Intrapartum ultrasound measurement of angle of progression at the onset of the second stage of labor for prediction of spontaneous vaginal delivery in term singleton pregnancies: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to investigate the diagnostic performance of transperineal ultrasound-measured angles of progression at the onset of the second stage of labor for the prediction of spontaneous vaginal delivery in singleton term pregnancies with cephalic presentation. DATA SOURCES: We performed a predefined systematic search in PubMed, Embase, Scopus, Web of Science, and Google Scholar from inception to February 5, 2021. STUDY ELIGIBILITY CRITERIA: Prospective cohort studies that evaluated the diagnostic performance of transperineal ultrasound-measured angles of progression (index test) at the onset of the second stage of labor (ie, when complete cervical dilation is diagnosed) for the prediction of spontaneous vaginal delivery (reference standard) were eligible for inclusion. Eligible studies were limited to those published as full-text articles in the English language and those that included only parturients with a singleton healthy fetus at term with cephalic presentation. STUDY APPRAISAL AND SYNTHESIS METHODS: Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Summary receiver operating characteristic curves, pooled sensitivities and specificities, area under the curve, and summary likelihood ratios were calculated using the Stata software. Subgroup analyses were done based on angle of progression ranges of 108° to 119°, 120° to 140°, and 141° to 153°. RESULTS: A total of 8 studies reporting on 887 pregnancies were included. Summary estimates of the sensitivity and specificity of transperineal ultrasound-measured angle of progression at the onset of the second stage of labor for predicting spontaneous vaginal delivery were 94% (95% confidence interval, 88%-97%) and 47% (95% confidence interval, 18%-78%), respectively, for an angle of progression of 108° to 119°, 81% (95% confidence interval, 70%-89%) and 73% (95% confidence interval, 57%-85%), respectively, for an angle of progression of 120° to 140°, and 66% (95% confidence interval, 56%-74%) and 82% (95% confidence interval, 66%-92%), respectively, for an angle of progression of 141° to 153°. Likelihood ratio syntheses gave overall positive likelihood ratios of 1.8 (95% confidence interval, 1-3.3), 3 (95% confidence interval, 2-4.7), and 3.7 (95% confidence interval, 1.7-8.1) and negative likelihood ratios of 0.13 (95% confidence interval, 0.07-0.22), 0.26 (95% confidence interval, 0.18-0.38), and 0.42 (95% confidence interval, 0.29-0.60) for angle of progression ranges of 108° to 119°, 120° to 140°, and 141° to 153°, respectively. CONCLUSION: Angle of progression measured by transperineal ultrasound at the onset of the second stage of labor may predict spontaneous vaginal delivery in singleton, term, cephalic presenting pregnancies and has the potential to be used along with physical examinations and other clinical factors in the management of labor and delivery.

Role of 'angle of progression' in prediction of delivery mode.

AIM: The aim of this study was to investigate the role of the 'angle of progression' (AOP) in the prediction of vaginal delivery. MATERIAL AND METHODS: In this prospective study, we followed 70 singleton pregnant women. AOP was measured at admission time and also at the beginning of the second stage immediately after digital examination. Digital and ultrasound examiners were unaware of each other's results. The digital examiner decided on the delivery mode based on clinical assessment. RESULTS: Sixty-five (92.9%) women had vaginal delivery. In the first stage of labor, the area under the curve was 87.5% (95% confidence interval [CI], 77.9-97.1; P = 0.005) for the AOP and 85.5% (95%CI, 75.2-95.6; P = 0.009) for digital examination and in the second stage of labor, the area under the curve was 90.2% (95%CI, 81-99.3; P = 0.003) for the AOP and 94.9% (95%CI, 89.1-100; P = 0.001) for digital examination. An AOP of ≥113° at the second stage was associated with a 90.8% probability of vaginal delivery. CONCLUSION: We found a significant relation between AOP and cervical dilatation during the first stage of labor. A larger angle at the beginning of the second stage was significantly associated with shorter time to delivery.

Doppler Finding, Cardiovascular Function Assessment, and Fetuses' Survival Following the Fetoscopic Laser in Twin-to-Twin Transfusion Syndrome.

