Hormonal and natural contraceptives: a review on efficacy and risks of different methods for an informed choice.

The debate about contraception has become increasingly important as more and more people seek safe and effective contraception. More than 1 billion women of reproductive age worldwide need a method of family planning, and wellbeing, socio-economic status, culture, religion and more influence the reasons why a woman may ask for contraception. Different contraceptive methods exist, ranging from 'natural methods' (fertility awareness-based methods - FABMs) to barrier methods and hormonal contraceptives (HCs). Each method works on a different principle, with different effectiveness.FABMs and HCs are usually pitted against each other, although it's difficult to really compare them. FABMs are a valid alternative for women who cannot or do not want to use hormone therapy, although they may have a high failure rate if not used appropriately and require specific training. HCs are commonly used to address various clinical situations, although concerns about their possible side effects are still widespread. However, many data show that the appropriate use of HC has a low rate of adverse events, mainly related to personal predisposition.The aim of this review is to summarize the information on the efficacy and safety of FABMs and HCs to help clinicians and women choose the best contraceptive method for their needs.

Correlation between Subpubic Arch Angle and Mode of Delivery in Large-for-Gestational-Age Fetuses.

OBJECTIVES: A narrow subpubic arch angle (SPA) has been associated with a higher risk of operative delivery and prolonged labor. The aim of this study was to evaluate the correlation between SPA and labor outcome in a cohort of women delivering a large-for-gestational-age (LGA) fetus. METHODS: An observational study involving two Italian tertiary centers (Parma and Rome) was carried out. Nulliparous women referred to the antepartum clinic between 35 and 39 weeks due to an increased risk of having an LGA fetus at birth were prospectively selected for the study purpose. Within the study cohort, SPA measurements were obtained by means of transperineal 3D ultrasound. Elective caesarean section and birth weight below 3,750 g represented exclusion criteria. In the final study group, SPA values were compared between the patients who underwent spontaneous vaginal delivery (SVD) and those who were submitted to unplanned obstetric intervention (UOI) due to prolonged or arrested labor (vacuum delivery or caesarean section). RESULTS: Overall, 129 women were included, and the mean birthweight of the neonates was 4,066 ± 263.03 g. SVD occurred in 63 patients (48.8%), whereas UOI due to prolonged or arrested labor was performed in 66 (51.2%), including 21 cases of vacuum delivery and 45 caesarean sections. The SPA was significantly smaller among women who underwent UOI than in those who achieved SVD (107.9 ± 13.4 vs. 120.7 ± 9.4°, p < 0.001). Furthermore, SPA width was inversely correlated with labor length (p < 0.001). Multivariable logistic regression analysis showed that a smaller SPA (OR 1.091, 95% CI 1.051-1.134, p < 0.001) and an increased birthweight (OR 1.002, 95% CI 1.000-1.004, p = 0.037) were independent risk factors for operative delivery. CONCLUSION: SPA measurement before labor is helpful in predicting the risk of operative delivery due to prolonged or arrested labor among nulliparous women delivering LGA fetuses.

Fetal head circumference and subpubic angle are independent risk factors for unplanned cesarean and operative delivery.

