Antenatal visualization of the caudo-thalamic groove at expert fetal neurosonography.

OBJECTIVE: to describe the normal features of the caudo-thalamic groove at antenatal brain ultrasound in a group of structurally normal fetuses at third trimester and to report a small series of cases with abnormal appearance of the caudothalamic groove at antenatal brain ultrasound. METHODS: This was an observational study conducted at two referral Fetal Medicine units. A non-consecutive cohort of pregnant women with a singleton non anomalous pregnancy were prospectively recruited and underwent 3D ultrasound of the fetal brain at 28-32 weeks. At offline analysis the ultrasound volumes were adjusted in the multiplanar mode according to a standardized methodology, until the caudothalamic groove was visible on the parasagittal plane. To evaluate the inter-observer agreement, two operators were independently asked to indicate if the caudothalamic groove was visible unilaterally or bilaterally on each volume. The digital archives of the two Centres were also retrospectively searched to retrieve cases with abnormal findings at the level of the caudothalamic groove at antenatal brain ultrasound which were postnatally confirmed. RESULTS: 180 non-consecutive cases fulfilling the inclusion criteria were prospectively included. At offline analysis of the 3D US volumes the caudo-thalamic groove was identified on the parasagittal plane by both operators at least unilaterally in 176 cases (97.8%) and bilaterally in 174 cases (96.6%). The K-coefficient for the agreement between the two independent operators in recognizing the caudo-thalamic groove was 0.89 and 0.83 on one and both hemispheres respectively. At the retrospective search of our archives 5 cases with abnormal appearance of the groove at antenatal brain ultrasound (2 haemorrhage and 3 cyst) were found. CONCLUSION: Our study has demonstrated that the caudo-thalamic groove is consistently seen among normal fetuses at third trimester submitted to multiplanar neurosonography and that abnormal findings at this level may be antenatally detected. This article is protected by copyright. All rights reserved.

Prediction of persistent occiput posterior position by sonographic assessment of fetal head attitude at start of second stage of labor: prospective study.

OBJECTIVES: To evaluate the relationship between the attitude of the fetal head quantified by means of the chin-to-chest angle (CCA) in fetuses in occiput posterior (OP) position at the beginning of the second stage of labor, and persistent OP position at birth. METHODS: This was a single-center, prospective observational study conducted at the University Hospital of Parma, Parma, Italy. We included singleton pregnancies at term with fetuses in the OP position at the beginning of the second stage of labor. The fetal head position, station by means of angle of progression and head-to-perineum distance, and attitude by means of CCA were assessed using transabdominal or transperineal ultrasound. The primary outcome was persistent OP position at birth. RESULTS: Between January and July 2022, 76 women were included in the study. There were 48 (63.2%) spontaneous rotations of the fetal head and spontaneous vaginal delivery occurred in all. Among the 28 (36.8%) fetuses that did not rotate spontaneously into an occiput anterior position, eight (28.6%) had a spontaneous vaginal delivery, while operative vaginal delivery and Cesarean delivery was performed in 11 (39.3%) and nine (32.1%) cases, respectively. Multivariable logistic regression analysis showed that the CCA (adjusted odds ratio (aOR), 2.15 (95% CI, 1.22-3.78); P = 0.008) and nulliparity (aOR, 0.20 (95% CI, 0.06-0.76); P = 0.02) were associated independently with persistent OP position at birth. Moreover, the CCA showed an area under the receiver-operating-characteristics curve of 0.69 (95% CI, 0.56-0.82); P = 0.005) for the prediction of persistent OP position. The optimal cut-off value of the CCA was 36.5°, and was associated with a sensitivity of 0.82 (95% CI, 0.63-0.94), specificity of 0.50 (95% CI, 0.35-0.65), positive predictive value of 0.49 (95% CI, 0.34-0.64), negative predictive value of 0.83 (95% CI, 0.64-0.94), positive likelihood ratio of 1.64 (95% CI, 1.18-2.29) and negative likelihood ratio of 0.36 (95% CI, 0.15-0.83). CONCLUSIONS: Our data show that, within a population of women with fetal OP position at the beginning of the second stage of labor, the sonographic fetal head attitude measured by means of the CCA might help in the identification of fetuses at risk of persistent OP position. Such findings can be useful for patient counseling when OP position is diagnosed at full cervical dilatation. Further studies should investigate if the CCA might select patients who may benefit from manual rotation of the fetal head. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Correlation between bituberous diameter and mode of delivery in a cohort of low-risk nulliparous women.

