External validation of a simple risk score based on the ASPRE trial algorithm for preterm pre-eclampsia considering maternal characteristics in nulliparous pregnant women: a multicentre retrospective cohort study

OBJECTIVE

To validate the performance of a first-trimester simple risk score based on the ASPRE trial algorithm for pre-eclampsia.

DESIGN

Multicentre retrospective cohort analysis.

SETTING

Four Italian hospitals.

POPULATION

Unselected nulliparous women at 11-13 weeks of gestation from January 2014 through to January 2018.

METHODS

Model performance was evaluated based on discrimination and calibration.

MAIN OUTCOME MEASURES

Delivery before 37 weeks of gestation with a diagnosis of pre-eclampsia.

RESULTS

Based on 73 preterm pre-eclampsia cases and 7546 controls (including 101 cases of late pre-eclampsia), the area under the receiver operating characteristics curve was 0.659 (95% CI 0.579-0.726). The sensitivity was 32.9% (95% CI 22.1-43.7) at a false-positive rate of 8.8%. The positive likelihood ratio was 3.74 (95% CI 2.67-5.23), the positive predictive value was 3.49% (95% CI 2.12-4.86%) and the negative predictive value was 99.3% (95% CI 99.1-99.5%). The sensitivity and positive likelihood ratio were approximately 40% lower than in the original study. The calibration analysis showed a good agreement between observed and expected risks (P = 0.037). Comparison with the Fetal Medicine Foundation (FMF) algorithm yielded a difference in the area under the curve of 0.084 (P = 0.007).

CONCLUSIONS

In our Italian population, the simple risk score had a lower performance than expected for the prediction of preterm pre-eclampsia in nulliparous women. The FMF algorithm applied to the same data set resulted in a better prediction.

TWEETABLE ABSTRACT

Simple risk score predicts preterm pre-eclampsia in Italy.

P837Neural networks algorithms improve GRACE Score performance

Background

Global Registry of Acute Coronary Events (GRACE) score is a well-known model used to predict the probability of events in acute coronary syndrome (ACS). GRACE model was developed using a logistic regression approach that can only model linear functions, a limitation that could be prevented using artificial neural networks (NN) a recognized tool for nonlinear statistical modeling. The aim of this study was to develop, train and test different NN algorithm-based models to improve the GRACE score performance.

Methods

We analyzed a prospective database including 1,255 patients admitted with diagnosis of ACS in a community hospital, between June 2008 and June 2017. The database included 40 demographic and laboratory admission variables. In the guided approach, only the individual predictors included in the GRACE score were used to train and test three NN algorithm-based models, one- and two-hidden layer multilayer perceptron (MLP), and a radial basis function network. In addition, three extra unguided models were built using the 40 admission variables. Finally, expected mortality according to the GRACE score was calculated using the logistic regression equation.

The database was split into 2 datasets: 70% for model training and 30% for validation. In order to choose the best model, the training process was repeated 50 times. Every time the models were tested on the validation cohort, accuracy, receiver operating characteristic (ROC) area, negative predictive value (NPV), and positive predictive value (PPV) were recorded. Only models showing the best discrimination power were selected for comparison with logistic regression outcomes. The end point was in-hospital all-cause mortality.

Results

In terms of accuracy, ROC area and NPV, almost all NN algorithms outperformed the logistic regression approach (accuracy 97.1, 96.7, 96.2, 97.3 and 94.1%, p<0.001; ROC area 0.89, 0.86, 0.84, 0.84 and 0.75, Hanley-McNeil p≤0.05; for guided and unguided one- and two-hidden layers MLP and GRACE score, respectively). Only radial basis function models obtained a better accuracy level based on NPV improvement (100 vs. 98.8%, p=0.0001), at the expense of PPV reduction (0.0% vs. 13.2%, p<0.0001) (ROC are 0.84 vs. 0.75, p=0.043). Compared with the logistic regression approach, one- and two-hidden layers in guided and unguided MLP models improved PPV from 13.2 to 18.2% (38% increase), 15.4% (17% increase), 27.3% (107% increase), and 25.0% (89% increase), respectively, although these differences were not statistically significant.

Conclusions

NN algorithms improve GRACE score performance in terms of discriminatory power for the prediction of in-hospital mortality. Its application should become a useful tool for the decision making in ACS patients

Levator ani muscle coactivation at term is associated with longer second stage of labor in nulliparous women

OBJECTIVE

To assess the effect of levator ani muscle (LAM) coactivation at term on outcome of labor in nulliparous women.

METHODS

This was a prospective study of 284 low-risk nulliparous women with a singleton pregnancy at term recruited before the onset of labor. The anteroposterior diameter of the levator hiatus was measured in each woman on transperineal ultrasound at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver before and after visual feedback. LAM coactivation was defined as a reduction in the anteroposterior diameter of the levator hiatus on maximum Valsalva maneuver in comparison with that at rest. The association of pelvic hiatal diameter values and LAM coactivation with mode of delivery and duration of labor was assessed.

RESULTS

No significant difference was found between women who underwent Cesarean delivery and those who had a vaginal delivery with regard to the anteroposterior diameter of the levator hiatus at rest, on pelvic floor muscle contraction and on Valsalva maneuver. Longer second stage of labor was associated with shorter anteroposterior diameter of the levator hiatus on all assessments, but in particular at rest and on Valsalva both before and after visual feedback. LAM coactivation was found in 89 (31.3%) and 75 (26.4%) women before and after visual feedback, respectively. Post visual feedback, women with LAM coactivation had a significantly longer second stage of labor than did those without LAM coactivation (83 ± 63 vs 63 ± 42 min; P = 0.006). On Cox regression analysis, LAM coactivation post visual feedback was an independent predictor of longer second stage of labor (adjusted hazard ratio, 1.499 (95% CI, 1.076-2.087); P = 0.017).

