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Cord entanglement in monochorionic monoamniotic (MCMA) pregnancy with a lethal discordant anomaly or twin reversed arterial perfusion (TRAP) sequence can lead to strangulation, preterm labor and demise of the healthy twin[1]. Cord to deceased twin is clearly visible as a thin band. gl The fourth case was a MCMA pregnancy complicated by cord entanglement, with one twin diagnosed with acrania, which presented at 17 weeks' gestation. GRAPH: Videoclip S1 Intraoperative fetoscopic video showing cord ablation and division at 22 weeks' gestation in monochorionic monoamniotic twin pregnancy complicated by twin reversed arterial perfusion sequence with cord strangulation at the placental insertion site. [Extracted from the article]

Objective Three-dimensional (3D) ultrasound is gaining popularity in prenatal diagnosis. While there are no studies regarding the safety of 3D ultrasound, it is now widely performed in non-medical facilities, for non-diagnostic purposes. The present study was aimed at comparing the acoustic output, as expressed by thermal index (TI) and mechanical index (MI), of conventional two-dimensional (2D) and 3D/4D ultrasound during pregnancy. Methods A prospective, observational study was conducted, using three different commercially available machines (iU22, Philips Medical Systems; Prosound Alfa-10, Aloka; and Voluson 730 Expert, General Electric). Patients undergoing additional 3D/4D ultrasound examinations were recruited from those scheduled for fetal anatomy and follow-up exams. Fetuses with anomalies were excluded from the analysis. Data were collected regarding duration of the exam, and each MI and TI during 2D and 3D/4D ultrasound exams. Results A total of 40 ultrasound examinations were evaluated. Mean gestational age was 31.1 ± 5.8 weeks, and mean duration of the exam was 20.1 ± 9.9 min. Mean TIs during the 3D (0.27 ± 0.1) and 4D examinations (0.24 ± 0.1) were comparable with the TI during B-mode scanning (0.28 ± 0.1, P = 0.343). The MIs during the 3D volume acquisitions were significantly lower than those in the 2D B-mode ultrasound studies (0.89 ± 0.2 vs. 1.12 ± 0.1, P = 0.018). The 3D volume acquisitions added 2.0 ± 1.8 min of actual ultrasound scanning time (i.e. not including data processing and manipulation, or 3D displays, which are all post-processing steps). The 4D added 2.2 ± 1.2 min. Conclusions Acoustic exposure levels during 3D/4D ultrasound examination, as expressed by TI, are comparable with those of 2D B-mode ultrasound. However, it is very difficult to evaluate the additional scanning time needed to choose an adequate scanning plane and to acquire a diagnostic 3D volume. Copyright [ABSTRACT FROM AUTHOR]

Objectives: The aim of the present study was to examine the changes in bacteria in hospitalized preterm infants during the first month of life., Methods: Rectal swabs were collected daily from 12 preterm infants. DNA was extracted from swabs from day of birth and weekly thereafter. Bacterial taxa were identified with next generation sequencing using universal bacterial primers targeted at the 16S ribosomal DNA on a 454 Roche titanium platform. Sequences were clustered into operational taxonomic units, and taxonomy was assigned against the Greengenes databank using Quantitative Insights Into Microbial Ecology version 1.4. Quantitative polymerase chain reaction was used to determine the abundance of Bifidobacterium spp. Functional assessment of the microbiome was performed with Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt)., Results: Average birth weight and gestational age were 1055 g and 28 weeks, respectively. There were 6 to 35 different bacterial families identified in the day-of-birth samples, unrelated to the mode of delivery. Richness decreased through hospitalization (week 1, 16.9 ± 7.7 vs weeks 3-5, 10.7 ± 3.4, P < 0.001). The Shannon diversity index demonstrated the lowest diversity at birth, an increase at week 2, followed by a rapid decline at weeks 3 to 5, suggesting the development of a more uniform microbiota composition after 2 weeks of stay at a neonatal intensive care unit. Enterobacteriaceae, Staphylococcaceae, and Enterococcaceae constituted the majority of the bacterial families. Bifidobacterium spp were infrequently detected at extremely low levels. PICRUSt analysis revealed the enhancement of peroxisome, PPAR, and adipocytokine signaling; plant-pathogen interaction; and aminobenzoate degradation pathways in week 1 samples., Conclusions: Our results suggest that although preterm infants have individualized microbiota that are detectable at birth, the differences decrease during the neonatal intensive care unit hospitalization with increasing prominence of pathogenic microbiota.