OBJECTIVE: The aim our study was to evaluate the association between the antepartum clinical measurement of the Bituberous Diameter (BTD) and the occurrence of unplanned obstetrical intervention (UOI) due to labor dystocia, including either operative vaginal delivery or caesarean section in a cohort of low-risk, nulliparous at term. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Tertiary maternity care. INTERVENTIONS: With the women lying in lithotomic the distance between two ischial tuberosities was assessed using a tape measure during the routine antenatal booking between 37 and 38 weeks of gestation. MEASUREMENTS AND FINDINGS: Overall, 116 patient were included, and of these 23(19.8%) were submitted to an UOI due to labor dystocia. Compared to women that had a spontaneous vaginal delivery, women submitted to an UOI had a shorter BTD (8.25 + 0.843 vs 9.60 + 1.12, p < 0.001), a higher frequency of epidural analgesia (21/23 or 91.3% vs 50/93 or 53.8%; p = 0.002) and of augmentation of labor (14/23 or 60.9% vs 19/93 or 20.4%; p < 0.001) as well as a longer first [455 (IQR 142-455 min vs 293 (IQR 142-455) min] and second stages of labor [129 (IQR 85-155) min vs 51 (IQR 27-78) min]. Multivariable logistic regression showed that the BTD (aOR 0.16, 95% CI 0.04-0.60; p = 0.007) and the length of the second stage of labor (aOR 6.83, 95% CI 2.10-22.23; p = 0.001) were independently associated with UOI. When evaluating the diagnostic accuracy of the BTD for the prediction of UOI due to labor dystocia, the BTD showed an AUC of 0.82 (95 %CI 0.73-0.91; p < 0.001) with an optimal cut-off value of 8.6 cm (78.3% (95 %CI 56.3-92.5) sensitivity, 77.4% (95 %CI 67.6-85.4) specificity, 46.2% (95% CI 30.1-62.8) PPV, 93.5% (95% CI 85.5-97.9) NPV, 3.5 (95% CI 2.3-5.4) positive LR, and 0.28 (95% CI 0.13-0.61) negative LR. A significant inverse correlation between the length of the second stage of labour and the BTD in patients that had a vaginal delivery was also demonstrated (Spearman's rho = -0.24, p = 0.01). KEY CONCLUSIONS: Our study suggests that antepartum clinical assessment of the BTD might be used as a reliable predictor of UOI due to labor dystocia in low-risk, nulliparous women at term gestation. IMPLICATIONS FOR PRACTICE: Antenatal identification of women at higher risk for labor dystocia might trigger some interventions during the second stage of labor, such as maternal position shifting, to increase the pelvic capacity and potentially improve outcomes or might prompt a referral of the patient to a district hospital prior to the onset of labor.

Normal and abnormal appearance of fetal ganglionic eminence on second-trimester three-dimensional ultrasound.

