The predictive value of transvaginal cervical length and cervical angle ultrasonography in term delivery outcomes: a cohort study.

BACKGROUND: Various techniques have been proposed to predict and evaluate the timing and conditions of childbirth in pregnant women at different stages of pregnancy. Providing precise methods for forecasting childbirth status can reduce the burden on the healthcare system. This study aimed to evaluate the predictive value of transvaginal sonography of cervical length (CL) and cervical angle (CA) on full-term delivery outcomes. METHODS: This cohort study analyzed 151 pregnant women between 37 and 42 weeks of gestational age who were treated at Rasoul Akram Hospital affiliated with Iran University of Medical Sciences from June 2023 to January 2024. All Participants received transvaginal examinations. This study evaluated the accuracy of CL and CA by transvaginal sonography in predicting outcomes like vaginal delivery, cesarean section, necessity for labor induction, and the rate of Premature Rupture of Membranes (PROM). The study used the Receiver Operating Characteristic (ROC) curve to determine the optimal cutoff for predicting birth outcomes. RESULTS: The mean age of the pregnant women was 28.9 ± 4.22 years, while the average duration of pregnancy was 39.8 ± 2.11 weeks. Cesarean delivery was performed on 45 individuals (29.8%) and 106 (70.1%) underwent vaginal delivery. The mean CL overall stood at 21.2 ± 6.4 mm. PROM was observed in 41 cases (27.1%) among full-term pregnancies. A significant difference was noted in mean CL between the cesarean and vaginal delivery groups (24.2 ± 2.4 vs. 20.1 ± 2.1 mm, p = 0.001). The predictive value of a CL measuring 21 mm for cesarean delivery was 72.2% sensitive and 79.1% specific. Similarly, a CL of 22 mm showed 66.6% sensitivity and 80.2% specificity for labor induction. Regarding PROM in full-term pregnancies, a CL assessment demonstrated 59.8% sensitivity and 69.1% specificity. Finally, a CA of 115.2° exhibited 70.3% sensitivity and 78.4% specificity in predicting vaginal delivery. CONCLUSION: The present study showed that evaluating CL and CA via transvaginal sonography demonstrated adequate diagnostic accuracy in predicting spontaneous birth, need for labor induction, cesarean delivery, and incidence of PROM in full-term pregnant women. This method is suggested to be an accurate and appropriate way to predict delivery results.

Value of fetal echocardiographic examination in pregnancies complicated by preterm premature rupture of membranes.

OBJECTIVES: Cardiopulmonary and infectious complications are more common in preterm newborns after preterm premature rupture of membranes (pPROM). Fetal echocardiography may be helpful in predicting neonatal condition. Our aim was to assess the cardiovascular changes in fetuses from pregnancies complicated by pPROM and possible utility in predicting the intrauterine or neonatal infection, and neonatal heart failure (HF). METHODS: It was a prospective study enrolling 46 women with singleton pregnancies complicated by pPROM between 18+0 and 33+6 weeks of gestation and followed until delivery. 46 women with uncomplicated pregnancies served as a control group. Fetal echocardiographic examinations with the assessment of cardiac structure and function (including pulmonary circulation) were performed in all patients. RESULTS: Mean gestational age of pPROM patients was 26 weeks. Parameters suggesting impaired cardiac function in fetuses from pPROM were: higher right ventricle Tei index (0.48 vs. 0.42 p<0.001), lower blood flow velocity in Ao z-score (0.14 vs. 0.84 p=0.005), lower cardiovascular profile score (CVPS), higher rate of tricuspid regurgitation (18.2 % vs. 4.4 % p=0.04) and pericardial effusion (32.6 vs. 0 %). Intrauterine infection was diagnosed in 18 patients (39 %). 4 (8.7 %) newborns met the criteria of early onset sepsis (EOS). HF was diagnosed in 9 newborns. In fetal echocardiographic examination HF group had shorter mitral valve inflow time and higher left ventricle Tei index (0.58 vs. 0.49 p=0.007). CONCLUSIONS: Worse cardiac function was observed in fetuses from pPROM compared to fetuses from uncomplicated pregnancies.

The Importance of Tissue Doppler Imaging and M-Mode Ultrasonography in Fetuses With Preterm Premature Rupture of Membranes: A Case-Control Study.