The objective of this study was to determine whether estimates of ultrasonic attenuation could detect changes in the cervix associated with medically induced cervical remodeling. Thirty-six full-term pregnant women underwent two transvaginal ultrasonic examinations separated in time by 12 h to determine cervical attenuation, cervical length and changes thereof. Ultrasonic attenuation and cervical length data were acquired from a zone (Zonare Medical Systems, Mountain View, CA, USA) ultrasound system using a 5-9 MHz endovaginal probe. Cervical attenuation and cervical length significantly decreased in the 12 h between the pre-cervical ripening time point and 12 h later. The mean cervical attenuation was 1.1 ± 0.4 dB/cm-MHz before cervical ripening agents were used and 0.8 ± 0.4 dB/cm-MHz 12 h later (p < 0.0001). The mean cervical length also decreased from 3.1 ± 0.9 cm before the cervical ripening was administered to 2.0 ± 1.1 cm 12 h later (p < 0.0001). Cervical attenuation and cervical length detected changes in cervical remodeling 12 h after cervical ripening administration., (Copyright © 2015 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Objective: The cheek-to-cheek diameter (CCD) has been shown to be an indicator of subcutaneous tissue mass in the fetus. However, the correlation between CCD and the abdominal circumference (AC) has not been investigated yet. The objective of the present study was to demonstrate whether a correlation exists between fetal CCD, AC, estimated fetal weight (EFW), and the 1 h, 50 g, glucose challenge test (GCT) levels in patients with and without gestational diabetes mellitus., Methods: A prospective, institutional review board approved study was performed. The CCD was obtained as part of the ultrasound for obstetric interval growth scans and biophysical profiles. Exams were performed during the third trimester. The CCD was obtained on a coronal view of the fetal face, at the level of the nostrils and lips. Patients were enrolled between November 2005 and May 2006. Pearson correlation coefficient and linear regression modeling were used as appropriate., Results: Eighty-three patients were enrolled, 29 (33%) of them were diabetic. The mean gestational age is 34.8 +/- 3 weeks and the mean maternal age is 29.9 +/- 5.1. A significant linear association was found between CCD and EFW (Pearson coefficient of correlation being 0.51, P = 0.01). The Pearson correlation coefficient of the relationship between the CCD and AC was 0.47 (P = 0.01). Using a linear regression model, controlling for gestational age at performance of the ultrasound, the association between CCD and EFW remained significant (P = 0.021). There were no significant differences between diabetic and non-diabetic patients regarding the CCD (6.2 +/- 0.9 vs. 6.3 +/- 0.9 respectively, P = 0.669) or the EFW (2,527.9 +/- 705 vs. 2,645 +/- 760 g). While AC was significantly correlated with the GCT levels (Pearson coefficient of correlation = 0.46, P = 0.024), no such correlation was demonstrated for CCD (Pearson correlation coefficient = 0.23, P = 0.160)., Conclusions: The cheek-to-cheek diameter is significantly correlated to the abdominal circumference and the estimated fetal weight. However, the abdominal circumference has a tighter correlation with the glucose challenge test.

Purpose: As a form of energy, diagnostic ultrasound has bioeffects on living tissues. The thermal index (TI), TIS (TI for soft tissue), TIB (TI for bone), TIC (TI for cranial bone) expresses the potential for rise in temperature at the ultrasound beam's focal point. The mechanical index (MI) indicates the potential for the ultrasound beam to induce inertial cavitation in tissues. The goal of this study was to characterize the acoustic output of clinical ultrasound instruments, as expressed by TI and MI, during routine first-trimester sonographic examinations., Methods: A prospective observational study was conducted. First-trimester patients were randomly selected from those scheduled for viability scans. An obstetrician collected data. Sonographers were blinded to the data being sought, which included gestational age, duration of the examination, and every variation in the MI and TI during each sonographic examination., Results: A total of 52 first-trimester examinations were evaluated. The mean gestational age was 8.9 +/- 1.9 weeks. The mean duration of the sonographic examinations was 8.1+/- 1.4 minutes. During the examinations, there were 178 MI variations (mean +/- SD, 0.9 +/- 0.3) and 167 TI variations (mean +/- SD, 0.2 +/- 0.1)., Conclusion: First-trimester sonographic examinations are associated with a negligible rise in TI.

Objective: The present study was aimed at evaluating acoustic outputs during clinical ultrasound examinations, as expressed by the thermal index (TI) and the mechanical index (MI), during the second half of pregnancy and comparing acoustic outputs between B-mode and Doppler examinations., Methods: Patients with suspected fetal growth problems undergoing Doppler studies of the fetal circulation in addition to B-mode sonography were selected. Examinations took place between 21 and 40 weeks' gestation. An obstetrician collected data prospectively. Sonographers were unaware of the data being sought. The analysis of variance test was applied for differences in continuous variables., Results: A total of 63 examinations were evaluated. The mean gestational age +/- SD was 31.6 +/- 5.1 weeks. The mean duration of the total examinations was 17.6 +/- 8.6 minutes, whereas the Doppler studies lasted 0.9 +/- 0.8 minutes. The TI was significantly higher in the pulsed wave Doppler studies (mean, 1.5 +/- 0.5; range, 0.9-2.8) and color flow imaging studies (mean, 0.8 +/- 0.1; range, 0.6-1.2) compared with B-mode sonography (mean, 0.3 +/- 0.1; range, 0.1-0.7; P < .01). During the examination, 190 B-mode MI variations were recorded (mean, 1.1 +/- 0.1), which were comparable with those of the 31 color flow Doppler studies (mean, 1.0 +/- 0.1; P = .09) but higher than the 190 pulsed wave Doppler MI variations (mean 0.9 +/- 0.2; P < .001)., Conclusions: Increased acoustic output levels, as expressed by TI levels, are reached during obstetric Doppler studies. In particular, TI levels may reach 1.5 and higher. Doppler procedures should be performed with caution and be as brief as possible during obstetric sonography.

