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Background: Optimal prenatal care relies on accurate gestational age dating. After the first trimester, the accuracy of current gestational age estimation methods diminishes with increasing gestational age. Considering that, in many countries, access to first trimester crown rump length is still difficult owing to late booking, infrequent access to prenatal care, and unavailability of early ultrasound examination, the development of accurate methods for gestational age estimation in the second and third trimester of pregnancy remains an unsolved challenge in fetal medicine. Objective. This study aimed to evaluate the performance of an artificial intelligence method based on automated analysis of fetal brain morphology on standard cranial ultrasound sections to estimate the gestational age in second and third trimester fetuses compared with the current formulas using standard fetal biometry. Study Design: Standard transthalamic axial plane images from a total of 1394 patients undergoing routine fetal ultrasound were used to develop an artificial intelligence method to automatically estimate gestational age from the analysis of fetal brain information. We compared its performance—as stand alone or in combination with fetal biometric parameters—against 4 currently used fetal biometry formulas on a series of 3065 scans from 1992 patients undergoing second (n=1761) or third trimester (n=1298) routine ultrasound, with known gestational age estimated from crown rump length in the first trimester. Results: Overall, 95% confidence interval of the error in gestational age estimation was 14.2 days for the artificial intelligence method alone and 11.0 when used in combination with fetal biometric parameters, compared with 12.9 days of the best method using standard biometrics alone. In the third trimester, the lower 95% confidence interval errors were 14.3 days for artificial intelligence in combination with biometric parameters and 17 days for fetal biometrics, whereas in the second trimester, the 95% confidence interval error was 6.7 and 7, respectively. The performance differences were even larger in the small-for-gestational-age fetuses group (14.8 and 18.5, respectively). Conclusion: An automated artificial intelligence method using standard sonographic fetal planes yielded similar or lower error in gestational age estimation compared with fetal biometric parameters, especially in the third trimester. These results support further research to improve the performance of these methods in larger studies. The research leading to these results was partially funded by Transmural Biotech S.L. In addition, the research has received funding from “la Caixa” Foundation under grant agreements LCF/PR/GN14/10270005 and LCF/PR/GN18/10310003, the Instituto de Salud Carlos III (PI16/00861, PI17/00675) within the Plan Nacional de I+D+I and cofinanced by Instituto de Salud Carlos III— Subdirección General de Evaluación together with the Fondo Europeo de Desarrollo Regional (FEDER) “Una manera de hacer Europa,” Cerebra Foundation for the Brain Injured Child (Carmarthen, Wales, United Kingdom), Cellex Foundation, ASISA Foundation, and Agency for Management of University and Research Grants under grant 2017 SGR number 1531. In addition, E.E. has received funding from the Departament de Salut under grant number SLT008/18/00156.

Artificial Intelligence (AI) has proven in the recent years to be a powerful tool to automate simple and complex tasks. One of the main fields where it has been applied is medical science where especially computer vision algorithms are gaining popularity. This project aims to be useful both for medical staff and future projects on the field, easing the process of data cleaning. Nowadays medical personnel have to invest time discarding corrupted images to clean the data from the ultrasounds. It is also an impediment for other machine learning projects as corrupted images can negatively affect the results. Our goal is to develop a Deep Learning (DL) algorithm not only able to identify the corrupted images but also to classify them by type of distortion. With this we will be able to clean the dataset and bring an opportunity to future projects to apply artifact cleaning. The proposed strategy has three main parts. First, we have designed a code to create semi random artifacts on correct images to generate a dataset big enough for our experiments. Secondly, we have studied the behavior under corrupted images of a previous deep learning model, designed by Vicent at [6]. With this we determined the boundary between corruption and correct images. Finally, we successfully created and compared the result of two models based on a Convolutional Neural Networks (CNNs) to identify and classify the corrupted images.

