[Usefulness of ultrasound in the delivery room]. / Impiego degli ultrasuoni in sala parto.

The use of diagnostic ultrasound and the diffusion of the technique improved the obstetric treatment and the usefulness of ultrasound increases in the delivery room for maternal and fetal care and as method of diagnosis of some obstetric complications. The knowledge of intrapartum ultrasound imaging can be considered useful for the obstetric team, since there is evidence that ultrasound can improve the obstetric management. The mean indications are described: fetal biometry and estimated fetal weight, amniotic fluid volume, fetal situation and presentation, placental localization and anatomy, assessment of size and location of uterine leiomyomas, fetal cardiac activity, evaluation of umbilical cord and fetal cardinal movements intrapartum. Besides, the use of ultrasound is reported in obstetric and postpartum complications. Actually ultrasonography, as a non-invasive, safety and low-cost technique, offers a diagnostic method in particular conditions during labour, delivery and postpartum.

Reproducibility of the fetal cerebral vessels assessment in full and late term pregnancies.

Objective: Data concerning feasibility of the fetal cerebral Doppler examination in full term and late term pregnancy is lacking. Our purpose was to perform an evaluation of these arteries with power Doppler ultrasound, calculating the percentage of identification and measurement and the intraobserver reproducibility.Methods: This was a cross sectional study evaluating a population of 578 normally grown fetuses divided according to the week of examination. The first group included fetuses examined at week 40 (N = 323) and the second fetuses examined at week 41 (N = 255). The three major branches of the internal carotid artery (anterior, middle and posterior cerebral arteries, ACA, middle cerebral artery (MCA), posterior cerebral arteries (PCA)) and their anastomosis (A1, A2, P1, P2) were examined with power Doppler ultrasonography by three independent ultrasonographers. The proportion of vessel identified and measured was calculated and the reproducibility among the three operators was investigated.Results: The major arteries at the circle of Willis were fully identified/measured in 65/56 and 62/48% of fetuses at 40 and 41 weeks. The MCA obtained the higher percentage of identification and measurement at both periods (> 80 and >70%). The entire set of anastomosis were less frequently identified/measured at both periods (50/< 50% of cases), especially in the A2 segment. The best agreement was obtained in the MCA and the worst in the PCA-P1 segment.Conclusions: At 40 and 41 weeks, the fetal cerebral vessels, especially the MCA, are suitable for power Doppler evaluation, providing an interesting tool to evaluate fetal hemodynamics in full and late term pregnancy.

[Postpartum hemorrhage]. / L'emorragia del postpartum.

Postpartum hemorrhage, frequently due to uterine atony, is an important cause of maternal death and morbidity. The knowledge of causes, of antenatal and intrapartum risk factors and of physiopathological changes in hemodynamics and coagulation during pregnancy are essential for the management of the condition. At the present time, many efforts are made to organize a multidisciplinary approach to this complication of delivery involving clinical and laboratory staffs, since the rapid correction of hypovolemia, the diagnosis and treatment of defective coagulation, the surgical and pharmacological control of bleeding are mandatory. Several medical options have been developed and the surgical management includes traditional and newer conservative procedures with variable success rates. The developments in the treatment of postpartum hemorrhage may reduce hysterectomy that is to be considered the last resort to resolve the hemorrhage in some cases. In the modern management of postpartum hemorrhage protocols and guidelines should be available in every delivery room.

Isolated mild fetal pyelectasis detected by transvaginal sonography in advanced maternal age.

