Maternal Hemodynamics from Preconception to Delivery: Research and Potential Diagnostic and Therapeutic Implications: Position Statement by Italian Association of Pre-Eclampsia and Italian Society of Perinatal Medicine.

OBJECTIVE: The Italian Association of Preeclampsia (AIPE) and the Italian Society of Perinatal Medicine (SIMP) developed clinical questions on maternal hemodynamics state of the art. STUDY DESIGN: AIPE and SIMP experts were divided in small groups and were invited to propose an overview of the existing literature on specific topics related to the clinical questions proposed, developing, wherever possible, clinical and/or research recommendations based on available evidence, expert opinion, and clinical importance. Draft recommendations with a clinical rationale were submitted to 8th AIPE and SIMP Consensus Expert Panel for consideration and approval, with at least 75% agreement required for individual recommendations to be included in the final version. RESULTS: More and more evidence in literature underlines the relationship between maternal and fetal hemodynamics, as well as the relationship between maternal cardiovascular profile and fetal-maternal adverse outcomes such as fetal growth restriction and hypertensive disorders of pregnancy. Experts agreed on proposing a classification of pregnancy hypertension, complications, and cardiovascular states based on three different hemodynamic profiles depending on total peripheral vascular resistance values: hypodynamic (>1,300 dynes·s·cm-5), normo-dynamic, and hyperdynamic (<800 dynes·s·cm-5) circulation. This differentiation implies different therapeutical strategies, based drugs' characteristics, and maternal cardiovascular profile. Finally, the cardiovascular characteristics of the women may be useful for a rational approach to an appropriate follow-up, due to the increased cardiovascular risk later in life. CONCLUSION: Although the evidence might not be conclusive, given the lack of large randomized trials, maternal hemodynamics might have great importance in helping clinicians in understanding the pathophysiology and chose a rational treatment of patients with or at risk for pregnancy complications. KEY POINTS: · Altered maternal hemodynamics is associated to fetal growth restriction.. · Altered maternal hemodynamics is associated to complicated hypertensive disorders of pregnancy.. · Maternal hemodynamics might help choosing a rational treatment during hypertensive disorders..

An update on maternal cardiac hemodynamics in fetal growth restriction and pre-eclampsia.

Pre-eclampsia and fetal growth restriction (FGR) have been long related to primary placental dysfunction, caused by abnormal trophoblast invasion. Nevertheless, emerging evidence has led to a new hypothesis for the origin of pre-eclampsia and FGR. Suboptimal maternal cardiovascular adaptation has been shown to result in uteroplacental hypoperfusion, ultimately leading to placental hypoxic damage with secondary dysfunction. In this review, we summarize current evidence on maternal cardiac hemodynamics in FGR and pre-eclampsia. We also discuss the different approaches for antihypertensive treatment according to the hemodynamic phenotype observed in pre-eclampsia and FGR.

Short-term morbidity and types of intrapartum hypoxia in the newborn with metabolic acidaemia: a retrospective cohort study.

OBJECTIVES: To assess labour characteristics in relation to the occurrence of Composite Adverse neonatal Outcome (CAO) within a cohort of fetuses with metabolic acidaemia. DESIGN: Retrospective cohort study. SETTING: Three Italian tertiary maternity units. POPULATION: 431 neonates born with acidaemia ≥36 weeks. METHODS: Intrapartum CTG traces were assigned to one of these four types of labour hypoxia: acute, subacute, gradually evolving and chronic hypoxia. The presence of CAO was defined by the occurrence of at least one of the following: Sarnat Score grade ≥2, seizures, hypothermia and death <7 days from birth. MAIN OUTCOME MEASURES: To compare the type of hypoxia on the intrapartum CTG traces among the acidaemic neonates with and without CAO. RESULTS: The occurrence of a CAO was recorded in 15.1% of neonates. At logistic regression analysis, the duration of the hypoxia was the only parameter associated with CAO in the case of an acute or subacute pattern (odds ratio [OR] 1.3; 95% CI 1.02-1.6 and OR 1.04; 95% CI 1.0-1.1, respectively), whereas both the duration of the hypoxic insult and the time from PROM to delivery were associated with CAO in those with a gradually evolving pattern (OR 1.13; 95% CI 1.01-1.3 and OR 1.04; 95% CI 1.0-1.7, respectively). The incidence of CAO was higher in fetuses with chronic antepartum hypoxia than in those showing CTG features of intrapartum hypoxia (64.7 vs. 13.0%; P < 0.001). CONCLUSIONS: The frequency of CAO seems related to the duration and the type of the hypoxic injury, being higher in fetuses showing CTG features of antepartum chronic hypoxia. TWEETABLE ABSTRACT: This study demonstrates that in a large population of neonates with metabolic acidaemia at birth, the overall incidence of short-term adverse outcome is around 15%. Such risk seems closely correlated to the duration and the type of hypoxic injury, being higher in fetuses admitted in labour with antepartum chronic hypoxia than those experiencing intrapartum hypoxia.

