Effects of septorhinoplasty on smell perception.

PURPOSE: To assess whether significant changes in smell perception occur after septorhinoplasty, and evaluate whether septum deviation, allergic rhinitis, and surgical technique affect postoperative smell perception. METHODS: Thirty-four patients (> 18 years old) awaiting septorhinoplasty were included, while those with previous severe hyposmia or anosmia were excluded. The participants self-assessed their smell perception using a 100-mm visual analogue scale (VAS), where 0 mm indicated the inability to smell and 100 mm indicated normal smell perception. The University of Pennsylvania Smell Identification Test (UPSIT) was applied before the procedure, and 4 and 12 weeks after surgery. RESULTS: The UPSIT score showed no significant changes at 4 (p = 0.59; 95% CI - 0.35 to + 2) or 12 weeks (p = 0.16; 95% CI - 1.13 to + 0.66). A comparison of the VAS scores before and 4 weeks after surgery (p = 0.62; 95% CI - 0.63 to + 0.39) yielded similar results. However, the average VAS scores improved 12 weeks after surgery (p = 0.007; 95% CI + 0.22 to + 1.30). Olfactory function, measured using the UPSIT, was not influenced by open or closed surgical techniques (p ≥ 0.10), the presence or absence of rhinitis (p ≥ 0.15), or obstructive septum deviation (p ≥ 0.38). Twelve weeks after surgery, self-evaluated smell perception was better in patients who underwent a closed procedure rather than an open procedure (p = 0.006; 95% CI: -1.39 to -0.37). CONCLUSION: A validated test demonstrates that septorhinoplasty does not compromise smell perception 4 and 12 weeks after surgery. However, it might improve smell perception by the self-report observation.

Analysis of Hearing and Tinnitus in Workers Exposed to Occupational Noise.

INTRODUCTION: Noise is one of the harmful agents to health that is present in the various branches of economic activity. Hearing loss and tinnitus are among the most frequently reported complaints by workers exposed to occupational noise. OBJECTIVE: To analyze the hearing and tinnitus in normal-hearing workers exposed to occupational noise. METHODS: This is a cross-sectional analytical trial in metallurgical industries, in which we evaluated normal-hearing workers through anamnesis, audiometry and otoacoustic emissions. RESULTS: It was observed high prevalence of failure of otoacoustic emissions (40%) and tinnitus (66.6%). Both in the amplitude and in the signal-to-noise ratio, the higher is the frequency of the sound, the worse the results. Despite having audiometry within normal limits, the results indicate that workers are suffering the effects of exposure and reveals association between failure of otoacoustic emissions and tinnitus in this population (X2 = 6,732). CONCLUSION: It is concluded that failures in DPOAE and tinnitus are predictors of hearing damage in normal-hearing workers.

Tinnitus Annoyance in Normal-Hearing Individuals: Correlation With Depression and Anxiety.

OBJECTIVE: To assess and correlate tinnitus annoyance in normal-hearing patients with auditory brainstem response and with anxiety/depression. METHODS: A sample of 84 individuals with tinnitus and normal hearing levels (pure-tone thresholds ≤25 dB HL) was compared to a matched control group of 47 normal-hearing individuals without tinnitus. All participants underwent auditory brainstem response testing. Tinnitus annoyance was assessed using the Tinnitus Handicap Inventory and depression and anxiety using the Beck Depression Inventory and Beck Anxiety Inventory, respectively. We compared auditory brainstem response and anxiety/depression symptoms between groups. In the study group, we correlated the degree of tinnitus annoyance with normal/abnormal auditory brainstem response and presence/level of anxiety/depression symptoms. RESULTS: All controls had normal auditory brainstem response; 30 patients with tinnitus had abnormal results. Thirty-five patients with tinnitus had depression and 41 anxiety, while only 2 controls had depression and none had anxiety, with a significant between-group difference (P < .001). Normal/abnormal auditory brainstem response showed no association with tinnitus annoyance, anxiety, or depression. A higher degree of tinnitus annoyance was associated with severity of depression and anxiety. CONCLUSIONS: Increased tinnitus annoyance was positively correlated with greater severity of anxiety and depression in normal-hearing patients but was unrelated to normal/abnormal auditory brainstem response.

