The sonopartogram.

The assessment of labor progress from digital vaginal examination has remained largely unchanged for at least a century, despite the current major advances in maternal and perinatal care. Although inconsistently reproducible, the findings from digital vaginal examination are customarily plotted manually on a partogram, which is composed of a graphical representation of labor, together with maternal and fetal observations. The partogram has been developed to aid recognition of failure to labor progress and guide management-specific obstetrical intervention. In the last decade, the use of ultrasound in the delivery room has increased with the advent of more powerful, portable ultrasound machines that have become more readily available for use. Although ultrasound in intrapartum practice is predominantly used for acute management, an ultrasound-based partogram, a sonopartogram, might represent an objective tool for the graphical representation of labor. Demonstrating greater accuracy for fetal head position and more objectivity in the assessment of fetal head station, it could be considered complementary to traditional clinical assessment. The development of the sonopartogram concept would require further undertaking of serial measurements. Advocates of ultrasound will concede that its use has yet to demonstrate a difference in obstetrical and neonatal morbidity in the context of the management of labor and delivery. Taking a step beyond the descriptive graphical representation of labor progress is the question of whether a specific combination of clinical and demographic parameters might be used to inform knowledge of labor outcomes. Intrapartum cesarean deliveries and deliveries assisted by forceps and vacuum are all associated with a heightened risk of maternal and perinatal adverse outcomes. Although these outcomes cannot be precisely predicted, many known risk factors exist. Malposition and high station of the fetal head, short maternal stature, and other factors, such as caput succedaneum, are all implicated in operative delivery; however, the contribution of individual parameters based on clinical and ultrasound assessments has not been quantified. Individualized risk prediction models, including maternal characteristics and ultrasound findings, are increasingly used in women's health-for example, in preeclampsia or trisomy screening. Similarly, intrapartum cesarean delivery models have been developed with good prognostic ability in specifically selected populations. For intrapartum ultrasound to be of prognostic value, robust, externally validated prediction models for labor outcome would inform delivery management and allow shared decision-making with parents.

A model to predict vaginal delivery in nulliparous women based on maternal characteristics and intrapartum ultrasound.

OBJECTIVE: Accurate prediction of whether a nulliparous woman will have a vaginal delivery would be a major advance in obstetrics. The objective of the study was to develop such a model based on maternal characteristics and the results of intrapartum ultrasound. STUDY DESIGN: One hundred twenty-two nulliparous women in the first stage of labor were included in a prospective observational 2-centre study. Labor was classified as prolonged according to the respective countries' national guidelines. Fetal head position was assessed with transabdominal ultrasound and cervical dilatation by digital examination, and transperineal ultrasound was used to determine head-perineum distance and the presence of caput succedaneum. The subjects were divided into a testing set (n = 61) and a validation set (n = 61) and a risk score derived using multivariable logistic regression with vaginal birth as the outcome, which was dichotomized into no/cesarean delivery and yes/vaginal birth. Covariates included head-perineum distance, caput succedaneum, and occiput posterior position, which were dichotomized respectively into the following: ≤40 mm, >40 mm, <10 mm, ≥10 mm, and no, yes. Maternal age, gestational age, and maternal body mass index were included as continuous covariates. RESULTS: Dichotomized score is significantly associated with vaginal delivery (P = .03). Women with a score above the median had greater than 10 times the odds of having a vaginal delivery as compared with those with a score below the median. The receiver-operating characteristic curve showed an area under the curve of 0.853 (95% confidence interval, 0.678-1.000). CONCLUSION: A risk score based on maternal characteristics and intrapartum findings can predict vaginal delivery in nulliparous women in the first stage of labor.

Intrapartum assessment of caput succedaneum by transperineal ultrasound: a two-centre pilot study.

Digital assessments of caput succedaneum are subjective; however, caput succedaneum can also be expressed as ultrasound measured skin-skull distance (SSD). In this study, we aimed to compare the clinical and ultrasound assessment of caput succedaneum (caput) in nulliparous women in the first stage of labour. Furthermore, we aimed to investigate the repeatability of ultrasound measurements. We observed a significant but low correlation between clinical and ultrasound assessments (Kappa value 0.29; P < 0.01). Interobserver repeatability for SSD showed an intraclass correlation coefficient of 0.96 (95% CI, 0.93-0.98). The mean difference for the caput measurements was -0.4 mm (95% CI, -0.85 to 0.05), and limits of agreement were -3.44 to 2.64 mm. We conclude that ultrasound measured SSD is an objective expression of caput with significant correlation with clinical assessment.

Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation.

Transjugular intrahepatic portosystemic shunt (TIPS) creation is effective in treating the sequelae of decompensated liver cirrhosis-including medically refractory ascites and variceal bleeding-by decompressing the portal venous system through a manmade portosystemic conduit within the liver. However, the altered physiology in which splenomesenteric blood bypasses intrahepatic portal venous perfusion can precipitate varying degrees of hepatic encephalopathy (HE). While the majority of post-TIPS HE cases can be treated medically, some require escalated management strategies, including endovascular interventions to modify the indwelling TIPS and/or occlude competitive physiologic spontaneous portosystemic shunts. This review article details the epidemiology, risk factors, diagnosis, classification, and treatment of post-TIPS HE.

Perinatal and 2-year neurodevelopmental outcome in late preterm fetal compromise: the TRUFFLE 2 randomised trial protocol.

INTRODUCTION: Following the detection of fetal growth restriction, there is no consensus about the criteria that should trigger delivery in the late preterm period. The consequences of inappropriate early or late delivery are potentially important yet practice varies widely around the world, with abnormal findings from fetal heart rate monitoring invariably leading to delivery. Indices derived from fetal cerebral Doppler examination may guide such decisions although there are few studies in this area. We propose a randomised, controlled trial to establish the optimum method of timing delivery between 32 weeks and 36 weeks 6 days of gestation. We hypothesise that delivery on evidence of cerebral blood flow redistribution reduces a composite of perinatal poor outcome, death and short-term hypoxia-related morbidity, with no worsening of neurodevelopmental outcome at 2 years. METHODS AND ANALYSIS: Women with non-anomalous singleton pregnancies 32+0 to 36+6 weeks of gestation in whom the estimated fetal weight or abdominal circumference is <10th percentile or has decreased by 50 percentiles since 18-32 weeks will be included for observational data collection. Participants will be randomised if cerebral blood flow redistribution is identified, based on umbilical to middle cerebral artery pulsatility index ratio values. Computerised cardiotocography (cCTG) must show normal fetal heart rate short term variation (≥4.5 msec) and absence of decelerations at randomisation. Randomisation will be 1:1 to immediate delivery or delayed delivery (based on cCTG abnormalities or other worsening fetal condition). The primary outcome is poor condition at birth and/or fetal or neonatal death and/or major neonatal morbidity, the secondary non-inferiority outcome is 2-year infant general health and neurodevelopmental outcome based on the Parent Report of Children's Abilities-Revised questionnaire. ETHICS AND DISSEMINATION: The Study Coordination Centre has obtained approval from London-Riverside Research Ethics Committee (REC) and Health Regulatory Authority (HRA). Publication will be in line with NIHR Open Access policy. TRIAL REGISTRATION NUMBER: Main sponsor: Imperial College London, Reference: 19QC5491. Funders: NIHR HTA, Reference: 127 976. Study coordination centre: Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS with Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University. IRAS Project ID: 266 400. REC reference: 20/LO/0031. ISRCTN registry: 76 016 200.

Intrapartum ultrasound for assessment of cervical dilatation.

Assessment of cervical dilatation by digital vaginal examination is commonly used during labor as one of the main indicators of labor progress. Despite consistent inaccuracies, this practice remains widely chosen among midwives and obstetricians. Several methods, including electromechanical and electromagnetic devices, have been trialed throughout the decades without being able to provide objective means of obtaining accurate measurements of cervical dilatation during labor. Intrapartum ultrasound in the form of transperineal or translabial applications has shown promising results in the assessment and monitoring of labor progress. Here, we described the validity of intrapartum ultrasound and its usefulness in the assessment of cervical dilatation during labor. Moreover, we highlighted the feasibility of ultrasound in obtaining these assessments.

Back from the future: Volitional postdiction of perceived apparent motion direction.

Among physical events, it is impossible that an event could alter its own past for the simple reason that past events precede future events, and not vice versa. Moreover, to do so would invoke impossible self-causation. However, mental events are constructed by physical neuronal processes that take a finite duration to execute. Given this fact, it is conceivable that later brain events could alter the ongoing interpretation of previous brain events if they arrive within this finite duration of interpretive processing, before a commitment is made to what happened. In the current study, we show that humans can volitionally influence how they perceive an ambiguous apparent motion sequence, as long as the top-down command occurs up to 300ms after the occurrence of the actual motion event in the world. This finding supports the view that there is a temporal integration period over which perception is constructed on the basis of both bottom-up and top-down inputs.