OBJECTIVE: To compare the cardiac functions of fetuses with preterm premature rupture of membranes (PPROM) between their control groups and investigate its relationship with perinatal outcomes. METHODS: This prospective study was conducted with 102 pregnant women. Pregnant women with PPROM were divided into two subgroups Group A, between 26 and 30 weeks, and Group B, between 30 and 34 weeks. A control group was formed by randomly including one healthy pregnant woman for each study patient. Sociodemographic, obstetric data, tissue Doppler imaging, and M-mode imaging results were compared. The relationship between echocardiographic parameters and perinatal outcomes was also investigated. RESULTS: Tricuspid annular plane systolic excursion (TAPSE), S', and ET' of systolic cardiac parameters were shortened in both groups compared with their controls. Diastolic function indicator E'/A', and global function indicator myocardial performance index' increased in both groups. Isovolumetric contraction time' did not change between groups. A correlation was found between myocardial performance index', and the length of neonatal intensive care unit stay in Group A and TAPSE and duration of respiratory support and length of neonatal intensive care unit stay in Group B. CONCLUSIONS: The fetal cardiac function seems to be affected by PPROM, and these changes are associated with neonatal outcomes. Therefore, administering fetal cardiac function evaluation in pregnancies complicated by PPROM may help physicians establish more appropriate clinical management protocols in this special population.

Multi-modal MRI reveals changes in placental function following preterm premature rupture of membranes.

PURPOSE: Preterm premature rupture of membranes complicates up to 40% of premature deliveries. Fetal infection may occur in the absence of maternal symptoms, delaying diagnosis and increasing morbidity and mortality. A noninvasive antenatal assessment of early signs of placental inflammation is therefore urgently required. METHODS: Sixteen women with preterm premature rupture of membranes < 34 weeks gestation and 60 women with uncomplicated pregnancies were prospectively recruited. A modified diffusion-weighted spin-echo single shot EPI sequence with a diffusion preparation acquiring 264 unique parameter combinations in < 9 min was obtained on a clinical 3 Tesla MRI scanner. The data was fitted to a 2-compartment T 2 * $$ {\mathrm{T}}_2^{\ast } $$ -intravoxel incoherent motion model comprising fast and slowly circulating fluid pools to obtain quantitative information on perfusion, density, and tissue composition. Z values were calculated, and correlation with time from between the rupture of membranes and the scan, gestational age at delivery, and time between scan and delivery assessed. RESULTS: Placental T 2 * $$ {\mathrm{T}}_2^{\ast } $$ was significantly reduced in preterm premature rupture of membranes, and the 2-compartmental model demonstrated that this decline is mainly linked to the perfusion component observed in the placental parenchyma. Multi-modal MRI measurement of placental function is linked to gestational age at delivery and time from membrane rupture. CONCLUSION: More complex models and data acquisition can potentially improve fitting of the underlying etiology of preterm birth compared with individual single-contrast models and contribute to additional insights in the future. This will need validation in larger cohorts. A multi-modal MRI acquisition between rupture of the membranes and delivery can be used to measure placental function and is linked to gestational age at delivery.

Role of cervical sliding sign in predicting preterm delivery in pregnancies complicated with preterm premature rupture of membranes.

OBJECTIVE: To investigate the effect of cervical sliding sign (CSS) to predict preterm delivery in patients with premature rupture of membranes. METHODS: This prospective cohort study included 88 pregnant women between 240/7 and 366/7  weeks of gestation who were complicated with preterm premature rupture of membranes (PPROM) between June 2020 and January 2022. We measured the cervical length (CL) and applied pressure to the anterior fornix of the cervix with the transvaginal probe to investigate the CSS, which is defined as the sliding of the anterior lip of the cervix on the posterior lip. RESULTS: The time between PPROM and delivery was significantly shorter in the CSS+ group (P < 0.001). Receiver operating characteristic curve analysis was performed for CSS with regard to predicting delivery within 7 days following PPROM (area under the curve, 0.749 [95% confidence interval, 0.642-0.857], P < 0.001). On logistic regression analysis, CL <25 mm increased the predictive accuracy of delivery within 7 days following PPROM 1.91-fold, and CSS increased the predictive accuracy of delivery within 7 days following PPROM 10.71-fold. CONCLUSION: CSS is an effective sonographic marker in predicting preterm delivery and provides better information of oncoming preterm delivery in patients with PPROM than CL measurement.

Magnetic resonance imaging of the supra-cervical fetal membrane detects an increased risk of prelabor rupture of membranes.