Risk of hearing alterations in newborns of mothers treated for malaria.

INTRODUCTION: The antimalarial drugs can cause irreversible sensorineural hearing loss, and chloroquine phosphate use can be ototoxic to the fetus. OBJECTIVE: To compare the results of hearing screening in newborns of mothers treated for malaria in pregnancy with the results of newborns of mothers untreated and check for increased risk of hearing alterations in the group exposed to treatment. METHOD: Retrospective cohort study which involved 284 infants, 30 in the exposed group to malaria treatment and 254 in the unexposed group, matched for gestational age, birth weight and risk indicators for hearing. They underwent hearing screening by means of transient evoked otoacoustic emissions and/or auditory brainstem response automatic. The variables were collected in an interview with the parents in the health record and the screening database. RESULTS: The prevalence of fail in exposed group (6.7%) was significant when compared with the unexposed group (1.2%). The risk of failing in the hearing screening in the exposed group was 5.64 (CI 1.17 to 27.3). CONCLUSION: Newborns of mothers treated for malaria in pregnancy had a prevalence of fail in hearing screening at 6.7% and 5.64 higher chances to fail than newborns of untreated mothers.

The chemopreventive effect of Ginkgo biloba extract 761 against cisplatin ototoxicity: a pilot study.

OBJECTIVE: The purpose of this study was to evaluate, by using distortion product otoacoustic emission test, the action of Ginkgo biloba extract 761, which has a known antioxidant property, as a possible otoprotective against cisplatin induced hearing loss. This prospective and double blinded study was conducted on individuals that were to begin cisplatin treatment in a tertiary university center. They were randomized and allocated in two groups: control group (CG) (n = 07) receiving placebo and cisplatin and study group (SG) (n = 08) receiving Ginkgo biloba extract 761 (240 mg/day) and cisplatin. METHODS: This prospective study was conducted on individuals that were treated by cancer with cisplatin (CDDP) in a tertiary University center. Both groups were instructed to ingest the either placebo or Ginkgo biloba extract 761 before the first cisplatin dose. They were rated and followed up for approximately 90 days. The maximum cumulative cisplatin dosage was 300 mg/m(2). The ototoxic effect was measured with distortion product otoacoustic emissions. Distortion product otoacoustic emissions were recorded before the first cisplatin cycle, 30, 60 and 90 days after the treatment. The average of the amplitude of the signals were calculated and used for comparisons between the groups. RESULTS: Comparisons were made between baseline measurements and those recorded after maximum cumulative CDDP dose. The control group showed smaller distortion product otoacoustic emissions mean amplitudes and smaller signal/noise ratio than the study group (p < 0.05). CONCLUSION: Ginkgo biloba extract 761 probably has antioxidant properties, and might play otoprotective effect against cisplatin ototoxicity in these patients.

Association between suppression of otoacoustic emissions and annoyance levels in tinnitus patients with normal hearing.

OBJECTIVE: To correlate the annoyance of tinnitus assessed by the Tinnitus Handicap Inventory and on a visual analogue scale with the evoked otoacoustic emission test result in tinnitus patients with normal hearing. STUDY DESIGN: Case-control study. SETTING: Public tertiary hospital. SUBJECTS AND METHODS: The sample was initially based on a population of 80 subjects with tinnitus; 20 of them had normal hearing and normal evoked otoacoustic emission test results and comprised the study group. For the purpose of comparison, a control group was formed, which consisted of 17 subjects with no hearing complaints and normal hearing. The participants were submitted to hearing tests, immittance testing and tests for the evaluation of acoustic reflexes, distortion product otoacoustic emissions, transient evoked otoacoustic emissions (TEOAEs), and suppression of TEOAEs. The tests were performed in a sound-treated booth using a linear contralateral noise of 60 dB. The presence of suppression effects was defined when the response amplitude was 0.5 dB or higher. RESULTS: Abnormal evoked otoacoustic emission suppression test results were observed in 52.9% of tinnitus patients and in 32.4% of control subjects (p = 0.086). Suppression effects of TEOAEs were absent in 38.5% of subjects with minimal or mild discomfort and in 61.9% of subjects with moderate or severe discomfort (p = 0.183). CONCLUSION: It was not possible to associate the annoyance caused by tinnitus with the TEOAE suppression test results, although suppression effects were found to decrease with increasing annoyance.

