Fetal brain development in pregnancies complicated by gestational diabetes mellitus

OBJECTIVES

Gestational diabetes mellitus (GDM) carries an increased risk of neurocognitive impairment in offsprings. However, the contribution of maternal hyperglycemia in affecting fetal brain development is not fully elucidated yet. The aim of this study was to evaluate fetal brain and sulci development in pregnancies complicated by GDM.

METHODS

Prospective observational study including 100 singleton pregnancies complicated by GDM and 100 matched controls. All fetuses underwent neurosonography at 29-34 weeks of gestation, including the assessment of the length of the corpus callosum (CC), cerebellar vermis (CV), Sylvian (SF), parieto-occipital (POF) and calcarine fissures (CF). Sub-group analysis according to the specific treatment regimen adopted (n 67 diet vs. 33 insulin therapy) was also performed.

RESULTS

Fetuses from mothers with GDM under insulin therapy had a smaller CC (35.54 mm) compared to both controls (40 mm; p<0.001) and women with GDM under diet (39.26 mm; p=0.022) while there was no difference in the HC between the groups. Likewise, when corrected for HC, CV depth was smaller in fetuses with GDM both under insulin therapy (7.03 mm) and diet (7.05 mm,) compared to controls (7.36 mm; p=0.013). Finally, when assessing the sulci development of the brain SF (p≤0.0001), POF (p≤0.0001) and CF (p≤0.0001) were significantly smaller in fetuses with maternal GDM. Post-hoc analysis showed that fetuses of GDM mothers requiring insulin therapy had significantly lower values of SF (p=0.032), POF (p=0.016) and CF (p=0.001).

CONCLUSIONS

Pregnancies complicated by GDM showed a peculiar pattern of fetal brain growth and cortical development and these changes, which are more evident in those requiring insulin supplementation.

Validation of an automated software (Smartpelvic™) in assessing hiatal area from three dimensional transperineal pelvic volumes of pregnant women: comparison with manual analysis

OBJECTIVES

The aim of this investigation was to evaluate the agreement between a manual and an automatic technique in assessing levator hiatus area (LHA) during pregnancy from three-dimensional (3D) pelvic floor volumes obtained by trans-perineal ultrasound (TPUS).

METHODS

3D volumes were acquired during rest, maximum pelvic floor contraction and Valsalva maneuver from 66 pregnant women. Manual selection of LHA and automatic software (Smart Pelvic™) were applied on TPUS volume starting from a C-plane view. To evaluate intra- and inter-observer variability measurements of LHA were performed twice by the same operator and once by a second sonographer. Reference hiatal contours obtained manually by the first operator were compared with the automated ones. Reproducibility was evaluated by intraclass correlation coefficients (ICC) and Bland-Altman plots.

RESULTS

LHA measurement, using automatic software, achieved excellent intra-observer and inter-observer reproducibility in pregnant women both at rest and after dynamic analysis (ICC>0.9). Further, an excellent agreement resulted between manual selection of the LHA and automatic imaging (ICC>0.9). The average time taken to obtain LHA manually was significantly longer when compared to the automatic analysis (p≤0.0001).

CONCLUSIONS

Smart pelvic software resulted from a reliable method for automatically measuring the LHA, showing high reproducibility and accuracy.

Effects of gender on fetal cortical development: a secondary analysis of a prospective cross-sectional study

OBJECTIVES

The primary objective was to evaluate the effects of fetal sex on fetal cortical development in low-risk pregnancies. Secondary objective was the evaluate the impact of gestational age.

METHODS

This was a secondary analysis of a prospective cross-sectional study on low-risk fetuses undergoing fetal neurosonography between 19 and 34 weeks of gestation. The depth of Sylvian Fissure (SF), Parieto Occipital Fissure (POF) and Calcarine Fissure (CF) were evaluated and related to fetal sex. Neurosonographic variables were normalized for fetal head circumference and expressed as multiple of the median (MoM).

RESULTS

A total of 344 fetuses were considered (173 male, 171 female). The baseline characteristic of the two groups were similar except a higher birthweight present in male fetuses (p=0.044). The depth SF (p=0.023) CF (p=0.014) and POF (p=0.046) showed significantly higher values in male fetuses when all the gestational age range was considered. However, when data were controlled for gestational age, these differences resulted significant only after 28 weeks.

CONCLUSIONS

Differences in cortical development related to gender occur after 28 weeks of gestation with an increase depth of SF, POF and CF in male fetuses.

Asymptomatic acute massive abruptio placenta at 30 weeks' gestation in a primigravida with no risk factors - clinical presentation and management

Abruptio placenta can be a catastrophic event with a high association with adverse maternal and fetal outcomes. We present a case of massive abruptio placenta occurring in a young asymptomatic mother at 30 weeks' gestation. Although electronic fetal monitoring and ultrasound allowed a prompt diagnosis of an 8 × 5 cm retroplacental hematoma, the fetus died at the time of emergency cesarean section. The fetus was intubated, but could not be resuscitated. Histologic examination of the placenta documented thinning and stacked hypercapillarized villi, with syncytial buds and foci of fibrinoid necrosis in the presence of hyaline streaks on both the maternal and fetal sides.

