Imaging fetal anatomy.

Due to advancements in ultrasound techniques, the focus of antenatal ultrasound screening is moving towards the first trimester of pregnancy. The early first trimester however remains in part, a 'black box', due to the size of the developing embryo and the limitations of contemporary scanning techniques. Therefore there is a need for images of early anatomical developmental to improve our understanding of this area. By using new imaging techniques, we can not only obtain better images to further our knowledge of early embryonic development, but clear images of embryonic and fetal development can also be used in training for e.g. sonographers and fetal surgeons, or to educate parents expecting a child with a fetal anomaly. The aim of this review is to provide an overview of the past, present and future techniques used to capture images of the developing human embryo and fetus and provide the reader newest insights in upcoming and promising imaging techniques. The reader is taken from the earliest drawings of da Vinci, along the advancements in the fields of in utero ultrasound and MR imaging techniques towards high-resolution ex utero imaging using Micro-CT and ultra-high field MRI. Finally, a future perspective is given about the use of artificial intelligence in ultrasound and new potential imaging techniques such as synchrotron radiation-based CT to increase our knowledge regarding human development

Optimisation of gestational age estimates in low-income settings

Accurate estimates of gestational age are fundamental to the provision of obstetric care, helping to facilitate appropriate antenatal care schedules and the identification and management of high-risk pregnancies. At a population level, accurate estimates of gestational age are required for the global reporting of obstetric and neonatal outcomes, for example, the rates of pre-term birth, and are a key component of strategies to reduce neonatal morbidity and mortality. Early pregnancy ultrasound is considered the most accurate way to determine gestational age and is undertaken as part of routine care in high-income settings. However, despite the recommendation from the World Health Organisation that all women receive at least one ultrasound prior to 24 weeks’ gestation, this remains unavailable to the majority of women in low-income settings. Instead, gestational age is derived from the last menstrual period or by measurement of the symphysis fundal height, methods known to be considerably less accurate. There are a number of barriers to the widespread provision of ultrasound as part of routine care in low- and middle- income settings, not least the lack of trained practitioners. Although effective, the length and complexity of many previous training programmes has been prohibitive, with practitioners struggling to secure cover for their clinical duties in order to provide or attend training. Furthermore, few initiatives have explored the widespread implementation of these programmes and how they may be sustained within pre-existing healthcare structures. Ultrasound determination of gestational age relies on the assumption that the size of the fetus is consistent with its age and is therefore best performed prior to 14 weeks’ gestation, when natural variation in fetal size is least apparent. Unfortunately, the majority of women in low- and middle- income countries do not seek antenatal care until later and would therefore require dating by different biometric parameters. In high-income settings the gold standard would be a combination of measurements, however there are concerns about the time investment required to develop such skills. The work in this Thesis explores the development of a novel strategy to optimise estimates of gestational age in Malawi, through the development and implementation of a bespoke education package to teach midwives how to date pregnancies using ultrasound measurement of the fetal femur length. A systematic review investigated the previous initiatives that had been undertaken to train practitioners in low- and middle- income countries to determine gestational age using ultrasound, finding major inconsistences in the current provision of ultrasound training and highlighting the need for a more consistent and robust approach. Less than half of the programmes met international recommendations for the delivery of safe and sustainable training, and many had not considered how ultrasound may be integrated into clinical practice thereafter. The evidence synthesised went on to inform the development of a new programme, where it was hypothesised that ultrasound-naive midwives could be taught to date pregnancies using fetal femur length. Pilot work helped to shape and refine the programme, which was delivered by local teams across six sites in Malawi in 2021. All but one midwife completed the course, with all demonstrating significant increases in their knowledge, confidence, and practical skills, achieving the criteria specified for competency within the specified two weeks. Skills were sustained at a 3-month follow up, and of the images submitted for remote image review, over 87% were deemed acceptable. These results suggest that femur length is a sufficiently simple measurement to be taught effectively over a short timescale, making it a potentially viable option for the upscale of ultrasound to date pregnancies in this setting. A mixed methods study, run by the wider collaborative group, evaluated the implementation of ultrasound into routine services, however the work in this Thesis focused more specifically on the provision of the programme itself. Outcomes were reported in the context of an implementation framework, providing valuable insight into factors influencing the longterm sustainability of such endeavours. It is clear this is an important area for ongoing research. In conclusion, this Thesis proposes that measurement of fetal femur length should be considered a potential option for the determination of gestational age in low- and middle- income settings. Not only is it considerably more accurate than the current standard of care, but midwives with no prior experience of ultrasound can be trained to perform these measurements, confidently and competently, after just two weeks of training, a substantially shorter training duration than many previous initiatives. Although many implementation challenges persist, this programme provides a potentially more sustainable means by which to provide a greater number of women more accurate estimates of gestational age

