Third-trimester ultrasound for antenatal diagnosis of placenta accreta spectrum in women with placenta previa: results from the ADoPAD study

OBJECTIVE

To evaluate the performance of third-trimester ultrasound for the diagnosis of clinically significant placenta accreta spectrum disorder (PAS) in women with low-lying placenta or placenta previa.

METHODS

This was a prospective multicenter study of pregnant women aged ≥ 18 years who were diagnosed with low-lying placenta (< 20 mm from the internal cervical os) or placenta previa (covering the internal cervical os) on ultrasound at ≥ 26 + 0 weeks' gestation, between October 2014 and January 2019. Ultrasound suspicion of PAS was raised in the presence of at least one of these signs on grayscale ultrasound: (1) obliteration of the hypoechogenic space between the uterus and the placenta; (2) interruption of the hyperechogenic interface between the uterine serosa and the bladder wall; (3) abnormal placental lacunae. Histopathological examinations were performed according to a predefined protocol, with pathologists blinded to the ultrasound findings. To assess the ability of ultrasound to detect clinically significant PAS, a composite outcome comprising the need for active management at delivery and histopathological confirmation of PAS was considered the reference standard. PAS was considered to be clinically significant if, in addition to histological confirmation, at least one of these procedures was carried out after delivery: use of hemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation or uterine artery embolization. The diagnostic performance of each ultrasound sign for clinically significant PAS was evaluated in all women and in the subgroup who had at least one previous Cesarean section and anterior placenta. Post-test probability was assessed using Fagan nomograms.

RESULTS

A total of 568 women underwent transabdominal and transvaginal ultrasound examinations during the study period. Of these, 95 delivered in local hospitals, and placental pathology according to the study protocol was therefore not available. Among the 473 women for whom placental pathology was available, clinically significant PAS was diagnosed in 99 (21%), comprising 36 cases of placenta accreta, 19 of placenta increta and 44 of placenta percreta. The median gestational age at the time of ultrasound assessment was 31.4 (interquartile range, 28.6-34.4) weeks. A normal hypoechogenic space between the uterus and the placenta reduced the post-test probability of clinically significant PAS from 21% to 5% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 9% in the subgroup with previous Cesarean section and anterior placenta. The absence of placental lacunae reduced the post-test probability of clinically significant PAS from 21% to 9% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 36% in the subgroup with previous Cesarean section and anterior placenta. When abnormal placental lacunae were seen on ultrasound, the post-test probability of clinically significant PAS increased from 21% to 59% in the whole cohort and from 62% to 78% in the subgroup with previous Cesarean section and anterior placenta. An interrupted hyperechogenic interface between the uterine serosa and bladder wall increased the post-test probability for clinically significant PAS from 21% to 85% in women with low-lying placenta or placenta previa and from 62% to 88% in the subgroup with previous Cesarean section and anterior placenta. When all three sonographic markers were present, the post-test probability for clinically significant PAS increased from 21% to 89% in the whole cohort and from 62% to 92% in the subgroup with previous Cesarean section and anterior placenta.

CONCLUSIONS

Grayscale ultrasound has good diagnostic performance to identify pregnancies at low risk of PAS in a high-risk population of women with low-lying placenta or placenta previa. Ultrasound may be safely used to guide management decisions and concentrate resources on patients with higher risk of clinically significant PAS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Intracervical lakes as sonographic marker of placenta accreta spectrum disorder in patients with placenta previa or low-lying placenta

OBJECTIVE

To evaluate the diagnostic accuracy of a new ultrasound sign, intracervical lakes (ICL), in predicting the presence of placenta accreta spectrum (PAS) disorder and delivery outcome in patients with placenta previa or low-lying placenta.

METHODS

This was a retrospective multicenter study of women with placenta previa or low-lying placenta at ≥ 26 weeks' gestation, who were referred to three Italian tertiary units from January 2015 to September 2018. The presence of ICL, defined as tortuous anechoic spaces within the cervix which appeared to be hypervascular on color Doppler, was evaluated on ultrasound images obtained at the time of referral. The primary aim was to explore the diagnostic accuracy of ICL in detecting the presence and depth of PAS disorder. The secondary aim was to explore the accuracy of this sign in predicting total estimated blood loss, antepartum bleeding, major postpartum hemorrhage at the time of Cesarean section and need for Cesarean hysterectomy. The diagnostic accuracy of ICL in combination with typical sonographic signs of PAS disorder, was assessed by computing summary estimates of sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios and diagnostic odds ratios (DOR).

