Publications by authors named "Wesley Lee"

115 Publications

Inter-twin differences in fetal echocardiographic findings are associated with decreased dual twin survival in twin-twin transfusion syndrome.

J Matern Fetal Neonatal Med 2021 Jan 17:1-7. Epub 2021 Jan 17.

Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital-Pavilion for Women, Houston, TX, USA.

Objective: To determine if inter-twin differences in fetal echocardiographic findings are associated with fetal survival in monochorionic pregnancies complicated by twin-to-twin transfusion syndrome (TTTS).

Methods: This study included women who underwent laser surgery for TTTS between 2012 and 2018 at a single institution. Echocardiographic cardiac parameters in the donor and recipient twins were compared using -scores and regression analyses (adjusted for confounding variables) to determine whether any measurable inter-twin differences were associated with neonatal survival at birth. Results are expressed as (Odds ratio [95% confidence interval], -value).

Results: Fetal echocardiography and delivery information was available in 124 TTTS cases. Dual live-birth occurred in 72% and at least one live-birth was seen in 89% of cases. Sixty-four percent (51/79) of recipient twins had evidence of cardiac dysfunction compared to 10% (8/79) of the donor twins ( < .01). In the logistic regression, inter-twin differences in left ventricle short axis dimension (0.62[0.44-0.87],  < .01), aortic valve diameter (0.67[0.45-0.99],  = .047), peak systolic velocity across the pulmonary artery (PA-PSV) (0.09[0.01-0.53],  < .01) and mitral valve diameter (0.56[0.38-0.84],  < .01) were associated with lower dual twin survival at birth.

Conclusion: Inter-twin differences in left cardiac geometry and function are associated with decreased survival at delivery in TTTS.
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http://dx.doi.org/10.1080/14767058.2021.1873268DOI Listing
January 2021

Thought Suppression in Primary Psychotic Disorders and Substance/Medication Induced Psychotic Disorder.

Int J Environ Res Public Health 2020 12 26;18(1). Epub 2020 Dec 26.

Department of Neuroscience, Victor Babeș University of Medicine and Pharmacy, 300041 Timișoara, Romania.

Introduction: First episode-psychosis (FEP) represents a stressful/traumatic event for patients. To our knowledge, no study to date has investigated thought suppression involved in FEP in a Romanian population. Our objective was to investigate thought suppression occurring during FEP within primary psychotic disorders (PPD) and substance/medication induced psychotic disorders (SMIPD). Further, we examined the relationship between thought suppression and negative automatic thoughts within PPD and SMIPD.

Methods: The study included 30 participants (17 females) with PPD and 25 participants (10 females) with SMIPD. Psychological scales were administered to assess psychotic symptoms and negative automatic thoughts, along a psychiatric clinical interview and a biochemical drug test.

Results: Participants in the PPD group reported higher thought suppression compared to SMIPD group. For the PPD group, results showed a positive correlation between thought suppression and automatic thoughts. For the SMIPD group, results also showed a positive correlation between thought suppression and automatic thoughts.

Conclusions: Patients with PPD rely more on thought suppression, as opposed to SMIPD patients. Thought suppression may be viewed as an unhealthy reaction to FEP, which is associated with the experience of negative automatic thoughts and might be especially problematic in patients with PPD. Cognitive behavioral therapy is recommended to decrease thought suppression and improve patients' functioning.
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http://dx.doi.org/10.3390/ijerph18010116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7795668PMC
December 2020

Growth patterns and cardiovascular abnormalities in SGA fetuses: 3. Late, adaptive and recovering growth restriction.

J Matern Fetal Neonatal Med 2020 Sep 16:1-10. Epub 2020 Sep 16.

Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland.

Objective: To characterize abnormal growth processes and their associated cardiovascular abnormalities in SGA fetuses using Individualized Growth Assessment (IGA).

Methods: This longitudinal investigation utilized a SGA cohort [EFW and BW <10th percentile] derived from the PORTO study. Fetuses categorized by their Fetal Growth Pathology Score [FGPS1] patterns [Pattern 2 { = 12}, Pattern 3 { = 11}, Pattern 5 { = 13}] were evaluated. Growth pathology was measured using the -FGPS1 and the individual composite Prenatal Growth Assessment Score {-icPGAS]. Paired cardiovascular assessments utilized measurements of the Pulsatility Index [umbilical artery {UA}, middle cerebral artery {MCA}, ductus venosus {DV}] and the myocardial performance index [MPI; heart]. Outcome variables were birth age [preterm or, term] and birth weight [small or normal (IGA criteria)].

Results: Pattern 2 was usually characterized by a single, growth abnormality (67% of cases) of variable magnitude that occurred within two weeks of delivery {median onset age: 37.6 weeks}. The incidence of UA abnormalities was low (25%) while those of MCA and DV/MPI were high {60%, 42%}. Most neonates were of normal size (67%) and delivered at term (67%). Pattern 3 had an initial progressive growth restriction phase, followed by constant but abnormally low growth. Growth pathology had an early onset (median age: 31.6 weeks), was moderate but persistently abnormal. The incidences of cardiovascular abnormalities were moderate [30-50%]. Most neonates were abnormally small (80%) but delivered at term (90%). Pattern 5 had an initial progressive phase with an early onset [onset age {median}: 31.6 weeks]. However, this process was arrested and returned toward normal. Growth pathology magnitudes were minor as were the incidences of cardiovascular abnormalities. Neonatal size was usually normal and all fetuses delivered at term.

Conclusions: Characteristics of SGA Growth Restricted, Patterns 2, 3 and 5 are clearly different from those found in SGA Normal or SGA Growth Restricted Pattern 1 groups. They also differed from one another, indicating that growth restriction can manifest itself in several different ways. Pattern 2 is similar to "late" growth restriction reported previously. Patterns 3 and 5 are novel and have been designated as "adaptive" and "recovering" types of growth restriction.
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http://dx.doi.org/10.1080/14767058.2020.1803262DOI Listing
September 2020

Growth patterns and cardiovascular abnormalities in SGA fetuses: 2. Normal growth and progressive growth restriction.

J Matern Fetal Neonatal Med 2020 Sep 13:1-10. Epub 2020 Sep 13.

Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland.

Objectives: To characterize growth processes and their associated cardiovascular abnormalities in SGA fetuses with normal growth and progressive growth restriction patterns as defined by Individualized Growth Assessment (IGA).

