Visual biofeedback for shortening second stage of labor: randomized controlled trial.

OBJECTIVE: To determine whether visual biofeedback can be used during labor as an effective tool for shortening the second stage of labor and reducing the need for instrumental delivery. METHODS: This was a single-center randomized controlled trial. Nulliparous women under epidural anesthesia were randomized at the point of full dilation into the biofeedback group (n = 50) or the control group (n = 50). Both groups received coached maternal pushing during four consecutive contractions, while an experienced obstetrician performed transperineal ultrasound. Only women in the biofeedback group observed the ultrasound display screen. Following this intervention, labor was managed routinely by the obstetric team. Angle of progression (AOP) was measured at rest and while pushing, before and during the first and fourth contractions. Second-stage duration and delivery outcomes were compared between groups. RESULTS: Visual biofeedback did not affect the duration of the second stage, which lasted for a median of 2.28 (interquartile range (IQR), 1.25-3.10) h in the biofeedback group vs 2.08 (IQR, 1.58-3.02) h in the control group (P = 0.981). AOP was significantly higher in the biofeedback group compared with the control group, both at rest before the fourth contraction (mean ± SD, 142.6° ± 15.9° vs 136.8° ± 13.1°; P = 0.049) and while pushing during the fourth contraction (mean ± SD, 159.3° ± 19.2° vs 149.4° ± 15.1°; P = 0.005). The increase in AOP was significantly higher in the biofeedback compared with the control group between rest and pushing at the last push (mean ± SD, 16.6° ± 11.0° vs 12.6° ± 8.3°; P = 0.041) and between the first rest and last push (mean ± SD, 24.4° ± 13.6° vs 17.9° ± 11.3°; P = 0.011). The rate of intact perineum was similar between groups (12% vs 8%; P = 0.505). CONCLUSIONS: Visual biofeedback during the second stage of labor may facilitate descent of fetal head during maternal pushing without affecting second-stage duration, possibly due to the short duration of the intervention. Future studies should focus on continuous intervention throughout the second stage of labor. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Optimal timing of fetal reduction from twins to singleton: earlier the better or later the better?

OBJECTIVES: To determine the rate of pregnancy complications and adverse obstetric and neonatal outcomes of twin pregnancies that were reduced to singleton at an early compared with a later gestational age. METHODS: This was a historical cohort study of dichorionic diamniotic twin pregnancies that underwent fetal reduction to singletons in a single tertiary referral center between January 2005 and February 2017. The study population was divided into two groups according to gestational age at fetal reduction: those performed at 11-14 weeks' gestation, mainly at the patient's request or as a result of a complicated medical or obstetric history; and selective reductions performed at 15-23 weeks for structural or genetic anomalies. The main outcome measures compared between pregnancies that underwent early reduction and those that underwent late reduction included rates of pregnancy complications, pregnancy loss, preterm delivery and adverse neonatal outcome. RESULTS: In total, 248 dichorionic diamniotic twin pregnancies were included, of which 172 underwent early reduction and 76 underwent late reduction. Although gestational age at delivery was not significantly different between the late- and early-reduction groups (38 weeks, (interquartile range (IQR), 36-40 weeks) vs 39 weeks (IQR, 38-40 weeks); P = 0.2), the rates of preterm delivery < 37 weeks (28.0% vs 14.0%; P = 0.01), < 34 weeks (12.0% vs 1.8%; P = 0.002) and < 32 weeks (8.0% vs 1.8%; P = 0.026) were significantly higher in pregnancies that underwent late reduction. Regression analysis revealed that late reduction of twins was an independent risk factor for preterm delivery, after adjustment for maternal age, parity, body mass index and the location of the reduced sac. Rates of early complications linked to the reduction procedure itself, such as infection, vaginal bleeding and leakage of fluids, were comparable between the groups (7.0% for early reduction vs 9.2% for late reduction; P = 0.53). There was no significant difference in the rate of pregnancy loss before 24 weeks (0.6% for early reduction vs 1.3% for late reduction; P = 0.52), and no cases of intrauterine fetal death at or after 24 weeks were documented. There was no significant difference in the prevalence of gestational diabetes mellitus, hypertensive disorders of pregnancy, preterm prelabor rupture of membranes or small-for-gestational age. The rates of respiratory distress syndrome (6.7% vs 0%; P = 0.002), need for mechanical ventilation (6.7% vs 0.6%; P = 0.01) and composite neonatal morbidity (defined as one or more of respiratory distress syndrome, sepsis, necrotizing enterocolitis, intraventricular hemorrhage, need for respiratory support or neonatal death) (10.7% vs 2.9%; P = 0.025) were higher in the late- than in the early-reduction group. Other neonatal outcomes were comparable between the groups. CONCLUSIONS: Compared with late first-trimester reduction of twins, second-trimester reduction is associated with an increased rate of prematurity and adverse neonatal outcome, without increasing the rate of procedure-related complications. Technological advances in sonographic diagnosis and more frequent use of chorionic villus sampling have enabled earlier detection of fetal anatomic and chromosomal abnormalities. Therefore, efforts should be made to complete early fetal assessment to allow reduction during the first trimester. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Cephalic extraction versus breech extraction in second-stage caesarean section: a retrospective study.

