Assessment of the Placental Cord Insertion Using 3‐Dimensional Ultrasound at the Time of the Structural Fetal Survey

Objectives The influence of placental morphologic characteristics on pregnancy outcomes is poorly understood. Our objective was to evaluate the relationship of the distance of the placental cord insertion from the placental edge (PCI‐D) with associated placental characteristics as well as birth outcomes. Methods We performed a retrospective cohort study of nulliparous women with singleton gestations undergoing obstetric ultrasound examinations between 14 and 23 weeks’ gestation with a cervical length of greater than 3.0 cm who delivered between 24 and 42 weeks. A 3‐dimensional volume of the placenta was evaluated. The PCI‐D was obtained with Virtual Organ computer‐aided analysis software (GE Healthcare, Milwaukee, WI). Generalized linear regression and generalized additive models were fitted to explore the associations between the PCI‐D in relation to demographic and clinical characteristics. Results A total of 216 pregnancies were included in the analysis. The PCI‐D did not correlate with maternal age, gestational age at delivery, mode of delivery, or 5‐minute Apgar score. Although not statistically significant, the birth weight z score (P = .09) was associated with a longer PCI‐D, and gravidity was associated with a shorter PCI‐D (P = .10). A low‐lying placenta or placenta previa was associated with a longer PCI‐D (P = .03). Conclusions The PCI‐D is associated with a low placental position in the second trimester. These data are helpful for understanding placental development. The PCI‐D may be associated with pregnancy‐related factors such as birth weight and multigravidity. More research is required to evaluate the effects of pregnancy‐related factors on the PCI‐D and the effect of the PCI‐D on pregnancy outcomes

Describing Self-confidence in Ultrasound Performance with Increased Exposure

Presented as a poster at 2020 IUSM Education Day

Fatty acid metabolism disorder not found on prenatal testing

Case Description: A 26 year old G3P2001 presented for amniocentesis due to a family history of carnitine palmitoyltransferase 2 (CPTII) deficiency. Her first child developed seizures and passed away soon after birth; CPTII deficiency was diagnosed on the newborn screen. Both parents were confirmed to be carriers. For her second pregnancy, she opted against invasive testing. The newborn was treated proactively. Testing confirmed the child was not affected, and treatment was halted. In the current pregnancy, she opted for amniocentesis, which revealed an affected male. Background: CPT II deficiency is a rare autosomal recessive disease caused by a mutation in a gene encoding carnitine palmitoyltransferase 2, an essential enzyme in fatty acid oxidation. Affected patients are at risk for hypoketotic hypoglycemia, seizures, hepatomegaly, cardiomyopathy, arrhythmias, and other downstream issues. A postnatal diagnosis via the newborn screen does not confer the benefit of advanced awareness of the disease and allow for preemptive treatment. CPT II deficiency can be confirmed prenatally with diagnostic testing. Amniocentesis is an invasive test associated with a low but present risk of pregnancy loss, so some may opt against the test. Conclusion: Carriers of CPT II mutations are counseled that future pregnancies confer a 25% risk of having an affected child. Prenatal diagnostic testing is recommended for prenatal diagnosis, which allows for planning of immediate treatment in the NICU. However, opting to forgo invasive testing and preemptively treat potentially affected child until newborn screening results return, as occurred in this patient’s second pregnancy, is also an option. Clinical Significance: CPT II deficiency is a rare disease that can have devastating effects in newborns without a known diagnosis. Parents with known carrier status must be extensively counseled on their options regarding prenatal and postnatal screening as well as immediate newborn care

Audiogram of a Cook Inlet beluga whale (Delphinapterus leucas)

Author Posting. © Acoustical Society of America, 2020. This article is posted here by permission of Acoustical Society of America for personal use, not for redistribution. The definitive version was published in Journal of the Acoustical Society of America 148(5), (2020): 3141, doi:10.1121/10.0002351.Noise is a stressor to wildlife, yet the precise sound sensitivity of individuals and populations is often unknown or unmeasured. Cook Inlet, Alaska belugas (CIBs) are a critically endangered and declining marine mammal population. Anthropogenic noise is a primary threat to these animals. Auditory evoked potentials were used to measure the hearing of a wild, stranded CIB as part of its rehabilitation assessment. The beluga showed broadband (4–128 kHz) and sensitive hearing (<80 dB) for a wide-range of frequencies (16–80 kHz), reflective of a healthy odontocete auditory system. Data were similar to healthy, adult belugas from the comparative Bristol Bay population (the only other published data set of healthy, wild marine mammal hearing). Repeated October and December 2017 measurements were similar, showing continued auditory health of the animal throughout the rehabilitation period. Hearing data were compared to pile-driving and container-ship noise measurements made in Cook Inlet, two sources of concern, suggesting masking is likely at ecologically relevant distances. These data provide the first empirical hearing data for a CIB allowing for estimations of sound-sensitivity in this population. The beluga's sensitive hearing and likelihood of masking show noise is a clear concern for this population struggling to recover.The work was conducted under Permit No. MMHSRP MMPA/ESA #18786-02 to T.R. and approved via the Institute for Animal Care and Use Protocol from the Woods Hole Oceanographic Institution. This publication was partially funded by the Joint Institute for the Study of the Atmosphere and Ocean (JISAO) under NOAA Cooperative Agreement No. NA15OAR4320063.2021-05-2

