Routine Ultrasound at 30th-33rd weeks versus 30th-33rd and 35th-37th weeks in Low-Risk Pregnancies: A Randomized Trial.

INTRODUCTION: The aim of this study was to evaluate the accuracy of 35-37 weeks' ultrasound for fetal growth restriction (FGR) detection and the impact of 30th-33rd weeks versus 30th-33rd and 35th-37th weeks' ultrasound on perinatal outcomes. METHODS: This was a randomized controlled trial that enrolled 1,061 low-risk pregnant women: 513 in the control group (routine ultrasound performed at 30th-33rd weeks) and 548 in the study group (with an additional ultrasound at 35th-37th weeks). FGR was defined as a fetus with an estimated fetal weight (EFW) below the 10th percentile. p values < 0.05 were considered statistically significant. RESULTS: The ultrasound at 35-37 weeks had an overall accuracy of FGR screening of 94%. Spearman's correlation coefficient between EFW and birthweight centile was higher for at 35-37 weeks' ultrasound (ρ = 0.75) compared with 30-33 weeks' ultrasound (ρ = 0.44). The study group had a lower rate of operative vaginal deliveries (24.4% vs. 39.3%, p = 0.005) and cesarean deliveries for nonreassuring fetal status (16.8% vs. 38.8%, p < 0.001). DISCUSSION/CONCLUSION: A later ultrasound (35-37 weeks) had a high accuracy for detection of FGR and had a higher correlation between EFW and birthweight centiles. Furthermore, it was also associated with lower adverse perinatal outcomes compared to an earlier ultrasound.

Transabdominal and transperineal ultrasound vs routine care before instrumental vaginal delivery - A randomized controlled trial.

INTRODUCTION: The role of intrapartum ultrasound as an ancillary method to instrumental vaginal delivery is yet to be determined. This study aimed to compare the use of transabdominal and transperineal ultrasound with routine clinical care before performing an instrumental vaginal delivery, regarding the incidence of adverse maternal and neonatal outcomes. MATERIAL AND METHODS: A randomized controlled trial was conducted between October 2016 and March 2019 in two tertiary care maternity hospitals in Lisbon, Portugal. Women at term, with full cervical dilatation, singleton fetuses in cephalic presentation, and with an established indication for instrumental vaginal delivery, were approached for enrollment. After informed consent was obtained, randomization into one of two groups was carried out. In the experimental arm, women underwent transabdominal ultrasound for determination of the fetal head position and transperineal ultrasound for evaluation of the angle of progression, before instrumental vaginal delivery. In the control arm, no ultrasound was carried out before instrumental vaginal delivery. Primary outcomes were composite measures of maternal and neonatal morbidity. Composite maternal morbidity consisted of severe postpartum hemorrhage, perineal trauma, and prolonged hospital stay. Composite neonatal morbidity consisted of low 5-minute Apgar score, umbilical artery metabolic acidosis, birth trauma, and neonatal intensive care unit admission. RESULTS: A total of 222 women were enrolled (113 in the experimental arm and 109 in the control arm). No significant differences between the two arms were found in composite measures of maternal (23.9% in the experimental group vs 22.9% in the control group, odds ratio 1.055, 95% CI 0.567-1.964) or neonatal morbidity (9.7% in the experimental group vs 6.4% in the control group, odds ratio 1.571, 95% CI 0.586-4.215), nor in any of the individual outcomes. CONCLUSIONS: In this small randomized controlled trial that was stopped for futility before reaching the required sample size, transabdominal and transperineal ultrasound performed just before instrumental vaginal delivery did not reduce the incidence of adverse maternal and neonatal outcomes, when compared with routine clinical care.

Effect of vaginal intercourse on spontaneous labor at term: a randomized controlled trial.

