Research Korner: Research Papers on Abortion

Advances in ultrasound assessment in the establishment and development of pregnancy

Advances in ultrasound assessment in the establishment and development of pregnancy Current data demonstrate that angiogenesis in the ovaries and uterus is an essential component of both follicular and luteal phases of menstrual cycle, tightly correlating with the levels of bioactive substances such as hormones, growth factors and interleukins. Ultrasound is used principally to demonstrate follicular growth, a receptive triple layer endometrium and to exclude pathologies such as fibroids and ovarian tumours. However, the development of new technologies such as CDI, CPA, 3D-US, 3D-CPA is now set to expand the role of ultrasound in the assessment of the processes in the ovaries, uterus and early pregnancy. There is growing evidence that studies of peri-follicular vascularity will predict the development of a healthy oocyte and subsequently an embryo. Endometnal blood flow studies with conventional CDI and the newer techniques of CPA and 3D-CPA will be important in predicting endometrial receptivity. Ovarian stromal vascularity appears to correlate with vascular endothelial growth factor (VEGF) levels and high vascularity is associated with PCO and a risk of ovarian hyperstimulation syndrome. 3D-CPA may improve our ability to assess ovarian and endometrial vascularization and blood circulation, to diagnose tubal patency. Increasingly, 3D ultrasound is being applied to diagnose the pathology of early singleton and multiple pregnancies. The female reproductive system is unique in that this is the only site in the uninjured adult body where angiogenesis (i.e. the formation of new blood vessels) occurs in a repetitive cyclic fashion. It is taking place in the ovary during folhcular development and corpus luteum formation, and in the endometrium during proliferative phase of menstrual cycle. Soon after formation of the follicular antrum, the follicle acquires a vascular sheath in the theca layer. The establishment of the vascular sheath, particularly the expansion of the inner capillary plexus of the theca interna, co-incides with a period of rapid growth and differentiation of the follicle1. The granulosa and theca cells of ovarian follicles are sources of angiogenic activity, which appear to be under the control of gonadotropins. At about the time of folhcular rupture, vessels of the theca begin to sprout and penetrate the membrana granulosa; then, they anastomose to form a dense network, ultimately bringing each lutein cell into close approximation to the vascular system. It has been shown that the rates of follicular and luteal blood flow are among the highest in the body (5-10 and 10-30 ml/min/g, respectively) as compared to normal renal flow of approximately 4—8 ml/min/g2'3. Endometrial growth and development in response to systemic concentrations of ovarian steroids are well known. The rate of blood flow to uterine tissues also varies throughout the menstrual cycle and during the pregnancy4. Details of angiogenic events in the ovary and endometrium have been pivotal in understanding folliculogenesis and implantation. Therefore, by coupling various ultrasound technologies to high frequency transvaginal probes it is possible to perform detailed studies of ovarian and endometrial vascularity which is important for the establishment and development of pregnancy. Recently, the introduction of colour Doppler imaging (CDI), colour power angiography (CPA) and three-dimensional ultrasound (3D-US) has increased the range of diagnostic information on angiogenesis within the ovary and endometrium, and morphological conditions in the uterus and Fallopian tubes. Doppler ultrasound makes use of the Doppler effect where the changes of frequency (frequency shift) caused when an ultrasound beam interacts with moving erythrocytes in blood vessels can be measured and displayed. This Doppler shift can be displayed either as a colour map of the blood vessels within the organ being studied or as a flow velocity waveform (spectral Doppler) which allows the measurements of absolute velocity (cm/s) and resistance to flow (pulsatility index). New modalities such as colour power angiography use the amplitude of the Doppler signals which represents the density of erythrocytes within the vessels being studied. This provides a more sensitive display of vasculature within an organ. Three-dimensional ultrasonography (3D-US) has been used to assess the uterine anatomy and to detect congenital anomalies of uterus. 3D-US differs from conventional 2D scanning m that a volume of echoes is captured instead of the usual 2D 'slices'. This volume can be obtained by equipment which can capture the volume from a free-hand sweep (positional information being provided by an electromagnetic sensor) or by means of an automatic capture of the volume by the transducer itself which moves in two planes. This latter device is quicker and more accurate and will obtain a volume within 5-20 s. When the volume has been obtained, it can be analysed in several different ways. Re-slicing This means that volume can be analysed with traditional 2D slices but now all planes can be obtained, even the plane at right angles to the surface of the probe which cannot be obtained by conventional imaging. An example of the value of this was demonstrated by Jurkovic et als, who showed that this technique could display the coronal plane of the uterus making it useful in detecting major congenital anomalies and intra-uterine defects. Volume measurements More accurate measurements of the volume especially of irregular structures can be obtained by using multiplanar reformatted sections method and built-in software. This has been shown to improve the measurements of ovarian, follicular6'7, uterine and endometrial volumes7'8. Improved volume measurements provide better staging of endometrial cancer9. However, the usefulness of those improved volume measurements have yet to be demonstrated in reproductive medicine. Surface rendering By means of shading and thresholding, surface rendered views can provide impressive 3D images of structures, especially if there is a solid/fluid interface. Impressive images can be obtained of the early