Achieving an appropriate cesarean birth (CB) rate and analyzing the changes using the Robson Ten-Group Classification System (TGCS): Lessons from a Tertiary Care Hospital in Italy.

BACKGROUND: To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes. STUDY DESIGN: An analysis of the contemporaneously collected data from all deliveries that occurred from 2014 to 2018. Major obstetric and neonatal outcomes were analyzed and grouped according to the Ten-Group Classification System (TGCS). RESULTS: A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported. CONCLUSIONS: A reduction in CB rate may be safely achieved through implementing a multifaceted strategy.

Intrapartum sonographic assessment of the fetal head flexion in protracted active phase of labor and association with labor outcome: a multicenter, prospective study.

BACKGROUND: To date, no research has focused on the sonographic quantification of the degree of flexion of the fetal head in relation to the labor outcome in women with protracted active phase of labor. OBJECTIVE: This study aimed to assess the relationship between the transabdominal sonographic indices of fetal head flexion and the mode of delivery in women with protracted active phase of labor. STUDY DESIGN: Prospective evaluation of women with protracted active phase of labor recruited across 3 tertiary maternity units. Eligible cases were submitted to transabdominal ultrasound for the evaluation of the fetal head position and flexion, which was measured by means of the occiput-spine angle in fetuses in nonocciput posterior position and by means of the chin-to-chest angle in fetuses in occiput posterior position. The occiput-spine angle and the chin-to-chest angle were compared between women who had vaginal delivery and those who had cesarean delivery. Cases where obstetrical intervention was performed solely based on suspected fetal distress were excluded. RESULTS: A total of 129 women were included, of whom 43 (33.3%) had occiput posterior position. Spontaneous vaginal delivery, instrumental delivery, and cesarean delivery were recorded in 66 (51.2%), 17 (13.1%), and 46 (35.7%) cases, respectively. A wider occiput-spine angle was measured in women who had vaginal delivery compared with those submitted to cesarean delivery owing to labor dystocia (126±14 vs 115±24; P<.01). At the receiver operating characteristic curve, the area under the curve was 0.675 (95% confidence interval, 0.538-0.812; P<.01), and the optimal occiput-spine angle cutoff value discriminating between cases of vaginal delivery and those delivered by cesarean delivery was 109°. A narrower chin-to-chest angle was measured in cases who had vaginal delivery compared with those undergoing cesarean delivery (27±33 vs 56±28 degrees; P<.01). The area under the curve of the chin-to-chest angle in relation to the mode of delivery was 0.758 (95% confidence interval, 0.612-0.904; P<.01), and the optimal cutoff value discriminating between vaginal delivery and cesarean delivery was 33.0°. CONCLUSION: In women with protracted active phase of labor, the sonographic demonstration of fetal head deflexion in occiput posterior and in nonocciput posterior fetuses is associated with an increased incidence of cesarean delivery owing to labor dystocia. Such findings suggest that intrapartum ultrasound may contribute in the categorization of the etiology of labor dystocia.

Intrapartum fetal heart rate between 150 and 160 bpm at or after 40 weeks and labor outcome.

