Maternal Fetal Medicine

Tiếp cận thai chậm tăng trưởng trong tử cung Bs Võ Tá Sơn BV Phụ sản-Nhi Đà Nẵng Thai chậm tăng trưởng trong tử cung (FGR) là một trong những biến chứng phổ biến nhất của thai kỳ. FGR liên quan đến sự thiếu dinh dưỡng của nhau thai và kết cục chu sinh bất lợi. Xử trí lâm sàng khó khăn bởi vì FGR có nhiều dạng biểu hiện lâm sàng. Thai nhỏ (cân nặng ước đoán dưới bách phân vị thứ 10 so với tuổi thai) vẫn là đặc điểm lâm sàng tốt nhất đại diện cho FGR. Tuy nhiên, một điều được chấp nhận là rõ ràng không phải tất cả các thai nhỏ đều là thai chậm tăng trưởng thực sự. Trong một phần đáng kể các thai nhỏ, không có bằng chứng về sự liên quan đến bệnh lý của bánh nhau, kết cục chu sinh gần như bình thường, và chúng chỉ được gọi là thai nhỏ so với tuổi thai (small for gestational age-SGA). Siêu âm Doppler có thể cải thiện xử trí lâm sàng của FGR; tuy nhiên, việc phải sử dụng một vài chỉ số đôi khi dẫn tới sự chồng lấp dẫn tới sự khó khăn khi diễn giải từ các dấu hiệu sang các quyết định xử trí lâm sàng. Chúng tôi đề xuất rằng việc xử trí FGR có thể đơn giản hóa sử dụng cách tiếp cận liên tiếp dựa vào 3 bước: (1) nhận dạng thai nhỏ, (2) phân biệt giữa FGR và SGA, và (3) thời điểm chẩm dứt thai kỳ theo một quy trình dựa trên các giai đoạn suy sụp của thai nhi. Giới thiệu Thai chậm tăng trưởng trong tử cung là một trong những nguyên nhân phổ biến nhất gây ra kết cục xấu chu sinh và dài hạn. Định nghĩa của FGR thực sự vẫn còn khó nắm bắt, và xử trí lâm sàng vẫn là thách thức vì có nhiều dạng biểu hiện lâm sàng. Phương pháp tốt nhất để nhận dạng FGR vẫn chưa được xác định. Thai nhỏ vẫn là đặc điểm nhận dạng tốt nhất trong thực hành lâm sàng, và cân nặng dưới bách phân vị thứ 10 là tiêu chuẩn được sử dụng phổ biến nhất. Tuy nhiên, thai nhỏ có thể do nhiều nguyên nhân khác nhau. Trong một tỷ lệ đáng kể các trường hợp, thai nhỏ là do sự thiếu dinh dưỡng của bánh nhau; tuy nhiên, trong một phần không nhỏ các trường hợp thai nhỏ khác, không có bằng chứng liên quan đến sự thiếu dinh dưỡng của bánh nhau. Bằng chứng lâm sàng gợi ý rằng thai nhỏ có sự thiếu

Pemantauan denyut jantung janin (DJJ) dalam persalinan bertujuan untuk mencegah morbiditas dan mortalitas janin yang dapat terjadi akibat asidosis metabolik atau hipoksia serebral selama persalinan. Keadaan janin yang buruk dapat terjadi selama kehamilan dan persalinan. Pemantauan DJJ dapat mendeteksi dini kondisi gawat janin, sehingga kehamilan dan persalinan dapat segera diakhiri  untuk mendapatkan liuaran janin yang lebih baik.
Pemantauan DJJ  intrapartum selalu dihubungkan dengan kontraksi rahim dengan pencatatan kardiotokografi (KTG) yang disebut juga Electronic Fetal Monitoring (EFM), sedangkan pemantauan saat kehamilan (antepartum) biasanya dihubungkan dengan gerakan janin yang dilakukan dengan uji tanpa beban (NST- Non Stress Test) atau uji dengan beban (Contraction Stress Test/CST , Oxytocin Challenge Test/OCT).

We report a case of feto-feto-fetal-transfusion-syndrome (FFFTS) in a spontaneous monochorionic triamniotic triplet pregnancy primarily diagnosed at 17 weeks of gestation. During the course of pregnancy, sequentially two triplets appeared as donor. Symptom of a recipient ( ...

