Cesarean scar pregnancy is a precursor of morbidly adherent placenta.

OBJECTIVE: To provide further sonographic, clinical and histological evidence that Cesarean scar pregnancy (CSP) is a precursor to and an early form of second- and third-trimester morbidly adherent placenta (MAP). METHODS: This is a report of 10 cases of CSP identified early, in which the patients decided to continue the pregnancy, following counseling that emphasized the possibility of both significant pregnancy complications and a need for hysterectomy. Pregnancies were followed at 2-4-week intervals with ultrasound scans and customary monitoring. The aim was for patients to reach near term or term and then undergo elective Cesarean delivery and, if necessary, hysterectomy. Charts, ultrasound images, operative reports and histopathological examinations of the placentae were reviewed. RESULTS: The ultrasound diagnosis of CSP was made before 10 weeks. By the second trimester, all patients exhibited sonographic signs of MAP. Nine of the 10 patients delivered liveborn neonates between 32 and 37 weeks. In the tenth pregnancy, progressive shortening of the cervix and intractable vaginal bleeding prompted termination, with hysterectomy, at 20 weeks. Two other patients in the cohort had antepartum complications (bleeding at 33 weeks in one case and contractions at 32 weeks in the other). All patients underwent hysterectomy at the time of Cesarean delivery, with total blood loss ranging from 300 to 6000 mL. Placenta percreta was the histopathological diagnosis in all 10 cases. CONCLUSION: The cases in this series validate the hypothesis that CSP is a precursor of MAP, both sharing the same histopathology. Our findings provide evidence that can be used to counsel patients with CSP, to enable them to make an informed choice between first-trimester termination and continuation of the pregnancy, with its risk of premature delivery and loss of uterus and fertility.

Caring too much? Cultural lag in African Americans' perceptions of filial responsibilities.

This paper explores African Americans' ideas about filial obligations. The findings are based on focus groups with eight different age-homogeneous groups. Although all age groups expressed strong commitment to filial obligations, they differed in their ability to recognize and accept constraints on family care. This variation was clearly related to cohort differences and participants' own experiences as caregivers or care receivers. Viewing our data through the lens of Clark and Anderson's (1965) adaptation model that distinguishes between adaptation, which is always positive, and adjustment, which may be negative, we found that younger cohorts' unbending idealism may lead to maladaptive behaviors should they be called upon suddenly and without preparation to assume the role of primary caregivers.

Three-dimensional ultrasound evaluation of the fetal brain: the three horn view.

OBJECTIVE: To describe an easy technique for obtaining one of the most important views of the fetal brain and image. The entire lateral ventricle including the anterior, posterior and inferior horns is demonstrated on one image. We propose to call this view, obtained in an oblique plane 'the three horn view'. METHODS: Depending upon the scanning technique employed there are two ways to obtain the three horn view: (1) by two-dimensional (2D) transvaginal transfontanelle sonography obtained by using the left and right Oblique-1 sections, and (2) by three-dimensional (3D) imaging of the fetal brain, is obtained by acquiring a volume scan of the brain orienting the fetal head in the three main orthogonal planes and by rotating or tilting the midcoronal section to the left and right. RESULTS: To illustrate the technique of obtaining the three horn view four normal fetal brains were scanned. Two scans utilized the 2D transvaginal transfontanelle approach and two scans utilized the 3D scanning technique. The same technique was then applied to six fetuses with various brain malformations with inflicted changes in the shape of the proposed three horn view. CONCLUSION: The three horn view, depicting the anterior, posterior, and inferior horns on the same image, was easy to obtain using both the 2D and the 3D ultrasound techniques. It provided diagnostic and clinically useful information much like neonatal transfontanelle ultrasound imaging after which it was emulated.

Three-dimensional transvaginal neurosonography of the fetal brain: 'navigating' in the volume scan.