INTRODUCTION: A baseline fetal heart rate between 110 and 160 bpm is considered normal. However, among normal fetuses the average baseline heart rate has been shown to diminish progressively and the 90th centile of the fetal heart rate at 40 weeks of gestation has been consistently found at around 150 bpm. The aim of our study was to assess the labor and neonatal outcome of fetuses at 40 gestational weeks or beyond, whose intrapartum baseline fetal heart rate was between 150 and 160 bpm. MATERIAL AND METHODS: Retrospective cohort study including singleton pregnancies with spontaneous onset of labor, gestational age between 40+0 and 42+0 weeks, category I CTG trace according to the FIGO guidelines 2015 with baseline fetal heart rate between 110 and 160 bpm during the first 60 minutes of active labor. Exclusion criteria were maternal hyperpyrexia at admission, fetal arrhythmias, maternal tachycardia (>110 bpm) and uterine tachysystole (>5 contractions/10 minutes). The following outcomes were compared between fetuses with a baseline ranging between 110 and 149 bpm and those with a baseline ranging between 150 and 160 bpm: incidence of meconium-stained amniotic fluid, intrapartum hyperpyrexia, mode of delivery, Apgar at 5 minutes <7, arterial pH <7.1 and Neonatal Intensive Care Unit admission, incidence of a composite adverse neonatal outcome. RESULTS: In all, 1004 CTG traces were included in the analysis, 860 in Group 110-149 bpm and 144 in Group 150-160 bpm. Group 150-160 bpm had a significantly higher incidence of meconium-stained amniotic fluid (odds ratio [OR] 2.6; 95% CI 1.8-3.8), maternal intrapartum hyperpyrexia (OR 4.7; 95% CI 1.1-14.6), urgent/emergent cesarean section for suspected fetal distress (OR 13.4; 95% CI 3.3-54.3), Apgar <7 at 5th min (OR 9.13; 95% CI 1.5-55.1) and neonatal acidemia (OR 3.5; 95% CI 1.5-55.1). Logistic regression including adjustiing for potential confounders showed that fetal heart rate between 150 and 160 bpm is an independent predictor of meconium-stained amniotic fluid (adjusted odds ratio [aOR] 2.2; 95% CI 1.5-3.3), cesarean section during labor for fetal distress (aOR 10.7; 95% CI 2.9-44.6), neonatal acidemia (aOR 2.6; 95% CI 1.1-6.7) and adverse composite neonatal outcome (aOR 2.6; 95% CI 1.2-5.6). CONCLUSIONS: In fetuses at 40 weeks or beyond, an intrapartum fetal heart rate baseline ranging between 150 and 160 bpm seems associated with a higher incidence of labor complications.

Antepartum evaluation of the obstetric conjugate at transabdominal 2D ultrasound: A feasibility study.

INTRODUCTION: The obstetric conjugate represents the shortest anteroposterior diameter of the birth canal and it reflects the capacity of the pelvic inlet to allow the passage and the engagement of the fetal head. The antepartum evaluation of this parameter may be attempted at digital examination to predict the risk of cephalopelvic disproportion, but the accuracy of clinical pelvimetry is notoriously poor. The aim of our study was to describe the sonographic measurement of the obstetric conjugate at transabdominal 2D-ultrasound and to assess its reproducibility. MATERIAL AND METHODS: This is a prospective cohort study conducted at a tertiary University hospital. A non-consecutive series of pregnant women with uncomplicated singleton pregnancies attending the antenatal clinic for routine booking from 34 weeks of gestation onward were included. The ultrasound probe was longitudinally placed above the level of the symphysis and the interpubic fibrocartilaginous disk was visualized. Then the promontory was identified as the most prominent segment of the sacral vertebral column. The obstetric conjugate was measured as the distance between the inner edge of the interpubic disk and the promontory. The inter- and intraobserver repeatability of this measurement was calculated using the intraclass correlation coefficient (ICC) and the Bland-Altman method. RESULTS: In all, 119 women were considered eligible for the study; of these, 111/119 (93.3%) women were included in the analysis with a median gestational age of 36.0 (35.0-37.0) weeks. The mean obstetric conjugate measurement was 11.4 ± 0.93 mm for the first operator and 11.4 ± 0.91 mm for the second operator. The overall interobserver ICC was 0.95 (95% [confidence interval] CI 0.92-0.96) and the overall intraobserver ICC was 0.97 (95% CI 0.96-0.98). Limits of agreement ranged from -0.84 to 0.80 for interobserver measures and from -0.64 to 0.62 for intraobserver measures. The degree of reliability was also analyzed for women with a body mass index ≥30 and for women with a gestational age ≥37 weeks. The inter- and intraobserver ICCs were respectively 0.97 (95% CI 0.90-0.98) and 0.98 (0.95-0.99) in the former group and 0.96 (95% CI 0.93-0.98) and 0.97 (95% CI 0.95-0.98) in the latter group. CONCLUSIONS: Our study demonstrated that among pregnant women at term gestation, sonographic measurement of the obstetric conjugate is feasible and reproducible.

Hemodynamic findings in normotensive women with small-for-gestational-age and growth-restricted fetuses.