Methods: A SGA cohort (EFW and BW < 10th percentile) was derived from the PORTO study that included 47 fetuses with normal growth outcome (SGA Normal) and 34 fetuses with progressive growth restriction (SGA Growth Restricted, Pattern 1). Composite fetal size parameters were used to quantify growth pathology at individual third trimester time points (individual composite Prenatal Growth Assessment Score {icPGAS}) and calculated cumulatively during the third trimester (Fetal Growth Pathology Score 1{FGPS1}). Paired Doppler evaluations of the umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV) and myocardial performance index (MPI) were used to detect cardiovascular anomalies. Outcome variables were birth age and birth weight.

Results: Ranking fetuses with respect to the severity of the 3rd trimester growth pathology (-FGPS1) revealed three subgroups in each of these two groups. In SGA Normal, no (51%), minimal (19%) or minor (30%) growth abnormalities were present. Although vascular flow abnormalities occurred without growth abnormalities (UA: 38%; MCA: 35%), they increased with minor growth disturbances (UA: 64%; MCA: 50%). All fetuses delivered at term and in only 7 cases (minor growth abnormalities subgroup) were the neonates abnormally small based on IGA criteria. In SGA Growth Restricted, Pattern 1, the progression of growth restriction was slow (47%), moderate (21%) and rapid (32%). Corresponding median -FGPS1 values were -1.34%, -2.67% and -4.88%, respectively. The median age of onset was 33.6, 29.7 and 29.7 weeks in these three subgroups. UA abnormalities occurred infrequently in the first two subgroups but were found in all cases of rapidly progressing pathology. Similar results were found for the MCA and DV + MPI Doppler parameters (rapid progression: MCA = 50%; DV + MPI = 50%). Premature delivery occurred less frequently with slow progression but was nearly 100% in the moderately and rapidly progressive subgroups.

Conclusions: Negative FGPS1 growth restriction patterns can be used to classify SGA fetuses. Subgroups, based on ranked -FGPS1 values in both SGA Normal and SGA Growth Restricted Pattern 1 groups had marked differences in cardiovascular abnormalities and neonatal outcomes. The characteristics of these two groups are consistent with small, normally growing fetuses and fetuses with "early" growth restriction, respectively.
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http://dx.doi.org/10.1080/14767058.2020.1807506DOI Listing
September 2020

Fetal Weight Estimation Using Automated Fractional Limb Volume With 2-Dimensional Size Parameters in Diabetic Pregnancies.

J Ultrasound Med 2021 Feb 25;40(2):279-284. Epub 2020 Jul 25.

Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, Texas, USA.

Objectives: To examine the effect of adding automated fetal fractional limb volume (FLV) with conventional 2-dimensional (2D) fetal weight estimation procedures in a cohort of diabetic pregnancies.

Methods: A pilot study of diabetic pregnancies measured standard fetal biometry within 7 days of delivery. Fractional arm volume (AVol) and fractional thigh volume (TVol) soft tissue parameters were measured with a commercially available automated software utility (5D Limb Vol; Samsung Medison Co, Ltd, Seoul, Korea). Three conventional weight prediction models that included only 2D size parameters were compared to FLV models that included AVol or TVol. Estimated and actual birth weight (BW) were assessed for the mean percent difference ± standard deviation of the percent differences. Systematic errors were evaluated by the Student t test, and random errors were compared by the Pitman test for correlated variances. The proportion of neonates with estimated fetal weight within 10% of BW was compared between groups by the McNemar test.

Results: Ninety gravid women were enrolled with pregestational (26.7%) or gestational (73.3%) diabetes. All prediction models were accurate, with the exception of small underestimations by the model of Schild et al (-3.8%; Ultrasound Obstet Gynecol 2004; 23:30-35). Random errors for the AVol (6.2%) and TVol (6.9%) models were significantly more precise than the other 3 prediction models: Hadlock et al (7.8%; Am J Obstet Gynecol 1985; 151:333-337), INTERGROWTH-21st (8.0%; Ultrasound Obstet Gynecol 2017; 49:478-486), and Schild et al (8.6%; P < .01). The greatest proportion of cases with BW ±10% was also classified by the AVol (91.1%) and TVol (91.1%) models, followed by Hadlock (83.3%), INTERGROWTH-21st (78.9%), and Schild (76.7%) predictions.

Conclusions: The addition of automated FLV measurements to conventional 2D biometry was associated with improved weight predictions in this cohort of diabetic pregnancies.
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http://dx.doi.org/10.1002/jum.15397DOI Listing
February 2021

Umbilical Artery Doppler Patterns and Right Ventricular Outflow Abnormalities in Twin-Twin Transfusion Syndrome.

J Ultrasound Med 2021 Jan 10;40(1):71-78. Epub 2020 Jul 10.

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA.

Objectives: To evaluate the association of abnormal Doppler velocimetric patterns in the umbilical arteries (UAs) and right ventricular outflow tract abnormalities (RVOTAs) in twin- twin transfusion syndrome (TTTS) cases.

Methods: This retrospective study involved women who had laser surgery for TTTS between January 2012 and May 2018 at a single institution. The prevalence of an RVOTA in either twin was compared among TTTS cases in which both twins had positive end-diastolic flow (EDF) in the UA and those in which either twin had intermittent or persistent absent/reversed UA EDF. Nonparametric tests were used for comparisons. Logistic regression was performed to identify variables associated with an RVOTA in either twin, adjusted for moderate or severe tricuspid regurgitation, right ventricular hypertrophy, right ventricular systolic or diastolic dysfunction, the Quintero stage, and other confounders. P < .05 was considered significant.

Results: A total of 126 consecutive TTTS cases were included. Right ventricular outflow tract abnormalities were seen in 8.7% (11of 126) of cases, all in recipient twins. Significant differences in the rate of RVOTAs in the recipient twin were seen between TTTS cases with intermittent absent/reversed UA EDF and those with positive UA EDF (26.9% [7 of 26] versus 3.7% [3 of 82]; P = .002]. However, no significant differences were noted among the other study groups. Intermittent absent/reversed UA EDF was associated with a significantly increased risk for an RVOTA (adjusted odds ratio, 20.6 [95% confidence interval, 3.1-138]; P = .002) after adjusting for confounders.

Conclusions: Intermittent changes in vascular impedance to UA flow may contribute to the pathogenesis of acquired right-sided cardiac lesions in the recipient twin affected with TTTS.
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http://dx.doi.org/10.1002/jum.15377DOI Listing
January 2021

Fetal Weight Estimation Using Automated Fractional Limb Volume With 2-Dimensional Size Parameters: A Multicenter Study.

