ObjectivesThis study describes the design, delivery and efficacy of a regional fetal cardiac ultrasound training programme. This programme aimed to improve the antenatal detection of congenital heart disease (CHD) and its effect on fetal and postnatal outcomes.Design setting and participantsThis was a prospective study that compared antenatal CHD detection rates by professionals from 13 hospitals in Wales before and after engaging in our ‘skills development programme’. Existing fetal cardiac practice and perinatal outcomes were continuously audited and progressive targets were set. The work was undertaken by the Welsh Fetal Cardiovascular Network, Antenatal Screening Wales (ASW), a superintendent sonographer and a fetal cardiologist.InterventionsA core professional network was established, engaging all stakeholders (including patients, health boards, specialist commissioners, ASW, ultrasonographers, radiologists, obstetricians, midwives and paediatricians). A cardiac educational lead (midwife, superintendent sonographer, radiologist, obstetrician, or a fetal medicine specialist) was established in each hospital. A new cardiac anomaly screening protocol (‘outflow tract view’) was created and training on the new protocol was systematically delivered at each centre. Data were prospectively collected and outcomes were continuously audited: locally by the lead fetal cardiologist; regionally by the Congenital Anomaly Register and Information Service in Wales; and nationally by the National Institute for Cardiac Outcomes and Research (NICOR) in the UK.Main outcome measuresPatient satisfaction; improvements in individual sonographer skills, confidence and competency; true positive referral rate; local hospital detection rate; national detection rate of CHD; clinical outcomes of selected cardiac abnormalities; reduction of geographical health inequality; cost efficacy.ResultsHigh levels of patient satisfaction were demonstrated and the professional skill mix in each centre was improved. The confidence and competency of sonographers was enhanced. Each centre demonstrated a reduction in the false-positive referral rate and a significant increase in cardiac anomaly detection rate. According to the latest NICOR data, since implementing the new training programme Wales has sustained its status as UK lead for CHD detection. Health outcomes of children with CHD have improved, especially in cases of transposition of the great arteries (for which no perinatal mortality has been reported since 2008). Standardised care led to reduction of geographical health inequalities with substantial cost saving to the National Health Service due to reduced false-positive referral rates. Our successful model has been adopted by other fetal anomaly screening programmes in the UK.ConclusionsAntenatal cardiac ultrasound mass training programmes can be delivered effectively with minimal impact on finite healthcare resources. Sustainably high CHD detection rates can only be achieved by empowering the regional screening workforce through continuous in...

A 37-year old woman booked at nine weeks of gestation in her third pregnancy. Fourteen years previously she had had an uncomplicated emergency lower segment caesarean section at 37 weeks for fulminating pre-eclampsia. Two years later, she had a normal delivery at term without complication. She had laser treatment to the cervix in 1987 for CIN 1. There was no other gynaecological history of note.At booking, a singleton pregnancy of nine weeks of gestation was confirmed on scan. The uterus was retroverted but although the ultrasound report commented on the presence of an 11cm anterior wall fibroid, this was not documented in the woman's case notes. A senior radiographer performed her routine anomaly scan at 19 weeks of gestation. All was well and the placenta was noted to be posterior. Again, the fibroid was noted but was not documented in the notes. She was followed-up regularly by both the midwife and the hospital antenatal clinic. She remained well and symptom free. Throughout the antenatal period from 28 weeks onwards the presentation was thought cephalic and the uterine size compatible with her dates. At 37 weeks the head was reported as being engaged, with three-fifths of the head palpable per abdomen. At 39 weeks of gestation she was seen in the antenatal clinic by a senior member of staff who found that the head was now two-fifths palpable and recommended that the woman could have a trial of labour.She was seen at term plus four days in the antenatal clinic. The symphysis -fundal height was appropriate for her dates, but the fetus had a transverse lie. A caesarean section was booked for the following day. However, she went into labour during the night. At 2cm dilatation, an emergency caesarean section was performed under a spinal anaesthetic. The abdomen was opened by a Pfannensteil incision. The uterus was found rotated to the left by 180 degrees. The rotation was corrected manually without difficulty. A large anterior wall fibroid was found extending from the upper segment to the previous caesarean scar in the lower segment. The whole of the anterior aspect of the lower segment was covered with fibroid and dense bladder adhesions. It was impossible to feel the lower extent of the fibroid. The anaesthetist continued with the operation under a spinal anaesthetic. A longitudinal incision was made in the upper segment over the fibroid to enucleate the fibroid. A myomectomy was performed. The uterus was opened transversely during the dissection and the opening enlarged to deliver the baby. The decidua was sutured with interrupted sutures of polyglactin polymer and the myometrium closed in three layers with a continuous stitch of the same material, the deepest layer being repaired transversely and the more superficial layers longitudinally. The operation lasted for 75 minutes. Blood loss was estimated to be 600ml. Her haemoglobin concentration fell by 0.4gldL. A prophylactic antibiotic was administered. She recovered well and was discharged home on her sixth post-operative day. Postnatal examination showed no ...

Male Sprague-Dawley rats were differentially housed for 21 days immediately after weaning. Isolated animals showed a selective suppression of exploration of the light side of a two compartment box; spending significantly less time in the light, and making fewer transitions between the light and dark compartments compared to socially reared controls. However, both basal and GABA-stimulated [3H] flunitrazepam binding was unaltered in the frontal cortex, hippocampus, amygdala and cerebellum following social isolation. These results are discussed in relation to other studies on central benzodiazepine receptor changes following a variety of experimental stressors.

Monoamniotic twins occur in approximately in 1% of monozygotic twins. The reported incidence varies from 1:1650- 1:93734 live births. Perinatal mortality of twin pregnancy is high, ranging from 28%-70%. The principal causes are umbilical cord entanglement and accidents, congenital anomalies, preterm delivery, intrauterine growth restriction and placental anastomotic events. Congenital anomalies occur with an increased frequency in Monoamniotic twins, are related to acardia, anencephaly and congenital cardiac defects. Accurate recognition of monoamnionicity is central to management strategies. Serial ultrasound every 2 weekly are done to assess fetal growth, amniotic fluid volume, and geography of the dual umbilical cord. The timing of the delivery in Monoamniotic twins is balance between the risk of preterm birth and the risk of intrauterine death. Recommended timing of the delivery varies between 32-35 weeks gestation. The majority of units uses caesarean birth as the preferred delivery mode for Monoamniotic after consideration of course of steroids for fetal lung maturity. We report here two cases of Monoamniotic twins, which are managed by Fetal medicine unit in our hospital. Both cases had caesarean section at 32 weeks of gestation with successful pregnancy outcome.