Diagnosis of Pregnancy Complications Using Blind Ultrasound Sweeps Performed by Individuals Without Prior Formal Ultrasound Training.

OBJECTIVE: To estimate the diagnostic accuracy of blind ultrasound sweeps performed with a low-cost, portable ultrasound system by individuals with no prior formal ultrasound training to diagnose common pregnancy complications. METHODS: This is a single-center, prospective cohort study conducted from October 2020 to January 2022 among people with second- and third-trimester pregnancies. Nonspecialists with no prior formal ultrasound training underwent a brief training on a simple eight-step approach to performing a limited obstetric ultrasound examination that uses blind sweeps of a portable ultrasound probe based on external body landmarks. The sweeps were interpreted by five blinded maternal-fetal medicine subspecialists. Sensitivity, specificity, and positive and negative predictive values for blinded ultrasound sweep identification of pregnancy complications (fetal malpresentation, multiple gestations, placenta previa, and abnormal amniotic fluid volume) were compared with a reference standard ultrasonogram as the primary analysis. Kappa for agreement was also assessed. RESULTS: Trainees performed 194 blinded ultrasound examinations on 168 unique pregnant people (248 fetuses) at a mean of 28±5.85 weeks of gestation for a total of 1,552 blinded sweep cine clips. There were 49 ultrasonograms with normal results (control group) and 145 ultrasonograms with abnormal results with known pregnancy complications. In this cohort, the sensitivity for detecting a prespecified pregnancy complication was 91.7% (95% CI 87.2-96.2%) overall, with the highest detection rate for multiple gestations (100%, 95% CI 100-100%) and noncephalic presentation (91.8%, 95% CI 86.4-97.3%). There was high negative predictive value for placenta previa (96.1%, 95% CI 93.5-98.8%) and abnormal amniotic fluid volume (89.5%, 95% CI 85.3-93.6%). There was also substantial to perfect mean agreement for these same outcomes (range 87-99.6% agreement, Cohen κ range 0.59-0.91, P<.001 for all). CONCLUSION: Blind ultrasound sweeps of the gravid abdomen guided by an eight-step protocol using only external anatomic landmarks and performed by previously untrained operators with a low-cost, portable, battery-powered device had excellent sensitivity and specificity for high-risk pregnancy complications such as malpresentation, placenta previa, multiple gestations, and abnormal amniotic fluid volume, similar to results of a diagnostic ultrasound examination using a trained ultrasonographer and standard-of-care ultrasound machine. This approach has the potential to improve access to obstetric ultrasonography globally.

Assessment of a Brief Standardized Obstetric Ultrasound Training Program for Individuals Without Prior Ultrasound Experience.

ABSTRACT: Obstetric volume sweep imaging (OB VSI) is a simple set of transducer movements guided by external body landmarks that can be taught to ultrasound-naive non-experts. This approach can increase access to ultrasound in rural/low-resources settings lacking trained sonographers. This study presents and evaluates a training program for OB VSI. Six trainees without previous formal ultrasound experience received a training program on the OB VSI protocol containing focused didactics and supervised live hands-on ultrasound scanning practice. Trainees then independently performed 194 OB VSI examinations on pregnancies >14 weeks with known prenatal ultrasound abnormalities. Images were reviewed by maternal-fetal medicine specialists for the primary outcome (protocol deviation rates) and secondary outcomes (examination quality and image quality). Protocol deviation was present in 25.8% of cases, but only 7.7% of these errors affected the diagnostic potential of the ultrasound. Error rate differences between trainees ranged from 8.6% to 53.8% ( P < 0.0001). Image quality was excellent or acceptable in 88.2%, and 96.4% had image quality capable of yielding a diagnostic interpretation. The frequency of protocol deviations decreased over time in the majority of trainees, demonstrating retention of training program over time. This brief OB VSI training program for ultrasound-naive non-experts yielded operators capable of producing high-quality images capable of diagnostic interpretation after 3 hours of training. This training program could be adapted for use by local community members in low-resource/rural settings to increase access to obstetric ultrasound.

No sonographer, no radiologist: New system for automatic prenatal detection of fetal biometry, fetal presentation, and placental location.