OBJECTIVE: To evaluate the importance and evolution of isolated, mild fetal pyelectasis, detected in early pregnancy by high-resolution transvaginal sonography, and to determine its association with abnormal fetal karyotypes. METHODS: Transvaginal scan at 11-16 weeks' gestation and transabdominal ultrasound examinations at the time of amniocentesis (16-18 weeks) were performed in 1093 pregnant women undergoing genetic amniocentesis because of advanced maternal age. In 795 cases, transabdominal scans were repeated at 22-24 weeks. Women were excluded if they had a spontaneous abortion, chose to terminate their pregnancy, or declined amniocentesis. Each patient was screened for fetal pyelectasis, defined as an increase in anteroposterior renal pelvic diameter, using cutoff values related to various stages of pregnancy. RESULTS: Isolated fetal pyelectasis was detected at the first ultrasound examination in 56 women (5.1%) in early pregnancy, in 32 (2.9%) at the time of amniocentesis, and in 23 (2.9%) at 22-24 weeks' gestation. Two fetuses with diagnoses of mild pyelectasis at the first transvaginal ultrasound demonstrated abnormal karyotypes at amniocentesis. In one case, the pyelectasis disappeared at 22-24 weeks' gestation. CONCLUSION: This retrospective study shows that pyelectasis is more frequently detectable by high-resolution transvaginal sonography in the first half of pregnancy than in the second half. When detected in early pregnancy, the finding is frequently transient and not associated with an increased risk of abnormal fetal karyotypes.

Transvaginal sonographic detection of embryonic-fetal abnormalities in early pregnancy.

OBJECTIVE: To estimate the detection rate of abnormalities by transvaginal ultrasound in early pregnancy. METHODS: We prospectively analyzed records of 3592 sequential pregnant women at 10-16 weeks' (singleton) gestation (mean 13 weeks and 2 days). After exclusion of 114 women, there were 3478 women in the study. Each woman underwent a transvaginal sonographic survey for fetal anomalies as well as biometric measurements. Fetuses diagnosed with malformations were followed to delivery, and those without underwent transabdominal sonography at 18-24 weeks' gestation. RESULTS: The anomaly detection rate by transvaginal ultrasound was 51.6% (33 of 64; 95% confidence interval [CI] 38.7, 64.2) in early pregnancy, and the detection rate by transvaginal ultrasound combined with second-trimester transabdominal ultrasound was 84.4% (54 of 64; 95% CI 73.1, 92.2). Cystic hygroma and fetal hydrops were the anomalies detected most frequently by transvaginal ultrasound. Low detection rates for abnormalities of the face and of the cardiac, skeletal, and urinary systems were found even when both methods were used. CONCLUSION: Transvaginal sonography appears to be an effective way to identify many congenital fetal anomalies in early pregnancy. There is a good probability of diagnosing cystic hygroma and fetal hydrops, although other abnormalities, particularly heart defects, are associated with lower detection rates.

Pelvic lymphocele following radical para-aortic and pelvic lymphadenectomy for cervical carcinoma: incidence rate and percutaneous management.

Thirty-six women, treated with radical hysterectomy (Piver types III-IV) plus systematic para-aortic and pelvic lymphadenectomy for cervical carcinoma, underwent serial postoperative ultrasound examinations to determine the incidence of lymphocele and the therapeutic efficacy of percutaneous catheter drainage. Pelvic lymphoceles, ranging in volume from 46-300 mL, occurred in eight patients (22.2%) between the 12-24th postoperative day. Percutaneous catheter drainage, inserted under local anesthesia, was used for a mean time of 14.5 days (range 4-32), resulting in a mean daily drainage of 92.2 mL and a mean total volume of 1727.5 mL per patient. Catheter drainage allowed complete clinical and sonographic remission in all cases, and only one asymptomatic recurrence was observed at 3-month and 6-month follow-up. Ultrasound-guided percutaneous catheter drainage has proved to be a well-tolerated, safe, and effective technique in the management of lymphocele that obviates the need for more invasive surgical procedures.

Transvaginal fetal biometry in early pregnancy.

