Is It Possible to Diagnose Surgical Uterine Prolapse With Transperineal Ultrasound? Multicenter Validation of Diagnostic Software.

OBJECTIVES: To validate an ultrasound software that uses transperineal ultrasound to diagnose uterine prolapse (UP). METHODS: Multicenter, observational and prospective study with 155 patients that had indications for surgical intervention for dysfunctional pelvic floor pathology. Each patient underwent an examination with Pozzi tenaculum forceps was performed in the operating room with the patient anesthetized, followed by surgical correction of stages II-IV UP. Transperineal ultrasound was used to assess the difference in the pubis-uterine fundus measurement. With a multivariate logistic regression binary model (with the measurement ultrasound at rest, the Valsalva maneuver and age) using nonautomated methods to predict UP. With the purpose of evaluating the model, a table with coordinates of the receiver operating characteristic (ROC) curve, after which sensitivity and specificity were assessed. RESULTS: A total of 153 patients were included (73 with a diagnosis of surgical UP). It was obtained from the AUC (0.89) of the probabilities predicted by the model (95% confidence interval, 0.84-0.95; P < .0005). Based on the ROC curve for the model, obtaining a sensitivity of 91.8% and a specificity of 72.7%, values that were superior to those for the clinical exam for surgical UP (sensitivity: 80.8%; specificity: 71.3%). CONCLUSIONS: We validated software that uses transperineal ultrasound of the pelvic floor and patient age to generate a more reliable diagnosis of surgical UP than that obtained from clinical examinations.

Identification of Surgical Uterine Prolapse in Premenopausal Patients With Clinical or Ultrasound Criteria? A Multicenter Comparative Study.

OBJECTIVES: It is unknown whether diagnosing uterine prolapse (UP) via ultrasound or surgical criteria is superior. Our objective is to determine whether the diagnostic capacity of ultrasound with surgical criteria differs from that of surgical criteria only. METHODS: This was a multicenter prospective observational study with 54 premenopausal patients with surgical criteria for a dysfunctional pelvic floor pathology who were consecutively recruited for 1 year. Clinical UP with surgical criteria was defined when UP stage II-IV was identified (during pelvic floor consultation), and UP diagnosed by ultrasound with surgical criteria was established when a difference ≥15 mm was found between rest and Valsalva applied to the pubis-uterine fundus. The sensitivity, specificity and positive and negative predictive values were determined to evaluate clinical and ultrasound methodologies as diagnostic tests. RESULTS: UP diagnosed by ultrasound with surgical criteria presented better sensitivity (78.57 vs 35.71%), specificity (92.11 vs 81.58%), positive predictive value (61.83 vs 23.99%), and negative predictive value (96.35 vs 11.37%) than UP diagnosed by surgical criteria only. CONCLUSION: Ultrasound with surgical criteria is superior to surgical criteria alone when diagnosing UP.

Interobserver variability of ultrasound measurements for the differential diagnosis of uterine prolapse and cervical elongation without uterine prolapse.

OBJECTIVES: Our study aims to determine the interobserver variability of different ultrasound measurements (pubis-cervix distance, pubis-uterine fundus distance, and pubis-Douglascul-de-sac distance) previously analyzed for the ultrasound differential diagnosis of uterine prolapse (UP) and cervical elongation CE without UP. MATERIALS AND METHODS: We conducted a prospective observational study with 40 patients scheduled to undergo surgical correction of UP and CE without UP. All patients underwent pelvic floor ultrasound examination by an examiner (E1) who acquired ultrasound images. Using these images, E1 measured the distances for the ultrasound differential diagnosis of UP and CE without UP, and these distances were compared with those measured by the other examiner (E2). Values were analyzed by calculating ICCs with 95% CIs. RESULTS: For UP, excellent reliability was obtained for all measurements except the pubis-Douglascul-de-sac measurement at rest, which was moderate (ICC 0.596; p = 0.028) and for the difference between the pubis-Douglascul-de-sac measurement at rest and during the Valsalva maneuver, which was good (ICC 0.691; p < 0.0005). For CE without UP, interobserver reliability was excellent for all measurements analyzed except the pubis-cervix measurement during the Valsalva maneuver, which was moderate (ICC 0.535; p = 0.052) and for the pubis-Douglascul-de-sac measurement at rest, which was good (ICC 0.768; p < 0.0005). CONCLUSIONS: There is excellent interobserver reliability in measurements of the difference in the distance from the pubic symphysis to the uterine fundus at rest and during the Valsalva maneuver for both UP and CE without UP, which are used for the ultrasound differential diagnosis of UP and CE without UP.