RESULTS

A total of 332 women with placenta previa or low-lying placenta were included in the analysis, with a median maternal age of 33.0 (interquartile range, 29.0-37.0) years. ICL were noted in 15.1% of patients. On logistic regression analysis, the presence of ICL was associated independently with major postpartum hemorrhage (odds ratio (OR), 3.3 (95% CI, 1.6-6.5); P < 0.001), Cesarean hysterectomy (OR, 7.0 (95% CI, 2.1-23.9); P < 0.001) and placenta percreta (OR, 2.8 (95% CI, 1.3-5.8); P ≤ 0.01), but not with the presence of any PAS disorder (OR, 1.6 (95% CI, 0.7-3.5); P = 0.2). Compared with the group of patients without ultrasound signs of PAS disorder, the presence of at least one typical sonographic sign of PAS disorder in combination with ICL had a DOR of 217.2 (95% CI, 27.7-1703.4; P < 0.001) for placenta percreta and of 687.4 (95% CI, 121.4-3893.0; P < 0.001) for Cesarean hysterectomy.

CONCLUSION

ICL may represent a marker of deep villus invasion in women with suspected PAS disorder on antenatal sonography and anticipate the occurrence of severe maternal morbidity. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Fetal monitoring indications for delivery and 2-year outcome in 310 infants with fetal growth restriction delivered before 32 weeks' gestation in the TRUFFLE study

OBJECTIVE

In the TRUFFLE (Trial of Randomized Umbilical and Fetal Flow in Europe) study on the outcome of early fetal growth restriction, women were allocated to one of three groups of indication for delivery according to the following monitoring strategies: (1) reduced fetal heart rate (FHR) short-term variation (STV) on cardiotocography (CTG); (2) early changes in fetal ductus venosus (DV) waveform (DV-p95); and (3) late changes in fetal DV waveform (DV-no-A). However, many infants per monitoring protocol were delivered because of safety-net criteria, for maternal or other fetal indications, or after 32 weeks of gestation when the protocol was no longer applied. The objective of the present posthoc subanalysis was to investigate the indications for delivery in relation to 2-year outcome in infants delivered before 32 weeks to further refine management proposals.

METHODS

We included all 310 cases of the TRUFFLE study with known outcome at 2 years' corrected age and seven fetal deaths, excluding seven cases with inevitable perinatal death. Data were analyzed according to the allocated fetal monitoring strategy in combination with the indication for delivery.

RESULTS

Overall, only 32% of liveborn infants were delivered according to the specified monitoring parameter for indication for delivery; 38% were delivered because of safety-net criteria, 15% for other fetal reasons and 15% for maternal reasons. In the CTG-STV group, 51% of infants were delivered because of reduced STV. In the DV-p95 group, 34% of infants were delivered because of abnormal DV and, in the DV-no-A group, only 10% of infants were delivered accordingly. The majority of infants in the DV groups were delivered for the safety-net criterion of spontaneous decelerations in FHR. Two-year intact survival was highest in the DV groups combined compared with the CTG-STV group (P = 0.05 for live births only, P = 0.21 including fetal death), with no difference between DV groups. A poorer outcome in the CTG-STV group was restricted to infants delivered because of FHR decelerations in the safety-net subgroup. Infants delivered because of maternal reasons had the highest birth weight and a non-significantly higher intact survival.

CONCLUSIONS

In this subanalysis of infants delivered before 32 weeks, the majority were delivered for reasons other than the allocated monitoring strategy indication. Since, in the DV group, CTG-STV criteria were used as a safety net but in the CTG-STV group, no DV safety-net criteria were applied, we speculate that the slightly poorer outcome in the CTG-STV group might be explained by the absence of DV data. The optimal timing of delivery of fetuses with early intrauterine growth restriction may therefore be best determined by monitoring them longitudinally, with both DV and CTG monitoring. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?

BACKGROUND

Reduced fetal middle cerebral artery Doppler impedance is associated with hypoxemia in fetal growth restriction. It remains unclear as to whether this finding could be useful in timing delivery, especially in the third trimester. In this regard there is a paucity of evidence from prospective studies.