Objective: In 10% of term deliveries and 40% of preterm deliveries, the fetal membrane (FM) ruptures before labor. However, the ability to predict these cases of premature rupture of membranes (PROM) and preterm premature rupture of membranes (PPROM) is very limited. In this paper, our objective was to determine whether a prediction method based on T2 weighted magnetic resonance imaging (MRI) of the supra-cervical FM could predict PROM and PPROM. Methods: This prospective cohort study enrolled 77 women between the 28th and 37th weeks of gestation. Two indicators of fetal membrane defects, including prolapsed depth >5 mm and signal abnormalities, are investigated for our prediction. Fisher's exact test was used to determine whether prolapsed depth >5 mm and/or signal abnormalities were associated with PROM and PPROM. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for prolapsed depth >5 mm, signal abnormalities, and the combination of prolapsed depth >5 mm and signal abnormalities. Result: Among 12 women with PROM (5 preterm and 7 term, prior to labor onset), 9 had membrane prolapse >5 mm and 5 had FM signal abnormalities. Among 65 women with rupture of membranes at term, 2 had membrane prolapse >5 mm and 1 had signal abnormalities. By Fisher's exact test both indicators, membrane prolapse >5 mm and signal abnormalities, were associated with PROM (P<0.001, P<0.001) and PPROM (P=0.001, P<0.001). Additionally, membrane prolapse >5 mm, signal abnormalities, and the combination of the two indicators all demonstrated high specificity for predicting PROM (96.9%, 98.5%, and 100%, respectively) and PPROM (90.3%, 97.2%, and 100%, respectively). Conclusion: MRI can distinguish the supra-cervical fetal membrane in vivo and may be able to identify women at high risk of PPROM.

The use of functional placental magnetic resonance imaging for assessment of the placenta after prolonged preterm rupture of the membranes in vivo: A pilot study.

INTRODUCTION: Preterm prelabor rupture of membranes (PPROM) complicates 3% of pregnancies in the UK. Where delivery does not occur spontaneously, expectant management until 37 weeks of gestation is advocated, unless signs of maternal infection develop. However, clinical presentation of maternal infection can be a late sign and injurious fetal inflammatory responses may already have been activated. There is therefore a need for more sensitive markers to aid optimal timing of interventions. At present there is no non-invasive test in clinical practice to assess for infection in the fetal compartment and definitive diagnosis of chorioamnionitis is by histological assessment of the placenta after delivery. This study presents comprehensive functional placental magnetic resonance imaging (MRI) quantification, already used in other organ systems, to assess for infection/inflammation, in women with and without PPROM aiming to explore its use as a biomarker for inflammation within the feto-placental compartment in vivo. MATERIAL AND METHODS: Placental MRI scans were performed in a cohort of 12 women (with one having two scans) with PPROM before 34 weeks of gestation (selected because of their high risk of infection), and in a control group of 87 women. Functional placental assessment was performed with magnetic resonance techniques sensitive to changes in the microstructure (diffusion) and tissue composition (relaxometry), with quantification performed both over the entire organ and in regions of interest between the basal and chorionic plate. Placental histology was analyzed after delivery where available. RESULTS: Normative evolution of functional magnetic resonance biomarkers over gestation was studied. Cases of inflammation, as assessed by histological presence of chorioamnionitis, and umbilical cord vasculitis with or without funisitis, were associated with lower T2* (mean T2* at 30 weeks 50 ms compared with 58 ms in controls) and higher fractional anisotropy (mean at 30 weeks 0.55 compared with 0.45 in controls). These differences did not reach significance and there was substantial heterogeneity both in T2* and Apparent Diffusivitiy across the cohort. CONCLUSIONS: This first exploration of functional placental assessment in a cohort of women with PPROM demonstrates that functional placental MRI can reveal a range of placental changes associated with inflammatory processes. It is a promising tool to gain information and in the future to identify inflammation in vivo, and could therefore assist in improving optimal timing for interventions designed to prevent fetal injury.

Amniotic band syndrome in a monochorionic diamniotic twin pregnancy after rupture of the dividing membrane in the early second trimester: A case report.