Ultrasound imaging is a vital component of high-quality Obstetric care. In rural and under-resourced communities, the scarcity of ultrasound imaging results in a considerable gap in the healthcare of pregnant mothers. To increase access to ultrasound in these communities, we developed a new automated diagnostic framework operated without an experienced sonographer or interpreting provider for assessment of fetal biometric measurements, fetal presentation, and placental position. This approach involves the use of a standardized volume sweep imaging (VSI) protocol based solely on external body landmarks to obtain imaging without an experienced sonographer and application of a deep learning algorithm (U-Net) for diagnostic assessment without a radiologist. Obstetric VSI ultrasound examinations were performed in Peru by an ultrasound operator with no previous ultrasound experience who underwent 8 hours of training on a standard protocol. The U-Net was trained to automatically segment the fetal head and placental location from the VSI ultrasound acquisitions to subsequently evaluate fetal biometry, fetal presentation, and placental position. In comparison to diagnostic interpretation of VSI acquisitions by a specialist, the U-Net model showed 100% agreement for fetal presentation (Cohen's κ 1 (p<0.0001)) and 76.7% agreement for placental location (Cohen's κ 0.59 (p<0.0001)). This corresponded to 100% sensitivity and specificity for fetal presentation and 87.5% sensitivity and 85.7% specificity for anterior placental location. The method also achieved a low relative error of 5.6% for biparietal diameter and 7.9% for head circumference. Biometry measurements corresponded to estimated gestational age within 2 weeks of those assigned by standard of care examination with up to 89% accuracy. This system could be deployed in rural and underserved areas to provide vital information about a pregnancy without a trained sonographer or interpreting provider. The resulting increased access to ultrasound imaging and diagnosis could improve disparities in healthcare delivery in under-resourced areas.

Stillbirth in women with diabetes: a retrospective analysis of fetal autopsy reports.

INTRODUCTION: Diabetes in pregnancy is associated with an increased rate of stillbirth. There are a wide variety of factors that have been implicated including placental insufficiency, hypoxia, hyperinsulinemia and impaired cardiac function. Furthermore, there is evidence that diabetic pregnancies have an increased rate of fetal cardiomyopathy as compared to non-diabetic pregnancies. Prior studies have indicated that this association can also be an etiology for diabetic stillbirth. The purpose of this study was to determine if diabetic pregnancies have an increased risk of fetal cardiomyopathy identified on fetal autopsy as compared to non-diabetic women with a stillbirth in a cohort of pregnancies that had evaluation with a fetal autopsy. MATERIALS AND METHODS: Retrospective cohort study of women with a stillbirth who consented to fetal autopsy at an academic medical center from 2011 to 2017. Stillbirth was defined as an intrauterine fetal demise at ≥20 weeks' gestation. Women with diabetes defined as pre-gestational diabetes type 1, pre-gestational diabetes type 2, and gestational diabetes were compared to women without diabetes. Primary outcome was fetal cardiomyopathy. Other etiologies for stillbirth were also evaluated and classified according to the Stillbirth Collaborative Research Network (SCRN) initial causes of fetal death. Fisher exact test, χ2 test, and Mann Whitney U tests were performed as appropriate, with p < .05 considered significant. Generalized linear models were performed for fetal organ weights controlling for gestational age of delivery, maternal chronic hypertension, delivery body mass index, and birthweight. RESULTS: A total of 78 women elected to have fetal autopsy examinations during the study period. Of these, 75 had complete information available for review. A total of 60 women did not have diabetes and 15 women had diabetes. Of pregnancies complicated by diabetes, 11 had insulin dependent diabetes and 4 had non-insulin dependent diabetes. Fetal cardiomyopathy was diagnosed on autopsy for 7 (46.7%) of pregnancies with diabetes and 2 (3.3% of pregnancies without diabetes (RR 14.00 [95% CI 3.23-60.65], p < .001). These associations were still significant even when analyzing only those pregnancies without fetal congenital heart disease (7 [46.7%] diabetic pregnancies with cardiomyopathy versus 1 [2.0%] nondiabetic pregnancy with cardiomyopathy, RR 23.80 [95% CI 3.17-178.46], p < .001). There was no difference between diabetic and non-diabetic pregnancies in regards to other causes for stillbirth. Stillbirths in pregnancies with diabetes also had larger fetal heart, liver, and adrenal weights on fetal autopsy. CONCLUSION: Women with diabetes have 14 times the risk of fetal cardiomyopathy identified at fetal autopsy as compared to women without diabetes. As the prediction and prevention of diabetic stillbirth is limited, information on potential causes of stillbirth may help future research identify those pregnancies at the greatest risk for adverse outcome.

Testing telediagnostic obstetric ultrasound in Peru: a new horizon in expanding access to prenatal ultrasound.