OBJECTIVE: To produce reference charts for fetal size with transvaginal sonography that are potentially helpful in evaluating normal and abnormal early pregnancies. DESIGN: A prospective cross-sectional study. SUBJECTS: 1081 normal singleton pregnancies with a normal fetal karyotype or normal healthy baby at delivery, at 9-16 weeks' gestation. Measurements included crown rump length, biparietal diameter, transverse cerebellar diameter, head and abdominal circumference, mean abdominal diameter, thoracic circumference, femur length, humerus length and foot length. RESULTS: The best description of the relationship between single ultrasonographic parameters and gestational age was achieved by polynomial regression analysis. All fetal biometric parameters correlated closely with gestational age. Biparietal diameter maintained the closest correlation with gestational age (r2 = 97.15, p < 0.001; y = -0.545 - 0.06x + 0.15x2); transverse cerebellar diameter showed the poorest correlation with gestational age (r2 = 88.17, p < 0.001). Reference ranges (5 degrees and 95 degrees percentile intervals) were constructed for all biometric parameters in relation to gestational age. Mean residuals are similar for all parameters with a very low range. CONCLUSIONS: These data provide normograms for first and early second trimester fetal measurements which may be of aid in the dating of pregnancies and can be useful in the early detection of genetic disorders affecting the growth of fetal structures.

A novel inositol mono-phosphatase inhibitor from Memnoniella echinata. Producing organism, fermentation, isolation, physicochemical and in vitro biological properties.

A novel inositol mono-phosphatase inhibitor, L-671,776 (1), was discovered from a culture of the hyphomycete, Memnoniella echinata (ATCC 20928). 1 has a molecular weight of 388 and a molecular formula of C23H32O5. The mode of inhibition is non-competitive, with a Ki of 450 microM. It shows no inhibition of myo-inositol 1,4-bisphosphate 1-phosphatase or myo-inositol 1,4,5-triphosphate 5-phosphatase, although it weakly inhibits myo-inositol 1,4,5-triphosphate 3-kinase (IC50 = 3 mM). It elevates inositol monophosphates in rat parotid slices (EC50 approximately 3 mM), but abolishes agonist effects. It also produces short-lived contraction of guinea pig trachea at 300 microM.

Ultrasound-guided fine needle aspiration of ovarian cysts during pregnancy.

OBJECTIVE: To evaluate the safety and efficacy of ultrasound-guided fine needle aspiration in the treatment of ovarian cysts during pregnancy. STUDY DESIGN: Nine out of twenty-nine patients between the 6th and the 16th week of gestation with unilateral ovarian cysts ranging between 65 and 540 cm3 in volume were selected for sonographically-guided fine needle aspiration. RESULTS: No complications were observed at either short or long-term follow-up; all patients delivered healthy infants at term. Clinical and sonographic post-partum follow-up was uneventful in all cases. In three cases it was necessary to repeat the procedure once and in one case twice during pregnancy. In one case a recurrent serous cyst was excised at operative laparoscopy performed 3 months after delivery. CONCLUSIONS: Ultrasound-guided fine needle aspiration was safely performed in nine patients as an alternative treatment to surgery when persistent monolateral and unilocular ovarian cysts with regular borders and completely anechoic structure are detected during pregnancy.

Ovarian carcinoma: an ultrasound study.

Between March 1986 and March 1989, 65 epithelial ovarian carcinomas were studied by means of real time high resolution ultrasound. The sonographic findings were correlated with FIGO stage, histotype and histological grade. The echostructure was compared with that of a group of 141 benign controls. Moreover, some sonographic patterns, significantly more frequent in the malignant tumors (ascites, irregular borders, peritoneal growths), were identified. The diagnosis of malignancy was as accurate as 90.0%, sensitivity and specificity were 84.7% and 92.3% respectively. Our results, coupled with the low costs involved and the non-invasiveness of the method, thus confirm that ultrasound can still be considered a primary technique in the preoperative assessment of ovarian masses.

[Early transvaginal measurement of cephalic index for the detection of fetuses at risk for Down syndrome]. / L'indice cefalico fetale come marker biometrico nella individuazione in epoca precoce di gravidanza di feti a rischio di trisomia 21.

