Mosaic derivative chromosomes at chorionic villi (CV) sampling are expression of genomic instability and precursors of cryptic disease-causing rearrangements: report of further four cases

Mosaic chromosomal anomalies arising in the product of conception and the final fetal chromosomal arrangement are expression of complex biological mechanisms. The rescue of unbalanced chromosome with selection of the most viable cell line/s in the embryo and the unfavourable imbalances in placental tissues was documented in our previous paper and in the literature. We report four additional cases with mosaic derivative chromosomes in different feto-placental tissues, further showing the instability of an intermediate gross imbalance as a frequent mechanism of de novo cryptic deletions and duplications. In conclusion we underline how the extensive remodeling of unbalanced chromosomes in placental tissues represents the 'backstage' of de novo structural rearrangements, as the early phases of a long selection process that the genome undergo during embryogenesis.

Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment

Smaller pelvic floor dimensions seem to have been an evolutionary need to provide adequate support for the pelvic organs and the fetal head. Pelvic floor dimension and shape contributed to the complexity of human birth. Maternal pushing associated with pelvic floor muscle relaxation is key to vaginal birth. Using transperineal ultrasound, pelvic floor dimensions can be objectively measured in both static and dynamic conditions, such as pelvic floor muscle contraction and pushing. Several studies have evaluated the role of the pelvic floor in labor outcomes. Smaller levator hiatal dimensions seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Furthermore, smaller levator hiatal dimensions are associated with a higher fetal head station at term of pregnancy, as assessed by transperineal ultrasound. With maternal pushing, most women can relax their pelvic floor, thus increasing their pelvic floor dimensions. Some women contract rather than relax their pelvic floor muscles under pushing, which is associated with a reduction in the anteroposterior diameter of the levator hiatus. This phenomenon is called levator ani muscle coactivation. Coactivation in nulliparous women at term of pregnancy before the onset of labor is associated with a higher fetal head station at term of pregnancy and a longer duration of the second stage of labor. In addition, levator ani muscle coactivation in nulliparous women undergoing induction of labor is associated with a longer duration of the active second stage of labor. Whether we can improve maternal pelvic floor relaxation with consequent improvement in labor outcomes remains a matter of debate. Maternal education, physiotherapy, and visual feedback are promising interventions. In particular, ultrasound visual feedback before the onset of labor can help women increase their levator hiatal dimensions and correct levator ani muscle coactivation in some cases. Ultrasound visual feedback in the second stage of labor was found to help women push more efficiently, thus obtaining a lower fetal head station at ultrasound and a shorter duration of the second stage of labor. The available evidence on the role of any intervention aimed to aid women to better relax their pelvic floor remains limited, and more studies are needed before considering its routine clinical application.

When time is brain: a systematic review about Wernicke encephalopathy as a dramatic consequence of thiamin deficiency in hyperemesis gravidarum

Nausea and vomiting affect up to 80% of all pregnancies, sometimes so severely that the condition of hyperemesis gravidarum (HG) is established. HG may in addition be a predisposing factor for Wernicke encephalopathy (WE), a severe and life-threatening condition due to vitamin B1 (thiamin) deficiency. If untreated, WE may progress to Korsakoff's syndrome, an irreversible cognitive disorder. We reported a case that recently occurred at our clinic and performed a systematic review of the literature to investigate the clinical presentation, maternal and perinatal outcomes and treatment of WE in women with HG.

METHODS

We performed a systematic review of case series and case reports searching the Medline database on Pubmed from inception until December 2021. We used as search terms (Wernicke encephalopathy) OR (Wernicke-Korsakoff syndrome) AND (hyperemesis gravidarum) AND (pregnancy) AND (thiamin deficiency). Articles were considered eligible for inclusion in our review if they described at least one case of WE due to thiamin deficiency in relation to HG. An overall of 82 cases of WE due to HG in pregnancy from 66 manuscripts, including our own, were selected.

RESULTS

The maternal mean age was 26.38 ± 5.23 years, while mean gestational week at hospitalization was 14.57 ± 4.12 after a mean of 6.6 ± 3.14 weeks of vomiting duration. WE manifestation occurred at a mean gestational age of 16.54 ± 3.06 weeks. Regarding clinical presentation, ocular signs and symptoms were reported by 77/82 (93.9%) women, 61/82 (74.4%) presented with ataxia and 63/82 (76.8%) with confusion. Dysarthria affected 15/82 women (18,3%), while muscular weakness was present in 36/82 (43.9%) and impaired reflexes in 42/82 (51.2%). Memory impairment involved 25/82 (30.5%) of the study population. Almost all cases reported a thiamin administration treatment, however data regarding the clinical course of the neurological condition and the perinatal outcomes were often missing and showed a great heterogeneity when reported.

CONCLUSION

WE is a challenging diagnosis, as its clinical presentation is nonspecific. A high clinical suspicion and the awareness of its possible predisposing conditions such as HG may help clinicians to get a prompt diagnosis and starting treatment, which are vital to prevent possible life-impairing neurological sequelae.

Mode of delivery and peripartum outcome in women with heart disease according to the ESC guidelines: an Italian multicenter study

INTRODUCTION

The European Society of Cardiology (ESC) guidelines (GL) provide indications on the mode of delivery in women with heart disease. However available data suggests that the rate of Cesarean Delivery (CD) is high and widely variable among such patients. In this study, we aimed to investigate the degree of adherence to the ESC recommendations among women delivering in four tertiary maternity services in Italy and how this affects the maternal and neonatal outcomes.

MATERIAL AND METHODS

Retrospective multicenter cohort study including pregnant women with heart disease who gave birth between January 2014 and July 2020. Composite adverse maternal outcome (CAM) was defined by the occurrence of one or more of the following: major postpartum hemorrhage, thrombo-embolic or ischemic event, de novo arrhythmia, heart failure, endocarditis, aortic dissection, need for re-surgery, sepsis, maternal death. Composite Adverse Neonatal outcome (CAN) was defined as cord arterial pH <7.00, APGAR <7 at 5 min, admission to the intensive care unit, and neonatal death. We compared the incidence of CAM and CAN between the cases with planned delivery in accordance (group "ESC consistent") or in disagreement (group "ESC not consistent") with the ESC GL.

RESULTS

Overall, 175 women and 181 liveborn were included. A higher frequency of CAN was found when delivery was not planned accordingly to the ESC guidelines [("ESC consistent" 9/124 (7.2%) vs "ESC not consistent" 13/57 (22.8%) p = 0.002 OR 3.74 (CI 95% 1.49-9.74) , while the occurrence of CAM was comparable between the two groups. At logistic regression analysis, the gestational age at delivery was the only parameter independently associated with the occurrence of CAN (p = 0.006).

CONCLUSION

Among pregnant women with heart disease, deviating from the ESC guidelines scheduling cesarean delivery does not seem to improve maternal outcomes and it is associated with worse perinatal outcomes, mainly due to lower gestational age at birth.

A case of massive fetal cardiac rhabdomyoma: ultrasound features and management

We report the case of a massive fetal cardiac rhabdomyoma recently occurred at our clinic. A woman at 23 weeks of gestational age was referred to our center for a fetal cardiac echogenic mass of 26 mm detected at the second-trimester screening ultrasound. During pregnancy, though, the mass progressively increased its dimensions until reaching 48 mm in diameter at 37 weeks of gestation. Fetal echoencephalography and brain magnetic resonance did not show any further fetal anomalies, but molecular genetic testing at amniocentesis revealed a heterozygotic missense variant of gene TSC2 associated with Tuberous Sclerosis. The mass was therefore most likely preferable to a single large rhabdomyoma of gradually increasing dimensions. The baby was delivered at term with a cesarean section. Because of the rhabdomyoma remarkable size and newborn ECG electrical alterations, postnatal therapies with Flecainide and Everolimus were started. Everolimus treatment led to a significant and progressive reduction in the cardiac mass volume. This case, therefore, shows the efficacy of what seems to be a promising treatment in pediatric patients with large rhabdomyomas.Learning points:Rhabdomyomas may present with different features: most often they appear as multiple masses along the interventricular sept, but they may also appear as a single large thoracic mass.When a rhabdomyoma is suspected, genetic counseling is recommended.Both before and after birth, a multidisciplinary approach is useful to choose the appropriate therapy for the newborn.mTOR inhibitors therapies look like promising therapeutic approaches to stimulate the involution of rhabdomyomas.

