A diagnostic dilemma of an 18-week cervical ectopic pregnancy: A case report.

INTRODUCTION: Cervical ectopic pregnancy (CEP) is characterised by the implantation of trophoblastic tissue within the cervical canal and is associated with a significant risk of maternal morbidity and mortality. This case report addresses a second-trimester CEP with unusual sonographic features suspicious of placenta accreta spectrum (PAS), which was successfully managed with an abdominal hysterectomy. CASE PRESENTATION: A 27-year-old woman, G6P2, presented to the labour ward of a rural hospital at 18 weeks of gestation with premature rupture of membranes. The index pregnancy was complicated by an absence of any antenatal care, as well as a history of cigarette smoking and cannabis use. An ultrasound scan demonstrated a live pregnancy with the foetal head within the cervical canal. A termination of pregnancy was arranged with misoprostol 200 mg orally followed by an oxytocin induction. However, a repeat ultrasound scan, after 12 h of oxytocin infusion, which failed to terminate the pregnancy, demonstrated a still live foetus as well as increased vascularity, concerning for PAS. The patient underwent an emergency abdominal hysterectomy, with an intraoperative diagnosis of a CEP. The postoperative course was unremarkable, and the patient was discharged home on day 3 post-operatively. DISCUSSION: Appropriate antenatal care and early booking-in would have identified a CEP early in gestation and allowed for minimally invasive management and potential conservation of fertility. When this is not possible in such cases, meticulous pre-operative planning by a gynaecologist with experience in advanced pelvic surgery can minimise the associated morbidity and mortality.

The risk of adverse maternal outcomes in cases of placenta praevia in an Australian population between 2007 and 2017.

BACKGROUND: Placenta praevia is characterised by an inferior placental margin that overlies or falls within 20 mm of the endocervical os. It remains a common cause of antepartum haemorrhage and is associated with adverse maternal and neonatal outcomes. AIMS: We aimed to determine the association between antepartum and postpartum haemorrhage and adverse outcomes in cases of placenta praevia. MATERIALS AND METHODS: The study population included women diagnosed with placenta praevia, who delivered between 1 April 2007 and 30 April 2017. The endpoints of interest included blood transfusion, emergency caesarean section, peripartum hysterectomy and admission to intensive care. RESULTS: There were 513 cases of placenta praevia, of which 67.3% delivered at term. Antepartum haemorrhage was associated with an increased risk of blood transfusion (relative risk (RR) 3.29; 95% CI 2.04-5.32), emergency caesarean section (RR 1.38; 95% CI 1.18-1.62) and preterm delivery, after 32 weeks gestation (RR 4.21; 95% CI 2.77-6.38). Postpartum haemorrhage more than doubled the risk of blood transfusion (RR 9.08 95% CI 5-16.44) and admission to the intensive care unit (RR 10.44; 95% CI 2.34-46.59), as well as increased the risk of peripartum hysterectomy (1.4%). We also described the management of 12 cases of placenta praevia (2.3% of the study population) delivered vaginally. CONCLUSIONS: Antepartum and postpartum haemorrhage in cases of placenta praevia are predictors of several adverse outcomes. However, the high rate of term deliveries reaffirms the current practice of expectant management.

The monaural spectral cues identified by a reverse correlation analysis of free-field auditory localization data.

The outer-ear's location-dependent pattern of spectral filtering generates cues used to determine a sound source's elevation as well as front-back location. The authors aim to identify these features using a reverse correlation analysis (RCA), combining free-field localization behaviour with the associated head-related transfer functions' (HRTFs) magnitude spectrum from a sample of 73 participants. Localization responses were collected before and immediately after introducing a pair of outer-ear inserts which modified the listener's HRTFs to varying extent. The RCA identified several different features responsible for eliciting localization responses. The efficacy of these was examined using two models of monaural localization. In general, the predicted performance was closely aligned with the free-field localization error for the bare-ear condition; however, both models tended to grossly over-estimate the localization error based on HRTFs modified by the outer-ear inserts. The RCA's feature selection notably had the effect of better aligning the predicted performance of both models to the actual localization performance. This suggests that the RCA revealed sufficient detail for both models to correctly predict localization performance and also limited the influence of filtered-out elements in the distorted HRTFs that contributed to the degraded accuracy of both models.

