Volumetric Blood Flow and Assessment of the Metabolic Profile of the Developing Brain in Growth Restricted Fetuses: An Ultrasound and Proton Magnetic Resonance Spectroscopy Study

Introduction Intrauterine growth restriction (IUGR) is a common obstetric condition causing significant perinatal morbidity and mortality. A phenomenon known as brain sparing occurs in IUGR fetuses whereby blood is preferentially diverted to supply the developing brain often at the expense of other organs. However, although this supposedly neuroprotective mechanism exists, children that were growth restricted in utero have a higher incidence of long term neurodevelopmental sequelae. This thesis therefore aims to explore the brain redistribution phenomenon in detail by investigating cerebral volume blood flow and the metabolic profile of the IUGR brain using high resolution ultrasound and proton magnetic resonance spectroscopy respectively. Methods 150 appropriately grown and 78 IUGR fetuses had volume blood flow assessed longitudinally using high resolution ultrasound and power Doppler in multiple fetal vessels. The metabolic status of the brain was then assessed in 46 appropriately grown and 26 growth restricted fetuses using Proton Magnetic Resonance Spectroscopy. Results IUGR fetuses had a generalised increase in vessel diameter in comparison with appropriately grown control fetuses, and when standardised for weight, increased volume blood flow was noted in the middle cerebral, renal, umbilical and carotid arteries and the ascending aorta. No difference in flow was noted in the descending aorta. N-acetylaspartate:Choline and N-acetylaspartate:Creatine ratios were reduced in IUGR fetuses and lactate was present in the developing brains of both appropriately grown and growth restricted fetuses. Conclusions Volume blood flow is significantly altered in IUGR fetuses, likely to be mediated by alterations in vessel diameter. This may be secondary to alterations in circulating vasoactive factors or as a result in alterations of the composition of vessel walls. The metabolic status of the brain tissue is also altered which may in part explain the higher incidence of neurodevelopmental sequelae in some fetuses that were growth restricted in utero

Caring and conflicted: mothers' ethical judgements about consumption

Literature on consumer ethics tends to focus on issues within the public sphere, such as the environment, and treats other drivers of consumption decisions, such as family, as non-moral concerns. Consequently, an attitude– behaviour gap is viewed as a straightforward failure by consumers to act ethically. We argue that this is based upon a view of consumer behaviour as linear and unproblematic, and an approach to moral reasoning, arising from a stereotypically masculine understanding of morality, which foregrounds abstract principles. By demonstrating the importance of context to consumption decisions and articulating the impact of caring relationships, we highlight how such decisions are both complex and situated. This is particularly evident for decisions involving the needs of others, as occurs in family life. We argue that the incorporation of care ethics provides both theoretical insights and a more complete account of consumer ethics. This is explored empirically through an investigation of the ethical dilemmas arising from consumption decisions made by mothers of young children. Such decisions juxtapose an ethical consumption orientation (representing impartial concerns) with care for one’s child. Therefore, what has been previously considered a failure to act ethically may in fact be the outcome of complex decision making, which involves competing ethical considerations. We discuss the implications of our findings for theory and practice and how this approach to consumer ethics could be applied more widely

Preterm Premature Rupture of the Membranes (PPROM):a study of patient experiences and support needs

BackgroundPreterm prelabour rupture of membranes (PPROM) is a common obstetric condition but outcomes can vary depending on gestation. Significant maternal and fetal complications occur including preterm birth, infection, abruption, cord prolapse, pulmonary hypoplasia and even death. Although the need for psychological support is recognised it is unclear how much is actually offered to women and their families. This study aimed to survey the views of women and their families who have undergone PPROM in order to understand the care and psychological burden these families face.MethodsAn online survey was conducted, recruiting women via social media with collaboration from the patient advocacy support group Little Heartbeats. Responses were collated where fields were binary or mean and standard deviations calculated. Framework analysis was used to identify and analyse themes in free text responses. Results180 PPROM pregnancies were described from 177 respondents. Although care was variable and respondents were from across the world there were common themes. Five themes were highlighted which were: a lack of balanced information regarding the condition, support in decision making and support with the process, specific psychological support and ongoing psychological consequences of PPROM.ConclusionThis survey highlights areas in which care needs to be improved for women with PPROM. Previous studies have shown that providing good care during the antenatal period reduces long term psychological morbidity for the whole family. The need for support, with regard both to information provided to women and their families and their psychological support needs to be addressed urgently.<br/

Placental multimodal MRI prior to spontaneous preterm birth <32 weeks' gestation: An observational study

Objective: To utilise combined diffusion‐relaxation MRI techniques to interrogate antenatal changes in the placenta prior to extreme preterm birth among both women with PPROM and membranes intact, and compare this to a control group who subsequently delivered at term. Design: Observational study. Setting: Tertiary Obstetric Unit, London, UK. Population: Cases: pregnant women who subsequently spontaneously delivered a singleton pregnancy prior to 32 weeks' gestation without any other obstetric complications. Controls: pregnant women who delivered an uncomplicated pregnancy at term. Methods: All women consented to an MRI examination. A combined diffusion‐relaxation MRI of the placenta was undertaken and analysed using fractional anisotropy, a combined T2*‐apparent diffusion coefficient model and a combined T2*‐intravoxel incoherent motion model, in order to provide a detailed placental phenotype associated with preterm birth. Subgroup analyses based on whether women in the case group had PPROM or intact membranes at time of scan, and on latency to delivery were performed. Main Outcome Measures: Fractional anisotropy, apparent diffusion coefficients and T2* placental values, from two models including a combined T2*‐IVIM model separating fast‐ and slow‐flowing (perfusing and diffusing) compartments. Results: This study included 23 women who delivered preterm and 52 women who delivered at term. Placental T2* was lower in the T2*‐apparent diffusion coefficient model (p < 0.001) and in the fast‐ and slow‐flowing compartments (p = 0.001 and p < 0.001) of the T2*‐IVIM model. This reached a higher level of significance in the preterm prelabour rupture of the membranes group than in the membranes intact group. There was a reduced perfusion fraction among the cases with impending delivery. Conclusions: Placental diffusion‐relaxation reveals significant changes in the placenta prior to preterm birth with greater effect noted in cases of preterm prelabour rupture of the membranes. Application of this technique may allow clinically valuable interrogation of histopathological changes before preterm birth. In turn, this could facilitate more accurate antenatal prediction of preterm chorioamnionitis and so aid decisions around the safest time of delivery. Furthermore, this technique provides a research tool to improve understanding of the pathological mechanisms associated with preterm birth in vivo