Introduction: This study aimed to evaluate the effectiveness of selective laser photocoagulation of communicating vessels (SLPCV) on cardiac function in twins with twin-to-twin transfusion syndrome (TTTS). Methods: This retrospective cohort study evaluated 178 women with twin pregnancies complicated with TTTS and scheduled for SLPCV between 16 and 26 weeks of gestation. The severity of TTTS was determined by Quintero staging and the severity of cardiovascular disorders by the CHOP (Children's Hospital of Philadelphia) score. Patient survival was evaluated through a one-month-after-birth follow-up of fetuses. Results: The study revealed significant improvements in Doppler indices in both donors and recipients after SLPCV. The CHOP score also significantly decreased after the intervention. One-month-after-birth survival rates were 55.1% in donors and 56.7% in recipients. Some Doppler indexes of fetuses before SLPCV could predict survival until one month after birth. Conclusion: The study suggests that SLPCV can improve cardiac function in fetuses with TTTS and that some Doppler indexes can predict survival outcomes. Additionally, the severity of TTTS can be a powerful indicator of the severity of cardiovascular complications.

Extreme ßHCG levels in first trimester screening are risk factors for adverse maternal and fetal outcomes.

Multiples of the normal median (MoM) of free ßHCG is a valuable parameter in evaluation of risk of adverse pregnancy outcomes. In the current retrospective study, we assessed the maternal and fetal outcomes in pregnant women having free ßHCG MoM levels < 0.2 or > 5 in their first trimester screening (FTS). Relative risk of trisomy 21 was significantly higher in patients having free ßHCG MoM > 5. On the other hand, relative risk of trisomies 13 and 18 and Turner syndrome were higher in those having free ßHCG MoM < 0.2. Other chromosomal abnormalities were nearly equally detected between those having free ßHCG MoM < 0.2 or > 5. Relative risk of hydrocephaly and hydrops fetalis was higher when free ßHCG MoM was below 0.2. On the other hand, relative risk of low birth weight was higher when free ßHCG MoM was above 5. Moreover, frequency of gestational diabetes mellitus, preeclampsia, preterm delivery and vaginal bleeding increased with levels of free ßHCG MoM. However, polyhydramnios had the opposite trend. Frequencies of premature rupture of membranes and pregnancy induced hypertension were highest among pregnant women having levels of free ßHCG MoM < 0.2. The current study indicates importance of free ßHCG MoM in identification of at-risk pregnancies in terms of both fetal and maternal outcomes. In fact, ßHCG MoM < 0.2 or > 5 can be regarded as risk factors for adverse maternal or fetal outcomes irrespective of the presence of other abnormalities in the FTS results.

Transversus abdominis plane block reduces postoperative pain intensity and analgesic consumption in elective cesarean delivery under general anesthesia.

PURPOSE: It is reported that following abdominal surgery, transversus abdominis plane (TAP) block can reduce postoperative pain. The primary outcome of this study was the evaluation of the efficacy of TAP block on pain intensity following cesarean delivery with Pfannenstiel incision. METHODS: Fifty pregnant women were randomized blindly to receive either a TAP block with 15 ml 0.25% bupivacaine in both sides (group T, n = 25) or no blockade (group C, n = 25) at the end of the surgery, which was performed with a Pfannenstiel incision under general anesthesia. The pain intensity in the patients was assessed by a blinded investigator at the time of discharge from recovery and at 6, 12, and 24 h postoperatively, with a visual analogue scale (VAS) for pain. RESULTS: The women in the TAP block group had significantly lower VAS pain scores at rest and during coughing and consumed significantly less tramadol than the women in group C [50 mg (0-150) vs. 250 mg (0-400), P = 0.001]. There was a significantly longer time to the first request for analgesic in the TAP block group [210 min (0-300) vs. 30 min (10-180) in group C, P = 0.0001]. CONCLUSION: Two-sided TAP block with 0.25% bupivacaine in parturients who undergo cesarean section with a Pfannenstiel incision under general anesthesia can decrease postoperative pain and analgesic consumption. The time to the first analgesic rescue was longer in the parturients who received the TAP block.