Objective: The aim of this program was to develop a multicenter, multidisciplinary anatomy and surgical skills training program for junior residents in obstetrics and gynecology and urology., Study Design: After administering a needs assessment, we developed a collaborative clinical anatomy and surgical skills training program for junior residents in obstetrics and gynecology and urology at 3 academic medical centers in Chicago., Results: Thirty-two residents participated in the program. Needs assessment results indicated that all residents felt they could benefit by more formal training in basic surgical skills. Learning objectives were developed for each of the 5 3-hour sessions that dealt with basic surgical skills, anterior abdominal wall anatomy, opening and closing the abdomen, female pelvic anatomy, and perineal anatomy and laceration repair. The cost of training each of the residents was approximately 600 dollars. Forty-five percent of the costs were one-time "start-up" costs for abdominal trainers and surgical instruments., Conclusion: By including multiple centers and disciplines, we were able to reduce costs of teaching basic surgical skills and anatomy and maximize faculty teaching time and effort.

Unlabelled: Perioperative management of patients with superior vena cava obstruction presents an anesthetic challenge because of severe cardiopulmonary compromise. This is particularly important in the parturient because of increased upper airway edema and inferior vena caval compression. We describe the management of a parturient who presented at 34 wk of gestation with signs and symptoms of superior vena cava obstruction from metastatic breast cancer. The patient was scheduled for a cesarean delivery followed by chemotherapy, as other therapies were deemed excessively risky because of the anatomic characteristics of the large mediastinal mass. This report describes the successful use of regional anesthesia in this setting and discusses the relevant anesthetic and perioperative management considerations for this complex scenario., Implications: Perioperative management of patients with superior vena caval obstruction presents an anesthetic challenge because of the severe cardiopulmonary compromise. This case report describes a parturient who presented for cesarean delivery with superior vena caval obstruction resulting from metastasis from breast cancer.

Objective: The aim of the study was to compare the diagnostic utility of the Gram stain, the amniotic fluid glucose level, and the ratio of amniotic fluid glucose level to serum glucose level in detecting intra-amniotic infection., Study Design: We conducted a prospective study of 127 patients with preterm labor and 26 patients with preterm premature rupture of the membranes (153 total). All patients underwent amniocentesis to diagnose intra-amniotic infection. The diagnostic criterion for intra-amniotic infection was a positive amniotic fluid culture result., Results: The Gram stain is 80% sensitive and 91% specific when a positive is considered the presence of white blood cells or bacteria. Amniotic fluid glucose level and the ratio of amniotic fluid glucose level to serum glucose level are significantly lower when amniotic fluid culture results are positive, but as diagnostic tests they are inferior to the Gram stain. Logistic regression models that combine predictors yield superior accuracy with respect to individual tests. The most accurate combination was amniotic fluid glucose level and Gram stain with white blood cells or bacteria. Although the number of patients with preterm premature rupture of the membranes was small in this study (n = 26), analysis of our data suggests that the diagnostic performance levels of these tests were similar when used in patients with preterm labor and intact membranes and in patients with premature rupture of the membranes., Conclusions: The amniotic fluid glucose level and the ratio of amniotic fluid to serum glucose level have equivalent diagnostic utility and are inferior to the Gram stain. The combination of Gram stain with amniotic fluid glucose level is superior to any individual test.

Pregnancies in women on dialysis and in women who have had renal transplant are no longer uncommon. Optimal obstetric outcomes require a multidisciplinary team approach, patient counseling, and clinicians who are knowledgeable and experienced in taking care of these patients. Counseling should begin before pregnancy, and all reproductive age women on dialysis and who have undergone renal transplant should receive family planning counseling. Preconceptional counseling should be provided to those patients who desire pregnancy. If the patient presents in early pregnancy, she should be informed about the maternal and fetal risks associated with her pregnancy. Prenatal care must include intensive surveillance for hypertension, preeclampsia, preterm labor, intrauterine growth restriction, anemia, infection, and renal allograft rejection. Aggressive treatment of complications is mandatory. There are limitations to our current knowledge about pregnancies in these patients. It is important for clinicians who provide care for these patients to be aware of these limitations when making obstetric management decisions. Cesarean section should be reserved for usual obstetric indications. Breast-feeding is not advised in patients taking cyclosporin or azathioprine. Transplant patients have unique gynecologic needs, so they should be encouraged to pursue follow-up gynecologic care after the pregnancy.