INTRODUCTION: The aim of this study was to ascertain whether combined ultrasound assessment of fetal head circumference (HC) and maternal subpubic angle (SPA) prior to the onset of labor may predict the likelihood of an unplanned operative delivery (UOD) in nulliparous women at term. MATERIAL AND METHODS: Prospective cohort study of singleton pregnancies in cephalic presentation. Pregnancies experiencing UOD secondary to fetal distress were excluded. HC was assessed transabdominally and SPA values were obtained from a reconstructed coronal plane on three-dimensional (3D) ultrasound performed translabially at 36-38 weeks of gestation. Maternal characteristics, HC expressed as multiple of median, and SPA were compared according to the mode of delivery. Logistic regression and receiver operating characteristics curve analyses were used to analyze the data. RESULTS: 597 pregnancies were included in the study. Spontaneous vaginal delivery occurred in 70.2% of the cases and UOD was required in 29.8%. There was no difference in pregnancy characteristics and birthweight between women who had a spontaneous vaginal birth compared with UOD. The HC multiple of median was larger (1.00 ± 0.02 vs. 1.03 ± 0.02, p ≤ 0.0001), whereas SPA was narrower in the UOD group (124.02 ± 13.64 vs. 102.61 ± 16.13, p ≤ 0.0001). At logistic regression, SPA (OR 0.91, 95% CI 0.89-0.93), HC multiple of median (OR 1.13, 95% CI 1.09-1.17) and maternal height (OR 0.95, 95% CI 0.92-0.99) were independently associated with UOD. When combined, the diagnostic accuracy of a predictive model integrating HC, SPA and maternal height was highly predictive of UOD with an area under the curve of 0.904 (95% CI 0.88-0.93). CONCLUSIONS: Ultrasound assessment of fetal HC and maternal SPA after 36 weeks of gestation can identify a subset of women at higher risk of UOD during labor, for whom early planned delivery might be beneficial.

Computerised analysis of antepartum foetal heart parameters: New reference ranges.

We selected 4012 cCTG records (one trace for each patient) performed in healthy pregnancies from 30th to 42nd gestational week using foetal heart rate (FHR), short-term variability (STV), long-term irregularity (LTI), Delta, approximate entropy (ApEn), spectral components as low frequency (LF), median frequency (MF), high frequency (HF) and LF/(HF + MF) ratio were analysed. Reference nomograms were created and sensitivity and specificity for the prediction of foetal compromise were calculated which were 90% and 89%, respectively. Changes of cCTG parameters according to gestational week were evaluated: FHR (r = -.65) and LF (r = -.87) showed a statistically significant reduction (p < .05) with gestational age. STV (r = .59), LTI (r = .69), Delta (r = .67), and MF (r = .88) showed a statistically significant increase (p < .05) with gestational age. In contrast, for ApEn (r = -.098), HF (r = .14) and LF/(HF + MF) ratio (r = -.47) a non-statistically significant change was found (p > .05). The identification of reference ranges for cCTG indexes in according to gestational age could provide a more objective examination of cCTG trace.

5D CNS+ Software for Automatically Imaging Axial, Sagittal, and Coronal Planes of Normal and Abnormal Second-Trimester Fetal Brains.

The purpose of this study was to test new 5D CNS+ software (Samsung Medison Co, Ltd, Seoul, Korea), which is designed to image axial, sagittal, and coronal planes of the fetal brain from volumes obtained by 3-dimensional sonography. The study consisted of 2 different steps. First in a prospective study, 3-dimensional fetal brain volumes were acquired in 183 normal consecutive singleton pregnancies undergoing routine sonographic examinations at 18 to 24 weeks' gestation. The 5D CNS+ software was applied, and the percentage of adequate visualization of brain diagnostic planes was evaluated by 2 independent observers. In the second step, the software was also tested in 22 fetuses with cerebral anomalies. In 180 of 183 fetuses (98.4%), 5D CNS+ successfully reconstructed all of the diagnostic planes. Using the software on healthy fetuses, the observers acknowledged the presence of diagnostic images with visualization rates ranging from 97.7% to 99.4% for axial planes, 94.4% to 97.7% for sagittal planes, and 92.2% to 97.2% for coronal planes. The Cohen κ coefficient was analyzed to evaluate the agreement rates between the observers and resulted in values of 0.96 or greater for axial planes, 0.90 or greater for sagittal planes, and 0.89 or greater for coronal planes. All 22 fetuses with brain anomalies were identified among a series that also included healthy fetuses, and in 21 of the 22 cases, a correct diagnosis was made. 5D CNS+ was efficient in successfully imaging standard axial, sagittal, and coronal planes of the fetal brain. This approach may simplify the examination of the fetal central nervous system and reduce operator dependency.

Ultrasonographic assessment of cervical length in pregnancies scheduled for a cesarean delivery: prediction of early spontaneous onset of labor.

