Case report: Chorionic bump detected in the third trimester.

A chorionic bump (CB) is a focal irregular bulge in the surrounding choriodecidual due to hematoma. The incidence of CB is between 1.5 and 7 per 1000 pregnancies. The presence of a chorionic bump is associated with a significantly higher risk of adverse perinatal outcomes. CB often decreases in size with time and rarely persists beyond the first trimester. Our case report presents and discusses a chorionic bump diagnosed in the third trimester. To our knowledge, this is the first case of CB to reported in the third trimester.

Caesarean scar pregnancy: time to explore indications of the caesarean sections?

A retrospective study was conducted in women with history of a caesarean scar pregnancy (CSP) to explore the possible causative mechanisms. Over a period of 40 months, a total of 16,926 deliveries and 3554 caesarean sections (CS) occurred in our hospital. Nine cases of CSP were identified at an incidence of 1:1880 births and 0.25% of all CS. Analysis of the indications of the previous CS revealed that 88.8% of women with known indication had undergone CS without labour. Out of them, 75% underwent CS at preterm gestation and 25% had term elective procedure for breech presentation. Of the patients, 77.7% had multiple CS. Conservation of the uterus was possible in 77.7% of patients utilising non-radical forms of treatment. As most of the women underwent CS with a non-contractile uterus without labour, we believe that the risk of CSP may be related to the indications of the previous CS as the number of CS alone could not explain the occurrence of CSP. It is time to explore this area so that screening strategies can be developed to detect CSP at the earliest possible gestation and to prevent life-threatening complications such as uterine rupture and severe hemorrhage. Impact statement What is already known on this subject? A caesarean scar pregnancy (CSP) is a life-threatening condition that can result in uterine rupture and in severe haemorrhage. Although the diagnostic criteria for the CSP have been established, the risk factors that favour the condition are not well understood. We know that the incomplete healing of the lower uterine segment (LUS) from poor vascularisation can create a microscopic dehiscent tract through which the blastocyst enters the myometrium. Some have postulated that the healing processes following the elective procedures, such as for breech deliveries performed in a non-developed LUS, might facilitate this process. What do the results of this study add? In this study, analysis of the indications of the previous CS revealed that majority of women with a known indication had undergone CS without labour, either at preterm gestation or term elective procedure for breech presentation. We have postulated the possible causative mechanisms in relation to the physiology of LUS development. To the best of our knowledge, this is the first study that has looked specifically at the relationship between the indications of previous CS and CSP. What are the implications of these findings for clinical practice and/or further research? Further studies exploring the indications of the previous CS are recommended so that early first-trimester screening strategies can be generated towards this subgroup of patients to detect CSP at the earliest possible gestation.

Transplacental transfer of 2-naphthol in human placenta.

OBJECTIVE: To determine the transfer of 2-naphthol (2-NPH) in fullterm human placental tissues. METHODS: Six placentas were studied. The ex-vivo dual closed-loop human placental cotyledon perfusion model was used. 2-NPH was added to the perfusate in the maternal compartment. Samples were obtained from the maternal and fetal up to 360 min measuring. RESULTS: The mean fetal weight was 2880 ± 304.2 g. Mean perfused cotyledon weight was 26.3 (±5.5) g. All unperfused placental tissue samples contained NPH with a mean level of 7.98 (±1.73) µg\g compared to a mean of 15.58 (±4.53) µg\g after 360 min perfusion. A rapid drop in maternal 2-NPH concentration was observed; from 5.54 µg\g in the first 15 min and 13.8 µg\g in 360 min. The fetal side increased from 0.65 µg\g in the initial 15 min to 1.5 µg\g in 360 min. The transfer rate of NPH was much lower than that of antipyrine. CONCLUSION: 2-NPH has the ability to rapidly across the placenta from the maternal to the fetal compartment within 15 min. The placenta seems to play a role in limiting the passage of 2-NPH in the fetal compartment.

Perinatal outcome of congenital heart disease in a population with high consanguinity.

