Short-term neonatal and long-term infant outcome of late-preterm twins: nationwide population-based study.

OBJECTIVES: To evaluate the short- and long-term outcome of late-preterm compared with term birth in twin pregnancy. METHODS: This retrospective observational cohort study included all women who had a twin delivery between 1 January 2007 and 31 December 2010 recorded in the claims database of the Korea National Health Insurance, with at least one follow-up recorded in the database of the National Health Screening Program for Infants and Children. Outcomes were analyzed at the pregnancy level, with adverse outcome being defined as an adverse outcome in one or both twins, identified by a diagnosis according to the International Classification of Diseases 10th Revision. The primary short-term outcome was composite morbidity, which included any of the following: transient tachypnea, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage and bronchopulmonary dysplasia. Long-term adverse outcome included any neurological or neurodevelopmental outcome, defined by prespecified neurological and developmental diagnoses; these were assessed by following up all neonates until the end of 2018, by which time they were 8-11 years of age. Outcomes were compared between twins delivered late preterm (34 + 0 to 36 + 6 weeks) and those delivered at term (≥ 37 weeks). RESULTS: Among 17 189 women who delivered twins at ≥ 34 weeks of gestation during the study period, 5032 (29.27%) women delivered in the late-preterm period. On multivariate analysis, compared with the twins delivered at term, the late-preterm twins had an increased risk for the primary short-term outcome of composite morbidity (adjusted odds ratio (aOR), 2.09; 95% CI, 1.90-2.30), including transient tachypnea (aOR, 1.85; 95% CI, 1.64-2.09), respiratory distress syndrome (aOR, 2.31; 95% CI, 2.04-2.62), necrotizing enterocolitis (aOR, 2.10; 95% CI, 1.20-3.69) and intraventricular hemorrhage (aOR, 2.13; 95% CI, 1.46-3.11). For the long-term outcome, the late-preterm twins also had an increased risk for any neurological or neurodevelopmental outcome (adjusted hazard ratio, 1.14; 95% CI, 1.07-1.21). CONCLUSIONS: Twins delivered in the late-preterm period have an increased risk for short- and long-term morbidity compared with twins delivered at term. These results should be considered when determining the timing of delivery in uncomplicated twin pregnancy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Morphologic and morphometric characteristics of the adductor minimus in Korean: its topographic relationship with respect to neighbouring anatomical structure and clinical significance.

BACKGROUND: The aim of this study was to clarify the morphologic and morphometric characteristics of the adductor minimus (AMi) and to observe its topographic relationships relative to the adjacent anatomical structures. MATERIALS AND METHODS: This study investigated 54 thighs of 27 Korean cadavers. RESULTS: The AMi was a small and flat muscle observed in 94.4% of the specimens. It originated from the inferior ramus of the pubis as the upper part of the adductor magnus (AMa), and inserted from the lesser trochanter to the upper part of the linea aspera. The AMi was completely separate from the AMa in 63.0% of the specimens. The medial circumflex femoral artery was always found at the superior border of the AMi, while the first and second perforating arteries were found inferior to the muscle in 55.6% and 37.0% of specimens, respectively. A supernumerary muscle was found with the AMi in 42.6% of the specimens, and it originated from the inferior ramus of the pubis and inserted into the posterior side of the lesser trochanter. The obturator externus and AMi were found superoposterior and inferior to the supernumerary muscle, respectively, while the posterior branch of the obturator nerve passed underneath it. CONCLUSIONS: The results of this study may provide physicians with the accurate anatomical knowledge that they require for managing groin pain and applying a regional nerve block with ultrasound guidance in this adductor region.

Female reproductive factors and the risk of dementia: a nationwide cohort study.