Too short or too long: impact of corpus callosal measurement on prenatal counseling

Linked article: This Correspondence comments on Corroenne et al. Click here to view the article.

Modeling fetal cortical development by quantile regression for gestational age and head circumference: a prospective cross sectional study

OBJECTIVES

To develop charts for fetal brain cortical structures following a proposed standardized methodology and using quantile regression.

METHODS

Prospective cross-sectional study including 344 low-risk singleton pregnancies between 19 and 34 weeks of gestation. The depth of Sylvian (SF), Parieto-occipital (POF) and Calcarine fissures (CF) were measured on ultrasound images using a standardized technique and their changes were evaluated by quantile regression as a function of gestational age (GA) interval or head circumference (HC).

RESULTS

The measurements of SF, POF and CF depth significantly increased with gestation. Linear models better described the changes of cortical variables with GA and HC. When the fit of sulci depth with GA and HC were compared, a close relationship was highlighted for the latter variable.

CONCLUSIONS

We provided prospective charts of fetal cortical development using quantile regression and following a strict standardized methodology These new charts may help in better identifying cases at higher risk of abnormal cortical neurodevelopment.

Modeling fetal cavum septum pellucidi width by quantile regression at 18-34 weeks of gestation: A prospective cross-sectional study

OBJECTIVE

Develop charts for cavum septum pellucidi (CSP) following a standardized methodology and using quantile regression. The secondary objective was to assess the influence of fetal gender on the generated reference curves.

METHODS

In a cross-sectional prospective study 453 low-risk singleton pregnancies were evaluated at a gestational age interval between 18 and 34 weeks. The width of CSP were measured on ultrasound images using a standardized technique and their changes were evaluated by quantile regression as a function of gestational age (GA) interval or head circumference (HC). Differences between sex were evaluated.

RESULTS

The measurement of CSP significantly increased with gestation and HC. Linear models better described the changes of CSP with GA and HC. The fits of CSP width with GA and HC were not significantly different. Male fetuses showed significantly higher CSP width when compared to female fetuses (u = 2.973; p = 0.005).

CONCLUSIONS

We generated prospective nomograms of fetal CSP development using quantile regression and following a strict standardized methodology. These new charts may be useful to better identify abnormal cases at higher risk of associated anomalies. Further our findings underline the potential effect of gender in developing fetal brain.

Ectrodactyly-ectodermal dysplasia-clefting syndrome. Prenatal prospective ultrasound diagnosis

OBJECTIVE

Prenatal diagnosis of the Ectrodactyly-Ectodermal dysplasia-clefting (EEC) syndrome has been based upon the detection of ectrodactyly, in association with facial clefting and/or positive family history. Our aim is to describe other ultrasonographic features indicating the presuntive diagnosis, regardless of genetic diagnosis, especially in cases of negative family history.

MATERIALS AND METHODS

A case report and a review of the literature was assessed.

RESULTS

Our case report showed a singleton foetus "lobster claw" deformities of hands and feet. Paternal history revealed bilateral agenesia of two fingers. Through literature, 15 case reports of prenatal diagnosis of EEC syndrome were found, 14 of which were eligible for our systematic review. The 33% of cases (5/15) had a familiar history of EEC, thus, we found one case of consanguinity of parents. Anomalies EEC-related were recognized in the 40% of cases (6/15). An association with genitourinary anomalies was found in 30% (5/15) of them.

CONCLUSIONS

A strong suspicion of final diagnosis of EEC may be done in the presence of ectrodactyly, facial clefting and urinary malformation especially in cases of negative family history. More attention should be given to a genetic counseling, especially to understand a possible relation to other genetic syndromes.

Evaluation of an artificial intelligent algorithm (Heartassist™) to automatically assess the quality of second trimester cardiac views: a prospective study

OBJECTIVES

The aim of this study was to evaluate the agreement between visual and automatic methods in assessing the adequacy of fetal cardiac views obtained during second trimester ultrasonographic examination.

METHODS

In a prospective observational study frames of the four-chamber view left and right outflow tracts, and three-vessel trachea view were obtained from 120 consecutive singleton low-risk women undergoing second trimester ultrasound at 19-23 weeks of gestation. For each frame, the quality assessment was performed by an expert sonographer and by an artificial intelligence software (Heartassist™). The Cohen's κ coefficient was used to evaluate the agreement rates between both techniques.

