Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture.

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.

Longitudinal transvaginal ultrasound evaluation of cesarean scar niche incidence and depth in the first two years after single- or double-layer uterotomy closure: a randomized controlled trial.

INTRODUCTION: Cesarean deliveries are the most common abdominal surgery procedure globally, and the optimal way to suture the hysterotomy remains a matter of debate. The aim of this study was to assess the incidence of cesarean scar niches and the depth after single- or double-layer uterine closure. MATERIAL AND METHODS: We performed a randomized controlled trial in which women were allocated to three uterotomy suture techniques: continuous single-layer unlocked, continuous locked single-layer, or double-layer sutures. Transvaginal ultrasound was performed six weeks and 6-24 months after cesarean delivery [Clinicaltrials.gov (NCT02338388)]. RESULTS: The study included 435 women. Six weeks after delivery, the incidence of niche was not significantly different between the groups (p = 0.52): 40% for single-layer unlocked, 32% for single-layer locked and 43% for double-layer sutures. The mean ± SD niche depths were 3.0 ± 1.4 mm for single-layer unlocked, 3.6 ± 1.7 mm for single-layer locked and 3.3 ± 1.3 mm for double-layer sutures (p = 1.0). There were no significant differences (p = 0.58) in niche incidence between the three groups at the second ultrasound follow up: 30% for single-layer unlocked, 23% for single-layer locked and 29% for double-layer sutures. The mean ± SD niche depth was 3.1 ± 1.5 mm after single-layer unlocked, 2.8 ± 1.5 mm after single-layer locked and 2.5 ± 1.2 mm after double-layer sutures (p = 0.61). There was a trend (p = 0.06) for the residual myometrium thickness to be thicker after double-layer repair at the long-term follow up. CONCLUSIONS: The incidence of cesarean scar niche formation and the niche depth was independent of the hysterotomy closure technique.

Pontine Tegmental Cap Dysplasia in an Extremely Preterm Infant and Review of the Literature.

Pontine tegmental cap dysplasia is a rare hindbrain malformation syndrome with a hypoplastic pons, a tissue protrusion into the fourth ventricle, and cranial nerve dysfunction. We here report clinical, imaging, and genetic findings of the first extremely low-birth-weight preterm infant with pontine tegmental cap dysplasia born at 25 weeks of gestation and provide an overview of 29 sporadic cases. A prenatally diagnosed hypoplastic and rostrally shifted cerebellum was indicative of a hindbrain defect and later identified as an early sign of pontine tegmental cap dysplasia in our patient. The neonate exhibited severe muscle hypotonia, persistent thermolability, and clinical signs of an involvement of facial, cochlear, and hypoglossal nerves. Furthermore, paroxysmal episodes of agonizing pain with facial tics, tonic and clonic muscle contractions, blepharospasm, and singultus are highlighted as new phenotypic features of pontine tegmental cap dysplasia. With our report, we present a severe case of pontine tegmental cap dysplasia and provide a brief overview of current knowledge on this rare disease.

Evaluating fetal head dimension changes during labor using open magnetic resonance imaging.

AIM: Fetal skull molding is important for the adaptation of the head to the birth canal during vaginal delivery. Importantly, the fetal head must rotate around the maternal symphysis pubis. The goals of this analysis were to observe a human birth in real-time using an open magnetic resonance imaging (MRI) scanner and describe the fetal head configuration during expulsion. METHODS: Real-time cinematic MRI series (TSE single-shot sequence, TR 1600 ms, TE 150 ms) were acquired from the midsagittal plane of the maternal pelvis during the active second stage of labor at 37 weeks of gestation. Frame-by-frame analyses were performed to measure the frontooccipital diameter (FOD) and distance from the vertex to the base of the fetal skull. RESULTS: During vaginal delivery in an occiput anterior position, the initial FOD was 10.3 cm. When expulsion began, the fetal skull was deformed and elongated, with the FOD increasing to 10.8 cm and 11.2 cm at crowning. In contrast, the distance from the vertex to the base of the skull was reduced from 6.4 cm to 5.6 cm at expulsion. CONCLUSIONS: Fetal head molding is the change in the fetal head due to the forces of labor. The biomechanics of this process are poorly understood. Our visualization of the normal mechanism of late second-stage labor shows that MRI technology can for the first time help define the changes in the diameters of the fetal head during active labor.

Prenatal decision-making in the second and third trimester in trisomy 21-affected pregnancies.