The prediction of hypertensive disorders by maternal hemodynamic assessment in the first trimester of pregnancy

BACKGROUND

Hypertensive disorders of pregnancy and fetal growth restriction share common etiopathological origins and could be caused by maternal hemodynamic maladaptation to pregnancy.

OBJECTIVE

The aim of our study is to evaluate if there is a correlation between maternal hemodynamic detected by UltraSonic Cardiac Output Monitor (USCOM^®) during the first trimester and the pregnancy outcome.

STUDY DESIGN

We recruited a nonconsecutive series of women in the first trimester of pregnancy with no previous history of hypertensive disorders. We measured the pulsatility index uterine arteries and performed a hemodynamic evaluation by USCOM^® device. After delivery, we reported the development of hypertensive disorders or intrauterine fetal growth restriction later during gestation.

RESULTS

A total of 187 women were enrolled during the first trimester; 17 (9%) developed gestational hypertension or preeclampsia while 11 (6%) delivered a restricted growth fetus. Mean uterine artery pulsatility index above the 95th percentile was significantly more frequent in both women who developed hypertension and those with fetal growth restriction compared to controls. Hemodynamic parameters (reduced cardiac output and increased total vascular resistance) were significantly different in the group that developed hypertensive disorders, compared to uncomplicated pregnancy. ROC curves demonstrated the usefulness of uterine artery pulsatility index in the prediction of fetal growth restriction, while hemodynamic parameters were significantly associated to the development of hypertensive disorders.

CONCLUSIONS

Hemodynamic maladaptation to pregnancy may predispose to the development of hypertension, while we demonstrated a significative relationship between growth restriction and mean uterine pulsatility index. Further studies are needed to assess the value of hemodynamics evaluation in screening protocols of preeclampsia.

The "cortical invagination sign": a midtrimester sonographic marker of unilateral cortical focal dysgyria in fetuses with complete agenesis of the corpus callosum

BACKGROUND

Agenesis of the corpus callosum is associated with several malformations of cortical development. Recently, features of focal cortical dysgyria have been described in fetuses with agenesis of the corpus callosum.

OBJECTIVE

This study aimed to describe the "cortical invagination sign," a specific sonographic feature of focal cortical dysgyria, which is consistently seen at midtrimester axial brain ultrasound in fetuses with complete agenesis of the corpus callosum.

STUDY DESIGN

This was a retrospective analysis of prospectively collected data from 2018 to 2021, including patients referred to 5 fetal medicine centers in the second trimester of pregnancy (19 0/7 to 22 0/7 weeks of gestation) with suspected complete agenesis of the corpus callosum. All cases with the diagnosis of complete agenesis of the corpus callosum were submitted to an axial sonographic assessment of the fetal brain on the transventricular plane. In this scanning section, the mesial profile of both cerebral hemispheres at the level of the frontal-parietal cortex was investigated. In this area, the operator looked for an abnormal invagination of the cortical surface along the widened interhemispheric fissure, which was referred to as the "cortical invagination sign." All fetuses were submitted to dedicated antenatal magnetic resonance imaging to reassess the ultrasound findings. Cases with additional brain anomalies, which did not involve the cortex, were excluded. The final diagnosis was confirmed at postnatal brain magnetic resonance imaging or postmortem examination, for cases undergoing termination of pregnancy. The primary outcome of this study was to evaluate the presence and laterality of the "cortical invagination sign" in fetuses with complete agenesis of the corpus callosum at antenatal ultrasound and magnetic resonance imaging.

RESULTS

During the study period, 64 cases of complete agenesis of the corpus callosum were included; of those cases, 50 (78.1%) resulted in termination of pregnancy, and 14 (21.9%) resulted in a live birth. The "cortical invagination sign" was detected at ultrasound in 13 of 64 cases (20.3%) and at targeted brain magnetic resonance imaging in 2 additional cases (23.4%), all of which were electively terminated. Moreover, the "cortical invagination sign" was found to be exclusively unilateral and on the left cerebral hemisphere in all the cases. There was a predominant number, although nonsignificant, of male fetuses (80.0% of cases; P=.06) in the group of complete agenesis of the corpus callosum with the "cortical invagination sign."

CONCLUSION

The "cortical invagination sign" is a specific marker of focal cortical dysgyria, which seems to characterize at midtrimester of pregnancy in a large group of fetuses with complete agenesis of the corpus callosum. The etiology, pathophysiology, and prognostic significance of this finding remain to be elucidated.

Identification of Fetuses at Increased Risk of Trisomies in the First Trimester Using Axial Planes

INTRODUCTION

The measurement of nuchal translucency (NT) is crucial for assessing risk of aneuploidies in the first trimester. We investigate the ability of NT assessed by a transverse view of the fetal head to detect fetuses at increased risk of common aneuploidies at 11-13 weeks of gestation.

METHODS

We enrolled a nonconsecutive series of women who attended our outpatient clinic from January 2020 to April 2021 for aneuploidy screening by means of a first trimester combined test. All women were examined by operators certified by the Fetal Medicine Foundation. In each patient, NT measurements were obtained both from the median sagittal view and transverse view. We calculated the risk of aneuploidy using NT measurements obtained both with sagittal and axial scans, and then we compared the results.

RESULTS

A total of 1,023 women were enrolled. An excellent correlation was found between sagittal and transverse NT measurements. The sensitivity and specificity of the axial scan to identify fetuses that were deemed at risk of trisomy 21 using standard sagittal scans were 40/40 = 100.0% (95% confidence interval [CI]: 91.2-100.0) and 977/983 = 99.4% (95% CI: 98.7-99.7), respectively. The sensitivity and specificity of the axial scan to identify fetuses at risk of trisomy 13 or 18 were 16/16 = 100.0% (95% CI: 80.6-100.0) and 1,005/1,007 = 99.8% (95% CI: 99.3-99.9).

CONCLUSIONS

When the sonogram, a part of combined test screening, is performed by an expert sonologist, axial views can reliably identify fetuses at increased risk of trisomies without an increase in false negative results.

Neurodevelopmental outcomes of very preterm infants born following early foetal growth restriction with absent end-diastolic umbilical flow

This study aims to assess the impact of time of onset and features of early foetal growth restriction (FGR) with absent end-diastolic flow (AEDF) on pregnancy outcomes and on preterm infants' clinical and neurodevelopmental outcomes up to 2 years corrected age. This is a retrospective, cohort study led at a level IV Obstetric and Neonatal Unit in Bologna, Italy. Pregnant women were eligible if having singleton pregnancies, with no major foetal anomaly detected, and diagnosed with early FGR + AEDF (defined as FGR + AEDF detected before 32 weeks gestation). Early FGR + AEDF was further classified according to time of onset and specific features into very early and persistent (VEP, FGR + AEDF first detected at 20-24 weeks gestation and persistent at the following scans), very early but transient (VET, FGR + AEDF detected at 20-24 weeks gestation and progressively improving at the following scans) and later (LA, FGR + AEDF detected between 25 and 32 weeks gestation). Pregnancy and neonatal outcomes and infant follow-up data were collected and compared among groups. Neurodevelopment was assessed using the revised Griffiths Mental Developmental Scales (GMDS-R) 0-2 years. A regression analysis was performed to identify early predictors of preterm infants' neurodevelopmental impairment. Fifty-two pregnant women with an antenatal diagnosis of early FGR + AEDF were included in the study (16 VEP, 14 VET, 22 LA). Four intrauterine foetal deaths occurred, all in the VEP group (p = 0.010). Compared to LA infants, VEP infants were born with lower gestational age and lower birth weight, had lower arterial cord blood pH and were at higher risk for intraventricular haemorrhage and periventricular leukomalacia (p < 0.05 for all comparisons). At 12 months, VEP infants had worse GMDS-R scores, both in the general quotient (mean [SD] 91.8 [12.4] vs 104.6 [8.7] in LA) and in the performance domain (mean [SD] 93.3 [15.4] vs 108.8 [8.8] in LA). This latter difference persisted at 24 months (mean [SD] 68.3 [17.0] vs 92.9 [17.7] in LA). In multivariate analysis, at 12 months corrected age, PVL was found to be an independent predictor of impaired general quotient, while the features and timing of antenatal Doppler alterations predicted worse scores in the performance domain.   Conclusion: Timing of onset and features of early FGR + AEDF might impact differently on neonatal clinical and neurodevelopmental outcomes. Shared awareness of the importance of FGR + AEDF features between obstetricians and neonatologists may offer valuable tools for antenatal counselling and for tailoring pregnancy management and neonatal follow-up in light of specific antenatal and neonatal risk factors. What is Known: • Foetal growth restriction (FGR), together with antenatal umbilical Doppler abnormalities, is known to affect maternal and neonatal outcomes. • Infants born preterm and growth-restricted face the highest risk for neurodevelopmental impairment, especially when FGR occurs early during pregnancy (early FGR, before 32 weeks gestation). What is New: • The timing of onset and features of FGR and antenatal umbilical Doppler abnormalities impact differently on maternal and neonatal outcomes; when FGR and Doppler abnormalities occur very early, at the limit of neonatal viability, and persist until delivery, infants face the highest risk for neurodevelopmental impairment. • Shared knowledge between obstetricians and neonatologists about timing of onset and features of FGR would provide a valuable tool for informed antenatal counselling in high-risk pregnancies.

