Προσδιορισμός της ηλικίας κυήσεως με βάση την ΤΕΡ και το CRL

Εισαγωγή: Ο ακριβής προσδιορισμός της ηλικίας κύησης αποτελεί ένα εξαιρετικά σπουδαίο στοιχείο στην διαχείριση μιάς εγκύου, καθώς πολλές κλινικές αποφάσεις κατα την διάρκεια της εγκυμοσύνης βασίζονται στην ηλικία κυήσεως. Η ηλικία της κύησης έχει ιδιαίτερη σημασία σε κυήσεις με οριακή βιωσιμότητα και ωριμότητα, ενώ καθορίζει και το ακριβή χρόνο περάτωσης της κύησης. Η απροσδιόριστη ή αβέβαιη ηλικία κυήσεως έχει συσχετιστεί με αυξημένα ποσοστά περιγεννητικής νοσηρότητας και θνησιμότητας. Ο προσδιορισμός της ηλικίας κυήσεως έχει ακόμα μεγαλύτερη σημασία σε πολύδυμες κυήσεις, εξαιτίας του μεγαλύτερου ποσοστού περιγεννητικών επιπλοκών όπως ο πρόωρος τοκετός και η ενδομήτρια καθηστέρηση της ανάπτυξης. Υλικά-Μέθοδος : Μελετήθηκαν 8 ηλεκτρονικές βάσεις δεδομένων όπως PUBMED, WebMD, Wikipedia, ΕΜΒΑSE, American Society of Obstetrics-Gynecology, MedLine, Royal College of Obstetricians and Gynaecologists, British Medical Ultrasound Society. Χρησιμοποιήθηκαν λέξεις κλειδιά, όπως: τελευταία έμμηνος ρύση (ΤΕΡ), κεφαλουραίο μήκος εμβρύου (CRL), ηλικία κύησης, πιθανή ημερομηνία τοκετού, υπερηχογράφημα πρώτου τριμήνου. Από την ανασκόπηση προέκυψαν: 56 βιβλιογραφικές αναφορές (55 αγγλικής και 1 ελληνικής βιβλιογραφίας). Αποτελέσματα : Σύμφωνα με το ACOG oι μετρήσεις του CRL μέχρι την ηλικία κυήσεως 13/6 προσδιορίζουν την ακριβή ηλικία κυήσεως με μια ακρίβεια της τάξεως +/- 5-7 ημερών. Μετά απο τις 14 0/7 εβδομάδες κυήσεως ή όταν το CRL είναι πάνω απο 84mm η ακρίβεια του CRL για την χρονολόγηση της κυήσεως μειώνεται και συστήνεται η χρήση των υπερηχογραφικών δεικτών του 2ου τριμήνου όπως το BPD. Αν η ΠΗΤ που προκύπτει απο τις υπερηχογραφικές μετρήσεις πριν τις 14 0/7 εβδομάδες διαφέρει πάνω απο 7 ημέρες απο την ΠΗΤ με βάσει την ΤΕΡ τότε τροποποιείται η ΠΗΤ με βάσει τα υπερηχογραφικά δεδομένα. Στο Ηνωμένο Βασίλειο, οι κατευθυντήριες οδηγίες προτείνουν ότι όλες οι κυήσεις πρέπει να χρονολογούνται με βάσει την πρώτη έγκυρη υπερηχογραφική μέτρηση του CRL και όχι με βάση την ΤΕΡ. Το 2013, οργανώθηκε μία μετανάλυση απο το Napolitano με στόχο την αξιολόγηση των εξισώσεων για το CRL. Από τη διαδικασία προέκυψαν 4 μελέτες που ικανοποιούσαν περισσότερα από 18 από τα 29 κριτήρια ποιότητας. Η χρήση καθεμιάς από τις παραπάνω 4 μελέτες αποδεικνύει ότι, όσο περισσότερα κριτήρια ποιότητας ικανοποιούνται, τόσο λιγότερες διαφορές εμφανίζονται στην εκτίμηση της ηλικίας κύησης. Στη μεθοδολογία είναι απαραίτητη η κοινή συναίνεση, με στόχο την εκτίμηση των πληθυσμιακών διαφορών στη μέτρηση του CRL. Το INTERGROWTH-21ST είναι ένα πολυκεντρικό, πολυεθνικό, πλυθησμιακό σχέδιο που διενεργήθηκε από το 2009 εώς το 2014 σε οκτώ αστικές περιοχές, οκτώ διαφορετικών χωρών. Η INTERGROWTH-21st μελέτη αποτελεί την πρώτη προσπάθεια στην ιστορία της σύγχρονης μαιευτικής για τον καθορισμό μιας παγκόσμιας εξίσωσης που θα υπολογίζει την ηλικία κυήσεως σε συνάρτηση με το κεφαλουραίο μήκος του εμβρύου. Συμπεράσματα : Η εκτίμηση της ηλικίας κυήσεως βασιζόμενη αυστηρά σε υπερηχογραφικές μετρήσεις συγκεκριμένων εμβρυικών ανατομικών δομών έχει το μειονέκτημα ότι εξαφανίζει οποιαδήποτε βιολογική ποικιλότητα για μα συγκεκριμένη τιμή του CRL. Μια υπόθεση η οποία φυσικά είναι βιολογικά αδύνατη. Όταν οι υπερηχογραφικές μετρήσεις συμφωνούν με μία αξιόπιστη ΤΕΡ, τότε μικρές διακυμάνσεις στην ηλικία κυήσεως μπορεί να ελλοχεύουν ένα εν γένη συστηματικό λάθος της μέτρησης του CRL. Αντιθέτως, όταν μία αξιόπιστη ΤΕΡ διαφέρει σημαντικά σε σχέση με τις υπερηχογραφικές μετρήσεις του CRL, αυτό αποτελεί ένδειξη πιθανής διαταραχής της εμβρυικής ανάπτυξης ή υποκείμενης παθολογίας που χρήζει περεταίρω παρακολούθησης. Τέλος, η εκτίμηση της ηλικίας κυήσεως θα πρέπει να αναφέρεται στη γυναίκα ως εκατοστιαία θέση ή ως μια σταθερή απόκλιση από τη μέση τιμή της εκάστοτε μετρήσεως και όχι ως μια συγκεκριμένη τιμή.Introduction: A dating of pregnancy is important, as up to 30% of women attending an antenatal clinic have uncertain or unreliable menstrual dates. Antenatal care and interventions aimed at improving pregnancy outcome rely on our knowledge of the gestational