Whole genome analysis of Salmonella Gallinarum strains isolated from a fowl typhoid outbreak in southern Brazil.

1. Salmonella Gallinarum strains isolated from a southern Brazil fowl typhoid outbreak were subjected to phenotypic and genotypic analyses to identify genetic elements that could improve prevention and control strategies.2. Whole-genome sequencing revealed the presence of the aac(6')-Iaa gene, conferring aminoglycoside resistance, along with novel chromosomal point mutations, including the first detection of parE p.S451F in Salmonella Gallinarum.3. Additionally, IncFII(S) plasmid replicons, Salmonella pathogenicity islands and 105 virulence genes associated with cell adhesion, invasion and antimicrobial peptide resistance were identified.4. These findings shed light on the molecular mechanisms of fowl typhoid and provide crucial insights into emerging antimicrobial resistance and virulence factors.

External validation of a simple risk score based on the ASPRE trial algorithm for preterm pre-eclampsia considering maternal characteristics in nulliparous pregnant women: a multicentre retrospective cohort study.

OBJECTIVE: To validate the performance of a first-trimester simple risk score based on the ASPRE trial algorithm for pre-eclampsia. DESIGN: Multicentre retrospective cohort analysis. SETTING: Four Italian hospitals. POPULATION: Unselected nulliparous women at 11-13 weeks of gestation from January 2014 through to January 2018. METHODS: Model performance was evaluated based on discrimination and calibration. MAIN OUTCOME MEASURES: Delivery before 37 weeks of gestation with a diagnosis of pre-eclampsia. RESULTS: Based on 73 preterm pre-eclampsia cases and 7546 controls (including 101 cases of late pre-eclampsia), the area under the receiver operating characteristics curve was 0.659 (95% CI 0.579-0.726). The sensitivity was 32.9% (95% CI 22.1-43.7) at a false-positive rate of 8.8%. The positive likelihood ratio was 3.74 (95% CI 2.67-5.23), the positive predictive value was 3.49% (95% CI 2.12-4.86%) and the negative predictive value was 99.3% (95% CI 99.1-99.5%). The sensitivity and positive likelihood ratio were approximately 40% lower than in the original study. The calibration analysis showed a good agreement between observed and expected risks (P = 0.037). Comparison with the Fetal Medicine Foundation (FMF) algorithm yielded a difference in the area under the curve of 0.084 (P = 0.007). CONCLUSIONS: In our Italian population, the simple risk score had a lower performance than expected for the prediction of preterm pre-eclampsia in nulliparous women. The FMF algorithm applied to the same data set resulted in a better prediction. TWEETABLE ABSTRACT: Simple risk score predicts preterm pre-eclampsia in Italy.

Effect of two lytic bacteriophages against multidrug-resistant and biofilm-forming Salmonella Gallinarum from poultry.

1. Salmonella Gallinarum (SG) infections cause fowl typhoid, which leads to important economic losses. Multidrug resistance (MDR) and the capacity for bacteria to form biofilms could play an important role in the persistence of SG in poultry flocks resulting in intermittent disease outbreaks. The aim of the following study was to assess the lytic activity of two new bacteriophages (Salmonella phages UPF_BP1 and UPF_BP2) against MDR and biofilm-forming SG. 2. Forty-six strains of SG, isolated in 2015, were characterised by antimicrobial resistance, biofilm formation profiles and susceptibility to two new bacteriophages. 3. Of these strains, 24% were multidrug resistant and more than 80% formed biofilm, with no statistical difference between incubation temperatures (42°C or 22°C). With regard to the lytic activity of the phages, 85% of strains were susceptible to at least one phage. Of these, 74% were lysed by both phages, including MDR and biofilm producing strains. 4. The use of salmonella phages UPF_BP1 and UPF_BP2 were shown to be promising alternatives for the biological control of fowl typhoid.

Levator ani muscle coactivation at term is associated with longer second stage of labor in nulliparous women.