embryo, but unique images can also be obtained of ovarian cysts, especially those with vegetations and submucous fibroids, particularly if hydrosonography is used. One of the most innovative applications of the surface rendering in gynaecology is its use to demonstrate tubal patency by obtaining threedimensional views of flow along the Fallopian tube by 3D-CPA10. Colour power angiography CPA is monochromatic and does not provide directional information, but its sensitivity to low flow makes this more useful to study tissue perfusion11. Quantitative analysis of the blood flow in the predefined volume is available by implementing the colour histogram mode, the results of which are expressed as various indices. The indices are calculated by the built-in or separate computer using specially developed software. Vascularization index (VI) This describes the vessel density in the selected volume (colour voxels/fcolour voxels + grey scale voxels]). Flow index (Fl) This describes the intensity of blood flow in these vessels (weighted colour voxels/colour voxels). Vascularization-flow index (VFI) Vascularization-flow index reflects to some extent perfusion of the selected volume (weighted colour voxels/[colour voxels + grey scale voxels]). Assessment of uterine receptivity At present, ultrasonographic parameters of endometrial receptivity have a strong negative value in setting some minimum criteria, although their value as prognostic indicators for implantation following embryo transfer has yet to be proven. Good uterine perfusion, as shown by good diastolic flow and low resistance to flow indices, was correlated with conception following assisted reproduction treatment. Several authors demonstrated statistically significant difference in the measurements of uterine artery pulsatUity index (PI) between those women who became pregnant and those who did not after IVF treatment. Steer et aJ}2 suggested that measurement of mean uterine PI on the day of embryo transfer to assess endometrial receptivity is a good method of assessing uterine receptivity in women undergoing FVFET treatment. A mean PI of greater than 3.0 before embryo transfer could predict up to 35% of failures to become pregnant. Similar results have been obtained by other authors in studies investigating uterine PI and implantation rates whether on the day of folhcular aspiration13 or on the day of human chorionic gonadotrophin (hCG) injection14'15. However, some authors were not able to demonstrate any predictive value of uterine artery PI in terms of uterine receptivity in IVF patients16"19. The uterine artery blood flow impedance on the day of embryo transfer was unrelated to the risk of the conceptus ending in spontaneous abortion or ectopic pregnancy20. This finding implies that poor uterine blood flow does not increase the risk of adverse pregnancy outcome, if pregnancy was achieved. Velocities and resistance indices were not correlated with endometrial thickness. However, combination of triple layered endometrium (thickness more than 8 mm) and of low vascular impedance in the uterine arteries (PI less than 3.0) have been suggested as reliable ultrasound markers for endometrial receptivity21. The uterine scoring system which included multiple ultrasonographic and colour Doppler parameters on day 22 of the menstrual cycle prior IVF treatment cycle appeared to be a useful predictor of implantation22. Assessment of subendometrial blood flow has been of interest recently. Using conventional CDI, the degree of penetration of vessels into the endometrium correlated with the success of implantation. Absent subendometrial vascularity correlated with failure of implantation21'23. Yang and coworkers24 used power Doppler imaging in assessment of endometrial vascularization by measuring the coloured area in the endometrium. Those women with an intra-endometrial coloured area <5 mm2 achieved a significantly lower implantation rates (8.1% versus 20.2%, P = 0.003 than those with area >5 mm2. Therefore, the number of transferred embryos should be determined on the basis of the quantity of intra-endometrial vascularity as well as the endometrial thickness, so as to improve the reproductive outcome for those with poorly vasculanzed endometrium, and to reduce the potential risk of multiple pregnancies for those containing adequate intra-endometrial vascularity24. Three-dimensional CPA quantitative assessment of blood circulation gives a deeper insight into evaluation of endometrial receptivity. On the day of pituitary suppression, Schild et aP5 found significant differences in subendometrial blood flow and vessel density between women who became pregnant and those who failed to become pregnant in an in vitro fertilisation programme. Surprisingly, they found lower 3D indices of volume flow in conception cycles compared with non-conceptional cycles, suggesting that a lesser degree of intra-uterine vascularization and perfusion at the beginning of ovarian stimulation indicated a more favourable endometrial milieu. Possibly, this reflected a better functional pituitary suppression following GnRH agonist administration which increases the chances of successful implantation. Various regimens of medications such as low dose aspirin, heparin and NO (nitric oxide) have been found to improve endometrial receptivity due to their promoting effects on uterine perfusion. Low-dose aspirin treatment in patients undergoing in vitro fertilisation cycles significantly improved ovarian responsiveness, uterine and ovarian blood flow velocity, subsequent implantation and pregnancy rates in FVF patients as shown in a large randomized, double-blind study26. In studies of women who had increased uterine artery PI in a previous IVF cycle, administration of NO donor27 or cGMP promoter (sildenafil)28 have been shown to improve uterine and endometrial blood flow which may lead to improvement of an in vitro fertilisation outcome. Further studies are needed to understand and evaluate the endometrial vascular pattern both in spontaneous and stimulated ovarian cycles using conventional CDI and also the 3D-CPA technique, as well as safety of the agents used to promote better endometrial vascularization. Fallopian tubes are important part in the chain of pregnancy establishment. Normally