J Ultrasound Med 2020 Jul 5;39(7):1317-1324. Epub 2020 Feb 5.

Diakovere Krankenhaus, Hannover, Germany.

Objectives: To develop new fetal weight prediction models using automated fractional limb volume (FLV).

Methods: A prospective multicenter study measured fetal biometry within 4 to 7 days of delivery. Three-dimensional data acquisition included the automated FLV that was based on 50% of the humerus diaphysis (fractional arm volume [AVol]) or 50% of the femur diaphysis (fractional thigh volume [TVol]) length. A regression analysis provided population sample-specific coefficients to develop 4 weight estimation models. Estimated and actual birth weights (BWs) were compared for the mean percent difference ± standard deviation of the percent differences. Systematic errors were analyzed by the Student t test, and random errors were compared by the Pitman test.

Results: A total of 328 pregnancies were scanned before delivery (BW range, 825-5470 g). Only 71.3% to 72.6% of weight estimations were within 10% of actual BW using original published models by Hadlock et al (Am J Obstet Gynecol 1985; 151:333-337) and INTERGROWTH-21st (Ultrasound Obstet Gynecol 2017; 49:478-486). All predictions were accurate by using sample-specific model coefficients to minimize bias in making these comparisons (Hadlock, 0.4% ± 8.7%; INTERGROWTH-21st, 0.5% ± 10.0%; AVol, 0.3% ± 7.4%; and TVol, 0.3% ± 8.0%). Both AVol- and TVol-based models improved the percentage of correctly classified BW ±10% in 83.2% and 83.9% of cases, respectively, compared to the INTERGROWTH-21st model (73.8%; P < .01). For BW of less than 2500 g, all models slightly overestimated BW (+2.0% to +3.1%). For BW of greater than 4000 g, AVol (-2.4% ± 6.5%) and TVol (-2.3% ± 6.9%) models) had weight predictions with small systematic errors that were not different from zero (P > .05). For these larger fetuses, both AVol and TVol models correctly classified BW (±10%) in 83.3% and 87.5% of cases compared to the others (Hadlock, 79.2%; INTERGROWTH-21st, 70.8%) although these differences did not reach statistical significance.

Conclusions: In this cohort, the inclusion of automated FLV measurements with conventional 2-dimensional biometry was generally associated with improved weight predictions.
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http://dx.doi.org/10.1002/jum.15224DOI Listing
July 2020

Growth patterns and cardiovascular abnormalities in small for gestational age fetuses: 1. Pattern characteristics.

J Matern Fetal Neonatal Med 2019 Oct 21:1-10. Epub 2019 Oct 21.

Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital , Dublin , Ireland.

Fetal growth restriction is being defined as either "early" or "late" depending on age of onset. A recent investigation using individualized assessment has identified five different growth restriction patterns. No previous study has related these patterns to cardiovascular abnormalities. To determine growth patterns in small fetuses (BW < 10th percentile) using Individualized Growth Assessment (IGA) and to relate cardiovascular abnormalities found with Doppler ultrasound to these patterns. A secondary analysis was carried out in 126 fetuses from the PORTO data set having both estimated weights and birth weights below the 10th percentile. Only fetuses with 2nd and 3rd trimester biometry scans appropriate for IGA and cardiovascular assessments were studied. There was one-to-one matching of biometry and Doppler evaluations in the 3rd trimester. Composite growth parameters were used to quantify growth pathology at individual time points (individual composite Prenatal Growth Assessment Score (icPGAS)) and during the 3rd trimester (Fetal Growth Pathology Score {FGPS1}). Normal and growth restriction patterns were identified using plots of FGPS1 values. Doppler measurements were classified as normal or abnormal based on published cross-sectional standards. Outcome variables were birth weight and birth age. In these SGA cases, 38.2% showed normal fetal growth and 61.8% had growth restriction. In the latter, seven different patterns were observed. Pattern 1 was most common (43.5%), followed by Patterns 5 (16.7%), 2 (15.4%) and 3 (14.1%). The characteristics of Pattern 1 indicated progressive growth restriction while Pattern 5 demonstrated recovery from an initial growth abnormality. Cardiovascular abnormalities were quite variable, with those in the umbilical artery being most frequent in Patterns 1 and 3. Pattern 2 had the highest incidence of middle cerebral artery abnormalities. Umbilical artery abnormalities were similar in the Normal and Pattern 5 groups as were those for the middle cerebral artery. Other cardiovascular abnormalities had low frequencies except in Pattern 2 where the ductus venosus incidence was high. Abnormally small neonates, as identified with IGA, were seen primarily in Patterns 1, 3 and 6 (80-88%). Premature deliveries occurred most frequently in Pattern 1 (56%), followed by Pattern 2 (33%). Growth in this SGA Group was very heterogeneous with a significant proportion of these small fetuses growing normally. Growth restriction did not appear to be a single process but was manifest as seven different FGPS1 patterns. Both growth pathology and cardiovascular abnormalities differed among patterns. Further investigation will be required to determine how specific growth abnormalities are related to fetal cardiovascular changes over time.
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http://dx.doi.org/10.1080/14767058.2019.1677592DOI Listing
October 2019

Comparison of fetal size standards obtained with conventional methods and individualized assessment: the effect of adjusting for differences in growth potential.

J Matern Fetal Neonatal Med 2020 Sep 30;33(18):3170-3176. Epub 2019 Apr 30.

Tulane University, New Orleans, LA, USA.

Detection of fetal growth restriction depends on the biometric standard definitions of normal variability. We examined the impact of correcting for differences in fetal growth potential on the variability of third-trimester size standards. Size standards, corrected differences in growth potential using Individualized Growth Assessment [IGA], were obtained in 119 pregnancies with normal neonatal growth outcomes. Using the same cohort, a second set of size standards, without these corrections, were determined with mixed modeling [IGA Cross-sectional]. An independent set of size standards, obtained by quantile regression in a population-based sample of 1387 pregnant women [World Health Organization (WHO)], was also evaluated. The anatomical parameters studied included BPD, HC, AC, FDL, THC, HDL, ArmC and EWT whenever possible. The variability measures compared were percent deviation reference range [IGA] or twice the coefficient of variation [IGA Cross-sectional, WHO] at weekly time points between 28 and 38 weeks, menstrual age. All six IGA variabilities were significantly smaller [range: 19-60%] when IGA and IGA-cross-sectional size standards were compared. Similar IGA-WHO comparisons showed that the IGA variabilities for 5 of 6 anatomical parameters were significantly smaller [range: 26-32%; exception: FDL (5.8%)]. Comparisons of cross-sectional size standards gave variable results depending on the anatomical parameter studied. Third-trimester variability measures, based on IGA, were consistently lower than those obtained with conventional cross-sectional methods in normal pregnancies. These results were found when the identical sample was used in both IGA and cross-sectional analyses. Decreased variability can improve the sensitivity of IGA for detecting restricted growth and may be partly responsible for its ability to identify different types of growth abnormalities earlier in pregnancy.
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http://dx.doi.org/10.1080/14767058.2019.1601695DOI Listing
September 2020

Characterization of Placental Microvasculature Using Superb Microvascular Imaging.