BACKGROUND AND PURPOSE: The aim was to investigate whether female reproductive factors are associated with dementia. METHODS: In all, 4 696 633 post-menopausal women without dementia were identified using the Korean National Health Insurance System database. Data on reproductive factors were collected using a self-administered questionnaire. Dementia was determined using dementia diagnosis codes and anti-dementia drug prescription. Cox proportional hazards regression was conducted to assess the hazard ratio (HR) for dementia according to reproductive factors. RESULTS: During a median follow-up of 5.74 years, there were 212 227 new cases of all-cause dementia (4.5%), 162 901 cases of Alzheimer's disease (3.5%) and 24 029 cases of vascular dementia (0.5%). The HR of dementia was 1.15 [95% confidence interval (CI) 1.03-1.16] for menarcheal age ≥17 years compared with menarcheal age 13-14 years, 0.79 (0.77-0.81) for menopausal age ≥55 years compared with menopausal age <40 years, and 0.81 (0.79-0.82) for fertility duration ≥40 years compared with fertility duration <30 years. Whilst being of parity one (HR 0.89, 95% CI 0.85-0.94) and breastfeeding <6 months (HR 0.92, 95% CI 0.88-0.95) was associated with lower risk of dementia, being of parity two or more (HR 1.04, 95% CI 0.99-1.05) and breastfeeding ≥12 months (HR 1.14, 95% CI 1.01-1.07) was associated with a higher risk of dementia than women without parity or breastfeeding history. Use of hormone replacement therapy and oral contraceptives independently reduced the dementia risk by 15% and 10%, respectively. CONCLUSIONS: Female reproductive factors are independent risk factors for dementia incidence, with higher risk associated with shorter lifetime endogenous estrogen exposure.

Blood lactate concentration and shock index associated with massive transfusion in emergency department patients with primary postpartum haemorrhage.

BACKGROUND: We hypothesised that lactate concentrations are independently associated with massive transfusion in patients with primary postpartum haemorrhage. Moreover, combining lactate concentrations with the shock index, defined as the ratio of heart rate to systolic arterial blood pressure, can improve the predictive performance for massive transfusion. METHODS: We retrospectively analysed patients with primary postpartum haemorrhage in the emergency department of a tertiary referral centre in Korea between January 1, 2004 and December 31, 2015. RESULTS: Of the 302 patients, 101 (33.4%) patients required massive transfusion. Lactate concentration was independently associated with the requirement for massive transfusion [odds ratio, 1.56; 95% confidence interval (CI), 1.31-1.87; P<0.01]. The area under the receiver operating characteristic curve of lactate concentration and shock index for massive transfusion was 0.788 (95% CI: 0.736-0.840; P<0.01) and 0.776 (95% CI: 0.717-0.836; P<0.01), respectively. Lactate elevation (>4.0 mM L-1) was associated with 86.1% specificity and 67.8% positive predictive value for massive transfusion. When combining elevated lactate concentrations (>4.0 mM L-1) with a shock index >1.0, the specificity and positive predictive value increased to 95.5% and 82.4%, respectively. CONCLUSIONS: Point-of-care testing of lactate concentrations in the emergency department may be useful to predict massive transfusion requirements in primary postpartum haemorrhage. Combining initial lactate concentrations with the shock index improves the predictive performance for massive transfusion requirements and may contribute to rapid risk stratification of patients with primary postpartum haemorrhage in need of transfusion and further focus on early interventions to control bleeding.

Zuckerkandl Tubercle of the Thyroid Gland: Correlations between Findings of Anatomic Dissections and CT Imaging.