they have to be patent, which means hollow through the entire tubal length. Hysterosalpingo-contrast sonography (HyCoSy) using a positive contrast has been widely used to provide a rapid ultrasound-based test of tubal patency29. This method can be incorporated into the set-up of the initial investigation for infertility patients. However, a number of difficulties in tubal visualisation are encountered. Due to tubal tortuosity, the entire tube can rarely be seen in a single scanning plane and the echo-contrast medium is usually observed in small sections. In theory, by manipulating the probe, the contrast agent can be followed to the fimbrial end of the tube where free spill may be observed; but, in reality, this is infrequently achieved because the contrast agent has the same echogenicity as the surrounding bowel. Three-dimensional ultrasound helps to overcome these problems, because it enables the capture of a volume which should include the full length of the tube. Power Doppler which is sensitive to slow flow makes it possible to detect the flow of contrast medium along the tube up to the fimbrial end where free spill is identified10. It allows the storage and retrospective analysis of the information acquired. More studies are required to estimate the cost-effectiveness of this procedure and to establish whether it can replace conventional diagnostic hysteroscopy and laparoscopy in the diagnosis of tubal patency. The reported low specificity in the various studies, ranging between 15—44%, obviously indicates that uterme receptivity is one among several different factors contributing to implantation. Studies using donor oocytes have generally demonstrated equivalent implantation and pregnancy rates among reproductive young and older recipients, suggestmg that oocyte and embryo quality are paramount in successful implantation30"32. However, good embryos can derive only from eggs in normally developmg follicles. Studies of ovarian stromal blood flow Adequate ovarian blood circulation is an important precondition for normal ovarian function. Blood flow patterns are different in the polycystic ovaries as demonstrated by Doppler ultrasound assessment than those in the normal ovaries33'34. Zaidi et al3S have shown that ovarian stromal blood flow velocity is significantly higher (P <0.001) in women with polycystic ovaries (PCO) compared to women with normal ovaries. The reason for this increased stromal flow is unknown, but it may be related to high levels of angiogenic cytokines in the theca cell layer. It has been shown that women with PCO have a higher ovarian stromal PSV and serum concentration of VEGF than those with normal ovaries36. It is well known that women with PCO are more susceptible to ovarian hyperstimulation syndrome (OHSS) and increased stromal flow may predict an increased susceptibility to this condition. VEGF is used to assess ovarian response during infertility treatment and a significant rise in serum VEGF concentration after hCG administration appears to be one of the most important predictors of OHSS37. Stromal flow velocities have also been used to study ovarian responsiveness in IVF treatment. Engmann et al38 studied 81 women with normal baseline serum FSH levels and normal ovaries; the ovarian stromal blood flow velocities measured after pituitary suppression appeared to be an independent predictor of ovarian response. In this study, patients with peak systolic velocity (PSV) greater than 10 cra/s has a better ovarian response and had a higher clinical pregnancy rate than those with PSV <10 cm/s. However, some of the studies16'17 have failed to demonstrate any significant difference in the intra-ovarian PI between those women who became pregnant and those who did not following an in vitro fertilisation treatment. This may be because PI is a less sensitive indicator of angiogenesis than PSV. Using three-dimensional power Doppler imaging, prominent changes of the vascularization and blood circulation in the dominant ovary during normal menstrual cycle were found. In midluteal phase, the vascularization index, flow index and vascularization-flow index in the dominant ovary were, respectively, 6.6-, 1.3- and 9.2-folds higher than in the non-dominant ovary39. This way of assessment of ovarian vascularization in normal menstrual cycles and pathological conditions may be more sensitive and more accurate in diagnosing the changes than colour and pulsed Doppler measurements. Evaluation of follicular function Campbell et at*0 first reported that indices of blood flow in the wall of the leading follicle could be monitored by transvaginal ultrasonography with colour Doppler imaging and spectral Doppler over the peri-ovulatory period. They showed that peak systolic velocity (PSV) around the follicle was a better indicator of angiogenesis than resistance (pulsatility index, PI). There was a significant rise in PSV from the time of the LH surge indicating a marked increase in blood flow during peri-ovulatory period40. There may be relationship between low follicular blood velocity and luteinised unruptured follicle (LUF) in spontaneous cycles41. Follicular vascularity in the stimulated ovary during in vitro fertilisation and embryo transfer (IVF-ET) treatment has also been studied. Analysis of these data showed that there was a significant relationship between the follicular PSV immediately before ultrasound-guided follicular aspiration, oocyte recovery and subsequent production of good quality preimplantation embryos. There was a 70% chance of producing a grade I or II embryo if the follicular PSV was greater than 10 cm/s but only 18% if no blood flow was detected42. The results of the study also showed that there was no direct relationship between follicular volume or flow resistance as indicated by the PI before the administration of human chorionic gonadotrophin (hCG). There was, however, a significant positive correlation between the detection of a follicular flow velocity waveform within a given follicle and the recovery of an oocyte. The factorial increase m PSV after hCG administration was significantly higher in follicles that subsequently produced good quality embryos43. Chui and coworkers17 developed the grading system of assessing the percentage of follicular