BACKGROUND: Amniotic band syndrome is a rare phenomenon, but it can result in serious complications. We report herein our experience of amniotic band syndrome in a monochorionic diamniotic twin pregnancy where rupture of the dividing membrane occurred early in the second trimester. CASE PRESENTATION: A 29-year-old nulliparous woman was referred to us for management of her monochorionic diamniotic twin pregnancy at 10 weeks of gestation. When we were unable to identify a dividing membrane at 15 weeks of gestation using two-dimensional ultrasonography, we used three-dimensional ultrasonography to confirm its absence. Both modalities showed that the left arm of baby B was swollen and attached to a membranous structure originating from the placenta at 18 weeks of gestation. Tangled umbilical cords were noted on magnetic resonance imaging at 18 weeks of gestation. Emergency cesarean delivery was performed at 30 weeks of gestation because of the nonreassuring fetal status of baby A. The left arm of baby B had a constrictive ring with a skin defect. Both neonates had an uncomplicated postnatal course and were discharged around 2 months after delivery. CONCLUSIONS: Attention should be paid to the potential for amniotic band syndrome if rupture of the dividing membrane between twins is noted during early gestation.

Comparison of sonographic fetal weight estimation formulas in patients with preterm premature rupture of membranes.

BACKGROUND: Estimation of fetal weight (EFW) by ultrasound is useful in clinical decision-making. Numerous formulas for EFW have been published but have not been validated in pregnancies complicated by preterm premature rupture of membranes (PPROM). The purpose of this study is to compare the accuracy of EFW formulas in patients with PPROM, and to further evaluate the performance of the most commonly used formula - Hadlock IV. METHODS: A retrospective cohort study of women with singleton gestations and PPROM, admitted to a single tertiary center between 2005 and 2017 from 220/7-330/7 (n = 565). All women had an EFW within 14 days of delivery by standard biometry (biparietal diameter, head circumference, abdominal circumference and femur length). The accuracy of previously published 21 estimated EFW formulas was assessed by comparing the Pearson correlation with actual birth weight, and calculating the random error, systematic error, proportion of estimates within 10% of birth weight, and Euclidean distance. RESULTS: The mean gestational was 26.8 ± 2.4 weeks at admission, and 28.2 ± 2.6 weeks at delivery. Most formulas were strongly correlated with actual birth weight (r > 0.9 for 19/21 formulas). Mean systematic error was - 4.30% and mean random error was 14.5%. The highest performing formula, by the highest proportion of estimates and lowest Euclidean distance was Ott (1986), which uses abdominal and head circumferences, and femur length. However, there were minimal difference with all of the first 10 ranking formulas. The Pearson correlation coefficient for the Hadlock IV formula was strong at r = 0.935 (p < 0.001), with 319 (56.5%) of measurements falling within 10%, 408 (72.2%) within 15% and 455 (80.5%) within 20% of actual birth weight. This correlation was unaffected by gender (r = 0.936 for males, r = 0.932 for females, p < 0.001 for both) or by amniotic fluid level (r = 0.935 for mean vertical pocket < 2 cm, r = 0.943 for mean vertical pocket ≥2 cm, p < 0.001 for both). CONCLUSIONS: In women with singleton gestation and PPROM, the Ott (1986) formula for EFW was the most accurate, yet all of the top ten ranking formulas performed quite well. The commonly used Hadlock IV performed quite similarly to Ott's formula, and is acceptable to use in this specific setting.

Dynamic measurement of amnion thickness during loading by speckle pattern interferometry.

INTRODUCTION: In previous studies on the mechanical parameters of amnions (AM), there is a limitation due to the lack of an accurate thickness measurement, which is an important parameter for determining AM-specific mechanical properties. As a bottleneck, the characterization of the basic mechanical properties of AM are greatly restricted, even with the proposal of fracture criteria. METHOD: First, the initial thickness of the AM is estimated by the interpolated-volume-area method. Second, through combinations of our self-developed mini-biaxial tensile device with speckle pattern interferometry, this is the first time that researchers can accurately obtain the AM thickness at each transient moment in the process of loading. RESULTS: Based on the experimental results, an accurate stress-strain curve could be obtained. Two important mechanical parameters-the fracture energy density and amnion rupture modulus-could be extracted as 0.184±0.036MPa and 108.57±17.32MPa, respectively. The fracture energy density and amnion rupture modulus provide objective criteria and a scientific basis for the evaluation of AM rupture. DISCUSSION: The tensile stress-strain curve of a normal human amnion shows a distinct J-shape. This proves that the experimental results are basically reliable. Both important parameters --the fracture energy density and amnion rupture modulus, can be calculated from the stress-strain curve. Extracting these two parameters is critical for the evaluation and prediction of ROM, PROM and PPROM.