INTRODUCTION: Fetal growth restriction (FGR) in most instances is a consequence of primary placental dysfunction due to inadequate trophoblastic invasion. Maternal cardiac maladaptation to pregnancy has been proposed as a possible determinant of placental insufficiency and impaired fetal growth. This study aimed to compare the maternal hemodynamic parameters between normotensive women with small-for-gestational-age (SGA) and FGR fetuses and to evaluate their correlation with neonatal outcome. MATERIAL AND METHODS: An observational cohort study including singleton pregnancies referred to our tertiary care center due to fetal smallness. At the time of diagnosis, fetuses were classified as SGA or FGR according to the Delphi consensus criteria, and pregnant women underwent hemodynamic assessment using a cardiac output monitor. A group of women with singleton uncomplicated pregnancies ar ≥35 weeks of gestation were recruited as controls. Cardiac output, systemic vascular resistance, stroke volume, and heart rate were measured and compared among the three groups (controls vs FGR vs SGA). The correlation between antenatal findings and neonatal outcome was also evaluated by multivariate logistic regression analysis. RESULTS: A total of 51 women with fetal smallness were assessed at 34.8 ± 2.6 weeks. SGA and FGR were diagnosed in 22 and 29 cases, respectively. The control group included 61 women assessed at 36.5 ± 0.8 weeks of gestation. Women with FGR had a lower cardiac output Z-score (respectively, -1.3 ± 1.2 vs -0.4 ± 0.8 vs -0.2 ± 1.0; P < .001) and a higher systemic vascular resistance Z-score (respectively, 1.2 ± 1.2 vs 0.2 ± 1.1 vs -0.02 ± 1.2; P < .001) compared with both SGA and controls, whereas no difference in the hemodynamic parameters was found between women with SGA and controls. The incidence of neonatal intensive care unit admission did not differ between SGA and FGR fetuses (18.2% vs 41.4%; P = .13), but FGR fetuses had a longer hospitalization compared with SGA fetuses (14.2 ± 17.7 vs 4.5 ± 1.6 days; P = .02). Multivariate analysis showed that the cardiac output Z-score at diagnosis (P = .012) and the birthweight Z-score (P = .007) were independent predictors of the length of neonatal hospitalization. CONCLUSIONS: Different maternal hemodynamic profiles characterize women with SGA or FGR fetuses. Furthermore, a negative correlation was found between the maternal cardiac output and the length of neonatal hospitalization.

Hyperechoic amniotic membranes in patients with preterm premature rupture of membranes (p-PROM) and pregnancy outcome.

OBJECTIVES: The early identification of women with preterm premature rupture of membranes (p-PROM) who are at higher risk of imminent delivery remains challenging. The aim of our study was to evaluate if an increased echogenicity of the amniotic membranes may represent a sonographic marker of impending delivery in women with p-PROM. METHODS: This was a prospective study including women with singleton pregnancies and diagnosis of p-PROM between 22 and 37 gestational weeks. A sonographic examination was performed within 24 h from the hospital admission and the appearance of the amniotic membranes close to the internal os was specifically evaluated. The membranes were defined as hyperechoic when their echogenicity was similar to that of the fetal bones or normoechoic in the other cases. The primary aim of the study was to compare the admission to spontaneous onset of labor interval and the pregnancy outcome between the cases of p-PROM with and without hyperechoic membranes. RESULTS: Overall, 45 women fulfilled the inclusion criteria with similar characteristics at admission. In women with hyperechoic membranes, the admission to spontaneous onset of labor interval was significantly shorter (11.5 [5.3-25.0] vs. 3.0 [1.5-9.0] p=0.04) compared to women with normo-echoic membranes. At binomial logistic regression after adjustment for GA at hospital admission, the presence of hyperechoic membranes was found as the only independent predictor of spontaneous onset of labor ≤72 h (aOR: 6.1; 95% CI: 1.0-36.9). CONCLUSIONS: The presence of hyperechoic membranes is associated with a 6-fold higher incidence of spontaneous onset of labor within 72 h independently from the gestational age at p-PROM.

Three-Dimensional Sonographic Evaluation of the Position of the Fetal Conus Medullaris at First Trimester.