OBJECTIVES: To describe the appearance and size of the ganglionic eminence (GE) in normal fetuses on midtrimester three-dimensional (3D) neurosonography and to report on the association between GE alterations (cavitation or enlargement) and malformation of cortical development (MCD). METHODS: This was a prospective multicenter cohort study of normal fetuses and a retrospective analysis of pathological cases with MCD. From January 2022 to June 2022, patients attending our tertiary centers for an expert fetal brain scan were recruited for the purpose of the study. A 3D volume of the fetal head, starting from the sagittal plane, was acquired in apparently normal fetuses using a transabdominal or transvaginal approach. Stored volume datasets were then evaluated independently by two expert operators. Two measurements (longitudinal diameter and transverse diameter) of the GE in the coronal view were obtained twice by each operator. Intra- and interobserver measurement variation was calculated. Reference ranges for GE measurements were calculated in the normal population. A previously stored volume dataset of 60 cases with MCD was also analyzed independently by the two operators using the same method in order to assess if GE abnormalities (cavitation or enlargement) were present. Postnatal follow-up was obtained in all cases. RESULTS: In the study period, 160 normal fetuses between 19 and 22 weeks of gestation were included in the study. The GE was visible in the coronal plane on 3D neurosonography in 144 (90%) cases and was not clearly visible in the remaining 16 (10%) cases. The intra- and interobserver agreement was almost perfect for the longitudinal diameter, with an intraclass correlation coefficient (ICC) of 0.90 (95% CI, 0.83-0.93) and 0.90 (95% CI, 0.86-0.92), respectively, and substantial for the transverse diameter, with an ICC of 0.80 (95% CI, 0.70-0.87) and 0.64 (95% CI, 0.53-0.72), respectively. A retrospective analysis of 50 cases with MCD in the second trimester showed that GE enlargement was present in 12 cases and GE cavitation was present in four cases. CONCLUSIONS: Systematic assessment of the GE in fetuses at 19-22 weeks of gestation is feasible on 3D neurosonography, with good reproducibility in normal cases. Cavitation or enlargement of the GE can be demonstrated in fetuses with MCD. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Role of fetal head-circumference-to-maternal-height ratio in predicting Cesarean section for labor dystocia: prospective multicenter study.

OBJECTIVE: To evaluate the relationship between the fetal head-circumference-to-maternal-height (HC/MH) ratio measured shortly before delivery and the occurrence of Cesarean section (CS) for labor dystocia. METHODS: This was a multicenter prospective cohort study involving four tertiary maternity hospitals. An unselected cohort of women with a singleton fetus in cephalic presentation, at a gestational age beyond 36 + 0 weeks and without any contraindication for vaginal delivery, was enrolled between September 2020 and November 2021. The MH and fetal HC were measured on admission of the patient to the labor ward. The primary outcome of the study was the performance of the HC/MH ratio in the prediction of CS for labor dystocia. Women who underwent CS for any indication other than failed labor progression, including fetal distress, were excluded from the final analysis. RESULTS: A total of 783 women were included in the study. Vaginal delivery occurred in 744 (95.0%) women and CS for labor dystocia in 39 (5.0%). CS for labor dystocia was associated with shorter MH (mean ± SD, 160.4 ± 6.6 vs 164.5 ± 6.3 cm; P < 0.001), larger fetal HC (339.6 ± 9.5 vs 330.7 ± 13.0 mm; P < 0.001) and a higher HC/MH ratio (2.12 ± 0.11 vs 2.01 ± 0.10; P < 0.001) compared with vaginal delivery. Multivariate logistic regression analysis showed that the HC/MH ratio was associated independently with CS for labor dystocia (adjusted odds ratio, 2.65 (95% CI, 1.85-3.79); P < 0.001). The HC/MH ratio had an area under the receiver-operating-characteristics curve of 0.77 and an optimal cut-off value for discriminating between vaginal delivery and CS for labor dystocia of 2.09, which was associated with a sensitivity of 0.62 (95% CI, 0.45-0.77), specificity of 0.79 (95% CI, 0.76-0.82), positive predictive value of 0.13 (95% CI, 0.09-0.19) and negative predictive value of 0.98 (95% CI, 0.96-0.99). CONCLUSIONS: In a large cohort of unselected pregnancies, the HC/MH ratio performed better than did fetal HC and MH alone in identifying those cases that will undergo CS for labor dystocia, albeit with moderate predictive value. The HC/MH ratio could assist in the evaluation of women at risk for CS for labor dystocia. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Epidural analgesia and the risk of operative delivery among women at term: A propensity score matched study.