OBJECTIVE: This study aimed at evaluating the effect of vaginal intercourse on spontaneous labor onset at term. METHODS: In a randomized controlled trial, patients with singleton, cephalic, term, and low-risk pregnancy were assigned to either vaginal intercourse at least twice a week or abstinence. The following data were assessed: demographics, parity, vaginal coitus frequency before and during pregnancy, Bishop score at 38th weeks, gestational age at delivery, mode of delivery, and days between recruitment and delivery. The primary outcome was spontaneous labor onset. RESULTS: Of the 123 patient analyzed, 63 were assigned to study group and 60 to control group. Mean interval between study recruitment and delivery was higher in sexually active women (15.05 days ± 0.8 compared with 14.17 days ± 0.8, p = 0.45) as well as the rate of cesarean delivery (14.3 % compared with 10 %, p = 0.58), but the differences were not statistically significant. The rate of spontaneous labor was similar in both groups (84.1 % in vaginal coitus group; 75 % in control group, p = 0.26). CONCLUSION: Our results showed that vaginal intercourse does not hasten spontaneous labor onset at term.

Uterine preservation with Alcides-Pereira's compressive sutures for postpartum uterine atony.

INTRODUCTION: Postpartum hemorrhage (PPH) is mostly caused by uterine atony and is the leading cause of maternal death. Hysterectomy may be necessary in severe cases, but uterine compressive sutures are an uterine-sparing alternative. In 2005, Alcides Pereira proposed a technique with serial superficial stiches around the uterus. To date, there were no further reports on its clinical use. OBJECTIVE: To evaluate a tertiary center's experience with Alcides-Pereira's compressive uterine sutures for severe PPH due to uterine atony, reviewing its efficacy, morbidity, and impact on reproductive outcomes. STUDY DESIGN: An 11-year retrospective cohort study of Alcides-Pereira's sutures for PPH at a single tertiary hospital. Demographic and obstetric data were collected. Details of subsequent pregnancies and fertility plans were collected through a telephonic interview. Comparison between women in which the sutures were effective and ineffective to prevent hysterectomy was made. RESULTS: Alcides-Pereira's sutures were applied in 23 patients with PPH due to uterine atony. The technique was successful in controlling the hemorrhage and avoiding hysterectomy in 20 patients (87%). When successful, the sutures avoided the need for any blood therapy in 55% (RR 0.45, 95% CI 0.28-0.73) of patients, intensive care unit admission in 80% (RR 0.2, 95% CI 0.08-0.48) and significantly shortened the length of hospital stay. All patients with preserved uterus resumed their usual menstrual pattern. One had a subsequent term vaginal delivery; one had three first trimester miscarriages. All other patients did not try to conceive. CONCLUSION: Alcides-Pereira's sutures are a feasible, uterine-sparing technique, providing an effective and safe option for PPH.

Use of external cephalic version in Portuguese public hospitals.

OBJECTIVE: To evaluate the use of external cephalic version (ECV) in Portuguese public hospitals with maternity services, as well as exploring the main motives for not offering the technique. METHODS: A cross-sectional observational study was conducted involving an online survey with 34 questions, accessed via an email addressed to all Heads of Department of Portuguese state-owned hospitals with maternity services. In centers where the technique was performed, information was requested on success rates, contraindications for the procedure, and practical aspects related to its use. In centers where ECV was not offered, the underlying reasons for this were queried. RESULTS: Answers were received from 41 out of the 43 state hospitals with maternity services (95.3%). Sixteen hospitals perform the technique (39%), with reported annual numbers ranging from 3 to 51, and success rates ranging from 25% to 85% (12 respondents). The main reasons for not offering the technique were lack of experience and lack of conditions to perform it safely. Most centers (87.8%) reported that they would welcome hands-on training in ECV. CONCLUSION: ECV is used in a minority of Portuguese state-owned hospitals. Efforts are needed to achieve a wider implementation of the technique, with a particular focus on simulation-based training.

Physical exercise at term for enhancing the spontaneous onset of labor: a randomized clinical trial.