BACKGROUND: Ninety-four percent of all maternal deaths occur in low- and middle-income countries, and the majority are preventable. Access to quality Obstetric ultrasound can identify some complications leading to maternal and neonatal/perinatal mortality or morbidity and may allow timely referral to higher-resource centers. However, there are significant global inequalities in access to imaging and many challenges to deploying ultrasound to rural areas. In this study, we tested a novel, innovative Obstetric telediagnostic ultrasound system in which the imaging acquisitions are obtained by an operator without prior ultrasound experience using simple scan protocols based only on external body landmarks and uploaded using low-bandwidth internet for asynchronous remote interpretation by an off-site specialist. METHODS: This is a single-center pilot study. A nurse and care technician underwent 8 h of training on the telediagnostic system. Subsequently, 126 patients (68 second trimester and 58 third trimester) were recruited at a health center in Lima, Peru and scanned by these ultrasound-naïve operators. The imaging acquisitions were uploaded by the telemedicine platform and interpreted remotely in the United States. Comparison of telediagnostic imaging was made to a concurrently performed standard of care ultrasound obtained and interpreted by an experienced attending radiologist. Cohen's Kappa was used to test agreement between categorical variables. Intraclass correlation and Bland-Altman plots were used to test agreement between continuous variables. RESULTS: Obstetric ultrasound telediagnosis showed excellent agreement with standard of care ultrasound allowing the identification of number of fetuses (100% agreement), fetal presentation (95.8% agreement, κ =0.78 (p < 0.0001)), placental location (85.6% agreement, κ =0.74 (p < 0.0001)), and assessment of normal/abnormal amniotic fluid volume (99.2% agreement) with sensitivity and specificity > 95% for all variables. Intraclass correlation was good or excellent for all fetal biometric measurements (0.81-0.95). The majority (88.5%) of second trimester ultrasound exam biometry measurements produced dating within 14 days of standard of care ultrasound. CONCLUSION: This Obstetric ultrasound telediagnostic system is a promising means to increase access to diagnostic Obstetric ultrasound in low-resource settings. The telediagnostic system demonstrated excellent agreement with standard of care ultrasound. Fetal biometric measurements were acceptable for use in the detection of gross discrepancies in fetal size requiring further follow up.

Improved Recognition of Maternal Deaths Using Modern Data Analytics.

OBJECTIVE: To use a data-fusion approach to improve ascertainment of maternal deaths not detected with standard surveillance strategies. METHODS: We conducted a retrospective cohort study from the electronic health records of a tertiary medical center from 2011 to 2018. Cases of maternal death were identified in two ways: 1) using a standard medical informatics service query of hospital data and 2) using the TriNetX discovery tool as patients with a vital status of "deceased" and evidence of antecedent pregnancy exposure based on such factors as obstetric diagnostic codes or obstetric-related procedures. Potential cases of maternal death identified by the latter method underwent chart review to confirm timing of death compared with timing of last appreciable pregnancy, and to characterize the details of these deaths. The primary outcome was pregnancy-associated mortality during pregnancy or within the first postpartum year in the discovery cohort compared with the hospital-identified cohort. Secondary outcomes included causes of death and comorbidities. RESULTS: During the study period, the standard service query identified 23 maternal deaths. The discovery tool identified 18 additional patients confirmed on subsequent chart review to represent pregnancy-associated deaths, a 78% increase in ascertainment of which a greater proportion represented postpartum deaths. The majority (61%) of newly ascertained mortalities were related to cardiac causes or other medical comorbidities. Although many hospital-ascertained cases were associated with deaths after delivery of a living newborn, more deaths after early pregnancy loss or termination were identified through the discovery tool. CONCLUSION: Improved recognition of pregnancy-associated deaths can be achieved with modern data analytics.

Maternal Marijuana Exposure and Birth Weight: An Observational Study Surrounding Recreational Marijuana Legalization.