BACKGROUND AND PURPOSE: The Zuckerkandl tubercle is located at the posteromedial border of the thyroid lobe, and it may be confused with a neoplasm or other mass. This study was performed to clarify the position and morphologic characteristics of the Zuckerkandl tubercle by dissecting cadavers and to compare the findings with the corresponding CT images obtained in the same cadavers. MATERIALS AND METHODS: One hundred thyroid lobes from 50 fresh cadavers were dissected for this study (20 males and 30 females; mean age at death, 77.3 ± 11.5 years). CT scans were obtained in 10 of the cadavers by using a 128-channel multidetector row CT scanner before dissection. RESULTS: The Zuckerkandl tubercle of the thyroid gland was observed in 83% of the specimens. It was mostly located at the posteromedial border of the thyroid lobe and within the middle two quarters (2nd and 3rd) of the thyroid lobe. The Zuckerkandl tubercle was classified into 3 types based on its direction of extension: posteromedial in 64% of the specimens, posteromedial and superior in 13%, and posteromedial and inferior in 6%. On axial CT, the Zuckerkandl tubercle was usually continuous with the posteromedial part of the thyroid lobe and extended posteromedially to the esophagus. The parts of the Zuckerkandl tubercle that protrude posteromedially and superiorly or posteromedially and inferiorly from the thyroid lobe appeared separated from the thyroid gland by a thin, low-density string on axial CT. CONCLUSIONS: Zuckerkandl tubercles that protrude toward the posteromedial and superior or inferior direction could cause confusion due to their separation when performing diagnoses with CT images.

Separate muscle bundles of the flexor digitorum superficialis overlying the ulnar nerve.

BACKGROUND: The aim of this study was to elucidate the morphological charac-teristics of the muscle bundles of the flexor digitorum superficialis (FDS) attached to the intermuscular aponeurosis (IMA) and any related structure that could potentially compress the ulnar nerve. MATERIALS AND METHODS: Fifty embalmed limbs of 34 adult cadavers were studied. RESULTS: The FDS arose as multiple separate bundles from the IMA of the lateral surface of the flexor carpi ulnaris in 76% of specimens. Below their origin, these separate bundles became attached continuously as a single mass to form the muscle belly. There were 1, 2, 3, 4 and 5 arising FDS muscle bundles in 28%, 30%, 4%, 10% and 4% of specimens, respectively. The muscle bundles were attached either only superficially (24% of cases) or across the entire width (20% of cases) of the IMA. In 32% of the specimens, bundles arose from the IMA in a combined fashion, being attached to the IMA superficially, deep and across the entire structure. The muscle bundles that arose from the deep part or entire width of the IMA were in contact with the ulnar nerve in 52% of specimens. In 11 (22%) specimens, the deep borders of the lowest muscle bundles close to the ulnar nerve were composed of tendinous fibres that divided from the IMA of the lateral surface of the flexor carpi ulnaris. The distance from the medial epicondyle to the lowest point of the FDS arising from the IMA was 62.0 ± 19.7 mm. CONCLUSIONS: The thick tendinous deep border of the lowest muscle bundle of the FDS where it attaches to the IMA is a potential cause of ulnar nerve compression.

Bleeding after dilatation and curettage: the efficacy of transcatheter uterine artery embolisation.

AIM: To evaluate safety and clinical outcomes of uterine artery embolisation (UAE) for bleeding after dilatation and curettage (D&C) performed for abortion or termination. MATERIALS AND METHODS: The outcomes were analysed in 11 patients who underwent UAE for bleeding after D&C for missed abortions (n=8), caesarean scar pregnancies (n=2), or planned termination (n=1) between October 2001 and December 2013. Angiograms and medical records were retrospectively reviewed in order to obtain the patients' baseline characteristics, technical/clinical success rate, complications, and follow-up data regarding menstruation. RESULTS: Technical success, defined as successful catheterisation of both uterine arteries with embolisation to haemostasis, was 100%, whereas clinical success, defined as cessation of bleeding after the initial session of UAE and without the need for additional UAE or surgery for the purpose of haemostasis, was 81.8% (nine of 11). In the two patients with clinical failure due to recurrent vaginal bleeding after UAE, one patient underwent repeat UAE and showed a successful outcome, whilst the other patient required hysterectomy with pathological results of placenta increta. Two other patients underwent hysterectomy for placenta percreta or hydatidiform mole-mimicking remnant placenta. None of the patients included in the present series had procedure-related complications. Menstruation resumed in all eight patients with an intact uterus during the mean follow-up period. CONCLUSION: UAE may be a safe and effective treatment for bleeding after D&C, especially for women who wish to preserve their fertility; however, hysterectomy may be indicated for patients with a placental abnormality.