Facial cleft detected: is the palate normal?

Despite advances in ultrasound technology, the sensitivity for detection of facial clefts at the routine mid-trimester details scan remains relatively poor. This can be improved by the use of a three-point ultrasound screening protocol, although this is not routine in many countries. When a facial cleft is suspected at the routine scan, further imaging is usually required to detail the extent of the cleft and presence or absence of any other abnormalities. Involvement of the fetal palate is an important finding that will determine the requirement for surgery, audiology, and orthodontic services well into teenage years. There remains little uniformity in how a facial cleft is described antenatally, with involvement of the alveolar ridge frequently and incorrectly taken to mean involvement of the palate. Further, midline clefts of the hard and soft palates, where the fetal lips and alveolar ridge are intact, are a feature of many genetic conditions, but are almost never diagnosed by prenatal ultrasound. In this chapter, we detail issues surrounding the nomenclature of facial clefts in relation to the palate, and describe some of the more commonly used two-dimensional and three-dimensional methodologies for imaging the fetal palate.

Severe systemic candidiasis following immunomodulation therapy in in vitro fertilisation-embryo transfer (IVF-ET).

A 41-year-old nulliparous woman, with a medical history of unexplained infertility and multiple in vitro fertilisation (IVF) cycles with immunosuppressive therapy, was admitted to our tertiary obstetrics unit with sepsis at 18 weeks of pregnancy with dichorionic diamniotic twins. Candida glabrata was grown from her blood cultures, then subsequently from the liquor and placentae. She was treated with intravenous ambisome (amphotericin), but unfortunately, the infection resulted in the rupture of her membranes, preterm labour and the demise of her twins. She delivered both twins at 23 weeks, 3 days apart. The antifungal agent was changed to high-dose fluconazole after delivery for 2 weeks and she is now well. Women undergoing IVF-embryo transfer with immunomodulation therapy have a potential risk of developing candidal chorioamnionitis and sepsis.

Intestinal perforation in the context of thoracoamniotic shunting and congenital diaphragmatic hernia.

A fetus was diagnosed by prenatal ultrasound with bilateral intrauterine pleural effusions that were subsequently drained in utero by insertion of bilateral thoracoamniotic shunts. Serial prenatal ultrasound scans were consistent with a left-sided diaphragmatic hernia. On the first day of life, the infant underwent an exploratory laparotomy for intestinal obstruction, with radiographic findings of pneumatosis intestinalis. Intraoperative findings were suggestive of prenatal bowel and diaphragm perforation, which might have occurred as a complication of thoracoamniotic shunting.

Cardiac function in early onset small for gestational age and growth restricted fetuses.

OBJECTIVE: To examine cardiac function in appropriately grown, small for gestational age and intrauterine growth restricted fetuses and investigate the relationship between cardiac function and fetal arterial and venous Doppler parameters. STUDY DESIGN: Myocardial performance index, isovolumetric contraction time, isovolumetric relaxation time, ejection time, and umbilical artery, middle cerebral artery and ductus venosus Doppler pulsatility index were measured for women between 24 and 32 weeks with small for gestational age and intrauterine growth restricted fetuses. Forty-eight appropriately grown, 11 small for gestational age and 12 intrauterine growth restricted cases were included. The relationship between cardiovascular parameters and gestation was defined and Doppler values converted to Z-scores in relation to gestational age. RESULTS: In small for gestational age fetuses and fetuses with intrauterine growth restriction the myocardial performance index was 0.66 (0.63-0.7) and 0.64 (0.60-0.67), respectively, and compared to appropriately grown fetuses, at 0.45 (0.43-0.47), was significantly increased (p=0.001). No relationship was found between the myocardial performance index and arterial and venous Doppler Z-score. CONCLUSION: Small for gestational age and intrauterine growth restricted fetuses demonstrate altered cardiac function in the late second and early third trimester of pregnancy. Importantly, the myocardial performance index is raised in small for gestational age fetuses before the arterial and venous Doppler abnormalities that characterize hypoxia are evident.