OBJECTIVES

The aim of this study was to determine whether there is an association between middle cerebral artery Doppler impedance and its ratio with the umbilical artery in relation to neonatal and 2 year infant outcome in early fetal growth restriction (26⁺⁰-31⁺⁶ weeks of gestation). Additionally we sought to explore which ratio is more informative for clinical use.

STUDY DESIGN

This is a secondary analysis from the Trial of Randomized Umbilical and Fetal Flow in Europe, a prospective, multicenter, randomized management study on different antenatal monitoring strategies (ductus venosus Doppler changes and computerized cardiotocography short-term variation) in fetal growth restriction diagnosed between 26⁺⁰ and 31⁺⁶ weeks. We analyzed women with middle cerebral artery Doppler measurement at study entry and within 1 week before delivery and with complete postnatal follow-up (374 of 503). The primary outcome was survival without neurodevelopmental impairment at 2 years corrected for prematurity. Neonatal outcome was defined as survival until first discharge home without severe neonatal morbidity. Z-scores were calculated for middle cerebral artery pulsatility index and both umbilicocerebral and cerebroplacental ratios. Odds ratios of Doppler parameter Z-scores for neonatal and 2 year infant outcome were calculated by multivariable logistic regression analysis adjusted for gestational age and birthweight p50 ratio.

RESULTS

Higher middle cerebral artery pulsatility index at inclusion but not within 1 week before delivery was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02-1.52). Middle cerebral artery pulsatility index Z-score and umbilicocerebral ratio Z-score at inclusion were associated with 2 year survival with normal neurodevelopmental outcome (odds ratio, 1.33; 95% confidence interval, 1.03-1.72, and odds ratio, 0.88; 95% confidence interval, 0.78-0.99, respectively) as were gestation at delivery and birthweight p50 ratio (odds ratio, 1.41; 95% confidence interval, 1.20-1.66, and odds ratio, 1.86; 95% confidence interval, 1.33-2.60, respectively). When comparing cerebroplacental ratio against umbilicocerebral ratio, the incremental range of the cerebroplacental ratio tended toward zero, whereas the umbilicocerebral ratio tended toward infinity as the values became more abnormal.

CONCLUSION

In a monitoring protocol based on ductus venosus and cardiotocography in early fetal growth restriction (26⁺⁰-31⁺⁶ weeks of gestation), the impact of middle cerebral artery Doppler and its ratios on outcome is modest and less marked than birthweight and delivery gestation. It is unlikely that middle cerebral artery Doppler and its ratios are informative in optimizing the timing of delivery in fetal growth restriction before 32 weeks of gestation. The umbilicocerebral ratio allows for a better differentiation in the abnormal range than the cerebroplacental ratio.

Fetal weight estimation in gestational diabetic pregnancies: comparison between conventional and three-dimensional fractional thigh volume methods using gestation-adjusted projection

OBJECTIVES

To evaluate the accuracy of gestation-adjusted birth-weight estimation using a three-dimensional (3D) fractional thigh volume (TVol) method in pregnant women with gestational diabetes mellitus (GDM), and to compare it with the conventional two-dimensional method of Hadlock et al.

METHODS

Pregnant women with GDM were referred at 34 to 36 + 6 weeks' gestation for ultrasound examination. Estimated fetal weight (EFW) was obtained using both the Hadlock and the TVol methods. Using a gestation-adjusted projection method, predicted birth weight was compared to actual birth weight at delivery.

RESULTS

Based on 125 pregnancies, the TVol method with gestation-adjusted projection had a mean (± SD) percentage error in estimating birth weight of -0.01 ± 5.0 (95% CI, -0.96 to 0.98)% while the method of Hadlock with gestation-adjusted projection had an error of 1.28 ± 9.1 (95% CI, -0.33 to 2.87)%. The mean percentage error of the two methods was significantly different (P = 0.039), while the random error was not (P = 1.0). For the prediction of macrosomia (birth weight ≥ 4000 g, n = 19), sensitivity was 84 and 63% for the TVol and Hadlock methods, respectively (95% CI for difference -2 to 44%, P = 0.22) and specificity was 96 and 89% for the TVol and Hadlock methods, respectively (95% CI for difference 5-9%, P = 0.01).