OBJECTIVE: To assess the effect of levator ani muscle (LAM) coactivation at term on outcome of labor in nulliparous women. METHODS: This was a prospective study of 284 low-risk nulliparous women with a singleton pregnancy at term recruited before the onset of labor. The anteroposterior diameter of the levator hiatus was measured in each woman on transperineal ultrasound at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver before and after visual feedback. LAM coactivation was defined as a reduction in the anteroposterior diameter of the levator hiatus on maximum Valsalva maneuver in comparison with that at rest. The association of pelvic hiatal diameter values and LAM coactivation with mode of delivery and duration of labor was assessed. RESULTS: No significant difference was found between women who underwent Cesarean delivery and those who had a vaginal delivery with regard to the anteroposterior diameter of the levator hiatus at rest, on pelvic floor muscle contraction and on Valsalva maneuver. Longer second stage of labor was associated with shorter anteroposterior diameter of the levator hiatus on all assessments, but in particular at rest and on Valsalva both before and after visual feedback. LAM coactivation was found in 89 (31.3%) and 75 (26.4%) women before and after visual feedback, respectively. Post visual feedback, women with LAM coactivation had a significantly longer second stage of labor than did those without LAM coactivation (83 ± 63 vs 63 ± 42 min; P = 0.006). On Cox regression analysis, LAM coactivation post visual feedback was an independent predictor of longer second stage of labor (adjusted hazard ratio, 1.499 (95% CI, 1.076-2.087); P = 0.017). CONCLUSION: LAM coactivation in nulliparous women at term is associated with a longer second stage of labor. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion.

OBJECTIVE: To investigate the association between application of fundal pressure during the second stage of labor (Kristeller maneuver) and the risk of levator ani muscle (LAM) injury. METHODS: This was a prospective case-control study of women recruited immediately after their first vaginal delivery in our university hospital between March 2014 and September 2016. Women who underwent the Kristeller maneuver were recruited as cases. For each case, a control (no Kristeller) was recruited matched for body mass index, use of epidural analgesia, duration of second stage of labor and birth weight. All women were invited to undergo four-dimensional (4D) transperineal ultrasound (TPU) 3-6 months postpartum. The main outcome measure was the presence of LAM avulsion on 4D-TPU. TPU results were compared between cases and controls. Multivariate logistic regression analysis was performed to identify independent risk factors for LAM avulsion. RESULTS: During the study period, 134 women in the Kristeller maneuver group and 128 women in the control group underwent TPU assessment. Women who underwent the Kristeller maneuver had a higher prevalence of LAM avulsion than did controls (38/134 (28.4%) vs 18/128 (14.1%); P = 0.005). In addition, women in the Kristeller-maneuver group had a larger hiatal area on maximum Valsalva maneuver and a greater increase in hiatal area from rest to maximum Valsalva. On multivariate logistic regression analysis, use of the Kristeller maneuver was the only independent factor associated with LAM avulsion (odds ratio, 2.5 (95% CI, 1.29-4.51)). CONCLUSION: The Kristeller maneuver is associated with an increased risk of LAM avulsion when applied in women during their first vaginal delivery. This should be taken into account when deciding to use fundal pressure to accelerate the second stage of labor and when counseling women following childbirth. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Is curved three-dimensional ultrasound reconstruction needed to assess the warped pelvic floor plane?