Comparison between vaginal and laparoscopic cerclage in women with mid-trimester pregnancy loss or history of spontaneous preterm delivery

BACKGROUND

Women with unfavorable obstetric history can benefit from prophylactic cerclage ("history indicated") which can be performed vaginally or transabdominally with laparoscopic techniques. The aim of our study is to evaluate the effectiveness in the prevention of preterm birth of the vaginal technique and of the minimally invasive laparoscopic technique in women with an unfavorable obstetric history.

METHODS

This was a retrospective cohort study examining elective cerclages performed in women with adverse obstetrics history. The primary outcome was rate of early preterm and second trimester deliveries while other outcomes analyzed were surgical complications, the time needed for cerclage procedures, live birth rate, gestational age at delivery, birth weight, Apgar score.

RESULTS

Data from 64 women were analyzed; among them, 14 underwent a laparoscopic procedure (22%) while 50 a vaginal cerclage (78%). The two groups were homogeneous in terms of demographic characteristics, but of course differed significantly in terms of obstetrics history, as well as for the surgical indications of cerclage procedures. The rate of early preterm deliveries and second trimester miscarriage were the same in the vaginal and laparoscopic group (8%), comparable to what was reported in literature. The operative time was longer in the laparoscopic group, but with similar duration of the hospital stay. We reported no intraoperative complications in both groups.

CONCLUSIONS

As the laparoscopic procedure, usually reserved for women with a previous failed vaginal cerclage, has been proved to be equally safe and effective, it may could be proposed to a wider group of women. Prospective randomized studies are needed to provide new and conclusive data about this topic.

Obliterated cavum septi pellucidi: Clinical significance and role of fetal magnetic resonance

INTRODUCTION

The objective of this study was to describe a cohort of fetuses with an ultrasound prenatal diagnosis of obliterated cavum septi pellucidi (oCSP) with the aim to explore the rate of associated malformations, the progression during pregnancy and the role of fetal magnetic resonance imaging (MRI).

MATERIAL AND METHODS

This was a retrospective multicenter international study of fetuses diagnosed with oCSP in the second trimester with available fetal MRI and subsequent ultrasound and/or fetal MRI follow-up in the third trimester. Where available, postnatal data were collected to obtain information on neurodevelopment.

RESULTS

We identified 45 fetuses with oCSP at 20.5 weeks (interquartile range 20.1-21.1). oCSP was apparently isolated at ultrasound in 89% (40/45) and fetal MRI found additional findings in 5% (2/40) of cases, including polymicrogyria and microencephaly. In the remaining 38 fetuses, fetal MRI found a variable amount of fluid in CSP in 74% (28/38) and no fluid in 26% (10/38). Ultrasound follow-up at or after 30 weeks confirmed the diagnosis of oCSP in 32% (12/38) while fluid was visible in 68% (26/38). At follow-up MRI, performed in eight pregnancies, there were periventricular cysts and delayed sulcation with persistent oCSP in one case. Among the remaining cases with normal follow-up ultrasound and fetal MRI findings, the postnatal outcome was normal in 89% of cases (33/37) and abnormal in 11% (4/37): two with isolated speech delay, and two with neurodevelopmental delay secondary to postnatal diagnosis of Noonan syndrome at 5 years in one case and microcephaly with delayed cortical maturation at 5 months in the other.

CONCLUSIONS

Apparently isolated oCSP at mid-pregnancy is a transient finding with the visualization of the fluid later in pregnancy in up to 70% of cases. At referral, associated defects can be found in around 11% of cases at ultrasound and 8% at fetal MRI indicating the need for a detailed evaluation by expert physicians when oCSP is suspected.

Increased nuchal translucency can be ascertained using transverse planes

BACKGROUND

The detection of increased nuchal translucency is crucial for the assessment risk of aneuploidies and other fetal anomalies.

OBJECTIVE

This study aimed to investigate the ability of a transverse view of the fetal head to detect increased fetal nuchal translucency at 11 to 13 weeks of gestation.

STUDY DESIGN

This was a prospective study enrolling a nonconsecutive series of women who attended our outpatient clinic from January 2020 to April 2021 for combined screening and were examined by operators certified by the Fetal Medicine Foundation. In each patient, nuchal translucency measurements were obtained both from a median sagittal view and from a transverse view. A second sonologist blinded to the results of the first examination obtained another measurement to assess intermethod and interobsever reproducibility.

RESULTS

A total of 1023 women were enrolled. An excellent correlation was found between sagittal and transverse nuchal translucency measurements, with a mean difference of 0.01 mm (95% confidence interval, -0.01 to 0.02). No systematic difference was found between the 2 techniques. The inter-rater reliability (intraclass correlation coefficient, 0.957; 95% confidence interval, 0.892-0.983) and intrarater reliability (intraclass correlation coefficient, 0.976; 95% confidence interval, 0.941-0.990) of axial measurements were almost perfect. Transverse measurements of 3.0 mm identified all cases with sagittal measurements of ≥3.0 with a specificity of 99.7%; transverse measurements of >3.2 mm identified all cases with sagittal measurements of 3.5 mm with a specificity of 99.7%. The time required to obtain transverse nuchal translucency measurements was considerably shorter than for sagittal measurements, particularly when the fetus had an unfavorable position.

CONCLUSION

When the sonogram is performed by an expert sonologist, the difference in nuchal translucency measurement obtained with a transverse or sagittal plane is minimal. Increased nuchal translucency can be reliably identified by using transverse views, and in some cases, this may technically be advantageous.

Hypertensive disorders and maternal hemodynamic changes in pregnancy: monitoring by USCOM® device

Hypertensive disorders are quite common, complicating about 10% of pregnancies, while preeclampsia occurs in 2-8% of cases. The most recognized etiopathogenetic factor for the development of preeclampsia is deficient remodeling of the spiral arteries during trophoblastic invasion. Recently, some authors speculated about the "cardiovascular origin of preeclampsia"; in particular, they postulate that placental dysfunction is not the primum movens of preeclampsia, but it could be caused by a failure of the maternal cardiovascular system to adapt to the pregnancy itself. Moreover, several studies have also shown that developing preeclampsia in pregnancy is associated with an increased risk of cardiovascular disease later in life. Due to the importance of this pathology, it would be crucial to have an effective screening in order to implement a prophylaxis; for this purpose, it could be useful to have an accurate and noninvasive device for the assessment of maternal hemodynamic variables. USCOM^® (Ultrasonic Cardiac Output Monitor) is a noninvasive Doppler ultrasonic technology which combines accuracy, reproducibility, noninvasiveness, and a fast learning curve. Maternal hemodynamic evaluation is important in order to monitor the changes that the maternal organism encounters, in particular a reduction in blood pressure, a decrease in total peripheral resistances, and an increase in cardiac output, resulting in a hyperdynamic circle. These hemodynamic modifications are lacking in pregnancies complicated by preeclampsia. For these reasons, it is crucial to have a tool that allows these parameters to be easily evaluated in order to identify those women at higher risk of hypertensive complications and more severe outcomes.