CONCLUSIONS

In women with GDM, a new method of estimating birth weight based on 3D-TVol measurements performed at 34 + 0 to 36 + 6 weeks' gestation and gestation-adjusted projection of estimated fetal weight, is more accurate than the standard method based on Hadlock's formula in predicting birth weight. The TVol method has comparable sensitivity but higher specificity than the Hadlock method in predicting neonatal macrosomia.

Prenatal ultrasound in the prediction of bowel obstruction in infants with gastroschisis

OBJECTIVE

To assess the value of prenatal ultrasound in predicting bowel obstruction requiring surgery in fetuses with prenatal diagnosis of gastroschisis.

METHODS

The database of our center was searched for cases with an antenatal diagnosis of gastroschisis. The ultrasound images were reviewed blindly to assess the presence of intra- or extra-abdominal bowel dilatation. Details of surgical procedures were noted and the discharge letters were obtained. Pediatric follow-up was also obtained from pediatric surgeons, general practitioners or parents.

RESULTS

In the 10-year period between November 1998 and September 2008 there were 62 cases with a prenatal diagnosis of gastroschisis. Postnatal outcome was not available for five cases, four pregnancies underwent termination and intrauterine fetal demise occurred in five cases. A final population of 48 liveborn infants was available for analysis. Intra-abdominal bowel dilatation was identified in 14 of these 48 fetuses (29.2%) and extra-abdominal bowel dilatation in 30 (62.5%) fetuses on prenatal ultrasound images. Eight fetuses (16.7%) had bowel obstruction. The relative risk of bowel obstruction with intra-abdominal bowel dilatation was 4.05 (95% CI, 1.12-14.70). On the other hand, the relative risk of bowel obstruction with extra-abdominal bowel dilatation was 1.0 (95% CI, 0.37-3.70). Four babies died, two of whom had intra- and one had extra-abdominal bowel dilatation.

CONCLUSIONS

Intra-abdominal dilatation of the bowel on prenatal ultrasound examination appears to predict postnatal bowel obstruction and the need for surgical resection. Extra-abdominal bowel dilatation is observed frequently on prenatal ultrasound scans, but is not predictive of bowel obstruction.

Outcome of fetuses with antenatally diagnosed short femur

OBJECTIVES

To examine the outcome of fetuses diagnosed with short femur length at the time of the routine anomaly scan.

METHODS

This was a retrospective review of all pregnancies referred to a tertiary referral unit with fetal femur length below the 5(th) centile for gestation at 18-24 weeks of gestation. All patients had undergone pregnancy dating and assessment of the risk of chromosomal abnormalities by measurement of fetal nuchal translucency at 11 to 13 + 6 weeks.

RESULTS

Over 5 years, 129 cases were evaluated. Detailed ultrasound examination showed associated fetal abnormalities in 46 (36%) cases, and these were classified as non-isolated. In this group, skeletal dysplasias (n = 16), chromosomal abnormalities (n = 10) and genetic syndromes (n = 4) were the most common associations. In contrast, there were no cases of chromosomal abnormalities or skeletal dysplasia in the 83 (64%) isolated cases. Early severe intrauterine growth restriction (IUGR) with abnormal umbilical artery Doppler findings and delivery before 37 weeks occurred in 33/83 (40%) cases with isolated short femur, and 90% of these had abnormal uterine artery Doppler findings at the time of presentation. These pregnancies also had high rates of pre-eclampsia (36%) and intrauterine death (33%). Those with normal uterine artery Doppler imaging were at low risk for these complications.

CONCLUSIONS

In a population previously screened by first-trimester fetal nuchal translucency measurement, the finding of isolated short femur at 18-24 weeks is unlikely to be due to aneuploidy. Severe IUGR associated with high mortality occurs in 40%, making uterine artery Doppler evaluation a useful clinical tool.

Outcome of antenatally diagnosed abdominal wall defects

OBJECTIVE

To examine the natural history and detailed outcome of antenatally diagnosed abdominal wall defects.

METHODS

This was a retrospective review of the antenatal reports, pediatric surgery records and subsequent follow-up information of all cases of omphalocele and gastroschisis diagnosed in a 10-year period in our tertiary referral center.

