Antibiotic therapy in patients with amniotic fluid sludge and risk of preterm birth: a meta-analysis.

PURPOSE: Amniotic Fluid Sludge (AFS) has been theorized to be sonographic evidence of an underlying infection/inflammation and studies have concluded that approximately 10% of the patients who show signs of preterm labor with intact membranes have an underlying intraamniotic infection, mostly subclinical, carrying an increased risk for preterm birth with its subsequent neonatal and maternal complications. The purpose of the present systematic review is to evaluate the impact of antibiotic therapy on preterm birth rates of women diagnosed with AFS. METHODS: We searched Medline, Scopus, the Cochrane Central Register of Controlled Trials CENTRAL, Google Scholar, and Clinicaltrials.gov databases for relevant articles published until the 30th of September 2022. Observational studies (prospective and retrospective) that evaluated the impact of antibiotics on preterm delivery rates of patients with AFS were considered eligible for inclusion. Statistical meta-analysis was performed with RStudio and we calculated pooled risk ratios (OR) and 95% confidence intervals (CI). To evaluate the information size, we performed trial sequential analysis (TSA) and the methodological quality of the included studies was assessed using RoBINS tools. RESULTS: Overall, four retrospective cohort studies were included in the present systematic review and 369 women were enrolled. We demonstrated that preterm delivery prior to 34, 32 and 28 weeks of gestational age was comparable among the groups of women that had antibiotics and those that did not (OR: 0.34, 95% CI 0.05, 2.14, 0.40 [0.09, 1.66], 0.35 [0.08, 1.58], respectively) but the statistical heterogenicity of the studies included was high for every gestational period that was examined. CONCLUSIONS: According to our study, we cannot conclude that the use of antibiotics in women with amniotic fluid sludge benefit the prognostic risk to deliver prematurely. It is quite clear that data from larger sample sizes and more well adjusted and designed studies are needed.

The role of the PLGF in the management of pregnancies complicated with fetal microsomia.

PURPOSE: To explore the contribution of maternal and fetal parameters in predicting the time interval between diagnosis and development of adverse events leading to delivery in singleton pregnancies complicated with fetal microsomia. METHODS: Prospective study on singleton pregnancies referred to a tertiary center because of suspicion of fetal smallness in the third trimester. The study cohort included cases with fetal abdominal circumference (AC) ≤ 10th centile or estimated fetal weight ≤ 10th centile or umbilical artery pulsatitlity index ≥ 90th centile. Development of pre-eclampsia, fetal demise, and fetal deterioration diagnosed by fetal Doppler studies or fetal heart rate monitoring and leading to delivery were considered as adverse events. Maternal demographics, obstetric history, blood pressure, serum PLGF, and fetal Doppler studies were explored as predictors of the time interval between the first visit to the clinic and the diagnosis of complications. RESULTS: In 59 women, the median incubation period from presentation to the clinic to an adverse event was 6, 2 weeks, whereas half of the pregnancies (52.5%) did not develop any adverse event. PLGF was the strongest predictor of adverse events. Both PLGF in raw values and PLGF MOM had equally good predictive ability (AUC 0.82 and 0.78 respectively). Optimal cut-off points were 177.7 pg/ml for PLGF raw values (sensitivity 83% and specificity 66.7%) and 0.277 MoM (sensitivity 76% and specificity 86.7%). On multiple Cox regression analysis, maternal systolic blood pressure, PLGF, fetal increased umbilical artery PI, and reduced CP ratio were independently associated with adverse events. Half of the pregnancies with low PLGF and only one in ten with high PLGF were delivered within two weeks after the initial visit. CONCLUSION: Half of the pregnancies carrying a small fetus in the third trimester will not develop maternal or fetal complications. PLGF is a strong predictor of adverse events that can be used to customize antenatal care.

Complete longitudinal vaginal septum resection. Description of a bloodless new technique.

PURPOSE OF INVESTIGATION: To describe a novel approach for longitudinal vaginal septum (LVS) resection. Materials and Methods: Two cases of young girls with a uterus didelphys and a longitudinal vaginal septum. The technique consisted in grasping the vaginal septum with a laparoscopic 33-cm long bipolar cutting forceps, five-mm in diameter, and divided it to its midportion towards the two cervices. RESULTS: In both cases, the procedure was straightforward, uncomplicated, completed within three minutes and the patients were discharged four hours later. It was associated with minimal blood loss, short recovery time, absence of local ischemia, and optimum healing process. CONCLUSION: The authors believe that surgical safety, efficacy and operative result make bipolar cutting forceps a tailored option for LVS resection.

Agenesis of ductus venosus in sequential first and second trimester screening.