RESULTS

The number and percentage of images considered adequate visually by the expert or with Heartassist™ were similar with a percentage >87 % for all the cardiac views considered. The Cohen's κ coefficient values were for the four-chamber view 0.827 (95 % CI 0.662-0.992), 0.814 (95 % CI 0.638-0.990) for left ventricle outflow tract, 0.838 (95 % CI 0.683-0.992) and three vessel trachea view 0.866 (95 % CI 0.717-0.999), indicating a good agreement between the two techniques.

CONCLUSIONS

Heartassist™ allows to obtain the automatic evaluation of fetal cardiac views, reached the same accuracy of expert visual assessment and has the potential to be applied in the evaluation of fetal heart during second trimester ultrasonographic screening of fetal anomalies.

Uterine artery Doppler in early labor and perinatal outcome in low-risk term pregnancy: prospective multicenter study

OBJECTIVE

The prediction of adverse perinatal outcomes in low-risk pregnancies is poor, mainly owing to the lack of reliable biomarkers. Uterine artery (UtA) Doppler is closely associated with placental function and may facilitate the peripartum detection of subclinical placental insufficiency. The objective of this study was to evaluate the association of mean UtA pulsatility index (PI) measured in early labor with obstetric intervention for suspected intrapartum fetal compromise and adverse perinatal outcome in uncomplicated singleton term pregnancies.

METHODS

This was a prospective multicenter observational study conducted across four tertiary maternity units. Low-risk term pregnancies with spontaneous onset of labor were included. The mean UtA-PI was recorded between uterine contractions in women admitted for early labor and converted into multiples of the median (MoM). The primary outcome of the study was the occurrence of obstetric intervention, i.e. Cesarean section or instrumental delivery, for suspected intrapartum fetal compromise. Secondary outcomes were the occurrence of adverse perinatal outcomes, including 5-min Apgar score < 7, low cord arterial pH, raised cord arterial base excess, admission to the neonatal intensive care unit (NICU) and postnatal diagnosis of small-for-gestational-age fetus. Composite adverse perinatal outcome was defined as the occurrence of at least one of the following: acidemia in the umbilical artery, defined as pH < 7.10 and/or base excess > 12 mmol/L, 5-min Apgar score < 7 or admission to the NICU.

RESULTS

Overall, 804 women were included, of whom 40 (5.0%) had abnormal mean UtA-PI MoM. Women who had an obstetric intervention for suspected intrapartum fetal compromise were more frequently nulliparous (72.2% vs 53.6%; P = 0.008), had a higher frequency of increased mean UtA-PI MoM (13.0% vs 4.4%; P = 0.005) and had a longer duration of labor (456 ± 221 vs 371 ± 192 min; P = 0.01). On logistic regression analysis, only increased mean UtA-PI MoM (adjusted odds ratio (aOR), 3.48 (95% CI, 1.43-8.47); P = 0.006) and parity (aOR, 0.45 (95% CI, 0.24-0.86); P = 0.015) were independently associated with obstetric intervention for suspected intrapartum fetal compromise. Increased mean UtA-PI MoM was associated with a sensitivity of 0.13 (95% CI, 0.05-0.25), specificity of 0.96 (95% CI, 0.94-0.97), positive predictive value of 0.18 (95% CI, 0.07-0.33), negative predictive value of 0.94 (95% CI, 0.92-0.95), positive likelihood ratio of 2.95 (95% CI, 1.37-6.35) and negative likelihood ratio of 0.91 (95% CI, 0.82-1.01) for obstetric intervention for suspected intrapartum fetal compromise. Pregnancies with increased mean UtA-PI MoM also showed a higher incidence of birth weight < 10th percentile (20.0% vs 6.7%; P = 0.002), NICU admission (7.5% vs 1.2%; P = 0.001) and composite adverse perinatal outcome (15.0% vs 5.1%; P = 0.008).

CONCLUSION

Our study, conducted in a cohort of low-risk term pregnancies enrolled in early spontaneous labor, showed an independent association between increased mean UtA-PI and obstetric intervention for suspected intrapartum fetal compromise, albeit with moderate capacity to rule in, and poor capacity to rule out, this condition. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Fetal brain biometry and cortical development after maternal SARS-CoV-2 infection in pregnancy: A prospective case-control study

OBJECTIVES

To assess cerebral growth and the development of fetal cortex using neurosonography in fetuses from pregnancies experiencing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) according to infection timing.

METHODS

Pregnancies with by SARS-CoV-2 during first and second trimesters were prospectively studied and matched with unaffected controls. Enclosed women underwent neurosonography at 30-34 weeks of gestation and corpus callosum (CC) and cerebellar vermis (CV) lengths measured. Further Sylvian fissure (SF), insula. Parieto-occipital fissure (POF), and calcarine sulci fissures (CSF) depths were obtained. The ultrasonographic variables considered were normalized with fetal head size.