OBJECTIVE: The objective of this study was to assess the position of the conus medullaris (CM) at the first trimester 3D ultrasound in a cohort of structurally normal fetuses. METHODS: This was a multicenter prospective study involving a consecutive series of structurally normal fetuses between 11 and 13 weeks of gestation (CRL between 45 and 84 mm). All fetuses were submitted to 3D transvaginal ultrasound using a sagittal view of the spine as the starting plane of acquisition. At offline analysis, the position of the CM was evaluated by 2 independent operators with a quantitative and a qualitative method: (1) the distance between the most caudal part of the CM and the distal end of the coccyx (CMCd) was measured; (2) a line perpendicular to the fetal spine joining the tip of the CM to the anterior abdominal wall was traced to determine the level of this line in relation to the umbilical cord insertion (conus to abdomen line, CAL). Interobserver agreement for the CCMd was evaluated. Linear regression analysis was used to determine the association between the CMCd and CRL, and a normal range was computed based on the best-fit model. The absence of congenital anomalies was confirmed in all cases after birth. RESULTS: In the study period between December 2019 and March 2020, 143 fetuses were recruited. In 130 fetuses (90.9%), the visualization of the CM was feasible. The mean value of the CMCd was 1.09 ± 0.16 cm. The 95% limits of agreement for the interobserver variability in measurement of the CMCd were 0.24 and 0.26 cm. The interobserver variability based on the intra-class correlation coefficient (ICC) for the CCMd was good (ICC = 0.81). We found a positive linear relationship between the CCMd and CRL. In all these fetuses, the CAL encountered the abdominal wall at or above the level of the cord insertion. CONCLUSION: In normal fetuses, the assessment of the CM position is feasible at the first trimester 3D ultrasound with a good interobserver agreement. The CM level was never found below the fetal umbilical cord insertion, while the CMCd was noted to increase according to the gestational age, confirming the "ascension" of the CM during fetal life.

Usefulness of an Intrapartum Ultrasound Simulator (IUSim™) for Midwife Training: Results from an RCT.

INTRODUCTION: We conducted a randomized study to determine whether a training session on a dedicated simulator (IUSim™) would facilitate the midwives in learning the technique of transperineal intrapartum ultrasound. METHODS: Following a 30-min multimedia presentation including images and videos on how to obtain and measure the angle of progression (AoP) and the head-perineum distance (HPD), 6 midwives with no prior experience in intrapartum ultrasound were randomly split into 2 groups: 3 of them were assigned to the "training group" and 3 to the "control group." The midwives belonging to the former group were taught to measure the 2 sonographic parameters during a 3-h practical session conducted on IUSim™ under the supervision of an expert obstetrician. In the following 3 months, all the 6 midwives were asked to independently perform transperineal ultrasound during their clinical practice and to measure on the acquired images either the AoP or the HPD. The sonographic images were examined in blind by the teaching obstetrician who assigned a 0-3 score to the image quality (IQS) and to the measurement quality (MQS). RESULTS: A total of 48 ultrasound images (24 patients) from 5 midwives were acquired and included in the study analysis. A midwife of the "training group" declined participation after the practical session. Independently from the randomization group, the image quality score (IQS + MQS) was significantly higher for the HPD compared with the AoP (2.5 ± 0.66 vs. 1.79 ± 1.14; p = 0.01). In the training group, the MQS of either AoP (2.66 ± 0.5 vs.1.46 ± 1.45. p = 0.038) and the HPD (2.9 ± 0.33 vs. 1.87 ± 0.83 p = 0.002) was significantly higher in comparison with the control group, while the IQS of both measurements was comparable between the 2 groups (1.91 ± 1.24 vs. 2.25 ± 0.865; p = 0.28). CONCLUSION: The use of a dedicated simulator may facilitate the midwives in learning how to measure the AoP and the HPD on transperineal ultrasound images.

Glial Periorbital Heterotopia: A Rare Type of Ocular Mass.

Congenital orbital masses are rare disorders. A wide variety of lesions, including malignant and benign tumors, may develop around the orbit; hemangioma, lymphangioma, and optic nerve meningioma are the most common. Counseling for the prognosis and postnatal treatment depends on antenatal suspicion. Glial heterotopia should also be considered for the differential diagnosis. Integration of antenatal ultrasound and magnetic resonance imaging characteristics could help in the differential diagnosis. For the first time to our knowledge, a literature review on fetal orbital tumors was performed, along with a systematic description of imaging characteristics, treatment, and the prognosis.

Maternal cardiac parameters can help in differentiating the clinical profile of preeclampsia and in predicting progression from mild to severe forms.