circumference in which flow was identified from a single cross-sectional slide. Poor follicular blood flow was significantly associated with poor outcome, and successful pregnancies occurred more frequently in those women with good blood flow17-44'45. A strong relationship between follicular vascularity and the cumulus activity in vitro was found46. Similar findings were observed in the stimulated intra-utenne insemination cycles when the grade of vascularized dominant follicles (larger than 16 mm in diameter) was recorded. As in IVF cycles, there was significant association between pregnancy rates and live birth rates and good blood flow47. The findings are consistent with the suggestion that changes in follicular vascularity may initiate biochemical events, which are essential within the follicular environment. There have been reports showing an association between oxygen concentration in follicular fluid48'49, or the oxygen consumption or adenosine tnphosphate (ATP) content of an oocyte50-51, and the production of a good pre-implantation embryo. Moreover, the dissolved oxygen content of the follicle has been shown to be related to colour Doppler qualitative patterns and vascular endothelial growth factor and subsequently associated with developmental competence of the corresponding oocyte52. The current findings of an association between follicular PSV and subsequent clinical pregnancy are consistent with the assumption that follicular blood flow may be associated with events essential for successful establishment of pregnancy. The knowledge gained from studies on follicular vascularity may be useful for designing future studies to understand physiological and biochemical events during folliculogenesis and to improve success rates of infertility treatment. Assessment of early pregnancy Key chronological landmarks in early human development seen on transvaginal sonography are still the same despite the developing ultrasound technique. The normal gestational sac can be first seen in the endometnum on transvaginal sonography 5 weeks after the last menstrual period (3 weeks after conception). It reaches the size of about 10 mm in diameter. Yolk sac becomes identifiable a few days later. The embryo adjacent to yolk sac and fetal heart pulsations (about 125 bpm) are first seen at 6 weeks. From then until 14 weeks, the growth of the embryo is measured from its crown-rump length (CRL). At 6 weeks of gestation, embryonic CRL is about 3 mm. At 8 weeks of gestation, embryo CRL is about 16 mm, heart rate 175 bpm and fetal body movements can now be observed. Recently, 3D ultrasound scanning in the first trimester was applied to visualize the surface of anatomical structures of the embryo and early fetus. The results of the investigations suggested that 3D ultrasonography is becoming an important modality in future embryological and early fetal research and detection of embryonic and fetal developmental disorders53"56. 3D power Doppler imaging has the potential to study process of placentation and fetal cardiovascular development. Over the last few years, intervillous blood circulation has been widely studied during the first trimester of pregnancy57"59. Findings were in concordance with histomorphological evidence that spiral arteries begin to open directly into the intervillous space during the second month of gestation57'60. The number of areas with the established intervillous circulation increases gradually with embryonic and placental growth. These findings indicate that establishment of the intervillous circulation is a continuous process rather than an abrupt event at the end of the first trimester. 3D power Doppler seems to be useful in visualizing intervillous blood circulation in the developing placenta56. Colour Doppler measurements failed to show the difference in uteroplacental circulation between patients with threatening miscarriage with a living embryo and those with normal pregnancy61'62. It was speculated that vascular injury is possibly so minimal that it cannot be detected by currect Doppler tecgniques. However, it appeared useful to select the patients who should undergo conservative or surgical management of first trimester miscarriages63 which were already imminent. Perhaps application of 3D power Doppler imaging in the studies of early pregnancy miscarriages will help to obtain more clinically useful results56. Perinatal morbidity and mortality of twin gestations is higher among monochorionic in comparison with dichononic twins64. Therefore, early diagnosis of multiple pregnancy is very important because it allows mothers and obstetricians to anticipate various multiple pregnancy related problems. Data in which both zygosity and chorionicity were determined support the observation that chorionicity rather than zygosity determines outcome65. Using high resolution, first trimester transvaginal sonography chorion and amnion types have been assessed in a number of large prospective studies64'66. If only one embryo is found in each gestational sac, the number of amnion and chorion sacs is equal. If two or more embryos are seen within any chorionic sac, the number of amnion sacs can be determined usually at about 8 weeks of pregnancy, because the earlier amniotic sac contains a small amount of fluid and membranes are too thin for visualisation. Mono-amniotic twins will be surrounded by a single amnion. Pregnancies are classified as dichorionic if there is a single placental mass and there is extension of placental tissue into the base of the inter-twin membrane, the 'lambda' sign. Pregnancies are classified as monochorionic if there is a single placental mass in the absence of the lambda sign67-68. Three-dimensional ultrasound scanning was described as a useful method to study inter-relationships and contacts of twin and triplet embryos and fetuses55'69. By rotating and translating the planes inside the acquired volume containing the whole gestational sac, two yolk sacs and two embryos could be clearly visualized and precise diagnosis of chorionicity and amnionicity can be achieved. The significantly adverse outcome of monochorionic twins is attributed mainly to the presence of communicating placental vascular anastomoses. Up to 35% of monochorionic twin gestations are