The association between fetal renal artery indices in late pregnancy and birth weight in gestational diabetes mellitus: A cohort study.

Background: Estimation of the fetal birth weight and diagnosis of small for gestational age in the fetuses of women with gestational diabetes mellitus (GDM) are currently imprecise. Objective: We aimed to evaluate the association between fetal renal artery Doppler indices and neonatal birth weight in women with GDM in late pregnancy. Materials and Methods: This cohort study recruited 246 pregnant women from Shariati Hospital in Tehran, Iran, in two GDM and healthy control groups. Participants underwent weekly Doppler ultrasounds in the late pregnancy period (37-40 wk) to determine the Doppler indices of the umbilical artery, middle cerebral, and renal arteries. Fetal growth indices including biparietal diameter, abdominal circumference, head circumference, and femur length were also recorded and compared between the two groups. Results: Fetal growth indices and estimated fetal weight were not significantly different between the two groups. Neonatal birth weight was significantly higher in the GDM group (p < 0.01). The GDM group had significantly higher renal artery indices (resistance index: p = 0.01, pulsatility index [PI]: p = 0.03, and systolic/diastolic ratio [S/D]: p = 0.01) compared to the control group. Also, there was an inverse linear correlation between umbilical indices and birth weight (PI: p = 0.01, S/D: p < 0.01), and between renal artery indices and birth weight (resistance index: p = 0.02, PI: p = 0.01, and S/D: p = 0.03). In the control group, only umbilical artery PI had an inverse linear correlation with birth weight (p = 0.03) and there was no correlation between renal artery indices and birth weight. Conclusion: Using Doppler hemodynamic indices of the renal artery in late pregnancy in women with GDM can be helpful for early detection of hypoxic fetuses, who are at risk of being small for gestational age or having intrauterine growth restriction, even when of normal weight.

Second trimester biparietal diameter size and the risk of adverse pregnancy outcomes.

OBJECTIVE: To identify the relationship between biparietal diameter (BPD) in the second trimester and adverse pregnancy outcomes in low-risk pregnancies. METHOD: This prospective cohort study was performed on 2219 singleton pregnant women from August 2008 to March 2010. The gestational age-specific percentiles of BPD at 17 to 24 weeks of gestation were established to categorize participants into three groups: a BPD < 10th percentile as small BPD, between 10th and 90th percentile as normal BPD and > 90th percentile as large BPD. Using logistic regression analysis, the association between BPD < 10th and > 90th percentile with pregnancy outcomes was evaluated after controlling for confounding factors. RESULTS: There was a significantly increased risk of macrosomia [odds ratio (OR(adj)) = 2.1; 95% confidence intervals (CI), 1.23-3.78] and preterm labor (PTL) (OR(adj) = 1.9; 95% CI, 1.19-3.05) in fetuses with a BPD > 90th percentile compared with fetuses with a normal BPD, and there was a significant relationship between small for gestational age (SGA) at delivery and a BPD < 10th percentile at the second trimester (OR(adj) = 2.4; 95% CI, 1.77-3.52). No association was present between preeclampsia and second trimester BPD. CONCLUSION: BPD in the first half of pregnancy is related to fetal size at term and risk of PTL.

The correlation between the cerebroplacental ratio and fetal arterial blood gas in appropriate-for-gestational-age fetuses: A cross-sectional study.

BACKGROUND: The cerebroplacental ratio (CPR) is an important index for predicting adverse pregnancy outcomes in small-for-gestational-age and appropriate-for-gestational-age fetuses. OBJECTIVE: To find out whether there is an association between the CPR level and the blood cord gases analysis in appropriate for gestational age fetuses. MATERIALS AND METHODS: This cross-sectional study included 347 pregnant women at the gestational age of 37-40 wk. Patients had an appropriate-for-gestational-age fetus confirmed from their first ultrasonography results. Participants were divided into two groups based on their CPR, measured before delivery. Finally, after delivery, arterial blood gas level and the incidence of emergency cesarean section, intrapartum fetal distress and neonatal intensive care unit admissions were compared between the two groups. RESULTS: Fifty-four (15.6%) cases had a CPR below the detection limit of the assay. The incidence of fetal distress, emergency cesarean section, neonatal hospitalization in the neonatal intensive care unit, and pH < 7.2 were significantly lower in women with CPR ≥ 0.67 multiples than in women with a CPR < 0.67 multiples of the median. CONCLUSION: The third-trimester CPR is an independent predictor of stillbirth and perinatal mortality and morbidity. The role of UA/MCA Doppler and the CPR in assessing the risk of adverse pregnancy outcomes should be evaluated prospectively.