Antenatal thymus volumes in fetuses that delivered <32 weeks' gestation: An MRI pilot study.

INTRODUCTION: Infection and inflammation have been implicated in the etiology and subsequent morbidity associated with preterm birth. At present, there are no tests to assess for fetal compartment infection. The thymus, a gland integral in the fetal immune system, has been shown to involute in animal models of antenatal infection, but its response in human fetuses has not been studied. This study aims: (a) to generate magnetic resonance imaging (MRI) -derived fetal thymus volumes standardized for fetal weight; (b) to compare standardized thymus volumes from fetuses that delivered before 32 weeks of gestation with fetuses that subsequently deliver at term; (c) to assess thymus size as a predictor of preterm birth; and (d) to correlate the presence of chorioamnionitis and funisitis at delivery with thymic volumes in utero in fetuses that subsequently deliver preterm. MATERIAL AND METHODS: Women at high-risk of preterm birth at 20-32 weeks of gestation were recruited. A control group was obtained from existing data sets acquired as part of three research studies. A fetal MRI was performed on a 1.5T or 3T MRI scanner: T2 weighted images were obtained of the entire uterine content and specifically the fetal thorax. A slice-to-volume registration method was used for reconstruction of three-dimensional images of the thorax. Thymus segmentations were performed manually. Body volumes were calculated by manual segmentation and thymus:body volume ratios were generated. Comparison of groups was performed using multiple regression analysis. Normal ranges were created for thymus volume and thymus:body volume ratios using the control data. Receiver operating curves (ROC) curves were generated for thymus:body volume ratio and gestation-adjusted thymus volume centiles as predictors of preterm birth. Placental histology was analyzed where available from pregnancies that delivered very preterm and the presence of chorioamnionitis/funisitis was noted. RESULTS: Normative ranges were created for thymus volume, and thymus volume was standardized for fetal size from fetuses that subsequently delivered at term, but were imaged at 20-32 weeks of gestation. Image data sets from 16 women that delivered <32 weeks of gestation (ten with ruptured membranes and six with intact membranes) and 80 control women that delivered >37 weeks were included. Mean gestation at MRI of the study group was 28+4  weeks (SD 3.2) and for the control group was 25+5  weeks (SD 2.4). Both absolute fetal thymus volumes and thymus:body volume ratios were smaller in fetuses that delivered preterm (P < .001). Of the 16 fetuses that delivered preterm, 13 had placental histology, 11 had chorioamnionitis, and 9 had funisitis. The strongest predictors of prematurity were the thymus volume Z-score and thymus:body volume ratio Z-score (ROC areas 0.915 and 0.870, respectively). CONCLUSIONS: We have produced MRI-derived normal ranges for fetal thymus and thymus:body volume ratios between 20 and 32 weeks of gestation. Fetuses that deliver very preterm had reduced thymus volumes when standardized for fetal size. A reduced thymus volume was also a predictor of spontaneous preterm delivery. Thymus volume may be a suitable marker of the fetal inflammatory response, although further work is needed to assess this, increasing the sample size to correlate the extent of chorioamnionitis with thymus size.

Branch pulmonary artery Doppler parameters predict early survival-non-survival in premature rupture of membranes.

BACKGROUND: Preterm premature rupture of membrane (pPROM) leads to high neonatal mortality due in part to severe lung hypoplasia (LH). In other causes of severe LH, fetal echo-based parameters of smaller branch pulmonary arteries (PA), shorter acceleration to ejection time ratio (AT/ET), increased peak early diastolic reverse flow (PEDRF), and higher pulsatility index (PI) are predictive of worse neonatal outcome. We sought to determine whether these parameters correlated with worse clinical outcome in pPROM. METHODS: Twenty-five pregnancies complicated by pPROM were prospectively recruited. Fetal echocardiography was used to evaluate branch PA diameters and Doppler parameters. Clinical records were reviewed. Fetal echo findings were compared between early survivors and non-survivors. RESULTS: Of 25 pPROM cases, 5 had early neonatal demise (≤3 days) due to respiratory insufficiency. While gestational age at pPROM, fetal echo, and at birth did not differ, amniotic fluid index (AFI) was significantly lower in early non-survivors compared to survivors (p = 0.05). No difference was observed in PA diameter, PEDRF, or PI; however, branch PA AT/ET was significantly shorter in non-survivors (right PA median 0.12 (0.11-0.16) vs. survivors 0.17 (0.14-0.21), p = 0.046 and left PA 0.12 (0.09-0.13) vs. survivors 0.16 (0.11-0.21), p = 0.042). CONCLUSIONS: We found a significantly lower AFI and shorter fetal bilateral branch PA AT/ET to be associated with early neonatal demise following pPROM.