CONTEXT. La Infermera de Pràctica Avançada és una figura que avança de manera diferent en cada país. Actualment encara falta estudiar sobre quin paper i quines funcions pot realitzar dins del cribratge precoç prenatal. OBJECTIU. Descriure quines són les competències que la Infermera de Pràctica Avançada pot desenvolupar en l’àmbit del cribratge prenatal per comparar la legislació espanyola amb la legislació d’altres països europeus. METODOLOGIA. La pregunta d’investigació és: La figura de la Infermera de Pràctica Avançada, experta en el cribratge precoç prenatal, està més desenvolupada en altres països d’Europa que no pas a Espanya?. Es realitza una revisió exploratòria a les bases de dades PubMed, Science Direct i Web of Science. Els estudis s’han publicat els últims 10 anys i tots parlen del cribratge prenatal. L’avaluació del rigor científic s’ha analitzat mitjançant les escales de CASPe i QARI. Els resultats s’han classificat segons el país europeu, el professional sanitari i s’han organitzat segons tres temàtiques, en funció de la informació aportada per cada article: rol en el cribratge prenatal, ecografia obstètrica i coneixements genètics. RESULTATS. En cada país europeu, les tasques realitzades per les infermeres/llevadores són similars però no iguals. No hi ha una legislació que defineixi quines competències han de tenir dins del cribratge. A Europa, la Infermera de Pràctica Avançada encara li falta agafar reconeixement, però els Estats Units, és un país on aquest concepte es troba més desenvolupat, ja que hi ha tasques que ja són reconegudes com habilitats avançades. CONCLUSIÓ. Les llevadores són les principals responsables del cribratge en la majoria de països europeus. Les tasques són similars, tot i que hi ha algun país on la infermera, amb formació prèvia, està capacitada per realitzar altres funcions. La falta de competències genètiques, produeix un baix domini dels conceptes necessaris per oferir informació i assessorament prenatal. CONTEXTO: La Enfermera de Práctica Avanzada es una figura que avanza de forma diferente en cada país. Todavía falta estudiar sobre qué papel y qué funciones puede realizar dentro del cribado precoz prenatal. OBJETIVO: Describir cuáles son las competencias que la Enfermera de Práctica Avanzada puede desarrollar en el ámbito del cribado prenatal para comparar la legislación española con la legislación de otros países europeos. METODOLOGÍA: La pregunta de investigación es: La figura de la Enfermera de Práctica Avanzada, experta en el cribado precoz prenatal, está más desarrollada en otros países de Europa que en España?. Se realiza una revisión exploratoria en las bases de datos PubMed, Science Direct y Web of Science. Los estudios se han publicados los últimos 10 años y todos hablan del cribado prenatal. La evaluación del rigor científico ha analizado mediante las escalas de CASPe y QARI. Los resultados se han clasificado según el país europeo, el profesional sanitario y se han organizado según tres temáticas, en función de la información aportada por cada artículo: rol en el cribado prenatal, ecografía obstétrica y conocimientos genéticos. RESULTADOS: En cada país europeo, las tareas realizadas por las enfermeras / matronas son similares pero no iguales. No hay una legislación que defina qué competencias deben tener dentro del cribado. En Europa, la Enfermera de Práctica Avanzada todavía le falta coger reconocimiento, pero los Estados Unidos, es un país donde este concepto se encuentra más desarrollado, ya que hay tareas que ya son reconocidas como habilidades avanzadas. CONCLUSIÓN: Las matronas son las principales responsables del cribado en la mayoría de países europeos. Las tareas son similares, aunque hay algún país donde la enfermera, con formación previa, está capacitada para realizar otras funciones. La falta de competencias genéticas, produce un bajo dominio de los conceptos necesarios para ofrecer información y asesoramiento prenatal. CONTEXT: The Advanced Practice Nurse is a figure that advances differently in each country. There is still a long way to go to study what role and what functions it can perform within prenatal early screening. OBJECTIVE: To describe the competencies that the Advanced Practice Nurse can develop in the field of prenatal screening to compare Spanish legislation with the legislation of other European countries. METHODOLOGY: The research question is: Is the figure of the Advanced Practice Nurse, an expert in early prenatal screening, more developed in other European countries than in Spain?. An exploratory review is performed on the PubMed, Science Direct, and Web of Science databases. The studies have been published for the last 10 years and all of them talk about prenatal screening. The assessment of scientific rigor has been analyzed using the CASPe and QARI scales. The results were classified according to the European country, the health professional and were organized according to three themes, based on the information provided by each article: role in prenatal screening, obstetric ultrasound and genetic knowledge. RESULTS: In each European country, the tasks performed by nurses / midwives are similar but not the same. There is no legislation that defines what competencies they should have within screening. In Europe, the Advanced Practice Nurse still needs recognition, but the United States is a country where this concept is more developed, as there are tasks that are already recognized as advanced skills. CONCLUSION: Midwives are the main culprits in screening in most European countries. The tasks are similar, although there are some countries where the nurse, with prior training, is trained to perform other functions. The lack of genetic skills produces a low mastery of the concepts needed to provide prenatal information and counseling.