OBJECTIVE: To investigate the correlation between epidural analgesia (EA) administered during labour and the risk of requiring an operative delivery (caesarean section or operative vaginal delivery). METHODS: This was a retrospective, multicentric cohort study. All singleton births of viable foetuses in cephalic presentation with a gestational age ≥ 37 weeks delivered between 2016 and2019 were included. A propensity score (PS) matching analysis was used to obtain comparable groups, balancing the maternal and pregnancy characteristics that required epidural analgesia during labour. The risk of operative delivery in women with and without epidural analgesia was estimated following PS-matching analysis (1:1 ratio). RESULTS: As per the unmatched analysis, the occurrence of Caesarean section (CS) was significantly higher in women administered EA compared with the non-EA group (14.0 % vs 5.0 %; p < 0.001). The incidence of operative vaginal delivery (OVD) (9.1 % vs 4.0 %; p < 0.001) showed a similar pattern. The PS algorithm matched 16.301 cases who were administered EA with 16.301 cases not administered EA and found a significantly increased risk of CS (OR, 1.6; 95 %CI 1.5-1.7) and OVD (OR, 1.2; 95 % CI 1.1-1.2) in the former group. CONCLUSION: The risk of operative delivery almost halved in the EA group compared with the non-EA group, compared with the baseline risk of the unmatched subjects.

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.

Prenatal diagnosis and outcome of fetuses with isolated agenesis of septum pellucidum: cohort study and meta-analysis.

OBJECTIVE: To evaluate the postnatal outcome of children with a prenatal diagnosis of apparently isolated agenesis of the septum pellucidum (ASP). METHODS: A retrospective cohort study of cases of prenatally diagnosed ASP followed in two tertiary centers and a meta-analysis combining data from the cohort study with data from published studies identified in a systematic review were carried out. Only cases with apparently isolated ASP on antenatal ultrasound and/or magnetic resonance imaging and with available postnatal follow-up data were considered eligible for inclusion. The following outcomes were analyzed: incidence of chromosomal anomalies, agreement between antenatal and postnatal findings, overall incidence of septo-optic dysplasia (SOD) and incidence of major neurological disability (motor, language, coordination or behavioral disorder or epilepsy) in non-SOD children. The incidence of SOD in infants with apparently normal optic pathways on antenatal imaging was also evaluated. RESULTS: Fifteen cases of isolated ASP, with median postnatal follow-up of 36 months (range, 12-60 months), were selected from the two centers. Six previously published studies met the inclusion criteria for the systematic review and a total of 78 cases were eligible for the analysis, including the 15 cases from our series. Genetic tests were carried out antenatally in 30 fetuses, of which two had an abnormal result (pooled proportion, 9.0% (95% CI, 1.8-20.7%); I2 = 0%). Additional or discordant imaging findings were noted postnatally in 9/70 (pooled proportion, 13.7% (95% CI, 3.5-29.0%); I2 = 63.9%) cases. Of all 78 neonates with available follow-up, SOD was diagnosed postnatally in 14 (pooled proportion, 19.4% (95% CI, 8.6-33.2%); I2 = 51.2%). In 60 cases, the optic pathways were considered to be normal on antenatal imaging, and six of these (pooled proportion, 9.1% (95% CI, 1.1-24.0%); I2 = 62.0%) were diagnosed postnatally with SOD. Of the 46 infants with available neurological follow-up who were not affected by SOD, a major neurological disability was diagnosed in three (pooled proportion, 6.5% (95% CI, 0.5-18.6%); I2 = 40.1%). CONCLUSIONS: In the vast majority of cases with a prenatal diagnosis of apparently isolated ASP, the prognosis is favorable. However, an additional anomaly is detected after birth in about 14% of cases and has a negative impact on clinical outcome. Detailed antenatal assessment of the brain and optic pathways is strongly recommended in order to identify the presence of associated anomalies. Antenatal visualization of apparently normal optic pathways does not rule out SOD. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

First-trimester fetal neurosonography: technique and diagnostic potential.