BACKGROUND: The aim of this study was to evaluate the utility of cephalic index screening in early pregnancy for the identification of fetuses at risk for trisomy 21. METHODS: Measurements of cephalic index, calculated as the ratio between biparietal diameter/occipito-frontal diameter, were obtained in 36 Down syndrome fetuses and the values were compared with normal data in the same gestational periods considered. RESULTS: Cephalic index was found to show fairly constant values throughout the period evaluated. The measurements obtained in Down syndrome fetuses were similar to those obtained in euploid fetuses. CONCLUSIONS: The data obtained show that in early pregnancy cephalic index cannot be considered a useful tool in the detection of fetuses at risk for Down syndrome.

[Early transvaginal sonographic measurement of cephalic index]. / Misurazione dell'indice cefalico fetale in epoca precoce di gravidanza mediante ecografia transvaginale.

BACKGROUND: The aim of this study is to obtain normal values of cephalic index by transvaginal scan early in pregnancy. METHODS: In this prospective cross-sectional study, transvaginal high-resolution sonography was performed between 57 and 112 days' gestation in 1087 euploid fetuses. Measurements of cephalic index with standard deviations, calculated as the ratio biparietal diameter/occipito-frontal diameter, were obtained in the single gestational periods considered. RESULTS: Cephalic index was found to show fairly constant values throughout the period evaluated with smaller values of standard deviation. The best correlation with gestational age was described by a linear correlation. CONCLUSIONS: The data obtained by transvaginal scan can be used as parameters of normal values in early pregnancy.

[Early diagnosis of embryo-fetal malformations by transvaginal echography in a high-risk population]. / Diagnostica precoce di patologia malformativa embrio-fetale mediante ecografia transvaginale in una popolazione ad alto rischio.

BACKGROUND: High resolution transvaginal sonography permits, in respect of traditional transabdominal scan, an earlier diagnosis of some fetal anomalies and malformations. METHODS: In our prospective study, between 11th to 16th weeks gestation, 820 pregnant patients at high risk for chromosomopathies and for fetal malformations were scanned in order to obtain a detailed survey of embryofetal structures and organs and an earlier diagnosis of fetal malformations. RESULTS: Thirty-two fetal anomalies and malformations (3.9%) were detected, and in 4 cases (0.49%) the diagnosis was obtained later in pregnancy. Fetuses with structural malformations were scanned during pregnancy and, if possible, postnatally. We reconsidered the pitfalls in relation to the time of transvaginal scan and the fetal pathology. CONCLUSIONS: En early prenatal diagnosis of fetal anomalies by transvaginal sonography is related to the knowledge of normal embryofetal development and the pathogenesis of malformations.

[Embryo-fetal ultrasonographic diagnosis in the early pregnancy using transvaginal echography]. / Diagnostica ultrasonografica embrio-fetale in epoche precoci di gravidanza mediante ecografia transvaginale.

The diagnostic capability of high resolution transvaginal sonography in early pregnancy is described. Transvaginal sonography allows for the visualisation of some fetal organs and structures one to four weeks earlier than transabdominal ultrasound thus permitting evaluation of several embryofetal parameters early in pregnancy. This technique permits formulation of fetal measurement charts and detection of embryo-fetal malformations during the initial stages of pregnancy. Knowledge of the transvaginal sonographic appearance of embryonal and fetal biometric and structural anatomy enables us to determine the appearance of the normal fetus. Transvaginal scan may be employed as a screening tool for the identification of fetal anomalies in early stages of pregnancy. An increasing number of case reports and documented records of cases of malformations and anomalies diagnosed during the first trimester of pregnancy using this technique have been reported in the literature. The most frequent embryo-fetal malformations and anomalies detected at transvaginal scan and the earliest gestational age of diagnosis are described. At present a limited number of anomalies can be diagnosed because only a part of the potentially recognizable anomalies have been described using this technique. The importance of this new imaging technique as well as the necessity of a through knowledge of embryology are evident. Transvaginal sonography allows for biometric evaluation, for a clearer visualization of embryo-fetal morphology and for detection of several malformations and anomalies during early pregnancy.