Recommendations on routine mid-trimester anomaly scan.

The purpose of this paper is to discuss the minimal requirements of the routine mid-trimester anomaly scan in Asian countries after taking into account various factors, including local circumstances, medical practice, guidelines, and availability of experienced sonographers and high-resolution ultrasound machines, which affect the prenatal detection rate of fetal anomalies. In general, a routine mid-trimester anomaly scan includes the assessment of the number of fetuses, fetal cardiac activity, size, anatomy, liquor and placental location. The most controversial issue is which fetal structures should at least be examined. We discussed the requirements of a basic routine scan, as well as the optional views, which can be obtained if feasible to improve the detection of fetal, placental or maternal abnormalities. Routine anomaly scan remains a clinical challenge.

Feasibility of using auto Mod-MPI system, a novel technique for automated measurement of fetal modified myocardial performance index.

OBJECTIVES: To evaluate the reproducibility of measurement of the fetal left modified myocardial performance index (Mod-MPI) determined using a novel automated system. METHODS: This was a prospective study of 116 ultrasound examinations from 110 normal singleton pregnancies at 12 + 1 to 37 + 1 weeks' gestation. Two experienced operators each measured the left Mod-MPI twice manually and twice automatically using the Auto Mod-MPI system. Intra- and interoperator reproducibility were assessed using intraclass correlation coefficients (ICCs) and the manual and automated measurements obtained by the more experienced operator were compared using Bland-Altman plots and ICCs. RESULTS: Both operators successfully measured the left Mod-MPI in all cases using the Auto Mod-MPI system. For both operators, intraoperator reproducibility was higher when performing automated measurements (ICC = 0.967 and 0.962 for Operators 1 and 2, respectively) than when performing manual measurements (ICC = 0.857 and 0.856 for Operators 1 and 2, respectively). Interoperator agreement was also better for automated than for manual measurements (ICC = 0.930 vs 0.723, respectively). There was good agreement between the automated and manual values measured by the more experienced operator. CONCLUSIONS: The Auto Mod-MPI system is a reliable technique for measuring fetal left Mod-MPI and demonstrates excellent reproducibility.

Memb-roller: an effective way of making membrane rolls for pathological examination and studies of human placenta.

For the pathological evaluation of the chorioamniotic membranes, a membrane roll is made to give an orientation to the sections and to cover more extended planes. We designed a new instrument, Annie's memb-roller, for easy preparation of membrane rolls. Annie's memb-roller has two non-toothed arms which are 2 mm wide, 1 mm thick, and 8 cm long. To test its effectiveness in making a membrane roll, the placentas obtained from pregnant women (n = 10) with various obstetrical conditions were used. Preparation of the membrane rolls using Annie's memb-roller was easy and successful in all cases tested. The lengths of the membranes measured from fresh placentas and paraffin sections showed a very good correlation (p < 0.001; r = 0.941). Application of the memb-roller would be very helpful in the semi-quantitative analysis of the chorioamniotic membranes and the standardization of placental pathology and research practice.

Ultrasound-guided transcervical forceps extraction of unruptured interstitial pregnancy.

This report introduces a method for ultrasound-guided transcervical forceps extraction (UTCE) of unruptured interstitial pregnancies; this method does not necessitate elective caesarean delivery for future pregnancies. This report also compares this technique with conventional methods. A retrospective review was conducted involving 16 women treated for interstitial pregnancies. Among these women, UTCE was successfully performed in six of 16 women, with only one woman requiring additional intervention; conventional treatment was performed in the other ten women. UTCE is a safe, effective and minimally invasive option for treating interstitial pregnancies and should be considered as an alternative treatment modality.

Distinct patterns of C4d immunoreactivity in placentas with villitis of unknown etiology, cytomegaloviral placentitis, and infarct.