AIM: To investigate whether the cervical length measured by transvaginal ultrasound at 35 to 36 weeks of gestation is predictive of spontaneous early onset of labor in pregnancies scheduled for elective cesarean section (CS). STUDY DESIGN: This was a prospective observational study on 167 women scheduled for elective CS at 39 weeks of gestation. The cervical length was measured ultrasonographycally at 35 to 36 weeks of gestation and the pregnancies characteristics were recorded. The presence or absence of spontaneous onset of labor before the time scheduled for elective CS was related to cervical length and pregnancies characteristics. RESULTS: Of the 167 pregnancies enrolled, 25 (14.97%) underwent early spontaneous onset of labor before the time scheduled for the elective CS. The cervical length was significantly shorter in these women when compared with those delivering with an elective CS (21 vs. 30 mm z=5.49 P<0.0001). The presence of ≥2 previous CS as an indicator for elective CS resulted a significant predictor of early onset of labor in univariate analysis (P=0.01). Multivariate logistic regression analysis showed that cervical length (adjusted odds ratio 1.40; 95% confidence interval (CI) 1.22-1.61; P≤0.0001) was the only predictor for the early onset of labor. The area under the receiver-operating characteristics curve for the prediction of early onset of labor was 0.844 (95% CI 0.738-0.950) for cervical length as test variable. Kaplan-Meier analysis demonstrated that a cervical length <24 mm was significantly associated with a short time interval to delivery (log rank test χ2=99,98; P≤0.0001). CONCLUSION: Cervical length at 35-36 weeks of gestation provides information about the likelihood of spontaneous early onset of labor in pregnancies scheduled for CS and may be useful in individualizing the gestational age for elective CS.

Viewing rate and reference ranges for papillary muscle areas of the fetal heart using four-dimensional ultrasound in the rendering mode.

OBJECTIVES: The aims of this study were to assess the viewing rate and determine reference ranges ​​for the papillary muscle areas in the fetal atrio-ventricular valves using four-dimensional (4D) ultrasound and spatio-temporal image correlation (STIC) in the rendering mode. METHODS: This cross-sectional prospective study included 310 4D STIC volume data sets of normal fetuses between 18 weeks 0 day and 34 weeks 0 day of gestation. The papillary muscles were antero-lateral (MPAL) and postero-medial (MPPM) to the mitral valve and antero-superior (MPAS), inferior (MPI) and septal (MPS) to the tricuspid valve. Polynomial regressions were built to determine the reference ranges, and adjustments were made using the determination coefficient (R(2) ). To assess inter-observer reproducibility, the intra-class correlation coefficient (ICC) was used. RESULTS: Identification of the papillary muscles was possible in 89.3% patients. The best-fit regression equations between papillary muscle areas and gestational age were second degree. The inter-observer reproducibility was good (ICC: 0.98 to MPAS, 0.97 to MPI, 0.98 to MPS, 0.98 to MPAL and 0.97 to MPPM). CONCLUSIONS: Identification of the papillary muscles of the fetal valves was possible in most of the 4D STIC volume data sets, enabling the determination of reference ranges using the rendering mode. The reference ranges ​​for the papillary muscle areas were determined.

First trimester placental volume and three dimensional power doppler ultrasonography in type I diabetic pregnancies.

OBJECTIVE: This study aimed to investigate the placental volume and three dimensional (3D) power Doppler vascularization in type I diabetic pregnancies during the first trimester METHODS: 3D-power Doppler ultrasonography of the placenta was performed at 11+0-13+6 weeks in 32 pregnancies complicated by type I diabetes. Placental volume, vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were calculated using a standardized setting. RESULTS: In nine pregnancies, a poor first trimester glycemic control was present as expressed by HbA1c levels ≥ 7%, whereas in the remaining 23 mothers, the HbA1c concentrations were <7%. No differences were found in the placental volumes of diabetic mothers when compared with reference limits. 3D Doppler placental vascular indices were significantly higher in diabetic mothers (VI delta value 0.99, p=0.0012; FI delta value 0.64, p=0.0008; VFI delta value 1.28, p=0.0039) when compared with reference limits. Pregnancies with HbA1c ≥ 7% exhibited higher placental vascular indices when compared with diabetic mothers with better glycemic control. CONCLUSIONS: In type I diabetic mothers, placental vascular indices are increased and these modifications are more evident in pregnancies with poor first trimester glycemic control.