Approach to Treatment of Cervical Pregnancy: A Case Report

CASE: A 25yo G1 at 11wk4d dated by LMP and confirmed with a 10 week ultrasound presents with a possible cervical ectopic pregnancy. Past medical, surgical, and OBGYN histories are unremarkable. A cervical pregnancy was suspected on ultrasound due to low implantation of the gestational sac, and a significant posterior bulge with an hourglass shaped uterus. MRI suggested implantation of the placenta in the posterior uterine and cervical wall due to extreme thinning of these structures. Our institution had previously created a protocol for multidisciplinary management of cesarean scar and cervical pregnancies. She desires fertility preservation, and so consented to combined local and systemic treatment with Methotrexate (MTX). Preprocedural Beta-hCG was 81,514.8 mU/mL. Ultrasound-guided transvaginal intra-gestational sac injection of MTX was performed without complication, though cardiac activity was still present at the conclusion of the procedure. The patient also received an IM injection of MTX before discharge. Serial Beta-hCG are still being followed, and are trending towards zero. CONCLUSION: The optimal management for cervical pregnancies is not known, and decisions around type of management are informed by the patient’s desire for fertility preservation. In this case, a protocol created by a multidisciplinary team was used to guide treatment. This protocol using MTX successfully treated the cervical pregnancy at 11wk4d and avoided a surgery that could complicate future fertility. CLINICAL SIGNIFICANCE: Due to the rare occurrence of cervical pregnancy, there is not a universally accepted treatment protocol. This case shows that medical management can be successful for cervical pregnancies. Clear guidelines must be established for cervical pregnancies to optimize outcomes, and decrease maternal morbidity and mortality and to preserve future fertility

Allies Welcomed to Advance Racial Equity (AWARE) Faculty Seminar Series: Program Design and Implementation

Introduction: In the wake of George Floyd's murder, White faculty in our department began to express the desire to gain a greater understanding of structural racism and racial inequity. To facilitate this learning, support allyship, and mitigate the emotional labor and taxation that frequently falls on faculty of color to respond to these appeals, we developed AWARE (Allies Welcomed to Advance Racial Equity), a faculty seminar series primarily designed for and led by a majority White faculty to tackle the topics of structural racism, Whiteness, and Anti-racist action. Methods: We developed a 6-session seminar series, identifying 5 White faculty as lecturers and a cadre of Black and White volunteer facilitators, to lead 60-minute sessions comprised of lecture, facilitated small group reflection, and large group sharing, that reviewed key topics/texts on structural racism, Whiteness, and Anti-racism. Results: Attendance ranged from 26 to 37 participants at each session. About 80% of faculty participated in at least 1 session of the program. The majority of participants (85%) felt "more empowered to influence their current environment to be more inclusive of others" and were "better equipped to advocate for themselves or others." Most (81%) felt "more connected to their colleagues following completion of the program." Ultimately, faculty thought highly of the program upon completion with 26/27 (96%) stating they would recommend the program to a colleague. Discussion: We offer a reproducible model to improve departmental climate by engaging in the shared labor of educating our colleagues and communities about structural racism, Whiteness, and Anti-racism to create a point of entry into reflection, dialogue, and deliberate actions for change

Barriers and facilitators to primary care research: views of GP trainees and trainers

Background: Primary care plays an important role in the conception and delivery of transformational research but GP engagement lacks, prompting calls for the promotion of academic opportunities in primary care. Aim: To identify potential barriers and facilitators amongst GP trainees and trainers in primary care research to inform support given by Local Clinical Research Networks (LCRNs). Design & setting: A cross sectional online survey was developed and distributed by the CRN to GP trainees and trainers in the North East and North West. Method: The survey covered areas including demographics, career intentions, current and potential engagement with research as well as their general understanding of research in primary care, that included barriers and facilitators to primary care research. Results: Trainees had low intentionality to pursue research and half of trainees did not engage with any research activity. Despite 1 in five trainees reporting intentions to include research in their career, only 1% would undertake a solely academic career. Medical school region is the only strongly associated factor with academic career intention. Just under 30% of trainers reported engagement in research, but far fewer (8.6%) were interested in contributing to research, and only 10% felt prepared to mentor in research. Conclusion: Among trainees, there is limited engagement in, and intentionality to pursue research and this is crucially reflected by responses from trainers. This study identifies the need for LCRN’s to assist with training in research mentoring and skills, funding opportunities and to develop resources to promote research in primary care

Postpartum endometritis and infection following incomplete or complete abortion: Case definition & guidelines for data collection, analysis, and presentation of maternal immunization safety data

Need for developing case definitions and guidelines for data collection, analysis, and presentation for postpartum endometritis and infection following incomplete or complete abortion as adverse events following maternal immunization