RESULTS

One hundred and seventy four consecutive pregnancies experiencing SARS COV 2 infection (81 before 14 weeks and 93 later) and 131 not affected pregnancies were considered. General and pregnancy characteristics were similar between the three groups of women. No significant differences existed in CC and CV lengths across groups. Similarly, insula, SF, POF And CSF depth did not result changed in fetuses of affected mothers.

CONCLUSIONS

SARS-CoV-2 infection does nor resulted associate with differential fetal cortical development or brain growth in mildly symptomatic pregnant women. This information may be useful to reassure infected mothers on the health of their fetuses.

Fetal heart foramen ovale area by three-dimensional ultrasound using stic in the rendering mode: reference range and applicability in congenital heart diseases

To determine reference values for the foramen ovale (FO) area of fetal hearts by three-dimensional (3D) ultrasound using spatio-temporal image correlation (STIC) method in the rendering mode, as well as applicability in fetuses with congenital heart disease (CHD). A retrospective and prospective study was performed of 242 normal fetuses and 36 fetuses with CHD between 20 and 33 + 6 weeks of gestation. The FO area was determined in the four-chamber view with manual delineation. To determine the reference curve of the FO area as a function of gestational age (GA), a linear regression model was utilized with an adjusted coefficient of determination (R²). For intra- and interobserver reproducibility calculations, the concordance correlation coefficient (CCC) was used. The mean ± standard deviation (SD) of the FO measurement area was 21.2 ± 1.8 and 48.1 ± 1.9 mm² at 20 and 33 weeks' gestation, respectively. A linear correlation was observed between the FO area and GA (1.924*GA - 17.95; R² = 0.91). Good intra- (CCC = 0.97) and interobserver (CCC = 0.94) agreement was observed for the FO area measurement. The mean difference in FO area between normal and CHD fetuses was - 14.4 mm² (p < 0.001). Reference values for the FO area of fetal hearts were determined by 3D ultrasound using STIC in the rendering mode. This method showed good intra- and interobserver reproducibility and could be used to assess different CHD types.

Induction of Labor in Women with Previous Cesarean Section and Unfavorable Cervix: A Retrospective Cohort Study

Background: The efficacy and safety of a cervical ripening balloon (CRB) in women with a previous cesarean section (CS) and unfavorable Bishop score are still controversial. Methods: A retrospective cohort study was performed across six tertiary hospitals from 2015 to 2019. Women with one previous transverse CS, singleton cephalic term pregnancy and BS < 6 were included if submitted to labor induction with a CRB. The main outcome was the rate of vaginal birth after cesarean (VBAC) after CRB ripening. Secondary outcomes were abnormal composite fetal and maternal outcomes. Results: Of the 265 women included, 57.3% had successful vaginal birth. Augmentation improved vaginal delivery (32.2% vs. 21.2%). Intrapartum analgesia was associated with an increased VBAC rate (58.6% vs. 34.5%). Maternal BMI ≥30 and age ≥40 years increased emergency CS rate (11.8% vs. 28.3% and 7.2 vs. 15.9%). Composite adverse maternal outcome occurred in 4.8% of CRB group women and increased to 17.6% when associated with oxytocin. Uterine rupture occurred in one case (0.4%) in the CRB-oxytocin group. Poorer fetal outcome occurred after emergency CS, if compared to successful VBAC (12.4% vs. 3.3%). Conclusions: In women with a previous CS and unfavorable Bishop score, induction of labor with a CRB can be considered safe and effective.

Use of artificial intelligence in obstetrics: not quite ready for prime time

Artificial intelligence is finding several applications in healthcare settings. This study aimed to report evidence on the effectiveness of artificial intelligence application in obstetrics. Through a narrative review of literature, we described artificial intelligence use in different obstetrical areas as follows: prenatal diagnosis, fetal heart monitoring, prediction and management of pregnancy-related complications (preeclampsia, preterm birth, gestational diabetes mellitus, and placenta accreta spectrum), and labor. Artificial intelligence seems to be a promising tool to help clinicians in daily clinical activity. The main advantages that emerged from this review are related to the reduction of inter- and intraoperator variability, time reduction of procedures, and improvement of overall diagnostic performance. However, nowadays, the diffusion of these systems in routine clinical practice raises several issues. Reported evidence is still very limited, and further studies are needed to confirm the clinical applicability of artificial intelligence. Moreover, better training of clinicians designed to use these systems should be ensured, and evidence-based guidelines regarding this topic should be produced to enhance the strengths of artificial systems and minimize their limits.