Assessment of Fetal Lung Maturity Using Quantitative Ultrasound Analysis in Patients with Prelabor Rupture of Membranes.

INTRODUCTION: Prelabor rupture of membranes (PROM) is a frequent clinical situation, and the decision about the best time for delivery remains controversial, mainly due to the risk of neonatal respiratory morbidity (NRM). Assessment of fetal lung maturity using ultrasound, a safe method and widely used in current obstetrical practice, could change this scenario. This study was designed to evaluate the ability of quantitative ultrasound method QuantusFLM® to predict NRM in patients with PROM and whether maternal BMI, gestational age, occurrence of the disease, and presence of oligohydramnios influenced the performance. METHODS: Patients with singleton gestations, diagnosis of PROM, and gestational age between 24 and 38 weeks and 6 days were included. Fetal lung image was acquired by ultrasound within 48 h prior to delivery and analyzed by QuantusFLM®. The results were then paired with neonatal outcomes to assess the program's ability to predict the NRM in this specific group. A logistic regression model was created to analyze factors that could affect the test results. RESULTS: Fifty-four patients were included. Mean maternal BMI was 28.99 kg/m2, and in 25 patients (46.2%), oligohydramnios was observed at the time of examination. Mean gestational age at delivery was 35 weeks and 4 days, and the NRM prevalence was of 18.5%. QuantusFLM® predicted NRM with a 60% sensitivity, 79.5% specificity, 40% positive predictive value, 89.7% negative predictive value, and 75.6% accuracy. Maternal BMI, disease occurrence, presence of oligohydramnios, and gestational age did not interfere with the evaluation. CONCLUSION: This study demonstrates a good accuracy of QuantusFLM® as a NRM predictor in patients with PROM, with particular reliability in identifying that pulmonary maturity has already occurred.

Membrane Separation and Perinatal Outcomes after Laser Treatment for Twin-Twin Transfusion Syndrome.

INTRODUCTION: Postoperative membrane separation is a complication of selective laser photocoagulation of communicating vessels (SLPCV) for the treatment of twin-twin transfusion syndrome (TTTS). OBJECTIVE: The aim of this work was to determine whether a quantitative grading system of membrane separation following SLPCV was associated with preterm premature rupture of membranes (PPROM) and preterm delivery (PTD). METHODS: Patients with membrane separation after SLPCV on postoperative day 1 were stratified into greatest width of separation <1 cm (Group A) or ≥1 cm (Group B) and compared to patients without separation by the following outcomes: PPROM ≤21 postoperative days, PTD <28 gestational weeks, and PTD <32 gestational weeks. RESULTS: Of 654 patients, 123 (18.8%) had membrane separation. Of these, 120 patients were eligible for study and divided into Groups A (n = 91) and B (n = 29). Multiple logistic regression analysis yielded associations with PPROM ≤21 days for Groups B (OR 8.60, 95% CI 3.38-21.90, p < 0.0001) and A (OR 2.39, 95% CI 1.05-5.40, p = 0.0369) compared to those without membrane separation. In similar models, Group B was associated with PTD <32 weeks (OR 2.41, 95% CI 1.10-5.28, p = 0.0274). CONCLUSION: Postoperative membrane separation was associated with an increased risk of PPROM ≤21 days. Membrane separation ≥1 cm had a higher risk of PTD <32 weeks.

Utility of ultrasound assessment in management of pregnancies with preterm prelabor rupture of membranes.