Most brain abnormalities are present in the first trimester, but only a few are detected so early in gestation. According to current recommendations for first-trimester ultrasound, the fetal head structures that should be visualized are limited to the cranial bones, the midline falx and the choroid-plexus-filled ventricles. Using this basic approach, almost all cases of acrania, alobar holoprosencephaly and cephalocele are detected. However, the majority of other fetal brain abnormalities remain undiagnosed until the midtrimester. Such anomalies would be potentially detectable if the sonographic study were to be extended to include additional anatomic details not currently included in existing guidelines. The aim of this review article is to describe how best to assess the normal fetal brain by first-trimester expert multiplanar neurosonography and to demonstrate the early sonographic findings that characterize some major fetal brain abnormalities. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

New technique for automatic sonographic measurement of change in head-perineum distance and angle of progression during active phase of second stage of labor.

OBJECTIVE: To evaluate the performance of a new ultrasound technique for the automatic assessment of the change in head-perineum distance (delta-HPD) and angle of progression (delta-AoP) during the active phase of the second stage of labor. METHODS: This was a prospective observational cohort study including singleton term pregnancies with fetuses in cephalic presentation during the active phase of the second stage of labor. In each patient, two videoclips of 10 s each were acquired transperineally, one in the axial and one in the sagittal plane, between rest and the acme of an expulsive effort, in order to measure HPD and AoP, respectively. The videoclips were processed offline and the difference between the acme of the pushing effort and rest in HPD (delta-HPD) and AoP (delta-AoP) was calculated, first manually by an experienced sonographer and then using a new automatic technique. The reliability of the automatic algorithm was evaluated by comparing the automatic measurements with those obtained manually, which was considered as the reference gold standard. RESULTS: Overall, 27 women were included. A significant correlation was observed between the measurements obtained by the automatic and the manual methods for both delta-HPD (intraclass correlation coefficient (ICC) = 0.97) and delta-AoP (ICC = 0.99). The high accuracy provided by the automatic algorithm was confirmed by the high values of the coefficient of determination (r2 = 0.98 for both delta-HPD and delta-AoP) and the low residual errors (root mean square error = 1.2 mm for delta-HPD and 1.5° for delta-AoP). A Bland-Altman analysis showed a mean difference of 0.52 mm (limits of agreement, -1.58 to 2.62 mm) for delta-HPD (P = 0.034) and 0.35° (limits of agreement, -2.54 to 3.09°) for delta-AoP (P = 0.39) between the manual and automatic measurements. CONCLUSIONS: The automatic assessment of delta-AoP and delta-HPD during maternal pushing efforts is feasible. The automatic measurement of delta-AoP appears to be reliable when compared with the gold standard manual measurement by an experienced operator. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

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.

Los espacios intracervicales como marcador ecográfico de trastornos del espectro de la placenta acreta en pacientes con placenta previa o placenta baja OBJETIVO: Evaluar la precisión del diagnóstico de un nuevo indicio de ultrasonido, los espacios intracervicales (EIC), para predecir la presencia de trastornos del espectro de la placenta acreta (EPA) y el resultado del parto en pacientes con placenta previa o placenta baja. MÉTODOS: Este fue un estudio multicéntrico retrospectivo de mujeres con placenta previa o placenta baja a ≥ 26 semanas de gestación, que se remitieron a tres unidades terciarias italianas desde enero de 2015 a septiembre de 2018. Se evaluó la presencia de EIC, definida como espacios anecoicos tortuosos dentro del cuello uterino que parecían ser hipervasculares en el Doppler a color, en imágenes de ecografías obtenidas en el momento de la remisión. El objetivo principal fue estudiar la precisión del diagnóstico mediante EIC en la detección de la presencia y la profundidad de un trastorno del EPA. El objetivo secundario fue explorar la precisión de este indicador para predecir la pérdida total estimada de sangre, la hemorragia antes del parto, la hemorragia puerperal importante en el momento de la cesárea y la necesidad de una histerectomía por cesárea. La precisión diagnóstica de EIC, en combinación con los indicios ecográficos típicos de los trastornos del EPA, se evaluó calculando estimaciones estadísticas descriptivas de la sensibilidad, la especificidad, los valores predictivos positivos y negativos, los cocientes de verosimilitud positivos y negativos y las razones de momios del diagnóstico (RMD). RESULTADOS: En el análisis se incluyó un total de 332 mujeres con placenta previa o placenta baja, con una mediana de la edad materna de 33,0 años (rango intercuartil, 29,0-37,0). Se observaron EIC en el 15,1% de las pacientes. En el análisis de regresión logística, la presencia de EIC se asoció de forma independiente con la hemorragia puerperal grave (razón de momios (RM), 3,3 (IC 95%, 1,6-6,5); P<0,001), la histerectomía por cesárea (RM, 7,0 (IC 95%, 2,1-23,9); P<0,001) y la placenta percreta (RM, 2,8 (IC 95%, 1,3-5,8); P≤0,01), pero no con la presencia de ningún trastorno del EPA (RM, 1,6 (IC 95%, 0,7-3,5); P=0,2). En comparación con el grupo de pacientes sin indicios de ultrasonido de algún trastorno del EPA, la presencia de al menos un indicio ecográfico típico de trastorno del EPA en combinación con EIC tuvo una RMD de 217,2 (IC 95%, 27,7-1703,4; P<0,001) para la placenta percreta y de 687,4 (IC 95%, 121,4-3893,0; P<0,001) para la histerectomía por cesárea. CONCLUSIÓN: Los EIC pueden representar un marcador de invasión profunda de las vellosidades en mujeres con sospecha de algún trastorno del EPA basado en la ecografía prenatal y anticipar la presencia de una morbilidad materna grave.