Background: Fetal alcohol spectrum disorder (FASD) is among the leading causes of developmental and intellectual disabilities in individuals. Although efforts are being made toward the prevention and management of FASD in South Africa, the prevalence remains high. The sustained high prevalence could be attributed to several factors, including the lack of policy for a coordinated effort to prevent, diagnose and manage FASD nationally. In this study, our aim was to explore the perspectives of service providers (health and allied professionals, teachers, social workers) on the prevention and management of FASD towards developing a guideline to inform policy.
Method: Guided by the exploratory qualitative research design, we purposively sampled relevant service providers in the field of FASD prevention and management for focus group discussions. Nine of these discussions were conducted with six to eight participants per discussion session. The discussants were asked various
questions on the current and required interventions and practices for the prevention and management of FASD. Following the Framework Method, data were transcribed verbatim and analysed using the thematic content analysis approach.
Results: Our findings show that aspects of the prevention and management of alcohol-related conditions are present in various policies. However, there is no clear focus on coordinated, mult-sectoral efforts for a more comprehensive approach to the prevention and management of FASD. The participants recognized the need for specific requirements on broad-based preventive awareness programs, training and support for parents and caregivers, inclusive education in mainstream schools and training of relevant professionals.
Conclusion: Comprehensive and coordinated prevention and management programs guided by a specific policy could improve the prevention and management of FASD. Policy formulation demonstrates commitment from the government, highlights the importance of the condition, and elaborates on context-specific prevention and management protocols.

ObjectiveIt has been shown that the modified myocardial performance index (Mod-MPI) is associated with higher reproducibility than conventional MPI because it uses mitral and aortic valve ‘clicks’ to calculate each time period. We aimed to construct normal reference values for the Mod-MPI after 19 weeks' gestation.It has been shown that the modified myocardial performance index (Mod-MPI) is associated with higher reproducibility than conventional MPI because it uses mitral and aortic valve ‘clicks’ to calculate each time period. We aimed to construct normal reference values for the Mod-MPI after 19 weeks' gestation.MethodsThe Mod-MPI was calculated in the left ventricle of 557 normal fetuses at 19–39 weeks' gestation. The isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT) and ejection time (ET) were measured using the Doppler signals (clicks) of the opening and closing of the mitral and aortic valves as landmarks. Mod-MPI was calculated as (ICT + IRT)/ET.The Mod-MPI was calculated in the left ventricle of 557 normal fetuses at 19–39 weeks' gestation. The isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT) and ejection time (ET) were measured using the Doppler signals (clicks) of the opening and closing of the mitral and aortic valves as landmarks. Mod-MPI was calculated as (ICT + IRT)/ET.ResultsThroughout gestation, there was a small increase in the Mod-MPI (at 19 weeks it was 0.35 ± 0.027 (mean ± SD); at 39 weeks, 0.37 ± 0.029; Mod-MPI = 0.33 + 0.001× gestational age (GA) (weeks), r2 = 0.017). Of the three components, ICT remained constant, IRT increased (IRT = 0.028 + 2.52 × GA (weeks)), and ET slightly decreased (ET = 0.184 − 3.65 × GA (weeks)). Fetal heart rate (FHR) had no effect on the Mod-MPI, but the duration of IRT, ICT and ET decreased by 13–15% when FHR increased from 130 to 160 beats per minute.Throughout gestation, there was a small increase in the Mod-MPI (at 19 weeks it was 0.35 ± 0.027 (mean ± SD); at 39 weeks, 0.37 ± 0.029; Mod-MPI = 0.33 + 0.001× gestational age (GA) (weeks), r2 = 0.017). Of the three components, ICT remained constant, IRT increased (IRT = 0.028 + 2.52 × GA (weeks)), and ET slightly decreased (ET = 0.184 − 3.65 × GA (weeks)). Fetal heart rate (FHR) had no effect on the Mod-MPI, but the duration of IRT, ICT and ET decreased by 13–15% when FHR increased from 130 to 160 beats per minute.ConclusionThe GA-adjusted reference values for the Mod-MPI and the three time periods used for its calculation can be applied to fetal cardiac evaluation in the presence of pregnancy-associated complications. Copyright © 2007 ISUOG. Published by John Wiley & Sons, Ltd.The GA-adjusted reference values for the Mod-MPI and the three time periods used for its calculation can be applied to fetal cardiac evaluation in the presence of pregnancy-associated complications. Copyright © 2007 ISUOG. Published by John Wiley & Sons, Ltd.