Prevalence of hearing loss in newborns of mothers who had malaria and were treated with antimalaric drugs in pregnancy.

INTRODUCTION: Gestational malaria is related to very bad perinatal outcomes and antimalarial drugs used during pregnancy can be ototoxic to the fetus. OBJECTIVE: To determine the prevalence of hearing loss in newborns of mothers who had malaria and treated with antimalarial drugs during pregnancy. MATERIALS AND METHODS: Cross-sectional study which involved 35 newborns. All underwent neonatal hearing screening with otoacoustic emissions combined with automatic auditory brainstem response. Those who failed were referred to audiological diagnosis with evoked otoacoustic emissions and brainstem auditory evoked potential associated with tympanometry (1000 Hz). Data were obtained through interviews with the mothers' and analyzing the patient chart and the newborn, and underwent to statistical tests analysis of variance, equality of two proportions and Chi-square test (p = 0.05). RESULTS: The infection by Plasmodium vivax and chloroquine treatment with the first quarter prevailed; 88.6% (n = 31) newborns passed the hearing screening and 11.4% (n = 4) failed, of these, 50% (n = 2) attended for diagnosis, being diagnosed with hearing loss. CONCLUSION: The prevalence of hearing loss in newborns of mothers who had vivax malaria and used chloroquine during pregnancy was 3%.

Task force of the Brazilian Society of Otology - evaluation and management of peripheral facial palsy.

OBJECTIVE: To review key evidence-based recommendations for the diagnosis and treatment of peripheral facial palsy in children and adults. METHODS: Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on peripheral facial palsy were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions. RESULTS: The topics were divided into 2 main parts: (1) Evaluation and diagnosis of facial palsy: electrophysiologic tests, idiopathic facial palsy, Ramsay Hunt syndrome, traumatic peripheral facial palsy, recurrent peripheral facial palsy, facial nerve tumors, and peripheral facial palsy in children; and (2) Rehabilitation procedures: surgical decompression of the facial nerve, facial nerve grafting, surgical treatment of long-term peripheral facial palsy, and non-surgical rehabilitation of the facial nerve. CONCLUSIONS: Peripheral facial palsy is a condition of diverse etiology. Treatment should be individualized according to the cause of facial nerve dysfunction, but the literature presents better evidence-based recommendations for systemic corticosteroid therapy.

Stapedotomy in a residency training program.

INTRODUCTION: The major objective of a stapedotomy is the restoration of hearing. In training centers, the hearing results obtained by resident physicians are lower than those achieved by more experienced surgeons. An analysis of the surgical results obtained by resident physicians is essential to identification of the deficiencies in the learning process. OBJECTIVE: To analyze the postoperative hearing results obtained by otosclerosis patients who underwent stapedotomy performed by surgeons in a residency program. METHODS: The pre- and postoperative audiometric results were evaluated in a retrospective study of 98 otosclerosis patients who underwent stapedotomy from January 2000 to December 2010. RESULTS: The distribution of patients according to the postoperative results was as follows: 68.4% of the patients achieved a postoperative gap of less than or equal to 10 dB, and 91.8% of the patients achieved a postoperative gap of less than or equal to 20 dB. Three (3.1%) patients had profound sensorineural hearing loss after the procedure. CONCLUSIONS: An improvement in surgical outcomes of doctors in training is essential for the continuation of training for stapes surgery during medical residency.

Effect of hormone replacement therapy on the auditory brainstem response of postmenopausal women.