Differential diagnosis of middle compartment pelvic organ prolapse with transperineal ultrasound.

INTRODUCTION AND HYPOTHESIS: The objective was to identify the best parameter (pubis-cervix measurement, pubis-uterine fundus measurement or pubis-pouch of Douglas measurement) on transperineal ultrasound, based on the difference between measurements taken at rest and with the Valsalva maneuver, for presurgical differential diagnosis between uterine prolapse (UP) and cervical elongation (CE) without UP. METHODS: A prospective observational study of 60 consecutively recruited patients who underwent corrective surgery of the middle compartment (UP or CE without UP). A transperineal ultrasound was performed, and the descent of the pelvic organ was measured in relation to the posteroinferior margin of the pubis in the midsagittal plane, referencing the uterine fundus, pouch of Douglas and the cervix at rest and with the Valsalva test. RESULTS: Receiver operating characteristic (ROC) curves were constructed for the three evaluated measures, based on the difference between rest and Valsalva, for the diagnosis of UP. For the pubis-cervix distance, an area under the curve (AUC) of 0.59 was obtained; for the pubis-uterine fundus distance, the AUC was 0.81; and for the pubis-pouch of Douglas distance, the AUC was 0.69. Based on the best AUC (the difference in the pubis-uterine fundus distance at rest and with the Valsalva maneuver), a cut-off point of 15 mm was established for the diagnosis of UP (sensitivity: 75%; specificity: 95%; positive predictive value: 86%; and negative predictive value: 89%). CONCLUSION: A difference of ≥15 mm in the pubis-uterine fundus distance at rest and with the Valsalva maneuver is useful for differentiating UP from CE without UP by ultrasound.

Molecular inflammation and oxidative stress are shared mechanisms involved in both myocardial infarction and periodontitis.

BACKGROUND AND OBJECTIVE: Our aims were to improve the understanding of the pathogenic relationship between cardiovascular diseases and periodontitis and to generate new perspectives in the prevention and treatment of acute myocardial infarction (AMI) and periodontitis. The present study evaluates possible differences in inflammation, oxidative stress, and autophagy markers among subject suffering AMI, periodontitis, or both, to explore possible common pathogenic mechanisms. MATERIAL AND METHODS: A total of 260 subjects were enrolled in the study: 106 subjects that survived to a first AMI (AMI group) and 154 subjects had no cardiac events in their clinical record (control group). A questionnaire was used to assess age, height, weight, blood pressure, and heart rate. The clinical probing depth, clinical attachment loss, number of remaining teeth, and average number of sites with bleeding on probing were assessed. Lipid peroxidation and protein levels of phosphorylated AMP-activated protein kinase (p-AMPK) and microtubule-associated proteins 1A/1B-light chain 3-II (LC3-II) were determined in isolated peripheral blood mononuclear cells by thiobarbituric acid reactive substances (TBARS) assay and Western blot, respectively. Plasma levels of interleukin-1ß were determined using a commercial ELISA kit. All the obtained variables were compared between subjects suffering an AMI with or without periodontitis and control subject periodontal healthy or with periodontitis. RESULTS: A higher proportion of subjects suffering AMI + periodontitis than only AMI (without periodontitis) was found. Higher levels of TBARS were found in subjects with periodontitis than in subjects without periodontitis in both AMI and control subjects. Positive correlations between IL-1ß levels and TBARS and between IL-1ß levels and LC3-II were found only in control subjects. CONCLUSION: Results from the present study are consistent with the suggestion of periodontitis as a potential risk factor for AMI. Periodontitis association with circulating lipid peroxides in both AMI and control subjects were found. The absence of differences in IL-1ß levels between AMI subjects (only AMI vs AMI + periodontitis) suggests that oxidative stress could be the main pathogenic link between AMI and periodontitis.

Are there differences in the damage to the pelvic floor between malmstrom's and kiwi omnicup vacuums? A multicenter study.

