Effect of maternal corticosteroid provision on middle cerebral artery peak systolic velocity readings in the potentially anaemic fetus prior to planned intrauterine transfusion

Purpose: Middle Cerebral Artery Peak Systolic Velocity (MCA-PSV) is the main tool for determining need for and timing of intrauterine transfusions (IUT) for severe fetal anaemia. It has been suggested that steroids temporarily decrease MCA-PSV, potentially increasing false-negative MCA-PSV findings in anaemic fetuses. We therefore aimed to assess whether maternal corticosteroid administration prior to IUT is associated with clinically significant temporary decreases in MCA-PSV. Methods: Retrospective review 2005–2016 of steroid provision prior to IUT, with correlation of MCA-PSV pre- and post-steroid administration and haemoglobin at IUT. Results: In 23 identified cases, there was no significant difference between average MoM pre- and post-steroid (1.71 ± 0.41 vs. 1.66 ± 0.38, −2.9% mean, P = 0.4). There was also no significant difference between pre- and post-steroid MoM taken within 3 days of each other (n = 19, P = 0.21). However, post-steroid MCA-PSV decreased by >15% in 6/23 cases (A-B zone in two cases, B-C zone in one case). Conclusions: This study found no sizeable, generalised effect of corticosteroid administration on MCA-PSV readings in the potentially anaemic fetus. A minority showed substantial shifts where reliance on post-steroid MCA-PSV could have unfavourably altered clinical management. Ultimately, further large-scale research is required before we can discount the potential impact of steroids on MCA-PSV values

Short-term outcomes following intrauterine transfusions for fetal anaemia: A retrospective cohort study

Background: Intrauterine transfusion (IUT) is the accepted standard for management of severe fetal anaemia. However, fetal transfusion may be associated with procedural complications such as fetal demise. There is a paucity of recent data on outcomes for severe fetal anaemia in Australia as compared with published outcomes from large international centres. Aims: To review the indications for and the procedural, obstetric and neonatal outcomes following intrauterine transfusion for fetal anaemia conducted at the New South Wales Fetal Therapy Centre (NSW FTC). Materials and Methods: Retrospective cohort study conducted between 2005 and 2017 of the outcomes of 85 IUT procedures (39 pregnancies). Data collected included maternal demographics, procedural and obstetric details and short-term neonatal outcomes. Results: Complete outcome data were available for 36/39 pregnancies. Red cell antibodies were the main indication for fetal transfusion (79%, predominantly D, Kell and other Rhesus antibodies) with parvovirus accounting for 8% of procedures. IUT was associated with a pregnancy loss rate of 1.2%/procedure, amounting to 2.6%/pregnancy. Fetal losses were limited to those complicated by hydrops prior to IUT (3/10 hydrops vs 0/26 non-hydropic; P = 0.003). Conclusions: Procedural outcomes at NSW FTC compare favourably with international centres (1.1–8.7% procedural loss rate). However, this comparison is limited, as no procedures were performed during the last 24 months of the study. Given this, a nationwide audit is recommended to help guide appropriate centralisation of procedures and thereby maximise clinician experience and outcome

Isolated ‘soft signs’ of fetal choroid plexus cysts or echogenic intracardiac focus – consequences of their continued reporting

BACKGROUND: Choroid plexus cysts (CPC) and echogenic intracardiac focus (EIF) are obsolete soft markers found on morphology ultrasound and not a valid reason for adjusting fetal risk of aneuploidy. METHOD: We conducted a retrospective audit of women referred to genetic counsellor and fetal medicine services at St George Hospital (SGH) and the Royal Hospital for Women (RHW) for CPC and EIF from 1 January 2006 to 31 December 2016 inclusive. RESULTS: In total, 208 CPC and/or EIF referrals were identified, 118 (57%) of which were for isolated CPC and/or EIF and 102 (49%) occurring in women low risk for aneuploidy prior to morphology ultrasound. Significantly, more women had undergone combined first-trimester screening in the 2014 to 2016 epoch vs. previous years at both SGH (P = 0.03) and RHW (P = 0.004). However, the number of women referred for CPC and EIF remained relatively constant. No fetus was born with a major structural or chromosomal abnormality in the group of low-risk women with isolated signs. However, 18% of these women were referred to both genetic counselling and fetal medicine services, 7% had NIPT after morphology, 14% had amniocentesis, and 33% had additional ultrasound(s). CONCLUSION: Despite advances in screening technology, low-risk women are still referred to specialist services for these 2 soft signs and undergoing unnecessary follow-up, NIPT and amniocentesis