BACKGROUND: A primary role of maternal heart dysfunction in the pathophysiology of preeclampsia had been previously advocated although if contradictory results have been reported. OBJECTIVES: The objectives of the study were to describe maternal hemodynamic parameters according to 2 main preeclampsia phenotypes and to investigate whether cardiac findings may be helpful in characterizing the severity and the progression of the disease. STUDY DESIGN: This was a prospective cohort study. We used an ultrasonic cardiac output monitor system to compare the hemodynamic parameters of women with preeclampsia with a group of healthy normotensive women enrolled as controls with a ratio of 1:2. Cardiac output, systemic vascular resistance, and stroke volume were compared among controls and preeclamptic women who were grouped in accordance to the following characteristics: early preeclampsia (<34 weeks' gestation) vs late preeclampsia onset (≥34 weeks' gestation); preeclampsia associated with appropriate for gestational age or small-for-gestational-age newborns. Hemodynamic characteristics were also compared between preeclamptic women with a mild form vs those who progressed toward a severe form. RESULTS: A total of 38 preeclamptic women and 61 normotensive women were included in the study. Both cases of preeclampsia associated with small-for-gestational-age neonates as those with normal-sized ones showed higher systemic vascular resistance compared with the control group (respectively, 1580.6 ± 483.2 vs 1479.1 ± 433.3 vs 1105.3 ± 293.1; P < .0001), while a lower cardiac output was reported only for preeclamptic women with small-for-gestational-age neonates compared with controls (5.7 ± 1.5 vs 6.5 ± 1.3; P = .02). Maternal cardiac parameters were comparable between these 2 groups of preeclamptic women (small-for-gestational-age vs appropriate-for-gestational-age preeclampsia) with the exception of a lower stroke volume in the former one (64.8 ± 24.4 vs 75.2 ± 17.8; P = .04). Similarly, women with both early and late preeclampsia showed higher systemic vascular resistance compared with controls (1559.5 ± 528.3 vs 1488.5 ± 292.9 vs 1105.3 ± 293.1, respectively; P < .001), while a lower cardiac output was noted only in the early-onset group compared with controls (5.5 ± 1.2 P = .02). Maternal cardiac findings were similar between women with early vs late-onset preeclampsia. Hemodynamic parameters are significantly different between those women with mild preeclampsia who remained stable compared with those who progressed toward a severe disease. Cardiac output Z-score, systemic vascular resistance Z-score, and uterine arteries' pulsatility index Z-score showed similar sensitivity (80% vs 75% vs 80%, respectively) and specificity (73% vs. 73% vs 74%, respectively), while the association of systemic vascular resistance Z-score and uterine arteries pulsatility index Z-score showed a sensitivity of 95% and a specificity of 80% (area under the curve, 0.90) in predicting evolution toward severe forms. CONCLUSION: Evaluation of maternal cardiovascular system could help clinician in defining a subset of preeclamptic patients with more profound placental impairment and might predict the likelihood of progression toward a severe condition in cases with a mild preeclampsia at clinical onset.

Prediction of spontaneous vaginal delivery in nulliparous women with a prolonged second stage of labor: the value of intrapartum ultrasound.

BACKGROUND: A limited number of studies have addressed the role of intrapartum ultrasound in the prediction of the mode of delivery in women with prolonged second stage of labor. OBJECTIVE: The objective of the study was to evaluate the role of transabdominal and transperineal sonographic findings in the prediction of spontaneous vaginal delivery among nulliparous women with prolonged second stage of labor. STUDY DESIGN: This was a 2-center prospective study conducted at 2 tertiary maternity units. Nulliparous women with a prolonged active second stage of labor, as defined by active pushing lasting more than 120 minutes, were eligible for inclusion. Transabdominal ultrasound to evaluate the fetal head position and transperineal ultrasound for the measurement of the midline angle, the head-perineum distance, and the head-symphysis distance were performed in between uterine contractions and maternal pushes. At transperineal ultrasound the angle of progression was measured at rest and at the peak of maternal pushing effort. The delta angle of progression was defined as the difference between the angle of progression measured during active pushing at the peak of maternal effort and the angle of progression at rest. The sonographic findings of women who had spontaneous vaginal delivery vs those who required obstetric intervention, either vacuum extraction or cesarean delivery, were evaluated and compared. RESULTS: Overall, 109 were women included. Spontaneous vaginal delivery and obstetric intervention were recorded in 40 (36.7%) and 69 (63.3%) patients, respectively. Spontaneous vaginal delivery was associated with a higher rate of occiput anterior position (90% vs 53.2%, P < .0001), lower head-perineum distance and head-symphysis distance (33.2 ± 7.8 mm vs 40.1 ± 9.5 mm, P = .001, and 13.1 ± 4.6 mm vs 19.5 ± 8.4 mm, P < .001, respectively), narrower midline angle (29.6° ± 15.3° vs 54.2° ± 23.6°, P < .001) and wider angle of progression at the acme of the pushing effort (153.3° ± 19.8° vs 141.8° ± 25.7°, P = .02) and delta-angle of progression (17.3° ± 12.9° vs 12.5° ± 11.0°, P = .04). At logistic regression analysis, only the midline angle and the head-symphysis distance proved to be independent predictors of spontaneous vaginal delivery. More specifically, the area under the curve for the prediction of spontaneous vaginal delivery was 0.80, 95% confidence interval (0.69-0.92), P < .001, and 0.74, 95% confidence interval (0.65-0.83), P = .002, for the midline angle and for the head-symphysis distance, respectively. CONCLUSION: Transabdominal and transperineal intrapartum ultrasound parameters can predict the likelihood of spontaneous vaginal delivery in nulliparous women with prolonged second stage of labor.