OBJECTIVE: To investigate whether hormone replacement therapy modifies the auditory brainstem response in postmenopausal women. METHODS: Nineteen postmenopausal women received hormone replacement therapy (study group) and 25 received no treatment nor placebo (control group). In both groups, age ranged from 45 to 60 years and pure-tone sensitivity was 25 dB or better at frequencies between 500 and 2000 Hz. Auditory brainstem response was evaluated before and after 3 months of hormone use in the study group. The control group was also evaluated at the same periods. The following auditory brainstem response parameters were compared between the two groups: latencies of waves I, III, and V; I-III, III-V, and I-V interpeak intervals. RESULTS: Mean age did not differ between groups (study group: 51.5 ± 0.7 years; control: 52.9 ± 0.6 years). No significant differences in wave latencies, or interpeak intervals were observed between the two groups (p > 0.05).

Changes in the communicative skills of young people as a result of a communication training.

PURPOSE: To analyze the effect of communication training developed for adolescents on the youth's communication skills. METHODS: Forty-one young people participated in the study and were divided into two groups. Group I received intervention - communication training for five weeks; Group II - were guided on the importance of voice for communication. Participants had their communication skills assessed before/after interventions through a self-administered questionnaire, answered by the participant and parents. Both groups had oral presentations recorded on video, which were analyzed by speech therapists through the evaluation of the communication profile, listing the aspects that should be observed as a point of strength/opportunity for improvement. Association between qualitative variables was assessed using Fischer's exact test, Pearson's chi-square test, McNemar's test, and McNemar-Bowker's test. To compare groups, paired t-test and t-test for independent samples, p level <0.05, were used. RESULTS: The analysis of questionnaires showed improvement in GI in two of the four skills assessed and no difference for GII. The video evaluations showed a significant difference between the groups in terms of eye contact and speech velocity. CONCLUSION: This study points out that the communication training method applied to young people might improve communicative skills, providing some insights into their communication strengths and potential areas for development.

Effect of melatonin on otoprotection in rodents: a systematic review with meta-analysis.

OBJECTIVES: To determinate the otoprotective efficacy of melatonin.in experimental models of rodents through a systematic review of the literature. METHODS: Altogether, 154 articles were found in four databases. The PICOS strategy (Population, Intervention, Comparison, and Outcome) was used to define the eligibility criteria. Studies that met the inclusion criteria for the second step were included in a qualitative synthesis. Each study type was analyzed with the CAMARADES quality of assessment's checklist and the SYRCLE RoBS risk of bias. RESULTS: Seven articles were selected, and four were included in the meta-analysis. It was possible to obtain seven outcomes according to the standard auditory frequencies presented among the studies, considering a minimum of three standard frequencies. The outcomes analyzed were for the frequencies of 1500, 2000, 3000, 4000, 5000, 6000, and 8000 Hz. CONCLUSION: Melatonin can provide protection against the ototoxic effects of cisplatin and aminoglycosides at 5000 Hz, 6000 Hz, and 8000 Hz, thereby minimizing the reduction in Otoacustic Emissions (OAE) amplitude. The same effect was not observed in the lower frequencies. Despite the limited number of studies that were evaluated, the results appeared consistent in higher frequencies. However, the methodology of the available studies did not meet the necessary methodological rigor that promotes the safe replicability of these studies.

Task force Guideline of Brazilian Society of Otology ‒ hearing loss in children - Part I ‒ Evaluation.

OBJECTIVES: To provide an overview of the main evidence-based recommendations for the diagnosis of hearing loss in children and adolescents aged 0 to 18 years. METHODS: Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on childhood hearing loss were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions. RESULTS: The evaluation and diagnosis of hearing loss: universal newborn hearing screening, laboratory testing, congenital infections (especially cytomegalovirus), genetic testing and main syndromes, radiologic imaging studies, vestibular assessment of children with hearing loss, auditory neuropathy spectrum disorder, autism spectrum disorder, and noise-induced hearing loss. CONCLUSIONS: Every child with suspected hearing loss has the right to diagnosis and appropriate treatment if necessary. This task force considers 5 essential rights: (1) Otolaryngologist consultation; (2) Speech assessment and therapy; (3) Diagnostic tests; (4) Treatment; (5) Ophthalmologist consultation.