OBJECTIVES: To evaluate the utility of ultrasound markers in the management of pregnancies complicated by preterm prelabor rupture of membranes (PPROM) between 23 + 0 and 33 + 6 weeks' gestation, and to assess the ability of ultrasound markers to predict adverse neonatal outcomes. METHODS: This was a retrospective cohort study of all patients with PPROM between 23 + 0 and 33 + 6 weeks' gestation and latency period (PPROM to delivery) > 48 h, who delivered before 34 weeks' gestation at a tertiary referral center between 2005 and 2017. All patients underwent a non-stress test daily and an ultrasound scan twice a week for assessment of amniotic fluid volume, biophysical profile (BPP) and umbilical artery (UA) pulsatility index (PI). In patients with suspected fetal growth restriction, fetal middle cerebral artery (MCA)-PI was also assessed and the cerebroplacental ratio (CPR) calculated. The last ultrasound examination performed prior to delivery was analyzed. We compared the characteristics and outcomes between women who were delivered owing to clinical suspicion of chorioamnionitis and those who were not delivered for this indication. The primary objective was to evaluate the utility of ultrasound in the management of patients with PPROM. The secondary objective was to assess the diagnostic performance of ultrasound markers (BPP score < 6, oligohydramnios, UA-PI > 95th percentile, MCA-PI < 5th percentile, CPR < 5th percentile) for the prediction of composite adverse neonatal outcome, which was defined as the presence of one or more of: perinatal death, respiratory distress syndrome, periventricular leukomalacia, intraventricular hemorrhage Grade 3 or 4, necrotizing enterocolitis, hypoxic ischemic encephalopathy, neonatal sepsis or neonatal seizures. RESULTS: A total of 504 women were included in the study, comprising 120 with suspected chorioamnionitis and 384 without. Women with suspected chorioamnionitis, compared with those without, were less likely to be nulliparous (34.2% vs 45.3%; P = 0.03) and more likely to have fever (50.8% vs 2.6%; P < 0.001) and be delivered by Cesarean section (69.2% vs 42.4%; P < 0.001), mainly owing to a history of previous Cesarean section (18.3% vs 9.1%; P = 0.005) and to having non-reassuring fetal heart rate tracings (32.5% vs 14.6%; P < 0.001). No significant differences were found between the two groups with regard to the median amniotic fluid volume, overall BPP score, BPP score < 6, MCA-PI or CPR. Median UA-PI was slightly higher in the suspected-chorioamnionitis group, yet the incidence of UA-PI > 95th percentile was similar between the two groups. There was a higher incidence of composite adverse neonatal outcome in the group with suspected chorioamnionitis than in the group without (78.3% vs 64.3%, respectively; P = 0.004). However, on logistic regression analysis, none of the ultrasound markers evaluated was found to be associated with chorioamnionitis or composite adverse neonatal outcome, and they all had a poor diagnostic performance for the prediction of chorioamnionitis and composite adverse neonatal outcome. CONCLUSIONS: Commonly used ultrasound markers in pregnancies complicated by PPROM were similar between women delivered for suspected chorioamnionitis and those delivered for other indications, and performed poorly in predicting composite adverse neonatal outcome. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

The use of antenatal fetal magnetic resonance imaging in the assessment of patients at high risk of preterm birth.

Preterm birth, defined as birth occurring prior to 37 weeks gestation is a common obstetric complication affecting 8% of pregnancies and is associated with significant morbidity and mortality. Infection/inflammation has been implicated in both the aetiology of preterm birth itself and associated neonatal pulmonary and neurological morbidity. Treatment options are currently limited to prolongation of the pregnancy using cervical cerclage, pessaries or progesterone or administration of drugs including steroids to promote lung maturity and neuroprotective agents such as magnesium sulphate, the timing of which are highly critical. Although delivery is expedited in cases of overt infection, decisions regarding timing and mode of delivery in subclinical infection are not clear-cut. This review aims to explore the use of magnetic resonance imaging (MRI) in the antenatal assessment of pregnancies at high risk of preterm birth and its potential to guide management decisions in the future.

Contribution of Amniotic Fluid along Gestation to the Prediction of Perinatal Mortality in Women with Early Preterm Premature Rupture of Membranes.

INTRODUCTION: To evaluate the largest vertical pocket (LVP) of amniotic fluid as a time-dependent factor to predict perinatal mortality in women with early preterm premature rupture of membranes (EPPROM). MATERIAL AND METHODS: Observational cohort study of singleton pregnancies with EPPROM <24 weeks. Termination of pregnancy (TOP) was considered if the LVP was <2 cm at 7 days. The maternal and neonatal characteristics of ongoing pregnancies were recorded. Prediction of perinatal mortality was estimated based on the influence of the LVP as a time-dependent factor after adjustment for maternal age, prior invasive procedure, and gestational age at EPPROM. RESULTS: Of 104 women, 39 requested TOP. Neonatal survival to discharge was 40%, increasing to 74% if pregnancies achieved 24 weeks. LVP at admission <1 cm, latency to delivery, and gestational age at delivery were independent predictors of perinatal mortality. When evaluating the LVP at different time points of gestation, the highest perinatal mortality risk was established at 2 weeks (odds ratio 14.67, p < 0.001) after membrane rupture, being 5.75 (p = 0.05) the week after and 10.93 (p = 0.037) beyond 2 weeks of EPPROM. DISCUSSION: When LVP measurement, gestational age at EPPROM, maternal age, and prior invasive procedure were considered, we found that the worst prognosis related to perinatal mortality was at 2 weeks after EPPROM.