OBJECTIVES: Caudal distension of the female pelvic floor is common and results in perineal descent and a caudally curved levator hiatus (warping). Image reconstruction of the pelvic floor using currently available ultrasound techniques involves a linear approach (flat-plane reconstruction). We aimed to evaluate the feasibility, reproducibility and potential usefulness of a new three-dimensional (3D) technique capable of reconstructing a curved plane of the levator hiatus. METHODS: Primiparous women were recruited to undergo a 3D/four-dimensional transperineal ultrasound examination 3-6 months after delivery. Levator ani muscle warping was evaluated on Valsalva maneuver by measuring the distance between the plane extending from the pubic rami to the anorectal angle and the plane of minimal hiatal dimensions on the coronal plane. Warping distance was used to reconstruct a curved plane of the levator hiatus using the curved OmniView volume contrast imaging (VCI) technique (C-OV). Intra- and interobserver reproducibility of the C-OV technique were assessed, as was intermethod agreement between the C-OV technique and the linear OmniView-VCI (L-OV) technique, for the measurement of levator hiatal area on Valsalva maneuver. RESULTS: Measurement of the levator hiatal area using C-OV was feasible in all 84 women recruited. The warping distance ranged from -3.5 to 9.7 mm, confirming that the 1-2-cm slice thickness traditionally used for linear reconstruction was adequate for proper assessment of levator hiatal area in our population. C-OV showed excellent intra- and interobserver reproducibility, as well as excellent agreement with the L-OV technique for measuring levator hiatal area. No systematic difference was demonstrated in any of the reproducibility studies performed. CONCLUSIONS: 3D reconstruction of the warped levator hiatal plane is feasible and highly reproducible. In our population, reconstruction of a curved plane to correct for levator hiatal warping did not offer any benefit over the traditionally performed linear reconstruction. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Pelvic floor muscle dysfunction on 3D/4D transperineal ultrasound in patients with deep infiltrating endometriosis: a pilot study.

OBJECTIVE: Pelvic floor muscle (PFM) dysfunction seems to play an important role in the pathophysiology of pelvic pain, including that associated with deep infiltrating endometriosis (DIE). The aim of this study was to evaluate the static and dynamic morphometry of the PFM using three-dimensional (3D) and four-dimensional (4D) transperineal ultrasound in women with DIE compared with asymptomatic healthy women. METHODS: This was a pilot, prospective study conducted at our tertiary center between March and November 2015. Fifty nulliparous women with DIE (study group) and 35 nulliparous asymptomatic healthy women (control group) were included. 3D/4D transperineal ultrasound examination of the PFM was performed in both groups. Levator hiatal area (LHA) and anteroposterior and left-right transverse diameters were evaluated at rest, on maximum PFM contraction and on maximum Valsalva maneuver. Persistent levator ani muscle (LAM) coactivation during Valsalva maneuver was investigated. RESULTS: Compared with the control group, women with DIE had a smaller LHA at rest (P = 0.03) and during Valsalva maneuver (P < 0.01). Furthermore, reduction in LHA during PFM contraction (P < 0.001) and enlargement in LHA during Valsalva maneuver (P = 0.01) were significantly less marked. In comparison with controls, women with DIE presented a higher frequency of LAM coactivation during Valsalva maneuver, although this difference did not reach statistical significance (P = 0.05). CONCLUSIONS: 3D and 4D transperineal ultrasound is an objective and non-invasive method for PFM morphometry and may have a role in detecting PFM dysfunction in women with DIE. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Backscattered electron SEM imaging of resin sections from plant specimens: observation of histological to subcellular structure and CLEM.

We have refined methods for biological specimen preparation and low-voltage backscattered electron imaging in the scanning electron microscope that allow for observation at continuous magnifications of ca. 130-70 000 X, and documentation of tissue and subcellular ultrastructure detail. The technique, based upon early work by Ogura & Hasegawa (1980), affords use of significantly larger sections from fixed and resin-embedded specimens than is possible with transmission electron microscopy while providing similar data. After microtomy, the sections, typically ca. 750 nm thick, were dried onto the surface of glass or silicon wafer and stained with heavy metals-the use of grids avoided. The glass/wafer support was then mounted onto standard scanning electron microscopy sample stubs, carbon-coated and imaged directly at an accelerating voltage of 5 kV, using either a yttrium aluminum garnet or ExB backscattered electron detector. Alternatively, the sections could be viewed first by light microscopy, for example to document signal from a fluorescent protein, and then by scanning electron microscopy to provide correlative light/electron microscope (CLEM) data. These methods provide unobstructed access to ultrastructure in the spatial context of a section ca. 7 × 10 mm in size, significantly larger than the typical 0.2 × 0.3 mm section used for conventional transmission electron microscopy imaging. Application of this approach was especially useful when the biology of interest was rare or difficult to find, e.g. a particular cell type, developmental stage, large organ, the interface between cells of interacting organisms, when contextual information within a large tissue was obligatory, or combinations of these factors. In addition, the methods were easily adapted for immunolocalizations.