CONCLUSION

LAM coactivation in nulliparous women at term is associated with a longer second stage of labor. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion

OBJECTIVE

To investigate the association between application of fundal pressure during the second stage of labor (Kristeller maneuver) and the risk of levator ani muscle (LAM) injury.

METHODS

This was a prospective case-control study of women recruited immediately after their first vaginal delivery in our university hospital between March 2014 and September 2016. Women who underwent the Kristeller maneuver were recruited as cases. For each case, a control (no Kristeller) was recruited matched for body mass index, use of epidural analgesia, duration of second stage of labor and birth weight. All women were invited to undergo four-dimensional (4D) transperineal ultrasound (TPU) 3-6 months postpartum. The main outcome measure was the presence of LAM avulsion on 4D-TPU. TPU results were compared between cases and controls. Multivariate logistic regression analysis was performed to identify independent risk factors for LAM avulsion.

RESULTS

During the study period, 134 women in the Kristeller maneuver group and 128 women in the control group underwent TPU assessment. Women who underwent the Kristeller maneuver had a higher prevalence of LAM avulsion than did controls (38/134 (28.4%) vs 18/128 (14.1%); P = 0.005). In addition, women in the Kristeller-maneuver group had a larger hiatal area on maximum Valsalva maneuver and a greater increase in hiatal area from rest to maximum Valsalva. On multivariate logistic regression analysis, use of the Kristeller maneuver was the only independent factor associated with LAM avulsion (odds ratio, 2.5 (95% CI, 1.29-4.51)).

CONCLUSION

The Kristeller maneuver is associated with an increased risk of LAM avulsion when applied in women during their first vaginal delivery. This should be taken into account when deciding to use fundal pressure to accelerate the second stage of labor and when counseling women following childbirth. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Pelvic floor muscle dysfunction on 3D/4D transperineal ultrasound in patients with deep infiltrating endometriosis: a pilot study

OBJECTIVE

Pelvic floor muscle (PFM) dysfunction seems to play an important role in the pathophysiology of pelvic pain, including that associated with deep infiltrating endometriosis (DIE). The aim of this study was to evaluate the static and dynamic morphometry of the PFM using three-dimensional (3D) and four-dimensional (4D) transperineal ultrasound in women with DIE compared with asymptomatic healthy women.

METHODS

This was a pilot, prospective study conducted at our tertiary center between March and November 2015. Fifty nulliparous women with DIE (study group) and 35 nulliparous asymptomatic healthy women (control group) were included. 3D/4D transperineal ultrasound examination of the PFM was performed in both groups. Levator hiatal area (LHA) and anteroposterior and left-right transverse diameters were evaluated at rest, on maximum PFM contraction and on maximum Valsalva maneuver. Persistent levator ani muscle (LAM) coactivation during Valsalva maneuver was investigated.

RESULTS

Compared with the control group, women with DIE had a smaller LHA at rest (P = 0.03) and during Valsalva maneuver (P < 0.01). Furthermore, reduction in LHA during PFM contraction (P < 0.001) and enlargement in LHA during Valsalva maneuver (P = 0.01) were significantly less marked. In comparison with controls, women with DIE presented a higher frequency of LAM coactivation during Valsalva maneuver, although this difference did not reach statistical significance (P = 0.05).

CONCLUSIONS

3D and 4D transperineal ultrasound is an objective and non-invasive method for PFM morphometry and may have a role in detecting PFM dysfunction in women with DIE. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Is curved three-dimensional ultrasound reconstruction needed to assess the warped pelvic floor plane?

OBJECTIVES

Caudal distension of the female pelvic floor is common and results in perineal descent and a caudally curved levator hiatus (warping). Image reconstruction of the pelvic floor using currently available ultrasound techniques involves a linear approach (flat-plane reconstruction). We aimed to evaluate the feasibility, reproducibility and potential usefulness of a new three-dimensional (3D) technique capable of reconstructing a curved plane of the levator hiatus.

METHODS

Primiparous women were recruited to undergo a 3D/four-dimensional transperineal ultrasound examination 3-6 months after delivery. Levator ani muscle warping was evaluated on Valsalva maneuver by measuring the distance between the plane extending from the pubic rami to the anorectal angle and the plane of minimal hiatal dimensions on the coronal plane. Warping distance was used to reconstruct a curved plane of the levator hiatus using the curved OmniView volume contrast imaging (VCI) technique (C-OV). Intra- and interobserver reproducibility of the C-OV technique were assessed, as was intermethod agreement between the C-OV technique and the linear OmniView-VCI (L-OV) technique, for the measurement of levator hiatal area on Valsalva maneuver.

RESULTS

Measurement of the levator hiatal area using C-OV was feasible in all 84 women recruited. The warping distance ranged from -3.5 to 9.7 mm, confirming that the 1-2-cm slice thickness traditionally used for linear reconstruction was adequate for proper assessment of levator hiatal area in our population. C-OV showed excellent intra- and interobserver reproducibility, as well as excellent agreement with the L-OV technique for measuring levator hiatal area. No systematic difference was demonstrated in any of the reproducibility studies performed.

CONCLUSIONS

3D reconstruction of the warped levator hiatal plane is feasible and highly reproducible. In our population, reconstruction of a curved plane to correct for levator hiatal warping did not offer any benefit over the traditionally performed linear reconstruction. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Narrow subpubic arch angle is associated with higher risk of persistent occiput posterior position at delivery

OBJECTIVE

To determine whether the subpubic arch angle (SPA) measured by three-dimensional ultrasound is associated with the fetal occiput position at delivery and the mode of delivery.

METHODS

Nulliparous women with an uncomplicated singleton pregnancy at ≥ 37 weeks' gestation were recruited from two tertiary centers between September 2013 and August 2015. All women underwent a three-dimensional transperineal ultrasound examination and the SPA was measured using the previously validated Oblique View Extended Imaging software. Data on the outcome of labor were obtained prospectively in all cases and the correlations between SPA and the fetal occiput position at delivery and the incidence of operative delivery were investigated.