Prenatal cadmium exposure has been associated with impaired fetal growth; much less is known about the impact during later childhood on growth and cardiometabolic traits. To elucidate the associations of prenatal cadmium exposure with child growth, adiposity, and cardiometabolic traits in 515 mother-child pairs in the Rhea Mother-Child Study cohort (Heraklion, Greece, 2007-2012), we measured urinary cadmium concentrations during early pregnancy and assessed their associations with repeated weight and height measurements (taken from birth through childhood), waist circumference, skinfold thickness, blood pressure, and serum lipid, leptin, and C-reactive protein levels at age 4 years. Adjusted linear, Poisson, and mixed-effects regression models were used, with interaction terms for child sex and maternal smoking added. Elevated prenatal cadmium levels (third tertile of urinary cadmium concentration (0.571-2.658 μg/L) vs. first (0.058-0.314 μg/L) and second (0.315-0.570 μg/L) tertiles combined) were significantly associated with a slower weight trajectory (per standard deviation score) in all children (β = -0.17, 95% confidence interval (CI): -0.32, -0.02) and a slower height trajectory in girls (β = -0.30, 95% CI: -0.52,-0.09; P for interaction = 0.025) and in children born to mothers who smoked during pregnancy (β = -0.48, 95% CI: -0.83, -1.13; P for interaction = 0.027). We concluded that prenatal cadmium exposure was associated with delayed growth in early childhood. Further research is needed to understand cadmium-related sex differences and the role of coexposure to maternal smoking during early pregnancy. The Rhea Mother-Child Cohort Study was financially supported by European Union projects (FP6-2003-Food-3-A NewGeneris, Food-CT-2006-036224 Hiwate, FP7/2007- 2011-GA-211250 ESCAPE Project, FP7-2008-226756 Envirogenomarkers, FP7-HEALTH-2009 single-stage 241604 CHICOS, and FP7-ENV.2008.1.2.1.6 proposal 226285 ENRIECO) and the Greek Ministry of Health (Program of Prevention of Obesity and Neurodevelopmental Disorders in Preschool Children, Heraklion District, Crete, Greece, 2011–2014; and “Rhea Plus”: Primary Prevention Program of Environmental Risk Factors for Reproductive Health and Child Health, 2012–2015). The present study was also funded by the Karolinska Institutet, the Swedish Research Council Formas (project 210-2013-751), and the Swedish Research Council (project 2015-03655).

