A New Method to Measure the Subpubic Arch Angle Using 3-D Ultrasound.

OBJECTIVES: The aim of this study was to assess the reproducibility of both a new contrast-enhancing technique (Oblique View eXtended Imaging, OVIX; Samsung) and the recently reported 3-D multiplanar technique (MPT) in the measurement of the subpubic angle (SPA) among a group of women at term gestation. In addition, we aimed to study the intermethod agreement between the OVIX technique and MPT. METHODS: We acquired a transperineal 3-D ultrasound volume from 155 women with a singleton uncomplicated term pregnancy before the onset of labor. Each 3-D dataset was analyzed by the MPT and OVIX algorithm. The angle formed by the lower edges of the pubic rami (SPA) was measured twice by an operator and once by another operator for each technique in order to assess intra- and interobserver reproducibility. Reproducibility and intermethod agreement were studied by means of the intraclass correlation coefficient (ICC) and Bland-Altman method. RESULTS: SPA measurements performed with OVIX showed high intraobserver [ICC 0.912, 95% confidence interval (CI) 0.882-0.935] and good interobserver (ICC 0.791, 95% CI 0.724-0.844) agreement, while those measured with MPT showed moderate intraobserver (ICC 0.573, 95% CI 0.457-0.670) and good interobserver (ICC 0.640, 95% CI 0.537-0.724) agreement. Whereas the intermethod analysis showed good agreement between the MPT and the OVIX techniques (ICC 0.614, 95% CI 0.414-0.757), the SPA measured by MPT were significantly wider than those measured by OVIX (125 ± 12 vs. 120 ± 11°, p = 0.006). CONCLUSIONS: OVIX is a reliable technique for SPA measurement. MPT overestimates the SPA in comparison with OVIX. Further studies are needed to assess its clinical utility.

Uterine artery Doppler longitudinal changes in pregnancies complicated with intrauterine growth restriction without preeclampsia.

OBJECTIVE: The objective of this article is to evaluate the longitudinal changes in uterine artery Doppler pulsatility index (UtA-PI) in pregnancies complicated with early onset intrauterine growth restriction (IUGR). METHOD: Case-control study comparing UtA-PI from 20 to 34 weeks gestation in pregnancies affected by IUGR at 20 to 28 weeks and confirmed at delivery (cases), matched with 1000 controls. Multivariable analyses were used to estimate the UtA-PI as a function of both gestational age and IUGR severity. Finally, bootstrapping technique was used to internally validate the models. RESULTS: We retrospectively retrieved 53 cases and 1000 controls. Regression line having log10 UtA-PI as dependent variable was a function of both gestational age and IUGR. UtA-PI decreased with gestational age in both groups. In IUGR group, UtA-PI was higher from 20 weeks onward and the difference with controls increased with gestational age. In fact, at 20 weeks, the UtA-PI ratio between cases and controls was 1.84, but at 30 weeks it rose to 2.05. Finally, the weight at delivery in the IUGR group was also inversely correlated with the UtA-PI values. CONCLUSION: We presented a reliable multivariable statistical model to evaluate the temporal changes of UtA-PI values as a function of both gestational age and IUGR.

Symptomatic cerebral cavernomas in pregnancy: a series of 6 cases and review of the literature.

OBJECTIVE: To present our experience of symptomatic cerebral cavernous malformations (CCMs) in pregnancy and to review the literature on the topic. METHODS: We retrospectively collected a case series of symptomatic CCMs during pregnancy or the puerperium. A literature search was performed to identify all similar reports. RESULTS: We collected 16 cases of symptomatic CCMs. Haemorrhage occurred in 10 patients. Two patients opted for termination of pregnancy. Delivery occurred preterm in four cases, in only one case due to neurological symptoms at 30 weeks' gestation. Caesarean section was performed in 9 cases; concern over CCM was the indication for delivery in eight of these cases. Four out of 16 patients underwent neurosurgery, three during pregnancy. CONCLUSION: Symptomatic CCMs seldom require neurosurgery either during or after pregnancy and are not associated with preterm delivery.