complicated by twin-totwin transfusion syndrome70, which can be essentially disregarded after ultrasonographic diagnosis of a dichorionic gestation65-71. Conjoined twins is the most frequently reported first trimester structural anomaly unique to twins72. The commonest type of conjoined twins is thoracopagus, where the twins are joined at the thorax; 3D transvaginal sonography has been used to depict thoraco-omphalopagus73. Although it was not essential, 3D scanning aided diagnosis by using multiplanar imaging as well as spatial surface animation. As a rule, due to the unclear prognosis associated with conjoined twins, whenever a mono-amniotic twin gestation is diagnosed, the possibility of conjoined twins should be considered. There are few data available on detection of fetal structural anomalies by high resolution transvaginal scans in early pregnancy in unselected populations. Detection rates reported in the literature are reaching up to 65%74'75. Sonographic recognition of congenital anomalies depends on knowledge of normal fetal development, ultrasound equipment used, and natural histories of the particular disorders. Scans during the first stage of pregnancy will miss some fetal anomalies because they appear later in pregnancy or might be undetectable at this stage. This is a scope of whole separate review. One thing is worth mentioning: 3D ultrasound appears useful in diagnosing fetal anomalies during the first trimester of pregnancy76. References Richards JS. 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Peri-folhcular vasculanty and m-vitro activity of human cumulus cells, markers of implantation from IVF-ET Fertil Steril 1998; 70 (Suppl): S14 47 Bhal PS, Pugh ND, Chui DK et al. The evaluation of ovanan vascular perfuson and its relationship widi outcome in IUI treatment cycles using power Doppler imaging. / Reprod Fertil 1997; 19 (Suppl.): 24 48 Gosden RG, Byatt-Smith JG. Oxygen concentration gradient across the ovanan follicular epithelium model, predictions and implications. Hum Reprod 1986; 1: 65-8 49 Fisher B, Kunzel W, Kleinstein J et al. Oxygen tension in follicular fluid falls with follicle maturation. Eur J Obstet Gynecol Reprod Biol 1992, 43: 39-43 50 Magnusson C, Hillensjo T, Hamberger L et al. Oxygen consumption by human oocytes and blastocysts grown in vitro. Hum Reprod 1986; 1: 183—4 51 Van Blerkom J, Davis PW, Lee J ATP content of human oocytes and developmental potential and outcome after in vttro fertilisation and embryo transfer Hum Reprod 1995; 10: 415-24 702 British Medical Bulletin 2000,56 (No 3) Advances in ultrasound assessment in the establishment and development of pregnancy 52 Van Blerkom J, Antczak M, Schrader R. The developmental potential of the human oocyte is related to the dissolved oxygen content of follicular fluid: association with vascular endothelial growth factor levels and penfollicular blood flow characteristics. Hum Reprod 1997; 12: 1047-55 53 Hata T, Aoki S, Manabe A et al. Three-dimensional ultrasonography in the first trimester of human pregnancy Hum Reprod 1997; 12: 1800-4 54 Hata T, Manabe A, Aoki S et al. Three-dimensional intrautenne sonography in the early firsttnmester of human pregnancy preliminary study. Hum Reprod 1998; 13: 740-3 55 Hata T, Aoki S, Miyazaki K et al. Three-dimensional ultrasonographic visualization of multiple pregnancy. Gynecol Obstet Invest 1998; 46: 26-30 56 Kurjak A, Kupesic S, Banovic I et al. The study of morphology and circulation of early embryo by three-dimensional ultrasound and power Doppler. / Pennat Med 1999; 27: 145-57 57 Valentin L, Sladkevicius P, Launni R et al. Uteroplacental and luteal circulation m normal firsttrimester pregnancies Doppler ultrasonographic and morphologic study. Am J Obstet Gynecol 1996; 174: 768-75 58 Kurjak A, Kupesic S. Doppler assessment of the intervillous blood flow in normal and abnormal early pregnancy. Obstet Gynecol 1997; 89: 252-8 59 Kurjak A, Kupesic S. Hafner T et al. Conflicting data on intervillous circulation in early pregnancy. / Perinat Med 1997; 25: 225-32 60 Carter AM. When is the maternal placental circulation established in man? Placenta 1997; 18: 83 61 Kurjak A, Zudenigo I, Predamc M et al. Assessment of the fetomatemal circulation in threatened abortion by transvaginal color Doppler. Fetal Diagn Ther 1994; 21: 521-6 62 Alcazar JL, Ruiz-Perez M. Uteroplacental circulation in patients with first trimester threatened abortion. Fertil Steril 2000; 73: 130-5 63 Schwarzler P, Holden D, Nielsen S et al. The conservative management of first trimester miscarriages and the use of colour Doppler sonography for patient selection. Hum Reprod 1999; 14: 1341-5 64 Sepulveda W. Chononicity determination in twin pregnancies: double trouble? Ultrasound Obstet Gynecol 1997; 10: 79-81 65 Bajona R, Kingdom J. The case for routine determination of chononicity and zygosity in multiple pregnancy. Prenat Diagn 1997; 17: 1207-25 66 Monteagudo A, Timor-Tntsch IE, Sharma S. Early and simple determination of chononic and amniotJC type m multifetal gestations in the first 14 weeks by high frequency transvaginal ultrasonography. Am J Obstet Gynecol 1994; 170: 824-9 67 Sepulveda W, Sebire NJ, Hughes K et al. The lambda sign at 10 to 14 weeks of gestation as a predictor of chononicity in twin pregnancies. Ultrasound Obstet Gynecol 1996, 7: 421—3 68 Sebire NJ, Smjders RJ, Hughes K et al. The hidden mortality of monochononic twin pregnancies. Br J Obstet Gynaecol 1997; 104 1203-7 69 Babinszki A, Mukherjee T, Kerenyi T et al Diagnosing amnionicity at 6 weeks of pregnancy with transvaginal three-dimensional ultrasonography: case report Fertil Steril 1999; 71: 1161-4 70 Ville Y. Monochononic twin pregnancies: 'les liaisons dangereuses'. Ultrasound Obstet Gynecol 1997; 10- 82-5 71 Brunner JP, Rosemond RL. Twin-to-twin transfusion syndrome: a subset of the twin oligohydramnios-polyhydrammos syndrome. Am] Obstet Gynecol 1993; 169: 925-30 72 Hill LM. The sonographic detection of early first trimester conjoined twins. 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Advances in ultrasound assessment in the establishment and development of pregnancy

Advances in ultrasound assessment in the establishment and development of pregnancy Current data demonstrate that angiogenesis in the...