Development of a scoring system for prediction of placenta accreta and determine the accuracy of its results.

Background: Optimal management of women with placenta accreta requires accurate preoperative diagnosis. Therefore, this study was conducted with the aim to evaluate a new prediction scoring items for risk assessment on placenta accreta and determine its accuracy ratio.Methods: This prospective cohort study was carried out on 159 suspected pregnant women morbidly adherent placenta (MAP) in Shariati, Imam Khomeini, and Yas Hospitals in Tehran from October 2016 to May 2018. The number of previous cesarean deliveries; lacunae stage, location of placenta; Doppler assessment; and loss of clear zone were used for review and scoring of ultrasound images. Ultimately after collecting scores, subjects fall into one of the following three categories: low (≤5 points), moderate (6-7 points), or high (8-10 points) probability for placenta accreta. Ultimately, diagnosis of accreta was based on hysterectomy during surgery or reports of pathology. A logistic regression model was used to calculate the probability of placenta accreta on univariable analysis, to assess the discriminant power of all explanatory variables assessed by the receiver operating characteristic (ROC) curve.Results: The area-under-the-ROC curve of the composite scores was 98% and the overall sensitivity, specificity, and positive and negative predictive values of our developed scoring system were 91.84%, 87.27%, 86.54%, and 92.31%, respectively.Conclusion: Combination of several simple ultrasound and clinical characteristics in a scoring system may be highly effective for prenatal risk assessment and prediction of placenta accreta. Output of scoring system helps medical staff to prepare appropriately before surgery and avoid perinatal mortality and morbidity.

Cervical gland area as an ultrasound marker for prediction of preterm delivery: A cohort study.

BACKGROUND: Preterm labor is a major cause of perinatal morbidity and mortality and it might be predicted by assessing the cervical change. OBJECTIVE: To assess the association between absence of cervical gland area (CGA) and spontaneous preterm labor (SPTL). MATERIALS AND METHODS: This prospective cohort study was performed on 200 singleton pregnant women with a history of SPTL, second-trimester abortion in the previous pregnancy or lower abdominal pain in current pregnancy. Each patient underwent one transvaginal ultrasound examination between 14-28 wk of gestation. Cervical length was measured and CGA was identified and their relationship with SPTL before 35 and 37 wk gestation was evaluated using STATA software version 10. RESULTS: The mean of cervical length was 36.5 mm (SD=8.4), the shortest measurement was 9 mm, and the longest one was 61 mm. Short cervical length (≤18mm) was significantly associated with SPTL before 35 and 37 wk gestation.Cervical gland area (the hypoechogenic or echogenic area around the cervical canal) was present in 189 (94.5%) patients. Absent of CGA had a significant relationship with SPTL before 35 and 37 wk gestation (p=0.01 and p<0.001, respectively). Cervical length was shorter in women with absent CGA in comparison with subjects with present CGA: 37±10 mm in CGA present group and 23±9 mm in CGA absent group (p<0.001). CONCLUSION: Our study showed that cervical gland area might be an important predictor of SPTL which should be confirmed with further researches.

Adverse perinatal outcomes in borderline amniotic fluid index.