The management of severe pre-eclampsia and HELLP syndrome in a twin pregnancy with a known morbidly adherent placenta: A case report.

INTRODUCTION: Morbidly adherent placenta (MAP) is a rare obstetric complication, especially in cases of multiple gestation. We present a case of MAP complicating a dichorionic diamniotic (DCDA) twin pregnancy requiring delivery by emergency cesarean hysterectomy at 30 + 2 weeks of gestation. CASE PRESENTATION: A 36-year-old woman, G3P2, with a DCDA twin pregnancy and known MAP presented to the labour ward at 30 + 2 weeks of gestation with evidence of pre-eclampsia and fulminating HELLP syndrome. Delivery was indicated due to fetal distress, demonstrated by pathological findings on cardiotocography, acutely deranged liver functions and worsening thrombocytopenia. An emergency cesarean hysterectomy was performed with postoperative monitoring in the intensive-care unit. The patient was discharged home on two oral antihypertensive agents. Her platelet count and liver functions were normalized prior to discharge. DISCUSSION: Delivery planning for pregnancies complicated by MAP should commence early in the antenatal period, especially in cases where there is an anticipated risk of preterm delivery, such as multiple pregnancy. Multidisciplinary elective and emergency care plans should be developed and include interventional radiology services when available. Established protocols help to standardize care of these high-risk pregnancies and aid in decision making in emergency scenarios, such as the one presented.

The Generalization of Auditory Accommodation to Altered Spectral Cues.

The capacity of healthy adult listeners to accommodate to altered spectral cues to the source locations of broadband sounds has now been well documented. In recent years we have demonstrated that the degree and speed of accommodation are improved by using an integrated sensory-motor training protocol under anechoic conditions. Here we demonstrate that the learning which underpins the localization performance gains during the accommodation process using anechoic broadband training stimuli generalize to environmentally relevant scenarios. As previously, alterations to monaural spectral cues were produced by fitting participants with custom-made outer ear molds, worn during waking hours. Following acute degradations in localization performance, participants then underwent daily sensory-motor training to improve localization accuracy using broadband noise stimuli over ten days. Participants not only demonstrated post-training improvements in localization accuracy for broadband noises presented in the same set of positions used during training, but also for stimuli presented in untrained locations, for monosyllabic speech sounds, and for stimuli presented in reverberant conditions. These findings shed further light on the neuroplastic capacity of healthy listeners, and represent the next step in the development of training programs for users of assistive listening devices which degrade localization acuity by distorting or bypassing monaural cues.

Accommodating to new ears: the effects of sensory and sensory-motor feedback.

Changing the shape of the outer ear using small in-ear molds degrades sound localization performance consistent with the distortion of monaural spectral cues to location. It has been shown recently that adult listeners re-calibrate to these new spectral cues for locations both inside and outside the visual field. This raises the question as to the teacher signal for this remarkable functional plasticity. Furthermore, large individual differences in the extent and rate of accommodation suggests a number of factors may be driving this process. A training paradigm exploiting multi-modal and sensory-motor feedback during accommodation was examined to determine whether it might accelerate this process. So as to standardize the modification of the spectral cues, molds filling 40% of the volume of each outer ear were custom made for each subject. Daily training sessions for about an hour, involving repetitive auditory stimuli and exploratory behavior by the subject, significantly improved the extent of accommodation measured by both front-back confusions and polar angle localization errors, with some improvement in the rate of accommodation demonstrated by front-back confusion errors. This work has implications for both the process by which a coherent representation of auditory space is maintained and for accommodative training for hearing aid wearers.