN) and eosinophil cationic protein (ECP) are generally regarded as eosinophil-specific proteins. We tested whether EDN and ECP are present in mature neutrophils. By indirect immunofluorescence, both eosinophils and neutrophils stained with antibodies to EDN and ECP. Lysates of purified (<0.1% eosinophil contamination) neutrophils contained EDN, 112+/-4 ng/10(6) cells, and ECP, 163+/-2 ng/10(6) cells, whereas eosinophil major basic protein (MBP) was not detectable. Electron microscopic examination of immunogold-labeled buffy coat cells stained with EDN antibody showed that EDN is localized to neutrophil granules. Finally, EDN mRNA was detected in lysates of highly purified neutrophils (0.001% eosinophil contamination) by the reverse transcription-polymerase chain reaction. We conclude that proteins that are either identical to or immunologically cross-reactive with EDN and ECP are present in neutrophils and that EDN is synthesized and localized to neutrophil granules. Thus, caution must be exercised in interpreting the presence of EDN and ECP as specific markers of eosinophil-associated inflammation in human disease.

Immunofluorescent staining for mast cells in idiopathic pulmonary fibrosis: quantification and evidence for extracellular release of mast cell tryptase.

In many diseases, retrospective analysis for determining the presence of mast cells has been difficult because of their loss of metachromatic staining properties once tissue has undergone formalin fixation. We quantified mast cells in peribronchiolar tissue of idiopathic pulmonary fibrosis (IPF) and in normal human lung by using rabbit antiserum to human mast cell tryptase. In lung biopsy specimens from 15 patients with IPF, the mean number of mast cells per high-power field in connective tissue directly adjacent to the lumen of small airways (0.5 to 2 mm in diameter) and other fibrotic foci was 29.9 +/- 10.8 in comparison with 13.7 +/- 3.5 in 16 normal controls (P < 0.001). In addition, mast cells in cases of IPF had an altered appearance--irregularity of the plasma membrane and release of extracellular tryptase. We conclude that the number of mast cells is increased in IPF and that the altered appearance of the mast cells suggests that they are activated and undergoing degranulation.

Chronic eosinophilic pneumonia and idiopathic bronchiolitis obliterans organizing pneumonia: comparison of eosinophil number and degranulation by immunofluorescence staining for eosinophil-derived major basic protein.

OBJECTIVE: To undertake additional assessment of the possible overlap between bronchiolitis obliterans organizing pneumonia (BOOP) and chronic eosinophilic pneumonia (CEP). DESIGN: We retrospectively reviewed open-lung biopsy specimens from six patients with CEP, five patients with idiopathic BOOP, and four patients with secondary BOOP, encountered during the 5-year period 1986 through 1991, for the presence of eosinophils and extent of eosinophil degranulation. MATERIAL AND METHODS: Using previously described immunofluorescence methods for detection of intact eosinophils and extracellular deposition of eosinophil-derived major basic protein, we counted the number of eosinophils per x160 microscopic field and evaluated the extent of eosinophil degranulation semiquantitatively. RESULTS: The median numbers of eosinophils were 221 (range, 26 to 343) in cases of CEP, 7 (range, 1 to 65) in cases of idiopathic BOOP, and 7.5 (range, 1 to 39) in cases of secondary BOOP. More eosinophils were found in CEP than in idiopathic BOOP or all cases of idiopathic and secondary BOOP. We found no differences in the extent of eosinophil degranulation among the three groups, although a tendency for more degranulation was noted in cases of CEP. CONCLUSION: Even though clinical and histologic overlap may exist between CEP and idiopathic BOOP, the exact relationship and the role of the eosinophil in idiopathic BOOP remain to be determined.

Efficacy of atropine methylnitrate alone and in combination with albuterol in children with asthma.

The bronchodilator effect of nebulized AMN, albuterol and their combination was evaluated in 16 steroid-dependent asthmatic children. In phase 1, maximal bronchodilation was determined by dose-response studies on separate days. Maximal bronchodilator dose of each drug was administered either alone or in combination during phase 2. In phase 1, 0.11 +/- 0.01 mg/kg of albuterol and 0.03 mg/kg of AMN produced maximum bronchodilation. In phase 2, the peak response to albuterol occurred within 30 min and to AMN, at 60 min. Maximal FEV1 achieved after AMN was 90 percent of the maximal achieved after albuterol. AMN FEV1 response was better than for placebo for 3 h; that for albuterol was better for 4 h. Combination therapy produced a peak response similar to that of albuterol but was better than albuterol by 6 h. Thus, the maximum bronchodilator effect of AMN is less than that of albuterol in asthmatic children, but the combination may extend the period of bronchodilatation.