RESULTS

Overall, 368 women were included in the study. Fetal position at delivery was occiput anterior in 339 (92.1%) cases and occiput posterior (OP) in 29 (7.9%) cases. A significantly narrower SPA was found in the OP group compared with the occiput anterior group (104.4 ± 16.8° vs 116.4 ± 11.9°; P < 0.0001). The SPA was significantly narrower in women requiring obstetric intervention compared with in women with a spontaneous vaginal delivery. From multivariable logistic regression analysis, SPA and maternal height appeared to be significant predictors of both the fetal occiput position at delivery and the risk of operative delivery. The best cut-off value of SPA for predicting an OP position at delivery was 90.5°.

CONCLUSION

A narrow SPA is associated with a higher risk of persistent OP position at delivery and of operative delivery. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Reliability of new three-dimensional ultrasound technique for pelvic hiatal area measurement

OBJECTIVE

To assess the reproducibility of a new technique for three-/four-dimensional (3D/4D) ultrasound imaging of the pelvic floor: OmniView™ volume contrast imaging (VCI) for measurement of the pelvic hiatal area on maximum contraction and Valsalva maneuver. In addition, we aimed to study the intermethod agreement between the new technique and the 3D/4D render method.

METHODS

We acquired one static 3D and two dynamic 4D transperineal volumes (one obtained during contraction and one during Valsalva maneuver) from 35 nulliparous asymptomatic healthy volunteers and 35 women with symptoms of pelvic floor dysfunction. Each 3D dataset was analyzed using the OmniView-VCI technique to measure the pelvic hiatal area at rest, on maximum contraction and on maximum Valsalva. Analysis was performed twice by the same operator and once by another operator in order to assess intra- and interobserver reproducibility. All measurements were repeated by one operator using the 3D/4D render method to evaluate the intermethod agreement. Reproducibility and intermethod agreement were studied by means of intraclass correlation coefficients (ICC) and the Bland-Altman method.

RESULTS

Measurement of hiatal area using the OmniView-VCI technique showed excellent intraobserver and interobserver reproducibility in both asymptomatic and symptomatic women at rest, on contraction and on Valsalva maneuver. In addition, excellent agreement was demonstrated between OmniView-VCI and 3D/4D render in both groups (ICCs on Valsalva in asymptomatic and symptomatic women were 0.894 and 0.975, respectively). No systematic difference was noted in any of the reliability studies performed.

CONCLUSIONS

OmniView-VCI is a reliable method for pelvic hiatal area measurement. Both rendering mode and OmniView-VCI can be used interchangeably for assessing pelvic hiatal area. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Caregiver's satisfaction with a video tutorial for shoulder dystocia management algorithm

In our questionnaire, a video tutorial illustrating the management of shoulder dystocia was considered by health personnel as a useful complementary training tool. We prepared a 5-min video tutorial on the management of shoulder dystocia, using a simulator that includes maternal pelvic and baby models. We performed a survey among obstetric personnel in order to assess their opinion on the tutorial by inviting them to watch the video tutorial and answer an online questionnaire. Five multiple-choice questions were set, focusing on the video's main objectives: clarity, simplicity and usefulness. Following the collection of answers, global and category-weighted analyses were conducted for each question. Out of 956 invitations sent, 482 (50.4%) answered the survey. More than 90% of all categories found the video tutorial to be clinically relevant and clear. For revising the management of shoulder dystocia most obstetric personnel would use the video tutorial together with traditional textbooks. In conclusion, our video tutorial was considered by health personnel as a useful complementary training tool.

Sonographic pattern of fetal head descent: relationship with duration of active second stage of labor and occiput position at delivery

OBJECTIVES

The objectives of this study were firstly to assess the longitudinal changes of various sonographic parameters of fetal head progression in relation to length of active second stage of labor, and secondly to compare ultrasound findings obtained longitudinally among fetuses with persistent occiput posterior (OP) vs those with persistent occiput anterior (OA) position.

METHODS

From a series of nulliparous low-risk women at term attending the labor ward of our university hospital, transperineal ultrasound volumes were prospectively acquired at the beginning of the active second stage (T1) and at 40-min intervals thereafter until delivery (T2, T3). Sonographic parameters were derived from offline analysis of each volume, including the angle of progression (AoP), progression distance (PD), head-symphysis distance (HSD), head direction (HD) and midline angle. These parameters were compared between patients who delivered within 60 min from the beginning of the active second stage of labor (early delivery) and those who remained undelivered by that time (late delivery). Fetal head position was determined from stored digital images of transabdominal examinations performed at the beginning of the active second stage. Comparison was performed between fetuses with OA and those with persistent OP position at delivery.

RESULTS

Spontaneous vaginal delivery was achieved in 58 (81.7%) cases, whereas vacuum extraction and Cesarean section were performed in eight (11.3%) and five (7.0%) cases, respectively. Delivery was achieved within 60 min from the beginning of the active second stage in 44 (62.0%) patients. In the early vs late delivery groups, measurements of AoP, HSD and PD at T1 were significantly different (AoP, 143.9 ± 20.5° vs 125.3 ± 15.0°, P < 0.001; HSD, 14.8 ± 4.5 mm vs 20.9 ± 5.8 mm, P < 0.001; PD, 44.0 ± 14.1 vs 35.0 ± 13.1 mm, P = 0.008). On logistic regression analysis of data obtained at T1, maternal body mass index, oxytocin administration, neonatal birth weight and HSD appeared to predict independently duration of the active second stage. Among fetuses delivering in the OP position (n = 10, 13.5%), Cesarean delivery was significantly more common than in those delivering in the OA position (n = 5 (50.0%) vs n = 2 (3.1%), P = 0.001). Women with persistent OP position compared with OA showed a significantly different AoP at T1 (122 ± 17° vs 138 ± 20°, P = 0.016), HD and HSD at T1 (HD, 112 ± 17 mm vs 86 ± 19 mm, P < 0.001; HSD, 16.5 ± 5.4 mm vs 22.8 ± 6.6 mm, P = 0.008) and at T2 (HD, 120 ± 16 vs 82 ± 27 mm, P = 0.008; HSD, 12.6 ± 3.4 mm vs 18.5 ± 5.4 mm, P = 0.038).