BACKGROUND: Normal amniotic fluid predicts normal placental function, fetal growth and fetal well-being. OBJECTIVE: To determine adverse pregnancy outcomes in borderline amniotic fluid index (AFI). MATERIALS AND METHODS: Pregnant women (37-40 wks) with diagnosis of borderline AFI between December 2012 and August 2014 were identified. Antepartum, intrapartum and neonatal data were collected and compared with those of pregnant women with normal AFI. An AFI less than 8 and more than 5 cm was defined for borderline AFI. Pregnancy outcomes included Cesarean section for non-reassuring fetal heart rate, meconium stained amniotic fluid, 5-min Apgar score <7, low birth weight, umbilical cord blood pH at term and NICU admission. RESULTS: Gestational age at delivery in pregnancies with borderline AFI was significantly lower than normal AFI. Cesarean section rate for non-reassuring fetal heart rate in women of borderline AFI was significantly higher and there was an increased incidence of birth weight less than 10th percentile for gestation age in borderline AFI group. Incidence of low Apgar score and low umbilical artery pH in pregnancies with borderline AFI was significantly higher than women with normal AFI. There were no significant difference in the rate of NICU admission and meconium staining in both groups. CONCLUSION: There are significant differences for adverse pregnancy outcomes , such as Cesarean section due to non-reassuring fetal heart rate, birth weight less than 10th percentile for gestation age, low 5 min Apgar score and low umbilical artery pH between pregnancies with borderline and normal AFI.

Multicenter screening for adverse pregnancy outcomes by uterine artery Doppler in the second and third trimester of pregnancy.

AIMS: Increased uterine artery pulsatility index (PI) is associated with adverse pregnancy outcomes. The aim of the study was to determine the role of uterine artery PI at 18-24 and 30-34 weeks, gestation in predicting adverse pregnancy outcomes. MATERIAL AND METHODS: Color Doppler assessment of the uterine arteries was carried out in 435 consecutive women attending an antenatal clinic at 18-24 weeks and in 134 women at 30-34 weeks. The 95th percentiles of the mean uterine PI and the presence or the absence of bilateral notches was recorded. Using the reference range, performance characteristics in the prediction of pregnancy outcomes were calculated. Association of mean PI at 30-34 weeks with pregnancy outcomes also was studied. The adverse pregnancy outcomes were defined as any or the combination of pre-eclampsia, fetal growth restriction, intrauterine fetal death, preterm delivery and placental abruption. RESULTS: The women with adverse pregnancy outcomes had significant higher mean PI (1.27 +/- 0.55 vs. 0.99+/-0.32; p=0.003) and higher prevalence of bilateral notch (20% vs. 4.6%, p=0.001) than those with normal outcomes. The mean (+/-SD) PI in women with severe adverse outcome was 1.66+/-0.66 vs. 1.0+/-0.32 in women with normal pregnancy outcome (p=0.002). For a screen positive rate of 10.6% (mean PI>95th percentile for gestational age and/or bilateral notches), the sensitivity for predicting an adverse outcome was 33.3%. The sensitivity increased to 60% for predicting a severe adverse outcome. Increased resistance in the third trimester was also associated with an adverse pregnancy outcome. CONCLUSION: Increased uterine artery PI in second and third trimester of pregnancy is associated with an increased risk of adverse pregnancy outcomes.

Random urine protein creatinine ratio as a preadmission test in hypertensive pregnancies with urinary protein creatinine ratio.

UNLABELLED: To evaluate the value of random urinary protein creatinine ratio in prediction of 24h proteinuria in hypertensive pregnancies. METHOD: Random urine samples and routine 24h urine collections were collected from hypertensive pregnant women (n=100). Reliability of random urinary protein-creatinine ratio was assessed by receiver operator characteristic (ROC) curve to detect significant proteinuria (≥300mg/day) using 24h. Urine protein as a gold standard. Forty six patients (46%) had significant proteinuria. The random protein creatinine ratio was correlated to 24h urine protein excretion (r(2)=0.777, P<0.001) Area under ROC curve to predict proteinuria was 0.926 (95% CI: 0.854-0.995, P<0.001). A cut off value of 0.22mg/mg for protein creatinine ratio best predicted significant proteinuria with sensitivity, specificity, positive and negative predictive values of 87%, 92.6%, 90.6% and 89.3% respectively. Random urinary protein creatinine ratio is a simple inexpensive and excellent alternative to 24h urine collection. It's helpful in diagnosis of preeclampsia and can be used as a pre admission test in PIH cases.