OBJECTIVES: Fetal neuroscan by ultrasound has gained in importance over recent years. Two-dimensional (2D) transvaginal sonography was an important step in understanding the constantly changing and developing fetal brain. The objective of this article is to describe the use of three-dimensional ultrasound of the fetal brain enhanced by the transvaginal transfontanelle scanning technique. METHODS: Thirty-four pregnant patients were referred to us because of a history of brain anomaly or suspected brain pathology. The fetuses were scanned transvaginally. Two-dimensional as well as three-dimensional (3D) images were generated. The volumes obtained by the 3D-ultrasound machine were displayed in the three conventional orthogonal planes (coronal, sagittal and axial). RESULTS: Of the 34 fetuses 10 had normal brain anatomy and 24 had brain pathology. In all 34 cases the 2D images as well as the 3D volumes were of diagnostic quality and all three planes could be obtained. The axial sections could only be obtained by the 3D re-construction of the volume scans. The 2D images produced were acquired from a common point originating from the foot print of the transvaginal probe at the fetal anterior fontanelle or the sagittal suture, the sections 'radiate' from this point. Therefore, these sections are not parallel sections, but are oblique to each other. In contrast, the 3D volume could be examined using the classical parallel sections in all three orthogonal planes. The posterior fossa could be seen better if the footprint of the probe was placed over the posterior fontanelle or on the sagittal suture. The marker dot enabled a precise creation of anatomy and pathology. In the 'angio mode' it was possible to follow the anterior cerebral and pericallosal artery. CONCLUSIONS: The 3D-ultrasound technology using the transvaginal approach is effective and practical to perform during fetal neuroscan. The ability to 'navigate' in the volume and the 'marker dot' enables exact location of normal structures and evaluation fetal brain pathology. The volume can be reviewed over and over again, can be mailed to an expert, could be shown to consultants (pediatric neurology and neurosurgeons) and used for teaching.

Long-term care case management: a look at alternative models.

Case management has increased substantially and is now an integral component of the home care system in the United States. Although case management has been implemented in home care programs since the 1970s, the core components of the intervention have remained unchanged. Standardization of practice can be important; however, it is also necessary for care paradigms to be modified as the health and long-term care systems change. This article presents alternative approaches to delivering case management now being tested in two home care programs funded through community property tax levies.

Consumer-directed home care: client profiles and service challenges.

This article presents the results of a study that sought to develop a profile of potential consumer-directed clients in a countywide home care program. In order to develop this profile, clients were assessed by the telephone case manager and the in-home assessor, each of whom made an independent decision about the appropriate level of case management for the client. Of the 278 clients assessed, 16.5% were identified by both professionals as candidates for consumer-directed care; for another 42.1%, the case manager and assessor agreed that a more intense level of care was appropriate. For the remaining clients (41.4%), there was disagreement between the two assessments about the appropriate level of case management. Clients identified as consumer-directed candidates were more likely to be female, to have fewer impairments, to receive fewer services, to have low incomes, and to live alone. Case managers' and assessors' comments indicated that the consumer-directed group consisted of those more likely to have stable health and a good support system, along with an understanding of the service system and a willingness to make contacts in case of problems or status changes. The article also explores the implications for service providers.

How can infant and perinatal mortality rates be compared internationally?

Much of the confusion surrounding international comparisons of infant and perinatal mortality rates could be removed if single definitions of live birth and fetal death were universally adopted. Suggestions as to how this might be achieved are made below.

PIP: Although infant and perinatal mortality rates are important indicators of health status, it is difficult to make valid international comparisons because of the great diversity of definitions of a live birth or a fetal death. In the 9th revision of the international classification of diseases, live birth is defined as the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy, which, after such separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. The above definition of live birth is unsatisfactory, because many aborted fetuses weighing 200-300 grams or less may move slightly after birth or have a transient heartbeat, even though gestation was less than 22 weeks. Also in the 9th revision, fetal death (stillbirth) is defined as death prior to the complete expulsion from its mother of a product of conception, irrespective of the duration of pregnancy; indicated by the fact that the fetus does not breathe or show any other evidence of life. The following new definitions are suggested. Live birth is the complete expulsion from its mother of a product of conception weighing 500 grams or more, irrespective of the duration of the pregnancy, which breathes or shows any other evidence of life. If a product of conception weighing less than 500 grams shows evidence of life 24 hours after birth, it should be considered as a live birth. When birth weight is unavailable, the gestational age (22 weeks) or body length corresponding to 500 grams should be used. Similarly, fetal death (stillbirth) is death prior to the complete expulsion or extraction from its mother of a product of conception weighing 500 grams or more, irrespective of the duration of the pregnancy.