Aim of the study: Is to evaluate factors most correlated to homeostatic model analysis (HOMA-IR) and to construct a formula which can predict HOMA from the cheaper biochemical, biophysical and hormonal risk factors. Study design; case control Methods: A total of 34 patients with polycystic ovarian syndrome were recruited from infertility clinic in Al-Yarmuok teaching hospital. From the epidemiological characteristics the following were recorded: BMI, waist to hip ratio, menstrual cycle, hirsutism which was scored by modified Ferriman Gallwey system and the mean ovarian volume from measuring both ovaries while from the hormonal and biochemical variables, luteinizing hormone and follicle stimulating hormone, total testosterone and lipid profile were measured for each patient. For each group of variables stepwise regression followed by best subset regression were implemented to isolate the factors most correlated with HOMA. Coefficient of Mallows (Cp) was used to sort out the single mo...

Placenta is the crucial organ for embryo and fetus development and plays a critical role in the development of fetal growth restriction (FGR). There are increasing evidences on the role of microRNAs (miRNAs) in a variety of pregnancy-related complications such as preeclampsia and FGR. More than 1880 miRNAs have been reported in humans and most of them are expressed in placenta. In this paper, we aimed to review the current evidence about the topic. According to retrieved data, controversial results about placental expression of miRNAs could be due (at least in part) to the different experimental methods used by different groups. Despite the fact that several authors have demonstrated a relatively easy and feasible detection of some miRNAs in maternal whole peripheral blood, costs of these tests should be reduced in order to increase cohorts and have stronger evidence. In this regard, we take the opportunity to solicit future studies on large cohort and adequate statistical power, in...

ObjectiveIt has been shown that the modified myocardial performance index (Mod-MPI) is associated with higher reproducibility than conventional MPI because it uses mitral and aortic valve ‘clicks’ to calculate each time period. We aimed to construct normal reference values for the Mod-MPI after 19 weeks' gestation.It has been shown that the modified myocardial performance index (Mod-MPI) is associated with higher reproducibility than conventional MPI because it uses mitral and aortic valve ‘clicks’ to calculate each time period. We aimed to construct normal reference values for the Mod-MPI after 19 weeks' gestation.MethodsThe Mod-MPI was calculated in the left ventricle of 557 normal fetuses at 19–39 weeks' gestation. The isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT) and ejection time (ET) were measured using the Doppler signals (clicks) of the opening and closing of the mitral and aortic valves as landmarks. Mod-MPI was calculated as (ICT + IRT)/ET.The Mod-MPI was calculated in the left ventricle of 557 normal fetuses at 19–39 weeks' gestation. The isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT) and ejection time (ET) were measured using the Doppler signals (clicks) of the opening and closing of the mitral and aortic valves as landmarks. Mod-MPI was calculated as (ICT + IRT)/ET.ResultsThroughout gestation, there was a small increase in the Mod-MPI (at 19 weeks it was 0.35 ± 0.027 (mean ± SD); at 39 weeks, 0.37 ± 0.029; Mod-MPI = 0.33 + 0.001× gestational age (GA) (weeks), r2 = 0.017). Of the three components, ICT remained constant, IRT increased (IRT = 0.028 + 2.52 × GA (weeks)), and ET slightly decreased (ET = 0.184 − 3.65 × GA (weeks)). Fetal heart rate (FHR) had no effect on the Mod-MPI, but the duration of IRT, ICT and ET decreased by 13–15% when FHR increased from 130 to 160 beats per minute.Throughout gestation, there was a small increase in the Mod-MPI (at 19 weeks it was 0.35 ± 0.027 (mean ± SD); at 39 weeks, 0.37 ± 0.029; Mod-MPI = 0.33 + 0.001× gestational age (GA) (weeks), r2 = 0.017). Of the three components, ICT remained constant, IRT increased (IRT = 0.028 + 2.52 × GA (weeks)), and ET slightly decreased (ET = 0.184 − 3.65 × GA (weeks)). Fetal heart rate (FHR) had no effect on the Mod-MPI, but the duration of IRT, ICT and ET decreased by 13–15% when FHR increased from 130 to 160 beats per minute.ConclusionThe GA-adjusted reference values for the Mod-MPI and the three time periods used for its calculation can be applied to fetal cardiac evaluation in the presence of pregnancy-associated complications. Copyright © 2007 ISUOG. Published by John Wiley & Sons, Ltd.The GA-adjusted reference values for the Mod-MPI and the three time periods used for its calculation can be applied to fetal cardiac evaluation in the presence of pregnancy-associated complications. Copyright © 2007 ISUOG. Published by John Wiley & Sons, Ltd.