OBJECTIVES: The objective of this study is to investigate a multicenter study to establish if differences exist in the levator ani muscle avulsion (LAM) rates between deliveries performed with Malmstrom's vacuum and the Kiwi vacuum. STUDY DESIGN: A prospective, multicenter observational study with 199 primiparous subjects was performed. All patients had undergone vaginal delivery by vacuum (Malmstrom's or Kiwi). Avulsion was defined as an abnormal insertion of LAM in the lower pubic branch in the multiplanar mode, as identified in the three central sections by transperineal 3/4D echography 6 months after delivery. The area of ​​the levator hiatus was measured in the plane of minimum dimensions at rest, during the Valsalva maneuver and during contraction. RESULTS: LAM avulsion occurred in 33.1% of cases in which Malmstrom's vacuum was used and in 29.4% of cases in which the Kiwi vacuum was used (the difference was not statistically significant), which resulted in a crude odds ratio (OR) of 0.977 (0.426, 2.241; P = .957) and an adjusted OR of 2.90 (0.691; 12.20; P = .146). Women in the Malmstrom's vacuum group had a larger LHA at rest 14.77 vs 12.64 cm2 ; P = .001) and at maximum contraction (13.41 vs 10.83 cm2 ; P < 0.001) in comparison with the Kiwi group, although the difference did not reach statistical significance under Valsalva maneuver (18.71 vs 17.21 cm2 ; P = .051).Differences between both groups were detected in the measurements of the hiatus area levator at rest (14.77 vs 12.64 cm2 ), during the Valsalva maneuver (18.71 vs 17.21 cm2 ) and during maximum contraction (13.41 vs 10.83 cm2 ). CONCLUSIONS: In the present study, Malmstrom's vacuum was not associated with a higher risk of LAM in comparison with Kiwi's Omnicup.

Association between sexual dysfunction and avulsion of the levator ani muscle after instrumental vaginal delivery.

INTRODUCTION: The effects of levator ani muscle (LAM) avulsion after instrumental delivery on the sexual function of patients are currently unknown. Therefore, the objective of our study was to use a validated questionnaire, namely, the Female Sexual Function Index (FSFI), to compare the sexual function in patients with and without LAM avulsion after instrumental vaginal delivery. MATERIAL AND METHODS: This was a prospective observational study of 112 primiparous women after instrumental (vacuum or forceps) vaginal delivery. The obstetric and general characteristics of the population were studied. At 6 months postpartum, the contraceptive method used and the occurrence of LAM avulsion (using four-dimensional transperineal ultrasound) were determined, and the FSFI was administered. RESULTS: A total of 100 patients (62 without avulsion and 38 with avulsion) completed the study. Thirty-eight (38%) were diagnosed with avulsion (42.1% after Kielland forceps delivery, 57.9% after Malmström vacuum delivery; P = .837). Women with LAM avulsion had significantly lower scores for desire (2.9 ± 1.2 vs 3.4 ± 1.1; P = .049), arousal (2.8 ± 1.7 vs 3.6 ± 1.4; P = .014), lubrication (2.3 ± 1.4 vs 3.0 ± 1.2; P = .011), orgasm (2.6 ± 1.6 vs 3.3 ± 1.2; P = .006) and satisfaction (3.1 ± 1.8 vs 3.9 ± 1.5; P = .051) than did women without LAM avulsion. The overall FSFI score was lower in patients with avulsion (16.7 ± 8.9 vs 20.7 ± 6.9, P = .033). These results were obtained after controlling for confounders (delivery mode, induced labor, birthweight, perineal tears, avulsion degree, contraceptive method and group assignment for the parent study) in the multivariate analysis (F = 4.974, P = .001). CONCLUSIONS: Patients with LAM avulsion present a higher degree of sexual dysfunction compared wiith patients without avulsion at 6 months after instrumental vaginal delivery.

Influence of epidemiological characteristics (age, parity and other factors) in the assessment of healthy uterine cervical stiffness evaluated through shear wave elastography as a prior step to its use in uterine cervical pathology.

PURPOSE: The purpose of this study was to evaluate stiffness changes occurring in the healthy uterine cervix according to age, parity, phase of the menstrual cycle and other factors by shear wave elastography (SWE). METHODS: Evaluations of cervical speed and stiffness measurements were performed in 50 non-pregnant patients without gynaecological pathology using SWE transvaginal ultrasound. We performed the evaluation in the midsagittal plane of the uterine cervix with measurements at 0.5, 1 and 1.5 cm from external cervical os, at both anterior and posterior cervical lips. RESULTS: We evaluated 44 patients by SWE and obtained a total average velocity of 3.48 ± 1.08 m/s and stiffness of 42.39 ± 25.33 kPa. We found differences in speed and stiffness according to the cervical lip and depth evaluated; thus, we observed a velocity of 2.70 m/s at 0.5 cm of depth in the anterior lip and 3.53 m/s at 1.5 cm of depth in the posterior lip (p < 0.05). We observed differences according to parity, obtaining a wave transmission speed of 2.67 m/s and 4.41 m/s at the cervical canal of nulliparous and multiparous patients, respectively (p < 0 0.002). We observed differences according to patient age (from a speed of 2.75 m/s at the cervical canal in the age group of 20-35 years to 5.05 m/s in the age group > 50 years) (p < 0.008). We did not observe differences in speed or stiffness according to the phase of the menstrual cycle, BMI, smoking status or the presence or absence of non-HPV infections. CONCLUSIONS: The wave transmission speed and stiffness of the uterine cervix evaluated by SWE varies according to the cervical lip and depth of the evaluation as well as according to the parity and age of the patient.

