Karen Kee Fung

Acquired right ventricular outflow tract obstruction in the recipient twin in twin-twin transfusion syndrome

OBJECTIVES The goal of this study was to determine the prevalence and evolution of acquired right ventricular outflow tract obstruction (RVOTO) in the recipient twin in twin-twin transfusion syndrome (TTTS). BACKGROUND Twin-twin transfusion syndrome complicates 4% to 26% of diamniotic monochorionic twin gestations and is associated with high fetal morbidity and mortality. Cardiac dysfunction and biventricular hypertrophy may develop in the recipient twin with the potential for RVOTO. METHODS This was a retrospective review of a two-center experience of TTTS to describe the prevalence and evolution of acquired RVOTO in the recipient twin. Right ventricular outflow tract obstruction was diagnosed or excluded by fetal or postnatal echocardiography or clinical assessment. RESULTS Of 73 twin pregnancies with TTTS identified between 1994 to 1998, a total of seven (9.6%) were complicated by RVOTO in the recipient twin: two subvalvar/muscular, four valvar and one combined. Of 44 pregnancies with fetal echo, six had in utero RVOTO with antegrade flow diagnosed at gestational ages ranging from 19 to 27 weeks. In utero progression occurred in four cases over a period of four to eight weeks, with the development of RVOT atresia by delivery. Postnatal progression of RVOTO occurred in two cases, one of which required pulmonary balloon valvuloplasty at age two years. Postnatal regression of subvalvar RVOTO occurred in two cases in early infancy. Death related directly or indirectly to the RVOTO occurred in all four patients who developed complete RVOT obliteration. CONCLUSIONS Right ventricular outflow tract obstruction may occur in the recipient twin of at least 9% of pregnancies complicated by TTTS. Right ventricular outflow tract obstruction progression is common in utero and may worsen neonatal outcome.

An Internet-based learning portfolio in resident education : the KOALA multicentre programme

To describe the Computerized Obstetrics and Gynecology Automated Learning Anaalysis (KOALA™), a multicentre, Internet‐based learning portfolio and to determine its effects on residents’ perception of their self‐directed learning abilities.

Prospective longitudinal study of ultrasound screening for endometrial abnormalities in women with breast cancer receiving tamoxifen

OBJECTIVE The goal of this work was to study the role of transvaginal ultrasonography (TVUS) together with colorflow Doppler imaging (CFDI) in the detection of significant endometrial abnormalities induced by tamoxifen. METHODS Over a 6-year period, 304 women on tamoxifen as adjuvant therapy for breast cancer were recruited into the current study. Standard demographic data as well as duration of tamoxifen use were collected. Patients were assessed at study entry and at yearly intervals with TVUS together with CFDI. All patients had an endometrial biopsy at the time of study entry, and repeat endometrial evaluations were done subsequently only if there were abnormal ultrasound findings or the presence of irregular vaginal bleeding. All ultrasonic characteristics and Doppler flow measurements were recorded. Descriptive statistics were used to describe the study group. Logistic regression was used to identify significant treatment- and ultrasound-related factors associated with the presence of significant uterine pathology. RESULTS One thousand and sixty-one ultrasound assessments were performed on 304 patients over a 6-year period. The mean age was 52.33 (range, 29-79). Seventy-two percent of the patients were postmenopausal at the time of breast cancer diagnosis. The median concentrations of estrogen and progesterone receptor were 75 and 73 fmol/L, respectively. Fifty-eight percent of the patients had received cytotoxic chemotherapy. The mean duration of tamoxifen use was 48.2 months. Thirty-two percent of the ultrasound examinations had associated significant uterine pathology defined as conditions that required further medical or surgical investigation and treatment. However, 80% of the abnormalities represented benign polyps. Six cases of primary endometrial cancer were detected. All cases presented with irregular bleeding. No recurrence of disease was detected at a median follow-up of 48 months. One case of metastatic breast cancer to the uterus was encountered. By setting the endometrial thickness cutoff at more than 9 mm to represent significant abnormality in this patient population, the sensitivity was 63.3%, specificity was 60.4%, positive predictive value was 43.3%, and negative predictive value was 77.5%. To detect endometrial cancer, the endometrial thickness cutoff at 9 mm had a positive predictive value of only 1.4%. Logistic regression analysis showed only endometrial thickness greater than 9 mm (OR 3.99, CI = 1.26-12.65, P = 0.018) and spiral artery pulsatility index measurement (OR 4.18, CI = 1.25-13.92, P = 0.02) to be associated with significant uterine abnormalities. CONCLUSIONS Routine sequential ultrasound surveillance in asymptomatic women on tamoxifen is not useful because of its low specificity and positive predictive value. A significant portion of screened asymptomatic women would need to undergo needless surgical evaluations of their endometrium if widespread use of ultrasound is implemented in this patient population.