J Ultrasound Med 2019 Sep 8;38(9):2485-2491. Epub 2019 Jan 8.

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA.

Superb Microvascular Imaging (SMI; Canon Medical Systems, Tustin, CA) uses clutter suppression to extract flow signals at rapid frame rates, which provides high-resolution vessel-branching details without the need for contrast agents. The potential diagnostic benefits of SMI, as described in other areas of medicine, requires further exploration during pregnancy. In this pictorial essay, we demonstrate the complementary use of SMI compared to conventional Doppler ultrasound and how it may improve our ability to characterize placental microvascular patterns without the need for ultrasound contrast agents.
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http://dx.doi.org/10.1002/jum.14919DOI Listing
September 2019

Cerebral oxygen metabolism during and after therapeutic hypothermia in neonatal hypoxic-ischemic encephalopathy: a feasibility study using magnetic resonance imaging.

Pediatr Radiol 2019 02 6;49(2):224-233. Epub 2018 Nov 6.

Department of Pediatrics (Neonatal-Perinatal Medicine), Department of Obstetrics and Gynecology, Penn State Health Children's Hospital, Hershey, PA, USA.

Background: Therapeutic hypothermia is the standard-of-care treatment for infants diagnosed with moderate-to-severe hypoxic-ischemic encephalopathy (HIE). MRI for assessing brain injury is usually performed after hypothermia because of logistical challenges in bringing acutely sick infants receiving hypothermia from the neonatal intensive care unit (NICU) to the MRI suite. Perhaps examining and comparing early cerebral oxygen metabolism disturbances to those after rewarming will lead to a better understanding of the mechanisms of brain injury in HIE and the effects of therapeutic hypothermia.

Objective: The objectives were to assess the feasibility of performing a novel T2-relaxation under spin tagging (TRUST) MRI technique to measure venous oxygen saturation very early in the time course of treatment, 18-24 h after the initiation of therapeutic hypothermia, to provide a framework to measure neonatal cerebral oxygen metabolism noninvasively, and to compare parameters between early and post-hypothermia MRIs.

Materials And Methods: Early (18-24 h after initiating hypothermia) MRIs were performed during hypothermia treatment in nine infants with HIE (six with moderate and three with severe HIE). Six infants subsequently had an MRI after hypothermia. Mean values of cerebral blood flow, oxygen extraction fraction, and cerebral metabolic rate of oxygen from MRIs during hypothermia were compared between infants with moderate and severe HIE; and in those with moderate HIE, we compared cerebral oxygen metabolism parameters between MRIs performed during and after hypothermia.

Results: During the initial hypothermia MRI at 23.5±5.2 h after birth, infants with severe HIE had lower oxygen extraction fraction (P=0.04) and cerebral metabolic rate of oxygen (P=0.03) and a trend toward lower cerebral blood flow (P=0.33) compared to infants with moderate HIE. In infants with moderate HIE, cerebral blood flow decreased and oxygen extraction fraction increased between MRIs during and after hypothermia (although not significantly); cerebral metabolic rate of oxygen (P=0.93) was not different.

Conclusion: Early MRIs were technically feasible while maintaining hypothermic goal temperatures in infants with HIE. Cerebral oxygen metabolism early during hypothermia is more disturbed in severe HIE. In infants with moderate HIE, cerebral blood flow decreased and oxygen extraction fraction increased between early and post-hypothermia scans. A comparison of cerebral oxygen metabolism parameters between early and post-hypothermia MRIs might improve our understanding of the evolution of HIE and the benefits of hypothermia. This approach could guide the use of adjunctive neuroprotective strategies in affected infants.
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http://dx.doi.org/10.1007/s00247-018-4283-9DOI Listing
February 2019

Estimated energy requirements increase across pregnancy in healthy women with dichorionic twins.

Am J Clin Nutr 2018 10;108(4):775-783

USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX.

Background: Estimated energy requirement (EER) has not been defined for twin pregnancy. This study was designed to determine the EER of healthy women with dichorionic-diamniotic (DCDA) twin pregnancies.

Objectives: We aimed to estimate energy deposition from changes in maternal body protein and fat; to measure resting energy expenditure (REE), physical activity level (PAL), and total energy expenditure (TEE) throughout pregnancy and postpartum; and to define the EER based on the sum of TEE and energy deposition for twin gestation.

Design: This is a prospective study of 20 women with DCDA twin gestations. Maternal EER, energy deposition, REE, TEE, and PAL were obtained during the first, second, and third trimesters of pregnancy and immediately postpartum. A mixed-effects linear regression model for repeated measures with random intercept was used to test for the effects of BMI groups and time.

Results: Gains in total body protein (mean ± SD: 2.1 ± 0.7 kg) and fat mass (5.9 ± 2.8 kg) resulted in total energy deposition of 67,042 ± 25,586 kcal between 0 and 30-32 weeks of gestation. REE increased 26% from 1392 ± 162 to 1752 ± 172 kcal/d across the 3 trimesters, whereas TEE increased 17% from 2141 ± 283 to 2515 ± 337 kcal/d. Physical activity decreased steadily throughout pregnancy. Reductions in physical activity did not compensate for the rise in REE and energy deposition, thus requiring an increase in dietary energy intake as pregnancy progressed. EER increased 29% from 2257 ± 325 kcal/d in the first trimester to 2941 ± 407 kcal/d in the second trimester, and stayed consistent at 2906 ± 350 kcal/d in the third trimester.

Conclusion: Increased energy intake, on average ∼700 kcal/d in the second and third trimesters when compared with the first trimester, is required to support gestational weight gain and the rise in energy expenditure of DCDA twin pregnancies.
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http://dx.doi.org/10.1093/ajcn/nqy184DOI Listing
October 2018

Impact of changes in maternal body composition on birth weight and neonatal fat mass in dichorionic twin pregnancies.