A simple model to predict the complicated operative vaginal deliveries using vacuum or forceps.

BACKGROUND: Complicated operative vaginal deliveries are associated with high neonatal morbidity and maternal trauma, especially if the procedure is unsuccessful and a cesarean delivery is needed. The decision to perform an operative vaginal delivery has traditionally been based on a subjective assessment by digital vaginal examination combined with the clinical expertise of the obstetrician. Currently there is no method for objectively quantifying the likelihood of successful delivery. Intrapartum ultrasound has been introduced in clinical practice to help predict the progression and final method of delivery. OBJECTIVE: The aim of this study was to compare predictive models for identifying complicated operative vaginal deliveries (vacuum or forceps) based on intrapartum transperineal ultrasound in nulliparous women. STUDY DESIGN: We performed a prospective cohort study in nulliparous women at term with singleton pregnancies and full dilatation who underwent intrapartum transperineal ultrasound evaluation prior to operative vaginal delivery. Managing obstetricians were blinded to the ultrasound data. Intrapartum transperineal ultrasound (angle of progression, progression distance, and midline angle) was performed immediately before instrument application, both at rest and concurrently with pushing. Intrapartum evaluation of fetal biometric parameters (estimated fetal weight, head circumference, and biparietal diameter) was also carried out. An operative vaginal delivery was classified as complicated when 1 or more of the following complications occurred: ≥3 tractions needed; third- to fourth-degree perineal tear; severe bleeding during episiotomy repair (decrease of ≥2.5 g/dL in the hemoglobin level); or significant traumatic neonatal lesion (subdural-intracerebral hemorrhage, epicranial subaponeurotic hemorrhage, skeletal injuries, injuries to spine and spinal cord, or peripheral and cranial nerve injuries). Six predictive models were evaluated (information available in Table 2). RESULTS: We recruited 84 nulliparous patients, of whom 5 were excluded because of the difficulty of adequately evaluating the biparietal diameter and head circumference. A total of 79 nulliparous patients were studied (47 vacuum deliveries, 32 forceps deliveries) with 13 cases in the occiput-posterior position. We identified 31 cases of complicated operative vaginal deliveries (19 vacuum deliveries and 12 forceps deliveries). No differences were identified in obstetric, neonatal, or intrapartum characteristics between the 2 study groups (operative uncomplicated vaginal delivery vs operative complicated vaginal delivery), with the following exceptions: estimated fetal weight (3243 ± 425 g vs 3565 ± 330 g; P = .001), biparietal diameter (93.2 ± 2.1 vs 95.2 ± 2.3 mm; P = .001), head circumference (336 ± 12 vs 348 ± 6.4 mm; P = .001), sex (female 62.5% vs 29.0%; P = .010), newborn weight (3258 ± 472 g vs 3499 ± 383 g; P = .027), and number of tractions (median, interquartile range) (1 [1-2] vs 4 [3-5]; P < .0005). To predict complicated operative deliveries, all 6 of the studied models presented an area under the receiver-operating characteristics curve between 0.863 and 0.876 (95% confidence intervals, 0.775-0.950 and 0.790-0.963; P < .0005). The results of the study met the criteria of interpretability and parsimony (simplicity), allowing us to identify a binary logistic regression model based on the angle of progression and head circumference; this model has an area under the receiver-operating characteristics curve of 0.876 (95% confidence interval, 0.790-0.963; P < .0005) and a calibration slope B of 0.984 (95% confidence interval, 0.0.726-1.243; P < .0005). CONCLUSION: The combination of the angle of progression and the head circumference can predict 87% of complicated operative vaginal deliveries and can be performed in the delivery room.

A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation.

