Evaluation of fetal middle cerebral artery doppler and umbilical artery doppler as predictors of perinatal outcome in small for gestational age fetuses

Doppler is one of the means used for in-utero monitoring of high risk pregnancy. It can provide useful information pertaining to the in-utero condition of fetuse with growth restriction, in high risk pregnancy and post-date pregnancy with oligohydromnios. Since its introduction in the field of obstetrics and gynaecology by Fitzgerald and Drumm in 1977, many studies were conducted to assess its sensitivity and specificity as an antenatal monitoring tool. In Hospital Universiti Sains Malaysia, Doppler study was used on a daily basis in management of high risk pregnancy. To evaluate the diagnostic performance of fetal middle cerebral artery (MCAPI), and umbilical artery (UA) Doppler Ultrasonography (US) as predictors of adverse perinatal outcome in Small for Gestational Age fetuses. Diagnostic Prospective Cross-Sectional Study This study was conducted in Hospital University Science Malaysia from October 2009 till October 2010. 72 patients were enrolled in the study after fulfilling the inclusion criteria. 70 (97.2%) patients were Malays and 1 was Chinese and 1 was Burmese. The mean patients’ age was 30.76 +7-6.294 years. The mean weight, height and body mass index was 53.05kg, 152.81cm and 22.66kg/m2 respectively. 45 (62.5%) patients had medical problems, whereby 30 (41.6%) of them had hypertension and its complication related to pregnancy. 6 (8.3%) had diabetis mellitus in which 2 of them had pre-existing diabetes diagnosed before pregnancy. 51 (70.8%) patients had normal Umbilical Artery Pulsatility Index (UAPI) and Middle Cerebral Artery Pulsatility Index (MCA PI), 4 (5.7%) patients had normal UA PI but abnormal MCA PI. 11 (15.2%) patients had both abnormal UA PI and MCA PI. The mean PI for normal umbilical artery Doppler was 0.91 +/- 0.18, the mean PI for suspicious umbilical artery Doppler was 1.33 +/- 0.11, and the mean PI for pathological umbilical artery Doppler was 3.11 +/- 0.76. The mean PI for normal Middle Cerebral Artery (MCA) Doppler was 1.41 +/- 0.32 and the mean PI for pathological MCA Doppler was 1.04 +/- 0.19. The mean gestational age at delivery was 36+/- 3.095. 25 patients underwent emergency lower segment Caesarean Section, 7 neonates had major adverse perinatal outcome, specifically necrotizing enterocolotis. 70 babies had APGAR score of more than 7 at 5 minutes, however, all babies had normal umbilical cord pH at birth. 12 babies needed intubation and admission to NICU and 2 babies had Early Neonatal Deaths due to extreme prematurity and sepsis. In this study, Umbilical Artery Pusatility Index (UA PI) is more sensitive, more specific and had more positive and negative predictive value compared with MCA PI and MCA/UA PI ratio. UA PI had a sensitivity of 55.5%, specificity 95.5%, positive predictive value of 88.2% and negative predictive value of 78.1%. While an abnormal UA PI is a better predictor of adverse perinatal outcome than an abnormal MCA PI and MCA/UA PI ratio, a normal MCA PI may help to identify fetuses without major adverse perinatal outcome. The 2 method used in combination had a better diagnostic and monitoring value. Base on the cord blood pH recorded in this study, the decision for early intervention was decided much before the fetus suffered any form of acidosis. It can be concluded that the caesarean section rate can be reduce further, by supporting the decision to deliver early base on combination of the Doppler finding and biophysical profile score as well as the clinical assessment

Role of first trimester ultrasound scan as a predictor of monochorionic diamniotic complications