Am J Clin Nutr 2018 10;108(4):716-721

USDA/Agricultural Research Service Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX.

Background: Although the impact of gestational weight gain (GWG) on birth weight in twin pregnancies has been demonstrated, the specific components of GWG have not been delineated for twin gestations. Fetal body composition has been shown to be modifiable in singleton gestations based on nutritional intervention strategies and may prove to have similar modifications in twin gestations.

Objective: We aimed to determine the relation of maternal body composition changes to birth weight, birth length, and neonatal fat mass (FM) in dichorionic-diamniotic twin pregnancies.

Design: This is a prospective study of 20 women with twin gestations. Comparisons were made between body composition variables during each trimester and for the entire pregnancy and compared with the outcomes of birth weight, neonatal fat percentage, and birth length.

Results: GWG within or above compared with below the IOM recommendations was associated with higher birth weights (P = 0.03, P = 0.04, respectively), but also with higher postpartum weight retention (P = 0.001). Total maternal protein gain over the pregnancy was positively associated with birth weight (P = 0.03). Changes in maternal fat-free mass (FFM), total body water (TBW), and FM from the first to the third trimester were not associated with either birth weight or neonatal FM percentage. However, maternal FM change from the second to the third trimester was significantly correlated to neonatal FM percentage (P = 0.02). Third trimester GWG and total protein gain were positively correlated with neonatal birth length (P = 0.02 and 0.03, respectively). Maternal FFM over all 3 trimesters showed a positive relation with neonatal birth length (P = 0.01).

Conclusions: Significant increases in maternal protein are associated with greater birth weight and neonatal birth length. Protein accretion, in contrast to TBW and FM gains, may be the most critical component of maternal GWG in dichorionic twin gestations.
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http://dx.doi.org/10.1093/ajcn/nqy180DOI Listing
October 2018

Fetal Tachycardia Is an Independent Risk Factor for Chromosomal Anomalies in First-Trimester Genetic Screening.

J Ultrasound Med 2019 May 23;38(5):1327-1331. Epub 2018 Sep 23.

Baylor College of Medicine, Houston, Texas, USA.

Objectives: The association of an abnormal fetal heart rate (FHR) and chromosomal anomalies in the first trimester of pregnancy remains unclear, probably because of the lack of control for known confounding factors. This study was designed to determine whether an increased FHR is an independent risk factor for chromosomal anomalies between 11 and 14 weeks' gestation.

Methods: This cohort study included women who underwent first-trimester genetic screening between 2011 and 2014 at a single institution. A multivariable logistic regression analysis was performed to determine whether an FHR of 170 beats per minute (bpm) or higher, derived from a receiver operating characteristic curve, is an independent risk factor for all chromosomal anomalies while controlling for known confounding factors. P < .05 was considered significant.

Results: An FHR of 170 bpm or higher was observed in 7% (228 of 3254), and chromosomal anomalies were present in 1.0% (31 of 3254) of the population. A higher proportion of fetuses with an FHR of 170 bpm or higher had chromosomal anomalies compared to those with an FHR lower than 170 bpm. An FHR of 170 bpm or higher was an independent risk factor for chromosomal anomalies after controlling for known confounding factors. Of note, in the group of fetuses with a nuchal translucency above the 95th percentile, the frequency of chromosomal anomalies was significantly higher among fetuses with an FHR of 170 bpm or higher compared to those with an FHR lower than 170 bpm.

Conclusions: Fetal tachycardia is a risk factor for chromosomal anomalies during first-trimester genetic screening, independent of increased nuchal translucency, nuchal septations, and maternal age.
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http://dx.doi.org/10.1002/jum.14813DOI Listing
May 2019

Inferring social structure from continuous-time interaction data.

Appl Stoch Models Bus Ind 2018 Mar-Apr;34(2):87-104. Epub 2017 Oct 20.

University of Washington.

Relational event data, which consist of events involving pairs of actors over time, are now commonly available at the finest of temporal resolutions. Existing continuous-time methods for modeling such data are based on point processes and directly model interaction "contagion," whereby one interaction increases the propensity of future interactions among actors, often as dictated by some latent variable structure. In this article, we present an alternative approach to using temporal-relational point process models for continuous-time event data. We characterize interactions between a pair of actors as either spurious or as resulting from an underlying, persistent connection in a latent social network. We argue that consistent deviations from expected behavior, rather than solely high frequency counts, are crucial for identifying well-established underlying social relationships. This study aims to explore these latent network structures in two contexts: one comprising of college students and another involving barn swallows.
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http://dx.doi.org/10.1002/asmb.2285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6020699PMC
October 2017

Ecology shapes the evolutionary trade-off between predator avoidance and defence in coral reef butterflyfishes.

Ecol Lett 2018 07 9;21(7):1033-1042. Epub 2018 May 9.

Department of Evolution and Ecology, University of California Davis, Davis, CA, 95616, USA.

Antipredator defensive traits are thought to trade-off evolutionarily with traits that facilitate predator avoidance. However, complexity and scale have precluded tests of this prediction in many groups, including fishes. Using a macroevolutionary approach, we test this prediction in butterflyfishes, an iconic group of coral reef inhabitants with diverse social behaviours, foraging strategies and antipredator adaptations. We find that several antipredator traits have evolved adaptively, dependent primarily on foraging strategy. We identify a previously unrecognised axis of diversity in butterflyfishes where species with robust morphological defences have riskier foraging strategies and lack sociality, while species with reduced morphological defences feed in familiar territories, have adaptations for quick escapes and benefit from the vigilance provided by sociality. Furthermore, we find evidence for the constrained evolution of fin spines among species that graze solely on corals, highlighting the importance of corals, as both prey and structural refuge, in shaping fish morphology.
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http://dx.doi.org/10.1111/ele.12969DOI Listing
July 2018

Individualized growth assessment: conceptual framework and practical implementation for the evaluation of fetal growth and neonatal growth outcome.

Am J Obstet Gynecol 2018 02;218(2S):S656-S678

Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI.