BackgroundDigital innovations have shown promise for improving maternal health service delivery. However, low- and middle-income countries are still at the adoption-utilization stage. Evidence on mobile health has been described as a black box, with gaps in theoretical explanations that account for the ecosystem of health care and their effect on adoption mechanisms. Bliss4Midwives, a modular integrated diagnostic kit to support antenatal care service delivery, was piloted for 1 year in Northern Ghana. Although both users and beneficiaries valued Bliss4Midwives, results from the pilot showed wide variations in usage behavior and duration of use across project sites. ObjectiveTo strengthen the design and implementation of an improved prototype, the study objectives were two-fold: to identify causal factors underlying the variation in Bliss4Midwives usage behavior and understand how to overcome or leverage these in subsequent implementation cycles. MethodsUsing a multiple case study design, a realist evaluation of Bliss4Midwives was conducted. A total of 3 candidate program theories were developed and empirically tested in 6 health facilities grouped into low and moderate usage clusters. Quantitative and qualitative data were collected and analyzed using realist thinking to build configurations that link intervention, context, actors, and mechanisms to program outcomes, by employing inductive and deductive reasoning. Nonparametric t test was used to compare the perceived usefulness and perceived ease of use of Bliss4Midwives between usage clusters. ResultsWe found no statistically significant differences between the 2 usage clusters. Low to moderate adoption of Bliss4Midwives was better explained by fear, enthusiasm, and high expectations for service delivery, especially in the absence of alternatives. Recognition from pregnant women, peers, supervisors, and the program itself was a crucial mechanism for device utilization. Other supportive mechanisms included ownership, empowerment, motivation, and adaptive responses to the device, such as realignment and negotiation. Champion users displayed high adoption-utilization behavior in contexts of participative or authoritative supervision, yet used the device inconsistently. Intervention-related (technical challenges, device rotation, lack of performance feedback, and refresher training), context-related (staff turnover, competing priorities, and workload), and individual factors (low technological self-efficacy, baseline knowledge, and internal motivation) suppressed utilization mechanisms. ConclusionsThis study shed light on optimal conditions necessary for Bliss4Midwives to thrive in a complex social and organizational setting. Beyond usability and viability studies, advocates of innovative technologies for maternal care need to consider how implementation strategies and contextual factors, such as existing collaborations and supervision styles, trigger mechanisms that influence program outcomes. In addition to informing scale-up of the Bliss4Midwives prototype, our results highlight the need for interventions that are guided by research methods that account for complexity.

Introduction: Previous studies have reported associations between prenatal cell phone use and child behavioral problems, but findings have been inconsistent and based on retrospective assessment of cell phone use. This study aimed to assess this association in a multi-national analysis, using data from three cohorts with prospective data on prenatal cell phone use, together with previously published data from two cohorts with retrospectively collected cell phone use data. Methods: We used individual participant data from 83,884 mother-child pairs in the five cohorts from Denmark (1996–2002), Korea (2006–2011), the Netherlands (2003–2004), Norway (2004–2008), and Spain (2003–2008). We categorized cell phone use into none, low, medium, and high, based on frequency of calls during pregnancy reported by the mothers. Child behavioral problems (reported by mothers using the Strengths and Difficulties Questionnaire or Child Behavior Checklist) were classified in the borderline/clinical and clinical ranges using validated cut-offs in children aged 5–7 years. Cohort specific risk estimates were meta-analyzed. Results: Overall, 38.8% of mothers, mostly from the Danish cohort, reported no cell phone use during pregnancy and these mothers were less likely to have a child with overall behavioral, hyperactivity/inattention or emotional problems. Evidence for a trend of increasing risk of child behavioral problems through the maternal cell phone use categories was observed for hyperactivity/inattention problems (OR for problems in the clinical range: 1.11, 95%CI 1.01, 1.22; 1.28, 95%CI 1.12, 1.48, among children of medium and high users, respectively). This association was fairly consistent across cohorts and between cohorts with retrospectively and prospectively collected cell phone use data. Conclusions: Maternal cell phone use during pregnancy may be associated with an increased risk for behavioral problems, particularly hyperactivity/inattention problems, in the offspring. The interpretation of these results is unclear as uncontrolled confounding may influence both maternal cell phone use and child behavioral problems. Keywords: Attention deficit disorder with hyperactivity, Cell phones, Child behavior, Child health, Electromagnetic radiation, Pregnancy