OBJECTIVE: Our primary objective was to compare maternal and neonatal outcomes based on the attempted mode of extraction. Our secondary objective was to compare the outcomes based on the actual mode of extraction. DESIGN: A retrospective cohort study at a single tertiary centre between the years 2011 and 2019. SETTING: The study included 1028 cases of term pregnancies in vertex presentation that were delivered by caesarean section at the second stage of delivery. POPULATION: Patients were grouped according to the attempted mode of extraction: attempted cephalic extraction (674) and breech extraction (354). A subgroup analysis was conducted, comparing successful cephalic extraction (615), failed cephalic extraction (59) and breech extraction (354). METHODS: Both maternal and neonatal complication rates were compared between the groups. RESULTS: There were significantly more uterine incision extensions (27.4 versus 11.9%, P < 0.001) and increased need for blood transfusion (10.7 versus 6.2%, P = 0.018) in the cephalic extraction compared with the breech extraction group. The highest rate of uterine incision extensions (45.8%) and need for blood transfusion (22%) was in the subgroup of failed cephalic extraction. The rate of adverse neonatal outcomes was comparable between the two groups. However, in the subgroup of failed cephalic extraction, there were higher rates of low 1-minute Apgar scores, NICU hospitalisation and limb fractures compared with successful cephalic extractions and breech extractions (P = 0.016, 0.01, <0.001, respectively). CONCLUSIONS: Breech extraction in second-stage caesarean section is associated with fewer maternal complications compared wiith attempted cephalic extraction without increasing neonatal complication rates. TWEETABLE ABSTRACT: In breech versus cephalic extraction, breech extraction was found to have better outcomes in second-stage caesarean section.

Apparent Diffusion Coefficient Levels and Neurodevelopmental Outcome in Fetuses with Brain MR Imaging White Matter Hyperintense Signal.

BACKGROUND AND PURPOSE: One of the perplexing findings of fetal brain MR imaging is white matter T2 hyperintense signal. The aims of our study were initially to determine the main etiologies associated with white matter T2 hyperintense signal, then to examine whether the different etiologies have different ADC values, and, last, to assess the association of white matter T2 hyperintense signal with developmental outcome. MATERIALS AND METHODS: This was a prospective cohort study of 44 MR imaging scans of fetal brains obtained for suspected brain pathologies at a tertiary medical center during 2011-2015. Clinical data were collected from electronic medical charts. ADC values were measured and averaged in the frontal, parietal, occipital, and temporal lobes. Neurodevelopmental assessments were performed with the Vineland Adaptive Behavior Scales II. RESULTS: Half of the cases of MRI hyperintense T2 signal of the fetal brain were associated with congenital cytomegalovirus infection. The other half were mainly idiopathic. Thus, the study group was divided to subgroups positive and negative for cytomegalovirus. Both groups had hyperintense signal in the temporal lobe. The group positive for cytomegalovirus had involvement of the parietal lobe. Only this group had increased ADC values in the temporal and parietal lobes. There was no association between the neurodevelopment outcome and the etiologies or ADC values. CONCLUSIONS: T2 hyperintense signal in fetal brain MRI associated with positive cytomegalovirus infection has increased ADC values in the temporal and parietal lobes, suggestive of brain edema in these areas. However, the association between this finding and neurodevelopment outcome requires further evaluation.

Neurodevelopmental outcome of fetal isolated ventricular asymmetry without dilation: a cohort study.