OBJECTIVE: The goal of this study is to evaluate the potential of first trimester (FT) screening in the diagnosis of agenesis of the ductus venosus (ADV) and to study its prevalence in a low-risk population, the associated conditions, and pregnancy outcome. METHOD: Prospective, sequential screening study at two tertiary units with morpho-functional evaluation of the ductus venosus during the first and second trimester screening. We quantified the FT detection rate, prevalence, and associated conditions: umbilical shunting type, concomitant anomalies, and outcome. RESULTS: In 6114 consecutive pregnancies, we identified 11 cases of ADV. Ten (91%) were identified during the FT examination. The prevalence was 1 in 556, similar for both centers (1/478 vs. 1/691). Major structural defects and fetal effusions were detected in 8 (73%). twenty two percent had a major chromosomal abnormality. In 3 cases, the anomaly was isolated and had normal outcome, independent of liver by-pass, caliber of the shunt, and NT thickness. CONCLUSIONS: Agenesis of the ductus venosus can be detected during FT. The early detection of ADV is important given its high association with major abnormalities.

Improved detection rate of structural abnormalities in the first trimester using an extended examination protocol.

OBJECTIVE: To assess the potential of first-trimester sonography in the detection of fetal abnormalities using an extended protocol that is achievable with reasonable resources of time, personnel and ultrasound equipment. METHODS: This was a prospective two-center 2-year study of 5472 consecutive unselected pregnant women examined at 12 to 13 + 6 gestational weeks. Women were examined using an extended morphogenetic ultrasound protocol that, in addition to the basic evaluation, involved a color Doppler cardiac sweep and identification of early contingent markers for major abnormalities. RESULTS: The prevalence of lethal and severe malformations was 1.39%. The first-trimester scan identified 40.6% of the cases detected overall and 76.3% of major structural defects. The first-trimester detection rate (DR) for major congenital heart disease (either isolated or associated with extracardiac abnormalities) was 90% and that for major central nervous system anomalies was 69.5%. In fetuses with increased nuchal translucency (NT), the first-trimester DR for major anomalies was 96%, and in fetuses with normal NT it was 66.7%. Most (67.1%) cases with major abnormalities presented with normal NT. CONCLUSIONS: A detailed first-trimester anomaly scan using an extended protocol is an efficient screening method to detect major fetal structural abnormalities in low-risk pregnancies. It is feasible at 12 to 13 + 6 weeks with ultrasound equipment and personnel already used for routine first-trimester screening. Rate of detection of severe malformations is greater in early- than in mid-pregnancy and on postnatal evaluation. Early heart investigation could be improved by an extended protocol involving use of color Doppler.

Neuroimaging parameters in early open spina bifida detection. Further benefit in first trimester screening?

OBJECTIVE: Morphological investigation of the central nervous system (CNS) in fetuses with positive markers for open spina bifida (OSB) detection, visualized by ultrasound during the first trimester of pregnancy. MATERIALS AND METHODS: Data from fetuses that underwent routine first trimester ultrasound scan in our center during September 2007-March 2011 and presented abnormal aspects of the fourth ventricle, also referred as intracranial translucency (IT), provided the morphological support to evaluate CNS features. A neuro-histological study of posterior cerebral fossa illustrated anatomical features of the structures involved in the sonographic first trimester detection of neural tube defects. RESULTS: Abnormal IT aspects were found in OSB cases examined in the first trimester, but also in other severe cerebral abnormalities. Brain stem antero-posterior diameter (BS) and brain stem to occipital bone (BSOB) ratio may be more specific for OSB detection. Correlations between histological aspects of posterior brain fossa and ultrasound standard assessment have been made; highlighting the anatomical features involved by the new techniques developed for OSB early detection. CONCLUSIONS: Preliminary results show that modern sonographic protocols are capable to detect abnormalities in the morphometry of the posterior brain. First trimester fourth ventricle abnormalities should be followed by careful CNS evaluation because are likely to appear in OSB affected fetuses, but also in other CNS severe anomalies; in such cases, normal BS and BSOB ratio may serve as indirect argument for spine integrity, if specificity is confirmed in large series of fetuses.

Screening for pre-eclampsia and fetal growth restriction by uterine artery Doppler and PAPP-A at 11-14 weeks' gestation.

OBJECTIVE: To assess the role of maternal demographic characteristics, uterine artery Doppler velocimetry, maternal serum pregnancy-associated plasma protein-A (PAPP-A) and their combination in screening for pre-eclampsia and small-for-gestational age (SGA) fetuses at 11-14 weeks. METHODS: This was a prospective study of 878 consecutive women presenting for a routine prenatal ultrasound examination at 11-14 weeks. Pulsed wave Doppler was then used to obtain uterine artery flow velocity waveforms and the mean pulsatility index (PI) of the uterine arteries was calculated. Maternal serum samples for PAPP-A were assayed. Along with maternal history, these measurements were compared in their ability to predict adverse outcome, defined as pre-eclampsia and/or SGA and/or placental abruption. RESULTS: Mean uterine artery PI > or = 95(th) centile and PAPP-A < or = 10(th) centile each predicted 23% of the women that developed pre-eclampsia and 43% of cases of placental abruption. For SGA < or = 5(th) centile, mean uterine artery PI > or = 95(th) centile predicted 23% of cases and PAPP-A < or = 10(th) centile predicted 34%. Independent predictors for subsequent development of pre-eclampsia were increased mean uterine artery PI > or = 95(th) centile (OR, 2.76; 95% CI, 1.11-6.81) and maternal history of pre-eclampsia/hypertension (OR, 50.54; 95% CI, 10.52-242.73). The predicting factors for SGA < or = 5(th) centile were increased mean uterine artery PI > or = 95(th) centile (OR, 2.0; 95% CI, 1.07-3.74) and low PAPP-A (OR, 0.43; 95% CI, 0.20-0.93). Increased uterine artery PI was the only independent factor in the prediction of placental abruption (OR, 8.49; 95% CI, 2.78-25.94). The combination of uterine artery PI and maternal history of pre-eclampsia/hypertension was better than was using uterine artery Doppler alone in predicting pre-eclampsia. Similarly, for the prediction of SGA < or = 5(th) centile, combining uterine artery Doppler and maternal serum PAPP-A was better than was uterine artery Doppler alone. In both cases, the difference approached statistical significance. CONCLUSIONS: The combination of maternal history with abnormal uterine artery Doppler and low PAPP-A level at 11-14 weeks achieves better results than does either test alone in the prediction of pre-eclampsia and SGA.