Introduction: Monochorionic twin pregnancies come with substantially higher complications compared to their dichorionic counterparts, which include intrauterine fetal death, fetal loss prior to 24 weeks, selective intrauterine growth restriction and twin-to-twin transfusion syndrome (TTTS). Objectives: This work aims to examine the inter-twin discrepancy in nuchal translucency thickness (NT), crown-rump length (CRL), fetal heart rate (FHR) and ductus venosus Doppler (DV), as predictors of complications in monochorionic diamnotic twins (MCDA). Methods: This is a retrospective study that involves 118 MCDA pregnancies followed-up in a tertiary centre, from January, 2011 to June, 2016. NT was measured at 11 to 13+6 weeks’ gestation in 23 MCDA pregnancies. Regression analysis was employed to determine the significance of the association between inter-twin discrepancy in NT, CRL, FHR and DV Doppler with intrauterine death of both fetuses and monochorionic (MC) complications such as TTTS, selective intrauterine growth restriction (sIUGR) and twin anemia and polycythemia sequence (TAPs). Results: Multiparous mothers (53.8%) aged between 19 and 35 years (89.9%) contributed to the majority of MCDA twin pregnancies. Among a total of 118 MCDA pregnancies, 16.8% (n=20) developed complications. About 3.4% (n=4) of them had TTTS, and 10.9% (n=13) had sIUGR, while only 0.9% (n=1) developed TAPs and intrauterine fetal death (IUFD) of both fetuses each. A significant prediction of MC complications and intrauterine death was provided by discordant NT of 35% or more (p= 0.021) with a relative risk of 4.0 (95% CI 1.2312.99), a sensitivity of 57.1% and a specificity of 88.2%. Otherwise, there exist no significant associations between discrepancy in CRL, FHR and DV Doppler and MC complications. Conclusions: Inter twin discordance in NT of 35% or more was reported in about 25% of MCDA twins in this group, with the risk of developing MC complications and intrauterine death of over 40%. Among other parameters, it is the early predictors of hemodynamic imbalance between both twins that significantly contribute to a more reliable screening tool for MCDA pregnancies with high specificity

Short term neonatal outcomes of singleton term breech delivery: two year experiences in a Malaysian tertiary hospital

Background: There are few neonatal complications of breech delivery including the low Apgar score, birth trauma, admission to neonatal unit and perinatal mortality. Objective: To review the short term complications and their associating factors among singleton term breech infants in relation to mode of delivery. Methodology: This is a cross-sectional study that involves 294 term singleton pregnant women with breech presentation in Hospital Serdang, Malaysia from January 1, 2014 to December 31, 2015. Data abstracted from the delivery record book and the hospital database computerised system were used to compare the short term outcomes of singleton term breech infants born via vaginal breech delivery and pre-labour or in-labour caesarean section. Results: Out of 294 cases, 25% (n=73) displayed a successful vaginal delivery, whereas the remaining 75% (n=221) have undergone caesarean delivery. It was more common in multiparous women (64.3%) and frank-typed of breech (59.9%) is more prevalence compared to others. Nulliparity was found significantly predominant in caesarean section delivery (OR 2.38, 95% CI 1.114-5.084, p= 0.005), while the complete-typed of breech was significantly lesser in caesarean section group (OR 0.47, 95% CI 0.246-0.915, p= 0.026). However, there was no significant difference discovered in adverse neonatal outcome regarding the mode of delivery. Conclusion: Pre or in- labour caesarean section and vaginal delivery in terms of singleton breech presentation contains a similar risk of adverse neonatal outcome. According to this study, the main risk factors affecting the mode of delivery are parity and type of breech presentation

Risk factors for spontaneous preterm labour with intact membrane: a case control study of Malay ethnic group in Hospital Serdang, Malaysia