OBJECTIVE: Fetal isolated ventricular asymmetry (IVA) is a relatively common finding in pregnancy, but data regarding its effect on neurodevelopmental outcome are scarce and founded principally on ultrasound-based studies. The purpose of this study was to assess the neurodevelopmental outcome of IVA cases in a magnetic resonance imaging (MRI)-based study. METHODS: Cases referred for fetal brain MRI as part of the assessment of IVA without ventriculomegaly (lateral ventricular atrial diameter ≤ 10 mm), identified during routine ultrasound examination, were assessed for possible inclusion. Asymmetry was defined as a difference in width of ≥ 2 mm between the two lateral ventricles. Forty-three cases were included in the study group and compared with a control group of 94 normal cases without IVA. Children were assessed at ages 13-74 months using the Vineland-II Adaptive Behavior Scales (VABS-II). RESULTS: VABS-II scores were within normal range. There was no significant difference in composite VABS-II score between the study and control groups (106.5 vs 108.0; P = 0.454). VABS-II scores did not differ between the groups when matched for gender and age at VABS-II interview (109.6 in study group vs 107.8 in control group; P = 0.690). CONCLUSION: In cases of IVA without ventriculomegaly on MRI, neurodevelopmental test scores were normal and did not differ from cases without IVA. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Fetal Brain Anomalies Associated with Ventriculomegaly or Asymmetry: An MRI-Based Study.

BACKGROUND AND PURPOSE: Fetal lateral ventriculomegaly is a relatively common finding with much debate over its clinical significance. The purpose of this study was to examine the association between ventriculomegaly and asymmetry and concomitant CNS findings as seen in fetal brain MR imaging. MATERIALS AND METHODS: Fetal brain MR imaging performed for various indications, including ventriculomegaly, with or without additional ultrasound findings, was assessed for possible inclusion. Two hundred seventy-eight cases found to have at least 1 lateral ventricle with a width of ≥10 mm were included in the study. Ventriculomegaly was considered mild if the measurement was 10-11.9 mm; moderate if, 12-14.9 mm; and severe if, ≥15 mm. Asymmetry was defined as a difference of ≥2 mm between the 2 lateral ventricles. Fetal brain MR imaging findings were classified according to severity by predefined categories. RESULTS: The risk of CNS findings appears to be strongly related to the width of the ventricle (OR, 1.38; 95% CI, 1.08-1.76; P = .009). The prevalence of associated CNS abnormalities was significantly higher (P = .005) in symmetric ventriculomegaly compared with asymmetric ventriculomegaly (38.8% versus 24.2%, respectively, for all CNS abnormalities and 20% versus 7.1%, respectively, for major CNS abnormalities). CONCLUSIONS: In this study, we demonstrate that the rate of minor and major findings increased with each millimeter increase in ventricle width and that the presence of symmetric ventricles in mild and moderate ventriculomegaly was a prognostic indicator for CNS abnormalities.

Trial of labour in twin pregnancies: a retrospective cohort study.

OBJECTIVE: To assess the success rate of vaginal delivery among women with twin pregnancies; the Twin Birth Study has shown that vaginal delivery and caesarean section are equally safe for twin delivery but >40% of the planned vaginal delivery group delivered by caesarean section. DESIGN: A retrospective cohort study. SETTING: A tertiary medical centre. POPULATION: A total of 2194 women with twin pregnancies not complicated with very low birthweight. METHODS: Planned mode of delivery was documented in the woman's electronic record upon entering the delivery room. Information regarding maternal age at delivery, parity, gestational age, presentation, previous history of caesarean delivery, birthweight and Apgar score was collected from the obstetric electronic charts. MAIN OUTCOME MEASURED: Rate of vaginal twin delivery. RESULTS: Of the 2194 women included, 1311 twin pregnancies had planned caesarean delivery and 883 underwent a trial of labour. Of the 883 women who underwent a trial of labour, the rate of vaginal delivery was 86.9%, whereas the rates of caesarean delivery and combined vaginal-caesarean delivery were 11.1% and 2.0%, respectively. Presentation of second twin, gestational age and maternal age did affect the chances of success. Nulliparity [odds ratio (OR) 2.38, 95% confidence interval (95% CI) 1.4-4.05], Foley induction of labour (OR 2.33, 95% CI 1.38-3.91) and body mass index >30 kg/m(2) (OR 1.76, 95% CI 1.03-3) were independent risk factors for caesarean delivery. CONCLUSIONS: The rate of vaginal delivery among women with twin pregnancies who undergo labour can be high, especially in women who laboured spontaneously and have delivered before. TWEETABLE ABSTRACT: The rate of vaginal delivery of twins can be high, especially in women who have delivered before.

Establishment and validation of a model for non-luteinized human mural granulosa cell culture.