Reliability of new three-dimensional ultrasound technique for pelvic hiatal area measurement.

OBJECTIVE: To assess the reproducibility of a new technique for three-/four-dimensional (3D/4D) ultrasound imaging of the pelvic floor: OmniView™ volume contrast imaging (VCI) for measurement of the pelvic hiatal area on maximum contraction and Valsalva maneuver. In addition, we aimed to study the intermethod agreement between the new technique and the 3D/4D render method. METHODS: We acquired one static 3D and two dynamic 4D transperineal volumes (one obtained during contraction and one during Valsalva maneuver) from 35 nulliparous asymptomatic healthy volunteers and 35 women with symptoms of pelvic floor dysfunction. Each 3D dataset was analyzed using the OmniView-VCI technique to measure the pelvic hiatal area at rest, on maximum contraction and on maximum Valsalva. Analysis was performed twice by the same operator and once by another operator in order to assess intra- and interobserver reproducibility. All measurements were repeated by one operator using the 3D/4D render method to evaluate the intermethod agreement. Reproducibility and intermethod agreement were studied by means of intraclass correlation coefficients (ICC) and the Bland-Altman method. RESULTS: Measurement of hiatal area using the OmniView-VCI technique showed excellent intraobserver and interobserver reproducibility in both asymptomatic and symptomatic women at rest, on contraction and on Valsalva maneuver. In addition, excellent agreement was demonstrated between OmniView-VCI and 3D/4D render in both groups (ICCs on Valsalva in asymptomatic and symptomatic women were 0.894 and 0.975, respectively). No systematic difference was noted in any of the reliability studies performed. CONCLUSIONS: OmniView-VCI is a reliable method for pelvic hiatal area measurement. Both rendering mode and OmniView-VCI can be used interchangeably for assessing pelvic hiatal area. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Narrow subpubic arch angle is associated with higher risk of persistent occiput posterior position at delivery.

OBJECTIVE: To determine whether the subpubic arch angle (SPA) measured by three-dimensional ultrasound is associated with the fetal occiput position at delivery and the mode of delivery. METHODS: Nulliparous women with an uncomplicated singleton pregnancy at ≥ 37 weeks' gestation were recruited from two tertiary centers between September 2013 and August 2015. All women underwent a three-dimensional transperineal ultrasound examination and the SPA was measured using the previously validated Oblique View Extended Imaging software. Data on the outcome of labor were obtained prospectively in all cases and the correlations between SPA and the fetal occiput position at delivery and the incidence of operative delivery were investigated. RESULTS: Overall, 368 women were included in the study. Fetal position at delivery was occiput anterior in 339 (92.1%) cases and occiput posterior (OP) in 29 (7.9%) cases. A significantly narrower SPA was found in the OP group compared with the occiput anterior group (104.4 ± 16.8° vs 116.4 ± 11.9°; P < 0.0001). The SPA was significantly narrower in women requiring obstetric intervention compared with in women with a spontaneous vaginal delivery. From multivariable logistic regression analysis, SPA and maternal height appeared to be significant predictors of both the fetal occiput position at delivery and the risk of operative delivery. The best cut-off value of SPA for predicting an OP position at delivery was 90.5°. CONCLUSION: A narrow SPA is associated with a higher risk of persistent OP position at delivery and of operative delivery. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

The hippocampal commissure: a new finding at prenatal 3D ultrasound in fetuses with isolated complete agenesis of the corpus callosum.