Outcome of non-visualization of fetal gallbladder on second-trimester ultrasound: cohort study and systematic review of literature.

OBJECTIVES: To investigate the ultrasound characteristics and outcome of fetuses with non-visualization of the fetal gallbladder (NVFGB) followed in our tertiary university hospital, and to provide a comprehensive review of the literature on prenatal findings and outcome of NVFGB. METHODS: NVFGB was defined as non-visualization of the gallbladder on two targeted ultrasound examinations performed within a 1-week period. First, we reviewed the medical records of NVFGB cases managed in our center over a 9-year period. Then, we performed a systematic review of the literature to identify studies on NVFGB. The incidence of chromosomal anomalies, later visualization of the gallbladder, gallbladder agenesis, cystic fibrosis and biliary atresia was assessed in fetuses with isolated and non-isolated NVFGB. The role of hepatic enzyme measurements in the diagnosis of cystic fibrosis and biliary atresia in fetuses with NVFGB was also reviewed. RESULTS: Sixteen cases of NVFGB were followed in our center, in 10 (62.5%) of which it was an isolated finding. The incidence of biliary atresia was 12.5% and that of gallbladder agenesis was 12.5%, while no case of cystic fibrosis was reported. The gallbladder was visualized later in pregnancy or postnatally in 43.8% and 25.0% of cases, respectively. A total of seven studies, including our cohort, involving a total of 280 NVFGB cases, met the inclusion criteria for the systematic review. Overall, 20.5% of fetuses had an associated ultrasound anomaly, and the incidence of chromosomal anomaly in this group was 20.4%. In cases with isolated NVFGB, the incidence of chromosomal anomaly was 1.9%. In fetuses with normal karyotype and isolated NVFGB, the gallbladder was later visualized in 70.4% of cases, while the incidence of gallbladder agenesis, cystic fibrosis and biliary atresia was 25.2%, 3.1% and 4.8%, respectively. In fetuses with non-isolated NVFGB, the incidence of cystic fibrosis and biliary atresia was 23.1% and 18.2%, respectively. The negative predictive value of amniotic fluid enzyme levels for the prediction of severe disease (including biliary atresia or cystic fibrosis) ranged between 94% and 100% when evaluated before 22 weeks' gestation, and dropped to 88% after 22 weeks. CONCLUSIONS: In cases with persistent NVFGB, the risk of a severe postnatal condition should be considered. A detailed ultrasound scan should be offered and parents tested for cystic fibrosis gene mutation. An invasive procedure for karyotyping and measurement of liver enzyme concentrations before 22 weeks constitutes a reasonable work-up. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