C4d deposition is considered to be evidence of antibody-mediated rejection. This study was conducted to compare C4d immunoreactivity between villitis of unknown etiology (VUE) and cytomegaloviral placentitis. C4d immunohistochemistry was performed in cases with VUE (n = 16) and cytomegaloviral placentitis (n = 5). Distinct, linear C4d immunoreactivity along the syncytiotrophoblast was found in all VUE cases. In cytomegaloviral placentitis, the intensity of C4d immunoreactivity along the syncytiotrophoblast was not prominent, but cytoplasmic C4d immunoreactivity of villous cytotrophoblasts was frequently observed. Further screening of the cases with placental infarcts (n = 5) demonstrated prominent C4d immunoreactivity in the chorionic villi adjacent to the infarct. We report the characteristic co-localization of VUE and C4d immunoreactivity. The overall findings in this study strongly suggest that the complement activation is a common mechanism of diverse placental injuries associated with rejection, infection, and ischemia.

Molecular genetic, cardiac and neurodevelopmental findings in cases of prenatally diagnosed rhabdomyoma associated with tuberous sclerosis complex.

OBJECTIVE: Rhabdomyoma is the most common type of cardiac tumor in fetuses and is often associated with tuberous sclerosis complex (TSC) with neurologic sequelae. The purpose of this study was to investigate the cardiac and neurodevelopmental outcomes of fetal rhabdomyoma. METHODS: We reviewed the clinical characteristics of 23 cases of cardiac rhabdomyoma diagnosed prenatally by fetal echocardiography at the Asan Medical Center between January 1998 and December 2009. We also reviewed postnatal results of brain magnetic resonance imaging, echocardiography, renal ultrasound examination and molecular genetic analysis to confirm the presence of cardiac rhabdomyoma with or without TSC. RESULTS: Among 23 cases, outcome data were available for 17 (73.9%) and six cases (26.1%) were lost to follow-up. The survival rate was 100.0% (17/17). Among the 17 cases with outcome data, spontaneous tumor regression occurred in eight (47.1%), and no change in tumor size and number was observed in the remaining nine cases (52.9%). There was no evidence of long-term cardiac dysfunction caused by persisting rhabdomyomas, regardless of tumor size. TSC was found in nine patients (52.9%), of whom five (55.6%) showed neurodevelopmental morbidity. We identified mutations in one of the TSC1 or TSC2 genes in four of nine TSC infants whose parents allowed us to perform molecular genetic analysis. Three of these (75.0%) were found to have neurologic impairment. Seven (77.8%) of nine TSC cases were non-familial. CONCLUSIONS: The overall outcome of isolated cardiac rhabdomyoma appears to be favorable. We suggest that systematic postnatal evaluation of TSC be performed even in cases of cardiac rhabdomyoma without a family history of TSC. Molecular characterization of TSC1 and TSC2 might be helpful in predicting short- and long-term neurodevelopmental outcomes.

Protective effect of fetal pulmonary sequestration in two cases of postnatal manifestation of congenital diaphragmatic hernia.

We describe two cases of postnatally diagnosed congenital diaphragmatic hernia (CDH) combined with pulmonary sequestration, both of which were diagnosed as isolated pulmonary sequestration on prenatal ultrasound. In these cases, prenatal ultrasonography demonstrated only a hyperechoic mass on the left lower lung and the diaphragm seemed intact. In each case both lungs showed otherwise normal development throughout pregnancy. Pulmonary sequestration may serve as a 'protector', preventing herniation of abdominal contents into the thoracic cavity. The co-occurrence of CDH may be obscured by a lung mass, especially on the left lower lung, and therefore it is necessary to deliver these infants at a tertiary center and parents should be counseled about the possibility of postnatal CDH.

Morphological study of the proximal boundary of the flexor retinaculum and of its constituent parts.

The proximal boundary of the flexor retinaculum is not readily demarcated, and previous reports of three distinct regions of the flexor retinaculum were not consistent with the authors' experience. This study was undertaken to clarify the proximal boundary and the constituent parts of the flexor retinaculum. A total of 56 cadaveric wrists were used in the study. The proximal boundary of the flexor retinaculum was identified by a change in thickness and colour of the longitudinally sectioned surface of the continuous membranous sheet of the flexor retinaculum and antebrachial fascia. Steel wires were placed on the proximal and distal boundaries, and anteroposterior radiographic images were taken. MRI was carried out before dissection or serial section. The locations of the proximal and distal boundaries of the flexor retinaculum varied. The flexor retinaculum was comprised of two parts, which were distinguishable by thickness and transparency. These two parts were also identified on MR images and by light microscopy.