OBJECTIVE: The aim of this research was to determine the prevalence and sonographic appearance of the hippocampal commissure in fetuses with isolated complete agenesis of the corpus callosum by three-dimensional neurosonography in the multiplanar mode. METHODS: This was a multicenter observational study. Stored volume datasets of fetuses with isolated complete agenesis of the corpus were retrospectively retrieved for analysis in three tertiary centers. The presence or absence of the hippocampal commissure was independently evaluated in the coronal and midsagittal planes by two operators. Postnatal follow-up was obtained in all cases. RESULTS: From November 2007 to February 2013, 41 cases between 19 and 30 weeks of gestation were retrieved for analysis. The hippocampal commissure was visible in the coronal and sagittal planes in 27/41 (65.8%), absent or not clearly recognizable in the remaining 14 cases. The qualitative analysis of the two operators was concordant in 100% of cases. CONCLUSIONS: In more than half of fetuses with complete callosal agenesis, the hippocampal commissure may be visualized at prenatal ultrasound. This is a residual interhemispheric connection, which in normal cases is hidden by the corpus callosum itself. Further research is needed to establish if this has an impact on postnatal outcome.

Caregiver's satisfaction with a video tutorial for shoulder dystocia management algorithm.

In our questionnaire, a video tutorial illustrating the management of shoulder dystocia was considered by health personnel as a useful complementary training tool. We prepared a 5-min video tutorial on the management of shoulder dystocia, using a simulator that includes maternal pelvic and baby models. We performed a survey among obstetric personnel in order to assess their opinion on the tutorial by inviting them to watch the video tutorial and answer an online questionnaire. Five multiple-choice questions were set, focusing on the video's main objectives: clarity, simplicity and usefulness. Following the collection of answers, global and category-weighted analyses were conducted for each question. Out of 956 invitations sent, 482 (50.4%) answered the survey. More than 90% of all categories found the video tutorial to be clinically relevant and clear. For revising the management of shoulder dystocia most obstetric personnel would use the video tutorial together with traditional textbooks. In conclusion, our video tutorial was considered by health personnel as a useful complementary training tool.

Agreement between two- and three-dimensional transperineal ultrasound methods for assessment of fetal head-symphysis distance in active labor.

OBJECTIVES: To assess the intermethod agreement between two-dimensional (2D) and three-dimensional (3D) transperineal ultrasound methods in measuring a new index of fetal head station (the fetal head-symphysis distance (HSD)) in active labor, and to assess potential factors that may affect their agreement. METHODS: HSD was measured by transperineal ultrasound in 86 women in active labor, once using a 2D and once using a 3D technique. 2D images were acquired first in 43 cases and 3D images were acquired first in the other 43 women. Intermethod agreement between 2D and 3D methods was analyzed by means of intraclass correlation coefficient (ICC) and Bland-Altman analysis. In addition, potential factors affecting the intermethod reproducibility were investigated including fetal occiput position, order of acquisition, fetal head station, stage of labor, maternal body mass index and use of epidural analgesia, using the ANOVA test to check for systematic bias and Levene's test for homoscedasticity. RESULTS: Good agreement was demonstrated between 2D and 3D measurements of HSD (ICC, 0.949 (95% CI, 0.914-0.984)). No evidence of systematic difference was shown between the two methods (average difference ± SD = 0.03 ± 2.29 mm; P = 0.888). The only factor that had a significant effect on systematic difference between 2D and 3D methods was order of acquisition (P = 0.042); the first observation was higher regardless of the method used. Fetal head station had a significant effect on the homogeneity between the two methods (P = 0.004) with a better 2D-3D agreement obtained at lower head stations (SD of differences: 1.63 vs 2.59 mm). CONCLUSIONS: There is very good agreement between 2D and 3D methods of assessing HSD. Agreement is better in lower fetal head stations.

Sonographic pattern of fetal head descent: relationship with duration of active second stage of labor and occiput position at delivery.