Umbilical cord insertion into the lower segment of the uterus at 11 to 13 weeks' gestation is associated with maternal serum PAPP-A.

OBJECTIVES: To evaluate whether the location of the placental cord insertion (CI) at 11 to 13 weeks' gestation affects the maternal serum pregnancy-associated plasma protein-A (PAPP-A). METHODS: Cohort study was conducted in patients who underwent the first trimester screening including nuchal translucency and blood test. We additionally documented the CI site. The thickness of the placenta under the CI and the minimum distance on the uterine wall between the internal cervical os and the CI (Dis) were measured. The subjects were divided into two groups. Below the tenth percentile in multiples of median (MoM) of Dis were defined as cases in which CI was located on the lower uterine segment (low CI) and the others were defined as controls. RESULTS: A total of 117 subjects were analyzed. The thickness of the placenta (r = 0.237, p = 0.010) and Dis (r = 0.243, p = 0.008) was correlated with the crown-rump length (CRL). The maternal serum PAPP-A MoM in the low CI group was lower than in controls (0.76 ± 0.34 vs 1.16 ± 0.55; p = 0.009), whereas the other ultrasonographic measurements and maternal demographics were not different between the two groups. CONCLUSION: CI on the lower segment of the uterus is associated with low maternal serum PAPP-A MoM levels.

The prognostic role of uterine artery Doppler studies in patients with late-onset preeclampsia.

OBJECTIVE: To evaluate the usefulness of uterine artery Doppler in the prediction of outcome in patients with late-onset preeclampsia. STUDY DESIGN: Patients with late-onset preeclampsia underwent Doppler interrogation of the uterine arteries. Patients with abnormal uterine artery Doppler were compared with those who had a normal uterine artery Doppler. RESULTS: Ninety-nine patients were included in the study group. Abnormal uterine artery Doppler group presented significantly lower gestational age at admission (36.1 +/- 2.1 weeks vs 37.2 +/- 1.9 weeks; P < .005), lower gestational age at delivery (36.5 +/- 1.9 weeks vs 37.7 +/- 1.7 weeks; P < .005), lower birthweight (2429 +/- 590 g vs 3013 +/- 597 g; P < .0001), and a higher admission rate to neonatal intensive care unit (17/51 vs 6/48; odds ratio, 3.5; 95% confidence interval, 1.2-9.5). No significant difference in the occurrence of maternal complications (10/51 vs 6/48; odds ratio, 1.7; 95% confidence interval, 0.5-4.9) was registered. CONCLUSION: Women with late-onset preeclampsia show a higher risk of perinatal complications if uterine resistance is increased although maternal outcome does not seem to be related to Doppler findings.

PLAC1 mRNA levels in maternal blood at induction of labor correlate negatively with induction-delivery interval.

OBJECTIVE: This study was conducted to determine whether, in low risk women having labor induced using prostaglandin gel (dinoprostone gel), there is a relationship between the concentration of mRNA for the PLAC1 gene (a trophoblast-specific gene) in maternal blood and the time elapsed between the first gel administration and spontaneous delivery. STUDY DESIGN: Blood was collected from 49 selected women at 40.2-41.4 weeks' gestation. Total RNA was extracted by means of an ABI Prism 6100 nucleic acid Prep Station and quantitative real-time PCR analysis was performed by use of a PE Applied Biosystems 5700 Sequence Detection System. Sequence data were obtained from the Genebank Sequence Database. To determine the amount of cDNA, the PLAC1 locus was used. RESULTS: Thirty women (61.2%) had a spontaneous delivery. A caesarean section, either for fetal dystocia or fetal distress, was performed in 19 (38.8%). The crude delivery rates of the women who ended up with a spontaneous delivery were 30% at 24 h and 43% at 48 h. Women (n=19) with a blood concentration of logPLAC1 mRNA>or=2.00 displayed a median time to delivery of 23.50h, (95% CI: 13.13-33.87) while those with a logPLAC1 mRNA<2.00 (n=30) had a median time of 54 h. (95% CI: 37.86-70.14; p=0.0043, log-rank test). By means of multivariate analysis, quantitative Bishop score (from 2 to 7) at the time of the first gel administration and logPLAC1 mRNA>or=2.00 were associated with a higher rate of delivery per unit of time with an odds ratio of 1.35 (95% CI: 1.07-1.71) and 3.48 (95% CI: 1.55-7.80), respectively. CONCLUSIONS: In induced term pregnancies, PLAC1 mRNA in maternal blood at the beginning of the treatment correlates with the time elapsed before delivery. This evidence demonstrates that the fetomaternal trafficking of nucleic acids is more consistent when the labor is about to begin.