Fetal growth abnormalities can pose significant consequences on perinatal morbidity and mortality of nonanomalous fetuses. The most widely accepted definition of fetal growth restriction is an estimated fetal weight less than the 10th percentile for gestational age according to population-based criteria. However, these criteria do not account for the growth potential of an individual fetus, nor do they effectively separate constitutionally small fetuses from ones that are malnourished. Furthermore, conventional approaches typically evaluate estimated fetal weight at a single time point, rather than using serial scans, to evaluate growth. This article provides a conceptual framework for the individualized growth assessment of a fetus/neonate based on measuring second-trimester growth velocity of fetal size parameters to estimate growth potential. These estimates specify size models that generate individualized third-trimester size trajectories and predict birth characteristics. Comparisons of measured and predicted values are used to separate normally growing fetuses from those with growth abnormalities. This can be accomplished with individual anatomical parameters or sets of parameters. A practical and freely available software (Individualized Growth Assessment Program) has been developed to allow implementation of this approach for clinical and research purposes.
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http://dx.doi.org/10.1016/j.ajog.2017.12.210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5882201PMC
February 2018

Fetal Growth: Evaluation and Management.

Am J Obstet Gynecol 2018 02;218(2S):S608

Department of Obstetrics and Gynecology, New York University Winthrop Hospital, Mineola, NY.

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http://dx.doi.org/10.1016/j.ajog.2018.01.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6053681PMC
February 2018

Prospective evaluation of the safety and feasibility of a pelvic floor dilator during active labor.

Int Urogynecol J 2018 Oct 6;29(10):1485-1492. Epub 2018 Feb 6.

Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, 6651 Main Street, Houston, TX, 77030, USA.

Introduction And Hypothesis: The objective was to assess the safety and feasibility of using a pelvic floor dilator during active labor to prevent injuries to the levator ani muscle (LAM) and perineum.

Methods: In a prospective pilot study, a pelvic floor dilator using soft pads was introduced into the vaginal canal to gradually expand the vagina, in 30 nulliparous women and in 10 controls. The primary outcomes were adverse events related to the device. Secondary outcomes were perineal lacerations after delivery, sonographically defined levator ani injury, hiatal area dimensions, and anal sphincter disruption, all at 12-20 weeks postpartum, and maximum pelvic floor dilation, time to achieve maximum dilation, and device retention rate.

Results: From October 2014 through November 2016, a total of 494 women were screened, and 61 consented to the study. Thirty women used the device and 27 returned for follow-up. No maternal or neonatal injuries were related to use of the dilator. The average maximum dilation of the vaginal canal was 7.4 cm (SD 0.7, range 5.5-8.0). Dilation time averaged 27 min (SD 13, range 5-60). Device insertion adjustment was needed in 13 out of 30 cases (43%). Similar rates of 3th-4th degree perineal lacerations were seen in both groups. Levator ani avulsion was diagnosed in 2 out of 27 (7%) in the device group and in 1 out of 9 (11%) in the control group (p = 0.2). The rate of partial injury in the device group was 2 out of 27 (7%) vs 2 out of 9 (22%) in the comparison group (p = 0.2).

Conclusion: The use of the pelvic floor dilator during active labor is feasible. No safety issues were identified.
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http://dx.doi.org/10.1007/s00192-018-3555-0DOI Listing
October 2018

Clinical assessment and brain findings in a cohort of mothers, fetuses and infants infected with ZIKA virus.

Am J Obstet Gynecol 2018 04 17;218(4):440.e1-440.e36. Epub 2018 Jan 17.

Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cediul-Cedifetal, Barranquilla, Colombia.

Background: Congenital Zika virus (ZIKV) infection can be detected in both the presence and absence of microcephaly and manifests as a number of signs and symptoms that are detected clinically and by neuroimaging. However, to date, qualitative and quantitative measures for the purpose of diagnosis and prognosis are limited.

Objectives: Main objectives of this study conducted on fetuses and infants with confirmed congenital Zika virus infection and detected brain abnormalities were (1) to assess the prevalence of microcephaly and the frequency of the anomalies that include a detailed description based on ultrasound and magnetic resonance imaging in fetuses and ultrasound, magnetic resonance imaging, and computed tomography imaging postnatally, (2) to provide quantitative measures of fetal and infant brain findings by magnetic resonance imaging with the use of volumetric analyses and diffusion-weighted imaging, and (3) to obtain additional information from placental and fetal histopathologic assessments and postnatal clinical evaluations.

Study Design: This is a longitudinal cohort study of Zika virus-infected pregnancies from a single institution in Colombia. Clinical and imaging findings of patients with laboratory-confirmed Zika virus infection and fetal brain anomalies were the focus of this study. Patients underwent monthly fetal ultrasound scans, neurosonography, and a fetal magnetic resonance imaging. Postnatally, infant brain assessment was offered by the use of ultrasound imaging, magnetic resonance imaging, and/or computed tomography. Fetal head circumference measurements were compared with different reference ranges with <2 or <3 standard deviations below the mean for the diagnosis of microcephaly. Fetal and infant magnetic resonance imaging images were processed to obtain a quantitative brain volumetric assessment. Diffusion weighted imaging sequences were processed to assess brain microstructure. Anthropometric, neurologic, auditory, and visual assessments were performed postnatally. Histopathologic assessment was included if patients opted for pregnancy termination.

Results: All women (n=214) had been referred for Zika virus symptoms during pregnancy that affected themselves or their partners or if fetal anomalies that are compatible with congenital Zika virus syndrome were detected. A total of 12 pregnant patients with laboratory confirmation of Zika virus infection were diagnosed with fetal brain malformations. Most common findings that were assessed by prenatal and postnatal imaging were brain volume loss (92%), calcifications (92%), callosal anomalies (100%), cortical malformations (89%), and ventriculomegaly (92%). Results from fetal brain volumetric assessment by magnetic resonance imaging showed that 1 of the most common findings associated with microcephaly was reduced supratentorial brain parenchyma and increased subarachnoid cerebrospinal fluid. Diffusion weighted imaging analyses of apparent diffusion coefficient values showed microstructural changes. Microcephaly was present in 33.3-58.3% of the cases at referral and was present at delivery in 55.6-77.8% of cases. At birth, most of the affected neonates (55.6-77.8%) had head circumference measurements >3 standard deviations below the mean. Postnatal imaging studies confirmed brain malformations that were detected prenatally. Auditory screening results were normal in 2 cases that were assessed. Visual screening showed different anomalies in 2 of the 3 cases that were examined. Pathologic results that were obtained from 2 of the 3 cases who opted for termination showed similar signs of abnormalities in the central nervous system and placental analyses, including brain microcalcifications.

