Peripheral cord insertion is associated with adverse pregnancy outcome only when accompanied by clinically significant placental pathology.

OBJECTIVE: To examine the relationship between umbilical cord insertion site, placental pathology and adverse pregnancy outcome in a cohort of normal and complicated pregnancies. METHODS: Sonographic measurement of the cord insertion and detailed placental pathology were performed in 309 participants. Associations between cord insertion site, placental pathology and adverse pregnancy outcome (pre-eclampsia, preterm birth, small-for-gestational age) were examined. RESULTS: A total of 93 (30%) participants were identified by pathological examination to have a peripheral cord insertion site. Only 41 of the 93 (44%) peripheral cords were detected by prenatal ultrasound. Peripherally inserted cords were associated significantly (P < 0.0001) with diagnostic placental pathology (most commonly with maternal vascular malperfusion (MVM)); of which 85% had an adverse pregnancy outcome. In cases of isolated peripheral cords, without placental pathology, the incidence of adverse outcome was not statistically different when compared to those with central cord insertion and no placental pathology (31% vs 18%; P = 0.3). A peripheral cord with an abnormal umbilical artery (UA) pulsatility index (PI) corresponded to an adverse outcome in 96% of cases compared to 29% when the UA-PI was normal. CONCLUSIONS: This study demonstrates that peripheral cord insertion is often part of the spectrum of findings of MVM disease and is associated with adverse pregnancy outcome. However, adverse outcome was uncommon when there was an isolated peripheral cord insertion and no placental pathology. Therefore, additional sonographic and biochemical features of MVM should be sought when a peripheral cord is observed. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Determination of fetal heart rate short-term variation from umbilical artery Doppler waveforms.

OBJECTIVE: To evaluate the feasibility of using umbilical artery (UA) Doppler waveforms to measure fetal heart rate (FHR) short-term variation (STV) across gestation. METHODS: This was a prospective longitudinal study, conducted at two study sites, of 195 pregnancies considered low risk. Pulsed-wave Doppler of the UAs was performed at 4-weekly intervals, between 14 and 40 weeks of gestation, using a standardized imaging protocol. Up to 12 consecutive UA Doppler waveforms were analyzed using offline processing software. FHR STV was calculated using average R-R intervals extracted from the waveforms and baseline corrected for FHR. RESULTS: Baseline-corrected FHR STV increased significantly with gestational age (conditional R2 = 0.37; P < 0.0001) and was correlated inversely with FHR (conditional R2 = 0.54; P < 0.0001). The STV ranged (median (interquartile range)) from 3.5 (2.9-4.1) ms at 14-20 weeks' gestation to 6.3 (4.8-7.7) ms at 34-40 weeks' gestation. The change in heart rate STV did not differ between study sites or individual sonographers. CONCLUSIONS: UA Doppler waveforms offer a robust and feasible method to derive STV of the FHR. It should be emphasized that the UA Doppler-derived STV is not interchangeable with measurements derived with computerized cardiotocography. Accordingly, further investigations are needed to validate associations with outcome, in order to determine the value of concurrent fetal cardiovascular and heart rate evaluations that are possible with the technique described here. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Radiotherapy of lymphoproliferative diseases of the orbit. Surveillance of 65 cases.

Sixty-five patients with lymphoproliferative disease of the orbit were treated at the Joint Radiation Oncology Center of the University of Pittsburgh. An analysis of these patients was stratified by their initial tumor histopathology: benign lymphoid hyperplasia (BLH) in 28, malignant lymphoma (ML) in 20, and lymphoid infiltrate of indeterminate histology (IH) in 17. The median follow-up was 42 months. Radiation treatment was efficacious in all three groups of patients. The actuarial local recurrence-free survival rate is 84%. Treatment programs usually consisted of 20 to 30 Gy delivered in 10 to 15 fractions. ML patients had significantly lower overall and disease-specific survival rates than IH and BLH patient (p less than or equal to 0.02). BLH patients had a significantly lower local recurrence-free survival than patients with IH and BLH (p = 0.03). There was no significant difference between the three groups of patients with regard to the subsequent development of systemic lymphoma. There were no significant differences in local (16%) or systemic (36%) relapse between patients irradiated with less than 30 Gy or greater than or equal to 30 Gy. Cataracts were detected in 46% of the patients treated with anterior-posterior fields, but none were detected in those treated with other techniques. The results of this study emphasize the importance of long-term follow-up and careful treatment planning for patients with lymphoproliferative diseases of the orbit.

Endoscopic surgery for lacrimal and orbital disease.

Recent interest in the application of endoscopic surgical techniques to the field of ophthalmic plastic and reconstructive surgery has occurred primarily in the areas of lacrimal and orbital disease. Examples of important innovations include endoscopic intranasal laser-assisted dacryocystorhinostomy (DCR), transcanalicular laser-assisted DCR, microendoscopy of the lacrimal drainage system, endoscopic orbital decompression, orbital endoscopy, and computer-assisted surgery. The evolution of these exciting and promising innovations is reviewed with emphasis on the need for continued critical evaluation of these techniques by rigorous clinical research prior to forming specific recommendations for their widespread general use.