Surgically-induced astigmatism after laser in situ keratomileusis for spherical myopia.

PURPOSE: To characterize the surgically-induced-astigmatism (SIA) associated with spherical LASIK. METHODS: Refractive outcomes in 70 eyes that underwent primary myopic LASIK with purely spherical ablation were analyzed. The Summit Apex Plus excimer laser was used. The Bausch & Lomb Hansatome with the 180-microm plate was used to produce superiorly hinged flaps. The relationship between refractive astigmatism and corneal topographic astigmatism was analyzed using linear regression and vector analysis. RESULTS: There was a statistically significant negative correlation (slope = -0.21) between refractive surgically-induced astigmatism and preoperative topographic cylinder. A 0.24-D with-the-rule shift was also found. Surgically-induced astigmatism was not correlated with the magnitude of laser ablation. CONCLUSION: The lamellar keratotomy portion of LASIK reduces pre-existing corneal astigmatism and produces a relative steepening of the hinge meridian.

Longitudinal study on distribution of Phlebotomus argentipes sandflies at different heights in cattleshed.

Distribution of Ph. argentipes at three levels (level I, 0-0.91 m; level II, 0.91-1.82 m; and level III 1.82-2.74 m) above the ground in 6 cattlesheds was studied during July 1989 to June 1990. Of the 8044 Ph. argentipes caught, 3151 (39.2%), 3936 (48.9%) and 957 (11.9%) were from levels I, II, and III respectively. Both male and fed, half-fed, gravid and unfed female sandflies were found at all the three levels and in all the three seasons viz., rainy, winter and summer, of the year. The maximum height of occurrence of sandflies was 2.51 m (8.3 ft) above the ground level.

Modified method of open laparoscopy.

A modified method of open laparoscopy was performed on 175 patients. The operations were done from July 1978 through March 1983 at Orange Memorial Hospital, Orange, Texas. All the surgical laparoscopies were performed under general anesthesia with intubation. A double incision was used in all cases. There were no complications during surgery and no major postoperative problems. Cellulitis of the umbilicus was noted in three cases and stitch abscess of the second incision in one case. The majority of the patients were discharged from the hospital within 24 hours of surgery. This modified open method seems to be simple, safe and uncomplicated.

PIP: Previous laparoscopy technics are complex and cumbersome; the main disadvantages of the open method are constant leakage of gas and wound infection. This article examines a modified method of open laparoscopy performed on 175 patients in a Texas hospital. The mean age of the patients was 27.5. No intraoperative or immediate postoperative complications were noted. Surgery technics and results are given. Findings show that there are definite advantages to direct entry into the peritoneal cavity. The main purpose of this technic is to eliminate the risk of injuring the major vessels and vital organs and to make the procedure easy and simple. The double puncture technic is superior to the single puncture technic in diagnostic laparoscopy. Conclusions reached for this modified method of open laparoscopy are 1) it is a suitable and safe gynecologic procedure, 2) the incision is hidden and thus provides excellent cosmetic results, 3) the operative and recovery times are minimal, and 4) in this study, no failure occurred, and no laparotomy was necessary for complications.

First rank symptoms: concepts and diagnostic utility.

First Rank Symptoms (FRS) were first defined by Schneider as diagnostic of schizophrenia. Since then, there has been an immense debate on their diagnostic and prognostic utility. This review attempts to understand the concepts of FRS as depicted over the years and the diagnostic and prognostic implications of FRS in mental illnesses including schizophrenia. Review of relevant material showed that there are wide variations in the concepts of FRS which may be classified according to broad and narrow definitions. These variations have also led to the differences in the diagnostic systems currently being used. Although the diagnostic utility of FRS in schizophrenia remains, it is not clearly so with other mental illnesses in which these symptoms may also be observed. In addition there is controversy over the prognostic implications with evidence divided between poor and no influence on outcome.