Sonographic knowledge of occiput position to decrease failed operative vaginal delivery: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This study aimed to assess the efficacy of sonographic assessment of fetal occiput position before operative vaginal delivery to decrease the number of failed operative vaginal deliveries.

DATA SOURCES

The search was conducted in MEDLINE, Embase, Web of Science, Scopus, ClinicalTrial.gov, Ovid, and Cochrane Library as electronic databases from the inception of each database to April 2021. No restrictions for language or geographic location were applied.

STUDY ELIGIBILITY CRITERIA

Selection criteria included randomized controlled trails of pregnant women randomized to either sonographic or clinical digital diagnosis of fetal occiput position during the second stage of labor before operative vaginal delivery.

METHODS

The primary outcome was failed operative vaginal delivery, defined as a failed fetal operative vaginal delivery (vacuum or forceps) extraction requiring a cesarean delivery or forceps after failed vacuum. The summary measures were reported as relative risks or as mean differences with 95% confidence intervals using the random effects model of DerSimonian and Laird. An I² (Higgins I²) >0% was used to identify heterogeneity.

RESULTS

A total of 4 randomized controlled trials including 1007 women with singleton, term, cephalic fetuses randomized to either the sonographic (n=484) or clinical digital (n=523) diagnosis of occiput position during the second stage of labor before operative vaginal delivery were included. Before operative vaginal delivery, fetal occiput position was diagnosed as anterior in 63.5% of the sonographic diagnosis group vs 69.5% in the clinical digital diagnosis group (P=.04). There was no significant difference in the rate of failed operative vaginal deliveries between the sonographic and clinical diagnosis of occiput position groups (9.9% vs 8.2%; relative risk, 1.14; 95% confidence interval, 0.77-1.68). Women randomized to sonographic diagnosis of occiput position had a significantly lower rate of occiput position discordance between the evaluation before operative vaginal delivery and the at birth evaluation when compared with those randomized to the clinical diagnosis group (2.3% vs 17.7%; relative risk, 0.16; 95% confidence interval, 0.04-0.74; P=.02). There were no significant differences in any of the other secondary obstetrical and perinatal outcomes assessed.

CONCLUSION

Sonographic knowledge of occiput position before operative vaginal delivery does not seem to have an effect on the incidence of failed operative vaginal deliveries despite better sonographic accuracy in the occiput position diagnosis when compared with clinical assessment. Future studies should evaluate how a more accurate sonographic diagnosis of occiput position or other parameters can lead to a safer and more effective operative vaginal delivery technique.

A prenatal standard for fetal weight improves the prenatal diagnosis of small for gestational age fetuses in pregnancies at increased risk

Objective

Our aim was to assess diagnostic accuracy in the prediction of small for gestational age (SGA <10th centile) and fetal growth restricted (FGR) (SGA <3rd centile) fetuses using three different sonographic methods in pregnancies at increased risk of fetal growth restriction: 1) fetal abdominal circumference (AC) z-scores, 2) estimated fetal weight (EFW) z-scores according to postnatal reference standard; 3) EFW z-scores according to a prenatal reference standard.

Methods

Singleton pregnancies at increased risk of fetal growth restriction seen in two university hospitals between 2014 and 2015 were studied retrospectively. EFW was calculated using formulas proposed by the INTERGROWTH-21st project and Hadlock; data derived from publications by the INTEGROWTH-twenty-first century project and Hadlock were used to calculate z-scores (AC and EFW). The accuracy of different methods was calculated and compared.

Results

The study group included 406 patients. Prenatal standard EFW z-scores derived from INTERGROWTH-21st project and Hadlock and co-workers performed similarly and were more accurate in identifying SGA infants than using AC z-scores or a postnatal reference standard. The subgroups analysis demonstrated that EFW prenatal standard was more or similarly accurate compared to other methods across all subgroups, defined by gestational age and birth weight.

Conclusions

Prenatal standard EFW z-scores derived from either INTERGROWTH-21 st project or Hadlock and co-workers publications demonstrated a statistically significant advantage over other biometric methods in the diagnosis of SGA fetuses.

The correlation between levator ani co-activation and fetal head regression on maternal pushing at term

OBJECTIVE

To assess the correlation between fetal head regression and levator ani muscle (LAM) co-activation under Valsalva maneuver.

STUDY DESIGN

This study was a secondary analysis of a prospective cohort study on the association between the angle of progression (AoP) and labor outcome. We scanned a group of nulliparous women at term before the onset of labor at rest and under maximum Valsalva maneuver. In addition to the previously calculated AoP, in the present study, we measured the anteroposterior diameter of LAM hiatus (APD) on each ultrasound image. LAM co-activation was defined as APD at Valsalva less than that at rest, whereas fetal head regression was defined as AoP at Valsalva less than that at rest. We calculated the correlation between the two phenomena. Finally, we examined various labor outcomes according to the presence, absence, or co-existence of these two phenomena.

RESULTS

We included 469 women. A total of 129 (27.5%) women presented LAM co-activation while 50 (10.7%) showed head regression. Only 15 (3.2%) women showed simultaneous head regression and LAM co-activation. Women with coexisting LAM co-activation and head regression had the narrowest AoP at Valsalva in comparison with other study groups (p < .001). In addition, they had the highest risk of Cesarean delivery (40%) and longest first, second, and active second stage durations, although none of these reached statistical significance.

CONCLUSION

In nulliparous women at term before the onset of labor fetal head regression and LAM co-activation at Valsalva are two distinct phenomena that uncommonly coexist.

Sonography of fetal holoprosencephaly: a guide to recognize the lesser varieties

BACKGROUND

Alobar holoprosencephaly (HPE) is easily detected during a first-trimester screening examination, conversely, recognizing the lesser varieties may be difficult even in the second trimester.

OBJECTIVES

To describe the imaging findings of a cohort of fetuses with holoprosencephaly (HPE) and to elucidate the appearances of the different anatomical varieties.

MATERIALS AND METHODS

We reviewed medical records and stored images of pregnant women referred to our clinic because of a diagnosis or the suspicion of various forms of HPE. We reported the imaging characteristics, the presence of other associated anomalies, magnetic resonance findings, karyotype and autoptic examinations when available.

RESULTS

Alobar forms show great distortion of normal brain anatomy, with a single ventricle detectable during the first trimester of pregnancy. Extracerebral, face and karyotype abnormalities are often associated. In semilobar and lobar forms the septum pellucidum is typically absent in axial planes, with fused frontal horns, while posterior fossa is often normal. At multiplanar neurosonogram, anomalies involving corpus callosum and cortex development can be detected. Face abnormalities are mild in lobar forms: receding forehead, various degrees of hypotelorism and the presence of a single central maxillary incisor are reported.

CONCLUSIONS

The alobar forms are detectable since the first trimester, with a peculiar single ventricle and extremely frequent extracerebral and karyotype abnormalities. The semilobar and lobar forms are more challenging and the diagnosis is easily missed in a mid-trimester screening exam unless a careful evaluation of both cavum septi pellucidi and frontal horns as well is conducted.

Plasma and amniotic fluid concentrations of nitric oxide: Effects on uterine artery and placental vasculature in women who underwent voluntary pregnancy termination and in women with missed and threatened abortion. A pilot study

OBJECTIVES

First trimester miscarriage is a multifactorial event. Various angiogenic factors have been proposed as possible early markers of non-viable pregnancies. The aim of the present study was to evaluate the systemic nitric oxide (NO) production in healthy early pregnancy and its possible role in first trimester miscarriage.