No visualización de la vesícula biliar fetal en la ecografía del segundo trimestre del embarazo: estudio de cohortes y revisión sistemática de la literatura sobre el resultado postnatal OBJETIVOS: Investigar las características ecográficas y los resultados de los fetos con no visualización de la vesícula biliar fetal (NVFGB, por sus siglas en inglés) a los que se ha dado seguimiento en un hospital universitario terciario, y ofrecer una revisión exhaustiva de la literatura sobre los hallazgos prenatales y los resultados de la NVFGB. MÉTODOS: La NVFGB se definió como la no visualización de la vesícula biliar en dos exámenes ecográficos específicos realizados en un período de una semana. Primero, se revisó los registros médicos de los casos de NVFGB tratados en este hospital durante un período de 9 años. Luego, se realizó una revisión sistemática de la literatura para identificar estudios sobre NVFGB. Se evaluó la incidencia de anomalías cromosómicas, la visualización posterior de la vesícula biliar, la agenesia vesicular, la fibrosis quística y la atresia biliar en fetos con NVFGB aislada y no aislada. También se examinó la función de las mediciones de las enzimas hepáticas en el diagnóstico de la fibrosis quística y la atresia biliar en fetos con NVFGB. RESULTADOS: Se siguieron dieciséis casos de NVFGB en este centro hospitalario, lo cual fue un hallazgo aislado en 10 de ellos (62,5%). La incidencia de atresia biliar fue del 12,5% y la de agenesia vesicular del 12,5%, mientras que no se reportó ningún caso de fibrosis quística. La vesícula biliar se visualizó más tarde en el embarazo o después del parto en el 43,8% y 25,0% de los casos, respectivamente. Un total de siete estudios cumplieron los criterios de inclusión para la revisión sistemática, incluidos los de la cohorte del mencionado hospital, con un total de 280 casos de NVFGB. En total, el 20,5% de los fetos presentaban una anomalía ecográfica asociada, y la incidencia de anomalías cromosómicas en este grupo fue del 20,4%. En los casos con NVFGB aislada, la incidencia de anomalías cromosómicas fue del 1,9%. En los fetos con cariotipo normal y NVFGB aislada, la vesícula biliar se visualizó posteriormente en el 70,4% de los casos, mientras que la incidencia de agenesia vesicular, fibrosis quística y atresia biliar fue del 25,2%, 3,1% y 4,8%, respectivamente. En los fetos con NVFGB no aislada, la incidencia de fibrosis quística y atresia biliar fue del 23,1% y 18,2%, respectivamente. El valor predictivo negativo de los niveles de enzimas del líquido amniótico para la predicción de una enfermedad grave (como la atresia biliar o la fibrosis quística) se situó entre el 94% y el 100% cuando se evaluó antes de las 22 semanas de gestación, y bajó al 88% después de las 22 semanas. CONCLUSIONES: En casos con NVFGB persistente, se debe considerar el riesgo de una condición postnatal severa. Se debe ofrecer una ecografía detallada y la madre y el padre deben someterse a pruebas para detectar mutaciones del gen de la fibrosis quística. Un examen diagnóstico razonable incluye un procedimiento invasivo para el cariotipado y la medición de las concentraciones de enzimas hepáticas antes de las 22 semanas.

Gestational weight gain as an independent risk factor for adverse pregnancy outcomes in women with gestational diabetes.