CONCLUSIONS

AoP, PD and HSD are significantly different between patients undergoing delivery before or after 60 min from the beginning of the active second stage of labor. Ultrasound parameters are among the significant predictors of duration of the active second stage. Moreover, in fetuses persisting in the OP position vs those delivering in the OA position, fetal head progression seems to differ at early phases of the active second stage.

Agreement between two- and three-dimensional transperineal ultrasound methods for assessment of fetal head-symphysis distance in active labor

OBJECTIVES

To assess the intermethod agreement between two-dimensional (2D) and three-dimensional (3D) transperineal ultrasound methods in measuring a new index of fetal head station (the fetal head-symphysis distance (HSD)) in active labor, and to assess potential factors that may affect their agreement.

METHODS

HSD was measured by transperineal ultrasound in 86 women in active labor, once using a 2D and once using a 3D technique. 2D images were acquired first in 43 cases and 3D images were acquired first in the other 43 women. Intermethod agreement between 2D and 3D methods was analyzed by means of intraclass correlation coefficient (ICC) and Bland-Altman analysis. In addition, potential factors affecting the intermethod reproducibility were investigated including fetal occiput position, order of acquisition, fetal head station, stage of labor, maternal body mass index and use of epidural analgesia, using the ANOVA test to check for systematic bias and Levene's test for homoscedasticity.

RESULTS

Good agreement was demonstrated between 2D and 3D measurements of HSD (ICC, 0.949 (95% CI, 0.914-0.984)). No evidence of systematic difference was shown between the two methods (average difference ± SD = 0.03 ± 2.29 mm; P = 0.888). The only factor that had a significant effect on systematic difference between 2D and 3D methods was order of acquisition (P = 0.042); the first observation was higher regardless of the method used. Fetal head station had a significant effect on the homogeneity between the two methods (P = 0.004) with a better 2D-3D agreement obtained at lower head stations (SD of differences: 1.63 vs 2.59 mm).

CONCLUSIONS

There is very good agreement between 2D and 3D methods of assessing HSD. Agreement is better in lower fetal head stations.

Sonographic evaluation of the lower uterine segment thickness in women with a single previous Cesarean section

AIM

The aim of this paper was to evaluate the lower uterine segment (LUS) thickness through transvaginal sonography in late preterm and full term pregnancies with a single previous Cesarean section, to correlate the obtained LUS measurements with intraoperative observations, and to identify a predictive cut-off value in order to select the best candidates for a vaginal birth after Cesarean delivery (VBAC).

METHODS

Two hundred and fourteen women with a single previous Cesarean section who had an ultrasound measurement of the LUS thickness (stratified in S1, S2 and S3) in pregnancy were enrolled. The outcome of interest was the visual finding of a thin uterine scar at the time of the iterative Cesarean section. Linear regression was used to correlate the LUS thickness with gestational age (GA). A ROC curve has been used to determine the detection rate (DR) and the risk of each actual value of LUS thickness versus a thin uterine scar (outcome of interest).

RESULTS

The LUS thickness was correlated with the gestational age (R2=0.034, P-value =0.005). The DR as estimated by ROC curves to detect a translucent lower uterine segment (S3) was 94.1% at a false positive rate (FPR) of 20%. The correspondent cut-off value was 1.8 mm. Finally a likelihood ratio (LR) of observing S3 was estimated. At the quoted cut-off of 1.8 mm the LR was 3. As demonstrated, for a segment of 1 mm the LR was instead about 13.

CONCLUSION

The obtained values lead us to the conclusion that a thickness less than 1.8 mm can be reasonably considered a valid cut-off value to identify patients with a higher risk of thin uterine scar.

Vaginal delivery rate in post-term pregnancies with one versus more than one dinoprostone gel administrations: an observational study

AIM

The study aims to calculate the probability of a successful vaginal delivery in post-term low-risk women by using a set of predictors (maternal, fetal, and ultrasonographic) according to the number of dinoprostone gel applications.

METHODS

This was an observational study of a cohort of 174 low-risk post-term singleton pregnancies. Parity, cervical status and length, and amniotic fluid volume (AFI) were evaluated immediately before prostaglandin gel induction at the Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy between January 2010 and October 2011.

RESULTS

A consistent difference in vaginal delivery rates was observed for women who had one gel administration (Group 1) versus those who received either two or three gel administrations (Group 2): 77.5% at 24 hours and 97.4% at 48 hours vs. 27% at 24 hours and 54% at 48 hours (P <0.001 for both the comparisons) respectively. The predictors of a vaginal delivery were cervix dilatation and short cervix for Group 1, lower AFI for Group 2, and parity for both groups.

CONCLUSION

Women who require more than one gel administration have a lower rate of vaginal delivery at 24 and 48 hours. Maternal, fetal, and ultrasonographic parameters can predict a successful vaginal delivery.

Intrapartum transperineal ultrasound assessment of fetal head progression in active second stage of labor and mode of delivery

OBJECTIVE

To compare longitudinal changes in angle of progression (AoP) and midline angle (MLA) during the active second stage of labor according to the mode of delivery.

METHODS

A three-dimensional transperineal ultrasound volume was acquired in a series of nulliparous women at the beginning of the active second stage (T1) and every 20 min thereafter (T2, T3, T4, T5 and T6). Following delivery, all ultrasound volumes were analyzed and AoP and MLA were measured.