CULTURAL IMPERIALISM: YESTERDAY, TODAY AND TOMORROW

CULTURAL IMPERIALISM: YESTERDAY, TODAY AND TOMORROW   Introduction             The paper includes a bulk of analysis about the definition and relevance of cultural imperialism.  To dig deeper to the definition of the subject, the writer tried to extract historical account about British cultural imperialism in Jamaica on the last quarter of nineteenth century, and at the same time, looked in the relatively recent Japan’s resistance to the possible threat from the West, particularly the United States, through personalizing Tokyo Disneyland.  As the initial sub-topic was focused in the past view about cultural imperialism, the second sub-topic is aimed to bridge the gap of the past and today’s relevance of the subject.  It highlights the implications of information technology and Internet boom from the West that infiltrates, with speed and accuracy, to the target consumers in the undeveloped, developing and developed countries.  Through the essay, the reader will be tossed to the broad scope of cultural imperialism which might be endless in certain aspects.  However, difficulty could be lessened due to the fact that the basic concepts about the subject will serve as the guide to understanding.   The Historical and Relatively Recent Definition of Cultural Imperialism To define cultural imperialism, one needs to think about a circle and spots within it.  A dominating political ideology, economic principle, legal system, or perhaps the delicate religious order (these are the spots, although the religion can be a large (1997), if not overlapping, spot) descends into people’s way of life through an existing and dominant culture (the circle).  With this, the way to imperialism can be withheld as long as the minority culture should be ended in the history as prerequisite for the consumption of the dominant one ( 1996).  A culture, say of a country, is so valuable to them because of its millennia-old construction that laid down the “spots within the circle”, even perhaps the Almighty One Himself, that cultural imperialism invited resistance from the minute nature of hatred to the revolutionary and patriotism-like aggressions resulted in the past centuries of wars.  This is the dominant versus the minority conflict as the common effect of cultural imperialism.  The major theme of the British rule in Jamaica from 1865 to 1920 was to transform the African-Creole inhabitants to civilized human beings through Victorian conduct teachings.  Because of the persistent culture of the early Jamaicans when it comes to decision-making, especially in aspects concerning their personal interests, the fruits of the mission of Victorian missionaries were slowly consumed and dimly observed until recently.  Before the mission began, morality was then alien to the Afro-Jamaicans that was eminent on their “illegitimate and concubinage” form of building a family, even clergymen were set to have their own families ( 2004 ).                 With the historical event in Jamaica, several conclusions could be derived towards cultural imperialism.  First, it was not strictly “armed-coercion in action strategy” ( 1985 ) to achieve its peripheral objective of material gratification for the part of the dominant country against the human and natural resources of the subject culture.  With the English partly diplomatic way of Afro-Jamaican transformation, they exemplified a constructive result of their mission with little life casualty and armed rebellion.  According to  (1985), some Jamaicans had practiced legal marriage and accepted the Christian doctrines which were attributed to the British endeavors. Second, cultural imperialism was aimed at the most-popular culture in the land that could be concluded as the British strategy to affect the greater number.  For long years, Indians and Chinese were prevalent in Jamaica, although in small number, but the mission was “hardly any effort aimed to civilize them” (1985 ).  Through this, it is clear at how the power of the politically, economically and culturally superior British minority outweighed the greater population of Jamaicans--- a result of the former thriving and visionary culture over individualism and subordination history of the latter. Lastly, the effects of cultural imperialism included adaptation on the part of the subjects over decades or even centuries of exploration if the passed-on culture was worthy to emulate.  The consumption of Jamaicans of the taught civilized manners of the British was lucidly observed not concurrent to the time of the mission but rather after it.  This could be an indication of the resistance of the popular Afro-Jamaican culture to end their history and served as the gravity that pulled the intentions of the mission rather slowly.  In more contemporary view, cultural imperialism is not exactly defined and there are no universal standard that could signal its potential, presence or on the extent of how one culture influences the other.  Such signal is important to protect a culture’s heritage and secure its continuity over time.  As culture could be corrupted by an eager one materially (through artifacts) or immaterially (behavior, norms), several culture around the globe exhibited strong stand to guard their own upon infiltration of the unpopular and implicitly-regarded poisonous foreign cultures.  As (2000) put it, strategy is for the dominant and policy is for the receiving culture.  Viewing these recent developments, a present-day meaning of cultural imperialism could be inferred.  The reign of British settlement in Jamaica was an example of the relatively slower rate of the changes effected by non-material culture than material ones (1998).  On the other hand, the case of Tokyo Disneyland in Japan experienced the latter, although the effects of Western culture transfer were less evident (1993 ).  As Afro-Jamaicans’ cultural expression and protection was hardly observable because of its intangible limitations, Japanese was the reverse.  Tokyo Disneyland was aggressively de-contextualized from the American culture to fit within the context of the receiving Japanese culture. This Japanese initiative resulted to another set of conclusions about cultural imperialism that could be derived from the general finding.  Its occurrence results in a basketball game where opponents exercise offensive-defensive tactics.  The world-wide success of Disneyland made the American influence in offense mode, as the country is known for, and imparts spots of cultural imperialism. However, Japanese defense is so aggressive that the Western representative barely had a buried shot.  