age (GA). The potential benefits of correct ultrasound dating in the first trimester include : the improved performance of first trimester screening for chromosomal abnormalities, reducing the number of pregnancies classified as preterm and the reduced incidence of post term delivery. It has also been shown that dating the pregnancy in the first rather than the second trimester can lead to a reduction in the number of unnecessary inductions of labor. The unknown or unreliable gestational age has been linked with higher rates of perinatal mortality and morbidity. The exact dating of the pregnancy has even higher importance in the case of a twin pregnancy due to the increase incidence of adverse perinatal outcomes such as preterm delivery or fetal growth restriction. Material-Methods: Eight electronic databases (PUBMED, WebMD, Wikipedia, ΕΜΒΑSE, American Society of Obstetrics-Gynecology, MedLine, Royal College of Obstetricians and Gynaecologists, British Medical Ultrasound Society) were systematically searched. We used the following keywords: last menstrual period, crown rump length, gestational age, estimated due date and first trimester ultrasound scan. Only articles written in English and Greek were considered. Our review resulted in 56 references (55 in English and 1 in Greek). Results: According to the ACOG up to and including 13 6/7 weeks of gestation, gestational age assessment based on the on measurement of the crown rump length has an accuracy of +/- 5-7 days. Beyond measurements of 84mm (corresponding to approximately 14 0/7 weeks of gestation), the accuracy of the CRL to estimate gestational age decreases, and in these cases, other second trimester biometric parameters should be used for dating. If ultrasound dating before 14 0/7 weeks of gestation differs by more than 7 days from LMP dating, the EDD should be changed to correspond with the ultrasound dating. According to the RCOG all pregnancies should be dated based on the measurement of CRL during the first trimester ultrasound scan and not based to the LMP. A recent meta analysis (Napolitano 2013) evaluated the methodological quality used in studies reporting CRL equations to estimated GA using a set of predefined criteria. The 4 studies with the highest scores (lowest risk of bias) satisfied 18 or more of the 29 criteria, these showed lower variation in GA estimation than the remaining lower scoring studies. This was more evident at the extremes of GA. The INTERGROWTH-21st is a multicenter, multiethnic, population based project conducted between 2009 and 2014 in eight urban areas in eight different countries. It’s the first study aiming to generate CRL data according to GA using an optimal design and prescriptive approach in order to develop international ,population based standards for early fetal linear size estimation and ultrasound dating in the first trimester that can be used throughout the world. Conclusions: A disadvantage of GA estimation based purely on the ultrasound measurement of fetal anatomical parameters is that all biological variation in the GA for a given value of CRL disappears, an assumption that is of course biologically implausible. That also occurs with any other biological parameter being predicted by a single measurement. When a reliable LMP and ultrasound estimate concur, small discrepancies in GA may mask inherent CRL measurement error. Conversely , an apparently reliable and accurate LMP with a substantial difference in estimated GA based on CRL should be considered as an indicator of possible growth disturbance or underlying pathology that needs to be monitored. It is important to emphasize that all estimates of GA should be explained and given to the corresponding measure of variability e.g. SD or centiles, to provide a measure of the error of the estimation. Finally when high methodological standards are met and populations adequately selected, early fetal growth is similar across populations. The adoption of these standards will standardize the evaluation of fetal growth across levels of care and facilitate comparisons internationally