Impact of fetal brain ultrasound tutor smartphone application on normal anatomy learning.

OBJECTIVE: The "Fetal Brain Tutor 4us" (FBTApp) is a recently developed application for interactive multiplanar navigation through the normal fetal brain. The purpose of this work was to assess its impact on normal anatomy learning. METHODS: A multiple-choice quiz (MCQ) was administered to first-year resident doctors in Obstetrics and Gynecology in two separate sessions, before and 2 weeks after downloading the FBTApp. For each MCQ, the junior trainee was asked to use one out of five items to label a specific cerebral structure on an ultrasound image of a normal midtrimester fetal brain. Six sonographic images of the fetal brain on each of the three scanning planes (axial, sagittal, and coronal) were shown to the participants at either session. The results of the two sessions were analysed and compared. RESULTS: Overall, 216 questions were administered to the trainees in the 2-week study, 108 before and 108 after the use of the FBTApp. From the first to the second sessions, a significant increase of correct answers was noted (from 47/108 or 43% to 77/108 or 71%, P < 0.01). Particularly, a better improvement was obtained in the correct labelling of cerebral structures on the nonaxial (from 32% to 67%, +35%) vs axial (from 67% to 81%, +14%) view planes of the brain (P < 0.01). CONCLUSION: The use of FBTApp seems capable to improve the knowledge of the normal fetal brain anatomy in subjects naive to dedicated prenatal ultrasound. This improvement seems greater on nonaxial planes.

Efficiency of prenatal diagnosis in Pierre Robin sequence.

OBJECTIVES: To analyze the efficiency of prenatal diagnosis of Pierre Robin sequence (PRS) regarding the final specific diagnosis and to determine whether infants have more severe respiratory disorders with than without prenatally suspected PRS. METHODS: Review of the outcome of all prenatal cases of suspected PRS managed in our prenatal diagnosis center during the last 15 years; analysis of the consistency between prenatal and postnatal diagnoses in 2 groups of women with and without a family history of PRS; comparison of the grades of disease severity for infants with and without prenatally suspected PRS. RESULTS: Fifty-nine files were studied. Prenatal and postnatal consistencies of a specific diagnosis of PRS were 100% for women with a family history of PRS and with prenatally suspected nonisolated PRS. It was 78.6% for those with prenatally suspected isolated PRS. We describe 13 terminations of pregnancy. The 41 children living beyond 18 months seem to have more functionally severe phenotypes than the 227 children without prenatally suspected PRS. CONCLUSION: Prenatal diagnosis of isolated PRS is a challenge as other features can be missed. Use of prenatal chromosomal microarray can improve the accuracy of diagnosis. In all cases, adequate neonatal care should be offered.

Correlation between intrapartum CTG findings and interleukin-6 levels in the umbilical cord arterial blood: A prospective cohort study.