Assessment of corpus callosum biometric measurements at 18 to 32 weeks' gestation by 3-dimensional sonography.

OBJECTIVES: The purposes of this study were to construct reference limits for corpus callosum dimensions measured on images reconstructed from 3-dimensional (3D) sonography and to evaluate the reproducibility of these measurements. METHODS: Three-dimensional sonographic volumes were acquired transabdominally from an axial view of the head in 361 fetuses cross-sectionally studied at 18 to 32 weeks' gestation. Offline analysis of the fetal brain midsagittal plane was used to evaluate the length and area of the corpus callosum and corpus callosum-cavum septi pellucidi complex. The agreement between 2-dimensional (2D) and 3D measurements as well as the interobserver variability in 3D measurements were assessed by interclass correlation coefficients (ICCs). RESULTS: Adequate visualization of the midsagittal plane was obtained in 98.1% of the fetuses. A clear distinction between the corpus callosum and cavum septi pellucidi was obtained in 35.7% of the fetuses, whereas in the remaining cases, the corpus callosum-cavum septi pellucidi complex was visualized as a single echogenic structure. The corpus callosum-cavum septi pellucidi complex length (r = 0.806; P < .0001), corpus callosum-cavum septi pellucidi complex area (r = 0.920; P < .0001), and corpus callosum area (r = 0.713; P < .0001) showed a significant linear growth with gestation. A good agreement was found between measurements from both 2D and 3D sonographic views (corpus callosum length ICC, 0.916) as well as between measurements obtained by different observers (corpus callosum-cavum septi pellucidi complex length ICC, 0.936; corpus callosum-cavum septi pellucidi complex area ICC, 0.931). CONCLUSIONS: Measurements of the corpus callosum and cavum septi pellucidi can be obtained from the midsagittal plane of the fetal brain reconstructed from 3D volumes acquired transabdominally. The constructed nomograms may facilitate the diagnosis of corpus callosum abnormalities.

Satisfactory rate of postprocessing visualization of standard fetal cardiac views from 4-dimensional cardiac volumes acquired during routine ultrasound practice by experienced sonographers in peripheral centers.

The aim of this study was to evaluate the feasibility of visualizing standard cardiac views from 4-dimensional (4D) cardiac volumes obtained at ultrasound facilities with no specific experience in fetal echocardiography. Five sonographers prospectively recorded 4D cardiac volumes starting from the 4-chamber view on 500 consecutive pregnancies at 19 to 24 weeks' gestation undergoing routine ultrasound examinations (100 pregnancies for each sonographer). Volumes were sent to the referral center, and 2 independent reviewers with experience in 4D fetal echocardiography assessed their quality in the display of the abdominal view, 4-chamber view, left and right ventricular outflow tracts, and 3-vessel and trachea view. Cardiac volumes were acquired in 474 of 500 pregnancies (94.8%). The 2 reviewers respectively acknowledged the presence of satisfactory images in 92.4% and 93.6% of abdominal views, 91.5% and 93.0% of 4-chamber views, in 85.0% and 86.2% of left ventricular outflow tracts, 83.9% and 84.5% of right ventricular outflow tracts, and 85.2% and 84.5% of 3-vessel and trachea views. The presence of a maternal body mass index of greater than 30 altered the probability of achieving satisfactory cardiac views, whereas previous maternal lower abdominal surgery did not affect the quality of reconstructed cardiac views. In conclusion, cardiac volumes acquired by 4D sonography in peripheral centers showed high enough quality to allow satisfactory diagnostic cardiac views.