Towards Early Prenatal Diagnosis Using the Third Dimension

The general aim of research of this thesis was to better understand normal physiological changes of the developing human embryo by using novel imaging techniques, serving as a background for determining the difference between normal and abnormal development. We examined the sonographic appearance of the brain, midgut, genitalia, feet and the curvature in the first trimester of pregnancy by means of both 3D and 3D VR technology

Echocardiography

The book "Echocardiography - New Techniques" brings worldwide contributions from highly acclaimed clinical and imaging science investigators, and representatives from academic medical centers. Each chapter is designed and written to be accessible to those with a basic knowledge of echocardiography. Additionally, the chapters are meant to be stimulating and educational to the experts and investigators in the field of echocardiography. This book is aimed primarily at cardiology fellows on their basic echocardiography rotation, fellows in general internal medicine, radiology and emergency medicine, and experts in the arena of echocardiography. Over the last few decades, the rate of technological advancements has developed dramatically, resulting in new techniques and improved echocardiographic imaging. The authors of this book focused on presenting the most advanced techniques useful in today's research and in daily clinical practice. These advanced techniques are utilized in the detection of different cardiac pathologies in patients, in contributing to their clinical decision, as well as follow-up and outcome predictions. In addition to the advanced techniques covered, this book expounds upon several special pathologies with respect to the functions of echocardiography

Ultrasound Imaging

This book provides an overview of ultrafast ultrasound imaging, 3D high-quality ultrasonic imaging, correction of phase aberrations in medical ultrasound images, etc. Several interesting medical and clinical applications areas are also discussed in the book, like the use of three dimensional ultrasound imaging in evaluation of Asherman's syndrome, the role of 3D ultrasound in assessment of endometrial receptivity and follicular vascularity to predict the quality oocyte, ultrasound imaging in vascular diseases and the fetal palate, clinical application of ultrasound molecular imaging, Doppler abdominal ultrasound in small animals and so on

P14.01 An example of too much too soon? A review of caesarean sections performed in the first stage of labour in Kenya

Objective: Caesarean Section (CS) has potential short and long-term complications and is associated with excess maternal death. Decisions to perform (CS) are frequently made by inexperienced and unsupported non-specialist doctors, sometimes resulting in inappropriate decision-making and surgery. Our study assesses decision-making for CS in the first stage of labour in Kenya. Method: A panel of one UK and six Kenyan expert obstetricians reviewed clinical data extracted from 87 case-notes, that were randomly selected from a series obtained from seven referral hospitals in five Kenyan counties over six months in 2020. Following a preliminary review of the data and email discussion, an online panel was convened to discuss outstanding cases where consensus was yet to be reached. Agreement was reached by the panel in all but 5 cases. Results: In 41.3% cases, CS was considered appropriate, including 8% where CS was performed too late. The decision to delivery interval exceeded 2 h in 58.6% cases, including 16 cases of non-reassuring fetal status. In 10.3% it was considered that due to delay, further reassessment should have occurred. In 9.1% the CS was done too soon. There was insufficient information available to make a full assessment in 21.8% of cases. In 11.5% the CS was inappropriate. Conclusion: This review demonstrates that unnecessary caesarean sections are being performed, while some with appropriate indications are subject to delays. There is need for improved support for decision-making, coupled with improved record-keeping, improved quality of fetal monitoring during labour and more timely surgery when necessary

P14.02 An electronic behaviour diary: Monitoring the effects of advanced obstetric surgical skills training

Objective: Training should lead to improvements in the quality of clinical care delivery. It is essential to follow up participants after a training intervention to monitor changes in behaviour associated with adoption of lessons learned into clinical practice. We introduced an electronic diary to facilitate monitoring whilst minimising effort for participants. Method: An electronic diary was created using a freely available on-line platform. Following a training intervention on advanced obstetric surgical skills, obstetric residents from Kenya were invited to pilot completing the diary after their labour ward shifts. Entries were anonymised. Participants were asked to enumerate the times they utilised specific skills, or to state why they had been unable to do so, using tick box options. Reflections on skills used were entered using free comments. Results: All participants reported changed behaviours, for example, improved surgical knot-tying, safer needle handling, separate closure of uterine incision angles and techniques for delivery of the impacted fetal head. 6 reported conducting vaginal breech birth and 6 performed vacuum-assisted birth. All reported improvements in use of the safe surgical checklist, obtaining consent and respectful maternity care. 7 had participated in newborn resuscitation. Reflections suggested participants experienced improved levels of confidence and satisfaction when implementing new skills. Conclusion: This pilot study has demonstrated the feasibility of monitoring clinical behaviour change following training using an electronic platform. Monitoring the effect of training is essential to prove that training results in improvements to clinical practice. We plan to roll out this intervention following future training interventions