OBJECTIVE: To report the perinatal pattern and outcome of fetuses with congenital heart disease (CHD) in consanguineous marriages. METHODS: Retrospective chart review was performed for fetuses undergoing fetal echocardiography (FE) in our institution. The primary outcome was survival at 28 days after birth. RESULTS: Between 1 January 2005 and 31 December 2010, 1950 pregnant women carrying 2151 fetuses underwent a total of 2828 FEs. CHD was diagnosed in 152 fetuses (7.1%), and perinatal outcome was available in 120, among which 78 (65%) had consanguineous parents. Thirteen fetuses died in utero, while 86 (71.7%) survived. The most prevalent lesions included left heart obstruction (25.8%), conotruncal malformations (21.7%), septal defects (18.3%), and cardiomyopathy (15.8%). Correct diagnosis was achieved in 92.2% of the cases. Extracardiac malformations occurred in 48.3% of the fetuses and were associated with increased mortality regardless of the type of CHD (P<0.001, odds ratio 6.8, 95% confidence interval 2.7-17.5). CONCLUSION: Joint FE clinics detect most CHD with high accuracy. Consanguinity contributes to a higher prevalence of fetal cardiac and non-cardiac malformations. The presence of extracardiac anomalies is associated with an increase in perinatal mortality.

Women's knowledge and attitude towards pregnancy in a high-income developing country.

OBJECTIVE: The aim of this study was to determine the knowledge and attitudes among women in a high-income developing country regarding pregnancy and antenatal care. METHODS: Women who participated in the study were asked to complete a questionnaire. The questionnaire enquired about age, level of education, Internet use, marital status, and employment. It also included questions regarding their knowledge of ultrasound, the effects of sexual activity and other exercise during pregnancy, breast feeding, and premature delivery. The collected data were subjected to statistical analysis using SPSS. RESULTS: The total number of women included in this study was 205. A total of 115 women (56.1%) thought that the most important benefit of ultrasound was to discover fetal abnormalities. Only 75 (36.6%) thought that regular exercise was not harmful during pregnancy. Of the total respondents 116 (56.6%) of 205 thought that sex during pregnancy was harmful to the fetus or did not know. Age (P=0.001), marital status (P=0.001) and working status (P=0.005) were found to significantly affect their knowledge. CONCLUSION: Knowledge about pregnancy among Emirati women is low. There is a need for effective prenatal classes that focus on educating women about issues related to pregnancy and antenatal care.

Diet restriction in Ramadan and the effect of fasting on glucose levels in pregnancy.

BACKGROUND: Maternal diet restriction might be associated with adverse maternal and perinatal outcomes due to metabolic changes. This study aimed to investigate the prevalence of changes in glucose levels due to Ramadan fasting in Emirati pregnant women. We conducted a cross-sectional observational study of 150 women from the United Arab Emirates, (76 during Ramadan and 74 after Ramadan), with uncomplicated pregnancies at a gestational age between 20 and 36 weeks. RESULTS: The two groups of pregnant women had similar physiological parameters. Using the oral glucose tolerance test, the mean random blood glucose level after 1 hour of breaking the fast was significantly higher (p = 0.002) in the Ramadan fasting group than in the control group, and this was not affected by the number of fasting days. In 50% of patients after Ramadan and 70.5% during Ramadan, this value was more than 6.7 mmol/l, which is high and not an acceptable postprandial level in pregnancy. CONCLUSION: Caregivers need to consider the 1-hour postprandial glucose level response after fasting in Muslim pregnant women. Research of an interventional design is required to determine remedial actions for this issue.

Superficial and deep learning approaches among medical students in an interdisciplinary integrated curriculum.

INTRODUCTION: Students' learning approaches have a significant impact on the success of the educational experience, and a mismatch between instructional methods and the learning approach is very likely to create an obstacle to learning. Educational institutes' understanding of students' learning approaches allows those institutes to introduce changes in their curriculum content, instructional format, and assessment methods that will allow students to adopt deep learning techniques and critical thinking. The objective of this study was to determine and compare learning approaches among medical students following an interdisciplinary integrated curriculum. METHODS: This was a cross-sectional study in which an electronic questionnaire using the Biggs two-factor Study Process Questionnaire (SPQ) with 20 questions was administered. RESULTS: Of a total of 402 students at the medical school, 214 (53.2%) completed the questionnaire. There was a significant difference in the mean score of superficial approach, motive and strategy between students in the six medical school years. However, no significant difference was observed in the mean score of deep approach, motive and strategy. The mean score for years 1 and 2 showed a significantly higher surface approach, surface motive and surface strategy when compared with students in years 4-6 in medical school. DISCUSSION: The superficial approach to learning was mostly preferred among first and second year medical students, and the least preferred among students in the final clinical years. These results may be useful in creating future teaching, learning and assessment strategies aiming to enhance a deep learning approach among medical students. Future studies are needed to investigate the reason for the preferred superficial approach among medical students in their early years of study.

Severe acute maternal morbidity in a high-income developing multiethnic country.