OBJECTIVE: Obesity and gestational diabetes mellitus (GDM) are rising worldwide. This study retrospectively evaluated the role of excessive gestational weight gain (eGWG) in women with GDM and different pre-pregnancy body mass indices (BMIs). PATIENTS AND METHODS: Optimal glycaemic control was defined as achieving glucose target thresholds in more than 80% of measurements. 283 women with GDM were categorized as underweight, normal weight, overweight or obese based on WHO's classification scheme. eGWG was defined as >18.0 kilograms for women who were underweight, >15.8 kilograms for those who were normal weight, >11.3 kilograms for those who were overweight and >9.0 kilograms for those who were obese. For the analysis, women were divided into two groups: normal and excessive GWG. The main outcomes measured were incidences of large/small for gestational age (LGA/SGA), macrosomia, preterm delivery, hypertensive disorders and caesarean sections (CS). RESULTS: Excessive GWG was associated with higher birth weight and percentile (p<0.001), and with a higher prevalence of LGA (p<0.001), macrosomia (p=0.002) and hypertensive disorders (p=0.036). No statistical differences were found for the week of delivery, or prevalence of CS and SGA. The multivariate analysis highlighted both pre-pregnant BMI and eGWG as independent risk factors for LGA and macrosomia. Women with a pre-pregnant BMI of at least 25 and eGWG have a 5.43-fold greater risk of developing LGA (p=0.005). CONCLUSIONS: When combined with an inadequate pre-pregnant BMI, eGWG acts as a "synergic risk factor" for a poor outcome. When obesity or GDM occur, an optimal GWG can guarantee a better pregnancy outcome.

Fetal intra-abdominal umbilical vein varix: retrospective cohort study and systematic review and meta-analysis.

OBJECTIVE: To investigate the ultrasound characteristics and outcome of pregnancies with fetal intra-abdominal umbilical vein varix (FIUVV). METHODS: Cases of FIUVV managed at our tertiary university hospital over an 8-year period were reviewed. Information retrieved included gestational age and diameter of the umbilical varix at diagnosis, increase in varix diameter, associated ultrasound or chromosomal anomalies and pregnancy outcome. Furthermore, a systematic review and meta-analysis of series of FIUVV in the literature was performed to assess the incidence of chromosomal anomalies, small-for-gestational age infants and intrauterine fetal demise (IUFD), and to pool odds ratio (OR) estimates on the relationship between the incidence of these outcomes and the presence of additional associated ultrasound anomalies. RESULTS: Thirteen cases of FIUVV were included in the cohort study. Additional ultrasound anomalies were found in two (15.4%) of 13 cases. One case of IUFD was observed and no case of chromosomal anomaly or thrombosis of varix was recorded. A total of five studies comprising 254 cases met the inclusion criteria of the systematic review. FIUVV was associated with additional ultrasound anomalies (non-isolated FIUVV) in 19% (95% CI, 10.9-29.1%) of cases. No case of chromosomal abnormality or IUFD was reported in fetuses with isolated FIUVV. In contrast, in the group of non-isolated FIUVV, the incidence of chromosomal anomalies was 19.6% and that of IUFD was 7.3%, with ORs of 14.8 (95% CI, 2.9-73.0) and 8.2 (95% CI, 1.05-63.1), respectively, when compared with the group of isolated FIUVV. CONCLUSION: When isolated, the outcome of cases affected by FIUVV is usually favorable. In about 20% of cases, additional ultrasound anomalies are found, which are associated with an increased risk for chromosomal abnormalities and IUFD. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Is there any role for the hydroxychloroquine (HCQ) in refractory obstetrical antiphospholipid syndrome (APS) treatment?

The best therapy regimen for refractory obstetrical antiphospholipid syndrome remains to be determined. Additional treatments with steroids, plasma exchanges and immunoglobulins failed to show any beneficial effect. We present a case of a woman who had a better pregnancy outcome after the administration of hydroxychloroquine (HCQ) as additional treatment. Furthermore, we highlighted that HCQ was able to dramatically reduce the antiphospholipid antibodies levels.

Fondaparinux in pregnancy: Could it be a safe option? A review of the literature.

During pregnancy thrombo-prophylaxis could be required in high risk women. If a severe allergic reaction to low-molecular-weight-heparin (LMWH) or a heparin-induced-thrombocytopenia (HIT) occurs, it's mandatory to stop the drug. Fondaparinux could be an effective option. In the present review, the maternal and pregnancy outcomes of 65 pregnancies in women using Fondaparinux were reported. It was well-tolerated and rate of pregnancy complications was similar to that observed in general population. Regarding congenital malformations, further studies are necessary to investigate the safety of the drug.