This defense was carried out far different and far tough from those showed by the Jamaicans seen in several modifications in the original lay-out and operations of Disneyland as conceptualized by the West. The self-expressionism of Japan brushed into the Tokyo Disneyland was made possible not only because of territorial aspect but more importantly due to the superb characteristics of the country.  Japan is “extremely a homogeneous society” ( 2004).  This fact blended into the economic affluence and political stability of the country in terms of leadership.  Leaders ruled dedicating their service until death like that of six decade-reign of Hirohito while the economic industrialization emerged as early as late nineteenth century ( 2004).  The inherent ideal government and economic structures in Japan made it independent and self-supporting that it needed little imports from the outside.  This could be one of the biggest barriers paralyzing the mechanism of cultural imperialism.     The same cultural modification at Tokyo Disneyland, the adoption of the Western originated Taylorism and Fordism in the Japanese business setting did not taken for granted the inclusion of Japanese theme.  The idea was still in action that required the transfer to suit the taste of the receiving country.  Group-goal orientation of the Japanese workplace was prioritized over the Western individual responsibilities ( 1994).  A sign that defense was present at all phases of Japanese life and the abundance also present in all phases of the country paid-off to elude the effects of cultural imperialism, or at least, to avoid its obvious impact that could damage the millennia-old history of the samurai-based dwelling.        With the Jamaican and Japan examples, the definition of cultural imperialism is timely to unfold.  Cultural imperialism is the “practice of promoting the culture or language of one nation in another.  It can take the form of an active, formal policy or general attitude” (2006).  The limitation of this is the blurred and broad meaning of the phrase “practice of promoting” and the absence of defining the effects of the word itself.  As obtained in the Jamaican and Japanese experiences, the culture promotion could take different mediums that can be cloaked with good intentions (a situation of civilizing the Afro-Jamaicans) or engraved on product patents where imported culture lies (a situation of Western Disneyland).  These media did not include the military-led coercion that ignited the World Wars where cultural differences motivated the extent of conflict.  Other media were unidentified because of the implicit nature of cultural imperialism as cause of war. Also, the effects mentioned here were not drastic and involved long period of adaptation to suit the receiving culture.  As complex and historical as it is, cultural imperialism direct effects to the lives of those affected could be isolated (as in the case of popular and persistent Jamaican personal-decision making) and hardly felt (as in the case of Tokyo Disneyland modification).  The important finding of the analysis is that the extent of the success of cultural imperialism invoked by a dominant culture to the receiving is grounded to the initiative and drive of the former, including its own definition of cultural imperialism, to affect the latter.  At the periphery, the rational dominant culture must demonstrate dominance and the capability to imperialize inferable not only to political, economic and military aspects, but more importantly, in the dominant culture itself (like the millennia-old culture of Japan that made it polished and resistant).  After this establishment, the dominant culture should infused harmony with receiving culture and wait until adaptation is observable.  Until then, cultural imperialism could achieve its purpose.             For the share of the receiving culture in the success or failure of cultural imperialism, the characteristics of the insisting culture of Jamaicans and culture-independence of Japanese were situated to block, at least initially (Jamaica) and focus to eradicate obvious features (Japan), the presence of cultural imperialism and mitigate its effects.  These guardians of culture are on top of the blazing patriotism to one’s country that was proven as reaction to oppression and intention to take away the most-celebrated mark of a civilization--- freedom.  Until the dominating culture does not resort to military imperialism, it will continue to be implicitly engraved within material and immaterial context imported by a receiving culture subject to transformation the latter deemed necessary to maintain the culture of their own. The Present and Future Relevance of Cultural Imperialism             Before the discussion under this sub-topic, it is noteworthy to reiterate the prevention of the above discussions to forward the notion of cultural clashes in the context of nation-to-nation collision strictly, although Jamaica and Japan situation was put into such standard.  This is assumed fitted because subaltern, another term for subordination (1999), culture is happening more explicitly within a country itself prominent with issues concerning cultural minorities voice within the dictatorship of the popular culture.  With the initial knowledge of receiving culture, being subaltern in the international arena destroys its shield that prevents the spread of cultural imperialism.  In the same manner, the concern is the equivalent in the local setting.  The United States, coined as one of the well-described cultural imperialist in history, have subaltern environment that resulted to conflicts across American diversity: homosexuals, black and white, diverging curriculum framework and disagreeing opinions concerning abortion, pornography, and school prayer (1996 ).  As the country is “largely immune to cultural expressions that do not project an American sensibility,” (2002) cultural imperialism could be tapped to unify differences.  Thus, cultural imperialism can be witnessed by people who live on the same soil like the dominant culture.  But for the remaining discussion, the above definition of cultural imperialism () seemed as a useful tool to obtain simplicity, and therefore, a wise move to apply.       The argument of  (1998) reflected the needed evidence that information age brought cultural imperialism into the rest of the world. “The Internet is like an American (or Western) tidal wave coming, and the rest of the world is in kayaks,” is the metaphor of how dominant culture tests its dominance against others through the infusion of Western material and immaterial cultures to produce hardware, software and content of computers/ Internet.  Several implications are accounted to the receiving countries.  