On the Dynamics of Comets in Extrasolar Planetary Systems

Since very recently, we acquired knowledge on the existence of comets in extrasolar planetary systems. The formation of comets together with planets around host stars now seems evident. As stars are often born in clusters of interstellar clouds, the interaction between the systems will lead to the exchange of material at the edge of the clouds. Therefore, almost every planetary system should have leftover remnants as a result of planetary formation in form of comets at the edges of those systems. These Oort clouds around stars are often disturbed by different processes (e.g., galactic tides, passing stars, etc.), which consequently scatter bodies from the distant clouds into the system close to the host star. Regarding the Solar System, we observe this outcome in the form of cometary families. This knowledge supports the assumption of the existence of comets around other stars. In the present work, we study the orbital dynamics of hypothetical exocomets, based on detailed computer simulations, in three star-planet systems, which are: HD~10180, 47~UMa, and HD~141399. These systems host one or more Jupiter-like planets, which change the orbits of the incoming comets in characteristic ways

Oral glucose tolerance test and continuous glucose monitoring for gestational diabetes diagnosis: a survey study of women and health care professionals

Aims: The oral glucose tolerance test (OGTT), used for gestational diabetes mellitus (GDM) diagnosis for over 65 years, has poor acceptability and tolerability. Continuous glucose monitoring is being considered as potential alternative. The aim of our study was to formally assess women’s and health care professionals’ perception of both tests as diagnostic tools for GDM. Methods: Participants in a pilot study on continuous glucose monitoring for GDM diagnosis were invited to fill two questionnaires, each of 6 Likert-scale and one optional open-ended question. A range of healthcare practitioners were also invited to fill a questionnaire of 13 Likert-scale and 7 optional open-ended questions. Results: Sixty women completed the OGTT and 70 the continuous glucose monitoring questionnaire. OGTT was reported as poorly acceptable. Continuous glucose monitoring was described as significantly more tolerable (81% vs 27% 5/5 general acceptability rate, p < 0.001); ninety-three percent of the participants would recommend it for GDM diagnosis. Thirty health care professionals completed the survey. Most of them (73%) had confidence in OGTT as a diagnostic test for GDM with 66% raising some concerns. Doubts on continuous glucose monitoring were raised in terms of costs, accessibility and accuracy for GDM diagnosis due to “lack of evidence”. Conclusions: Continuous glucose monitoring was substantially better tolerated for women than OGTT. Current lack of evidence for diagnostic accuracy for GDM underlines the need for studies on correlation between continuous glucose monitoring parameters and pregnancy outcomes to strengthen evidence for its use as diagnostic test for GDM

Fetal abdominal wall defects in an Australian tertiary setting: contemporary characteristics, ultrasound accuracy, and outcome

Purpose: In this study, we aimed to comprehensively evaluate risk factors, ultrasound estimation of fetal weight, prenatal management, and pregnancy outcomes of gastroschisis and omphalocele at a metropolitan Australian hospital. Material and methods: This was a retrospective single-center cohort study from 2006 to 2014 at a tertiary hospital with colocated neonatal surgical facilities. Demographic, pregnancy, ultrasound, birth and neonatal data were compared between gastroschisis and omphalocele. Correlation between routine (Hadlock 1 &2) and specific (Siemer) estimated fetal weight (EFW) estimation formulae with birth weight (BW) was made for those 50 gastroschisis cases with ≥2 third trimester scans and last scan ≤2 weeks prior to birth. Results: There were 126 abdominal wall defects: 83 gastroschisis and 43 omphalocele. Consistent with international literature, the average maternal age was lower for gastroschisis and rates of smoking higher, while there were more intrauterine deaths and pregnancy terminations in omphalocele. Gastroschisis mothers were more likely living outside Sydney, had more infections in pregnancy and were followed with a larger number of antenatal visits, with a shorter period from the last visit to birth. In omphalocele pregnancies, amniocentesis was more likely performed, with more abnormal results than in gastroschisis fetuses. All EFW formulae had a good correlation between Z score for the last US and actual BW (ICC 0.693–0.815), with Hadlock 2 being the best. Siemer formula had the best correlation from first to the last scan. Gastroschisis newborns were born earlier (36.8 versus 38.2 wks p =.001), with smaller birthweight (2.52 versus 3.03 kg, p <.001), a longer request of intensive care (central line, parenteral nutrition, intubation) and second surgery, along with more multisystem complications (average 1.5 versus 0.7, p =.004) and a longer hospital stay (58.8 versus 36.8 d, p <.001). Conclusion: Demographic, antenatal, and pregnancy outcome data for abdominal wall defects correlated well with the international literature. Hadlock 1–2 gave the most consistent EFW estimate, with all formulae showing good correlation