STUDY DESIGN

We prospectively enrolled women referred to our Unit for elective termination of pregnancy, threatened abortion or missed abortion. Blood samples were taken for testing circulating NO plasma levels. Subsequently, all patients underwent 2-D ultrasonographic analysis and Color Doppler imaging to assess the pulsatility index of the uterine arteries. 3-D ultrasonographic and power Doppler analysis allowed a volumetric and vascular reconstruction of the placenta. During dilatation and vacuum aspiration, amniotic fluid was collected.

RESULTS

Seventy-two patients were enrolled: 25 with elective termination of pregnancy (Group I); 17 with threatened abortion (Group II); 30 with missed abortion (Group III). Group II showed greater placental volume and lower uterine arteries PI than others. The plasma NO concentration resulted statistically higher in women with threatened abortion, while amniotic fluid NO concentration were higher in the viable pregnancies (Group I) than in the aborted fetuses (Group III). Plasma NO was inversely correlated with both mean arterial pressure and uterine artery PI and was positively correlated with amniotic fluid NO and CRL; amniotic fluid NO was positively correlated with placental Vascularization Index and Vascularization-Flow Index.

CONCLUSION

Amniotic NO concentration was higher in viable pregnancies and positively related to Doppler 3D indices of vascularization and blood flow within the placenta. Further studies are needed to elucidate its role in first trimester miscarriage.

Role of prenatal magnetic resonance imaging in fetuses with isolated severe ventriculomegaly at neurosonography: A multicenter study

OBJECTIVE

The aim of this study was to report the rate of additional anomalies detected exclusively at prenatal magnetic resonance imaging (MRI) in fetuses with isolated severe ventriculomegaly undergoing neurosonography.

METHOD

Multicenter, retrospective, cohort study involving 20 referral fetal medicine centers in Italy, United Kingdom, Spain and Denmark. Inclusion criteria were fetuses affected by isolated severe ventriculomegaly (≥15 mm), defined as ventriculomegaly with normal karyotype and no other additional central nervous system (CNS) and extra-CNS anomalies on ultrasound. In all cases, a multiplanar assessment of fetal brain as suggested by ISUOG guidelines on fetal neurosonography had been performed. The primary outcome was the rate of additional CNS anomalies detected exclusively at fetal MRI within two weeks from neurosonography. Subgroup analyses according to gestational age at MRI (<vs ≥ 24 weeks of gestation) and the laterality of ventriculomegaly (unilateral vs bilateral) were also performed. Univariate and multivariate logistic regression analysis was used to analyze the data.

RESULTS

187 fetuses with a prenatal diagnosis of isolated severe ventriculomegaly on neurosonography were included in the analysis. Additional structural anomalies were detected exclusively at prenatal MRI in 18.1% of cases. When considering the type of anomaly, malformations of cortical development were detected on MRI in 32.4% cases, while midline or acquired (hypoxemic/hemorrhagic) lesions were detected in 26.5% and 14.7% of cases, respectively. There was no difference in the rate of additional anomalies when stratifying the analysis according to either gestational age at MRI or laterality of the lesion. At multivariate logistic regression analysis, the presence of additional anomalies only found at MRI was significantly higher in bilateral compared versus unilateral ventriculomegaly (OR: 4.37, 95% CI 1.21-15.76; p = 0.04), while neither maternal body mass index, age, severity of ventricular dilatation, interval between ultrasound and MRI, nor gestational age at MRI were associated with the likelihood of detecting associated anomalies at MRI.

CONCLUSION

The rate of associated anomalies detected exclusively at prenatal MRI in fetuses with isolated severe ventriculomegaly is lower than previously reported, but higher compared to isolated mild and moderate ventriculomegaly. Fetal MRI should be considered as a part of the prenatal assessment of fetuses presenting with isolated severe ventriculomegaly at neurosonography.

[Fetal aortic valvuloplasty in a patient with critical, congenital aortic valve stenosis and severe left ventricular dysfunction]

We present a case of prenatal diagnosis of critical congenital aortic valve stenosis with progressive systolic left ventricular failure. An ultrasound-guided balloon aortic valvuloplasty was performed at 28 weeks of gestational age because of left ventricular dysfunction associated with signs of fetal heart failure. There were no significant post-procedural complications and the pregnancy was carried to term with elective cesarean section at 38 weeks of gestational age. At birth, an echocardiogram showed severe aortic valve stenosis with global hypokinesia of the left ventricle. Therefore a percutaneous balloon aortic valvuloplasty was repeated through transseptal approach with prompt improvement of the antegrade aortic flow and of the left ventricular systolic function. The baby is currently 2 months old and he is doing fine.

Fetal Biometry: A Method for Comparing Local Curve Populations with Those from Major Reference Standards

OBJECTIVES

This study aimed to present a statistical method for assessing potential differences between fetal growth standard curves and local curve population.

METHODS

This was an observational repeated measures longitudinal study. We used a simulation model to generate random distribution of the international population from the IG-21st for fetal AC using the original equations of means and standard deviations (SD) obtained by the fractional polynomial method. A general linear model (GLM) allowed us to calculate new equations originating from simulated intergrowth-21st data (SIM_IG21st) and to compare them, by visual inspection of the estimated coefficients and their 95% CI, with the original published. We used further GLMs for evaluating the goodness of fitting of our local curve and comparing the relative equations of means and SD with those of SIM_IG21st. Finally, the impact of percentile differences between the 2 curves was quantified.

RESULTS

SIM_IG21st data yielded very similar coefficients than those of IG-21st reference to such an extent that means and SD and percentiles of interest were identical to the original. The comparison between SIM_IG21st curve and local curves showed a nonsignificant intercept and a slight difference of the 2 slopes (GA and GA3) for the equations of the mean. As a result, the local curve resulted in greater AC values. A difference in the intercept but not in the slopes (GA2, GA3, and GA3 * lnGA) was instead reported for the equations of the SD. In the percentile comparison, the local curve resulted in an overestimation of the 3rd and the 10th percentile that corresponded to the 4th and 12th percentiles of SIM_IG21st, respectively.

CONCLUSION

This statistical method allows sonographers to assess potential differences between standard curves and local curve population, enabling a more proper identification of abnormal growth trajectories.

Breech progression angle: new feasible and reliable transperineal ultrasound parameter for assessment of fetal breech descent in birth canal

OBJECTIVE

To assess the feasibility and reliability of transperineal ultrasound in the assessment of fetal breech descent in the birth canal, by measuring the breech progression angle (BPA).

METHODS

Women with a singleton pregnancy with the fetus in breech presentation between 34 and 41 weeks' gestation were recruited. Transperineal ultrasound images were acquired in the midsagittal view for each woman, twice by one operator and once by another. Each operator measured the BPA after anonymization of the transperineal ultrasound images. BPA was defined as the angle between a line running along the long axis of the pubic symphysis and another line extending from the most inferior portion of the pubic symphysis tangentially to the lowest recognizable fetal part in the maternal pelvis. Each operator was blinded to all other measurements performed for each woman. Intra- and interobserver reproducibility of BPA measurement was evaluated using the intraclass correlation coefficient (ICC). To investigate the presence of any bias, intra- and interobserver agreement was also analyzed using Bland-Altman analysis. Student's t-test and Levene's W₀ test were used to investigate whether a number of different clinical factors had an effect on systematic differences and homogeneity, respectively, between BPA measurements.

RESULTS

Overall, 44 women were included in the analysis. BPA was measured successfully by both operators on all images. Both intra- and interobserver agreement analyses showed excellent reproducibility in BPA measurement, with ICCs of 0.88 (95% CI, 0.80-0.93) and 0.83 (95% CI, 0.71-0.90), respectively. The mean difference between measurements was 0.4° (95% CI, -1.4 to 2.2°) for intraobserver repeatability and -0.4° (95% CI, -2.6 to 1.8°) for interobserver repeatability. The upper limits of agreement were 12.0° (95% CI, 8.9-15.1°) and 13.6° (95% CI, 9.9-17.3°) for intra- and interobserver repeatability, respectively. The lower limits of agreement were -11.2° (95% CI, -14.3 to -8.1°) and -14.4° (95% CI, -18.2 to -10.7°) for intra- and interobserver repeatability, respectively. No systematic difference between BPA measurements was found on either intra- or interobserver agreement analysis. None of the clinical factors examined (maternal body mass index, maternal age, gestational age at the ultrasound scan and parity) showed a statistically significant effect on intra- or interobserver reliability.