INTRODUCTION: Physical exercise at term is empirically used as a method of enhancing the spontaneous labor onset. The objective of this study was to evaluate the effect of controlled maternal physical exercise at term as a method of enhancing the spontaneous labor onset. MATERIALS AND METHODS: At 38 weeks low-risk pregnant women, with a singleton cephalic fetus and no previous cesarean deliveries were randomly allocated to one of two arms: the experimental group performed 30 min of walking 3 times a week at 4 km/h, and the control group maintained their usual work and household activities. The primary outcome measure was the rate of labor induction. A sample size of 60 per group was planned to detect a 10% difference in labor induction rate, at a significance level of 0.05 and a power of 0.80. RESULTS: The exercise group had a lower rate of labor induction (17.5 versus 33.3%, adjusted odds ratio [OR] = 0.28, 95% confidence interval [CI]; 0.14-0.87) and fewer operative vaginal deliveries (20.6 versus 38.1%, adjusted OR = 0.42, 95% CI; 0.17-0.92). No differences were found in gestational age at onset of spontaneous labor, duration of the active phase of labor, interval between induction and the active phase of labor, cesarean section rates, birth weight, and Apgar scores. No maternal or fetal heart rate abnormalities were recorded during the exercise sessions. CONCLUSIONS: For low-risk women at term walking for 30 min 3 times a week at 4 km/h from 38-week onwards is safe, enhances the spontaneous onset of labor and reduces operative vaginal delivery rates. KEY MESSAGE: Physical exercise at term is empirically used as a method of enhancing the spontaneous labor onset. In finding that for low-risk women walking for 30 min 3 times a week at 4 km/h from 38-week onwards enhances spontaneous labor onset of and reduces operative vaginal delivery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov. www.clinicaltrials.gov NCT02460185.

Placenta Accreta Overlying a Caesarean Section Scar: A 10-Year Experience in a Tertiary-Care Centre in Portugal.

INTRODUCTION: Placenta accreta spectrum disorders are among the leading causes of maternal morbidity and mortality and their prevalence is likely to increase in the future. The risk of placenta accreta spectrum disorders is highest in cases of placenta previa overlying a previous cesarean section scar. Few studies have evaluated placenta accreta spectrum disorders in Portugal. The aim of this study was to review the cases of placenta accreta spectrum overlying a cesarean section scar managed in a Portuguese tertiary center over the last decade. MATERIAL AND METHODS: Retrospective, cross-sectional study, with data collected from hospital databases. Only cases with histopathological confirmation of placenta accreta spectrum were included. RESULTS: During the study period, 15 cases of placenta accreta spectrum overlying a cesarean section scar were diagnosed (prevalence 0.6/1000). All cases were diagnosed antenatally. A transverse cesarean section was present in all cases; 13 were managed by a scheduled multidisciplinary approach, while two required emergent management. Total or subtotal hysterectomy was performed in 12 cases. There were no cases of maternal or neonatal death. Histopathological evaluation confirmed nine cases of placenta accreta, three cases of placenta increta and three cases of placenta percreta. DISCUSSION: Early antenatal diagnosis is important for a programmed multidisciplinary management of these cases, which may reduce potential morbidity and mortality and ensure better obstetric outcomes. CONCLUSION: This case series of placenta accreta spectrum overlying a cesarean section scar reports the reality of a tertiary-care perinatal center in Portugal, in which no maternal or neonatal mortality due to placenta accreta spectrum was registered over the last decade; this may be attributed to prenatal diagnosis and a coordinated multidisciplinary team approach.