OBJECTIVES: The objectives of this study were firstly to assess the longitudinal changes of various sonographic parameters of fetal head progression in relation to length of active second stage of labor, and secondly to compare ultrasound findings obtained longitudinally among fetuses with persistent occiput posterior (OP) vs those with persistent occiput anterior (OA) position. METHODS: From a series of nulliparous low-risk women at term attending the labor ward of our university hospital, transperineal ultrasound volumes were prospectively acquired at the beginning of the active second stage (T1) and at 40-min intervals thereafter until delivery (T2, T3). Sonographic parameters were derived from offline analysis of each volume, including the angle of progression (AoP), progression distance (PD), head-symphysis distance (HSD), head direction (HD) and midline angle. These parameters were compared between patients who delivered within 60 min from the beginning of the active second stage of labor (early delivery) and those who remained undelivered by that time (late delivery). Fetal head position was determined from stored digital images of transabdominal examinations performed at the beginning of the active second stage. Comparison was performed between fetuses with OA and those with persistent OP position at delivery. RESULTS: Spontaneous vaginal delivery was achieved in 58 (81.7%) cases, whereas vacuum extraction and Cesarean section were performed in eight (11.3%) and five (7.0%) cases, respectively. Delivery was achieved within 60 min from the beginning of the active second stage in 44 (62.0%) patients. In the early vs late delivery groups, measurements of AoP, HSD and PD at T1 were significantly different (AoP, 143.9 ± 20.5° vs 125.3 ± 15.0°, P < 0.001; HSD, 14.8 ± 4.5 mm vs 20.9 ± 5.8 mm, P < 0.001; PD, 44.0 ± 14.1 vs 35.0 ± 13.1 mm, P = 0.008). On logistic regression analysis of data obtained at T1, maternal body mass index, oxytocin administration, neonatal birth weight and HSD appeared to predict independently duration of the active second stage. Among fetuses delivering in the OP position (n = 10, 13.5%), Cesarean delivery was significantly more common than in those delivering in the OA position (n = 5 (50.0%) vs n = 2 (3.1%), P = 0.001). Women with persistent OP position compared with OA showed a significantly different AoP at T1 (122 ± 17° vs 138 ± 20°, P = 0.016), HD and HSD at T1 (HD, 112 ± 17 mm vs 86 ± 19 mm, P < 0.001; HSD, 16.5 ± 5.4 mm vs 22.8 ± 6.6 mm, P = 0.008) and at T2 (HD, 120 ± 16 vs 82 ± 27 mm, P = 0.008; HSD, 12.6 ± 3.4 mm vs 18.5 ± 5.4 mm, P = 0.038). CONCLUSIONS: AoP, PD and HSD are significantly different between patients undergoing delivery before or after 60 min from the beginning of the active second stage of labor. Ultrasound parameters are among the significant predictors of duration of the active second stage. Moreover, in fetuses persisting in the OP position vs those delivering in the OA position, fetal head progression seems to differ at early phases of the active second stage.

Outcome of severe placental insufficiency with abnormal umbilical artery Doppler prior to fetal viability.

OBJECTIVE: To evaluate the outcome of pregnancies complicated by placental insufficiency and abnormal umbilical artery Doppler prior to viability. DESIGN: A retrospective cohort study. SETTING: Italy. POPULATION: Singleton pregnancies with fetal growth restriction and absence of end-diastolic velocities (AEDVs) in the umbilical arteries prior to 24 weeks. METHODS: A retrospective cohort study of singleton pregnancies with fetal growth restriction and AEDVs in the umbilical arteries prior to 24 weeks. MAIN OUTCOME MEASURES: Fetal growth restriction and AEDVs in the umbilical arteries prior to 24 weeks. RESULTS: Of 16 fetuses first seen at 20-23 weeks, only 12 survived and one of these developed cerebral palsy. Severe hypertensive disorders occurred in three mothers. In four women, the Doppler waveforms progressively improved and developed a normal pulsatility. These fetuses had a better outcome than those that had persistent alterations: they were delivered later (34 versus 28 weeks), had a larger birthweight (1598 versus 630 g) and developed fewer complications. CONCLUSIONS: Placental insufficiency with AEDV in the umbilical arteries prior to fetal viability is associated with a high probability of perinatal death and neonatal complications. However, progressive amelioration of Doppler indices occurs in a subset of women, and these fetuses have a much better outcome.

Fetal head-symphysis distance: a simple and reliable ultrasound index of fetal head station in labor.