To identify the etiology and pregnancy outcome of hydrops fetalis in a cohort of pregnancies referred to a tertiary maternal fetal medicine center in the UK. These data allow the review of a large series of pregnancies affected by hydrops fetalis and emphasize the importance of investigation and then treatment of individual cases. This provides parents with improved information and especially specific prognostic information. A retrospective review of 63 consecutive cases of hydrops fetalis managed between September 1996 and March 1999. Of the pregnancies, 12.7% (n = 8) were associated with an 'immune' etiology. Of these, 62.5% (n = 5) had fetal anemia due to anti-D, 25% (n = 2) anti-Kell and 12.5% (n = 1) anti-c antibodies. The remaining 55 cases (87.3%) had a non-immune cause. Eight (14.5%) were due to human parvovirus B19 infection. Fourteen cases (25.5%) were associated with aneuploidy and, in four (7.3%), a primary hydrothorax was the cause of the non-immune hydrops fetalis. A cardiac cause was found in five (9.1%) cases. Three of these had supraventricular tachycardia and one had congenital complete heart block. Cystic hygroma was associated with hydrops fetalis in six cases. Twin-twin transfusion syndrome was the cause for hydrops in two cases. Massive transplacental hemorrhage was identified in one case. Fetal akinesia and muscular dystrophy caused hydrops in one case each. In 14.5% (8/55) of cases no obvious cause was identified and these were classified as 'idiopathic'. Three other cases could not be classified because parents declined investigations (unclassified). In the pregnancies with non-immune hydrops fetalis, the outcome was favorable in 27.3% (15/55) of cases. The prognosis of hydrops fetalis differs markedly between different etiological groups. Etiologies range from treatable causes with a good outcome and probably no long-term side-effects (as in case of parvovirus B19), to others which are incompatible with life or are associated with considerable perinatal morbidity and mortality.

Abstract Congenital pulmonary lymphangiectasia (CPL) is a rare congenital disorder that typically presents with intractable respiratory failure in the first few days of life. There is an association non-immun hydrops and CPL. In this study we reviewed four CPL cases between January2006 and January 2014 among 684 fetal-pediatric autopsies. All cases were in the second trimester. In light microscopy there were marked dilatated channels in the subpleural -peribronchial-subseptal region of the lungs. The channels were lined with flattened cells which were expressing CD 31 and D2-40, negative for CD34. Although pulmonary interstitial emphysema (PIE) was considered an important differential diagnosis, a giant cell reaction surrounding the interstitial cystic lesions, a histological hallmark of PIE. CPL is characterized by dilatation of the pulmonary lymphatic vessels and occurs as a congenital anomaly. Noonan classified it into three groups. Primary developmental defect of pulmonary lymphatics is group 3. Group 3 is called also as CPL; normal regression of the connective tissue elements fails to occur after the 16th week of fetal life, associated with an aggressive clinical course, poor prognosis. In fetal autopsy examination CPL should be recognized if there is a fetus with pleural effusion, non-immune hydrops. There is no clinical evidence for CPL.

To measure the effect of multiple courses of antenatal betamethasone, used for lung maturation, on long-term cognition of mice offspring. Forty gravid CD-1 mice were randomly assigned to receive one of four treatments (n = 10 per group): 0.1 mg betamethasone or saline placebo, given subcutaneously either once daily on gestational days 13-16 or twice daily on days 14 and 15. This dose of betamethasone given on gestational day 14 causes fetal lung maturation in mice. Three offspring per gender in each litter underwent standard cognitive tasks as juveniles and as adults. Analysis of variance or Kruskal-Wallis testing was used to compare data. Learning acquisition and memory were indistinguishable between the betamethasone-exposed and the corresponding placebo-exposed offspring when performing the following tasks: juvenile runway with adult memory, adult water runway and Morris spatial maze. This lack of difference in task performance between treatment groups persisted after controlling for gender and for each multiple-course regimen. Multiple courses of antenatal corticosteroids did not impact the mouse offsprings' long-term learning and memory.

Mid-trimester maternal serum AFP and hCG have been associated with adverse pregnancy outcomes in the absence of aneuploidy or neural tube defects. Mid-trimester maternal serum AFP levels > 2.5 MoM are thought to reflect a defect in placentation and are associated with an increased risk of complications in later pregnancy including: late fetal loss, gestational hypertension, preeclampsia, IUGR, preterm delivery and IUFD. Mid-trimester maternal serum hCG > 2.5 MoM is associated with an increased risk of complications in later pregnancy including: late fetal loss, gestational hypertension, preeclampsia, IUGR, preterm delivery and IUFD.
Combined mid-trimester elevation in maternal serum AFP and hCG levels suggest a more complex type of placental pathology. They are more strongly associated with complications in later pregnancy including: late fetal loss, gestational hypertension, preeclampsia, IUGR, preterm delivery and IUFD. Mid-trimester maternal serum AFP and/or hCG levels alone cannot detect all pregnant women with increased risk of developing pregnancy complications. Multiparameter testing of placental function in
mid-trimester (maternal serum AFP and hCG screening, uterine artery Doppler and placental morphology) may allow us to identify women with increased risk of developing severe placental insufficiency and pregnancy complications.