Planetary systems around close binary stars: the case of the very dusty, Sun-like, spectroscopic binary BD+20 307

Field star BD+20 307 is the dustiest known main sequence star, based on the fraction of its bolometric luminosity, 4%, that is emitted at infrared wavelengths. The particles that carry this large IR luminosity are unusually warm, comparable to the temperature of the zodiacal dust in the solar system, and their existence is likely to be a consequence of a fairly recent collision of large objects such as planets or planetary embryos. Thus, the age of BD+20 307 is potentially of interest in constraining the era of terrestrial planet formation. The present project was initiated with an attempt to derive this age using the Chandra X-ray Observatory to measure the X-ray flux of BD+20 307 in conjunction with extensive photometric and spectroscopic monitoring observations from Fairborn Observatory. However, the recent realization that BD+20 307 is a short period, double-line, spectroscopic binary whose components have very different lithium abundances, vitiates standard methods of age determination. We find the system to be metal-poor; this, combined with its measured lithium abundances, indicates that BD+20 307 may be several to many Gyr old. BD+20 307 affords astronomy a rare peek into a mature planetary system in orbit around a close binary star (because such systems are not amenable to study by the precision radial velocity technique).Comment: accepted for ApJ, December 10, 200

Development and evaluation of an online questionnaire to identify women at high and low risk of developing gestational diabetes mellitus

Background: Established risk factors for Gestational Diabetes Mellitus (GDM) include age, ethnicity, family history of diabetes and previous GDM. Additional significant influences have recently been demonstrated in the literature. The oral glucose tolerance test (OGTT) used for GDM diagnosis has sub-optimal sensitivity and specificity, thus often results in GDM misdiagnoses. Comprehensive screening of risk factors may allow more targeted monitoring and more accurate diagnoses, preventing the devastating consequences of untreated or misdiagnosed GDM. We aimed to develop a comprehensive online questionnaire of GDM risk factors and triangulate it with the OGTT and continuous glucose monitoring (CGM) parameters to better evaluate GDM risk and diagnosis. Methods: Pregnant women participating in two studies on the use of CGM for GDM were invited to complete the online questionnaire. A risk score, based on published literature, was calculated for each participant response and compared with the OGTT result. A total risk score (TRS) was then calculated as a normalised sum of all risk factors. Triangulation of OGTT, TRS and CGM score of variability (CGMSV) was analysed to expand evaluation of OGTT results. Results: Fifty one women completed the questionnaire; 29 were identified as ‘high-risk’ for GDM. High-risk ethnic background (p < 0.01), advanced age, a family diabetic history (p < 0.05) were associated with a positive OGTT result. The triangulation analysis (n = 45) revealed six (13%) probable misdiagnoses (both TRS and CGMSV discordant with OGTT), consisting of one probable false positive and five probable false negative by OGTT results. Conclusions: This study identified pregnant women at high risk of developing GDM based on an extended evaluation of risk factors. Triangulation of TRS, OGTT and CGMSV suggested potential misdiagnoses of the OGTT. Future studies to explore the correlation between TRS, CGMSV and pregnancy outcomes as well as additional GDM pregnancy biomarkers and outcomes to efficiently evaluate OGTT results are needed

