Prenatal diagnosis versus first-trimester screening of trisomy 21 among pregnant women aged 35 or more.

OBJECTIVE: To compare the policy of prenatal diagnosis versus first trimester screening of trisomy 21 among pregnant women of advanced age. METHODS: A retrospective study was conducted on patients aged ≥35 divided in two groups: patients who requested first trimester combined test and only in case of screen-positive result underwent invasive testing (group A); patients undergoing chorionic villous sampling or amniocentesis as first investigation (group B). The following outcome variables were compared: antenatal detection of trisomy 21, occurrence of trisomy 21 at birth, miscarriage rate, hospitals' costs. RESULTS: 4527 women were included. Of these, 534 (11.80%) underwent T21 screening whereas 3993 (88.20%) requested primary invasive testing. In group A, 64 combined test were positive (11.99%) and 8 trisomy 21 cases were diagnosed (1.50%); the loss of euploid fetuses after invasive procedure was 4.55% (2/44). No false-negative case was observed. In group B 57 cases of trisomy 21 were diagnosed (1.43%), and pregnancy loss rate of chromosomally normal fetuses was 0.45% (17/3806). The estimated cost was, respectively, 67.720€ for the primary screening versus 1.996.500€ for direct prenatal diagnosis. CONCLUSION: First trimester screening of trisomy 21 is highly accurate and cost saving among women ≥35.

Fetal head-symphysis distance and mode of delivery in the second stage of labor.

OBJECTIVE: To evaluate whether the fetal head-symphysis distance measured by three-dimensional transperineal ultrasound during the active second stage predicts operative delivery. DESIGN: Prospective observational study. SETTING: University hospital, Bologna, Italy. POPULATION: Seventy-one nulliparous women at term in active second stage of labor. METHODS: We acquired a series of sonographic volumes at the beginning of the active second stage (T1) and every 20 min thereafter (T2, T3, T4, T5, T6) until delivery. All volumes were retrospectively analyzed and head-symphysis distance was measured for each acquisition. We compared head-symphysis distance between women with spontaneous vaginal delivery and those with operative delivery. Receiver operator characteristic curves were constructed to estimate the accuracy of head-symphysis distance in the prediction of operative delivery. Logistic regression was used to identify independent variables associated with operative delivery. MAIN OUTCOME MEASURES: Operative delivery (vacuum or cesarean). RESULTS: Of the women included, 81.7% had a spontaneous vaginal delivery and 18.3% underwent operative delivery. Women with spontaneous vaginal delivery had shorter head-symphysis distance than women in the operative delivery group at T1 (p < 0.001), T2 (p < 0.001) and T3 (p = 0.025), whereas no significant differences were recorded thereafter. Receiver operator characteristic curves revealed accuracy values of 81.0%, 87.9% and 77.6% in the prediction of operative delivery at T1, T2 and T3, respectively. At multivariate logistic regression head-symphysis distance and epidural analgesia were the only independent predictors of operative delivery among ultrasonographic, maternal and intrapartum variables. CONCLUSIONS: Ultrasonographic measurement of head-symphysis distance in the second stage of labor can be used to predict operative delivery.

The descent of the fetal head is not modified by mobile epidural analgesia: a controlled sonographic study.

The aim of our study was to assess the sonographic indices of fetal head progression obtained by three-dimensional ultrasound during the second stage of labor in women with and without mobile epidural analgesia. Sonographic volume data sets were obtained with a transperineal approach every 20 min from the beginning of the active second stage until delivery. The ultrasound parameters were calculated off-line from each volume and compared between women with and without epidural analgesia. All the sonographic measurements of the fetal head descent were comparable at each time interval between the two groups. This observation suggests that mobile epidural analgesia is not likely to affect the dynamics of the second stage of labor.

The usefulness of volume NT software in measuring the fetal nasal bone at 11 to 13 + 6 weeks of gestation.

OBJECTIVE: The objective of this study is to investigate the reproducibility of 3D ultrasound to measure the fetal nasal bone (NB) at first trimester. METHODS: A group of singleton viable pregnancies attending the 11 to 13 + 6 weeks aneuploidy screening at the University of Bologna were prospectively selected. For each patient, fetal NB was measured by 2D ultrasound. Subsequently, a 3D ultrasound of the fetal head was acquired, and fetal NB was measured by offline analysis using the volume nuchal translucency software. The correlation between 2D and 3D ultrasounds and the reproducibility of fetal NB measurement at 3D ultrasound were assessed. RESULTS: Overall, 161 Caucasian women were included in the study. At 3D ultrasound, NB measurement showed an excellent intraobserver [Oper 1, intraclass correlation coefficient (ICC) = 0.98; Oper 2, ICC = 0.921] and interobserver agreement (rc = 0.92). The agreement between 2D and 3D measurements was moderate (rc = 0.77). CONCLUSIONS: A 3D ultrasound supported by the volume nuchal translucency software may provide reliable measurements of the fetal NB in the first trimester.

The pregnancy outcome in women with incidental diagnosis of septate uterus at first trimester scan.