RESULTS

Among 71 women included in the study, 58 underwent spontaneous vaginal delivery (group A) and 13 underwent operative delivery (group B) (eight by vacuum extraction and five by Cesarean section). When compared with Group B, Group A had a wider AoP only at T1 (140.0 ± 20.2° vs. 122.9 ± 16.7°; P = 0.010) and T2 (149.7 ± 20.7° vs. 126.9 ± 17.5°; P = 0.006). MLA was narrower in group A only at T3 (21.2 ± 11.7° vs. 40.8 ± 27.9°; P = 0.043), T4 (18.2 ± 15.0° vs. 47.4 ± 29.6°; P = 0.020) and T5 (18.3 ± 6.0° vs. 34.7 ± 4.2°; P = 0.034). On stepwise forward multiple logistic regression analysis, both AoP and MLA were independently associated with operative delivery (OR = 0.955 and OR = 1.018, respectively).

CONCLUSION

Ultrasonographic assessment of fetal head descent in the second stage of labor may play a role in the prediction of the mode of delivery.

Fetal head-symphysis distance: a simple and reliable ultrasound index of fetal head station in labor

OBJECTIVES

To assess the reproducibility of measurement of a new sonographic index of fetal head station in labor, the fetal head-symphysis distance (HSD), using three-dimensional ultrasound, and its correlation with digital assessment of fetal head descent and with the angle of progression (AoP).

METHODS

Three-dimensional (3D) ultrasound volumes were acquired from 47 nulliparous women in active labor following assessment of fetal head station with digital examination. The HSD (the distance between the lower edge of the pubic symphysis and the nearest point of the fetal skull) was measured independently by two operators in order to evaluate intra- and interobserver reproducibility. The correlation between HSD, AoP and fetal head station was evaluated using regression analysis. Using 3D tomographic ultrasound imaging (TUI), measurements of the HSD were obtained in different parasagittal planes to evaluate the influence of inaccurate alignment of the probe with the midline of the pelvis.

RESULTS

Measurement of HSD showed high intraobserver (intraclass correlation coefficient (ICC) = 0.995; 95% CI, 0.991-0.997) and interobserver (ICC = 0.991; 95% CI, 0.984-0.995) reliability. In addition, a high correlation was demonstrated between mid-sagittal and parasagittal HSD measurements. HSD showed significant negative correlation with both fetal head station and AoP.

CONCLUSION

Fetal HSD is a simple and reliable method for the assessment of fetal head descent in labor.

Occurrence of septic shock in a patient submitted to emergency cerclage following a negative amniocentesis: report of a case

BACKGROUND

Second trimester emergency cerclage is an option for pregnant women presenting bulging fetal membranes. Despite a significant prolongation of pregnancy might be achieved, serious fetal and maternal events have been reported. Exclusion of infections through preprocedure amniocentesis has been proposed.

METHODS

A 37-year-old woman, gravida 4 para 1, was admitted at 21 weeks of gestation to our University Hospital due to bulging fetal membranes. An amniocentesis was performed in order to exclude an actual amniotic infection. Our Microbiology Department found a negative amniotic culture for bacteria and Mycoplasma and a normal glucose and interleukin-6 level, so a cervical cerclage was performed. The patient was discharged home on oral erythromycin.

RESULTS

After 48 h, the patient complained of hyperpyrexia, shivers and reduced fetal movements. Ultrasound at admission showed absent cardiac activity and after cerclage removal a non-viable fetus was delivered vaginally. Piperacillin and tazobactam were started, but the clinical course of the patient deteriorated and she developed a cold septic shock and was submitted to hysterectomy and transferred to the ICU of our hospital.

CONCLUSION

This report heralds that even after negative amniocentesis, a life-threatening infection may not be excluded in women candidate for emergency cerclage due to bulging fetal membranes.

Parvovirus B19 in pregnancy: possible consequences of vertical transmission

OBJECTIVE

The aim was to determine the outcome of pregnancies complicated by maternal Parvovirus B19 (B19) infection.

METHOD

Among 175 pregnant women referred to our clinic because of suspicion of a B19 infection, 63 with confirmed laboratory diagnosis of acute/recent B19 infection were followed up by ultrasound and Doppler measurement of the middle cerebral artery peak systolic velocity.

RESULTS

The vertical transmission rate was 31.7% (20/63). Of the 20 infected, 8 had hydrops, 1 had signs suggestive of meconium peritonitis and 1 had an isolated hydrothorax. Three fetuses presenting with hydrops were treated with intrauterine blood transfusion. Two of them died while the last showed resolution of anemia. Among the five untreated hydropic fetuses, one presented with mild signs that resolved spontaneously, two died at 16 and 17 weeks of gestation and two had also cardiomegaly and the parents opted for elective termination of pregnancy. All the anemic fetuses had middle cerebral artery peak systolic velocity values more than 1.8 multiples of the median. No stillbirth occurred.

CONCLUSIONS

The outcome of uncomplicated cases with B19 infection is good. In the presence of hydrops prognosis was very poor. It seems therefore logical to attempt to pick up this ominous signs early.

Brainstem-vermis and brainstem-tentorium angles allow accurate categorization of fetal upward rotation of cerebellar vermis

OBJECTIVE

To evaluate the role of the brainstem-vermis (BV) and brainstem-tentorium (BT) angles in the differential diagnosis of upward rotation of the fetal cerebellar vermis.

METHODS

The BV and BT angles were measured retrospectively on median sonographic views of the brain in 31 fetuses at 19-28 weeks' gestation with upward rotation of the cerebellar vermis due to Blake's pouch cyst (n = 12), Dandy-Walker malformation (n = 12) and cerebellar vermian hypoplasia (n = 7). Eighty normal fetuses at 20-24 weeks were included as controls.