INTRODUCTION: Forceps delivery is associated with a high rate of levator ani muscle (LAM) trauma (avulsion) at 35%-65% whereas data on avulsion rates after vacuum delivery vary greatly. Nevertheless, a common characteristic of all previous studies carried out to evaluate the association between instrumental deliveries (forceps and vacuum) and LAM avulsion, is the fact that characteristics of the instrumentation have not been described or evaluated. The objective of this study is to compare the rate of LAM avulsion between forceps and vacuum deliveries according to the characteristics of the instrumentation. MATERIAL AND METHODS: Prospective, observational study, including 263 nulliparous women, who underwent an instrumental delivery with either Malmström vacuum or Kielland forceps. The characteristics of the instrumentation, position (anterior position and other position) and height of the fetal head at the moment of instrumentation (low instrumentation [vertex at +2 station] and mid-instrumentation [head is involved but leading part above +2 station]) were assessed. Evaluation of LAM avulsion was performed at 6 months postpartum by three-/four-dimensional transperineal ultrasound. Using the multi-view mode, a complete avulsion was diagnosed when the abnormal muscle insertion was identified in all three central slices, that is, in the plane of minimal hiatal dimensions and the 2.5-mm and 5.0-mm slices cranial to this one. To detect a 30% or 15% difference in the LAM injury rate, with 80% power and 5% α-error, we needed, respectively 42 and 99 women per study group. RESULTS: In all, 263 nulliparous individuals have been evaluated (162 vacuum deliveries, 101 forceps deliveries). Instrumentation in an occipito-anterior position was more frequent in vacuum deliveries (75.3% vs 56.4%, P = .002), whereas other positions were more frequent in the forceps deliveries group (24.7% vs 43.6%). No statistically significant differences were noted regarding the height of the fetal head at the moment of instrumentation. No statistically significant differences were found in the presence of LAM avulsion (41.4% vs 38.6%) between vacuum and forceps deliveries. The univariate analysis of the crude odds ratio was 1.17, 95% CI 0.67-1.98, P = .70 for the avulsion of the LAM and the multivariate of the adjusted OR 0.90, 95% CI; 0.53-1.55, P = .71. CONCLUSIONS: We consider that, in our population, LAM avulsion rate should not be a factor taken into account when choosing the type of instrumentation (Malmström vacuum or Kielland forceps) in an operative delivery.

Influence of the disengagement of the forceps on levator ani muscle injuries in instrumental delivery: A multicenter study.

INTRODUCTION: Forceps use is the main risk factor for levator ani muscle (LAM) injuries. We believe that the disengagement of the forceps branches before delivery of the fetal head could influence LAM injuries, so we aimed to determine the influence of the disengagement of the forceps on the occurrence of LAM avulsion during forceps delivery. MATERIAL AND METHODS: A prospective, observational, multicenter study was conducted with 261 women who underwent forceps delivery. The women were classified according to whether the branches of the forceps had been disengaged before delivery of the fetal head. LAM avulsion was defined using a multislice mode (3 central slices). RESULTS: In all, 255 women completed the study (160 without disengagement and 95 with disengagement). LAM avulsions were observed in 37.9% of women in the group with disengagement and in 41.9% of women in the group without disengagement. The crude OR (without disengagement vs with disengagement) for avulsion was 0.90 (95% CI 0.49-1.67, P = 0.757) and an adjusted OR of 0.82 (95% CI 0.40-1.69, P = 0.603). CONCLUSIONS: We did not observe a statistically significant reduction in the LAM avulsion rate with disengagement of the forceps branches before delivery of the fetal head.

The correlation between the type of forceps application and the rate of levator ani muscle avulsion: A prospective cohort study.

OBJECTIVES: The association between the use of forceps and levator ani muscle (LAM) avulsion seems to be clear-cut. However, whether the lesion is due to the mechanical trauma yielded by the instrument or to the intrinsic complexity of this type of delivery, is yet to be determined. This study aims at determining the difference in LAM avulsion rate between Kielland rotational forceps and non-rotational forceps. STUDY DESIGN: Prospective observational study with 94 nulliparous women with forceps-assisted deliveries (FD) between July 2015 and January 2016. 3D-TpUS was performed 6 months after every patient's delivery, during which LAM avulsion, and levator hiatus area and anteroposterior and transverse diameters were assessed. RESULTS: A total of 89 nulliparous were studied, comprising 27 rotational-FD, and 62 non-rotational-FD. No differences in obstetric, intrapartum, or neonatal characteristics were observed between study groups. There were no statistically significant differences in the presence of avulsion between cases of rotational forceps (44.4% vs 35.5%, OR: 1.5 [0.6-3.6]), correction of asinclitism of the fetal head (34.4% vs. 40.4% OR: 0.8 [0.3-1.9]) or station (midforceps: 32.8% vs low forceps: 50.0% OR: 2.0 [0.8-5.1]). CONCLUSIONS: We have not observed differences in the LAM-avulsion rate between rotational forceps and non-rotational forceps performed by highly experienced personnel in instrumental deliveries.