PLAC1 mRNA in maternal blood correlates with Doppler waveform in uterine arteries in normal pregnancies at the second and third trimester.

Doppler analysis of the uterine arteries is currently used for pre-eclampsia (PE) screening. PLAC1 is a trophoblast-specific gene, and it is known that in normal pregnancies, trophoblastic cells are released into the maternal circulation, where specific trophoblastic mRNA can be detected. In PE, as in women who eventually develop PE, an abnormal passage of fetal and placental cells is also present. In this study, we aimed to verify whether, in normal pregnancies, Doppler waveform of the uterine arteries correlates with PLAC1 mRNA concentrations. Thirteen cases of normal pregnancies at 37 weeks' gestation (23-41) were enrolled in the study. PLAC1 mRNA was extracted from 2 mL of blood by ABI PRISM 6100 nucleic acid Prep Station (Applied Biosystems, Foster City, CA) and quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) analysis was performed by a PE 5700 Sequence detection system. Bulk RNA from normal placental tissue was used as the reference curve, and the amount of PLAC1 mRNA in the study samples was then expressed as the "relative amount" of weight of placental tissue (ng/mL). The uterine arterial mean resistance index (RI) and presence/absence of a dicrote waveform were calculated by using a 5 MHz transabdominal probe (Tecnos, ESAOTE) at the uterine cervico-corporal junction. Doppler measurement was performed on the same day as blood collection. The median of the means of uterine arterial RI was 0.52 (0.39-0.68). RI of uterine arteries and PLAC1 mRNA were significantly correlated in a log-linear regression (R(2) = 0.483, P = 0.024). Our data support that in normal pregnancy, the passage of trophoblast material into the maternal circulation is correlated with the quantitative measurement of uterine hemodynamics.

Total activin A in maternal blood as a marker of preterm delivery in low-risk asymptomatic patients.

OBJECTIVES: To retrospectively evaluate whether increased serum levels of total activin A (t-activin A) are found in women who subsequently experience preterm delivery (PTD). METHODS: Data on maternal serum t-activin A concentrations were available from a total of 84 singleton pregnant women and included 14 PTD pregnancies, each matched for gestational age and length of freezer storage, with 5 control pregnancies having term delivery (TD). Analyte values were expressed as multiple(s) of the control median. RESULTS: The median t-activin A for controls and cases was 1.00 +/- 0.45 and 1.27 +/- 0.53 MoM, respectively. Univariate analysis of the MoM values was performed using the Kaplan-Meier algorithm. Differences in the rate of delivery using a t-activin A MoM cut-off of > or = 1 SD (equivalent to 1.26 MoM) were analysed using the log rank test. The cumulative rate of PTD (< 37 weeks) was significantly higher for women with t-activin A concentrations > or = 1.26 MoM than those with t-activin A concentrations below this cut-off (40% vs.. 10%, p-value = 0.0218 log rank test). CONCLUSIONS: T-activin A concentration is higher in women who will develop PTD in a low-risk population. T-activin A values are inversely proportional to the time elapsed from blood test to delivery. Prospective studies would determine the precise discriminability of this marker for PTD and the best week for performing the blood test, allowing for a proper calculation of the detection rate and a positive predictive value.