Enhancing vaginal delivery in Greece through educational and behavioral interventions among maternity care providers regarding labor management: the engage stepped-wedge randomized prospective trial protocol

Background: There is an emerging need to systematically investigate the causes for the increased cesarean section rates in Greece and undertake interventions so as to substantially reduce its rates. To this end, the ability of the participating Greek obstetricians to follow evidence-based guidelines and respond to other educational and behavioral interventions while managing labor will be explored, along with barriers and enablers. Herein discussed is the protocol of a stepped-wedge designed intervention trial in Greek maternity units with the aforementioned goals in mind, named ENGAGE (ENhancinG vAGinal dElivery in Greece). Methods: Twenty-two selected maternity units in Greece will participate in a multicenter stepped-wedge randomized prospective trial involving 20,000 to 25,000 births, with two of them entering the intervention period of the study each month (stepped randomization). The maternity care units entering the study will apply the suggested interventions for a period of 8–18 months depending on the time they enter the intervention stage of the study. There will also be an initial phase of the study lasting from 8 to 18 months including observation and recording of the routine practice (cesarean section, vaginal birth, and maternal and perinatal morbidity and mortality) in the participating units. The second phase, the intervention period, will include such interventions as the application of the HSOG (the Hellenic Society of Obstetrics and Gynecology) Guidelines on labor management, training on the correct interpretation of cardiotocography, and dealing with emergencies in vaginal deliveries, while the steering committee members will be available to discuss and implement organizational and behavioral changes, answer questions, clarify relevant issues, and provide practical instructions to the participating healthcare professionals during regular visits or video conferences. Furthermore, during the study, the results will be available for the participating units in order for them to monitor their own performance while also receiving feedback regarding their rates. Τhe fnal 2-month phase of the study will be devoted to completing follow-up questionnaires with data concerning maternal and neonatal morbidities that occurred after the completion of the intervention period. The total duration of the study is estimated at 28 months. The primary outcome assessed will be the cesarean section rate change and the secondary outcomes will be maternal and neonatal morbidity and mortality. Discussion: The study is expected to yield new information on the efects, advantages, possibilities, and challenges of consistent clinical engagement and implementation of behavioral, educational, and organizational interventions described in detail in the protocol on cesarean section practice in Greece. The results may lead to new insights into means of improving the quality of maternal and neonatal care, particularly since this represents a shared efort to reduce the high cesarean section rates in Greece and, moreover, points the way to their reduction in other countries

A Rare Case Report of a Tail-Gut Cyst from a Gynecological Point of View

A tail-gut cyst can be often a misleading clinical entity. In half of the patients there is no presenting symptom. On the other half, the patients most commonly present with a variety of symptoms such as rectal pain, constipation, lower back pain, dysuria or dyspareunia. The recommended treatment of choice for the tail-gut cyst is complete surgical excision without rupture of the cyst. We present the case of a 29-year-old female with history of dyspareunia over a 5-month period, who discovered an “ovarian” cyst during an annual scheduled ultrasound appointment. However, the intraoperative findings were surprising. The bottomline is always to keep in mind the Pandora’s Box of the retrorectal space.

