Prediction of adverse pregnancy outcome in monochorionic diamniotic twin pregnancy complicated by selective fetal growth restriction.

OBJECTIVE: To identify key factors associated with adverse perinatal outcome in monochorionic diamniotic twin pregnancy complicated by selective fetal growth restriction (sFGR). METHODS: This was a retrospective cohort study of all monochorionic diamniotic twin pregnancies diagnosed with sFGR at ≥ 16 weeks' gestation, in a single tertiary referral center between March 2000 and May 2015. The presence of coexisting twin-twin transfusion syndrome (TTTS) was noted. Fetal biometry and Doppler indices, including those of the umbilical artery (UA) and ductus venosus (DV), were recorded at the time of diagnosis. The type of sFGR was diagnosed according to the pattern of end-diastolic flow in the UA of the smaller twin. DV pulsatility indices for veins (DV-PIV) were converted to Z-scores and estimated fetal weight values to centiles, to correct for gestational age (GA). Cox proportional hazards model was used to examine for independent predictors of adverse perinatal outcome, which was defined according to survival and included both intrauterine fetal demise and neonatal death of the FGR twin. RESULTS: We analyzed 104 pregnancies, of which 66 (63.5%) were diagnosed with Type-I and 38 (36.5%) with Type-II sFGR at initial presentation. In pregnancies complicated by Type-II sFGR, the diagnosis of sFGR was made earlier than in those complicated by Type-I sFGR (mediam GA, 19.6 vs 21.5 weeks; P = 0.012), and Type-II sFGR was associated with increased risk of adverse perinatal outcome (intrauterine demise of the smaller twin, 34.2% vs 10.6%; P = 0.004). Twin pregnancies complicated by sFGR resulting in perinatal demise had a significantly earlier diagnosis (P = 0.002) and lower birth-weight centile of the smaller twin (P < 0.01), those with Type-I sFGR had earlier GA at delivery (P = 0.007) and those with Type-II sFGR had higher DV-PIV Z-score of the smaller twin (P = 0.003), when compared with pregnancies resulting in live birth. Coexisting TTTS had no significant impact on the perinatal outcome of pregnancies diagnosed with either Type-I or Type-II sFGR (P > 0.05 for both). Earlier GA at diagnosis (hazard ratio (HR), 0.70 (95% CI, 0.56-0.88); P = 0.002), Type-II sFGR (HR, 3.53 (95% CI, 1.37-9.07); P = 0.008) and higher DV-PIV Z-score (HR, 1.36 (95% CI, 1.12-1.65); P = 0.001) were significantly associated with increased risk of adverse perinatal outcome of the smaller twin. CONCLUSIONS: Pregnancies complicated by Type-II sFGR are diagnosed significantly earlier and are associated with increased risk of adverse perinatal outcome compared with those with Type-I sFGR. Coexisting TTTS has no significant impact on the perinatal outcome of pregnancies diagnosed with either Type-I or Type-II sFGR. Earlier GA at diagnosis, Type-II sFGR and higher DV-PIV Z-score are associated significantly with increased risk of adverse perinatal outcome of the smaller twin. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

De-novo abnormal uteroplacental circulation in third trimester: pregnancy outcome and pathological implications.

OBJECTIVE: Hypertensive disorders of pregnancy (HDP) are associated with impaired placentation, as evidenced by abnormal uterine artery (UtA) Doppler. In normal pregnancy, mean UtA pulsatility index (PI) shows a progressive decline with gestational age (GA). However, previous studies have reported that a proportion of pregnancies demonstrate worsening UtA Doppler in later pregnancy. The aim of this study was to investigate the incidence of HDP according to the change in mean UtA-PI between the second and third trimesters. METHODS: This was a retrospective cohort study of singleton pregnancies between March 1997 and March 2016 that underwent longitudinal UtA Doppler assessment in the second and third trimesters. All parameters were converted into centiles or multiples of the median (MoM), adjusting for GA. The study cohort was divided into two groups, according to change in mean UtA-PI between the second and third trimesters (those with a decrease or no change and those with an increase). HDP included women who developed pre-eclampsia and/or gestational hypertension. Logistic regression analysis was used to adjust for potential confounders. RESULTS: The analysis included 5887 pregnancies. The incidence of HDP was significantly higher in the group with increasing mean UtA-PI compared with those without (7.9% vs 5.8%; P = 0.002). Logistic regression analysis demonstrated that both third-trimester UtA-PI MoM (odds ratio (OR), 7.35; 95% CI, 4.66-11.6; P < 0.001) and stable or decrease in UtA-PI MoM between the second and third trimesters (OR, 0.43; 95% CI, 0.31-0.60; P < 0.001) were significant independent predictors for the development of HDP. CONCLUSION: Worsening of UtA Doppler is associated with HDP, independent of the value recorded in the second trimester. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Reduced fetal movements and cerebroplacental ratio: evidence for worsening fetal hypoxemia.