Down syndrome (DS) is the most common chromosome abnormality among live-born infants and the most frequent genetic cause of intellectual disability. The majority of pregnancies affected by DS are terminated. The decision concerning whether or not to continue a pregnancy following the prenatal diagnosis of DS is complex and amongst others, motivated by attitudes towards termination, socioeconomic factors, and ultrasound findings. In Germany, termination of pregnancy (TOP) is a legal option, even during the later stages of gestation. The aim of the present study was to evaluate the pregnancy outcomes as well as possible factors that influence the decisions made by women with trisomy 21-affected pregnancies. In our study 112 pregnancies affected by trisomy 21 were included. Our data confirm that most patients are more likely to terminate a trisomy 21-affected pregnancy [76 (67.9%) vs. 36 (32.1%) continued pregnancies]. Beyond that we found that women who continued their pregnancy tended to be at an advanced stage in their pregnancy at the time of karyotyping. With regards to factors from their medical history as well as sonographic findings there was no identifiable single factor that could distinguish between women that opted to continue or terminate their pregnancy.

Value of Doppler sonography near term: can umbilical and uterine artery indices in low-risk pregnancies predict perinatal outcome?

AIM: The goal of this study was to evaluate the umbilical and uterine Doppler velocimetry waveforms for predicting the perinatal outcome of low-risk pregnancies at term. METHODS: We prospectively recruited 514 women with low risk pregnancies and performed umbilical and uterine artery Doppler assessments between 37 and 41 weeks of gestation. Ultrasound measurements (completed in 365 patients) were correlated with the perinatal outcome. RESULTS: The velocimetry waveforms of the umbilical artery were significantly associated with birthweight, placental weight, and postpartal umbilical artery pH. Low pH, placental weight, and birthweight were correlated with increasing pulsatility index (PI) and resistance index (RI). An umbilical artery PI > 1.2 and a uterine artery RI > 0.5 were associated with statistically higher rates of infants that were small for gestational age (SGA). Also, high cesarean delivery rates were correlated with an umbilical artery PI > 1.2. CONCLUSIONS: In our low-risk pregnancies population, the elevated umbilical artery indices at term appeared to be associated with the higher rates of infants that were SGA and cesarean deliveries. The Doppler waveforms at term had low prognostic value for predicting neonatal acidosis or decreased Apgar scores.

Proteomic analysis of midtrimester amniotic fluid to identify novel biomarkers for preterm delivery.

OBJECTIVE: The aim of this study was to identify possible biomarkers for preterm delivery by analyzing midtrimester amniotic fluid. METHODS: Thirty-two amniotic fluid samples were studied; 16 patients had a spontaneous preterm delivery and 16 patients delivered at term. The proteomic technique consisted of surface-enhanced laser desorption ionization time-of-flight (SELDI-TOF) using different types of solid chromatographic chips (Q10, CM10 and IMAC30). RESULTS: Mass spectrometry tracings were obtained from the amniotic fluids of both patients who delivered preterm and patients who delivered at term. Seven potential markers were identified to be differentially expressed in patients who delivered preterm. CONCLUSIONS: Proteomic analysis of amniotic fluid obtained in the midtrimester reveals the presence of a set of proteins in patients at risk for preterm delivery.

Human birth observed in real-time open magnetic resonance imaging.

OBJECTIVE: Knowledge about the mechanism of labor is based on assumptions and radiographic studies performed decades ago. The goal of this study was to describe the relationship between the fetus and the pelvis as the fetus travels through the birth canal, using an open magnetic resonance imaging (MRI) scanner. STUDY DESIGN: The design of the study used a real-time MRI series during delivery of the fetal head. RESULTS: Delivery occurred by progressive head extension. However, extension was a very late movement that was observed when the occiput was in close contact with the inferior margin of the symphysis pubis, occurring simultaneously with gliding downward of the fetal head. CONCLUSION: This observational study shows, for the first time, that birth can be analyzed with real-time MRI. MRI technology allows assessment of maternal and fetal anatomy during labor and delivery.

Doppler in obstetrics: beyond the umbilical artery.

Doppler analysis of the umbilical and uterine arteries has long been performed in perinatal medicine to assess fetal health and maternal risk for preeclampsia. Several other vessels can be interrogated to obtain additional, vital information. Velocimetry in the fetal middle cerebral artery can yield evidence of the presence or absence of anemia and, in cases of delayed growth, of the risk of hypoxic damage. Ductus venosus waveforms are a very good indicator of impeding fetal jeopardy and should be used when umbilical artery waveforms become abnormal. Early pregnancy uterine artery Doppler reflects the status of the placental vasculature and, as such, is an excellent tool for predicting the risk of preeclampsia or intrauterine growth restriction.