Introdução: O acretismo placentário está entre as principais causas de morbilidade e mortalidade materna, sendo provável que a sua prevalência venha a aumentar. O risco é máximo em casos de placenta prévia sobre cicatriz de cesariana. Existem poucos estudos sobre esta realidade em Portugal. O objetivo deste estudo foi rever os casos de acretismo placentário sobre cicatriz de cesariana prévia, ocorridos ao longo da última década num centro terciário português. Material e Métodos: Estudo retrospetivo, transversal, com dados recolhidos de bases de dados hospitalares; foram incluídos apenas casos com confirmação histopatológica de acretismo placentário. Resultados: Foram diagnosticados 15 casos durante o período do estudo (prevalência 0,6 / 1000). Todos os casos foram diagnosticados durante a gravidez. Em todos os casos foi realizada cesariana; 13 foram agendadas com base numa abordagem multidisciplinar, e duas foram emergentes. Em 12 casos foi realizada histerectomia total ou subtotal. Não se registaram casos de mortalidade materna ou neonatal. O estudo histopatológico confirmou nove casos de placenta acreta, três de placenta increta e três de placenta percreta. Discussão: O diagnóstico pré-natal precoce é fundamental para um planeamento multidisciplinar que permita reduzir a potencial morbilidade e mortalidade e garantir melhores desfechos obstétricos. Conclusão: Esta série de casos de acretismo placentário sobre cicatriz de cesariana relata a realidade de um centro de assistência perinatal terciário em Portugal, no qual não se registou mortalidade materna ou neonatal ao longo da última década; esta situação é atribuível ao diagnóstico pré-natal eficiente e à abordagem coordenada por uma equipa multidisciplinar.

Is Vaginal Breech Delivery Still a Safe Option?

OBJECTIVE: To determine whether there was any difference in neonatal and maternal outcomes between breech vaginal delivery and cephalic vaginal delivery. METHODS: A retrospective, case-control study was conducted between January 2015 and December 2017 in a Portuguese hospital. A total of 26 cases of breech vaginal delivery were considered eligible and 52 pregnant women formed the control group. RESULTS: Induced labor was more frequent in the breech vaginal delivery group (46% versus 21%, p = 0.022). Episiotomy was more common in the breech vaginal delivery group (80% versus 52%, p = 0.014), and one woman had a 3rd degree perineal laceration. Newborns in the study group had a lower birthweight (2,805 g versus 3,177 g, p < 0.001). There was no significant difference in the neonatal outcomes. CONCLUSION: The present study showed that breech vaginal delivery at term compared with cephalic presentation was not associated with significant differences in neonatal and maternal morbidity. It also suggests that breech vaginal delivery remains a safe option under strict selection criteria and in the presence of an experienced obstetrician.

OBJETIVO: Avaliar se existem diferenças nos desfechos perinatal e materno entre os partos pélvicos vaginais e eutócicos. MéTODOS: Realizou-se um estudo retrospectivo, caso controle, entre janeiro de 2015 e dezembro de 2017 em um hospital terciário em Portugal. Foram incluídos 26 casos de parto pélvico vaginal e o grupo controle foi formado por 52 grávidas. RESULTADOS: A indução do trabalho de parto ocorreu com mais frequência no grupo do parto pélvico vaginal (46% versus 21%, p = 0.022), bem como a realização de episiotomia (80% versus 52%, p = 0.014). Verificou-se um caso de laceração perineal de 3° grau. Os recém-nascidos do grupo de estudo apresentaram um peso inferior ao nascimento (2.805 g versus 3.177 g, p < 0.001). Em relação aos desfechos perinatais, não se observaram diferenças estatisticamente significativas. CONCLUSãO: O presente estudo mostrou que o parto pélvico vaginal no termo quando comparado com o parto eutócico não se associou a diferenças estatisticamente significativas na morbidade perinatal e materna, e sugere ainda que o parto pélvico vaginal parece ser uma opção segura em casos rigorosamente selecionados e na presença de um obstetra experiente.

Cesarean Section Rate Analysis in a Tertiary Hospital in Portugal According to Robson Ten Group Classification System.