Transvaginal sonographic assessment of cervix in prediction of admission to delivery interval in preterm premature rupture of membranes.

OBJECTIVE: To assess the usefulness of cervical parameters measured by transvaginal sonography, that is, cervical length and posterior cervical angle, in predicting the admission to delivery interval in women with preterm rupture of membranes. METHODS: This prospective study was conducted in a tertiary care centre in South India. Women with preterm premature rupture of membranes at 28-34 weeks, confirmed clinically, not in labour and presenting within 24 hours to hospital were included. We evaluated the relationship between latency interval and transvaginal sonographic parameters (cervical length and posterior cervical angle), parity, age, Amniotic Fluid Index (AFI), total leucocyte count at admission using Cox proportional hazards model. RESULTS: Mean time interval between the membrane rupture and delivery was 96.9 h. Majority of the women (63.8% (n = 51)) delivered within 48 hours. Transvaginal sonographic cervical length was not shown to be associated with latency interval (p = .559), whereas. Posterior cervical angle was shown to be significantly associated with the interval (hazard ratio 1.03, 95%CI: 1.01-1.06; p = .003) Conclusions: Posterior cervical angle assessment using transvaginal sonography is an useful tool in the assessing the latency interval in women with preterm premature rupture of membranes (PPROM). This could help in counselling and planning timely referral to centres with neonatal facilities.

Chorioamniotic Membrane Separation after Fetoscopic Laser Photocoagulation.

INTRODUCTION: This study aimed to investigate the risk factors, incidence, and influence on the perinatal outcome of chorioamniotic membrane separation (CMS) after fetoscopic laser photocoagulation (FLP). MATERIAL AND METHODS: This retrospective study included 312 women who underwent FLP for twin-to-twin transfusion syndrome (TTTS). Clinical records were used to review obstetrical examinations, complications, operative data, ultrasonographic findings, and perinatal and neonatal follow-up data in all patients. RESULTS: A total of 260 cases of TTTS were analyzed. The incidence of CMS was 12.7% (33 cases). The only independent risk factor of CMS was performing FLP before 20 weeks of gestational age (GA) (odds ratio = 3.38 [1.44-7.93], p = 0.005). Concerning perinatal outcome, CMS was only related with increased risk of premature rupture of membranes (PROM) before 32 weeks (33.3 vs. 13.9%, p = 0.005), with no differences in GA at delivery and survival rate. DISCUSSION: In our cohort, the incidence of CMS after FLP was approximately 13%, with surgery before 20 weeks being the only risk factor identified. Although in our population CMS did not worsen perinatal outcome in terms of preterm delivery or survival, the preterm PROM rate was increased and this should be considered for the patients' management.

Computer modeling tools to understand the causes of preterm birth.

The mechanical integrity of the soft tissue structures supporting the fetus may play a role in maintaining a healthy pregnancy and triggering the onset of labor. Currently, the level of mechanical loading on the uterus, cervix, and fetal membranes during pregnancy is unknown, and it is hypothesized that the over-stretch of these tissues contributes to the premature onset of contractility, tissue remodeling, and membrane rupture, leading to preterm birth. The purpose of this review article is to introduce and discuss engineering analysis tools to evaluate and predict the mechanical loads on the uterus, cervix, and fetal membranes. Here we will explore the potential of using computational biomechanics and finite element analysis to study the causes of preterm birth and to develop a diagnostic tool that can predict gestational outcome. We will define engineering terms and identify the potential engineering variables that could be used to signal an abnormal pregnancy. We will discuss the translational ability of computational models for the better management of clinical patients. We will also discuss the process of model validation and the limitations of these models. We will explore how we can borrow from parallel engineering fields to push the boundary of patient care so that we can work toward eliminating preterm birth.