OBJECTIVE: to investigate the correlation between the intrapartum CardioTocoGraphic (CTG) findings "suggestive of fetal inflammation" ("SOFI") and the interleukin (IL)-6 level in the umbilical arterial blood. STUDY DESIGN: prospective cohort study conducted at a tertiary maternity unit and including 447 neonates born at term. METHODS: IL-6 levels were systematically measured at birth from a sample of blood taken from the umbilical artery. The intrapartum CTG traces were retrospectively reviewed by two experts who were blinded to the postnatal umbilical arterial IL-6 values as well as to the neonatal outcomes. The CTG traces were classified into "suggestive of fetal inflammation (SOFI)" and "no evidence of fetal inflammation (NEFI) according to the principles of physiologic interpretation the CTG traces. The CTG was classified as "SOFI" if there was a persistent fetal heart rate (FHR) increase > 10 % compared with the observed baseline FHR observed at the admission or at the onset of labor without any preceding repetitive decelerations. The occurrence of Composite Adverse Outcome (CAO) was defined as Neonatal Intensive Care Unit (NICU) or Special Care Baby Unit (SCBU) admission due to one or more of the following: metabolic acidaemia, Apgar score at 5 min ≤ 7, need of neonatal resuscitation, respiratory distress, tachypnoea/polypnea, jaundice requiring phototherapy, hypotension, body temperature instability, poor perinatal adaptation, suspected or confirmed early neonatal sepsis. MAIN OUTCOME MEASURES: To compare the umbilical IL-6 values between the cases with intrapartum CTG traces classified as "SOFI" and those classified as "NEFI"; to assess the correlation of umbilical IL-6 values with the neonatal outcome. RESULTS: 43 (9.6 %) CTG traces were categorized as "SOFI"; IL-6 levels were significantly higher in this group compared with the "NEFI" group (82.0[43.4-325.0] pg/ml vs. 14.5[6.8-32.6] pg/mL; p <.001). The mean FHR baseline assessed 1 h before delivery and the total labor length showed an independent and direct association with the IL-6 levels in the umbilical arterial blood (p <.001 and p = 0.005, respectively). CAO occurred in 33(7.4 %) cases; IL-6 yielded a good prediction of the occurrence of the CAO with an AUC of 0.72 (95 % CI 0.61-0.81). CONCLUSION: Intrapartum CTG findings classified as "SOFI" are associated with higher levels of IL-6 in the umbilical arterial blood.

The "Preeclampsia and Hypertension Target Treatment" study: a multicenter prospective study to evaluate the effectiveness of the antihypertensive therapy based on maternal hemodynamic findings.

BACKGROUND: Despite major advances in the pharmacologic treatment of hypertension in the nonpregnant population, treatments for hypertension in pregnancy have remained largely unchanged over the years. There is recent evidence that a more adequate control of maternal blood pressure is achieved when the first given antihypertensive drug is able to correct the underlying hemodynamic disorder of the mother besides normalizing the blood pressure values. OBJECTIVE: This study aimed to compare the blood pressure control in women receiving an appropriate or inappropriate antihypertensive therapy following the baseline hemodynamic findings. STUDY DESIGN: This was a prospective multicenter study that included a population of women with de novo diagnosis of hypertensive disorders of pregnancy. A noninvasive assessment of the following maternal parameters was performed on hospital admission via Ultrasound Cardiac Output Monitor before any antihypertensive therapy was given: cardiac output, heart rate, systemic vascular resistance, and stroke volume. The clinician who prescribed the antihypertensive therapy was blinded to the hemodynamic evaluation and used as first-line treatment a vasodilator (nifedipine or alpha methyldopa) or a beta-blocker (labetalol) based on his preferences or on the local protocols. The first-line pharmacologic treatment was retrospectively considered hemodynamically appropriate in either of the following circumstances: (1) women with a hypodynamic profile (defined as low cardiac output [≤5 L/min] and/or high systemic vascular resistance [≥1300 dynes/second/cm2]) who were administered oral nifedipine or alpha methyldopa and (2) women with a hyperdynamic profile (defined as normal or high cardiac output [>5 L/min] and/or low systemic vascular resistances [<1300 dynes/second/cm2]) who were administered oral labetalol. The primary outcome of the study was to compare the occurrence of severe hypertension between women treated with a hemodynamically appropriate therapy and women treated with an inappropriate therapy. RESULTS: A total of 152 women with hypertensive disorders of pregnancy were included in the final analysis. Most women displayed a hypodynamic profile (114 [75.0%]) and received a hemodynamically appropriate treatment (116 [76.3%]). The occurrence of severe hypertension before delivery was significantly lower in the group receiving an appropriate therapy than in the group receiving an inappropriately treated (6.0% vs 19.4%, respectively; P=.02). Moreover, the number of women who achieved target values of blood pressure within 48 to 72 hours from the treatment start was higher in the group who received an appropriate treatment than in the group who received an inappropriate treatment (70.7% vs 50.0%, respectively; P=.02). CONCLUSION: In pregnant individuals with de novo hypertensive disorders of pregnancy, a lower occurrence of severe hypertension was observed when the first-line antihypertensive agent was tailored to the correct maternal hemodynamic profile.