Short-rib-polydactyly syndrome presenting with increased nuchal translucency in a high-risk family.

Short-rib-polydactyly syndrome represents a group of rare, autosomal recessive, lethal skeletal dysplasias characterized by hypoplastic thorax, short ribs, short limbs, polydactyly, and visceral abnormalities. We describe an affected fetus from a high-risk family presenting with increased nuchal translucency at 13 weeks of pregnancy. The diagnosis was established in the 2nd trimester.

Assessment of fetal anatomy at the 11-14-week ultrasound examination.

OBJECTIVE: To assess the feasibility of examining cardiac and non-cardiac fetal anatomy in a low-risk population in the setting of the routine 11-14-week ultrasound scan. METHODS: This was a prospective study of 1144 women with viable, singleton pregnancies at 11-14 weeks of gestation. The ultrasound examination was performed transabdominally and transvaginally and fetal anatomy assessment included visualization of the skull, brain, face, spine, four-chamber and three-vessel views of the heart, stomach, abdominal wall, kidneys, bladder and extremities. RESULTS: Complete examination of the fetal anatomy was achieved in 48% of the fetuses, whereas non-cardiac anatomy was examined successfully in 86% of the fetuses. The use of the transvaginal approach increased successful examination of the fetal anatomy from 72% to 86% of the fetuses and transvaginal scanning was particularly helpful in examining the face, kidneys and bladder. Non-cardiac anatomy visualization increased from 65% for fetuses with a crown-rump length of 45-54 mm, to 84%, 93% and 96% for fetuses with a crown-rump length of 55-64 mm, 65-74 mm and more than 74 mm, respectively. In the same groups the four-chamber view was seen in 67%, 86%, 93% and 97% of fetuses, and the three-vessel view was seen in 25%, 46%, 58% and 67% of fetuses, respectively. Maternal habitus and crown-rump length were found to be statistically significant contributors to the rate of successful examination of fetal anatomy. CONCLUSION: Examination of fetal anatomy is feasible during the routine 11-14-week scan. The optimal gestational age for examining both cardiac and non-cardiac anatomy is from the beginning of the 12th week to the end of the 13th week of gestation. Access to the transvaginal approach is important for completeness of the examination.

The dependence identification neural network construction algorithm.

An algorithm for constructing and training multilayer neural networks, dependence identification, is presented in this paper. Its distinctive features are that (i) it transforms the training problem into a set of quadratic optimization problems that are solved by a number of linear equations, (ii) it constructs an appropriate network to meet the training specifications, and (iii) the resulting network architecture and weights can be further refined with standard training algorithms, like backpropagation, giving a significant speedup in the development time of the neural network and decreasing the amount of trial and error usually associated with network development.

A simple method to derive bounds on the size and to train multilayer neural networks.

A new derivation is presented for the bounds on the size of a multilayer neural network to exactly implement an arbitrary training set; namely the training set can be implemented with zero error with two layers and with the number of the hidden-layer neurons equal to #1>/= p-1. The derivation does not require the separation of the input space by particular hyperplanes, as in previous derivations. The weights for the hidden layer can be chosen almost arbitrarily, and the weights for the output layer can be found by solving #1+1 linear equations. The method presented exactly solves (M), the multilayer neural network training problem, for any arbitrary training set.

Neural networks for control systems.

A description is given of 11 papers from the April 1990 special issue on neural networks in control systems of IEEE Control Systems Magazine. The emphasis was on presenting as varied and current a picture as possible of the use of neural networks in control. The papers described cover: the design of associative memories using feedback neural networks; a method to use neural networks to control highly nonlinear systems; the modeling of nonlinear chemical systems using neural networks; the identification of dynamical systems; the comparison of conventional adaptive controllers and neural-network-based controllers; a method to provide adaptive control for nonlinear systems; neural networks and back-propagation; the back-propagation algorithm; the use of trained neural networks to regulate the pitch attitude of an underwater telerobot; the control of mobile robots; and the issues involved in integrating neural networks and knowledge-based systems.