RESULTS

In the control group, BV and BT angles were 9.1 ± 3.5° (range, 4-17°) and 29.3 ± 5.8° (range, 21-44°), respectively. The BV angle was significantly increased in each of the three subgroups of anomalies: Blake's pouch cyst (23 ± 2.8°; range, 19-26°), vermian hypoplasia (34.9 ± 5.4°; range, 24-40°) and Dandy-Walker malformation (63.5 ± 17.6°; range, 45-112°), the angle increasing with increasing severity of the condition. The BT angle had a similar pattern but there was overlap among the different groups.

CONCLUSION

The BV angle and, to a lesser degree, the BT angle are simple and reproducible measurements that provide valuable additional information for the categorization of upward rotation of the fetal cerebellar vermis. From mid gestation, a BV angle > 45° is strongly suggestive of a Dandy-Walker malformation, while a measurement < 30° favors the diagnosis of a Blake's pouch cyst.

[Identification of preterm labor: the role of the fibronectin and ultrasound cervicometry and their association]

OBJECTIVE

The aim of this study was to evaluate the effectiveness of the fetal fibronetcin (fFN) test and ultrasonographic cervical length measurement used alone or in combination with each other in order to further improve the identification of patients in preterm labor.

METHODS

Prospective multicenter observational study on patients between 24 and 32 weeks of gestation with symptoms of preterm labor (total patients = 132). The endpoint was the delivery at 34 weeks or more. The screening methods used were: the fFN test (group 1), the cervical length measurement by transvaginal ultrasound (group 2) or a combination of both tests (group 3) according to an established protocol. The statistical analysis was performed using the χ2 test using the SPSS software.

RESULTS

Group 1: positive fFN test in 25.7% of cases, incidence of preterm birth (<34 weeks) of 18%. Group 2: cervical length <25 mm in 56.2% of cases, incidence of preterm birth (<34 weeks) of 18.5%. The negative predictive value is equivalent to 99.0% for the fFN test and 95.2% for cervicometry; combined use reaches 100%, compared to 54% positive predictive value.

CONCLUSION

The identification of women at high risk of preterm delivery carried out with the fFN test or with transvaginal ultrasound cervicometry is clinically valid. The study also showed that the contextual use of biochemical and biophysical tests reaches a high negative predictive value (100%), making it a very useful method to identify patients truly at risk and to further reduce the incidence of non adequate treatment.

Maternal cardiac function in complicated twin pregnancy: a longitudinal study

OBJECTIVE

To evaluate longitudinally a cohort of twin pregnancies and to assess whether the occurrence of adverse pregnancy outcome may be related to specific maternal cardiac findings.

METHODS

Women with twin pregnancies were enrolled prospectively and underwent serial maternal echocardiography at 20-23 weeks, 26-29 weeks and 30-33 weeks of gestation. Patients were excluded if delivery took place prior to 34 weeks. Cardiac findings were compared between patients with uneventful pregnancy outcome and those who developed one of the following complications: pre-eclampsia or gestational hypertension; small-for-gestational age (SGA) neonates (birth weight of one or both twins < 5(th) centile for gestational age).

RESULTS

A group of 28 twin gestations was obtained for analysis, including eight complicated cases. At each visit, mean ± SD cardiac output (CO) was significantly higher in uncomplicated than complicated twin pregnancies (6.55 ± 0.82 vs 4.99 ± 0.67 L/min, P < 0.001 at 20-23 weeks; 7.31 ± 0.74 vs 5.66 ± 1.17 L/min, P < 0.001 at 26-29 weeks; 7.50 ± 0.89 vs 5.32 ± 0.74 L/min, P < 0.001 at 30-33 weeks), as was stroke volume (83.4 ± 12.2 vs 64.5 ± 9.2 mL, P = 0.001 at 20-23 weeks; 84.4 ± 15.6 vs 64.5 ± 12.0 mL, P = 0.003 at 26-29 weeks; 85.0 ± 19.2 vs 65.6 ± 10.7 mL, P = 0.013 at 30-33 weeks), whereas total vascular resistance (TVR) was lower (1005 ± 137 vs 1406 ± 159 dynes × s/cm(5) , P < 0.001 at 20-23 weeks; 924 ± 100 vs 1249 ± 231 dynes × s/cm(5) , P < 0.001 at 26-29 weeks; 929 ± 96 vs 1400 ± 244 dynes × s/cm(5) , P < 0.001 at 30-33 weeks). Moreover, CO, blood pressure (BP), heart rate (HR) and TVR remained stable throughout the assessed pregnancy interval in women developing a complication, whereas significant changes (rise in CO, HR and BP; fall in TVR) were noted in the uncomplicated group.

CONCLUSIONS

Maternal cardiac function in twin pregnancies complicated by pre-eclampsia or SGA neonates apparently does not undergo the profound longitudinal changes that occur in uneventful twin pregnancies.

Maternal cardiac function in normal twin pregnancy: a longitudinal study

OBJECTIVE

To investigate maternal cardiac function in a cohort of uncomplicated twin gestations assessed longitudinally.

METHODS

Women with twin pregnancies were enrolled prospectively and underwent serial maternal echocardiography at 20-23 weeks, 26-29 weeks and 30-33 weeks of gestation. Patients were excluded if any of these complications occurred after recruitment: delivery < 34 weeks; pre-eclampsia or gestational hypertension; small-for-gestational age neonates (birth weight of one or both twins < 5(th) centile for gestational age). Cardiac findings were compared with those obtained at the same gestational age periods in a group of singleton gestations.