Intra and interobserver variability of intrapartum transperineal ultrasound measurements with contraction and pushing.

The aim of this study was to evaluate the inter- and intraobserver correlation of the different intrapartum-transperineal-ultrasound-parameters(ITU) (angle of progression (AoP), progression-distance (PD), head-direction (HD), midline-angle (MLA) and head-perineum distance (HPD)) with contraction and pushing. We evaluated 28 nulliparous women at full dilatation under epidural analgesia. We performed a transperineal ultrasound evaluating AoP and PD in the longitudinal plane, and MLA and HPD in the transverse plane. Interclass correlation coefficients (ICC) with 95% CIs and Bland-Altman analysis were used to assess intra- and interobserver measurement's repeatability. The ICC of the ITU for the same observer was adequate for all the parameters (p < .005) AoP 0.98 (95%CI, 0.96-0.99), PD 0.98 (95%CI, 0.97-0.99), MLA 0.99 (95%CI, 0.97-0.99), HPD 0.96 (95%CI, 0.88-0.99). The ICC of the ITU for interobserver was: AoP 0.93 (95%CI, 0.79-0.98), PD 0.92 (95%CI, 0.76-0.97), MLA 0.77 (95%CI, 0.42-0.92), HPD 0.47 (95%CI, -0.12-0.8). The HD had an interobserver correlation of 0.53 (95%CI, 0.1-0.9) (Kappa C). The mean difference of the AoP was 2.42°, of the PD 1 mm and 0.28° MLA (Bland-Altman test). ITU has an adequate intra- and interobserver correlation for its use with contraction and pushing under epidural analgesia. Impact statement What is already known on this subject: The intrapartum transperineal ultrasound parameters can be used with contraction and pushing under epidural analgesia. What the results of this study add to what we know: ITU may be used to evaluate the difficulty of instrumental delivery/to evaluate the difficulty of instrumentation in vaginal operative deliveries and this study concludes that ITU is reproducible during uterine contraction with pushing. What the implications are of these findings for clinical practice and/or further research: Therefore, ITU could be used without difficulty with an adequate intra- and interobserver correlation for the prediction of instrumentation difficulty in operative vaginal deliveries.

Evaluation of isolated urinary stress incontinence according to the type of levator ani muscle lesion using 3/4D transperineal ultrasound 36 months post-partum.

INTRODUCTION: Vaginal delivery can lead to pelvic floor disorders. Many authors have described pelvic floor injuries that can predict future defects such as urinary incontinence and pelvic organ prolapse. We propose the assessment of urinary stress incontinence and its association with levator ani muscle (LAM) microtrauma (>20% in the levator hiatus area during Valsalva) and macrotraumas (avulsion) identified by 3/4D transperineal ultrasound (3D-TpUS) 36 months post-partum. MATERIALS AND METHODS: This was a prospective observational study including 168 nulliparous women. All patients included were nulliparous with singleton gestation in cephalic presentation, at ≥37 weeks and were recruited on the first day after delivery. Thirty-six months after delivery, 3D-TpUS was carried out to identify LAM lesions (macro or micro). Clinical assessment of urinary stress incontinence (USI) was based on the ICIQ-UI-SF test; a simple stress test and urodynamic test were carried out in the same visit. RESULTS: A total of 105 nulliparous women were studied (51 spontaneous deliveries [SpD] and 54 vacuum-assisted deliveries [VD]). Microtraumas were identified in 35.3% of SpD and 20.4% of VD. Macrotraumas (avulsion) were identified in 9.8% of SpD and 35.2% of VD (p = 0.006). No differences were found in USI between study groups or in relation to the identification of LAM defects (19.2% in the no lesion group, 25% in the macrotrauma and 13.8% in the microtrauma groups; p = not significant). Nor were significant differences found in the results from the different study groups in the International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF) test (12.7±2.2 in the no lesion group, 12.5±4.2 in the macrotrauma and 13.25±4.8 in the microtrauma groups; p = NS). CONCLUSION: No difference was observed in USI between patients with and without LAM lesions (microtrauma or macrotrauma) 36 months post-delivery.

Intrapartum transperineal ultrasound used to predict cases of complicated operative (vacuum and forceps) deliveries in nulliparous women.