The role of ultrasound in the diagnosis and management of postpartum hemorrhage

Postpartum hemorrhage (PPH) is the leading cause of death or severe morbidity for the mother after delivery. As a consequence healthcare staff working in the delivery room should be trained to perform a prompt diagnosis and adequate management of PPH. Uneventful outcome is induced correct identification of the underlying cause of hemorrhage. Ultrasound is a promising technique for the prompt diagnosis of PPH etiology. Indeed, it is easily available, with relatively low cost, not using ionizing radiation, and can be used in different settings including the labor room, the operating theater and at the bedside of an affected women. In order to be effective Obstetricians should have an adequate knowledge of postpartum ultrasonography. In this article, we will review the sonographic findings occurring in PPH, in the differential diagnosis of the underlying cause of hemorrhage, that include retained placenta, morbidly adherent placenta, rupture of the uterus uterine, vascular anomalies of the uterine arteries and uterine inversion. We will also provide an algorithm to manage PPH according to the ultrasonographic findings.

Prenatal predictors of adverse perinatal outcome in congenital cytomegalovirus infection: a retrospective multicenter study

OBJECTIVES

To identify predictors of adverse perinatal outcome in congenital cytomegalovirus (CMV) infection.

METHODS

In a multicenter study fetuses with congenital CMV infection diagnosed by PCR on amniotic fluid and normal prenatal imaging at the time of diagnosis were included. Primary outcome was the occurrence of structural anomalies at follow-up ultrasound or prenatal magnetic resonance imaging (MRI). Secondary outcomes were the occurrence of anomalies detected exclusively postnatally and the rate of symptomatic infection.

RESULTS

One hundred and four fetuses with congenital CMV were included in the study. Anomalies were detected at follow-up ultrasound or MRI in 18.3% (19/104) cases. Additional anomalies were found after birth in 11.9% (10/84) of cases and 15.5% (13/85) of newborns showed clinical symptoms related to CMV infection. There was no difference in either maternal age (p=0.3), trimester (p=0.4) of infection and prenatal therapy (p=0.4) between fetuses with or whiteout anomalies at follow-up. Conversely, median viral load in the amniotic fluid was higher in fetuses with additional anomalies at follow-up (p=0.02) compared to those without. At multivariate logistic regression analysis, high viral load in the amniotic fluid, defined as ≥100,000 copies/mL was the only independent predictor for the occurrence of anomalies detected exclusively at follow-up ultrasound assessment or MRI, with an OR of 3.12.

CONCLUSIONS

Viral load in the amniotic fluid is a strong predictor of adverse perinatal outcome in congenital CMV infection. The results of this study emphasize the importance of adequate follow up even in case of negative neurosonography to better predict postnatal adverse outcomes of infected newborns, especially in amniotic fluid high viral load.

Prognostic value of amniotic fluid viral load to predict adverse outcome in pregnancies complicated by congenital Cytomegalovirus infection: a multicenter study

INTRODUCTION

To report the prognostic value of Cytomegalovirus (CMV) viral load in the amniotic fluid (AF) in predicting the outcome of infected pregnancies.

METHODS

Multicenter retrospective study involving 11 Italian referral centers from 2012 to 2021. Inclusion criteria were fetuses with confirmed congenital CMV infection. The primary outcome was the prognostic value accuracy of CMV qPCR in AF in predicting the risk of additional anomalies detected either at follow-up ultrasound or fetal MRI. The secondary outcome was prediction of post-natal clinical symptoms related CMV infection. Multivariate logistic regression and area under the curve (AUC) analyses were used to analyze the data.

RESULTS

104 fetuses were included. Associated anomalies detected at follow-up ultrasound or fetal MRI were detected in 14.4% of cases (15/104). Mean AF CMV viral load was significantly higher in fetuses with compared to those without additional anomalies at follow-up ultrasound or fetal MRI (3346634.27±402582.95 vs 761934±222513,2 p<0.001). At multivariate logistic regression analysis, CMV AF viral load was independently associated with the presence of additional anomalies at follow up ultrasound or MRI, with an OR of 1.07 (p= 0.010), while maternal age(p=0.24), trimester at maternal infection (p= 0.97), type of infection (primary vs non-primary) (p=0.12) were not. CMV AF viral load had AUC of 0.755 for the occurrence of anomalies due to CMV infection, with an optimal cut-off point of >1310520 copies/ml, a sensitivity of 66.7% and a specificity of 84.3% a positive likelihood ratio of 4.24. Once excluding fetuses with anomalies at ultrasound or MRI, the diagnostic performance of qPCR in identifying fetuses with symptomatic infection after birth was low, with an AUC of 0.586, Conclusion: CMV viral load at second trimester amniocentesis has a moderate accuracy for the occurrence of CMV related anomalies in fetuses with congenital infection and normal ultrasound at the initial diagnosis. Conversely, prediction of symptomatic infection is low.  .

Assessment of fetal heart aortic and pulmonary valve annulus area by three-dimensional ultrasonography: reference curves and applicability in congenital heart diseases

OBJECTIVES

To determine reference curves for fetal aortic and pulmonary valve annulus area by three-dimensional ultrasonography using the spatio-temporal image correlation (STIC) in the rendering mode, and to ascertain its applicability in congenital heart disease (CHD).

