A 68-year-old man developed bilateral sequential non-arteritic anterior ischaemic optic neuropathy, each episode occurring with a close temporal relationship to influenza vaccination.
Successful training strategies in all authorities implementing Looking After Children cover the following issues: implementation at all levels of the organisation; introducing the materials as a creative work tool; and uses of the data in research and planning.
The development of fetoscopy in our center has incorporated the synchronous use of real-time ultrasound scanning during the procedure. The need for ultrasound guidance in fetoscopy has already been emphasized,' and its role in facilitating intrauterine transfusions has also been stressed.2 In using ultrasound to monitor fetoscopy, we have noted a regularly reproducible artifactual echo which we wish to describe, as it has enhanced and facilitated the fetoscopic procedure. The artifact is a curvilinear series of short lines (Fig 1) which projects from the intra-amniotic tip of the fetoscope. This observation has enabled us to define rapidly the intra-amniotic end of the fetoscope, and thereby to assist in directing the fetoscope to specific fetal structures. While this echo has been regularly produced using sector scanning with a 3.0-MHz transducer, the 5.0-MHz transducer has produced less consistent results because of greater attenuation of the sound beam. The methods of evoking this echo and our investigations of the nature of this observation will be described.
MATERIAL AND METHODSPatients used in this study were volunteers undergoing second trimester termination of pregnancy. The gestational age of the fetuses in these cases varied between 18 and 23 wk. An initial ultrasound examination of the uterus was carried out to exclude multiple pregnancy, t o establish the placental position and fetal lie, and to select a safe site for the insertion of the fetoscope (Needlescope-Dyonics, Inc.). The anterior abdominal wall was prepared with povidone iodine solution and the hand-held transducer, enclosed in a thin, sterile polyethylene bag, was applied with a sterile coupling medium to the skin over the uterus. The transducer was positioned over the shaft of the fetoscope near its insertion site and oriented so that the scanning plane included the axis of the cannula, allowing the shaft of the fetoscope to be seen on the display screen. In this position, one or more linear artifacts were seen to arise from the fetoscope (Fig 1). The curvilinear artifact identifying the tip (Fig 1) was evoked by sweeping the transducer slowly through a 90 degree arc as it was moved in the direction of the intra-amniotic end of the instrument.The artifact was observed early in the development of our program, and the reproducibility and nature of the echo were tested in our ultrasound laboratory. The fetoscopy instruments were handheld in a warm water bath (22"C), and scanned with both a 3.0-MHz sector scanner (ATL) and a 3.5-MHz linear array transducer (ADR). Under these conditions it was possible to reproduce artifacts with both transducers, but the nature of the artifacts differed.
RESULTSUsing the sector scanner, in addition to the curvilinear echo from the tip, a triangular and/or linear series of echoes emanated from a point proximal to the intra-amniotic end of the fetoscope. When the fetoscope, cannula, and trocar were tested separately and together, the curvilinear echo pattern was demonstrated to arise from the end of the cannula ...
Fetoscopic visualization may be used for the prenatal diagnosis of external structural malformations of the fetus. Objective documentation of these fetoscopic findings would be desirable. The photographic equipment and techniques required for fetoscopic photography have been investigated, and the results of these investigations with standard fetoscopic instruments in current clinical usage are described. The factors evaluated include the light source, camera equipment, camera settings and film.
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