Occurrence and predictors of cesarean delivery for the second twin after vaginal delivery of the first twin.

OBJECTIVE: To estimate the occurrence and to assess clinical predictors of emergent cesarean delivery in the second twin after vaginal delivery of the first twin. METHODS: We conducted a population-based cohort study, using the 1995–1997 linked mother/infant twin data from the United States. The adjusted risk ratios and population attributable risks of clinical predictors of emergent cesarean delivery in second twins were estimated for the overall study sample and for those born at less than 36 or 36 weeks or more of gestation. RESULTS: Among the 61,845 second twin births with the first twin delivered vaginally, 5,842 (9.45%) were delivered by cesarean. The cesarean delivery rate was increased in infants born to mothers with medical or labor and delivery complications. Breech and other malpresentations were the most important predictors of emergent cesarean delivery for the second twin (population attributable risk 33.2%; 95% confidence interval 31.8%, 34.6%). Operative vaginal delivery of the first twin was associated with a decreased risk of cesarean delivery for the second twin. Prediction of emergent cesarean for the second twin by clinical factors was stronger in term births than preterm births. CONCLUSION: In the general population, the cesarean delivery rate for the second twin after vaginal delivery of the first twin is approximately 9.5%. With the presence of breech and other malpresentations, the need for emergent cesarean delivery of the second twin after vaginal delivery of the first twin is increased by 4-fold. LEVEL OF EVIDENCE: II-2

The association between fetal sex and preterm birth in twin pregnancies.

OBJECTIVE: To assess the association between the fetal sex and preterm birth. METHODS: We performed a retrospective population-based cohort study using the 1995–1997 registration twin data in the United States (148,234 live-birth twin pairs). The twin pairs were divided into 3 groups: male-male (male-male), female-female, and opposite sex. We used 3 different cutoff values of preterm birth: less than 28, 32, and 36 gestational weeks. The preterm birth rates among the 3 study groups were compared, and the adjusted risk ratios (relative risk) were estimated by multiple logistic regression. RESULTS: The male-male twin pairs had the highest preterm birth rate (less than 28 weeks: 4.9%; less than 32 weeks: 12.4%; less than 36 weeks: 40.2%), the female-female twin pairs were intermediate (less than 28 weeks: 4.1%; less than 32 weeks: 10.6%; less than 36 weeks: 37.8%), and the opposite-sex twin pairs had the lowest rate (less than 28 weeks: 4.1%; less than 32 weeks: 10.1%; less than 36 weeks: 36.8%). Adjustment for important confounding factors or excluding twin pairs born to mothers who had an induction of labor or a cesarean delivery with medical complications did not change the results. The adjusted relative risks (95% confidence intervals) were 1.19 (1.11, 1.27), 1.21 (1.16, 1.26), and 1.09 (1.07, 1.11), respectively, for male-male twins compared with the opposite-sex twins under the 3 different cutoff values of preterm births. CONCLUSION: Male sex is associated with increased risk of preterm births in twin pregnancy. LEVEL OF EVIDENCE: II-2

Perinatal outcomes of normal cotwins in twin pregnancies with one structurally anomalous fetus: a population-based retrospective study.

We examined the impact of the presence of one anomalous fetus in a twin pregnancy on perinatal outcomes in the normal cotwin. Perinatal outcomes in cotwins with an anomalous twin and cotwins without an anomalous twin were compared using data from the 1995 to 1997 United States Matched Multiple Births dataset. The two groups were matched by maternal age, parity, birth order, gender, and sex concordance (1:4 matching). The risks of preterm birth, low birth weight, small-for-gestational-age birth, fetal distress, the use of assisted ventilation, low Apgar score, fetal death, neonatal death, and infant death in the 3307 normal cotwins with a twin affected by structural anomalies were significantly higher than those of the 12,813 matched cotwins without an anomalous twin. The presence of one structurally anomalous fetus in a twin pregnancy increases the risks of adverse perinatal outcomes in the cotwin without a fetal anomaly.