METHODS

We performed a retrospective cross-sectional study of 328 normal fetuses and 42 fetuses with CHD between 20 and 33 weeks 6 days of gestation. The outflow plane view of the great vessels was used to measure the areas of the valvar annuli, and the measurements were performed in systole. A linear regression model adjusted according to the determination coefficient (R²) was utilized to construct the reference intervals. The concordance correlation coefficient (CCC) was used to calculate the reproducibility of the mitral and tricuspid valve areas.

RESULTS

The mean ± standard deviation (SD) of the aortic and pulmonary valve annulus areas ranged from 6.6 ± 1.2 to 32.9 ± 1.1 mm² and 10.7 ± 1.3 to 40.3 ± 1.2 mm², respectively. We observed a linear relationship and strong positive correlation between the area of the aortic and pulmonary valve annuli with r=0.97 and 0.96, respectively. Good intra (CCC=0.99) and interobserver agreement (CCC=0.98) was observed for the measurement of the aortic valve annulus area. A good intra (CCC=0.99) and interobserver (CCC=0.97) agreement was also observed for the measurement of the pulmonary valve annulus area. The mean ± SD of the difference of the areas of the aortic and pulmonary valve annuli between the normal fetuses and those with CHD were -1.801 ± 1.429 mm² (p=0.208) and -1.033 ± 1.467 mm² (p<0.0001), respectively.

CONCLUSIONS

The reference curves for the areas of the aortic and pulmonary valve annuli of fetal hearts were determined, and showed good inter and intraobserver reproducibility. The constructed reference curves showed applicability in different types of CHD.

Fetal brain biometry and cortical development in congenital heart disease: A prospective cross sectional study

OBJECTIVE

To evaluate brain biometry and cortical development by neurosonography in fetuses with congenital heart defect (CHD) and evaluate differences among different type of CHD.

METHODS

In a prospective cross sectional study singleton fetus with CHD were matched with controls and grouped into two categories according to the predicted severity of cerebral arterial oxygen deficit induced by the CHD: Group A mildly reduced or normal and Group B moderately to severely reduced. Neurosonography was done at 30-33 weeks to obtain measurements of corpus callosum (CC), cerebellar vermis (CV), Sylvian fissure (SF) insula, parieto-occipital fissure (POF), and calcarine sulci fissures (CSF). All the neurosonographic parameters were adjusted by head circumference (HC).

RESULTS

A total of 78 fetuses with CHD (group A 30; group B 48) and 80 matched controls form uncomplicated pregnancies were considered. CHD fetuses have significantly smaller CC, CV, SF, and POF and bigger insula when compared to control fetuses. These differences are more marked in group B fetuses. These differences remained significant after correction for HC values.

CONCLUSION

Fetuses with CHD have an impaired cortical development and these variations are more evident in those with a predicted lower oxygen delivery to the brain.

Role of fetal head-circumference-to-maternal-height ratio in predicting Cesarean section for labor dystocia: prospective multicenter study

OBJECTIVE

To evaluate the relationship between the fetal head-circumference-to-maternal-height (HC/MH) ratio measured shortly before delivery and the occurrence of Cesarean section (CS) for labor dystocia.

METHODS

This was a multicenter prospective cohort study involving four tertiary maternity hospitals. An unselected cohort of women with a singleton fetus in cephalic presentation, at a gestational age beyond 36 + 0 weeks and without any contraindication for vaginal delivery, was enrolled between September 2020 and November 2021. The MH and fetal HC were measured on admission of the patient to the labor ward. The primary outcome of the study was the performance of the HC/MH ratio in the prediction of CS for labor dystocia. Women who underwent CS for any indication other than failed labor progression, including fetal distress, were excluded from the final analysis.

RESULTS

A total of 783 women were included in the study. Vaginal delivery occurred in 744 (95.0%) women and CS for labor dystocia in 39 (5.0%). CS for labor dystocia was associated with shorter MH (mean ± SD, 160.4 ± 6.6 vs 164.5 ± 6.3 cm; P < 0.001), larger fetal HC (339.6 ± 9.5 vs 330.7 ± 13.0 mm; P < 0.001) and a higher HC/MH ratio (2.12 ± 0.11 vs 2.01 ± 0.10; P < 0.001) compared with vaginal delivery. Multivariate logistic regression analysis showed that the HC/MH ratio was associated independently with CS for labor dystocia (adjusted odds ratio, 2.65 (95% CI, 1.85-3.79); P < 0.001). The HC/MH ratio had an area under the receiver-operating-characteristics curve of 0.77 and an optimal cut-off value for discriminating between vaginal delivery and CS for labor dystocia of 2.09, which was associated with a sensitivity of 0.62 (95% CI, 0.45-0.77), specificity of 0.79 (95% CI, 0.76-0.82), positive predictive value of 0.13 (95% CI, 0.09-0.19) and negative predictive value of 0.98 (95% CI, 0.96-0.99).