RESULTS

There were 109 cases of abdominal wall defects, including omphalocele in 67 cases and gastroschisis in 42 cases. Of the 67 cases of omphalocele there were 26 (39%) with chromosomal abnormalities and 22 (33%) underwent termination of pregnancy, mainly for associated structural abnormalities. Of the ongoing 19 cases there were five (26%) in-utero deaths, 12 (63%) survivors and two (11%) neonatal deaths, both associated with prematurity. Excluding chromosomal abnormalities, the survival rate in isolated omphalocele was 7/16 (44%) whilst it was 5/25 (20%) in those with associated abnormalities. Gastroschisis was isolated in 40 (95%) cases. Among these 40 isolated cases there were two (5%) terminations. Of the 38 ongoing cases, there were two (5%) in-utero deaths, and 36 (95%) live births. Four of the 36 liveborn infants (11%) died in the postoperative period owing to complications of small bowel atresia.

CONCLUSIONS

Although only 18% of infants with antenatally diagnosed omphalocele were alive in the neonatal period, postoperative morbidity was low. The majority (90%) of fetuses with antenatally diagnosed gastroschisis survived to delivery, but the mortality in affected newborns was 11%.

Severe twin-twin transfusion syndrome: outcome after fetoscopic laser ablation of the placental vascular equator

OBJECTIVE

To assess the safety and efficacy of a modified fetoscopic laser ablation technique for the management of severe twin-twin transfusion syndrome (TTTS) in a large series of pregnancies.

DESIGN

Prospective cohort study.

SETTING

Tertiary referral fetal medicine unit.

POPULATION

Women with pregnancies complicated by severe TTTS (Quintero stage III or IV), before 26 weeks of gestation.

METHODS

Fetoscopic laser ablation of placental anastomoses was performed. The sonoendoscopic approach was used to identify the placental vascular equator and to photocoagulate crossing vessels.

MAIN OUTCOME MEASURES

Overall survival, fetal and perinatal mortalities, gestational age at delivery, birthweight, operating time and recurrence of TTTS.

RESULTS

A total of 77 women underwent the procedure. The mean gestational age at treatment was 20 (range 16-26) weeks. On average, four vessels were ablated during each procedure, with a mean operative time of 15 (range 5-25) minutes. None of the women required a repeat fetoscopic laser treatment for recurrence of the TTTS. There was at least one survivor in 74% (57/77) of pregnancies, and the overall survival rate was 57% (88/154).

CONCLUSIONS

Fetoscopic laser ablation is a safe and effective form of treatment in the management of severe TTTS. The technique of identifying the common villous district of the placenta by ultrasound and photocoagulating any vessels crossing the vascular equator appears to be an acceptable alternative to both the nonselective and highly selective methods described so far. This approach is associated with a short operating time, low likelihood of TTTS recurrence or fetal anaemia and with survival results that are equivalent to previously reported techniques.

First-trimester uterine artery Doppler and spontaneous preterm delivery

OBJECTIVES

To assess the relationship between first-trimester uterine artery Doppler measurements and spontaneous preterm delivery.

METHODS

This was a retrospective analysis of uterine artery Doppler findings at 11-14 weeks in 73 singleton pregnancies with spontaneous preterm labor and 2417 pregnancies delivered at term.

RESULTS

The uterine artery mean resistance index (RI) was 0.68 (coefficient of variation 19%) and 0.69 (17%) in the preterm and term delivery groups, respectively (P = 0.35). The mean pulsatility index (PI) was 1.42 (39%) and 1.42 (46%) in the term and preterm delivery groups, respectively (P = 0.95). Bilateral diastolic notches were present in 34% of preterm deliveries and 33% of controls (P = 0.84). Restricting the analysis to the 19 pregnancies with preterm delivery before 34 weeks of gestation, no significant difference from controls was observed for RI (mean 0.71, coefficient of variation 11%, P = 0.41), PI (mean 1.56, coefficient of variation 29%, P = 0.27) or the number of bilateral notches (42%, P = 0.41).

CONCLUSIONS

Despite pathological evidence suggesting that defective placentation is associated with spontaneous preterm delivery, first trimester uterine artery resistance, as assessed by Doppler ultrasound investigation, is not different in pregnancies subsequently complicated by preterm labor compared to pregnancies delivered at term. This finding may be explained by a late failure of trophoblast development in cases destined to deliver preterm.