OBJECTIVE: The Robson 10 group classification system (RTGCS) is a reproducible, clinically relevant and prospective classification system proposed by the World Health Organization (WHO) as a global standard for assessing, monitoring and comparing cesarean section (CS) rates. The purpose of the present study is to analyze CS rates according to the RTGCS over a 3-year period and to identify the main contributors to this rate. METHODS: We reviewed data regarding deliveries performed from 2014 up to 2016 in a tertiary hospital in Portugal, and classified all women according to the RTGCS. We analyzed the CS rate in each group. RESULTS: We included data from 6,369 deliveries. Groups 1 (n = 1,703), 2 (n = 1,229) and 3 (n = 1,382) represented 67.7% of the obstetric population. The global CS rate was 25% (n = 1,594). Groups 1, 2, 5 and 10 were responsible for 74.2% of global CS deliveries. CONCLUSION: As expected, Groups 1, 2, 5 and 10 were the greatest contributors to the overall CS rate. An attempt to increase the number of vaginal deliveries in these groups, especially in Groups 2 and 5, might contribute to the reduction of the CS rate.

OBJETIVO: A Classificação de Robson é um instrumento reprodutível, clinicamente relevante e prospectivo proposto pela Organização Mundial de Saúde (OMS) para avaliar, monitorar e comparar as taxas de cesarianas. O objetivo do presente estudo é analisar a taxa de cesarianas ao longo de 3 anos de acordo com a Classificação de Robson e identificar os grupos que contribuíram mais significativamente para essa taxa. MéTODOS: Recolhemos dados relativos aos partos ocorridos entre 2014 e 2016 em um hospital terciário de Portugal e classificamos todas as grávidas de acordo com a Classificação de Robson. Analisamos a taxa de cesarianas em cada grupo. RESULTADOS: Incluímos dados relativos a 6,369 partos. Os grupos 1 (n = 1,703), 2 (n = 1,229) e 3 (n = 1,382) representaram 67.7% da população obstétrica. A taxa de cesarianas foi de 25% (n = 1,594). Os grupos 1, 2, 5 e 10 contribuíram para 74.2% da taxa de cesarianas. CONCLUSãO: Tal como esperado, os grupos 1, 2, 5 e 10 foram os que mais contribuíram para a taxa de cesarianas. Aumentar o número de partos vaginais nestes grupos, principalmente nos grupos 2 e 5, poderá contribuir para a redução da taxa de cesarianas.

Management of pregnancy in case of multiple and giant uterine fibroids.

Uterine fibroids are common among women of reproductive age. During the pregnancy, the potential complications of fibroids, although rare, are of frequent clinical concern. Available studies describing management and obstetrical outcomes in pregnant women with giant fibroids are limited. We present the case of a 39-year-old pregnant woman with multiple and large uterine fibroids. During the pregnancy, there was adequate fetal development, without major maternal complications. Given the characteristics of the fibroids and breech position of the fetus, an elective caesarean section was decided, and postpartum hysterectomy planned. This challenging obstetrical case required a multidisciplinary approach.We considered crucial discussing five main issues: preconceptional counselling, tailored pregnancy surveillance, decision of time and route of delivery, decision to perform a peripartum hysterectomy and management of decreasing blood loss perioperatively. Given the limitation of the published reports, we believe that sharing our experience, along with a literature review, is beneficial for other clinicians.

Labor induction with 25-microg misoprostol vaginal capsules.

AIM: To evaluate the success rate and the safety profile of labor induction with a new misoprostol formulation - vaginal capsules of 25 microg of misoprostol. METHODS: Labor induction was performed in 250 singleton term pregnancies; 149 (59.6%) were nulliparous. Vaginal capsules of 25 microg of misoprostol were placed in the posterior vaginal fornix every 6 h. Success rate, contractility and fetal heart rate abnormalities and fetal outcomes were evaluated. RESULTS: The success rate of labor induction was 97.6%. The average number of vaginal administrations was 1.5. The mean interval between induction and active labor was 10 h and 20 min and the average length of labor was 15 h and 35 min. The cesarean section rate was 18.8%. There were 15 cases of tachysystole, 3 cases of hypertonus and 1 case of hyperstimulation syndrome. There were no adverse neonatal outcomes. CONCLUSIONS: This study allowed to conclude that labor induction with vaginal capsules of 25 microg of misoprostol is associated with an excellent success rate and safety profile.