With declining maternal mortality, the study of severe acute maternal morbidity (SAMM) provides an opportunity to measure the quality of maternal care and to identify ways to improve it. The objective was to study the epidemiology of severe acute maternal morbidity in a high income, rapidly developing, multiethnic country in the Middle East, and to determine the role of ethnicity in maternal morbidity. We included all births occurring in maternal units with more than 500 births a year over a 6 year period in Abu Dhabi emirate, the largest province of the United Arab Emirates. Data on SAMM was collected retrospectively for the first 3 years and prospectively for the later 3 years. A clinical criteria based approach was used to define SAMM. Over the 6 year period there were 122,705 deliveries, and a total of 926 cases of SAMM were identified. The SAMM to births ratio was 7.5/1,000 deliveries. The leading cause of maternal morbidity was hypertensive disorders (59.5 %) followed by hemorrhage (39.6 %). There were clear ethnic differences. Preeclampsia was significantly higher in women from the Indian sub-continent and hemorrhage was more prevalent in UAE women. We have shown that it is possible to use a clinical criteria based approach to study the epidemiology of SAMM. The leading contributors to SAMM were hypertensive disorders and hemorrhage with clear ethnic links supporting earlier reports of a complex interaction between ethnicity, socioeconomic status and maternal health.

Trauma in women of child-bearing age in a high-income developing country.

BACKGROUND: We aimed to study the distribution and causes of trauma in women of child-bearing age. METHODS: Data were collected from Al-Ain Hospital (United Arab Emirates-UAE) Trauma Registry. Females aged 16 to 45 years (child-bearing age) who were admitted with trauma between March 2003 and March 2006 were included in the study. RESULTS: Females represented 9% (n=171) of all trauma patients (n=1809) of the same age group, of which 29% were UAE nationals. The mean age for females was 30.5 years. Road traffic collision (RTC) was the main mechanism of injury (n=78, 46%). Burns were significantly higher in females than males (p=0.001). Cervical fractures were significantly higher in females (p=0.04), while lumbar fractures were significantly higher in males (p=0.03). In females, pelvic fractures were diagnosed in 6.4%, spinal fractures in 7%, and both injuries in 1.2%. Three females died (1.7%), and all were due to RTC. CONCLUSION: The majority of females involved in trauma were aged 20- 34 years. RTC is the main mechanism of injury and fatality. Female trauma is associated with a high incidence of pelvic fractures. A higher rate of cervical injuries was observed in females in contrast to lumbar injuries in males.

The role of ultrasound in life-threatening situations in pregnancy.

Pregnant women are at an increased risk of a number of conditions that are associated with bleeding. Conditions such as ectopic pregnancy, retained products of conception, placenta previa, abruptio placentae, morbid adhesion of the placenta, and postpartum hemorrhage can be associated with massive bleeding that endangers the maternal life and health. Screening, early detection, and prevention play a key role in reducing maternal morbidity and mortality caused by these conditions. Ultrasound, in experienced hands, is an effective tool that can assist in diagnosing many of these obstetrical conditions. The advances in technology and the non-invasive nature of ultrasound examination have made it popular in our daily obstetrical practice. The review discusses the role of ultrasound in the most common life-threatening conditions during pregnancy.

Confidential enquiries into maternal mortality in the United Arab Emirates: a feasibility study.

AIM: Routine confidential enquiry into maternal deaths is not yet part of the United Arab Emirates health care system. A confidential enquiry into maternal deaths was undertaken to test the feasibility of this approach and to identify the causes and preventability of maternal deaths. MATERIAL & METHODS: Data on all maternal deaths over a six year period from 1998 to 2003 were abstracted and reviewed by a panel of experts to assign the cause if in doubt, and to determine whether the deaths were preventable. RESULTS: Over the six year period, 26 deaths were identified with 122,075 births and the maternal mortality ratio was 21.2/100,000 live births. The mean maternal age at death was 32.3 years and two-thirds of the deaths occurred during the postpartum period. The leading causes of death were thromboembolic events, hemorrhage and infection. After reviewing the clinical data the expert panel concluded that one third of the deaths were avoidable. CONCLUSION: This first ever confidential enquiry has shown that it is feasible to adopt this approach in the United Arab Emirates and the causes identified would be of help in prioritizing clinical guidelines development and training programs aimed at professionals, which will ultimately lead to safer motherhood for women.

Pregnancy outcome in late maternal age in a high-income developing country.