P04.41 Exploring reasons for and outcomes of second stage caesarean section and assisted vaginal birth in selected hospitals in Kenya

Objective: Obstetric vacuum devices for assisted vaginal birth (AVB) can avoid the need for unnecessary second-stage caesarean sections (SSCS), associated with increased morbidity and mortality. Despite emergency obstetric training since 2019, AVB was rarely performed. This study sought to better understand missed opportunities and reasons for non-performance of AVB in Kenya. Method: A mixed-methods design incorporated a review of randomly selected SSCS and AVB case notes, and key informant interviews with healthcare providers, from 8 purposively selected, high-volume hospitals in Kenya. The reviews were carried out by four experienced obstetricians (3 Kenyan, 1 British). The interviews were semi-structured and conducted online and analysed using a thematic approach. Results: Six AVB and 66 SSCS cases were reviewed. Nine percent of SSCS could have been AVB, and 58% reviewers were unable to determine appropriateness due to poor record keeping. Perinatal mortality was 9%, and 11% of infants and 9% of mothers experienced complications following SSCS. Twenty interviews, with obstetricians, midwives and medical officers, explored themes of previous experience, confidence, and adequacy of training relating to AVB. Reasons for non-performance included lack of equipment and staff. Conclusion: Increases in appropriate use of AVB could save the lives of infants and mothers and reduce ongoing morbidity. In order to achieve this, the varied reasons for non-performance of AVB need to be systematically addressed at local, regional and national levels

Prediction of adverse perinatal outcomes following induction of labour

Induction of labour (IOL) is one of the most common obstetric procedures which is carried out in 20-30% of pregnancies. More than a third of women having IOL will need either an instrumental delivery or a caesarean section. Induction will fail for approximately 10% of women who undergo the process. The number of indications for IOL have increased in the last few years with guidelines from professional bodies recommending induction for a range of obstetric and medical complications. This has a significant impact on the capacity and flow on antenatal wards and delivery suites across the country. There are currently no effective methods that can accurately predict the success of IOL. The current method for assessment prior to IOL includes a vaginal examination to assess the Bishop Score, which is an objective way of defining the extent of cervical ripening. There are other methods described in the current literature such as the measurement of cervical length, posterior cervical angle and more recently the angle of progression (AOP), head to perineum distance (HPD) and cervical compression index (CCI). There is also some evidence that biochemical markers such as placental alpha macroglobulin-1 and fetal fibronectin may predict the onset of labour. This has been used in management of patients with threatened preterm birth. However, there is no composite model for the accurate prediction of adverse maternal or neonatal outcomes following IOL. The main objective of this thesis is to examine which factors amongst maternal demographics and components of obstetric history, biophysical and biochemical markers, are altered in women who have adverse outcomes following IOL. I propose to develop a model that will accurately predict the risk of caesarean section for failure to progress or for suspected fetal distress using a combination of maternal and fetal factors measured at a pre-induction clinic (PIC). This model would be of significant benefit in counselling women prior to IOL

Serious bacterial infections among Ugandan neonates: Aetiology, clinical findings and one year outcomes

