Maternal abdominal subcutaneous fat thickness as a predictor for adverse pregnancy outcome: a longitudinal cohort study.

OBJECTIVE: To assess maternal abdominal subcutaneous fat thickness (SFT) measured by ultrasound as an independent predictor of adverse pregnancy outcomes. DESIGN: A prospective longitudinal cohort study performed on pregnancies delivered between 2012 and 2014. SETTING: Sydney, Australia. POPULATION: About 1510 pregnant women attending routine obstetric ultrasounds. METHODS: Maternal SFT was measured on routine ultrasounds at 11-14 weeks' gestation (SFT1) and 18-22 weeks' gestation (SFT2). SFT measurements were assessed for estimating risks for obesity-related pregnancy outcomes using logistic regression modelling adjusted for maternal age, parity, smoking status and body mass index (BMI). MAIN OUTCOME MEASURES: Hypertensive disease, gestational diabetes, caesarean section, low birthweight, preterm delivery, neonatal respiratory distress, Apgar scores, and admission to a neonatal intensive care unit. RESULTS: SFT1 and SFT2 were measured on 1461 and 1363 women, respectively. Mean thickness (range) were 21.2 mm (6.9-73.9) for SFT1 and 20.3 mm (7.5-68.0) for SFT2. Complete outcome data were available for 1385 pregnancies. In all, 54% of the women were overweight/obese. The SFT measures decreased from early to mid-pregnancy in overweight/obese women. There was moderate correlation between BMI and SFT1 (R(2) = 0.56) and BMI and SFT2 (R(2) = 0.55). In a multivariate model, SFT1 and SFT2 were better predictors for adverse pregnancy outcomes than BMI. CONCLUSION: Maternal SFT is a significant independent predictor of adverse pregnancy outcomes. Incorporation of SFT into future models for adverse pregnancy outcome may prove valuable.

Sonographically detected caesarean section scar defects and menstrual irregularity.

The purpose of this study was to estimate the frequency of post-caesarean section scar defects (PCSD) on transvaginal ultrasound and to correlate these with the presence of abnormal menstrual bleeding. We reviewed the pelvic ultrasound images of 318 women referred for a gynaecological scan in a private women's ultrasound clinic. The incidence of defects at the expected location of a caesarean scar was evaluated and then correlated with patient responses to a questionnaire on abnormal menstrual bleeding. Of the 318 patients, 71 had a history of caesarean section and technically adequate pelvic ultrasound images. Fluid-filled defects in the hysterotomy incision were noted in 29 (40%). The presence of a PCSD was significantly associated with patients reporting prolonged periods or post-menstrual spotting. The larger the defect, the higher was the incidence of abnormal vaginal bleeding.

Predicting operative delivery.

OBJECTIVE: Unplanned operative delivery (vaginal or abdominal) is associated with maternal anxiety, maternal and neonatal morbidity and increased resource use. We aimed to identify potential predictors for emergency operative delivery. METHODS: This was a prospective observational study of 202 nulliparous women in a tertiary antenatal unit between 36 and 40 weeks' gestation. The assessment included an interview, a vaginal examination for Bishop score (optional), and a translabial ultrasound examination performed with the woman in a supine position and after voiding to determine cervical length, bladder position on Valsalva, and fetal head engagement. Clinical data were obtained from the institutional obstetric database and patient records. RESULTS: In the late third trimester, body mass index (P = 0.016), maternal age at due date (P < 0.0001), history of Cesarean section in first-degree relatives (P = 0.009), Bishop score (P = 0.0004), cervical length (P = 0.001), bladder position on Valsalva (P = 0.003) and head engagement (P < 0.0001) were significantly associated with delivery mode. On multivariate logistic regression analysis, the best model for predicting normal vaginal delivery contained maternal age, history of Cesarean section, Bishop score and bladder position on Valsalva and had excellent ability to discriminate between normal vaginal delivery and operative delivery (c = 0.85). The model with the best ability to discriminate between vaginal delivery and Cesarean section contained the same parameters plus body mass index; this model performed even better (c = 0.87). CONCLUSIONS: Identification of women at increased risk of operative delivery appears feasible. A combination of clinical and ultrasound variables yielded a model that is likely to predict delivery mode accurately in up to 87% of cases. Such a model may become useful as an entry criterion for intervention trials in women at low or very high risk of operative delivery.

Measuring engagement of the fetal head: validity and reproducibility of a new ultrasound technique.

OBJECTIVE: Fetal head engagement can be assessed by translabial ultrasound and has been shown to be predictive of delivery mode. We attempted to validate the technique by comparing ultrasound with abdominal and vaginal palpation. Reproducibility was tested in a blinded test-retest series. METHODS: In a prospective clinical study, 139 nulliparous women between 35 + 3 and 40 + 4 weeks' gestation were assessed by translabial ultrasound, abdominal palpation of the fetal head (n = 139) and vaginal examination (n = 112). Ultrasound was performed using two methods, with the symphysis pubis as reference. A test-retest series was performed in 90 women. RESULTS: Ultrasound of head engagement correlated strongly with abdominal palpation, full Bishop scores and vaginal assessment (all P < 0.001 for Kendall's tau-b). Intraclass correlation coefficients (n = 90) for the two methods were 0.75 and 0.92, signifying excellent interobserver agreement. Reproducibility was higher for the method using the central symphyseal axis as reference. CONCLUSION: Quantitation of head engagement by translabial ultrasound is highly reproducible and correlates strongly with clinical measures of head engagement. We are now undertaking a prospective study to assess the predictive value of this new parameter for intrapartum events.

Ectopic pregnancy in lower segment uterine scar.

A case of ectopic pregnancy in a lower uterine segment scar following previous Caesarean section is reported. A significant scar defect may result in deep implantation within the myometrium with the risk of persistent pain and bleeding followed inevitably by uterine rupture. In this report we discuss a number of management options. Except in the special situation of superficial implantation in a shallow scar defect where there is ultrasound evidence of continuity of the gestational sac with the uterine cavity we would strongly advise termination of the pregnancy.