AIM: This study aimed to compare the pregnancy outcome at maternal age 35 years and above with those aged between 20 and 34 years in a high-income developing country. METHODS: In this prospective study, pregnant women that delivered at Al-Ain Hospital from the 1st April 2009 till 30th September 2009 were included. The obstetrical and perinatal outcome of mothers aged between 20 and 34 years and those aged 35 years old and above was compared. RESULTS: There were a total of 888 patients. 699/888 (78.7%) were aged between 20 and 34 years and 189 (21.3%) were aged 35 years and above. Advanced maternal age was significantly associated with a higher incidence of type II diabetes mellitus (p = 0001), hypothyroidism (p = 0.02), history of miscarriages (p = 0.0001), GDM (p = 0.0001), placenta previa p = 0.04, induction of labor (p = 0.04), and Cesarean section (p = 0.009). CONCLUSION: Pregnant women at 35 years and above have higher incidence of gestational diabetes mellitus, placenta previa, and operative delivery. However, perinatal outcome are comparable to younger mothers.

Antenatal diagnosis of pompe disease by fetal echocardiography: impact on outcome after early initiation of enzyme replacement therapy.

Hypertrophic cardiomyopathy (HCM) affects most infants with Pompe disease (PD), and may serve as a marker for its antenatal diagnosis (ANDx) by fetal echocardiography (FE). Fetuses diagnosed with HCM between 2006 and 2009 were included in this study. HCM, defined as Z-score of mean left ventricular wall thickness (LVWT) and/or mass (LVM) above 2, was detected in 5/1,268 fetuses (0.39%) carried by 1,137 pregnant women referred for FE. Three fetuses (0.24%) had postnatal confirmation of PD. Their gestational age and fetal weight at diagnosis was (mean ± standard deviation) 31 ± 3.6 weeks and 1.9 ± 0.2 kg, respectively. Fetal Z-score of LVM and LVWT was 3.8 ± 0.9 and 3.1 ± 0.6, respectively. Postnatally, acid α-glucosidase (GAA) enzyme activity was nearly absent in all patients, 2 were homozygous for the mutation 1327-2A>G in the GAA gene, and 1 was homozygous for 340insT. Enzyme replacement therapy (ERT) was initiated 4.9 ± 7.8 days after birth (range 2 h-14 days), and continued every 2 weeks. Two infants are alive at 4 and 31 months, and one died of aspiration pneumonia at 19 months. Cardiac hypertrophy resolved after 10-12 weeks of ERT in all patients, and none required any respiratory support. One patient had normal neurodevelopmental assessment at 25 months, and one had severe global delay at 15 months before death. ANDx of PD by FE is feasible based on fetal HCM. It promotes early initiation of ERT which may improve outcome in some patients. However, larger studies and longer follow-ups are required.

Inseparable thoraco-omphalopagus twins.

Conjoined twins occur at the rate of 1 in 50 to 200,000 live births, and 75% of these share the thorax (thoracopagus) or the thorax and upper abdomen (thoraco-omphalopagus), resulting in cardiac and hepatic sharing. Antenatal diagnosis can delineate the cardiac anatomy and provide parental counseling on whether separation is possible after birth. In the majority of cases, thoracopagus twins have a complex cardiac anatomy and share a common pericardial sac. Separation and survival depend on the extent to which the cardiac chambers and conduction system are fused. When the twins share the atria, ventricles, or both, death is inevitable even if surgical separation is occasionally attempted.

The significance of fetal renal pelvic dilatation as a predictor of postnatal outcome.

OBJECTIVES: To define the clinical outcome of fetal renal pelvic dilatation (FRPD) in cohort of infants in United Arab Emirates. STUDY DESIGN: Data were collected from all fetuses having FRPD from January 2005 to February 2008. FRPD was graded as normal (<5 mm), mild (5-9 mm), moderate (10-15 mm), and severe (>15 mm). RESULTS: Data from 80 fetuses with 120 kidneys were studied. Nine resolved antenatally and seven were lost to follow up. Of the remaining 89 FPRD (64 patients), 36% had normal postnatal ultrasound, 22.5% significant uropathy, and 41.5% had isolated hydronephrosis. Pelvi-ureteric junction obstruction was the commonest identified underlying abnormality. Severe FRPD predicted significant postnatal uropathy with a sensitivity of 65% and a specificity of 98.6%. Moderate FRPD increased the sensitivity to 95% but decreased the specificity to 60.9%, mild FPRD was seldom (4%) associated with significant postnatal pathology. Postnatal resolution was significantly (p = 0.01) higher in mild RPD than in the moderate or severe group. CONCLUSION: Severe FRPD need comprehensive postnatal assessment. Although moderate FRPD had a high prevalence of uropathy, they rarely needed surgical intervention. Parents could be reassured that RPD of less than 10 mm in the third trimester is unlikely to be associated with significant uropathology.