VEGF signaling on hematopoietic precursors restricts B-lymphoid commitment in vitro and in vivo.

Vascular endothelial growth factor (VEGF) signals on vascular and hematopoietic cells via its receptors, VEGFR-2 (KDR) and VEGFR-1 (FLT-1). Elevated levels of VEGF, such as during tumor growth or inflammation, have been suggested to suppress hematopoiesis; most studies refer to KDR as the main receptor involved in this inhibitory effect. In the present study, having detected expression of FLT-1 in B-lymphoid precursors, we exploited the possibility that VEGF signaling via FLT-1 might affect early B-cell commitment. Using a well-established in vitro B-cell differentiation assay, we demonstrate that FLT-1 blockade promotes B-cell commitment and subsequent differentiation, while KDR blockade has no effect on B-cell commitment. In agreement, in vivo transplantation of human (CD34+) or murine (Sca1+l/Lin-) FLT-1-negative hematopoietic precursors into irradiated severe combined immune-deficient mice restored the bone marrow lymphoid compartment, while transplanting the FLT-1-positive counterpart failed to repopulate the lymphoid compartment, and unexpectedly resulted in early death of the irradiated recipients due to hematopoietic suppression. Taken together, we suggest that VEGF signaling via FLT-1 on hematopoietic precursors may restrict lymphopoiesis.

Detailed molecular characterization of cord blood-derived endothelial progenitors.

OBJECTIVE: Given their involvement in pathological and physiological angiogenesis, there has been growing interest in understanding and manipulating endothelial progenitor cells (EPC) for therapeutic purposes. However, detailed molecular analysis of EPC before and during endothelial differentiation is lacking and is the subject of the present study. MATERIALS AND METHODS: We report a detailed microarray gene-expression profile of freshly isolated (day 0) human cord blood (CB)-derived EPC (CD133+KDR+ or CD34+KDR+), and at different time points during in vitro differentiation (early: day 13; late: day 27). RESULTS: Data obtained reflect an EPC transcriptome enriched in genes related to stem/progenitor cells properties (chromatin remodeling, self-renewal, signaling, cytoskeleton organization and biogenesis, recruitment, and adhesion). Using a complementary DNA microarray enriched in intronic transcribed sequences, we observed, as well, that naturally transcribed intronic noncoding RNAs were specifically expressed at the EPC stage. CONCLUSION: Taken together, we have defined the global gene-expression profile of CB-derived EPC during the process of endothelial differentiation, which can be used to identify genes involved in different vascular pathologies.

Glucose intolerance in the third trimester is not predictive of adverse outcomes.

OBJECTIVE: To evaluate the incidence of abnormal third trimester oral glucose tolerance tests (OGTT) results in non-diabetic women and to compare the obstetric and neonatal outcomes with those of women with normal OGTT results. METHODS: Women with third trimester singleton pregnancies with negative gestational diabetes test results earlier in their pregnancy were enrolled into an observational prospective study at a tertiary care hospital between June 1, 2014 and September 30, 2017. All underwent an additional 75 g OGTT between 32 and 36 weeks and were classified as having normal or abnormal results. Healthcare professionals were blinded to the results. Pregnancy and perinatal outcomes were compared. RESULTS: Four hundred and sixty-seven women agreed to participate and 334 fulfilled the inclusion criteria. Forty-five (13.5%) had an abnormal third trimester OGTT result. In this group, post-term induction of labor was more frequent (70.6% vs 38.1%, adjusted odds ratio (aOR) 4.28, 95% confidence interval (CI) 1.33-13.77, P=0.015) as was cesarean delivery (31.1% vs 15.2%, aOR 2.57, 95% CI 1.14-5.81, P=0.023), regardless of surgery indication. Macrosomia was more common, but not significantly after adjusting for confounders (17.8% vs 4.2%, aOR 3.80, 95% CI 0.60-24.17, P=0.157). No other significant differences were found. CONCLUSION: Post-term induction of labor and cesarean delivery were more frequent in women with an abnormal third trimester OGTT result, but there was no increased risk of serious maternal or perinatal adverse outcomes.