Undeveloped and Developed countries are extremely opposite in terms of political and economic attributes but could have parallel stand (defense) against the technological proliferation.  The former can be depicted in most countries of African region (except Botswana, South Africa and Nigeria) that are identified as primarily agriculture-dependent, unstable political system, propagation of health problems like AIDS and occurrence of violent separatist movement like in Casamance ( 2004 , 2006).  As these characteristics are hardly compatible with the advancement of Western technology, cultural imperialism would be ridiculed when initiated.  If however tried, it would involve considerable amount of financing, time and line of programs to infuse dominance and succeed to influence their culture.  For the developed countries like Japan, the above-mentioned national affluence and cultural heritage are the clear obstacles in the Western initiative of cultural imperialism.  Even though, the nation has lucrative features at the extreme of Africa, cultural pillars etched in all facets of life (from the government down to the people) are built against the threat of foreign influence.  In relation to the western technology, Japan 1995 data showed its share was a minimal 2% among the Internet hosts all over the world (1998).  It was not entirely an anti-cultural imperialism intended to mitigate the influence of the West but rather a result of exhibiting “a way of life” that Japanese had treasured through its history.  The country is the world leader in automobile production but consume less of such products than any other G -7 nations (1998).  These unusual data were possible from a country that possesses a “clearly delineated, highly formalized, benevolently paternalistic arrangement of people bound together in predominantly face-to-face dependency relationships” (1998). Apart from these two, developing countries display relatively conducive environment for cultural imperialism.  These countries like the Philippines or China requires the fuel to stimulate the local economy which can be provided by opening the trade barriers from the outside.  With the command of information technology to link different countries, developing nations benefit to the “services not available to them domestically” (1996).  The opening, however, is not exclusively entrenched to trade relations.  It could also provide an entry point to the mechanisms of cultural imperialism.  This claim calls for the policy of the receiving country or its effects can devastate their culture initially at small increments until the foundations are eaten up. Since “fuel” is required to run and make active the developing economy, policy-makers would choose to grant this requirement since international trade is the trend and result of globalization.  Besides, effects to the receiving culture are seen indirectly through artifacts.  However, open-mindedness entails flexibility and flexibility is achieved through stability and strong culture.  Thus, a country lacks flexibility if it cannot support its own supply of local food, except in times of fortuitous disasters, or cannot solve its own internal conflict with the leftist.  With the absence of political and economic dependence like Japan, everything about the exports, including the mechanisms of cultural imperialism, could be consumed because of too much dependency.  The receiving country might end up a puppet by the dominant one who enlarges the restrictions of the trade opening up to the extent of cultural infiltration.  On the other hand, Japan did not modify features of Tokyo Disneyland from the original California- and Florida-type in terms of customer relations of the employees.  The courtesy mind-set blended the Japanese culture and also written in the country’s working standards of employees (1993).  This is an indication that selective approach to the presence and effects of cultural imperialism can achieve optimal benefits.  Good and positive spills of cultural imperialism need not be ignored and prohibited in the strict and myopic ground of cultural insubordination.  Like Japanese, who see themselves having a dominant culture, had accepted the Western influence because it suited their treasured values, although cultural imperialism had presence, its effects were lessened. The concern is now emphasized to Tibet.  There was an admonition of cultural imperialism by the Western countries against China’s mission to uplift the Tibetan cultural defects as the result partly of Cultural Revolution.  Data showed that Tibet has “life expectancy of thirty-six years; 95 percent of Tibetans were illiterate; 95 percent of the population was hereditary serfs and slaves owned by monasteries and nobles, and the cutting of the slaves and enemies’ head is popular” (1999).  Is the provision of good and meaningful life under cultural imperialism worthy to disregard, or at least, set aside for the meantime the popular culture as the developments are ensued?  The answer is a matter of survival on one hand and cultural protection on the other.  Tibetans could choose the two and realize the ideal or select only one and lead to reality.      Conclusion             As the time goes by, the definition of cultural imperialism adapts to the level of changes across different countries.  The purpose is clear as to civilize the Afro-Jamaicans in the last quarter of the nineteenth century.  While the Japan experience recently did not clearly establish the purpose, their ways and actions toward the Disneyland modification was enough to consider their avoidance of possible occurrence of cultural imperialism.              The present and future purpose of such was becoming hi-tech as the emergence of information technology and Internet in the industrial relations.  Its meaning becomes even blurred and broad as the world approach mutation from the historic samurai to the digital age.  For the undeveloped and developed countries, the impact to culture could be prevented.  But for the developing countries, extra-caution should be given into contract entered to identify trade zones or commonly termed as free trade areas.  More importantly, the dynamism of information technology should also be checked because it is capable to transmit information in a blink of an eye.  The giant leap towards development should begin not just with a single step, but more crucially, to carry the pride and heritage of the ancestry.  Such additional burden or constraint to developmental journey is not intended to increase the load alone.  It is an indication that the nation is stable and enthusiastic to achieve its goal.

CULTURAL IMPERIALISM: YESTERDAY, TODAY AND TOMORROW

CULTURAL IMPERIALISM: YESTERDAY, TODAY AND TOMORROW Introduction The paper includes a bulk of analysis about the def...