ENhancinG vAGinal dElivery in Greece through educational and behavioral interventions among maternity care providers regarding labor management: the ENGAGE stepped-wedge randomized prospective trial protocol

Background: There is an emerging need to systematically investigate the causes for the increased cesarean section rates in Greece and undertake interventions so as to substantially reduce its rates. To this end, the ability of the participating Greek obstetricians to follow evidence-based guidelines and respond to other educational and behavioral interventions while managing labor will be explored, along with barriers and enablers. Herein discussed is the protocol of a stepped-wedge designed intervention trial in Greek maternity units with the aforementioned goals in mind, named ENGAGE (ENhancinG vAGinal dElivery in Greece). Methods: Twenty-two selected maternity units in Greece will participate in a multicenter stepped-wedge randomized prospective trial involving 20,000 to 25,000 births, with two of them entering the intervention period of the study each month (stepped randomization). The maternity care units entering the study will apply the suggested interventions for a period of 8–18 months depending on the time they enter the intervention stage of the study. There will also be an initial phase of the study lasting from 8 to 18 months including observation and recording of the routine practice (cesarean section, vaginal birth, and maternal and perinatal morbidity and mortality) in the participating units. The second phase, the intervention period, will include such interventions as the application of the HSOG (the Hellenic Society of Obstetrics and Gynecology) Guidelines on labor management, training on the correct interpretation of cardiotocography, and dealing with emergencies in vaginal deliveries, while the steering committee members will be available to discuss and implement organizational and behavioral changes, answer questions, clarify relevant issues, and provide practical instructions to the participating healthcare professionals during regular visits or video conferences. Furthermore, during the study, the results will be available for the participating units in order for them to monitor their own performance while also receiving feedback regarding their rates. Τhe final 2-month phase of the study will be devoted to completing follow-up questionnaires with data concerning maternal and neonatal morbidities that occurred after the completion of the intervention period. The total duration of the study is estimated at 28 months. The primary outcome assessed will be the cesarean section rate change and the secondary outcomes will be maternal and neonatal morbidity and mortality. Discussion: The study is expected to yield new information on the effects, advantages, possibilities, and challenges of consistent clinical engagement and implementation of behavioral, educational, and organizational interventions described in detail in the protocol on cesarean section practice in Greece. The results may lead to new insights into means of improving the quality of maternal and neonatal care, particularly since this represents a shared effort to reduce the high cesarean section rates in Greece and, moreover, points the way to their reduction in other countries. Trial registration: NCT 04504500 (ClinicalTrials.gov). The trial was prospectively registered. Ethics Reference No: 320/23.6.2020, Bioethics and Conduct Committee, School of Medicine, National and Kapodistrian University of Athens, Athens, Greec

Συμβολή στη μελέτη της ακοής σε άτομα με τρισώμια 21 (σύνδρομο DOWN) στον Ελληνικό χώρο

120 children with Down's syndrome were examined during the period 1988-1990. Clinical examination included otoscopy, tympanometry, acoustical reflexes, pure-tone audiometry and evoked responses were taken. The observations made concerning minimal and average degree of hearing loss pertained to the conduction type hearing loss. Diagnostic method included both objective and subjective testing in conjuction with relevant cross-checks and comparative analysis of these results.Η παρούσα μελέτη αποδεικνύει ότι σε παιδιά με σύνδρομο Down-τρισωμία 21 η παρατηρούμενη μικρή ή μέτρια βαρηκοϊα αφορά συχνά πάθηση του μέσου ωτός. Οι παράγοντες που συμβάλλουν στην εμβάθηση της βαρηκοϊας αγωγιμότητας ήσαν η στενότητα του ρινιφάρυγγα, η διάγνωση των αδενοειδών και αμυγδαλών, η δυσλειτουργία δυσραχιακής σάλπιγγας, η ιδρυματική διαβίωση και η έλλειψη στοργής από το οικογενειακό περιβάλλον. Η μελέτη βασίστηκε στον έλεγχο της ακοής σε 120 παιδιά με τη μέθοδο της ακουομετρίας-τυμπανομετρίας-λήψη ακουστικών αντανακλαστικών και προκλητών ακουστικών δυναμικών εγκεφάλου

Training the trainees: a pilot study of inter-observer discrepancy and learning curve in the maternal foetal unit of a tertiary centre