Uterine artery Doppler velocimetry at 11-14 weeks in singleton pregnancies conceived by assisted reproductive technology

OBJECTIVE

Singleton pregnancies resulting from assisted reproductive technologies (ART) have an increased risk of preterm delivery, pre-eclampsia and intrauterine growth restriction. The aim of the present study was to determine whether first-trimester trophoblastic invasion, as assessed by uterine artery Doppler velocimetry, is different in singleton pregnancies resulting from ART compared to those conceived naturally.

METHODS

Case-control study on 31 singleton ART pregnancies (26 in-vitro fertilization-embryo transfer, five intracytoplasmic sperm injection) and 62 matched pregnancies conceived spontaneously. Doppler velocimetry was performed at 11-14 weeks of gestation.

RESULTS

The mean resistance index (coefficient of variation) was 0.70 (17%) and 0.70 (18%) in ART and controls, respectively (P = 0.92). The corresponding values for mean pulsatility index were 1.40 (44%) and 1.47 (44%) in ART and controls, respectively (P = 0.58). Pregnancies with no, unilateral or bilateral diastolic notches were 48%, 26%, 26% and 36%, 37%, 27%, in ART and controls, respectively (P = 0.43).

CONCLUSION

There are no differences in uterine artery Doppler indices between pregnancies obtained by invasive ART and naturally conceived matched controls. This finding suggests that there is no major difference in trophoblastic invasion of the maternal spiral arteries between ART and spontaneous pregnancies.

Outcome of prenatally diagnosed agenesis of the corpus callosum

OBJECTIVE

To investigate the natural history, associated abnormalities and outcome in fetuses diagnosed prenatally with agenesis of the corpus callosum (ACC).

METHODS

A retrospective study of all cases of prenatally detected ACC was performed in patients referred to two tertiary units between January 1993 and October 2003. Associated abnormalities, pregnancy outcome and infant follow-up were recorded.

RESULTS

ACC was diagnosed in 117 cases. In 82 (70%) cases this was associated with other fetal structural (n = 49) or chromosomal abnormalities (n = 33). ACC was classified as an isolated prenatal finding in 35 (30%) cases. Assuming normal development in all cases lost to follow-up, significant developmental delay was present in 36% (95% CI, 15-65%) of isolated ACC. Furthermore, developmental delay was present in all cases with ventriculomegaly of at least 15 mm and in one of four cases with ventricular measurements less than 15 mm.

CONCLUSIONS

The outcome of prenatally detected ACC is mainly dependent on the presence or absence of associated anomalies. The full assessment of fetal ACC mandates karyotyping, MRI and a search for more subtle ultrasound features of certain genetic syndromes. In this series, at least 36% (95% CI, 15-65%) of cases with isolated ACC exhibited significant developmental delay when assessed postnatally.

Labor course and delivery in epidural analgesia: a case-control study

BACKGROUND

We aimed to establish if epidural analgesia is associated with a higher incidence of operative vaginal delivery, longer duration of labor and more frequent use of oxytocin than labor without analgesia.

METHODS

We analyzed a cohort of 207 women with no risk factors who delivered with epidural analgesia in the labor unit of Spedali Civili, Brescia, Italy, during 2001. Length of the first and second stage of labor, mode of delivery, neonatal cord blood pH, neonatal Apgar score and neonatal outcomes were evaluated.

RESULTS

Epidural analgesia was performed on request in 6%: in this group (group A) there were 141 (68%) nulliparae and 66 (32%) pluriparae; mean ( +/- standard deviation) gestational age at delivery was 39.4 +/- 1.3 weeks (range: 34.1-41.5 weeks). In this group, 184 (89%) had vaginal delivery and 23 (11%) delivered by Cesarean section. Among controls (group B), 368 (89%) had a vaginal delivery and 46 (11%) delivered by Cesarean section; vacuum extraction was used in 18 deliveries (9%) in group A and in 13 deliveries (3%) in group B. The duration of the second stage of spontaneous labor in the nulliparae of group A was significantly longer than in group B. No statistically significant differences were found between mean umbilical artery pH values of groups A and B.

CONCLUSION

Our results confirm that epidural analgesia does not affect the rate of Cesarean delivery, while increasing the use of oxytocin augmentation, the duration of the second stage of labor and the rate of instrumental vaginal delivery.