Task force Guideline of Brazilian Society of Otology - hearing loss in children - Part II - Treatment.

OBJECTIVES: To provide an overview of the main evidence-based recommendations for the diagnosis of hearing loss in children and adolescents aged 0-18 years. METHODS: Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on childhood hearing loss were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions. RESULTS: The topics were divided into 2 parts: (1) treatment of sensorineural hearing loss: individual hearing aids, bilateral cochlear implants, cochlear implants in young children, unilateral hearing loss, and auditory neuropathy spectrum disorder; and (2) treatment of conductive/mixed hearing loss: external/middle ear malformations, ventilation tube insertion, and tympanoplasty in children. CONCLUSIONS: In children with hearing loss, in addition to speech therapy, Hearing AIDS (HAs) or implantable systems may be indicated. Even in children with profound hearing loss, both the use of HAs and behavioral assessments while using the device are important.

Brazilian Society of Otology task force - Otosclerosis: evaluation and treatment.

OBJECTIVES: To review and provide evidence-based recommendations for the diagnosis and treatment of otosclerosis. METHODS: Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on otosclerosis were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions. RESULTS: The topics were divided into 2 parts: 1) Diagnosis - audiologic and radiologic; 2) Treatment - hearing AIDS, pharmacological therapy, stapes surgery, and implantable devices - bone-anchored devices, active middle ear implants, and Cochlear Implants (CI). CONCLUSIONS: The pathophysiology of otosclerosis has not yet been fully elucidated, but environmental factors and unidentified genes are likely to play a significant role in it. Women with otosclerosis are not at increased risk of worsening clinical condition due to the use of contraceptives or during pregnancy. Drug treatment has shown little benefit. If the patient does not want to undergo stapedotomy, the use of hearing aids is well indicated. Implantable systems should be indicated only in rare cases, and the CI should be indicated in cases of profound deafness.

Brazilian Society of Otology task force - Vestibular Schwannoma ‒ evaluation and treatment.

OBJECTIVE: To review the literature on the diagnosis and treatment of vestibular schwannoma. METHODS: Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on vestibular schwannoma were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions. RESULTS: The topics were divided into 2 parts: (1) Diagnosis - audiologic, electrophysiologic tests, and imaging; (2) Treatment - wait and scan protocols, surgery, radiosurgery/radiotherapy, and systemic therapy. CONCLUSIONS: Decision making in VS treatment has become more challenging. MRI can diagnose increasingly smaller tumors, which has disastrous consequences for the patients and their families. It is important to develop an individualized approach for each case, which highly depends on the experience of each surgical team.

Otoacoustic emissions in normal-hearing workers exposed to different noise doses.

INTRODUCTION: The otoacoustic emission test is useful in monitoring hearing changes not yet detectable in pure-tone audiometry, as well as in monitoring cochlear damage caused by exposure to noise. OBJECTIVE: To evaluate distortion product otoacoustic emissions in normal-hearing workers exposed to different occupational noise doses. MATERIALS AND METHOD: This is a cohort prospective study performed in metalworking industries, in which normal-hearing workers were assessed by being divided into three different groups: GI not exposed, GII sporadically exposed and GIII often exposed to occupational noise. RESULTS: Otoacoustic emission alterations were found in groups II and III bilaterally. Both in the amplitude and in the signal/noise ratio it was observed that as higher was the frequency, worse were the results of GII and GIII (p > 0.001), and the greater the exposure dose is, the lower the averages found in otoacoustic emission. CONCLUSION: The otoacoustic emissions are worse in the exposed groups compared to the unexposed group and the greater are the noise dose, worse are the results.

Melatonin prevents age-related hearing loss in the murin experimental model.