Objective: Perinatal morbidity and mortality were well-associated with preterm births. Spontaneous preterm births as a single entity or preterm births in general were commonly used in identification of risk factors. These factors, however, are lacking due to absence of subtype-specific aetiologies. In this investigation, risk factors linked with spontaneous preterm births with intact membrane were investigated. Methods: This case-control study using secondary data was conducted at the Department of Obstetrics and Gynaecology, Hospital Serdang, Malaysia over the course of three years. A total of 1,559 Malay pregnant women were involved. It consisted of subjects with spontaneous preterm labours with intact membrane, and the controls consisted of matched pregnant women with term delivery. Information in terms of socio-demographic factors, history of prior pregnancies, maternal health during pregnancy, foetal characteristics, and biophysical profile were taken from the patients' medical records and collected using a set data collection sheet. Any associations with spontaneous preterm labour with intact membrane were determined and analysed by employing both chi square bivariate and multivariable logistic regression via SPSS software. Results: Incidence rate of spontaneous preterm labour with intact membrane peaked during the late preterm stage of gestation. Risk factors, in order of decreasing odds ratios (OR), preeclampsia (OR=31.92, 95% confidence interval (CI):12.57-81.09), placenta previa (OR=11.14, 95% CI: 5.19-23.92), history of preterm delivery (OR=5.43, 95% CI: 3.15-9.36), young mother (OR=5.14, 95% CI:2.68-9.848), unmarried mother (OR=3.81, 95% CI:1.78-8.13), systemic infection (OR=4.04, 95% CI:1.96-8.30), urinary tract infection (OR=3.21, 95% CI:1.73-5.93), absence of antenatal follow-up (OR=2.62, 95% CI:1.14-5.99), grand multiparity (OR=2.59, 95% CI:1.01-6.86), hypertension (OR=2.40, 95% CI:1.36-4.26), pregnancy induced hypertension (OR=2.28, 95% CI:1.17-4.46), oligohydramnios (OR=1.94, 95% CI:1.14-3.29), vaginal tract infection (OR=1.76, 95% CI:1.17-2.65) and poor/low socioeconomic status (OR=1.31, 95% CI:1.02-1.67). This was suggested by the final multivariable model. Conclusion: Variables identified as risk factors for spontaneous preterm labour with intact membrane are family income, no utilization of prenatal care, marital status, maternal age, history of prematurity, preeclampsia, placenta previa, infection (systemic, urinary tract and vaginal tract), hypertension, pregnancy induced hypertension, grand multiparity, and oligohydramnios. Therefore, women with these risk factors require more attention through careful antenatal care

Role of predictive mortality calculator in antenatal assessment of congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is one of the most common major congenital anomalies. In utero visceral organ herniation into the thoracic cavity can result in lung hypoplasia and pulmonary hypertension may ensue. Post-natal mortality rates in isolated CDH remain high reaching up to 80% in severe cases. Several prenatal predictors of morbidity and mortality have been proposed. Reliable predictive markers can aid clinicians in providing effective family counselling, prediction of survival, and propose therapeutic options. Decreased total fetal lung volume (TFLV) via magnetic resonance imaging (MRI) has been reported to be significantly associated with mortality. We report on 2 cases of CDH, with fetal MRI performed at third trimester, focusing on the TFLV and observed-to-expected TFLV. We would like to highlight the importance of predictive mortality calculator which provides statistical data for healthcare providers in counselling families and aids in risk-stratification

Fetal MRI assessment of head & neck vascular malformation in predicting outcome of EXIT-to-airway procedure

Objectives: The objective of this clinical case report is to highlight the MRI features and staging system which may guide clinicians in determining further management. Case presentation: Three different cases with fetal head and neck vascular malformation diagnosed during prenatal screening were presented. MRI demonstrates large cystic neck masses which may compromise fetal airway during delivery. Thus, this required multidisciplinary team management among obstetricians, otolaryngologists, pediatricians, anesthesiologists, and radiologists. A decision for complex birth delivery through the cesarean section aided with EXIT-to-airway procedure was made. Each of these procedures demonstrates the different challenges and outcomes of the neonates which correlated with the characterization and staging based on prenatal MRI. Conclusions: EXIT-to-airway procedure in head and neck malformation may be beneficial in transiting complicated and potentially catastrophic delivery situations to a more controlled environment. However, it also needs to align with prenatal MRI evaluation, which provides a more objective assessment guide for the clinicians

Characterisation of the probiotic qualities exhibited by lactobacilli strains isolated from the anogenital tract