Evaluation of the usefulness of the fetal femur length with respect to gestational age to detect Down syndrome in Korean subjects.

OBJECTIVE: We investigated the usefulness of shortening of the fetal femur length (FL) to predict Down syndrome at different gestational ages in Korean subjects. METHODS: This study involved 110 Korean Down syndrome fetuses and 602 randomly selected euploid controls. The expected FL for any biparietal diameter (BPD) was calculated based on the control group data. Subjects were divided into four groups according to gestational age periods: 14-18 weeks; 19-23 weeks; 24-28 weeks and 29-36 weeks. The value of measured/expected FL ratio to predict Down syndrome was analyzed for each group. RESULTS: The values of FL for any BPD in Down syndrome patients were significantly different from those in the control group (p < 0.001). A low ratio of measured/expected FL increased the risk of fetal Down syndrome (p < 0.001) with a mean measured/expected FL in Down syndrome of 0.907 (SD 0.075). At a fixed false positive rate of 5%, the sensitivities of FL were lower than 32.8% (95% CI 0.705-0.915) in three second trimester groups, and 71.1% (95% CI 0.924-0.997) in the third trimester group. CONCLUSION: Short FL is a poor marker of Down syndrome in the second trimester in Korean subject. It may be used as a screening marker only in the third trimester.

Diagnostic value of the matrix metalloproteinase-8 rapid test for detecting microbial invasion of the amniotic cavity.

The purpose of this paper was to compare the MMP-8 PTD Check (MPC) test with other indirect tests for detecting microbial invasion of the amniotic cavity (MIAC). Amniotic fluid (AF) was analyzed in 155 women for white blood cell (WBC) count, glucose concentration, and an MPC test and evaluated for MIAC using cultures for aerobic/anaerobic bacteria and mycoplasmas and polymerase chain reaction (PCR) of chlamydia. The median AF glucose concentration was lower and the median AF WBC count was higher in women with MIAC than in women without MIAC (p < 0.01 and p < 0.001, respectively). Also, the positive rate of the MPC test was higher in women with MIAC than in women without MIAC (p < 0.001). The sensitivities of AF glucose concentration, AF WBC count, and the MPC test for the detection of MIAC were 58.6%, 75.9%, and 86.2%, respectively. The specificities for the detection of MIAC were 76.2%, 80.2%, and 74.6%, respectively. We conclude that the MPC test is a rapid, easily performed, and accurate indirect method for detecting MIAC.

Spontaneous resolution of prenatally diagnosed dural sinus thrombosis: a case report.

Fetal thrombosis of the dural sinus is an extremely rare congenital cerebrovascular condition that is potentially fatal. We report a case of dural sinus thrombosis diagnosed by prenatal ultrasonography and fetal magnetic resonance imaging (MRI) in the second trimester. The thrombosis showed partial resolution during pregnancy and resolved spontaneously after birth without neurological complications. This is the first report of spontaneous postnatal resolution, and may provide helpful information on the natural history and prenatal counseling of fetal thrombosis of the dural sinus.

Successful vesicoamniotic shunting of posterior urethral valves in the first trimester of pregnancy.

Prenatal ultrasonography early in gestation allows diagnosis of posterior urethral valves. We report on a fetus with posterior urethral valves treated using vesicoamniotic shunting at 13 + 5 weeks' gestation. A double-basket catheter was used for shunting. A 2582-g male neonate was delivered at 33 weeks' gestation, and the infant continued to show normal renal function at 3 years of age. To the best of our knowledge this is the first report of successful vesicoamniotic shunt placement using a double-basket catheter in the first trimester of pregnancy.