CONCLUSIONS

BPA represents a new feasible and highly reproducible measurement for the evaluation of fetal breech descent in the birth canal. Future studies assessing its usefulness in the prediction of successful external cephalic version and breech vaginal delivery are needed. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

The maternal pelvic floor and labor outcome

Vaginal birth is the major cause of pelvic floor damage. The development of transperineal ultrasound has improved our understanding of the relationship between vaginal birth and pelvic floor dysfunction. The female pelvic floor dimensions and function can be assessed reliably in pregnant women. Maternal pushing associated with pelvic floor muscle relaxation is the central requirement of vaginal birth. Many studies have evaluated the role of the pelvic floor on labor outcomes. Smaller levator hiatal dimensions and incomplete or absent levator ani muscle relaxation seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Here, we presented an overview of the current knowledge of the correlation between female pelvic floor dimension and function, as assessed by transperineal ultrasound, and labor outcome.

The correlation between transperineal ultrasound assessment of the levator ani muscle and postpartum urinary incontinence

AIMS

The primary aim of the present study was to assess the association between levator ani muscle (LAM) integrity and function on the one hand, and the risk of urinary incontinence (UI) on the other. A secondary objective was to assess the association between fundal pressure in the second stage of labor (Kristeller maneuver) and the risk of postpartum UI.

METHODS

In this prospective cohort study, women underwent a clinical and transperineal ultrasound examination at rest, at pelvic floor muscle contraction (PFMC), and at Valsalva maneuver 3-6 months after their first vaginal delivery. LAM avulsion and levator hiatal area (LHA) were evaluated. In addition, women were interviewed about the presence of UI, whether stress (SUI) or urgency (UUI).

RESULTS

Overall, data of 244 women were analyzed. SUI was reported in 50 (20.5%), while UUI was reported in 19 (7.8%) women. Women who reported SUI had a higher prevalence of LAM avulsion and less proportional reduction in LHA from rest to a maximum contraction in comparison to women with no SUI. Women who reported UUI had a greater LHA at rest, during contraction, and during maximal Valsalva in comparison to women without UUI. No significant association was found between the Kristeller maneuver and the incidence of any UI.

CONCLUSION

Levator ani avulsion and less proportional reduction of LHA with PFMC appear to be associated with a higher risk of postpartum urinary stress incontinence.

Prenatal sonography of the foramen ovale predicts urgent balloon atrial septostomy in neonates with complete transposition of the great arteries

BACKGROUND

Hypoxia caused by inadequate intracardiac mixing owing to a restrictive foramen ovale is a potentially life-threatening complication in neonates with dextro-transposition of the great arteries. An urgent balloon atrial septostomy is a procedure of choice in such cases, but dependent on the availability of a 24-hour interventional cardiology facility. The prenatal identification of predictors for an urgent balloon atrial septostomy at birth would help in optimizing the management of these neonates, minimizing the risk of hypoxic damage.

OBJECTIVE

This study aimed to predict with prenatal echocardiography the need of urgent balloon atrial septostomy in neonates with dextro-transposition of the great arteries.

STUDY DESIGN

This was a retrospective cohort study of patients with a prenatal diagnosis of transposition of the great arteries that were delivered in our center between 2010 and 2019, for whom fetal ultrasound echocardiograms obtained at less than 3 weeks before delivery were available. The following parameters were systematically obtained at fetal echocardiography: size and appearance of the foramen ovale, septum primum excursion (foramen ovale flap angle at the maximal excursion), diameters of the atria, and size of the ductus arteriosus. Balloon atrial septostomy was defined as urgent if performed within 12 hours from birth in neonates with restrictive foramen ovale. Neonatal follow-up was obtained through medical records analysis.

RESULTS

From November 2007 to April 2019, 160 fetuses with complete transposition of the great arteries were referred to our echocardiography laboratory and 60 of these were included in the analysis; 27 underwent urgent balloon atrial septostomy, 11 elective balloon atrial septostomy, and 22 no balloon atrial septostomy. The size of the foramen ovale was the best predictor of an urgent balloon atrial septostomy. A measurement of >6.5 mm had a sensitivity of 100% and a false positive rate of 45%.

CONCLUSION

Fetal echocardiography predicts the need of an urgent balloon atrial septostomy in fetuses with dextro-transposition of the great arteries although with a limited precision. In our experience, a measurement of the foramen ovale within 3 weeks of delivery had the greatest accuracy.

Fetal head progression and regression on maternal pushing at term and labor outcome

OBJECTIVES

The aim of our study was two-fold. First, to evaluate the association between the change in the angle of progression (AoP) on maternal pushing and labor outcome. Second, to assess the incidence and clinical significance of the reduction of AoP on maternal pushing.

METHODS

This was a prospective cohort study of nulliparous women with singleton pregnancy at term. AoP was measured at rest and on maximum Valsalva maneuver before the onset of labor, and the difference between AoP on maximum Valsalva and that at rest (ΔAoP) was calculated for each woman. Following delivery and data collection, we assessed the association between ΔAoP and various labor outcomes, including Cesarean section (CS), duration of the first, second and active second stages of labor, Apgar score and admission to the neonatal intensive care unit (NICU). The prevalence of women with reduction of AoP on maximum Valsalva maneuver (AoP-regression group) was calculated and its association with the mode of delivery and duration of different stages of labor was assessed.

RESULTS

Overall, 469 women were included in the analysis. Among these, 273 (58.2%) had spontaneous vaginal birth, 65 (13.9%) had instrumental delivery and 131 (27.9%) underwent CS. Women in the CS group were older, had narrower AoP at rest and on maximum Valsalva, higher rate of epidural administration and lower 1-min and 5-min Apgar scores in comparison with the vaginal-delivery group. ΔAoP was comparable between the two groups. On Pearson's correlation analysis, AoP at rest and on maximum Valsalva maneuver had a significant negative correlation with the duration of the first stage of labor. ΔAoP showed a significant negative correlation with the duration of the active second stage of labor (Pearson's r, -0.125; P = 0.02). Cox regression model analysis showed that ΔAoP was associated independently with the duration of the active second stage (hazard ratio, 1.014 (95% CI, 1.003-1.025); P = 0.012) after adjusting for maternal age and body mass index. AoP reduction on maximum Valsalva was found in 73 (15.6%) women. In comparison with women who showed no change or an increase in AoP on maximum Valsalva, the AoP-regression group did not demonstrate significant difference in maternal characteristics, mode of delivery, rate of epidural analgesia, duration of the different stages of labor or rate of NICU admission.

CONCLUSIONS

In nulliparous women at term before the onset of labor, narrower AoP at rest and on maximum Valsalva, reflecting fetal head engagement, is associated with a higher risk of Cesarean delivery. The increase in AoP from rest to Valsalva, reflecting more efficient maternal pushing, is associated with a shorter active second stage of labor. Fetal head regression on maternal pushing is present in about 16% of women and does not appear to have clinical significance. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Unusual umbilical Doppler waveform and fetal distress likely due to hypercoiled cord

Both reduced and increased umbilical cord coiling patterns have been associated with fetal distress and adverse perinatal outcomes, including fetal death. Prenatal diagnosis of cord coiling anomalies is challenging but potentially very useful for identifying those that may benefit from a more intensive monitoring. Nevertheless, there is no standardized approach for this potentially lethal complication when suspected. We report a case of fetal Doppler alterations and cardiotocographic anomalies likely due to hypercoiled cord in a 29-week primigravida referred to our clinic, who therefore underwent an emergency cesarean section. This case could help clinicians to consider cord anomalies as a possible cause of fetal distress.

Isolated Upward Rotation of the Fetal Cerebellar Vermis (Blake's Pouch Cyst) Is a Normal Variant: An Analysis of 111 Cases

INTRODUCTION

The objective of the study was to provide more detailed data about fetal isolated upward rotation of the cerebellar vermis rotation (Blake's pouch cyst) in particular regarding pregnancy outcome.