INTRODUCTION: The objective of this study was to investigate the predictive value of intrapartum transperineal ultrasound in the identification of complicated operative (vacuum or forceps) deliveries in nulliparous women. MATERIAL AND METHODS: Prospective observational study of nulliparous women with an indication for operative delivery who underwent intrapartum transperineal ultrasound before fetal extraction. Managing obstetricians were blinded to the ultrasound data. Intrapartum transperineal ultrasound was performed immediately before blade application, both at rest and concurrently with contractions and active pushing. Operative delivery was classified as complicated when one or more of the following situations occurred: three or more tractions; a third-/fourth-degree perineal tear; significant bleeding during the episiotomy repair; major tear or significant traumatic neonatal lesion. RESULTS: A total of 143 nulliparous women were included in the study (82 vacuum-assisted deliveries and 61 forceps-assisted deliveries), with 20 fetuses in occiput posterior position. Forty-seven operative deliveries were classified as complicated deliveries (28 vacuum-assisted deliveries, 19 forceps-assisted deliveries). No differences in obstetric, intrapartum or neonatal characteristics were observed between the study groups, with the following exceptions: birthweight (3229 ± 482 uncomplicated deliveries vs. 3623 ± 406 complicated deliveries; p < 0.003) and number of vacuum tractions (1.4 uncomplicated deliveries, 4.5 complicated deliveries; p < 0.0005). The strongest predictors of a complicated delivery, using the area under the receiver-operating characteristics curve (AUC), were the angle of progression with active pushing (AoP2) (AUC 86.9%) and the progression distance with active pushing (PD2) (AUC 74.5%). The optimal cut-off value for predicting a difficult operative delivery was an AoP2 of 153.5° (sensitivity 95.2%; false-positive rate 5.9%) or PD2 of 58.5 mm (sensitivity 95.2%; false-positive rate 7.1%). CONCLUSIONS: The sonographic parameters AoP2 and PD2 can be used to predict cases of complicated operative deliveries in nulliparous women.

Assessment of Osstell ISQ's reliability for implant stability measurement: a cross-sectional clinical study.

UNLABELLED: Resonance frequency analysis (RFA) allows assess implant stability by measuring implant oscillation frequency on the bone. RFA is an objective and non-invasive method for implant stability measurement, although scarce evidence has been provided so far on its reliability. OBJECTIVE: Assess the Osstell ISQ system's reliability (i.e., its measurement reproducibility and repeatability) by means of the intraclass correlation coefficient (ICC) as statistical method. DESIGN OF THE STUDY: Two implant stability registers were completed by means of Osstell ISQ on 85 implants on 23 patients. Six measurements were completed on each implant by means of two different SmartPegs (types I and II); that is, three consecutive measurements with each transducer. RESULTS: Average ISQ was 72.40, 72.22 and 72.79, and 72.06, 72.59 and 72.82 in the first, second, and third measurements with SmartPegs I and II, respectively. Equal values or differences below three ISQ points were observed in 52.9% and 62.4% of the cases with SmartPegs I and II, respectively. The intraclass correlation coefficient was 0.97 for both SmartPegs, and repeatability and reproducibility also reached 0.97 for both SmartPegs. CONCLUSIONS: The RFA system Osstell ISQ presents almost perfect repeatability and reproducibility after intraclass correlation coefficient analysis. Osstell ISQ measurements are highly reliable regarding reproducibility. Therefore, one measurement proves enough.

Assessment of late on-set fetal growth restriction using SMI (superb microvascular imaging) Doppler.

Background: The identification of late-onset fetal growth restriction (FGR) fetuses remains a challenge, given the difficulty to distinguish them from healthy small for gestational age (SGA) fetuses. Given the limitations of conventional Doppler for the identification of placental insufficiency, the appearance of superb microvascular imaging (SMI) Doppler seems promising. Our main objective was to evaluate the diagnostic capability of SMI Doppler for the detection of placental insufficiency findings. Methods: A prospective observational study was conducted at a tertiary care center, including 51 patients who had been diagnosed with late on-set SGA or FGR. A placental ultrasonographic evaluation was carried out using SMI Doppler. Patients were sorted into two groups attending to the histologic evaluation of the placentas after delivery: Group 1 (21 cases), Normal group; and Group 2 (30 cases), FGR group. Results: Placentas in the FGR group had lower peak systolic velocity (PV) values of the chorionic plate. The PV of the other vessels were consistently lower in the FGR group that in the normal group, although without reaching statistical significance. Conclusions: The PV of the chorionic plate measured with SMI Doppler, have the capacity to identify placental insufficiency findings. Ultrasonographic placental assessment using SMI Doppler appears to be a useful technique for the evaluation of suspected late on-set placental insufficiency.