OBJECTIVE: To investigate the fetal cerebroplacental ratio (CPR) in women presenting with reduced fetal movements (RFM). METHODS: This was a retrospective cohort study of data collected over an 8-year period at a fetal medicine unit at a tertiary referral center. The cohort comprised 4500 singleton pregnancies presenting with RFM at or after 36 weeks' gestation and 1527 control pregnancies at a similar gestational age without RFM. Fetal biometry and Doppler parameters were recorded and converted into centiles and multiples of the median (MoM). CPR was defined as the ratio between the fetal middle cerebral artery (MCA) pulsatility index (PI) and the umbilical artery (UA) PI. Subgroup analysis for fetal size and for single vs multiple episodes of RFM was performed. RESULTS: Compared with controls, pregnancies with RFM had lower MCA-PI MoM (median, 0.95 vs 0.97; P < 0.001) and CPR MoM (median, 0.97 vs 0.99; P = 0.018). Compared with women presenting with single episodes of RFM, pregnancies with multiple episodes (≥ 2 episodes) had lower CPR MoM (median, 0.94 vs 0.98; P = 0.003). On subgroup analysis for fetal size, compared with controls, appropriate-for-gestational-age fetuses in the RFM group had lower MCA-PI MoM (median, 0.96 vs 0.97; P = 0.003) and higher rate of CPR below the 5th centile (5.3% vs 3.6%; P = 0.015). Logistic regression analysis demonstrated an association of risk of recurrent RFM with maternal age (OR, 0.96; 95% CI, 0.93-0.99), non-Caucasian ethnicity (OR, 0.72; 95% CI, 0.53-0.97), estimated fetal weight centile (OR, 1.01; 95% CI, 1.00-1.02) and CPR MoM (OR, 0.24; 95% CI, 0.12-0.47). CONCLUSION: Pregnancies complicated by multiple episodes of RFM show significantly lower CPR MoM and MCA-PI MoM compared with those with single episodes and controls. This is likely to be due to worsening fetal hypoxemia in women presenting with recurrent RFM. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Perinatal loss at term: role of uteroplacental and fetal Doppler assessment.

OBJECTIVE: To examine the associations of uterine artery (UtA) Doppler indices and cerebroplacental ratio (CPR) with perinatal outcome at term. METHODS: This was a retrospective cohort study conducted at a tertiary referral center that included all singleton pregnancies undergoing ultrasound assessment in the third trimester that subsequently delivered at term. Fetal biometry and Doppler assessment, including that of the umbilical artery (UA), fetal middle cerebral artery (MCA) and UtA, were recorded. Data were corrected for gestational age, and CPR was calculated as the ratio of MCA pulsatility index (PI) to UA-PI. Logistic regression analysis was conducted to examine for independent predictors of adverse perinatal outcome. RESULTS: The study included 7013 pregnancies, 12 of which were complicated by perinatal death. When compared with pregnancies resulting in perinatal survival, pregnancies complicated by perinatal death had a significantly higher proportion of small-for-gestational-age infants (25.0% vs 5%; P = 0.001) and a higher incidence of low (< 5th centile) CPR (16.7% vs 4.5%; P = 0.041). A subgroup analysis comparing 1527 low-risk pregnancies that resulted in fetal survival with pregnancies complicated by perinatal death demonstrated that UtA-PI multiples of the median (MoM), CPR < 5th centile and estimated fetal weight (EFW) centile were all associated significantly with the risk of perinatal death at term (all P < 0.05). After adjusting for confounding variables, only EFW centile (odds ratio (OR) 0.96 (95% CI, 0.93-0.99); P = 0.003) and UtA-PI MoM (OR 13.10 (95%CI, 1.95-87.89); P = 0.008) remained independent predictors of perinatal death in the low-risk cohort. CONCLUSION: High UtA-PI at term is associated independently with an increased risk of adverse perinatal outcome, regardless of fetal size. These results suggest that perinatal mortality at term is related not only to EFW and fetal redistribution (CPR), but also to indices of uterine perfusion. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Control of triceps surae stimulation based on shank orientation using a uniaxial gyroscope during gait.