METHODS

This is a retrospective study of all cases of fetal isolated upward rotation of the cerebellar vermis (URCV) diagnosed in 3 referral centers in Italy from January 2009 to November 2019. Whenever possible, prenatal magnetic resonance imaging (MRI) was performed and a fetal karyotype was obtained. A detailed follow-up was obtained by consultation of medical records, interview with the parents, and the pediatricians.

RESULTS

Our study population included 111 patients with a prenatal diagnosis of isolated URCV made at a median gestational age of 21 weeks +3 days (interquartile range (IQR) 21 + 0-22 + 2). The median brain stem-vermis (BV) angle was 27° (IQR 24-29°). In 37.9% of the cases, a regression of the finding with restoration of normal anatomy was noted at a follow-up scan or at postnatal checks. A BV angle of 25° or less predicted regression with a probability in excess of 90%. MRI was performed in utero or at birth in 101 patients and always confirmed sonographic diagnosis. Fetal CGH array and/or karyotype was available in 97 cases and was always normal, but in 1 case. A postnatal follow-up was available in 102 infants (mean 7 months, range 0-10 years of age) and documented a normal neurologic development in all the cases.

CONCLUSIONS

Isolated URCV is most likely a normal variant of fetal anatomy without clinical consequences, at least at an early follow-up. A BV angle of 25° or less predicts intrauterine regression of the finding, but the outcome is good in all the cases. When a confident sonographic diagnosis is made, MRI is not mandatory. The risk of a chromosomal anomaly in these cases is probably low.

Fetal speckle-tracking echocardiography: a comparison between two-dimensional and electronic spatio-temporal image correlation (e-STIC) technique

BACKGROUND

Speckle tracking technology has been applied to assess ventricular deformation throughout the cardiac cycle. An electronic four dimensional probe that allows rapid acquisition of electronic spatio-temporal image correlation volumes (eSTIC) has been recently introduced.

OBJECTIVES

The aim of our study was to investigate whether e-STIC acquisition improves deformation analyses reproducibility.

STUDY DESIGN

We recruited fetuses between 20 and 40 weeks of gestation. We obtained a 2D video clip and an e-STIC volume of a four-chamber view. We focused on left ventricular global strain (LV-GS) and left ventricular ejection fraction (LV-FE). Intraobserver, interobserver and intermethod agreement were assessed by means of intraclass correlation coefficient (ICC) and illustrated by Bland-Altman plots. Systematic differences between measurements were assessed using a paired t-test.

RESULTS

The mean difference between LV-GS values obtained with e-STIC and 2D analysis was -0.10 (95% CI -2.28, 2.08). No systematic differences were found between the two techniques for LV-GS values (p-value = .927). The mean difference between LV-FE values obtained with e-STIC and 2D analysis was 7.55 (95% CI 4.16, 10.95; p-value <.001). The inter-rater reliability of LV-GS was moderate-to-substantial for both e-STIC and 2D. The inter-rater reliability of LV-FE obtained via e-STIC was superior to that obtained via 2D analysis. The intra-rater reliability of LV-GS obtained with e-STIC was superior to that obtained with 2D analysis (ICC 0.857; 95% IC 0.761-0.917). The intra-rater reliability of LV-FE obtained via e-STIC was superior to that obtained via 2D analysis (ICC 0.647; IC 0.51-0.783).

CONCLUSIONS

e-STIC seems to be a better technique than 2D analysis for intra-rater reliability of LV-GS. 4D acquisition might improve intrinsic limitations of speckle tracking echocardiography.

Sylvian fossa sonographic measurements in 18 to 23 weeks fetuses with and without cerebral malformations

BACKGROUND

Abnormal sulcation of the brain is frequently associated with severe malformations, but the prenatal diagnosis is challenging, especially in early pregnancy.

OBJECTIVE

Our study aimed to investigate the value of Sylvian fossa sonographic biometry in the diagnosis of cerebral malformation in the second trimester of gestation.

STUDY DESIGN

We prospectively established the normal values of the Sylvian fossa depth in a cohort of nonconsecutive patients, with singleton pregnancies and normal fetuses between 18+0 and 23+0 weeks' gestation. For each patient, a coronal view of the fetal brain, with a clear visualization of the anterior complex and the Sylvian fissure, was acquired by 1 sonologist, who also measured the depth of the fossa. Reproducibility for each parameter was assessed by a second sonologist using stored images. We also retrospectively acquired the same measurements in second trimester fetuses with central nervous system anomalies.

RESULTS

In 103 fetuses with a normal sonogram, the mean depth of the Sylvian fossa was 3.9±0.8 mm Interobserver reproducibility analysis demonstrated good results. Notably, 11 of 31 fetuses with cerebral malformations had a Sylvian fossa depth of <-2 z-scores, and these were found to have malformations of cortical development, lissencephaly in particular, or microcephaly.

CONCLUSION

Sonographic measurement of the Sylvian fossa during second trimester is feasible and reproducible. A shallow Sylvian fossa is associated with malformations of cortical development, microcephaly, or both.

Maternal hemodynamic assessment by USCOM® device in the first trimester of pregnancy

BACKGROUND

Preeclampsia is a main obstetric disease and could be caused by the inability of the woman hemodynamic system to face the cardiovascular effort required by gestation.

OBJECTIVE

The aim of the present study is to evaluate the correlation between maternal hemodynamic parameters detected by UltraSonic Cardiac Output Monitor (USCOM^®) and ultrasound or biochemical parameters in women during the first-trimester screening of chromosomal abnormalities.

METHODS

This was a prospective observational study with 162 women enrolled during the first-trimester ultrasound, recording demographic, biochemical and ultrasound data, including the pulsatility index of uterine arteries (UTPI). Hemodynamic indices were obtained using the USCOM^® system. We also analyzed the outcomes of pregnancy of those women who delivered in our clinic.

RESULTS

As for the correlation between biochemical and ultrasound parameters, pregnancy-associated plasma protein A (PAPP-A) relates inversely with the mean UTPI (r _s -0.298, p < .001). We also reported a statistically significant correlation between the mean UTPI and the maternal haemodynamic parameters detected by USCOM^® (higher values of mean UTPI are associated with lower values of indexed cardiac output, CO, and higher indexed peripheral resistances, TVR). When comparing women with higher UTPI and TVR or lower CO to patients who had regular values of these parameters, we noticed that between these groups there were significant differences in all the remaining hemodynamic parameters, including inotropy index and stroke volume, as well as in the biochemical values of PAPP-A. Analyzing postpartum data, if we combine the onset of hypertensive disorders and fetal growth restriction, the most predictive parameter is indexed TVR.

CONCLUSION

Our study confirmed the correlation between PAPP-A and placental function, expressed through the determination of the pulsatility index of the uterine arteries. Moreover, we found a clear correlation between biochemical markers, placental function and maternal hemodynamics, since the first trimester of pregnancy. The inclusion of maternal hemodynamic evaluation could be useful in the screening protocols of preeclampsia. If we combine the onset of hypertensive disorders and of fetal growth restriction, the most predictive parameter is indexed total vascular resistances.

Usefulness of USCOM® evaluation in women with chronic hypertension who developed severe preeclampsia with low platelets and elevated liver enzymes

Cardiovascular changes that occur during pregnancy have been recently described and are matter of debate; during gestation we observe an increase in cardiac output and a reduction of peripheral total vascular resistance (TVR). In pregnancies complicated by hypertensive disorders, instead, these changes are lacking, with a persisting low cardiac output and high peripheral resistances. In this case report, we observed that in patients with chronic hypertension TVR are high, while the cardiac output is able to face the needs of pregnancy. The increase in TVR before the decision to deliver, due to bad blood pressure control despite therapy, may precede the alterations in blood tests (platelet decreasing and high liver enzymes). This data may be useful for monitoring patients with chronic hypertension and identifying those at higher risk of developing HELLP/severe preeclampsia.