Gastroschisis: Antenatal Sonographic Predictors of Adverse Neonatal Outcome

Objectives. The aim of this review was to identify clinically significant ultrasound predictors of adverse neonatal outcome in fetal gastroschisis. Methods. A quasi-systematic review was conducted in PubMed and Ovid using the key terms “gastroschisis,” “predictors,” “outcome,” and “ultrasound.” Results. A total of 18 papers were included. The most common sonographic predictors were intra-abdominal bowel dilatation (IABD), intrauterine growth restriction (IUGR), and bowel dilatation not otherwise specified (NOS). Three ultrasound markers were consistently found to be statistically insignificant with respect to predicting adverse outcome including abdominal circumference, stomach herniation and dilatation, and extra-abdominal bowel dilatation (EABD). Conclusions. Gastroschisis is associated with several comorbidities, yet there is much discrepancy in the literature regarding which specific ultrasound markers best predict adverse neonatal outcomes. Future research should include prospective trials with larger sample sizes and use well-defined and consistent definitions of the adverse outcomes investigated with consideration given to IABD.

Ultrasound and MRI in the Athenatal Diagnosis of Schizencephaly

BACKGROUND Schizencephaly is a brain anomaly that can be associated with severe neonatal morbidity and mortality. Precise antenatal diagnosis is critical to help families make a decision regarding the continuation of pregnancy. A sequence of magnetic resonance imaging (MRI) called HASTE (Half-Fourier Acquisition Single-Shot Turbo Spin-Echo) has been used prenatally for this purpose. CASE We used an additional MRI sequence called true-FISP (True Fast Imaging with Steady-State Precession) to diagnose schizencephaly in a 15-year-old primigravid woman. This sequence has not been previously described in prenatal MRI. CONCLUSION HASTE sequence provides the grey-white matter differentiation that is necessary to make the diagnosis of grey-matter-lined schizencephaly clefts. True-FISP sequence has potentially higher resolution images because it is not prone to blurring of edges and is less sensitive to flowing fluid movement. Using these two MRI sequences is essential for confirming the diagnosis of schizencephaly and can provide information regarding other commonly associated anatomic anomalies.

Medical Education in the New Millennium. Medical Informatics, Evidence-based Medicine, Self-directed Learning and the K.O.A.L.A.© Programme

Abstract Medical education has changed drastically in recent years in response to political, social and economical pressures. The information age, increasing accountability and fiscal restraint are causing physicians and medical educators to re-examine the way they practise and teach medicine. No longer is a core curriculum of basic and clinical sciences sufficient to produce physicians competent to practise in contemporary society. Additional skills are required for the new millennium. These skills broach the fields of medical informatics, evidence-based medicine and self-directed teaming. The challenge for medical education, in these times of shrinking financial and human resources, is how to incorporate these new skilk into the culture of resident training programmes. The Computerized Obstetrics and Gynaecology Automated learning Analysis (K.O.A.L.A.©) programme, a computerized, Internet-based, teaming portfolio, allows residents to document cases/patient encounters and critical incidents of teaming. Through the identification of these incidents and access to immediate on-line resources, this unique teaming tool encourages residents to be learners for life, to apply the rules of evidence to medical practice, and it also cultivates computer literacy, promoting essential skills for the new millennium.

The K.O.A.L.A.™ Continuous Professional Development Programme: An Integral Part of the Lifelong Learning Continuum

Abstract The quest for lifelong learning is shared by residents and practising physicians alike. They willingly participate in continuing medical education (CME) activities to update and maintain professional knowledge and skills. The ever-changing health care society and the wider and more rapid distribution of information over the Internet have forced physicians and medical societies to acknowledge the limitations of traditional ad hoc CME activities. The search for a method that recognizes the need for systematic documentation of competence, protects personal learning autonomy, allows for societal review and audit, encompasses elements of feedback and self-assessment and acknowledges the wider responsibility of physicians beyond the medical expert, led to the concept of continuous professional development (CPD). This new approach (CPD) embraces the multidimensional aspects of physician practice. Inherently, traditional CME is a subset of CPD. In response to these challenges, the Royal College of Physicians and Surgeons of Canada identified seven essential roles of specialist physicians, and accepted a 1997 recommendation that mandatory maintenance of certification be initiated within five years. The programme will provide standard documentation and encourage specialist involvement in a range of accredited educational activities demonstrating that these individuals are committed learners for life. The Society of Obstetricians and Gynaecologists of Canada (SOGC) will, during the 1999 calendar year, initiate a pilot project using the Computerized Obstetrics and Gynaecology Automated Learning Analysis (K.O.A.L.A.™) Continuous Professional Development (CPD) programme. In addition to the learning portfolio component of the original K.O.A.L.A.™ version, K.O.A.L.A.™ CPD includes a point system, peer and self-evaluation components, real-time graphical representation of progress over time and links to Web-based sites. The programme is merely a tool for systematic documentation that proves to all stakeholders the physician willingness to address their needs and goals while remaining relevant and competitive.