OBJECTIVE: The present study aimed to perform a morphological and morphometric analysis of cochlear structures of C57BL/6J mice receiving oral melatonin for a 12-month period. METHODS: 32 male C57BL/6J were divided into control and melatonin groups. Control received saline and ethanol solution and melatonin group, 50 µL of 10 mg of melatonin/kg/day orally for a 12-month period. After de experiment the animals were sacrificed into a 40% concentration of CO2 chamber, and the blades were morphological and morphometrically analyzed. RESULTS: The melatonin group revealed a higher median density of viable cells (45 ±â€¯10.28 cells/100 µm2, 31-73, vs. 32 ±â€¯7.47 cells/100 µm2, 25-48). The median area of stria vascularis was 55.0 ±â€¯12.27 cells/100 µm2 (38-80) in the control, and 59.0 ±â€¯16.13 cells/100 µm2 (40-134) in the melatonin group. The morphometric analysis of the spiral ligament reveals a higher median of total viable neurons in the melatonin (41 ±â€¯7.47 cells/100 µm2, 27-60) than in the control group (31 ±â€¯5.68 cells/100 µm2, 21-44). CONCLUSION: Although melatonin is a potent antioxidant, it does not completely neutralize the occurrence of presbycusis; however, it may delay the onset of this condition.

Etiopathogenic features of severe epistaxis in histological samples from individuals with or without arterial hypertension.

There is a consensus that arterial hypertension (AH) is associated with stroke. Therefore, this study aimed to evaluate the histology of the microvasculature associated with the mucosa of the posterior nasal cavity to identify possible factors related to vascular weakening and rupture. Histological sections were obtained from hypertensive and normotensive individuals, regardless of epistaxis. Our results showed that the group with AH had: (a) smaller median diameter of the lumen of arteries and arterioles; (b) increased thickness of the intimal arteries and arterioles, slight inflammatory infiltrate, and rupture of internal elastic lamina; (c) greater thickness of the middle tunica in arterioles; (d) lower percentage of histological sections with non-injured intimal layers in capillaries, arterioles, and small arteries; (e) lower percentage of histological sections with intact media tunic and/or myocytes juxtaposed in arteries and arterioles; (f) no difference between the diameters of small arteries or arterioles. The intima was thicker in individuals with severe epistaxis than in the normotensive group, but it did not differ from the AH group. Thus, hypertension may cause structural lesions in the vascular layers, and in the absence of tissue repair and the persistence of AH, these lesions may favour vascular rupture, especially during hypertensive peaks.

Hearing of neonates without risk indicators for hearing loss and use of antimalarial drugs during pregnancy: a historical cohort study in the Northern Region of Brazil.

INTRODUCTION: Studies have demonstrated the ototoxic effects of antimalarial drugs in individuals who receive these drugs, but little is known regarding the toxicity of these drugs in the newborn auditory system when administered to the mother receive the drug during pregnancy. OBJECTIVE: To verify the incidence of hearing loss in neonates who have no other associated risk indicators, born to mothers treated for malaria during pregnancy. METHODS: A retrospective, quantitative cohort study was developed at Hospital de Base Dr. Ary Pinheiro and Clínica Limiar, both located in the municipality of Porto Velho (Rondônia). The sample consisted of 527 newborns divided into two groups: exposed to antimalarials drugs during pregnancy group (n = 32) and non-exposed group (n = 495). Data collection took place from September 2014 to December 2015, through an interview with the mothers and/or guardians of the newborn, through the newborns' and the mothers' records, and the neonatal hearing screening database of the above-mentioned institutions. RESULTS: All the neonates in the exposed group, assessed through the recording of transient otoacoustic emissions associated with the automated brainstem auditory evoked potential test, underwent neonatal hearing screening in the first examination. Among the newborns in the non-exposed group, 30 showed failure and were retested. Of these, one continued to fail and was referred for diagnosis, in whom the results showed to be within the normal range. Among the neonates of the exposed group, infection with Plasmodium vivax was the most frequent, and was similarly distributed among the gestational trimesters, and chloroquine was the most commonly used antimalarial drug treatment more often given during the third trimester; these findings did not show any influence on the audiological findings of the studied neonates. CONCLUSION: The present study did not identify any cases of hearing loss in neonates born to mothers who used antimalarial drugs during gestation.