[Echographic markers of fetal chromosomopathies. Diagnostic possibilities with transvaginal ultrasonography and our experience]. / "Markers" ecografici di cromosomopatie fetali. Possibilità diagnostiche mediante ecografia transvaginale e nostra esperienza.

OBJECTIVE: Aim of this study was to evaluate, during early pregnancy, the correlation of some anomalies and malformations with fetal chromosomopathies. EXPERIMENTAL DESIGN: Morphostructural and biometric anomalies in chromosomopathic fetuses were evaluated. PATIENTS: 1331 pregnancies at high risk for genetic disease and malformations referred to our center for prenatal diagnosis. METHOD: Scans were performed using endovaginal convex probes (5.0 to 7.0 MHz). SURVEYS: Urinary, cardiac and cerebral malformations as well as alterations of bone growth were evaluated. RESULTS: With respect to the other malformations, cystic hygroma is more frequently associated with an abnormal fetal karyotype. CONCLUSIONS: The majority of morphostructural abnormalities diagnosed during first trimester by transvaginal sonography cannot, in according to personal experience, be used as markers of chromosomopathies.

[Early prognostic ultrasonographic indices in pregnancy with fetal cystic hygroma]. / Indici ecografici prognostici precoci in gravidanze con igroma cistico fetale.

OBJECTIVE: Aim of this study was the correlation of same early ultrasonographic signs with fetal karyotype, prognosis of pregnancy and neonatal outcome. EXPERIMENTAL DESIGN: Volume of cystic hygroma and presence of septations are correlated with fetal karyotype and an ultrasonographic follow-up was carried out during pregnancy. Details concerning neonatal outcome were recorded at delivery. PATIENTS: Diagnosis was performed in 13 patients between 8.3 to 16.5 weeks' gestation referred to our center for prenatal diagnosis or for obstetric reasons. METHOD: Ultrasonographic examinations were performed using 5.0 and 6.0 MHz endovaginal convex probes. SURVEYS: Hygroma was diagnosed as a cystic dilatation in the nuchal region larger than 3 mm in diameter in the anterolateral aspects. The volume was calculated considering the lesion as spherical and using the standard formula for an ellipsoid volume; the presence of septations was considered. RESULTS: A volume greater than 70 cc3 and the presence of septations demonstrated a strictly correlation with fetal karyotype, evolution of the features, pregnancy and neonatal outcome. CONCLUSIONS: Prognosis varies depending on fetal karyotype, volume, presence of septations and other associated malformations. The volume of the hygroma and the presence of septa are associated with higher incidence of chromosomal diseases and a poorer fetal prognosis.

[Visualization of the fetus in early pregnancy with transvaginal sonography]. / Visualizzazione fetale in epoche precoci di gravidanza mediante ecografia transvaginale.

The aim of this prospective study is to define in early pregnancy the time and percentage of visualization of embryo-fetal structures and organs. 820 patients at high risk for fetal genetic anomalies and/or malformations were scanned by high resolution transvaginal probe between 10 and 16 weeks' gestational age. Criteria for exclusion were: fetal malformations, multiple pregnancies and loss of pregnancy. We determined percentage of visualization in the different weeks of: orbits, face, cerebellum, cisterna magna, cardiac chambers, abdomen, diaphragm, stomach, kidneys and bladder. The percentage of visualization of fetal organs and structures investigated increased with gestational age and at 13 weeks ranged from 80% to 100%. With the introduction of high-frequency transvaginal probes in early pregnancy embryo-fetal structures and organs can be imaged and studied in great detail and more accurately identified than with traditional abdominal ultrasound, up to 4 weeks earlier. Another important advantage is the fact that some fetal malformations can be detected earlier.