CONCLUSIONS

In a large cohort of unselected pregnancies, the HC/MH ratio performed better than did fetal HC and MH alone in identifying those cases that will undergo CS for labor dystocia, albeit with moderate predictive value. The HC/MH ratio could assist in the evaluation of women at risk for CS for labor dystocia. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Systematic Review and Critical Evaluation of Quality of Clinical Practice Guidelines on Nutrition in Pregnancy

Objective: To report the quality and clinical heterogeneity of the published clinical practice guidelines (CPGs) on nutrition in pregnancy. Methods: MEDLINE, Embase, Scopus, and ISI Web of Science databases were searched. The following aspects related to nutrition in pregnancy were addressed: specific requirements during pregnancy, description of a balanced diet, weight gain, prevention of food-borne, nutrition in peculiar sub-groups of women, and maternal or perinatal outcomes. The assessment of the risk of bias and quality assessment of the included CPGs were performed using “The Appraisal of Guidelines for REsearch and Evaluation (AGREE II)” tool divided in six quality domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, editorial independence. Mean ± standard deviation (SD) was used to summarize the scores across all the guidelines per domain. The quality of each guideline was computed using the scoring system proposed by Amer et al. A cut-off of >60% was sued to define a CGP as recommended. Results: Eighteen CPGs were included. There was a substantial heterogeneity in the recommended dose for vitamins, folic acid, and micronutrient intake during pregnancy among the different published CPGs. 27.8% (5/18) of the CPGs recommended a daily intake of folic acid of 200 mcg, 38.8% (7/18) 400 mcg, 16.7% (3/18) 600 mcg while the remaining CPGs suggested dose between 400 and 600−800 mc per day. Adequate maternal hydration was advocated in the large majority of included CPGs, but a specific amount of water intake was not reported in 83.3% (15/18) cases. There was also significant heterogeneity in various other aspects of nutrition recommendation among the different CPGs, including gestational weight gain (55.5%), prevention of food-borne diseases in pregnancy (72.2%), nutrition in particular groups of pregnant women (83.3%), maternal and perinatal outcomes (72.2%). The AGREE II standardized domain scores for the first overall assessment (OA1) had a mean of 65% but only half scored more than 60%. Conclusion: The published CPGs on nutrition in pregnancy show an overall good methodology, but also a substantial heterogeneity as regard as different major aspects on nutrition in pregnancy.

Maternal cardiovascular function in the prediction of fetal distress in labor: a prospective cohort study

OBJECTIVE

To explore the strength of association and the diagnostic accuracy of maternal hemodynamic parameters detected noninvasively in predicting an adverse perinatal outcome in labor.

METHODS

Prospective cohort study of singleton women undergoing antepartum care at 37-39 weeks of gestation. A noninvasive ultrasonic cardiac output monitor (USCOM®) was used for cardiovascular assessment. The study outcome was a composite score of adverse perinatal outcome, which included at least one of the following variables: Cesarean or instrumental delivery for abnormal fetal heart monitoring, umbilical artery pH <7.10 or admission to neonatal special care unit. Attending clinicians were blinded to maternal cardiovascular indices. Multivariate logistic regression and area under the curve (AUC) analyses were used to test the diagnostic accuracy of different maternal and ultrasound characteristics in predicting adverse perinatal outcome.

RESULTS

A total of 133 women were recruited. The rate of adverse perinatal outcome was 25.6% (34/133). Women who delivered without abnormal perinatal outcome (controls) were more likely to be parous, compared to those who had an adverse perinatal outcome (44.4 vs. 73.5%; p = .005). Control women had significantly lower systemic vascular resistance (SVR) (median, 1166 vs. 1352 dynes × s/cm⁵, p = .023) and SVR index (SVRI) (median, 2168 vs. 2627 dynes × s/cm⁵/m², p = .039) compared to women who had an adverse perinatal outcome. In this latter group the prevalence of SV <50 ml was significantly higher than in the control group (38.2% (13/34) vs. 11.1%, (11/99) p = .0012). At multivariable logistic regression analysis, SVR (aOR 1.307; 95% CI 1.112-2.23), SV <50 ml (aOR 4.70; 95% CI 1.336-12.006) and parity (3.90: 95% CI 1.545-10.334) were the only variables independently associated with adverse perinatal outcome. A model considering only SVR showed an AUC of 0.631. Integration of SVR with SV <50 ml and parity significantly improves the diagnostic performance of SVR alone to predict adverse outcome (AUC 0.732; p = .016).

CONCLUSION

Pre-labor modifications of maternal cardiovascular variables are associated with adverse perinatal outcome. However, their predictive accuracy for perinatal compromise is low, and thus their use as standalone screening test for adverse perinatal outcome in singleton pregnancies at term is not supported.