Correlation of midtrimester amniotic fluid cytokine concentrations with adverse pregnancy outcome in terms of spontaneous abortion, preterm birth, and preeclampsia.

OBJECTIVE: To assess midtrimester amniotic fluid concentrations of three major proinflammatory cytokines (IL-6, IL-8, and TNF-α) in asymptomatic pregnancies with adverse outcomes. METHODS: A prospective follow up study at the Charité University Hospital, Berlin, Germany of women with uncomplicated singleton pregnancies at second trimester and amniocentesis. Concentrations of IL-6, IL-8, and TNF-α were measured by enzyme-linked immunosorbent assay following amniotic fluid assessment by midtrimester amniocentesis performed from gestation days 15 weeks 0 days up to 20 weeks 6 days. Values from normal pregnancies were compared to those from pregnancies having adverse outcomes of spontaneous abortion, preterm delivery, preeclampsia, or eclampsia. Main outcome measure IL-6, IL-8 and TNF-α in relation to adverse pregnancy outcome. RESULTS: A total of 298 consecutive patients were evaluated. Median patient age was 35 years (range 19-43). Controls consisted of 273 women who delivered without further complications after 37 weeks gestation. The range values of IL-6, IL-8, and TNF-α in the control group were 4.9-2620 pg/mL, 36.2-5843 pg/mL, and 8.0-28.2 pg/mL, respectively. Patients with adverse pregnancy outcome (n = 25) were classified into three groups: spontaneous abortion group (n = 4), preterm delivery group (n = 17), and preeclampsia/eclampsia group (n = 4). There were no significant differences in IL-6, IL-8, and TNF-α between controls and study groups, regardless of the type of complication (p > 0.05). CONCLUSION: Midtrimester amniotic fluid concentrations of the proinflammatory cytokines IL-6, IL-8, and TNF-α are not predictive of adverse pregnancy outcome in terms of spontaneous abortion, preterm delivery or preeclampsia/eclampsia in our study population.

Angle of progression measurements of fetal head at term: a systematic comparison between open magnetic resonance imaging and transperineal ultrasound.

OBJECTIVE: During labor, transperineal sonography is increasingly used to evaluate fetal head descent. The aim of this study was to compare the angle of progression assessed by open magnetic resonance imaging (MRI) vs transperineal ultrasound. STUDY DESIGN: A total of 31 pregnant women at term (>37 weeks), who were not in labor, underwent MRI in an open 1.0-T system. A midsagittal plane of the maternal pelvis was stored. Immediately after, without changing the supine position, a transperineal ultrasound was performed. The angle of progression was measured offline by transperineal ultrasound and MRI. RESULTS: The angles of progression measured by transperineal ultrasound (mean, 79.05 degrees; SD 11.44) and MRI (mean, 80.48 degrees; SD 11.06) correlated significantly (P < .001). The intraclass correlation coefficient between the 2 methods was 0.89 (95% confidence interval, 0.78-0.94). CONCLUSION: The angle of progression measurements obtained by transperineal ultrasound and open MRI showed very good agreement.

Evidence in a human fetus of micrognathia and cleft lip as potential effects of early cytomegalovirus infection.

Human cytomegalovirus (CMV) infection is one of the most frequent congenital infections, affecting 0.2-2% of all live births. Approximately 30-50% of pregnant women are seronegative at the beginning of pregnancy, and 1% will develop primary infection during pregnancy. Fetal CMV infection is associated with a phenotype that has been described to include central nervous system anomalies, hydrops fetalis and oligohydramnios. Impaired first branchial arch development as well as orofacial clefts after CMV infection have been shown in animal models. We present a case in which ultrasound examination at 29 weeks of gestation revealed marked micrognathia and slight cleft lip as well as multiple signs of fetal infection. We focus on the detection of fetal face and skull anomalies.

Three-dimensional ultrasound in evaluating the fetus.

In recent years three-dimensional (3D) ultrasound has made a place in clinical practice and has become a major field of research in obstetrics. In this article we will review the diagnostic performance of the most widely used 3D ultrasound applications in the assessment of fetal anomalies, explain the technique to gain correct 3D images and offer some practical advice for their efficient use. Examples are given to demonstrate the applicability and vividness of 3D in daily routine.