OBJECTIVE: This study aimed to study the relationship between prenatal marijuana and infant birth weight using natural cohorts established before, during and after the 20-month lapse between legalization and legal recreational sales in Washington State. STUDY DESIGN: Over 5 years, 5,343 pregnant women with documented urine drug screen (UDS) results delivered at Tacoma General Hospital or Good Samaritan Hospital. Maternal medical data were extracted for three delivery cohorts established based on before (T1), during (T2), and after legalization (T3) of recreational marijuana and legalized availability. Univariate and multivariate models were created to study marijuana exposure on infants' birth weight. RESULTS: Marijuana exposure increased the risk of low birth weight (LBW; odds ratio [OR] = 1.42, 95% confidence interval [CI]: 1.01-2.01). This was more pronounced in full-term babies (OR = 1.72, 95% CI: 1.10-2.69), and was independently associated with a higher risk for small for gestational age (SGA; OR = 1.51, 95% CI: 1.49-1.53). The associations between marijuana exposure and SGA were maintained in cohort-specific models (OR = 1.53, 95% CI: 1.01-2.32 for T2, and OR = 1.43, 95% CI: 1.01-2.02 for T3, respectively). CONCLUSION: Marijuana exposure verified by UDS was associated with LBW and SGA. However, recreational marijuana legalization and availability did not have direct impact on newborns' risk of LBW or SGA.

New Ultrasound Telediagnostic System for Low-Resource Areas: Pilot Results From Peru.

Billions of people around the world lack access to diagnostic imaging. To address this issue, we piloted a comprehensive ultrasound telediagnostic system, which uses ultrasound volume sweep imaging (VSI) acquisitions capable of being performed by operators without prior traditional ultrasound training and new telemedicine software capable of sending imaging acquisitions asynchronously over low Internet bandwidth for remote interpretation. The telediagnostic system was tested with obstetric, right upper quadrant abdominal, and thyroid volume sweep imaging protocols in Peru. Scans obtained by operators without prior ultrasound experience were sent for remote interpretation by specialists using the telemedicine platform. Scans obtained allowed visualization of the target region in 96% of cases with diagnostic imaging quality. This telediagnostic system shows promise in improving health care disparities in the developing world.

Demographic Discrepancies in Prenatal Urine Drug Screening in Washington State Surrounding Recreational Marijuana Legalization and Accessibility.

OBJECTIVES: This study evaluated demographic patterns related to prenatal cannabinoid urine drug screening (UDS) over a 5-year period during which recreational marijuana was legalized and became accessible in Washington State. METHODS: Using electronic health record data, we performed a retrospective analysis for deliveries occurring over a 5-year period that encapsulated the transitions to marijuana legalization and legal access. For three cohorts of women delivering prior to legalization, between legalization and accessibility, and following accessibility, the UDS completion rate and screening demographic characteristics were assessed using Chi-squared tests and multivariate logistic regression. RESULTS: 25,514 deliveries occurred between March 2011 and March 2016. A significantly higher percentage of women underwent UDS post-accessibility (24.5%) compared to pre-legalization (20.0%, p < 0.001). A corresponding increase was not observed in the percentage of marijuana-positive UDS in tested patients (22.7% vs. 23.3%, p = 0.86). African American women had 2.8 times higher odds than Latinas of being tested, 2.1 times higher odds than Asian women, 1.7 times higher odds than White women, and 1.4 times higher odds than women of other races (all p < 0.001). Subsidized insurance status was also strongly associated with increased likelihood of testing (aOR = 3.5, p < 0.001). CONCLUSIONS FOR PRACTICE: Prenatal UDS testing patterns changed as recreational marijuana possession and accessibility became legal. Demographic discrepancies in testing reveal biases related to race and insurance status, which may be a proxy for socioeconomic status. As such discrepancies are potential contributors to health outcome disparities, it is important for providers and health care systems to examine their practices and ensure they are being appropriately, equally, and justly applied.

North American Fetal Therapy Network: Timing of and indications for delivery following laser ablation for twin-twin transfusion syndrome.