La incidència d’embarassos múltiples (EM) ha viscut un increment exponencial. Segons l’Institut d’Estadística de Catalunya (IDESCAT), a Catalunya, s’ha triplicat el número d’EM durant els darrers 20 anys. Aquest increment, s’ha esdevingut sobretot per dues causes principals: la utilització de les tècniques de reproducció assistida (TRA) i la major edat materna. Els EM estan associats a diverses complicacions o patologies tant per la mare com pels nounats: preeclàmpsia, depressió post-part, part prematur, nadons amb baix pes gestacional, etc. A més a més, aquestes famílies són més vulnerables a patir problemàtica social i/o econòmica. Diferents autors coincideixen en que el recolzament tant familiar com professional és un factor essencial en tots els embarassos. El paper de la infermera/llevadora en aquests casos és imprescindible. Ella és la responsable de donar tota la informació a la dona, de resoldre els seus dubtes i recolzar-la en tot moment. L’objectiu principal d’aquest estudi és identificar els coneixements que tenen les mares embarassades d’un EM sobre tots aquells temes relacionats amb el seu estat. Així com el recolzament i els sentiments que tenen. Es tractarà d’un estudi de disseny descriptiu transversal. El tipus de mostreig serà no probabilístic consecutiu. La instrumentació es farà mitjançant un qüestionari d’auto administració, basat amb preguntes d’escales validades i amb preguntes d’elaboració pròpia. La població d’estudi seran totes aquelles dones embarassades d’un EM que pertanyin a una de les 8 ABS del Gironès (Girona 1, Girona 2, Girona 3, Girona 4, Salt, Sarrià de Ter, Celrà i Cassà de la Selva). S’utilitzaran els estadístics adients per a l’anàlisi en funció de la categoria de les variables de les dades quantitatives o qualitatives obtingudes del qüestionari. Totes les dades seran analitzades amb l’ajuda del programa Statistical Package for the Social Science (SPSS) The incidence of multiple pregnancies (MP) has undergone an exponential increase. According to the Statistical Institute of Catalonia (IDESCAT), in Catalonia has tripled the number of MP over the past 20 years. This increase has occurred mainly for two main reasons: the use of assisted reproduction techniques (ART) and the increased maternal age. The MP are associated with different diseases or complications for both the mother and new-borns by: preeclampsia, postpartum depression, premature birth, infants with low gestational weight... Moreover, these families are more vulnerable to social and/or economic problems. Different authors agree that both family and professional support is an essential factor in all pregnancies. The role of the nurse/midwife in these cases is essential. She is responsible for all information given to women to solve their doubts and support it at all times. This study aims to identify the knowledge of the pregnant women with a MP about all matters related to their status. As well as the support and the feelings they have. This will be a descriptive and transversal study. The sample will be probabilistic consecutive. The instrumentation will be based on a self-administration questionnaire, with questions of validated scales and questions of own elaboration. The study population will be all those pregnant women with a MP belonging to one of the eight ABS (Girona 1 Girona 2, 3 Girona, Girona 4, Salt Sarria de Ter, Celrà and Cassa de la Selva). The appropriate statistical analysis will be used according to the category of the data variables quantitative or qualitative which we will have obtained in the questionnaires. All data will be analysed with the help of the program Statistical Package for the Social Science (SPSS)

Objetivo: Conocer el momento en que se inicia la suplementación con ácido fólico en las mujeres gestantes y las que acuden a una visita preconcepcional. Sujetos y método: Estudio descriptivo y transversal de gestantes que acuden a su primera visita con la matrona para el seguimiento de su embarazo. Resultados: En el periodo de estudio se realizaron 567 primeras visitas de mujeres embarazadas. Se seleccionaron para el estudio 183 mujeres (32,3%). La primera visita con la matrona se realizó alrededor de la octava semana de gestación (desviación estándar [DE] ± 3). El 38,7% de las mujeres (n= 71) no habían iniciado la suplementación con ácido fólico en el momento de la primera visita. La cuarta semana de gestación es el promedio de inicio de toma de ácido fólico (DE ± 6,37). Un 26,8% (n= 49) de las mujeres inició la ingesta de ácido fólico durante el periodo recomendado. La fuente principal de información fue la matrona en un 51,3% (n= 94) de los casos; en el 42% (n= 77) de los casos la primera visita de embarazo con la matrona coincidió con el momento de información y el inicio de la suplementación con ácido fólico. Ninguna mujer había realizado visita preconcepcional. Conclusiones: La tasa de ingesta correcta de ácido fólico durante el embarazo en las mujeres de este estudio fue baja, aunque superior a la de otros estudios de prevalencia; la ingesta se inició como promedio en la cuarta semana de gestación. La principal fuente de información de consumo de ácido fólico era la matrona (51,3%), pero la primera visita se realizó alrededor de la octava semana de gestación, lo que retrasaba con frecuencia el inicio de la toma del suplemento.

