Malmström vacuum or Kielland forceps: which causes more damage to pelvic floor?

OBJECTIVE: To determine whether differences exist in the rate of levator ani muscle (LAM) avulsion between women who had undergone either Malmström vacuum delivery (MVD) or Kielland forceps delivery (KFD), allowing for potential confounding factors. METHODS: This was a prospective observational study of nulliparous women undergoing instrumental delivery using Malmström vacuum extractor or Kielland forceps, at two hospital centers in Spain. Fetal head position (anterior, posterior or transverse) and fetal head station (low or mid) were assessed by ultrasound and digital examination, respectively. Avulsion was defined on tomographic ultrasound imaging as an abnormal insertion of the LAM in the three central slices from the plane of minimal hiatal dimensions. RESULTS: In total, 414 patients were included in the study (212 MVD and 202 KFD). We observed a higher rate of LAM avulsion in the KFD group (KFD 49.5% vs MVD 32.5%; P = 0.001). When the results were evaluated according to fetal head position and station, we observed no differences in LAM avulsion. The crude odds ratio (OR) for the difference in avulsion between women in the KFD and MVD groups was 2.03 (95% CI, 1.36-3.03). However, when adjusted for duration of second stage of labor, fetal head circumference and fetal head station, the OR was no longer statistically significant (OR, 2.14 (95% CI, 0.95-4.85); P = 0.068). CONCLUSION: When potential confounding factors are taken into account, the rate of LAM avulsion does not differ between women according to whether they have undergone KFD or MVD. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Resolution of hydrops fetalis caused by atrioventricular block: good postnatal evolution with terbutaline treatment.

INTRODUCTION: Complete atrioventricular block (CAVB) is rarely seen, as it occurs in only 1:11 000 to 1:20 000 newborns. There is a serious risk of mortality in CAVB, mainly in those cases associated with hydrops, fetal cardiac frequency ≤ 55 beats/minute, and premature delivery. CASE REPORT: Case of complete atrioventricular block with a poor prognosis (hydrops fetalis and foetal cardiac frequency < 5 beats/minute) caused by anti-La and anti-Ro antibodies. Intrauterine symptoms improved after treatment with terbutaline, permit- ting foetal viability and successful postnatal treatment with a cardiac pacemaker. DISCUSSION: In case of complete atrioventricular block of cause autoimmune with poor prognosis should be treated with positive inotropic drugs, anticholinergics or b-mimetic in the attempt to maintain adequate ventricular frequency, and thus prevent hydrops fetalis from occurring.

Online learning for 3D/4D transperineal ultrasound of the pelvic floor.

Introduction. To evaluate the feasibility of an online learning process for performing and analyzing 3D/4D transperineal ultrasound imaging of the pelvic floor.Materials and methods: A prospective study was conducted with 20 patients. The learning process of three inexperienced examiners (IEs) performing and analyzing 3D/4D transperineal ultrasound volumes was evaluated. The learning process for the IEs was conducted online by an expert examiner (EE); no face-to-face tutoring was provided. The IEs' competency and analysis of the volumes were estimated using the intraclass correlation coefficient (ICC).Results: The interobserver analysis of the levator hiatus dimensions provided by the EE and those from each IE (for the 20 studied cases) had ICCs ranging from 0.81 to 0.96. The dimensions of the levator hiatus performed by the IEs for the first 10 patients showed ICCs ranging from 0.55 to 0.9. However, when the IEs proceeded with the next 10 patients, they obtained ICCs ranging from 0.81 to 0.96.Conclusions: Conducting 3D/4D transperineal ultrasound of the pelvic floor is a technique that can be learned online in a short period of time. A learning programme designed specifically for this purpose provides excellent reliability.Key Message: Conducting 3D/4D transperineal ultrasound of the pelvic floor is a technique that can be learned online in a short period of time.

Levator ani muscle injuries associated with vaginal vacuum assisted delivery determined by 3/4D transperineal ultrasound.

OBJECTIVES: To determine the rate of pelvic floor trauma, levator ani muscle (LAM) avulsion as well as the mean difference in levator hiatus area, after normal vaginal deliveries (NVD) and vacuum assisted deliveries (VD), assessed with three-dimensional transperineal ultrasound (3D-TpUS). MATERIALS AND METHODS: Prospective observational study with 151 nulliparous women with NVD or VD at ≥37 weeks between 9-2012 and 6-2013. 3D-TpUS was performed six months after every patient's delivery, during which LAM, anteroposterior diameter, transverse diameter and levator hiatus area were assessed. RESULTS: A total of 146 nulliparous were studied, comprising 73 NVD and 73 VD. No differences in obstetric, intrapartum or neonatal characteristics were observed between study groups, with the following exceptions: maternal age (28.1 ± 5.4 versus 30.4 ± 5.5; p = 0.008, OR = 1.1) and episiotomy rate (35.6% versus 97.3%; p = 0.011, OR = 4.3). LAM avulsion rate was 9.6% in NVD versus 34.2% in VD (p = 0.001, OR 3.99), while levator hiatus area at rest was 16.5 ± 3.2 versus 18.2 ± 3.9 (p = 0.016). CONCLUSIONS: Vacuum assisted deliveries present a higher rate of LAM avulsion, as well as a greater increase in levator hiatal area than in NVD.