Title: Serious bacterial infections among Ugandan neonates: Aetiology, clinical findings and one year outcomes. Author: K L Burgoine Background: Globally, serious bacterial infections, such as sepsis, pneumonia and meningitis, are a leading cause of neonatal mortality. In sub-Saharan Africa (SSA) there are believed to be up to 2.6 million cases of pSBI every year, leading to an estimated 250,000 deaths. Diagnosis is challenging since signs and symptoms are often non-specific and laboratory facilities are limited. In low-resource settings, the diagnosis of a possible serious bacterial infection (pSBI) relies on clinical algorithms. Cranial ultrasound (cUS) is a relatively cheap, safe and portable method of assessing the neonatal brain that could be used to detect findings indicative of CNS involvement. There are also limited data on the outcomes of pSBI survivors. This is one of the first studies in SSA to assess the role of cUS in the evaluation of infants with pSBI and the early developmental outcome of infants admitted with pSBI. Aims: In term neonates presenting with pSBI to a neonatal unit in eastern Uganda: • Describe the clinical presentation, aetiology and neonatal outcomes • Describe findings on cUS scans at presentation and correlate the imaging findings with presentation, CSF analysis and neonatal mortality • Compare cUS findings to a cohort of similar aged well term neonates. • Describe findings on serial cUS scans up to 28 days • Evaluate mortality, growth and developmental impairment up to 12 months of age and compare it to the contemporaneous control cohort • Investigate the risk factors that contribute to poor early childhood outcome in term-born infants that experienced a possible severe bacterial infection (pSBI) during the neonatal period. Methods: Over a 1-year period, any term neonates presenting to the neonatal unit at Mbale Regional Referral Hospital who met the definition of pSBI were screened for inclusion. We described the microbiological aetiology using blood and CSF culture, the presenting clinical features and the neonatal outcomes. Each neonate had a standard cUS examination performed. The images were interpreted systematically by one of two experts blinded to the clinical details. A contemporaneous cohort of well term neonates were recruited. They underwent the same clinical and cUS examination. We followed-up surviving infants at 2, 6 and 12 months of age to evaluate survival, growth and development. The Bayley Scales of Infant Development-3rd edition (BSID-III) was used and developmental impairment was defined as a scaled-score <-1SD below the mean. Poor outcome was defined as either death, hydrocephalus, post-neonatal seizures or developmental impairment at 12 months of age. Results: 214 neonates with pSBI were recruited. Definite or possible pathogens were identified in 5.6% (12/214) of blood cultures. The most common pathogens isolated were Staphylococcus Aureus, Klebsiella and Escherichia coli. Potential pathogens were isolated in 0% (0/189) of CSF cultures. The overall neonatal mortality was 9.3% (20/214). The neonatal mortality from neonatal meningitis was 22.2% (6/27). Early cUS scans were available for 196/214 (91.6%) neonates with pSBI. There was no observed association between cUS findings at presentation and neonatal mortality. Moderate and severe cortical and/or white matter (WM) echogenicities were significantly associated with abnormal CSF analysis. The presence of signs suggestive of encephalopathy or meningism were associated with abnormal cortical, WM, and basal ganglia and thalami (BGT) echogenicity, ventricular dilatation and bright ventricular lining. At 12 months 164/187 survivors of pSBI were available for assessment; 4/187 infants had died during the post-neonatal period. Developmental impairment was evident across all domains of the BSID-III and the rates of impairment ranged from 7.9% to 14.6%. 24/44 control infants were available for assessment and none of these infants were impaired in any of the 5 domains. The raw scores and the scaled scores for all five neurocognitive domains were significantly lower for survivors of pSBI compared to control infants. Survivors of neonatal meningitis, had the highest rates of developmental impairment, being 24%, 35% and 24% in cognitive, language and motor domains respectively. Survivors of neonatal meningitis had a 12 to 18-fold increased risk of developmental impairment across all domains. By 12 months of age 30.5% (54/177) of infants had a poor outcome. After adjustment for sex, age and weight, the following factors increased the risk of poor outcome: age <48 hours at presentation, respiratory distress (aOR 2.7, 95%CI 1.2-6.2), neonatal seizures (aOR 13.0 (5.2-32.4)), opisthotonus (aOR 9.5 (3.5-27.0)), hypotonia (aOR 3.0 (1.1-8.3)) and raised CSF protein (aOR 9.5 (2.3-38.6)). cUS findings at presentation, significantly associated with poor outcome were abnormal cortex (aOR 6.9 (2.0-23.5)), abnormal white matter (aOR 2.0 (1.0-3.9)), abnormal basal ganglia (aOR 13.6 (2.7-68.2)) and abnormal thalami (aOR 5.28 (1.8-15.2)). Conclusion: It is clear that serious bacterial infections during the neonatal period, even without meningitis, may have a substantial public health and economic burden in SSA. Presentation before 48 hours of age, lower weight, several readily recognisable clinical signs as well as raised CSF protein and cortical, white matter, and central grey matter abnormalities seen on cUS, were all significant predictors of poor outcome. These risk factors will enable us to better consider which infants need more intensive follow-up, early intervention and support. Improving our understanding of the specific aetiologies associated with mortality, developmental impairment and post-infectious hydrocephalus, is now necessary to inform prevention strategies and treatment approaches