Conclusion: Congenital microcephaly is not an optimal screening method for congenital Zika virus syndrome, because it may not accompany other evident and preceding brain findings; microcephaly could be an endpoint of the disease that results from progressive changes that are related to brain volume loss. Long-term studies are needed to understand the clinical and developmental relevance of these findings.
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http://dx.doi.org/10.1016/j.ajog.2018.01.012DOI Listing
April 2018

Obstetric and gynecologic ultrasound curriculum and competency assessment in residency training programs: consensus report.

Am J Obstet Gynecol 2018 01;218(1):29-67

Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA.

Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With increasing educational demands and limited hours in residency programs, dedicated time for training and achieving competency in ultrasound has diminished substantially. The American Institute of Ultrasound in Medicine assembled a multisociety task force to develop a consensus-based, standardized curriculum and competency assessment tools for obstetric and gynecologic ultrasound training in residency programs. The curriculum and competency assessment tools were developed based on existing national and international guidelines for the performance of obstetric and gynecologic ultrasound examinations and thus are intended to represent the minimum requirement for such training. By expert consensus, the curriculum was developed for each year of training, criteria for each competency assessment image were generated, the pass score was established at, or close to, 75% for each, and obtaining a set of 5 ultrasound images with pass score in each was deemed necessary for attaining each competency. Given the current lack of substantial data on competency assessment in ultrasound training, the task force expects that the criteria set forth in this document will evolve with time. The task force also encourages use of ultrasound simulation in residency training and expects that simulation will play a significant part in the curriculum and the competency assessment process. Incorporating this training curriculum and the competency assessment tools may promote consistency in training and competency assessment, thus enhancing the performance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology.
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http://dx.doi.org/10.1016/j.ajog.2017.10.016DOI Listing
January 2018

Obstetric and Gynecologic Ultrasound Curriculum and Competency Assessment in Residency Training Programs: Consensus Report.

J Ultrasound Med 2018 Jan;37(1):19-50

Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA.

Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With increasing educational demands and limited hours in residency programs, dedicated time for training and achieving competency in ultrasound has diminished substantially. The American Institute of Ultrasound in Medicine assembled a multisociety task force to develop a consensus-based, standardized curriculum and competency assessment tools for obstetric and gynecologic ultrasound training in residency programs. The curriculum and competency assessment tools were developed based on existing national and international guidelines for the performance of obstetric and gynecologic ultrasound examinations and thus are intended to represent the minimum requirement for such training. By expert consensus, the curriculum was developed for each year of training, criteria for each competency assessment image were generated, the pass score was established at, or close to, 75% for each, and obtaining a set of 5 ultrasound images with pass score in each was deemed necessary for attaining each competency. Given the current lack of substantial data on competency assessment in ultrasound training, the task force expects that the criteria set forth in this document will evolve with time. The task force also encourages use of ultrasound simulation in residency training and expects that simulation will play a significant part in the curriculum and the competency assessment process. Incorporating this training curriculum and the competency assessment tools may promote consistency in training and competency assessment, thus enhancing the performance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology.
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http://dx.doi.org/10.1002/jum.14519DOI Listing
January 2018

Proceedings: Beyond Ultrasound First Forum on Improving the Quality of Ultrasound Imaging in Obstetrics and Gynecology.

J Ultrasound Med 2018 Jan;37(1):7-18

Eastern Virginia Medical School, Norfolk.

The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.
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http://dx.doi.org/10.1002/jum.14504DOI Listing
January 2018

Second trimester growth velocities: assessment of fetal growth potential in SGA singletons.

J Matern Fetal Neonatal Med 2019 Mar 7;32(6):939-946. Epub 2017 Nov 7.

b Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research , Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda , MD and Detroit , MI , USA.

Objective: To evaluate the validity of second trimester growth velocities as measures of fetal growth potential in Small-for-Gestational-Age (SGA) singletons.

Methods: Second trimester growth velocities for biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur diaphysis length (FDL) were determined by linear regression analysis or direct measurement in 53 SGA singletons with normal growth outcomes (SGA N Group) and 73 with growth restriction (SGA GR) based on a composite fetal growth pathology score (FGPS1). The latter were subdivided into six groups based on their growth restriction pattern (Patterns group). Similar data were available for 118 singletons with normal neonatal growth outcomes (NNGO group). Coefficients of determination (R) and growth velocities for each anatomical parameter were compared between Patterns subgroups and the SGA N, SGA GR and NNGO groups.

Results: Median R values in the six Patterns subgroups ranged from 98.2% (Pattern 2, FDL) to 99.9% (Pattern 5, AC). Within each anatomical parameter set, no significant differences were found (Kruskal-Wallis). Patterns subgroup data were pooled to form the SGA GR group for each anatomical parameter. Mean values for the three main groups ranged from 98.4% (SGA N, FDL) to 99.6% (SGA N, HC). No significant differences between groups (ANOVA) were found for any anatomical parameter (ANOVA). Only 1.7-3.8% had R values <95th%. No significant differences in median second trimester growth velocities among different Patterns subgroups were found for any anatomical parameter. In the SGA N and SGA GR groups, mean BPD and HC values did not differ but were significantly smaller than the NNGO group values. No differences in mean FDL values were seen. With AC, all three means were significantly different, having the following order: NNGO > SGA N > SGA GR. Of all 504 second trimester growth rates, 92.5% were within their respective 95% reference ranges.

Conclusion: Growth in the second trimester is linear in fetuses at risk for growth restriction. Except for FDL, growth velocities were lower than those for fetuses with NNGO. Only AC had mean velocities that differed between the SGA N and the SGA GR groups. Since most velocities (92.5%) were within normal reference ranges, they are reasonable measures of growth potential in fetuses at risk for growth restriction.
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http://dx.doi.org/10.1080/14767058.2017.1395849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5938145PMC
March 2019

Prenatal Diagnosis and Evaluation of Abnormal Placentation.

Clin Obstet Gynecol 2017 09;60(3):596-607

Department of OB-GYN, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, Texas.

Abnormalities in placental location or adherence can have important consequences on pregnancy outcome for both mother and fetus. Accurate antenatal detection is crucial for delivery timing and planning to help reduce perinatal risks for adverse events. We review the relevant literature and present a practical approach for the prenatal detection of abnormal placentation.
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http://dx.doi.org/10.1097/GRF.0000000000000297DOI Listing
September 2017

Proceedings: Beyond Ultrasound First Forum on improving the quality of ultrasound imaging in obstetrics and gynecology.

Am J Obstet Gynecol 2018 01 6;218(1):19-28. Epub 2017 Jul 6.