BACKGROUND: Septate uterus seems to be strongly associated with an adverse pregnancy outcome. However, the possible relationship between septate uterus and miscarriage has only been retrospectively ascertained. The aim of our study was to describe the reproductive outcome in women with incidental diagnosis of malformed uterus at first trimester scan. METHODS: Women at their first pregnancy attending our centre for a routine viability scan with an incidental suspicion of uterine anomaly at standard sonography were submitted to transvaginal volume ultrasound. All the cases with a 3D diagnosis of septate uterus were prospectively recruited and followed up. RESULTS: Overall 24 patients with a single intrauterine pregnancy were included at a median gestational age of 8.2 weeks. The cumulative pregnancy progression rate, as quoted by Kaplan-Meier algorithm, was 33.3% due to the occurrence of early (≤ 13 weeks) or late miscarriages (14-22 weeks) in 13 and 3 cases, respectively. CONCLUSION: The pregnancy outcome is poor if a septate uterus is incidentally diagnosed in the early stage of a viable intrauterine pregnancy.

Three-dimensional ultrasound is an accurate and reproducible technique for fetal crown-rump length measurement.

OBJECTIVE: The aim of the study was to evaluate the accuracy and reproducibility of fetal crown-rump length (CRL) measurement using three-dimensional ultrasound (3DUS). METHODS: We included a series of women with singleton pregnancy at 6-13 + 6 weeks. Following CRL measurement by the two-dimensional ultrasound (2DUS), a 3DUS volume was acquired. On the reconstructed midsagittal plane, CRL was measured twice by an operator and once by another. The correlation between CRL measured by 3DUS and 2DUS, as well as the intraobserver and interobserver agreement, was then calculated. Furthermore, the agreement between 2DUS and 3DUS CRL measurements together with intraobserver and interobserver agreement was calculated separately for the groups with a midsagittal acquisition plane (MSAP) and non-midsagittal acquisition plane (NMSAP). RESULTS: Overall, 137 pregnancies were included in the analysis. CRL measurements performed using 3DUS showed excellent correlation with 2DUS [intraclass correlation coefficient (ICC) = 0.992]. In addition, the 3DUS showed a high intraobserver and interobserver agreement (ICC = 0.999 and 0.993, respectively). Finally, when we divided the acquired volumes according to the plane of acquisition, excellent 2DUS-3DUS, as well as intraobserver and interobserver agreement, was maintained for both MSAP and NMSAP. CONCLUSION: 3DUS is a highly accurate and reproducible tool for fetal CRL measurement regardless of the fetal position at the time of 3D volume acquisition.

Unilaterally increased uterine artery resistance, placental location and pregnancy outcome.

OBJECTIVE: To evaluate the outcome of pregnancies with second trimester unilaterally increased uterine artery resistance. STUDY DESIGN: Between January 2007 and December 2009 all low-risk patients with unilateral increase of uterine artery pulsatility index (PI) but normal mean pulsatility at 20-22 weeks of gestation were included in the study group. Among these, cases with central placenta (group A) were distinguished from those with lateral placenta (group B). A control group was selected among patients with bilaterally normal uterine artery PI. Pregnancy outcome was considered for all cases and compared with controls. RESULTS: In the study period, 131 patients with second trimester unilaterally increased uterine artery PI were identified. Placental location was central in 67 (51.1%) patients (group A) and lateral in 64 (48.9%) patients (group B). In the study group (n=131) compared to controls (n=131), mean gestational age at delivery (38.9 ± 1.4 weeks vs. 38.8 ± 1.6 weeks; p=0.43), mean birth weight (3251 ± 445 vs. 3276 ± 388; p=0.63), Z-score of birth weight (-0.17 ± 0.87 SD vs. -0.04 ± 0.69 SD; p=0.19), occurrence of pre-eclampsia (4/131 vs. 3/131; p=1), low birth weight (7/131 vs. 7/131; p=1) and caesarean section due to fetal distress (9/131 vs. 6/131; p=0.5) were not significantly different. The same variables were compared within the study group between cases with central (group A) vs. lateral (group B) placenta and none of them was significantly different. CONCLUSION: Patients with unilaterally abnormal uterine artery pulsatility, but normal mean PI, do not seem at increased risk for obstetric and perinatal complications, irrespectively of placental location.

Mode of delivery in the preterm gestation and maternal and neonatal outcome.

OBJECTIVE: To determine if the mode of delivery in preterm gestations is associated with changes in maternal and neonatal outcome. METHODS: A retrospective cohort study that included all singleton deliveries occurring after spontaneous onset of labour between 25+0 and 32+6 weeks of gestation. Cases of early preterm delivery were identified from clinical records and classified according to the mode of delivery. The following outcomes were derived for each case and compared between caesarean and vaginal deliveries: perinatal death, cranial findings compatible with haemorrhage or white matter disease in the neonate, new-onset of maternal severe anaemia or pyrexia. RESULT: From 1990 to 2007, 109 cases of spontaneous preterm labour were retrospectively selected, including 50 (45.8%) caesarean sections and 59 (54.2%) vaginal deliveries. Perinatal death occurred in 10 infants (9.1%), whereas among survivors abnormal cerebral findings were detected in 20, including 6 cases with haemorrhage, 12 with white matter findings and 2 with both. At multiple logistic regression, a birthweight lower than 1100 g was the only predictor of all adverse outcomes, whereas male sex increased the risk of white matter findings. Caesarean section compared to vaginal delivery conferred a higher risk of maternal complications (23/50 or 46% vs. 6/59 or 10.2%; OR: 11.9, CI 95%: 4.2-333; p<0.0005). CONCLUSIONS: In severely premature infants born after spontaneous onset of labour, the risk of adverse perinatal outcome does not seem to depend upon the mode of delivery, whereas the risk of maternal complications is significantly increased after Caesarean section.