Background: Despite improvements in fetal survival for pregnancies affected by twin-twin transfusion syndrome since the introduction of laser photocoagulation, prematurity remains a major source of neonatal morbidity and mortality. Objective: To investigate the indications and factors influencing the timing of delivery following laser treatment, we collected delivery information regarding twin-twin transfusion syndrome cases in a large multicenter cohort. Study Design: Eleven North American Fetal Therapy Network (NAFTNet) centers conducted a retrospective review of twin-twin transfusion syndrome patients who underwent laser photocoagulation. Clinical, demographic and ultrasound variables including twin-twin transfusion syndrome stage, and gestational age at treatment and delivery were recorded. Primary and secondary maternal and fetal indications for delivery were identified. Univariate analysis was used to select candidate variables with significant correlation with latency and GA at delivery. Multivariable Cox regression with competing risk analysis was utilized to determine the independent associations. Results: A total of 847 pregnancies were analyzed. After laser, the average latency to delivery was 10.11 ± 4.8 weeks and the mean gestational age at delivery was 30.7 ± 4.5 weeks. Primary maternal indications for delivery comprised 79% of cases. The leading indications included spontaneous labor (46.8%), premature rupture of membranes (17.1%), and placental abruption (8.4%). Primary fetal indications accounted for 21% of cases and the most frequent indications included donor non-reassuring status (20.5%), abnormal donor Dopplers (15.1%), and donor growth restriction (14.5%). The most common secondary indications for delivery were premature rupture of membranes, spontaneous labor and donor growth restriction. Multivariate modeling found gestational age at diagnosis, stage, history of prior amnioreduction, cerclage, interwin membrane disruption, procedure complications and chorioamniotic membrane separation as predictors for both gestational age at delivery and latency. Conclusion: Premature delivery after laser therapy for twin-twin transfusion syndrome is primarily due to spontaneous labor, preterm premature rupture of membranes and non-reassuring status of the donor fetus. Placental abruption was found to be a frequent complication resulting in early delivery. Future research should be directed toward the goal of prolonging gestation after laser photocoagulation to further reduce morbidity and mortality associated with twin-twin transfusion syndrome.

Prenatal Prediction of Difficult Intubation in Periviable Neonates Using Standard Fetal Biometric Parameters.

OBJECTIVE: To assess whether standard fetal biometric parameters can be used to predict difficult intubations in periviable neonates undergoing resuscitation. STUDY DESIGN: This is a retrospective case-control study of periviable neonates delivered at 23 to 256/7 weeks at an academic hospital during a 5-year period in whom intubation was attempted. Standard fetal biometric measurements were included if they were taken within 7 days of delivery. Primary outcome was intubation in one attempt and was compared with more than one attempt. Data were also collected for fetal gestational age at delivery, neonatal birth weight, estimated fetal weight, head circumference, biparietal diameter, and abdominal circumference. Parametric and nonparametric statistical tests used p < 0.05 as significant. RESULTS: In total, 93 neonates met the inclusion criteria. The mean estimated fetal weight was 675 g (standard deviation [SD] ± 140), and the mean neonatal birth weight was 706 g (SD ± 151). The median interval between fetal ultrasound and delivery was 3 days (range: 0-7 days). A total of 45 neonates (48.3%) required more than one intubation attempt. The median number of intubation attempts was 1 (range: 1-10). There was no association between intubation difficulty and fetal abdominal circumference, biparietal diameter, head circumference, gestational age, estimated fetal weight, and neonatal birth weight (all p > 0.05). CONCLUSION: Standard biometry in periviable neonates does not predict intubation difficulty.

The transitional phase of ductus venosus reversed flow in severely premature IUGR fetuses.

The guiding hypothesis for this work is that in severe intrauterine growth-restricted (IUGR) fetuses, the time from ductus venosus (DV) reversed flow (RF) appearance to intrauterine fetal demise (IUFD) or nonreassuring fetal testing is variable. As such, there must be a transitional phase between the presence of end-diastolic forward flow (FF) and absent or reversed end-diastolic flow (A/REDF). Ductus venosus Doppler was serially studied in 19 IUGR fetuses (estimated fetal weight < 10th percentile and umbilical artery pulsatility index > 95th percentile) from diagnosis until demise or delivery occurring for nonreassuring fetal testing. Ductus venosus waveforms were assessed qualitatively: forward flow versus absent or reversed flow in diastole. Two sets of at least 30 consecutive ductus venosus waveforms were obtained at each examination. If the waveforms differed between the two sets, they were defined as alternating. Cord arterial pH and base excess (BE) were obtained at birth. In 14 cases, DVRF occurred intermittently between periods of FF during the same clinical visit. Intermittent DVRF was present from 2 to 57 days (median, 13 days) and became continuous from 1 to 23 days (median, 7 days) before the occurrence of delivery for nonreassuring fetal testing or fetal demise. One fetus had an abnormal arterial pH (< 7.0) and one had an abnormal BE (< -12). These data show that (1) there is a transitional phase in which DV alternates FF and A/RF before RF becomes persistent; (2) the time from the appearance of DVRF to delivery or IUFD is variable, and (3) not all very preterm IUGR fetuses with continuous DVRF are acidemic. Because of these findings, the decision of delivery regarding early severe IUGR fetuses should be individualized, and the DVRF Doppler information has to be integrated with other antenatal fetal parameters.