Evaluation of an objective method of image assessment for first-trimester nasal bone.

OBJECTIVE: To evaluate the degree of agreement in first-trimester nasal bone assessment in a group of sonographers before and after training, using a semi-quantitative scoring system. METHODS: Four sonographers who routinely perform first-trimester screening were first shown 46 images from both normal and trisomy 21 pregnancies. For each image, they were asked to score from 0 (disagree) to 3 (agree) on five different criteria that were deemed important in nasal-bone assessment, including image size, plane and visibility of nasal bone. A training program was then conducted, and a repeat exercise was carried out using the same 46 images. Finally, in a third exercise, images from 42 patients were presented, some having more than one image. The sonographers were required to give one overall nasal-bone score for each patient. In each exercise interobserver agreement was evaluated by intraclass correlation coefficient (ICC). RESULTS: Before training, the sonographers agreed reasonably well on the five proposed criteria (ICC, 0.752), with some disagreement on their perceived image quality. The training program further improved the agreement (ICC, 0.790), particularly on whether the nasal bone was the biggest and brightest echogenic component. Agreement was excellent when they were asked to give one overall score on the nasal bone based on multiple images from one patient (ICC, 0.929). CONCLUSION: The proposed scoring system can be used to improve consistency and reliability in first-trimester nasal-bone assessment.

Obstetric outcomes in women with end-stage renal disease on chronic dialysis: a review.

Pregnancies in women on chronic dialysis for end-stage renal disease are high risk, but outcomes appear to have improved with increasing experience and advances in dialysis care. This paper reviews the existing data on outcomes in such pregnancies to enable evidence-based preconception counselling and anticipation of antenatal complications.

Methotrexate treatment for ectopic pregnancy at the KK Women's and Children's Hospital, Singapore.

INTRODUCTION: Ectopic pregnancy is an acute emergency in the first trimester where surgery is the mainstay of treatment. With the advent of improved diagnostic techniques like high-resolution transvaginal ultrasonography and expedient serum human chorionic gonadotrophin (HCG) assay, ectopic pregnancy is now diagnosed early. At this stage, the conceptus is often small, causing minimal or no symptoms. Medical management may then present an appealing alternative to surgery. Methotrexate has been widely used to treat ectopic pregnancy. A methotrexate ectopic treatment protocol was introduced by the Minimally Invasive Surgery Centre at KK Women's and Children's Hospital, Singapore. We present the results of this treatment. METHODS: A prospective review of 110 cases of medical management of ectopic pregnancy since the implementation of the treatment protocol was undertaken. Demographical data, clinical presentation, treatment progress and outcome were captured using a computer database. All patients were managed as outpatients, and a telephone call-out service was provided to ensure that treatment side effects were monitored and potential treatment failures were identified early. RESULTS: From August 2003 to October 2006, 93 (84.5 percent) patients with ectopic pregnancy were successfully treated with intramuscular methotrexate. 16 patients eventually required surgery and only one patient defaulted on follow-up. There was no major side effect detected in this cohort. The minor side effects reported included mucositis (19.1 percent) and abdominal pain (28.2 percent). CONCLUSION: Methotrexate treatment of ectopic pregnancy is safe. Our treatment protocol enabled us to achieve a reasonable treatment success rate of 84.5 percent.

Ultrasonographical features of morbidly-adherent placentas.

Morbidly-adherent placentas manifest as placenta accreta, increta or percreta, depending on the depth of placental invasion. These conditions present high risks of severe obstetrical haemorrhage at delivery. The underlying pathology is due to defects in the decidua basalis caused by a variety of insults, such as previous surgery, excessive curettage or infection. The incidence of morbidly-adherent placentas is rising as the frequency of caesarean sections increase. Imaging plays an important role in the antenatal detection of this condition. Based on the case series seen at our local institution, we describe the imaging characteristics of this condition as seen on grayscale ultrasonography, colour/power Doppler ultrasonography, three-dimensional ultrasonography and magnetic resonance imaging.

Study on psychosocial aspects and support of in vitro fertilisation programme in an Asian population.

INTRODUCTION: Undergoing in vitro fertilisation (IVF) treatment is an emotional and physical burden. Couples rate the experience of waiting for the outcome of the IVF treatment and an unsuccessful IVF treatment cycle as the most stressful. The outcome of treatment would affect how they feel about their IVF experience. Our survey aimed to increase understanding of how couples feel about the experience of IVF before and during IVF treatment so that strategies to improve their experience can be devised. METHODS: A prospective self-comparative study on the psychosocial aspects and support of patients undergoing an IVF programme was done. The questionnaire compared their responses before and during the IVF treatment. RESULTS: A total of 50 couples (100 respondents) participated in our survey. 78 percent were Chinese, 11 percent Malay and ten percent Indian. 64 percent have had tertiary education. 39 percent were married for three to five years, while 38 percent were married for six to nine years. 83 percent have no children prior to IVF treatment. Prior to counselling, 55 percent had some medical knowledge on types of treatment procedures, the treatment options and the risks of IVF. This increased to 81 percent after counselling. 80 percent found the medical counselling helpful. 80 percent found psychosocial counselling helpful in understanding the emotional issues involved in undergoing IVF treatment. 70 percent of couples felt that ongoing psychosocial counselling was useful, especially during the most stressful stage of IVF. CONCLUSION: This study increased our understanding of the emotional aspects of IVF. Current strategies of providing medical and psychosocial counselling before IVF help prepare couples psychologically. Emotional support and psychosocial counselling before and during IVF were identified as important areas, particularly while waiting for the pregnancy test result.