Brain views that benefit from three-dimensional ultrasound

PURPOSE OF REVIEW

Fetal central nervous system malformations are among the most common congenital anomalies. Whereas simple axial views are sufficient for basic fetal brain examination, other important views are essential for a more detailed examination, which are sometimes challenging to obtain. Three-dimensional ultrasound can be helpful in obtaining standardized and reproducible images of many difficult fetal brain views. The aim of the present review is to explore the most recent evidence on the utility and technique of three-dimensional ultrasound in the examination of the fetal brain, with particular emphasis on the brain views that benefit from three-dimensional ultrasound.

RECENT FINDINGS

The article describes the various techniques of acquisition and analyses of three-dimensional ultrasound volumes of the fetal brain and their usefulness in the assessment of normal and abnormal fetal brain anatomy. Three-dimensional ultrasound has also permitted the application of many new technologies, such as artificial intelligence and deep machine learning. Recently, thanks to high-quality three-dimensional ultrasound, fetal cortical development can be assessed quantitatively and reliably.

SUMMARY

Three dimensional ultrasound can help as a complementary tool to two-dimensional ultrasound in the assessment of the fetal brain development and malformations. In addition, it paves the way for the application of promising technologies in the evaluation of fetal brain.

VIDEO ABSTRACT

A video summarizing the findings of the article. The video illustrates the various approaches and techniques applied for the examination of the fetal brain using three-dimensional ultrasound. Furthermore, the advantages and future perspectives of the application of three-dimensional ultrasound in the examination of the fetal brain are discussed, http://links.lww.com/COOG/A74.

Transperineal ultrasound assessment of maternal pelvic floor at term and fetal head engagement

OBJECTIVES

To evaluate the association between pelvic floor dimensions in nulliparous women at term and fetal head engagement, as assessed by transperineal ultrasound.

METHODS

This was a prospective observational study of nulliparous women at term. Before the onset of labor, transperineal ultrasound was used to measure the anteroposterior diameter (APD) of the levator hiatus and the angle of progression (AoP) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver (before and after visual feedback). We assessed the correlation between pelvic floor static and dynamic dimensions (levator hiatal APD and levator ani muscle coactivation) and AoP, which is an objective index of fetal head engagement.

RESULTS

In total, 282 women were included in the analysis. Among these, 211 (74.8%) women had a vaginal delivery while 71 (25.2%) had a Cesarean delivery. AoP was narrower in the Cesarean-delivery group at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva, whereas no differences in levator hiatal APD were found between the two groups. We found a negative correlation between levator hiatal APD at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva and the duration of the second stage of labor. There was a positive correlation between AoP and levator hiatal APD on maximum Valsalva maneuver after visual feedback (r = 0.15, P = 0.01). Women with levator ani muscle contraction on Valsalva maneuver (i.e. coactivation), both pre and post visual feedback, had a narrower AoP at rest and on maximum Valsalva. After visual feedback, women with levator ani muscle coactivation had a longer second stage of labor than did those without (80.8 ± 61.4 min vs 62.9 ± 43.4 min (P = 0.04)).

CONCLUSIONS

Smaller pelvic floor dimensions and levator ani muscle coactivation are associated with higher fetal head station and with a longer second stage of labor in nulliparous women at term. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Prediction of neonatal coarctation of the aorta at fetal echocardiography: a scoring system

INTRODUCTION

Coarctation of the aorta (CoA) is common and can lead to neonatal emergency. Despite its burden, antenatal detection of this condition remains inaccurate.

OBJECTIVE

To evaluate the diagnostic performance of fetal echocardiography and to design a scoring system for risk stratification of CoA in suspected cases.

DESIGN

A retrospective cohort study.

SETTING

S. Orsola Hospital, Bologna, Italy.

POPULATION

About 140 fetuses referred for suspected CoA to our tertiary center in a 9-year period.

METHODS

The following parameters were systematically obtained at fetal echocardiography: ventricular disproportion, great vessels asymmetry, transverse aortic arch hypoplasia, flow turbulence, and Z-scores of the ascending aorta and of the aortic isthmus. Associated anomalies were recorded, if present. When CoA was not confirmed at birth, neonates were followed up for 12 months to identify also a tardive onset of this condition.

MAIN OUTCOME MEASURES

The primary outcome was the presence of COA after birth.

RESULTS

108 fetuses were eligible for the purpose of the study. CoA was confirmed postnatally in 55 neonates (50.9%). Arch hypoplasia yielded the highest correlation with CoA. The affected neonates presented also significantly lower Z scores of the ascending aorta and of the aortic isthmus. Earlier gestational age at referral was positively correlated with neonatal CoA. An odds ratio-based multiparametric model was designed to build a scoring system (AUC 0.89).

CONCLUSION

In our cohort, no single ultrasound parameter was sufficiently accurate to predict postnatal CoA. The scoring system permitted a better identification of the affected fetuses.

Timing of induction for term prelabor rupture of membranes and intravenous antibiotics

BACKGROUND

Induction of labor usually within 24 hours is recommended for term prelabor rupture of membranes. It is still unclear when within the 24 hours induction of labor for term prelabor rupture of membranes should be initiated. Antibiotic prophylaxis for group B Streptococcus is usually recommended for prolonged prelabor rupture of membranes.

OBJECTIVE

The aim of our study was to evaluate whether induction of labor at ≤6 hours from prelabor rupture of membranes with intravenous oxytocin in singleton pregnancies at ≥37 weeks' gestation without regular uterine contractions reduces the administration of intravenous antibiotic agents.

STUDY DESIGN

This was a retrospective cohort study including all women with prelabor rupture of membranes at ≥37 weeks' gestation and without regular uterine contractions in which labor was induced using intravenous oxytocin. Women were divided into 2 groups according to the timing of induction (≤6 hours vs >6 hours after prelabor rupture of membranes).

RESULTS

A total of 166 women with term prelabor rupture of membranes were included, 53 of whom (31.9%) were induced within 6 hours of prelabor rupture of membranes and 113 (68.1%) were induced after 6 hours. There were no differences in demographic characteristics and risk factors for term prelabor rupture of membranes between the 2 groups. Women who underwent induction of labor at ≤6 hours were significantly less exposed to intravenous antibiotic prophylaxis compared with women induced at >6 hours (36% vs 80.5%, respectively; odds ratio, 0.14; 95% confidence interval, 0.07-0.28). Furthermore, for women induced within 6 hours after prelabor rupture of membranes, the chances of delivering at <12 or <24 hours were increased, nonreassuring cardiotocogram significantly less common, and hospital stay significantly shorter. No differences were found in regard to neonatal outcomes.

CONCLUSION

Induction of labor at ≤6 hours with intravenous oxytocin after term prelabor rupture of membranes is significantly associated with lesser use of antibiotic agents, shorter latency to delivery, lower incidence of nonreassuring cardiotocogram, and shorter hospital stay than induction of labor at >6 hours after prelabor rupture of membranes.

The dynamic change of the anteroposterior diameter of the levator hiatus under Valsalva maneuver at term and labor outcome

AIM

The aim of the present study was to evaluate the correlation between the proportional change of anteroposterior diameter (APD) of levator hiatus from rest to maximum Valsalva maneuver in nulliparous women at term and labor outcome.

METHODS

We prospectively recruited nulliparous women at term before the onset of labor. Women underwent a two-dimensional transperineal ultrasound, measuring the APD of the levator hiatus at rest and under maximum Valsalva's maneuver. APD change from rest to maximum Valsalva was described both in terms of absolute figures and proportional change. Correlation of APD change with the mode of delivery and with labor durations was assessed.

RESULTS

Overall, 486 women were included in the analysis. No significant association between change in APD and the mode of delivery. We found a significant negative correlation between change of APD from rest to Valsalva and the duration of active second stage both in terms of absolute change (Pearson's r = -0.138, P = .009) and in terms of proportional change (Pearson's r = -0.154, P = .004). Survival outcomes based on Cox-regression model showed that APD was independently associated with the duration of active second stage of labor after adjusting for epidural analgesia, maternal age and body mass index (hazard ratio, 1.008; 95% confidence interval, 1.001-1.016; P = .04) CONCLUSION: Women with higher increase of the anteroposterior diameter of the levator hiatus from rest to Valsalva have a shorter active second stage of labor.