Women perception of SARS-CoV-2 vaccination during pregnancy and subsequent maternal anxiety: a prospective observational study

OBJECTIVE

The use of Coronavirus 2 (SARS-CoV-2) vaccine in pregnant women is controversial and still not performed in Italy. Our objective was to evaluate the propensity of a population of Italian women to receive the vaccine and its psychological impact.

METHODS

A prospective, observational study was performed on pregnant women attending Ospedale Cristo Re Università Roma TorVergata. A multi-section questionnaire was sent to each included woman on the first day of available SARS-CoV-2 vaccination. Part-A was finalized to acquire maternal characteristics and to test the women's perception of vaccinations in pregnancy and their fear-induced by vaccines. Part-B included the State-Trait-Anxiety-Inventory (STAI) a validated test for scoring trait anxiety (basal anxiety, STAI-T) and state anxiety (STAI-S). An abnormal value of STAI was considered when ≥40. Comparisons of maternal variables were performed according to their vaccine attitude.

RESULTS

The questionnaire was completed by 161 women (80.5% of the population considered). A positive attitude toward the vaccine was present in 136 (84.5%) women (positive) while the remaining 25.5% considered the vaccine not useful (negative). Among the former group 52.9% were favorable to obtain the vaccine during pregnancy despite the current national limitations, a percentage significantly higher (p = .02) than in the negative groups. Women with a negative attitude to the vaccine had a lower educational (p = .002) and employment level (p = .016) when compared to the positive group. In all the women a significant increase of STAI-S from STAI-T values was evidenced (p < .0001). The incidence of abnormal STAI T values (basal anxiety) was similar between the 2 groups (p = .81), while there was a significant increase of STAI-S values in the negative group (negative 88.0%; vs positive 63.4%; p = .018).

CONCLUSIONS

The majority of pregnant women considered have a positive attitude to SARS-CoV-2 vaccine. Vaccine campaign seems to increase the maternal level of anxiety and this increase is more marked with a negative attitude toward the vaccine.

Prediction of delivery after 40 weeks by antepartum ultrasound in singleton multiparous women: a prospective cohort study

OBJECTIVE

Universal elective induction of labor (IOL) in singleton parous pregnancies has been advocated to reduce the rate of cesarean section (CD), without impacting on maternal outcome. However, about 50% of women deliver after 40 weeks; therefore, an accurate estimation of the time of delivery might avoid unnecessary early IOL. The aim of this study was to test the diagnostic accuracy of ultrasound in predicting delivery ≥40 weeks of gestation in singleton parous women.

METHODS

Prospective cohort study of singleton parous women undergoing a dedicated ultrasound assessment at 36-38 weeks of gestation. The primary outcome was spontaneous vaginal delivery ≥40 weeks of gestation. Cervical length (CL), posterior cervical angle (PCA), sonoelastographic hardness ratio (HR), angle of progression (AoP) and head perineal distance (HPD) were measured. Multivariate logistic regression and area under the curve (AUC) analyses were used to test the diagnostic accuracy of different maternal and ultrasound characteristics in predicting delivery ≥40 weeks.

RESULTS

518 singleton pregnancies were included in the analysis and 235 (45.4%) delivered ≥40 weeks. CL (29 vs 19 mm; p ≤ .0001) and HPD (50 vs 47 mm; p = .001) were longer, HR higher (38.9 vs 35.5; p = .04), while PCA (98° vs 104°; p ≤ .0001) and AOP narrower (93° vs 98°; p = .029) in pregnancies delivered compared to those not delivered after 40 weeks of gestation. At multivariable logistic regression analysis, CL (aOR 1.206; 95% CI 1.164-1.250), HPD (aOR 1.127; 95% CI 1.066-1.191) and HR (aOR 1.022; 95% CI 1.003-1.041 were the only variables independently associated with delivery ≥40 weeks. CL showed had an AUC of 0.863 in predicting delivery ≥40 weeks of gestation, with an optimal cutoff of 23.5 mm. Integration of HPD and HR did not significantly improve the diagnostic performance of CL alone to predict delivery ≥40 weeks (AUC 0.870; p = .472).

CONCLUSION

Cervical length at 36-38 weeks has a good diagnostic accuracy to predict spontaneous vaginal delivery at ≥40 weeks. Universal assessment of CL in the third trimester of pregnancy may help in identifying those women who may benefit of elective IOL at 39 weeks.

Which is the best time to perform balloon valvuloplasty in critically fetal aortic stenosis: Prenatally or after birth?

Fetal aortic valvuloplasty may prevent the progression of severe fetal aortic stenosis to hypoplastic left heart syndrome at birth. Since it is an high risk procedure a careful selection of fetuses that can benefit from the prenatal treatment instead of waiting for postnatal intervention.