RESULTS

A group of 20 uncomplicated twin gestations was obtained for analysis and 10 singleton pregnancies were then selected as controls. At each visit, mean ± SD cardiac output (CO) was significantly higher in twins than in singletons (6.55 ± 0.82 vs 5.62 ± 0.82 L/min, P = 0.007 at 20-23 weeks; 7.31 ± 0.74 vs 6.39 ± 0.74 L/min, P = 0.003 at 26-29 weeks; 7.50 ± 0.89 vs 6.68 ± 0.65 L/min, P = 0.015 at 30-33 weeks), whereas total vascular resistance (TVR) was lower (1005 ± 137 vs 1179 ± 199 dynes × s/cm(5) , P = 0.009 at 20-23 weeks; 924 ± 100 vs 1070 ± 138 dynes × s/cm(5), P = 0.003 at 26-29 weeks; 929 ± 96 vs 1031 ± 122 dynes × s/cm(5), P = 0.018 at 30-33 weeks). In both twins and singletons, CO showed a significant increase while TVR decreased significantly throughout the assessed pregnancy time period.

CONCLUSION

In twin gestation, maternal cardiac function apparently undergoes more profound changes compared with in singleton gestation, as testified by higher CO and lower TVR values at each stage of pregnancy starting from the mid-trimester.

Increased uterine artery pulsatility index at 34 weeks and outcome of pregnancy

OBJECTIVES

To evaluate pregnancy outcome in patients with increased uterine artery (UtA) pulsatility at 34 weeks' gestation as an isolated finding.

METHODS

Normotensive women attending at 34 weeks' gestation for fetal growth assessment were enrolled in the study if fetal growth was appropriate for age and mean UtA pulsatility index (PI) was persistently above the 95(th) centile for gestational age. Patients were excluded with any of the following conditions: multiple pregnancy, sonographic suspicion of fetal anomaly or fetal growth restriction, history of chronic maternal disease, hypertensive disorder or diabetes in the current pregnancy or one or more adverse events in their past obstetric history. The control group consisted of age- and body mass index-matched low-risk women attending at 34 weeks with normal uterine artery Doppler since the midtrimester.

RESULTS

Sixty-six normotensive patients with normal fetal growth and increased UtA-PI at 34 weeks were included in the study group. Women with abnormal Doppler findings compared with controls showed significantly lower gestational age at delivery (38.2 ± 1.6 vs. 38.9 ± 1.3 weeks, P = 0.006), birth weight (2942 ± 583 vs. 3404 ± 469 g, P < 0.001), birth-weight Z-score (-0.61 ± 1.07 vs. 0.19 ± 1.05, P < 0.001) and increased risk of a small-for-gestational-age (SGA) newborn (13/66 vs. 1/66, P < 0.001). The occurrence of late pre-eclampsia (3/66 vs. 0/66, P = 0.24), admission to the neonatal intensive care unit (6/66 vs. 4/66, P = 0.74), rate of induction of labor (16/66 vs. 14/66, P = 0.83) and rate of Cesarean section due to fetal distress (6/66 vs. 3/66, P = 0.49) were comparable between the two groups.

CONCLUSION

Increased UtA-PI as an isolated finding at 34 weeks' gestation is associated with an increased risk of delivering an SGA neonate.

[Neuropsychiatric systemic lupus erythematosus: where are we now?]

When dealing with Neuropsychiatric Systemic Lupus Erythematosus (NPSLE) there are still many controversial topics. In 1999 the American College of Rheumatology gave classification criteria for 19 clinical syndromes. However major problems are still related to low specificity of some of them such as headache, cognitive impairment or mood disorders. Even though a frequency of CNS involvement from 14 to 75% has been described, depending on both the population studied and the methodology of assessment, a lower frequency ranging from 21 to 28 % derived by larger case series seems more realistic. The introduction of the concept of "borderline cases", proposed by Italian Study Group for NP-SLE, is based both on clinical and instrumental evaluation and could represent a useful tool when dealing with conditions which do not fulfil ACR classification. Also the relationship between SLE activity and NP involvement is a debated issue. Concerning pathogenesis, it seems reasonable to consider multifactorial mechanisms related to antibody-mediated damage, antiphospholipid pro-thrombotic effect, non-inflammatory vasculopathy and cytokines mediated cytotoxycity. However, direct and unequivocal evidence for the implication of any of the above-mentioned mechanisms is still lacking. Although a wide range of neuroimaging tools have been used to evaluate CNS involvement, no single technique has proven to be definitive and, when dealing with a patient with suspected NPSLE, it is important to combine different diagnostic techniques. Due to the lack of effective imaging along with limitation in knowledge of underlying pathogenetic mechanisms and paucity of histopathologic findings, therapeutic approach in NPSLE remains a difficult issue and is currently based on personal experience. Italian Study Group for NP-SLE proposes the creation of a national registry on NPSLE to validate ACR classification criteria. Furthermore, the possibility to collect large series and stratifying them for each of the included neuro-psychiatric syndromes seems a good strategy for planning multicentric controlled therapeutic trials in the near future.

Prenatal diagnosis and outcome of partial agenesis and hypoplasia of the corpus callosum

OBJECTIVE

To present antenatal sonographic findings and outcome of fetuses with hypoplasia or partial agenesis of the corpus callosum.

METHODS

The database of our ultrasound laboratory was searched retrospectively for cases of hypoplasia or partial agenesis of the corpus callosum suspected at antenatal neurosonography between 1998 and 2008 and confirmed by pathology or postnatal neuroimaging. In surviving infants, clinical follow-up had been arranged to assess neurodevelopmental outcome.

RESULTS

Nineteen fetuses with callosal underdevelopment were identified at a median gestational age of 22 (range, 21-33) weeks and confirmed at follow-up, including 14 with partial agenesis and five with hypoplasia. Among the 14 fetuses with partial agenesis, there were additional brain findings in 10, including two with absent cavum septi pellucidi, four with mild isolated ventriculomegaly and four with cerebellar abnormalities, two of which also had ventriculomegaly. Pregnancy was terminated electively in seven of the cases with partial agenesis and there was one neonatal death. Among the six surviving infants, neurodevelopmental outcome was appropriate for age in three at follow up, including two cases with isolated partial agenesis of the corpus callosum. Among the five fetuses with prenatally diagnosed callosal hypoplasia, additional anomalies were present in four. Two cases were terminated electively and three were alive at the time of writing, with a median age of 3 years. Among them, apparently normal neurological development was observed in only one case.