New evidence for the fetal insulin hypothesis: fetal angiotensinogen M235T polymorphism is associated with birth weight and elevated fetal total glycated hemoglobin at birth.

BACKGROUND: Low birth weight is associated with an increased risk of cardiovascular events in later life. Insulin resistance is a key finding in adult patients with cardiovascular diseases. The neonatal phenotype of an individual with insulin resistance might be low birth weight, as insulin influences fetal growth. The renin-angiotensin-aldosterone system has been associated with cardiovascular disease and insulin resistance. We analyzed whether fetal polymorphisms of the angiotensinogen (AGT) and angiotensin-converting enzyme genes influence birth weight and/or fetal total glycated hemoglobin (fTGH), a surrogate parameter of fetal insulin resistance at birth. METHOD: In 1132 white women delivering singletons, neonatal umbilical blood samples and clinical data of the mothers and newborns were obtained. Newborns were genotyped with respect to the AGT M235T and angiotensin-converting enzyme insertion/deletion polymorphism. RESULTS: The AGT M235T TT polymorphism is associated with reduced birth weight (TT: 3288 g versus TM + MM: 3435 g, P < 0.05). Furthermore, newborns with a high percentage of fTGH (>6.5%) are more likely to have the TT genotype than those with normal fTGH (

Interaction of maternal peroxisome proliferator-activated receptor gamma2 Pro12Ala polymorphism with fetal sex affects maternal glycemic control during pregnancy.

It was suggested that fetal sex may substantially affect maternal glycemic control during pregnancy in genetically susceptible mothers. The peroxisome proliferator-activated receptor gamma2 (PPARgamma2) Pro12Ala polymorphism is known to affect glycemic control and may act in a sex-specific manner. This polymorphism is thus an attractive candidate to test this hypothesis using a second independent functionally relevant polymorphism. We analyzed the impact of fetal sex on maternal glycemic control during pregnancy in relation to the maternal PPARgamma2 Pro12Ala polymorphism. Two-thousand fourteen Caucasian women without preexisting diabetes and preexisting hypertension with singleton pregnancies delivering consecutively at the Charité obstetrics department were genotyped. Glycemic control was analyzed by measuring total glycated hemoglobin at birth. Correction for confounding factors and multiple testing was considered in the analysis. The maternal PPARgamma2 Pro12Ala polymorphism without consideration of fetal sex had no effect on blood pressure, new onset of proteinuria and total glycated hemoglobin at delivery. Mothers carrying both G alleles (GG genotype) delivering a girl had a higher (P = 0.015) total glycated hemoglobin (6.81 or - 0.50%) versus mothers carrying the same alleles but delivering boys (5.85 + or - 0.58%). Comparing mothers with the GG genotype delivering girls with mothers with CC or CG genotypes also delivering girls (6.32 + or - 0.72%) revealed a significantly higher maternal total glycated hemoglobin at delivery in the former group (P < 0.009). Fetal sex/sex chromosomes may substantially affect maternal glycemic control in mothers who are carriers of the GG alleles of the PPARgamma2 Pro12Ala polymorphism.

Isolated left-sided congenital diaphragmatic hernia: cardiac axis and displacement before fetal viability has no role in predicting postnatal outcome.

OBJECTIVES: The purpose of this retrospective study was to determine whether objective assessment of cardiac shifting on two-dimensional ultrasonography can predict postnatal outcome in fetuses with isolated left-sided congenital diaphragmatic hernia (CDH). MATERIALS AND METHODS: Still images at the level of the four-chamber view were obtained in 23 fetuses with left-sided CDH. A group of 12 fetuses (3 non-survivors and 9 survivors) were examined at two periods, between 20 and 30 weeks and between 31 and 40 weeks. A further 11 fetuses (2 non-survivors and 9 survivors) were examined between 31 and 40 weeks. Fetal heart axis and position were determined manually and associated with postnatal outcome. RESULTS: The cardiac axis remained constant in the 9 survivors (15.5 +/- 3.2 versus 17.2 +/- 3.3, p = 0.71) and 3 non-survivors (19.0 +/- 11.5 versus 18.5 +/- 11.8, p = 0.97). There was no statistical difference between the 9 survivors and 3 non-survivors at the two periods. Cardiac displacement remained constant in the 9 survivors (0.2 +/- 0.02 versus 0.2 +/- 0.02, p = 0.32) but increased significantly in the 3 non-survivors (0.2 +/- 0.04 versus 0.4 +/- 0.02, p = 0.015). The difference between survivors and non-survivors was statistically significant between the18 survivors and 5 non-survivors examined between 31 and 40 weeks of gestation (0.2 +/- 0.02 versus 0.4 +/- 0.02, p = 0.037). CONCLUSION: This study does not support the hypothesis that objective assessment of mediastinal shift in fetuses with left-sided CDH has a role in predicting postnatal outcome before fetal viability, which is when it would be more useful for counseling patients regarding whether to continue with the pregnancy or to opt for termination.