Treball de fi de grau en Biologia Humana Supervisor: Vincenzo Cirigliano Prenatal screening and diagnostic tests for the detection of fetal chromosomal/nabnormalities are routine standard of care in pregnancy management. Traditional/nmethods consist of a non-invasive combined test, which gives an individual risk,/nfollowed by an invasive procedure if necessary. Recently, non-invasive prenatal testing/n(NIPT) through the analysis of cell-free DNA (cfDNA) in maternal blood, has been/nshown to accurately detect common fetal autosomal trisomies during the first trimester/nof pregnancy. About 6-20% of cell free DNA circulating in maternal plasma are small/nDNA molecules coming from apoptotic trophoblastic cells. This approach, whose/nefficacy exceeds by far that of conventional screening, is based on sequencing and/ncounting the cfDNA sequences originating from different maternal and fetal genomic/nregions. In pregnancies with aneuploid fetuses, the extra or missing copy of the/naffected chromosome would alter the proportional representation of this specific/nchromosome in the maternal plasma. This innovative approach is more sensitive and/nspecific, offering a greater detection rate (DR) and a significantly lower false-positive/nrate (FPR), which would result in a reduction of invasive diagnostic procedures that/ncarry a risk of miscarriage. CfDNA testing is gaining widespread acceptability./nHowever, its high cost is actually still limiting its application to high- and intermediaterisk/npatients, identified as such by the conventional first-line method of screening. This/nproject is based on a detailed bibliographic search of recent and relevant studies to/nreview the current state of the art regarding the cfDNA screening test and its future/nperspectives and applicability in clinical practice.

Background The aim of this study was to estimate the cost of childbirth in a teaching hospital in Barcelona, Spain, including the costs of prenatal care, delivery and postnatal care (3 months). Costs were assessed by taking into account maternal origin and delivery type. Methods We performed a cross-sectional study of all deliveries in a teaching hospital to mothers living in its catchment area between October 2006 and September 2007. A process cost analysis based on a full cost accounting system was performed. The main information sources were the primary care program for sexual and reproductive health, and hospital care and costs records. Partial and total costs were compared according to maternal origin and delivery type. A regression model was fit to explain the total cost of the childbirth process as a function of maternal age and origin, prenatal care, delivery type, maternal and neonatal severity, and multiple delivery. Results The average cost of childbirth was 4,328€, with an average of 18.28 contacts between the mother or the newborn and the healthcare facilities. The delivery itself accounted for more than 75% of the overall cost: maternal admission accounted for 57% and neonatal admission for 20%. Prenatal care represented 18% of the overall cost and 75% of overall acts. The average overall cost was 5,815€ for cesarean sections, 4,064€ for vaginal instrumented deliveries and 3,682€ for vaginal non-instrumented deliveries (p < 0.001). The regression model explained 45.5% of the cost variability. The incremental cost of a delivery through cesarean section was 955€ (an increase of 31.9%) compared with an increase of 193€ (6.4%) for an instrumented vaginal delivery. The incremental cost of admitting the newborn to hospital ranged from 420€ (14.0%) to 1,951€ (65.2%) depending on the newborn's severity. Age, origin and prenatal care were not statistically significant or economically relevant. Conclusions Neither immigration nor prenatal care were associated with a substantial difference in costs. The most important predictors of cost were delivery type and neonatal severity. Given the impact of cesarean sections on the overall cost of childbirth, attempts should be made to take into account its higher cost in the decision of performing a cesarean section.