A new continuous glucose monitor for the diagnosis of gestational diabetes mellitus: a pilot study

Background: Gestational Diabetes Mellitus (GDM) incidence and adverse outcomes have increased globally. The validity of the oral glucose tolerance test (OGTT) for GDM diagnosis has long been questioned, with no suitable substitute reported yet. Continuous Glucose Monitoring (CGM) is potentially a more acceptable and comprehensive test. The aim of this study was to assess the Freestyle Libre Pro 2 acceptability as a diagnostic test for GDM, then triangulating its results with OGTT results as well as risk factors and sonographic features of GDM. Methods: Women wore the CGM device for 7 days at 24–28 weeks, undergoing the OGTT before CGM removal. CGM/OGTT acceptability as well as GDM risk factors evaluation occurred via three online surveys. CGM distribution/variability/time in range parameters, combined in a CGM Score of Variability (CGMSV), were triangulated with OGTT results and a risk-factor-based Total Risk Score (TRS). In a subgroup, GDM ultrasound features (as modified Ultrasound Gestational Diabetes Score – m-UGDS) were also incorporated. Results: Of 107 women recruited, 87 (81%) were included: 74 (85%) with negative OGTT (NGT) and 13 (15%) positive (GDM). No significant difference was found between NGT and GDM in terms of demographics (apart from family history of diabetes mellitus), CGM parameters and perinatal outcomes. Women considered CGM significantly more acceptable than OGTT (81% versus 27% rating 5/5, p < 0.001). Of the 55 NGT with triangulation data, 28 were considered ‘true negative’ (TRS concordant with OGTT and CGMSV): of these 4/5 evaluated at ultrasound had m-UGDS below the cut-off. Five women were considered ‘false negative’ (negative OGTT with both TRS and CGMSV above the respective cut-offs). Triangulation identified also six ‘false positive’ women (positive OGTT but TRS and CGM both below the cut-offs). Only one woman for each of the last two categories had m-UGDS evaluated, with discordant results. Conclusions: CGM represents a more acceptable alternative for GDM diagnosis to the OGTT. CGM triangulation analysis suggests OGTT screening may result in both false positives and negatives. Further research including larger cohorts of patients, and additional triangulation elements (such as GDM biomarkers/outcomes and expanded m-UGDS) is needed to explore CGM potential for GDM diagnosis

Continuous Glucose Monitoring for the Diagnosis of Gestational Diabetes Mellitus: A Pilot Study

Background. Gestational diabetes mellitus (GDM) is diabetes first diagnosed in pregnancy. GDM, together with its short- A nd long-term negative outcomes, is increasing in incidence all over the world. The current diagnostic method for GDM, the oral glucose tolerance test (OGTT), is dated and has been reported as inconvenient for women as well as poorly reproducible and reliable. Aims. We aimed at assessing the acceptability, feasibility, and accuracy of continuous glucose monitoring (CGM) as a diagnostic test for GDM and explore its correlation with the OGTT and risk factors for GDM. Methods. In this prospective cohort study, pregnant women due for or having completed OGTT underwent CGM for seven days, performing daily finger-prick blood glucose levels before completing an acceptability questionnaire. Data on GDM risk factors and CGM variability were analyzed and compared with OGTT results. Results. Seventy-three women completed CGM (40 GDM, 33 normal glucose tolerances); 34 concurrently underwent OGTT. CGM was acceptable and generally well-tolerated, with skin irritation/itchiness the only adverse event (11 mild, one severe). CGM and OGTT strongly correlated for fasting glucose values (r=0.86, p<0.05) only. Triangulating GDM risk factors, OGTT results and CGM variability parameters with the application of machine learning highlighted the possibility of unmasking false positive (11 showed low CGM variability and demographic risks but positive OGTT) and false-negative OGTT diagnoses (1 showed high CGM variability and demographic risks but negative OGTT). Conclusions. CGM was well-tolerated, showing poorer glycaemic control in GDM, and revealing potential misdiagnosis of the OGTT when combined with GDM risk factors. Future research is needed to determine cut-off values for CGM-defined and OGTT-independent screening criteria for GDM