A pilot randomized controlled trial of complete bed rest versus activity restriction after preterm premature rupture of the membranes.

OBJECTIVE: To assess the impact of bed rest on maternal and neonatal outcomes in pregnancies complicated by preterm premature rupture of the membranes (PPROM), enabling proper sample size calculation for a powered randomized controlled trial (RCT). STUDY DESIGN: We conducted a pilot unblinded randomized controlled trial with a 1:1 allocation ratio (complete bed rest vs activity restriction groups) on singleton pregnancies complicated by PPROM at 24 + 0-33 + 6 weeks. Maternal and neonatal data were compared between groups with an intent-to-treat analysis. The primary outcomes were the latency time to delivery and the incidence of chorioamnionitis. The trial was conducted in a tertiary center of the Portuguese national healthcare system. Patients received standard antibiotic prophylaxis. Delivery was planned for the 34th week of gestation, except in cases of spontaneous labor or another complication. RESULTS: Thirty-two cases were randomized and analyzed, 14 in the complete bed rest group and 18 in the activity restriction group. The median gestational age at PPROM was 30 vs 29 weeks (p = 0.82). In the complete bed rest group, the incidence of chorioamnionitis was nonsignificantly lower (14% vs 28%, p = 0.43). Median latency time was 11.5 days (95% CI, 2-20) in the complete bed rest group and 7.5 days (95% CI, 3-11) in the activity restriction group, lacking statistical significance on univariate (p = 0.6) and survival analyses (log-rank test, p = 0.75). No difference was found between groups regarding indication or type of delivery and maternal or neonatal morbidity. The median gestational age at delivery was 32 weeks for both groups (p = 0.94). A sample size of 2052 participants was calculated for a powered RCT, considering latency as the primary outcome. CONCLUSION: In this pilot trial, bed rest did not increase latency to delivery and did not improve maternal or neonatal morbidity in the setting of PPROM at 24 + 0-33 + 6 weeks. A sample size calculation is now available for a powered RCT.

National-survey for evaluation of the best screening method of late fetal growth restriction in low risk pregnancy: A prospective study.

OBJECTIVE: To compare knowledge and practices surrounding third trimester screening of fetal growth restriction (FGR) in low risk pregnancies among Portuguese Gynecologists/Obstetricians (GOs) and General Practitioners (GPs). Primary outcome was to compare the proportion of GOs that consider the need of a third trimester ultrasound (estimation of fetal weight) for screening of FGR in low risk pregnancies and the best time to perform it with the corresponding proportion of GPs. STUDY DESIGN: We have conducted a prospective, observational cohort study based on application of surveys to GOs and GPs. Questionnaires were sent by e-mail to physicians and they filled them online. A second reminder e-mail was sent 7 days later. Recruitment was also done personally at scientific meetings. A total of 573 surveys were available for analysis, 298 corresponded to GOs and 275 to GPs. We used χ2 test to compare dichotomous variables and Kruskal-Wallis test for the comparison of ordinal variables. P values <0.05 were considered statistically significant. RESULTS: The vast majority of GOs and GPs (93%) considered that third trimester ultrasound is useful and needed for surveillance of low risk pregnancy. A higher proportion of GOs (38%) selected 35th-37th weeks as the best time to perform the ultrasound compared to GPs (10%) (p < 0.001). GOs (51%) consider that symphysis-fundus distance is a measurement with moderate accuracy for screening of FGR while GPs (61%) attribute a low accuracy (p < 0.001). Fifty percent (50%) of GOs consider that performing a third trimester ultrasound will have no impact on cesarean delivery rate for fetal distress, while 41% of GPs consider that routine ultrasound will contribute to increase this rate (p < 0.001). The majority of GPs (52%) consider that routine ultrasound will contribute to diminish the admission rate to neonatal intensive care unit while GOs revealed a dichotomy with 43% of respondents reporting that it will diminish the rate and 40% that it will have no impact. CONCLUSION: Varied opinions among the clinicians included in our sample reflect the controversy that remains on the best screening of FGR in low risk pregnancies.