Introduction: Lactobacilli are well-documented probiotics that exert health benefits on their host. They exhibit characteristics that make them potential alternative treatments to address the antimicrobial resistance conundrum and diseases. Their mechanism of action varies with strain and species. Five lactobacilli strains previously isolated from the anogenital region were subjected to several assessments highlighted in the FAO/WHO document, ‘Guidelines for the Evaluation of Probiotics in Food’ to determine its suitability as potential probiotics. Methods: The five lactobacilli strains were subcultured onto Man de Rogosa agar (MRS). Their ability to auto- and co-aggregate was determined spectrophotometrically. Simultaneously, the cell surface hydrophobic properties of these strains towards xylene and toluene were evaluated using the microbial adhesion to hydrocarbon (MATH) test. The lactobacilli strains were also tested for their ability to withstand acid, bile and spermicide to determine their level of tolerance. Results: Lact. reuteri 29A, L. delbrueckii 45E and L. reuteri 29B exhibited the highest degree of auto- and co-aggregation properties. These lactobacilli strains also demonstrated high cell surface hydrophobicity, with the exception of L. delbrueckii 45E. Further tests to evaluate the isolated lactobacilli tolerance identified L. reuteri 29B as the most tolerant strain towards low pH (pH 2.5 for 4 h), high bile concentration (0.5% for 4 h) and high spermicides concentration (up to 10%). Conclusion: Out of the five lactobacilli strains which possessed high antimicrobial activities, L. reuteri 29B portrayed the best probiotic qualities with good auto- and co-aggregation abilities and high tolerance against acid, bile and spermicide

Voltammetric determination of human papillomavirus 16 DNA by using interdigitated electrodes modified with titanium dioxide nanoparticles

A gene sensor for rapid detection of the Human Papillomavirus 16 (HPV 16) which is associated with the appearance of cervical cancer was developed. The assay is based on voltammetric determination of HPV 16 DNA by using interdigitated electrodes modified with titanium dioxide nanoparticles. Titanium dioxide nanoparticles (NPs) were used to modify a semiconductor-based interdigitated electrode (IDE). The surface of the NPs was then functionalized with a commercial 24-mer oligomer DNA probe for HPV 16 that was modified at the 5′ end with a carboxyl group. If the probe interacts with the HPV 16 ssDNA, the current, best measured at a working voltage of 1.0 V, increases. The gene sensor has has a ∼ 0.1 fM limit of detection which is comparable to other sensors. The dielectric voltammetry analysis was carried out from 0 V to 1 V. The electrochemical sensitivity of the IDE is 2.5 × 10⁻⁵ μA·μM⁻¹·cm⁻². Graphical abstractSchematic of an interdigitated electrode (IDE) modified with titanium dioxide nanoparticles for voltammetric determination of HPV 16 DNA by using an appropriate DNA probe

Preterm intraamniotic infection and inflammation: search for protein biomarkers via proteomics approach

Preterm delivery (PTD) is commonly caused by intraamniotic infection and inflammation (IAI) and is one of the leading causes of maternal and neonatal morbidity or mortality worldwide. IAI in pregnant women with high risk of PTD can be classified according to the membrane status; preterm labour with intact membranes (PLIM) and preterm pre-labour rupture of membranes (PPROM). At present, the treatment for PTD-associated IAI is principally based on antibiotic therapy. However, this therapy is found to be only beneficial to PPROM. Several IAI related protein biomarkers have been identified. Unfortunately, most of the studies that discovered the biomarkers focused on categorising term delivery and PTD-associated IAI, and to a lesser extent on the membrane status. Therefore, identifying a panel of highly sensitive and specific protein biomarkers that are able to discriminate IAI pregnant women at high risk of PTD with PLIM from PPROM are urgently needed to improve the treatment benefits. Over the past decade, proteomics technologies have been applied widely in identifying PTD-associated IAI biomarkers. This review brings together information on PTD-associated IAI protein biomarkers and touches on the combination of multivariable biomarkers to develop a more sensitive and specific biomarkers to discriminate PTD-associated IAI with PLIM from PPROM. Proteomics technologies and its workflow on protein biomarkers discovery are also included in this review