This article presents a stimulation control method using a uniaxial gyroscope measuring angular velocity of the shank in the sagittal plane, to control functional electrical stimulation of the triceps surae to improve push-off of stroke subjects during gait. The algorithm is triggered during each swing phase of gait when the angular velocity of the shank is relatively high. Subsequently, the start of the stance phase is detected by a change of sign of the gyroscope signal at approximately the same time as heel strike. Stimulation is triggered when the shank angle reaches a preset value since the beginning of stance. The change of angle is determined by integrating angular velocity from the moment of change of sign. The results show that the real-time reliability of stimulation control was at least 95% for four of the five stroke subjects tested, two of which were 100% reliable. For the remaining subject, the reliability was increased from 50% found during the experiment, to 99% during offline processing. Our conclusion is that a uniaxial gyroscope on the shank is a simple, more reliable alternative to the heel switch for the purpose of restoring push-off of stroke subjects during gait.

Antibiotic resistance and R-factors in the fecal coliform flora of urban and rural dogs.

The incidence of antibiotic-resistant fecal coliforms in the rectal flora of 106 healthy dogs in the Galway area was investigated. As far as could be determined, none of the dogs had received antimicrobial drugs. Half of the dogs sampled were from homes within the city boundaries, whereas the remainder were from farms within a 40-mile (24.8-km) radius of the city. Of the dogs sampled, 47 had a highly susceptible fecal coliform flora, with less than 1% of the coliform population resistant to any of the four test antibiotics. Fecal coliforms resistant to one or more of the test drugs comprised between 40 and 100% of the total fecal coliform population of 36% of the rural dogs and 13% of the urban dogs sampled. Of the 473 resistant Escherichia coli isolates studied, the highest number of associated resistance determinants encountered was 5, with a medium number of 2.5. Of the E. coli isolates from rural dogs, 52% were resistant to three or more antibiotics compared with 37% of the isolates from urban dogs. A total of 64% of the isolates were shown to transfer some or all of their resistance determinants by conjugation. The transferability of ampicillin (77%) and chloramphenicol (70%) resistance determinants was higher than that of streptomycin (40%) or tetracycline (44%).

Influence of climate on the prevalence of mania.

Monthly rates of admission of manic patients to the Department of Psychiatry in Galway Regional Hospital were examined for a five-year period. Monthly variation in admission rates was compared with monthly levels of sunshine, temperature and daylength. Results indicated a significant seasonal variation in the prevalence of mania: admission rates were higher in the sunnier months and in months with a greater average daylength. It is suggested that the presentation of mania in this fashion is due to an abnormal response to light in these patients.

The interaction of anthraquinone dyes with the plasmid-mediated OXA-2 beta-lactamase.

Although beta-lactamases do not require any nucleotide co-substrates, the OXA-2 type is inhibited competitively by Cibacron Blue 3GA, and by other anthraquinone dyes, including some simpler compounds with no side chain. The enzyme causes a red shift in the spectrum of Cibacron Blue. The beta-lactamase can be adsorbed in Blue Sepharose and specifically eluted by benzylpenicillin. These results indicate that the binding of anthraquinone dyes is a specific effect similar to that seen with many nucleotide-binding enzymes.

Is serodiagnosis of herpes simplex encephalitis safe?

We present a case of probable tuberculous meningitis in which serological changes 'diagnostic' of herpes simplex encephalitis were found. Evidence is provided that the serological changes in this case represent a true false positive, and that reliance on clinical plus serological criteria to diagnose herpes simplex encephalitis could result in failure to diagnose and treat tuberculous meningitis.

Radionuclide migration through the genital tract in infertile women with endometriosis.

The migration of radionuclide through the genital tract was observed, comparing 20 patients with endometriosis and infertility with a control group of 23 infertile patients who had a normal pelvis. All patients had patent tubes at laparoscopy and chromopertubation, performed in both groups for the investigation of infertility and to diagnose the presence and extent of endometriosis. A radionuclide tubal test, using human albumin microspheres labelled with 99m-technetium (99mTc) was subsequently undertaken to observe the extent of genital tract migration of radionuclide to uterus, Fallopian tube and peritoneal cavity. The results show that radionuclide migration to the peritoneal cavity was impaired in patients with endometriosis, compared with the control group (30 versus 83%, respectively; P < 0.001). There was no relationship between migration and the severity of endometriosis. We conclude that impaired tubal function may be a cause of infertility in some patients with endometriosis.