Effect of simulation-based training on the accuracy of fetal head position determination in labor.

OBJECTIVES: The objective of this study was to evaluate the effect of simulation-based training on the accuracy of fetal head position determination by junior residents during the second stage of labour. STUDY DESIGN: This prospective study was conducted in a tertiary care university hospital. During an initial period of 12 weeks, 13 junior residents were asked to routinely evaluate fetal head position by digital examination during the second stage of labour, in women with term singletons in cephalic presentation. Digital examination was followed immediately by transabdominal ultrasound to confirm fetal head position, performed by an experienced physician. Following this initial period, all participants attended a workshop where simulation-based training of fetal head position determination was provided. A second 12-week period was subsequently completed, with similar characteristics to the initial one. The accuracy of clinical evaluations was assessed by the percentage of exact evaluations, the percentage of correct evaluations within a 45° error margin, and by Cohen's kappa coefficient of agreement. RESULTS: A total of 83 observations were performed in the initial period of the study and 74 observations were performed in the second period. The accuracy of fetal head position determination during the first period of the study was 59.0% (95% CI 47.7-69.7), k = 0.517 (95%CI 0.391 - 0.635), corresponding to a moderate agreement. Considering a 45° margin of error, accuracy was 71.1% (95% CI 60.1-80.5), k = 0.656 (95% CI 0.538 - 0.763), corresponding to substantial agreement. Following simulation-based training, the accuracy of fetal head position determination was 70.3% (95% CI 58.5-80.3), k = 0.651 (95% CI 0.526 - 0.785), corresponding to a substantial agreement. Considering a 45° margin of error, accuracy was 78.4% (95% CI 67.3-87.1), k = 0.745 (95% CI 0.631 - 0.854), corresponding to a substantial agreement. CONCLUSIONS: Although a trend towards increased accuracy in fetal head position determination was observed after simulation-based training, the difference was not statistically significant. Further studies are needed to clarify the role of simulation-based training for fetal head position determination during residency.

Prenatal ultrasonographic diagnosis of vein of Galen aneurysms--report of two cases.

Aneurysms of the vein of Galen (AVG) represent less than 1% of all intracranial arteriovenous malformations. Two cases of prenatal diagnosis made by color Doppler ultrasonography at 32 weeks of gestation are reported. Both cases presented with antenatal mild cardiomegaly and both developed severe cardiac failure in the neonatal period. Embolization was unsuccessful and both infants died. These cases highlight the need for a careful evaluation of the time and mode of delivery; embolization must be performed after a fully informed decision.

Ability of women to self-classify into the Robson ten-group classification system.

OBJECTIVE: Recent guidelines from WHO and the International Federation of Gynecology and Obstetrics (FIGO) state that the Robson ten-group classification system (TGCS) should be universally applied to pregnant women. Such information might enable women to make an informed decision about the place and mode of delivery. We assessed whether women could self-classify correctly according to the TGCS. METHODS: A prospective study was conducted in a tertiary level maternity hospital between March 6 and July 31, 2017. We included post-partum women admitted to the puerperium ward. Participants were instructed to complete a multiple-choice questionnaire with a simplified description of TGCS and to classify themselves into one of the ten groups. A practitioner reclassified women into the correct TGCS group. Cohen κ was applied to measure the rate of agreement between these two evaluations. RESULTS: 400 women were enrolled, with a global rate of agreement of 81.8% between women's self-evaluation and the evaluation by the practitioner. A subanalysis showed that the highest rate of agreement was among the group with higher level education (84.0%). CONCLUSION: Women of different ages and education backgrounds were able to correctly classify themselves into the TGCS. The higher the educational level, the greater the rate of agreement.