Three-dimensional multi-slice view: new prospects for evaluation of congenital anomalies in the fetus.

OBJECTIVES: The purpose of this study was to describe the use and potential of Multi-Slice View 3-dimensional (3D) ultrasonographic software (Medison Co, Ltd, Seoul, Korea) in showing fetal congenital anomalies. METHODS: Fetuses with congenital anomalies diagnosed by means of 2-dimensional ultrasonography were prospectively included in the study. Good-quality 3D volumes of the region of interest were obtained in each case. Subsequently, these volumes were reviewed with use of 3D eXtended Imaging with Multi-Slice View and SonoMR (Medison Co, Ltd). Image processing was performed through the use of off-line software (Medison XI Viewer, version 1.0.0.218). RESULTS: A total of 6 fetuses (median gestational age, 27 weeks; range, 16-35 weeks) with the following anomalies were examined: dacryocystocele, esophageal atresia, right-sided aortic arch, hydrometrocolpos, horseshoe kidney, and hemivertebra. Images of diagnostic quality were obtained from all patients. According to the respective underlying anomalies and the positions of the fetuses, images were obtained from the initial axial plane in 2 cases (esophageal atresia and right-sided aortic arch) and from reconstructed planes in the remaining 4 cases (dacryocystocele, hydrometrocolpos, horseshoe kidney, and hemivertebra). CONCLUSIONS: Three-dimensional Multi-Slice View can deliver informative images of the region of interest regardless of fetal position. It may be particularly helpful for evaluation of difficult anomalies in the fetus.

Three-dimensional ultrasonographic reslicing of the fetal brain to assist prenatal diagnosis of central nervous system anomalies.

OBJECTIVES: The purpose of this study was to evaluate the potential of 3-dimensional ultrasonographic planar and nonplanar reslicing techniques. METHODS: Fetuses with severe brain anomalies diagnosed by means of 2-dimensional ultrasonography were prospectively included in the study. Good-quality 3-dimensional volumes of the fetal head were obtained in each case. Subsequently, these volumes were reviewed with use of 3-dimensional extended imaging with Oblique View and DynamicMR (Medison Co, Ltd, Seoul, Korea). RESULTS: Eight fetuses (mean gestational age, 23 weeks; range, 20-30 weeks) with the following central nervous system anomalies were examined: semilobar holoprosencephaly, absent cavum septum pellucidum, porencephaly in twin-to-twin transfusion syndrome, partial agenesis of the corpus callosum, Dandy-Walker variant, open-lip schizencephaly, aneurysm of the vein of Galen, and dilated cavum vergae. CONCLUSIONS: Planar and nonplanar reslicing of the volumes delivered informative images in any reconstructed plane. One important prerequisite, however, was the absence of acoustic shadowing during data acquisition.

Mid-facial anthropometry in second-trimester fetuses with trisomy 21: a three-dimensional ultrasound study.

OBJECTIVES: The aim of this study was to evaluate whether fetuses with trisomy 21 and detectable nasal bones have a distinct facial anthropometry that can be objectively defined using three-dimensional (3D) ultrasonography. METHODS: A prospective cross-sectional study of 40 fetuses in the second trimester, 17 with trisomy 21 and 23 controls, was performed. The 3D volume datasets of each case were evaluated for documentation of the nasal bones using the multiplanar and the maximum mode. The nasal bone length and the angle formed by the two maxillary bones at the level of the frontal process were then measured. RESULTS: The nasal bones were absent in 7 (41%) of the 17 fetuses with Down syndrome. All of the 23 normal fetuses had detectable nasal bones. The difference between nasal bone length in trisomy 21 fetuses and controls did not reach statistical significance (p = 0.087). The mean maxillary angle in trisomy 21 fetuses with nasal bones was significantly wider compared to controls (p = 0.029). CONCLUSIONS: The nasal bones are present in the majority of fetuses with trisomy 21 in the second trimester. This group of fetuses has a characteristic mid-facial anthropometry (wider maxillary angle) that can be assessed by means of 3D ultrasonography.