Eastern Virginia Medical School, Norfolk, VA.

The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.
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http://dx.doi.org/10.1016/j.ajog.2017.06.033DOI Listing
January 2018

Third trimester growth restriction patterns: individualized assessment using a fetal growth pathology score.

J Matern Fetal Neonatal Med 2018 Aug 6;31(16):2155-2163. Epub 2017 Jul 6.

b Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research , Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda , MD , USA.

Objective: To qualitatively and quantitatively characterize third trimester growth patterns in fetuses/neonates with growth restriction using Individualized Growth Assessment.

Methods: Serial fetal size measurements from 73 fetuses with proven growth restriction were evaluated using a novel composite parameter, the Fetal Growth Pathology Score (FGPS1). Third trimester FGPS1 measurements plotted against fetal age were examined for patterns. Identified patterns were characterized using the four components of the FGP1 [head circumference (HC), abdominal circumference (AC), femur diaphysis length (FDL), estimated weight (EWT)]. A secondary characterization using age of onset, duration and magnitude of the growth abnormality process was also performed. Frequencies and magnitudes of abnormal values in different FGPS1 patterns were compared.

Results: Five growth restriction patterns were found in 70/73 (95.9%) of the cases, with progressive worsening [Pattern 1 (37.0%)] and abnormal growth identified only at last scan [Pattern 2 (27.4%)] being the most common. These two patterns were usually statistically different from each other and the other three with respect to size parameter abnormalities and abnormal growth process characteristics (MANOVA). Growth abnormalities in all parameters of the FGPS1 contributed to the five abnormality patterns although AC and EWT were most important. The age of onset, duration and magnitude were similar between patterns except for Pattern 2, which had a late onset and a short duration (GLM + contrasts).

Conclusions: Our study represents the first detailed evaluation of third trimester growth restriction using methods that consider the growth potential of each fetus. Five distinctive and repetitive patterns were found, suggesting that fetal growth restriction evolves in different ways. Further research is needed to determine the relationships of these patterns to physiological/biochemical changes and adverse outcomes associated with growth restriction.
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http://dx.doi.org/10.1080/14767058.2017.1337741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5756517PMC
August 2018

Automated Fractional Limb Volume Measurements Improve the Precision of Birth Weight Predictions in Late Third-Trimester Fetuses.

J Ultrasound Med 2017 Aug 25;36(8):1649-1655. Epub 2017 Apr 25.

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA.

Objectives: Fetal soft tissue can be assessed by using fractional limb volume as a proxy for in utero nutritional status. We investigated automated fractional limb volume for rapid estimate fetal weight assessment.

Methods: Pregnant women were prospectively scanned for 2- and 3-dimensional fetal biometric measurements within 4 days of delivery. Performance of birth weight prediction models was compared: (1) Hadlock (Am J Obstet Gynecol 1985; 151:333-337; biparietal diameter, abdominal circumference, and femur diaphysis length); and (2) Lee (Ultrasound Obstet Gynecol 2009; 34:556-565; biparietal diameter, abdominal circumference, and automated fractional limb volume). Percent differences were calculated: [(estimated birth weight - actual birth weight) ÷ (actual birth weight] × 100. Systematic errors (accuracy) were summarized as signed mean percent differences. Random errors (precision) were calculated as ± 1 SD of percent differences.

Results: Fifty neonates were delivered at 39.4 weeks' gestation. The Hadlock model generated the most accurate birth weight (0.31%) with a mean random error of ±7.9%. Despite systematic underestimations, the most precise results occurred with fractional arm volume (-9.1% ± 5.1%) and fractional thigh (-5.2% ± 5.2%) models. The size and distribution of these prediction errors were improved after correction for systematic errors.

Conclusions: Automated fractional limb volume measurements can improve the precision of weight predictions in third-trimester fetuses. Correction factors may be necessary to adjust underestimated systematic errors when using automated fractional limb volume with prediction models that are based on manual tracing of fetal limb soft tissue borders.
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http://dx.doi.org/10.7863/ultra.16.08087DOI Listing
August 2017

Fetal growth pathology score: a novel ultrasound parameter for individualized assessment of third trimester growth abnormalities.

J Matern Fetal Neonatal Med 2018 Apr 20;31(7):866-876. Epub 2017 Mar 20.

c Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research , Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD and Detroit , MI , USA.

Objectives: To study fetal growth in pregnancies at risk for growth restriction (GR) using, for the first time, the fetal growth pathology score (FGPS1).

Methods: A retrospective cohort study of GR was carried out in 184 selected SGA singletons using a novel, composite measure of growth abnormalities termed the FGPS1. Serial fetal biometry was used to establish second trimester Rossavik size models and determine FGPS1 values prior to delivery. FGPS1 data were compared to neonatal growth outcomes assessed using growth potential realization index (GPRI) values (average negative pathological GPRI (av - pGPRI)). Growth at the end of pregnancy was evaluated from differences in negative, individual composite prenatal growth assessment scores (-icPGAS) measured at the last two ultrasound scans. The FGPS1 and av - pGPRI values were used to classify fetal growth and neonatal growth outcomes, respectively, as Normal (N) or Abnormal (A).

Results: The risk of neonatal GR (based on birth weight (BW)) was moderate (MR: between 5th and10th percentiles (n = 113)) or significant (SR:<5th percentile) (n = 71)). Individual pregnancies were grouped into four categories, two representing agreement (N-N (29%), A-A (40%)) and two representing discordance (N-A (11%), A-N (20%)). In the largest and most variable subgroup (A-A,<5%tile, n = 49), there was a statistically significant correlation (0.63, p < .0001) between the FGPS1 and av - pGPRI. In N-A, all 20 cases (100%) had long last-scan-to-delivery intervals (1.9 weeks or greater), suggesting late development of the growth abnormality. For A-N, in approximately equal proportions, GR was improving, progressing or unclassifiable at the end of pregnancy.

Conclusions: Significant agreement between prenatal and postnatal growth assessments was found using a novel approach for quantifying fetal growth pathology (FGPS1). Discordances appear to be due to lack of appropriate prenatal scans or an inadequate set of neonatal measurements. Evidence for a quantitative relationship between assessment methods was seen in the largest and most variable subgroup. The FGPS1 has the potential for characterizing GR in the third trimester and may provide a means for predicting the severity of corresponding abnormal neonatal growth outcomes.
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http://dx.doi.org/10.1080/14767058.2017.1300646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5813490PMC
April 2018