CONCLUSIONS

An antenatal diagnosis of callosal underdevelopment is possible by expert sonography. There is often association with other major anomalies. However, even in fetuses with apparently isolated findings, the prognosis is uncertain.

Bilateral cleft lip and palate without premaxillary protrusion is associated with lethal aneuploidies

OBJECTIVE

To investigate the clinical implications of two categories of fetal bilateral cleft lip and palate (BCLP): with premaxillary protrusion and with a flattened profile.

METHODS

This was a retrospective study of fetuses with a prenatal diagnosis of BCLP at the Department of Obstetrics and Gynecology of the University of Bologna in the period 1991-2005.

RESULTS

BCLP was diagnosed prenatally in 14 cases (mean gestational age at diagnosis, 21 (range, 12-36) weeks). In nine of these, there was a premaxillary pseudomass; in the remaining five, the profile was flat. Associated structural and/or chromosomal anomalies were found in two of the nine with a premaxillary pseudomass and in all five of those with a flat profile (P = 0.02). All fetuses with a flat profile had aneuploidies (three trisomy 18, one trisomy 13, one trisomy 8 mosaic), as did one of the nine with a premaxillary pseudomass. Eight of the pregnancies were terminated, including three of those with a premaxillary pseudomass and all five of those without. All continuing pregnancies resulted in live births, although one neonate affected by Krabbe's disease died shortly after birth.

CONCLUSIONS

Our findings suggest that a third of cases of BCLP diagnosed in utero have a flat profile and these are at high risk of lethal aneuploidies.

Meningioma and systemic lupus erythematosus: a matter of pure coincidence?

To describe three cases of meningioma observed in a large cohort of 546 patients with systemic lupus erythematosus (SLE) followed at our Department in the last 15 years. We identified three cases of meningioma among 181 patients with SLE who underwent a brain magnetic resonance imaging (MRI) during their disease course (prevalence 1.65%). All three SLE cases were women with a disease onset at 47-, 18- and 42 -years-old, respectively. All patients presented neuropsychiatric (NP) symptoms and had an incidental finding of a meningioma at brain MRI. One patient presented simultaneously a breast cancer. Only one patient had the surgical removal of the mass without improvement of her symptoms while in the other two patients, the removal was not indicated. The association between meningioma and SLE may be a pure coincidence. However, it draws our attention because its detection may represent a confounding factor in the setting of a NPSLE patient.

Characterization of the structure and composition of gecko adhesive setae

The ability of certain reptiles to adhere to vertical (and hang from horizontal) surfaces has been attributed to the presence of specialized adhesive setae on their feet. Structural and compositional studies of such adhesive setae will contribute significantly towards the design of biomimetic fibrillar adhesive materials. The results of electron microscopy analyses of the structure of such setae are presented, indicating their formation from aggregates of proteinaceous fibrils held together by a matrix and potentially surrounded by a limiting proteinaceous sheath. Microbeam X-ray diffraction analysis has shown conclusively that the only ordered protein constituent in these structures exhibits a diffraction pattern characteristic of beta-keratin. Raman microscopy of individual setae, however, clearly shows the presence of additional protein constituents, some of which may be identified as alpha-keratins. Electrophoretic analysis of solubilized setal proteins supports these conclusions, indicating the presence of a group of low-molecular-weight beta-keratins (14-20 kDa), together with alpha-keratins, and this interpretation is supported by immunological analyses.

Diagnosis of station and rotation of the fetal head in the second stage of labor with intrapartum translabial ultrasound

OBJECTIVE

To investigate the ability of intrapartum translabial sonography to diagnose fetal station in the second stage of labor.

METHODS

Patients with uncomplicated pregnancies at term gestation with fetuses in vertex presentation in the second stage of labor underwent serial translabial sonography and digital examinations. In a sagittal section of the maternal pelvis, the direction of the head was noted and categorized as downward, horizontal or upward. By rotating the transducer in the transverse plane the cerebral midline echo was also visualized and the rotation of the head was noted. Clinical and ultrasound data were compared using Somer's d-test.

RESULTS

Sixty patients underwent a total of 168 clinical and sonographic examinations. When on the sonogram the fetal head was directed downward, the station assessed clinically was most frequently <or= + 1 cm from the ischial spines (44/57 (77.2%) cases); when the direction was horizontal, the station was most frequently <or= + 2 cm (53/59 (89.8%) cases); when the fetal head was directed upward, the station was usually >or= + 3 cm (46/52 (88.5%) cases). Failure to visualize the cerebral midline or a rotation >or= 45 degrees were associated with a station of + 2 cm or less in 98/103 (95.1%) examinations. Conversely, a rotation of < 45 degrees was associated with a station of + 3 cm or more in 45/65 (69.2%) examinations. All comparisons between clinical and sonographic findings demonstrated a statistically significant relationship (P < 0.0001). The probability of a station + 3 cm or more was particularly high when an upward direction of the head was seen in combination with a rotation of < 45 degrees (40/42 (95.2%) examinations). The interobserver variability (Cohen's kappa 0.795 and 0.727 for station and rotation, respectively; P < 0.001) and intraobserver variability (0.845 for both station and rotation, P < 0.001) suggested good reproducibility of the method.

CONCLUSIONS

Translabial sonography allows a diagnosis of fetal station with an accuracy comparable to that of digital examination and may provide useful information for diagnosing obstructed labor in the second stage as well as assisting in the choice of instrumental delivery.