We report a case of diamniotic, dichorionic pregnancy presented at 24 weeks with premature rupture of the first amnionic sac. Seven days later, premature labour and delivery of the first twin took place, with unfortunate outcome. The second twin was left in utero. The management included combination of tocolytics, antibiotics and cervical cerclage. Caesarean section was performed 48 days later, at 32 weeks and we delivered a live male infant, successfully.

Objectives: Recent advances in Spatial Temporal Image Correlation (STIC) 4 D fetal echocardiography include the application of eSTIC based on electronic probe image acquisition. We aimed to directly compare the performance of conventional STIC versus eSTIC technique (B-Mode and color Doppler imaging) during off-line reconstruction of STIC/eSTIC fetal heart volume pairs. Methods: Pairs of B-Mode and Color Doppler STIC volumes were acquired sequentially by firstly conventional (STIC) followed by electronic (eSTIC) probes during 33 consecutive obstetric scans at median 23 (range 13-31) gestational weeks. The resulting 66 fetal heart volume pairs were assessed blindly off-line by a fetal cardiologist who documented feasibility of reconstruction, presence of motion artifacts, subjective image quality on a 4-level scale: 1-best to 4-non-diagnostic and morphological diagnosis, to enable a paired comparison of STIC and eSTIC in the same fetus under similar scanning conditions. Results: eSTIC volumes had higher temporal resolution (37 vs. 24 frames per second, p < .001), less motion during acquisition (12 vs. 20 cases, O.R. 7.0, p ¼ .002) and better average image quality (1.9 vs. 2.2, p ¼ .006) compared to STIC volumes. More diagnostic reconstructions were achieved by eSTIC (n ¼ 55, 86%) than STIC (n ¼ 52, 78.8%), p ¼ .001), in a comparable analysis time (mean 4.96 vs. 4.94 min). During a comparison of image quality of the original acquisition (A) and reconstructed planes (B and C planes) e STIC was superior in 22 (33%), 39 (59%) and 21 (38%) volumes, respectively, with the remaining cases being of similar quality (<10% in each plane in favor of STIC). Imaging mode and gestational age had a similar impact on both eSTIC and STIC performance: diagnostically acceptable studies in 49 (75.8%) vs. 48 (72.2%) by B-Mode, 60 (90.9%) vs. 56 (84.8%) by Color Doppler Mode, 8 (62.5%) vs. 10 (50%) in early scans, 38 (95%) vs. 38 (95%) in mid-gestation scans, and 7 (70%) vs. 6 (60%) in third trimester scans. Eight obstetric scans identified a fetus with a cardiac variant or structural abnormality. Diagnostic concordance of the two STIC approaches was comparable (40/48 concordant interpretations, kappa 0.657) all confirmed by fetal and/or postnatal echocardiography. Conclusions: eSTIC was associated with more effective 4 D fetal heart reconstruction due to reduced motion artifacts and superior image quality in all planes, when compared to STIC. Early gestation reconstructions were not generally successful using either technology. Further study is needed to define the cost-effectiveness and diagnostic impact of eSTIC over conventional STIC and their role over, or in addition to, screening 2 D fetal echocardiography by appropriately trained sonographers.

The study was aimed to the investigation of the maternal heart rate variability involvement in regulation of fetal circulatory system in case of healthy pregnancy and in fetal growth restriction. 98 patients at 34-40 weeks of gestation were enrolled in the study. And 30 of them were involved in Group I (control). In Group II 34 pregnant women with fetal growth restriction and normal Doppler indices were observed. 34 patients with decreased values of hemodynamic indices were monitored in Group III. The circulatory abnormalities in the utero-placental bed in patients with fetal growth restriction induced maternal and fetal autonomic response. The development of fetal compromise was due to an increased sympathetic and decreased parasympathetic tones. The fact of the considerable relationship between fetal and maternal heart rate variability in healthy pregnancy demonstrated the oscillatory nature of their interaction. Placental bed pathology in patients with fetal growth restriction an...