[Estimate of fetal long bone length in early pregnancy: comparison between mathematical formulae]. / Stima della lunghezza delle ossa lunghe fetali in epoca precoce di gravidanza: confronto tra formule matematiche.

BACKGROUND: The aim of this study was to determine the efficacy of different mathematical formulae described in the literature and to propose new mathematical formulae to estimate fetal long bones biometry in early pregnancy. METHODS: In 1481 singleton euploid fetuses a transvaginal ultrasound examination was performed between 9 and 16 week's gestation. To determine the relationship between the biparietal diameter and long bone lengths, a sample group of 100 randomly chosen normal fetuses was evaluated by regression equations. The equations derived were then tested in the remaining 1381 control fetuses and the mean absolute percentage error and the mean systematic error with their standard deviations were compared with previously reported mathematical formulae by other authors. RESULTS: All previous formulae described in literature when applied to our population revealed an overestimation of expected long bones measurements. Using our mathematical formulae, the mean absolute percentage error and the mean systematic error were 11.5% and 1% in estimating femur and 10.9% and 0.8% in estimating humerus length, respectively. CONCLUSIONS: These newly derived ultrasound morphometric formulae could be proposed as reliable models in estimating fetal long bone lengths in early pregnancy.

[Therapy and prevention of obstetric hemorrhage by tamponade using a balloon catheter]. / Terapia e prevenzione dell'emorragia ostetrica mediante tamponamento con catetere a palloncino.

The aim of this study was to verify the possibility to use a balloon catheter as hemostatic method in pregnancies at high risk for hemorrhage as an alternative to less conservative surgical procedures. In 4 pregnancies at risk for hemorrhage, a compressive endouterine or endocervical method, consisting of a balloon catheter filled of warm saline solution, was used in order to stop or to prevent otherwise uncontrollable bleeding. In the cases treated the use of the balloon catheter was safe and effective both in the treatment of hemorrhage due to abnormal placentation and in the prevention of hemorrhagic complications due to abnormal implantation of pregnancy. Among novel medical and surgical approaches developed to control obstetric hemorrhage, tamponade using a balloon catheter could be considered a valid option. Moreover, this procedure, by avoiding radical surgical treatments, such as hysterectomy, which are frequently performed in unstable patients, could offer the advantage of preserving fertility.

[Ultrasonographic and clinical methods in the management of prolonged pregnancy]. / Confronto tra metodiche cliniche e strumentali nella gestione della gravidanza protratta.

AIM: The aim of this study was to evaluate the role of Bishop score, sonographic measurements of uterine cervical length and maternal characteristics, as predictors of spontaneous onset of labor within 24 hours, as well as response to induction in prolonged pregnancies. METHODS: Pregnancies with gestational age over 280 days were followed as outpatient. Patients were included in the study if spontaneous delivery occurred between 286 and 295 days of gestation, or in pregnancies with gestational age of 291-293 days who required labor induction. Data about Bishop score, ultrasonographic cervical characteristics (length, funneling, volume) and maternal features (parity, body mass index and age) registered at the last control immediately before the delivery were retrieved from clinical charts. RESULTS: Data from 195 patients were available. Bishop score and, in particular, ultrasonographic cervical length can predict the spontaneous onset of labor with a positive predictive value (PPV) of 22% and 44%, respectively in 24 hours. On the other hands, in patients requiring labor induction, parity and ultrasonographic cervical length remained the only predictive parameters with a PPV of 39% and 42%, respectively. In term of predictive performance, the value of 30 mm was identified as the best cut-off value for the ultrasonographic cervical length (specificity 59% and sensitivity 69%). CONCLUSION: In prolonged pregnancies, Bishop score and ultrasonographic cervical length were shown to be relevant in the prediction of spontaneous onset of labor, while in patients who required labor induction, ultrasonographic cervical length represented the only clinic parameter predicting the onset of labor.