Cell culture techniques of human mural granulosa cells (MGCs) serve as a major in vitro tool. However, the use of luteinized MGCs has major limitations due to their luteinized state. Our aim was to establish a standardized protocol for the culture of MGCs as a model for different stages of folliculogenesis. We showed that early-non-luteinized, preovulatory-non-luteinized and luteal-MGCs have distinct gene expression pattern. After 4 days of incubation of luteinized-MGCs, ovulatory genes mRNA's achieve expression levels similar to the early non-luteinized follicles. FSH stimulation for 48 h of these 4 days cultured MGCs showed ovulatory genes mRNA's expression similar to the pre-ovulatory non-luteinized follicles. These FSH-stimulated cells responded to hCG stimulation in a pattern similar to the response of pre-ovulatory follicles. This novel model may provide a standardized research tool for delineation of the molecular processes occurring during the latter stages of follicular development in the human ovary.

[Treatment of flail chest].

We present our experience in the treatment of 82 patients with flail chest (FC). They were evaluated according to the number of fractured ribs, which apparently correlates with the degree of lung contusion. Treatment methods compared were oxygen mask therapy, epidural analgesia, continuous positive airway pressure (CPAP), intermittent mandatory ventilation (IMV) plus positive end respiratory pressure (PEEP), and high frequency ventilation (HFV) plus PEEP. Oxygen therapy alone was not effective in those with more than 5 fractured ribs, while CPAP was effective in those with up to 10 fractured ribs. No significant difference was found between IMV and HFV. The purpose of respiratory support in FC is to reduce atelectasis and the resulting shunt, and to improve removal of mucus from airways. The patients were discharged without compromise in respiratory function, despite persistence of FC. We conclude that the primary mechanism of respiratory impairment in FC is not the mechanical disturbance, but rather the degree of lung contusion suffered.

[Extracorporeal support technics in the treatment of multisystem failure. Our experience]. / Tecniche di supporto extracorporeo nel trattamento dello scompenso multisistemico. Nostra esperienza.

Mortality rate among patients with septic, oliguric, multiple organ failure is high. Conventional hemodialysis has often detrimental effects on critically ill patients. Continuous arteriovenous hemofiltration (CAVH), continuous arteriovenous hemodialysis (CAVH/D) and continuous arteriovenous hemodialysis associated with sequential plasmapheresis (CAVHP/D) could reduce mortality in septic (hypercatabolic, oliguric) ARDS induced MOF patients. These techniques are simple and can be managed without superspecialized personnel.

Use of extracorporeal supportive techniques as additional treatment for septic-induced multiple organ failure patients.

We compared retrospectively four similar groups of patients with multiple organ failure (MOF) due to sepsis. All of them were treated initially with conventional therapy, aprotinin as protease inhibitor and vitamin C with allopurinol as possible scavengers of oxygen-free radicals, were also added. After 24 h of no clinical progress, continuous arteriovenous hemofiltration (CAVH), CAVH/dialysis (CAVH/D), and sequential plasmafilter-dialysis with slow continuous hemofiltration (CAVHP/D) were respectively added to groups 2 (n = 14), 3 (n = 6), and 4 (n = 11). Mortality was 87% for group 1, 71% for group 2, 50% for group 3, and 36% for group 4. In the latter we were able to remove possible MOF-inducing mediators from the bloodstream, to give fluids without restriction (even in oliguric patients), and to improve removal of metabolic waste products. It is possible that these extracorporeal supports, associated with conventional therapy, and pharmacologic drugs such as protease inhibitors and possible scavengers of oxygen-free radicals, helped to reduce the mortality rate. We conclude that, although the number of study patients was too small to reach firm conclusions, the good results observed with CAVHP/D suggest clinical trials to assess the efficacy of this technique.

Superimposed high frequency ventilation with conventional mechanical ventilation.

A 73-year-old man with ARDS-multiple organ failure due to Chlamydia psittaci, was successively supported with conventional respiratory techniques. After 48 hours of no clinical improvement, HFV was superimposed to CMV in order to combine the advantages of each one. Since improvement has been seen in all ventilatory parameters, this method is suggested as another mode of ventilation for patients with refractory hypoxia and hypercarbia who do not respond to conventional respiratory care.

Differential lung ventilation: a review and 2 case reports.

The respiratory parameters of some of the patients with acute respiratory failure deteriorates while using conventional ventilation. These patients suffer unilateral lung disease and the failure to respond favourably to therapy is due to increased intrapulmonary shunt. There is a reflex vasodilation in the injured lung. Functional residual capacity is reduced in the injured lung and the compliance decreases. Gas flow is then deviated to the other lung, thus increases alveolar collapse and decreases regional compliance in the injured lung. These events cause severe hypoxemia. We present here two cases with unilateral lung disease that failed to respond to conventional mechanical ventilation. Asynchronized differential lung ventilation was found to be the therapeutic answer to the problem. We discuss the pathophysiology of unilateral lung injury and the physiology of differential lung ventilation.