Can Intrapartum Ultrasonography Improve the Placement of the Vacuum Cup in Operative Vaginal Deliveries?

Although the fetal head position has traditionally been evaluated by digital examination (DE), it has a failure rate ranging between 20 and 70%; hence, intrapartum transabdominal ultrasonography (TUS) has become relevant. We aimed to evaluate the utility of the TUS to identify the fetal head positions in vacuum-assisted deliveries. We performed a prospective observational study including 101 pregnant patients in active labor who required a vacuum-assisted delivery. The fetal head position was assessed by a DE and a TUS prior to vacuum cup placement. After delivery, the optimal vacuum cup placement was evaluated as the distance between the chignon and the flexion point ≤2 cm. The general concordance rate between the DE and TUS was 72.2%, with the poorest concordance rate for occiput posterior positions at 46.1%. In five cases (4.9%), it was not possible to determine the fetal head position through the DE. The correlation was higher in low and medium planes, with 77% and 68.1% concordance rates, respectively, while it was lower in high planes (60%). In 90.1% of cases, the vacuum cup placement was optimal. Our findings show that intrapartum transabdominal ultrasonography is a useful technique to identify the fetal head position allowing optimal placement of the vacuum cup necessary for correct vacuum-assisted delivery.

Reproducibility of the anorectal angle with transperineal ultrasound.

Background: The anorectal angle (ARA) has been assessed with different imaging methods and its measurement has traditionally been based on defecography or magnetic resonance studies. Different ultrasound methodologies have also been used for ARA assessment and have been validated as alternatives for the ARA measurement, such as three-dimensional (3D) endovaginal ultrasound and 3D transperineal ultrasound. 3D transperineal ultrasound does not require the introduction of ultrasound transducers inside the anal canal. Therefore, it is reasonable to think that the use of transperineal ultrasound can provide more reproducible ARA measurements, something that has not been established by 3D endovaginal probe or defecography. Our objective is to determine the intraobserver and interobserver variability of transperineal ultrasound for the assessment of ARA. Methods: A retrospective observational study was performed with 40 patients. The study of the ARA was performed from the mid-sagittal plane (at rest, Valsalva and maximum contraction), visualizing the anorectal canal, the anorectal junction and the rectal ampulla. ARA measurements were performed initially by explorer 1 (E1), subsequently by explorer 2 (E2) and finally again by E1. Intraobserver and interobserver variability was calculated by calculating the intraclass correlation coefficient (ICC) with 95% confidence interval (CI). Results: Intraobserver variability was excellent for all measurements of the ARA at rest, Valsalva and maximal contraction, with ICC ranging from 0.968 to 0.975. Interobserver variability was also superb for all measurements of the ARA at rest, Valsalva and maximal contraction, with ICC ranging from 0.971 to 0.979. Conclusions: Intraobserver and interobserver variability were excellent for the ARA measurements by transperineal ultrasound.

Multicenter study of the evolution of different types of avulsion over the 12 months after delivery.

OBJECTIVE: To perform a multicenter study of muscle recovery in levator ani muscle (LAM) avulsion during the first 12 months postpartum according to the type of LAM avulsion suffered. METHODS: This was a multicenter prospective observational study including 242 primiparas. Transperineal ultrasound was performed at 6 months and 12 months after delivery. Type I LAM avulsion was present when most of the lateral fibers of the pubovisceral muscle were observed at the muscle's insertion at the pubic level. Type II LAM avulsion was defined as complete detachment of the pubovisceral muscle from its insertion at the pubic level. RESULTS: Among the 56 patients who completed the study (with ultrasound at 6 and 12 months after delivery), 76 avulsions (10 cases of bilateral avulsion) were identified at 6 months after delivery, and the total number of avulsions had decreased to 58 at 12 months after delivery (P < 0.001; 95% confidence interval [CI] 13.9%-33.5%). This decrease was due to the disappearance of 69.2% of the cases of Type I LAM avulsions (P < 0.001; 95% CI: 50.2%-88.2%). However, the number of Type II LAM avulsions remained constant at 6 months and 12 months after delivery. CONCLUSION: The spontaneous resolution of LAM avulsion during the first 12 months postpartum occurs in cases of Type I LAM avulsion but is not observed in Type II LAM avulsion.