OBJECTIVES: To assess the reproducibility of measurement of a new sonographic index of fetal head station in labor, the fetal head-symphysis distance (HSD), using three-dimensional ultrasound, and its correlation with digital assessment of fetal head descent and with the angle of progression (AoP). METHODS: Three-dimensional (3D) ultrasound volumes were acquired from 47 nulliparous women in active labor following assessment of fetal head station with digital examination. The HSD (the distance between the lower edge of the pubic symphysis and the nearest point of the fetal skull) was measured independently by two operators in order to evaluate intra- and interobserver reproducibility. The correlation between HSD, AoP and fetal head station was evaluated using regression analysis. Using 3D tomographic ultrasound imaging (TUI), measurements of the HSD were obtained in different parasagittal planes to evaluate the influence of inaccurate alignment of the probe with the midline of the pelvis. RESULTS: Measurement of HSD showed high intraobserver (intraclass correlation coefficient (ICC) = 0.995; 95% CI, 0.991-0.997) and interobserver (ICC = 0.991; 95% CI, 0.984-0.995) reliability. In addition, a high correlation was demonstrated between mid-sagittal and parasagittal HSD measurements. HSD showed significant negative correlation with both fetal head station and AoP. CONCLUSION: Fetal HSD is a simple and reliable method for the assessment of fetal head descent in labor.

Intrapartum transperineal ultrasound assessment of fetal head progression in active second stage of labor and mode of delivery.

OBJECTIVE: To compare longitudinal changes in angle of progression (AoP) and midline angle (MLA) during the active second stage of labor according to the mode of delivery. METHODS: A three-dimensional transperineal ultrasound volume was acquired in a series of nulliparous women at the beginning of the active second stage (T1) and every 20 min thereafter (T2, T3, T4, T5 and T6). Following delivery, all ultrasound volumes were analyzed and AoP and MLA were measured. RESULTS: Among 71 women included in the study, 58 underwent spontaneous vaginal delivery (group A) and 13 underwent operative delivery (group B) (eight by vacuum extraction and five by Cesarean section). When compared with Group B, Group A had a wider AoP only at T1 (140.0 ± 20.2° vs. 122.9 ± 16.7°; P = 0.010) and T2 (149.7 ± 20.7° vs. 126.9 ± 17.5°; P = 0.006). MLA was narrower in group A only at T3 (21.2 ± 11.7° vs. 40.8 ± 27.9°; P = 0.043), T4 (18.2 ± 15.0° vs. 47.4 ± 29.6°; P = 0.020) and T5 (18.3 ± 6.0° vs. 34.7 ± 4.2°; P = 0.034). On stepwise forward multiple logistic regression analysis, both AoP and MLA were independently associated with operative delivery (OR = 0.955 and OR = 1.018, respectively). CONCLUSION: Ultrasonographic assessment of fetal head descent in the second stage of labor may play a role in the prediction of the mode of delivery.

Occurrence of septic shock in a patient submitted to emergency cerclage following a negative amniocentesis: report of a case.

BACKGROUND: Second trimester emergency cerclage is an option for pregnant women presenting bulging fetal membranes. Despite a significant prolongation of pregnancy might be achieved, serious fetal and maternal events have been reported. Exclusion of infections through preprocedure amniocentesis has been proposed. METHODS: A 37-year-old woman, gravida 4 para 1, was admitted at 21 weeks of gestation to our University Hospital due to bulging fetal membranes. An amniocentesis was performed in order to exclude an actual amniotic infection. Our Microbiology Department found a negative amniotic culture for bacteria and Mycoplasma and a normal glucose and interleukin-6 level, so a cervical cerclage was performed. The patient was discharged home on oral erythromycin. RESULTS: After 48 h, the patient complained of hyperpyrexia, shivers and reduced fetal movements. Ultrasound at admission showed absent cardiac activity and after cerclage removal a non-viable fetus was delivered vaginally. Piperacillin and tazobactam were started, but the clinical course of the patient deteriorated and she developed a cold septic shock and was submitted to hysterectomy and transferred to the ICU of our hospital. CONCLUSION: This report heralds that even after negative amniocentesis, a life-threatening infection may not be excluded in women candidate for emergency cerclage due to bulging fetal membranes.