Prenatal diagnosis of triploidy associated with holoprosencephaly: a case report and review of the literature.

We sought to identify risk factors of prenatal presentation of holoprosencephaly associated with triploidy. A case report is presented with review of the literature performed using the PubMed database. The latest search was done in June 2008. Literature review showed 11 reports with a total of 15 cases of holoprosencephaly associated with triploidy. The mean maternal age at diagnosis was 27 +/- 4.9 years, and the mean gestational age at diagnosis was 13.6 +/- 3.3 weeks. Triploidy was mainly associated with the alobar type of holoprosencephaly. Only 3 (20%) cases had associated placental abnormalities. In all cases, the pregnancy was terminated. The latest gestational age at which termination was performed was 23 weeks. Facial abnormalities were the most common associated feature (66.6%). The association of triploidy with holoprosencephaly is very rare. This association does not seem to be related to maternal age. It is mainly associated with alobar holoprosencephaly. Diagnosis is possible during the first trimester. Fetuses can survive up to the third trimester.

Effect of maternal fasting on uterine arterial blood flow.

AIM: To determine the effect maternal diet pattern on the uterine artery Doppler flow velocimetry. METHODS: This is a cross-sectional observational study. The uterine artery Doppler flow velocimetry was measured between 20 and 24 weeks' gestation in healthy pregnant women observing Ramadan. For each fasting mother, a non-fasting healthy pregnant woman was recruited as a control. Maternal blood glucose level was measured. RESULTS: A total of 106 pregnant women were studied. The mean hours since last oral intake were significantly longer, and the maternal glucose level was significantly lower in the study group than in the control group. The Mean (95% CI) of the uterine artery pulsatility index, resistance index, peak systolic velocity, end diastolic velocity and systolic/diastolic ratio was similar in both groups. CONCLUSION: Maternal fasting is not associated with significant changes in the uterine artery Doppler flow velocimetry.

Gestational diabetes mellitus: fetal liver length measurements between 21and 24 weeks' gestation.

PURPOSE: To evaluate sonographic measurements of the fetal liver, fetal abdominal fat layer, interventricular septum, and Wharton's jelly area between 21 and 24 weeks' gestation in women with gestational diabetes mellitus (GDM). METHODS: A total of 123 consecutive healthy pregnant women underwent sonographic examination at 21-24 weeks' gestational age. The measurements included fetal biometry, detailed anomaly scan, and fetal body composition measurements (subcutaneous fat, liver size, cardiac muscle thickness, and Wharton's jelly area). GDM was confirmed by way of a 75-g oral glucose tolerance test using World Health Organization criteria within 1 week of the examination. RESULTS: Nineteen (15.4%) women were diagnosed with GDM, while 104 (84.6%) women were without GDM. The mean fetal liver length was 36 mm (95% CI 32-37) in women with GDM and 31 mm (95% CI 30-33) in women without GDM (p < 0.01). Liver enlargement was related to maternal fasting glucose levels and not 2-hour postprandial levels. There was no significant difference in the fetal biometric and other fetal body measurements between the 2 groups. CONCLUSIONS: The findings of this study suggest that midtrimester fetal liver length appears to be longer in GDM than in normal pregnancies. However, the fetal abdominal fat layer, interventricular septum, and Wharton's jelly were not affected. Nevertheless, further, larger randomized studies are required to confirm these findings.

The effect of maternal diet restriction on pregnancy outcome.

The purpose of this study was to determine the effect of intermittent maternal fasting on pregnancy outcome. The course and outcome of 168 fasted pregnant women were reviewed. A total of 168 fasted and 156 control pregnant women were studied. The incidence of gestational diabetes (GDM) was significantly higher in the fasted group than in the control group ( p = 0.001). Labor was induced in 26 of 168 women (15.5%) in the fasted group compared with 11 of 156 women (7.1%) in the control group ( p = 0.004). The cesarean section rate was significantly higher in the fasted group ( p = 0.01). There was no difference in Apgar score at 1 and 5 minutes between the two groups. Admission to the special care baby unit (SCBU) was significantly more frequent in the fasted group than the control group ( p = 0.001). Maternal diet restriction is associated with an increased risk of GDM and induction of labor. The frequency of neonatal admission to SCBU is increased.