Our study aims to present the preliminary findings of an ongoing prospective cohort study that assesses the trainees’ ability to perform foetal biometry during the third trimester of pregnancy. Sixty-three women with third-trimester singleton pregnancies were included. A biometry scan was performed byboth residents and a foetal medicine specialist in the Third department of Obstetrics and Gynaecology of Attikon University Hospital. For each case, the ultrasonographic measurements of the two operator groups were compared. The mean difference of the resident group compared to the specialist group was: for the biparietal diameter +1.3 mm (CI 95%, range −10.6 to +13,3, ±1.96 SD), for the occipitofrontal diameter −2.6 mm (CI 95%, range −31.5 to +26.2), for the anterior-posterior abdominal diameter −2.6 mm (CI 95%, range −17.9 to +12.8), for the transverse abdominal diameter −0.7 mm (CI 95%, range −17.1 to +15.7) and for the femur length −1.1 mm (CI 95%, range −11.7 to +9.6). We observed that, among all biometric parameters, the most accurate -based on the specialist group were the head circumference measurements. The highest discrepancy was noted for the abdominal assessment. Given that foetal biometry is of utmost importance in obstetrical clinical evaluation and management, a study that highlights the weaknesses of residents in this field could open new horizons in optimising the learning procedure.Impact statement What is already known on this subject? After review of the literature, we found only a few studies on inter- and intra-observer discrepancy in foetal biometry measurements among specialists. What the results of this study add? To our knowledge, our study is the first to evaluate residents' capacity of performing a biometry scan, by comparing their measurements to those of MFM specialists. What the implications are of these findings to clinical practice and/or further research? The need for constant evaluation of residents is indisputable. Our study could help to improve their ultrasound skills by giving emphasis on residents' weaknesses. With further research on this subject, a standard system of evaluation could be formed and determine the duration and type of training required for each resident

Quality of life of patients who underwent aesthetic rhinoplasty: 100 cases assessed with the Glascow Benefit Inventory

Objectives/Hypothesis: The aim of the present study is to assess the long-term effect of classic rhinoplasty on patients' quality of life. Study Design: Outcomes research. Methods: The study included 100 operated patients; there were 34 males and 66 females. The ages ranged between 23 and 57 years old, with a mean of 36.4 years. A minimum of 3 years between the operation and the study was selected to assess the long-term effect of the operation on the patients' quality of life and exclude any short-term impressions. The time elapsed between surgery and the time of the study ranged from 3 to 13 years, with a mean of 6.8 years. Patients were assessed using the Glasgow Benefit Inventory, which has been proven valid and reliable in ear, nose, and throat interventions. Results: From the 100 patients included in the study, 92 reported improvement in their quality of life due to the operation and only eight worsening. In the social support subscale, 97 patients reported better quality of life, and only three patients reported worse quality of life. The patients' overall life markedly improved, reaching a mean of 80% in the Glasgow Benefit Inventory. Conclusions: The present long-term study using a validated and reliable instrument concludes that rhinoplasty improves the quality of life of patients in all sectors. Level of Evidence: 2c Laryngoscope, 127:2017–2025, 2017. © 2017 The American Laryngological, Rhinological and Otological Society, Inc

Detection and Quantification of Neurotrophin-3 (NT-3) and Nerve Growth Factor (NGF) Levels in Early Second Trimester Amniotic Fluid: Investigation into a Possible Correlation with Abnormal Fetal Growth Velocity Patterns

Background: Abnormal fetal growth is associated with adverse perinatal and long-term outcomes. The pathophysiological mechanisms underlying these conditions are still to be clarified. Nerve growth factor (NGF) and neurotrophin-3 (NT-3) are two neurotrophins that are mainly involved in the neuroprotection process, namely promotion of growth and differentiation, maintenance, and survival of neurons. During pregnancy, they have been correlated with placental development and fetal growth. In this study, we aimed to determine the early 2nd trimester amniotic fluid levels of NGF and NT-3 and to investigate their association with fetal growth. Methods: This is a prospective observational study. A total of 51 amniotic fluid samples were collected from women undergoing amniocentesis early in the second trimester and were stored at −80 °C. Pregnancies were followed up until delivery and birth weight was recorded. Based on birth weight, the amniotic fluid samples were divided into three groups: appropriate for gestational age (AGA), small for gestational age (SGA), and large for gestational age (LGA). NGF and NT-3 levels were determined by using Elisa kits. Results: NGF concentrations were similar between the studied groups; median values were 10.15 pg/mL, 10.15 pg/mL, and 9.14 pg/mL in SGA, LGA, and AGA fetuses, respectively. Regarding NT-3, a trend was observed towards increased NT-3 levels as fetal growth velocity decreased; median concentrations were 11.87 pg/mL, 15.9 pg/mL, and 23.5 pg/mL in SGA, AGA, and LGA fetuses, respectively, although the differences among the three groups were not statistically significant. Conclusions: Our findings suggest that fetal growth disturbances do not induce increased or decreased production of NGF and NT-3 in early second trimester amniotic fluid. The trend observed towards increased NT-3 levels as fetal growth velocity decreased shows that there may be a compensatory mechanism in place that operates in conjunction with the brain-sparing effect. Further associations between these two neurotrophins and fetal growth disturbances are discussed