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.

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.

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.

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.

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.

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.

Ultrasonic estimation of fetal weight at term: an evaluation of eight formulae.

AIM: To compare the accuracy of eight sonographic formulae for predicting fetal birth weight at term in a multiethnic population. METHODS: Pregnant women at term who were booked for induction of labor or elective cesarean section were included in the study. Eight ultrasonic fetal biometric formulae were used to predict fetal birth weight. RESULTS: A total of 173 patients were included in the study; 53 (30.6%) patients were from the Indian subcontinent, 44 (25.4%) patients were from Africa, 33 (19.1%) patients were from the Arabian Peninsula and 43 (24.9%) were from other ethnic groups. The mean absolute error ranged from a minimum of 0.3% (+/-11.3) for Hadlock (biparietal diameter [BPD], head circumference [HC], abdominal circumference [AC], femur length [FL]) to a maximum of 37.5% (+/-10.0) for Warsof (FL). The correlation of estimated fetal weight with actual birth weight ranged from a minimum of 0.09 with Warsof (FL) to a maximum of 0.77 with Shepard and Warsof (BPD, AC) and Hadlock (BPD, HC, AC, FL). The combination of AC with BPD measurements rather than FL achieves a high level of accuracy. CONCLUSIONS: Shepard (BPD, AC) provides a simple and accurate logarithm for the prediction of fetal weight at term in the studied multiethnic population.

Comparison between visual and computerized cardiotocography in low risk pregnancy.

OBJECTIVE: To compare between visual and computerized cardiotocography (cCTG) in low-risk pregnant women in predicting pregnancy outcome. METHODS: One hundred and fifty-three consecutive computerized fetal heart tracings were recorded from non-laboring pregnant women at > or = 30 weeks gestation. All traces were reviewed by 2 experienced obstetricians. The study was carried out at Al-Ain Medical District, United Arab Emirates, between August 2004 and December 2004. RESULTS: Of the 153 pregnant women, 11 (7.2%) were delivered by cesarean section. The interobserver agreement was 0.60. The observers cCTG agreement were 0.48 and 0.45. The difference in cesarean section rate was not statistically significant. Observers' interpretation and cCTG did not correlate well with Apgar score at 5 minutes and admission to special care baby unit. CONCLUSIONS: Computerized CTG has little advantage over conventional CTG in the prediction of Apgar score and need for neonatal intensive care unit admission in a low-risk population.

The effect of intermittent maternal fasting on computerized fetal heart tracing.

OBJECTIVE: To determine effects of maternal fasting on antepartum computerized fetal heart tracing analysis. STUDY DESIGN: This was a cross-sectional study of two groups of healthy pregnant women who were recruited, a fasting and a nonfasting control group. Each pregnant woman gave a blood sample, and had a computerized fetal heart tracing. RESULTS: A total of 124 pregnant women were studied. The mean hours since the last oral intake were significantly different between the two groups (p=0.003). Fetuses of fasted mothers had fewer episodes of large acceleration compared to the controls (p=0.001). This difference was significantly associated with maternal appreciation of fetal movement (p=0.003). CONCLUSION: The number of large accelerations in computerized fetal heart tracing is decreased in pregnant women abstaining from food and water.

Pregnancy outcome post renal transplantation.

BACKGROUND: The success in performing organ transplantations and prevention of rejection has resulted not only in a substantial increase in life expectancy, but also improvement in the patients' quality of life. Thus, women who underwent organ transplantation are now reaching puberty and the age of reproduction. This has presented new challenges regarding the teratogenicity and the long-term effect of immunosuppressive medications used by these patients. Previous studies have shown that pregnancies after renal transplantation are associated with an increased risk for both the mother and the fetus. There is, however, very little information available on neonatal and long-term pediatric follow-up of babies born to mothers who have undergone renal transplantation and have been exposed to immunosuppressive medications, compared to controls. We report the experience of our center, the largest in Canada, regarding the prenatal and long-term postnatal outcome of pregnancies after renal transplantation. METHODS: This is a retrospective case series reporting the outcome of 44 consecutive pregnancies followed by the Toronto Renal Transplant Program. Follow-up data were gathered on the 32 live born children by either a return visit to the clinic or by telephone interview. Medical, as well as developmental information, was gathered on all children and the study group was compared to controls, matched for maternal age (+/-2 years) and smoking status, obtained through the Motherisk Program. RESULTS: Of the 44 pregnancies followed by us, there were 32 live-born children delivered by 26 mothers and 12 stillborn/abortuses. Twenty-six pregnancies were treated with cyclosporine, azathioprine and prednisone, 13 with azathioprine and prednisone and five with cyclosporine and prednisone. The mean gestational age at delivery in the study group was 36.5 +/- 2.7 weeks compared to 40.2 +/- 1.6 weeks in the control group (P < 0.001). The mean birthweight in the study group was 2.54 +/- 0.67 kg, compared to 3.59 +/- 0.53 kg in the control group (P < 0.0001). In the study group there was one child with multiple anomalies and four stillbirths compared to zero in the control group. There were also six spontaneous abortions and two therapeutic abortions in the study group. On follow-up (from 3 months to 11 years of age) there was one child with insulin-dependent diabetes mellitus, two children with asthma and one child with recurrent otitis media. Developmental follow-up revealed one child with moderate to severe sensorineural hearing loss, one child with a learning disability and one child with pervasive developmental disorder. In none of these cases were there signs of perinatal asphyxia. CONCLUSION: There are significantly more stillbirths, preterm deliveries and increased incidence of low birth weight in the transplant group. Most pregnancies in the study group went well, however, and their offspring had normal postnatal growth and development. Further studies with long-term pediatric follow-up are needed to delineate their outcome and rule out possible long term effects of the immunosuppressive medication on their growth, development, reproduction and general health.