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Cornthwaite K, van der Scheer JW, Kelly S, Schmidt-Hansen M, Burt J, Dixon-Woods M, Draycott T, Bahl R. Management of impacted fetal head at cesarean birth: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:1702-1713. [PMID: 38787368 PMCID: PMC11324922 DOI: 10.1111/aogs.14873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Despite increasing incidence of impacted fetal head at cesarean birth and associated injury, it is unclear which techniques are most effective for prevention and management. A high quality evidence review in accordance with international reporting standards is currently lacking. To address this gap, we aimed to identify, assess, and synthesize studies comparing techniques to prevent or manage impacted fetal head at cesarean birth prior to or at full cervical dilatation. MATERIAL AND METHODS We searched MEDLINE, Emcare, Embase and Cochrane databases up to 1 January 2023 (PROSPERO: CRD420212750016). Included were randomized controlled trials (any size) and non-randomized comparative studies (n ≥ 30 in each arm) comparing techniques or adjunctive measures to prevent or manage impacted fetal head at cesarean birth. Following screening and data extraction, we assessed risk of bias for individual studies using RoB2 and ROBINS-I, and certainty of evidence using GRADE. We synthesized data using meta-analysis where appropriate, including sensitivity analyses excluding data published in potential predatory journals or at risk of retraction. RESULTS We identified 24 eligible studies (11 randomized and 13 non-randomized) including 3558 women, that compared vaginal disimpaction, reverse breech extraction, the Patwardhan method and/or the Fetal Pillow®. GRADE certainty of evidence was low or very low for all 96 outcomes across seven reported comparisons. Pooled analysis mostly showed no or equivocal differences in outcomes across comparisons of techniques. Although some maternal outcomes suggested differences between techniques (eg risk ratio of 3.41 [95% CI: 2.50-4.66] for uterine incision extension with vaginal disimpaction vs. reverse breech extraction), these were based on unreliable pooled estimates given very low GRADE certainty and, in some cases, additional risk of bias introduced by data published in potential predatory journals or at risk of retraction. CONCLUSIONS The current weaknesses in the evidence base mean that no firm recommendations can be made about the superiority of any one impacted fetal head technique over another, indicating that high quality training is needed across the range of techniques. Future studies to improve the evidence base are urgently required, using a standard definition of impacted fetal head, agreed maternal and neonatal outcome sets for impacted fetal head, and internationally recommended reporting standards.
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Affiliation(s)
- Katie Cornthwaite
- Royal College of Obstetricians & Gynaecologists, London, UK
- University Hospitals Bristol and Weston, Bristol, UK
| | - Jan W van der Scheer
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Sarah Kelly
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | | | - Jenni Burt
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Tim Draycott
- Royal College of Obstetricians & Gynaecologists, London, UK
- North Bristol NHS Trust, Bristol, UK
| | - Rachna Bahl
- Royal College of Obstetricians & Gynaecologists, London, UK
- University Hospitals Bristol and Weston, Bristol, UK
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Cornthwaite KR, Bahl R, Lattey K, Draycott T. Management of impacted fetal head at cesarean delivery. Am J Obstet Gynecol 2024; 230:S980-S987. [PMID: 38462267 PMCID: PMC11000504 DOI: 10.1016/j.ajog.2022.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/05/2022] [Accepted: 10/09/2022] [Indexed: 03/12/2024]
Abstract
Globally, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full cervical dilatation. In these circumstances, and when labor has been prolonged in the first stage of labor, the fetal head can become low and wedged deep in the woman's pelvis, making it difficult to deliver the baby. This emergency is known as impacted fetal head. These are technically challenging births associated with serious risks to both the woman and the baby. The difficulty in disimpacting the fetal head increases maternal risks of hemorrhage and injury to adjacent organs and may have long-term consequences for future pregnancies. In addition, there can be associated neonatal consequences, such as skull fractures, brain hemorrhage, hypoxic brain injury, and, rarely, perinatal death. Globally, maternity staff are increasingly encountering this emergency, with studies in the United Kingdom suggesting that impacted fetal head may complicate as many as 1 in 10 emergency cesarean deliveries. Moreover, there has been a sharp increase in reports of perinatal brain injuries associated with impaction of the fetal head at cesarean delivery. When an impacted fetal head occurs, the maternity team can employ a range of approaches to help deliver the fetal head, including an assistant (another obstetrician or midwife) pushing the head up from the vagina, delivering the baby feet first (reverse breech extraction), administering tocolysis to relax the uterus, and using a balloon cephalic elevation device (Fetal Pillow) to elevate the baby's head. However, there is currently no consensus on how best to manage these births, resulting in a lack of confidence among maternity staff, variable practice, and potentially avoidable harm in some circumstances. This article examined the evidence for the prevention and management of this critical obstetrical emergency and outlined recommendations for best practices and training.
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Affiliation(s)
- Katie R Cornthwaite
- University of Bristol and Royal College of Obstetricians and Gynaecologists, Bristol, United Kingdom.
| | - Rachna Bahl
- University Hospitals Bristol NHS Trust and Royal College of Obstetricians and Gynaecologists, Bristol, United Kingdom
| | | | - Tim Draycott
- North Bristol NHS Trust and Royal College of Obstetricians and Gynaecologists, Bristol, United Kingdom
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Lee LTL, Chiu CPH, Ma MKT, Kwong LT, Hung MWC, Chan YYY, Wong EJ, Lai THT, Chan OK, So PL, Lau WL, Leung TY. The use of bubble charts in analyzing the global second-stage cesarean delivery rates: a systematic review. AJOG GLOBAL REPORTS 2024; 4:100312. [PMID: 38380079 PMCID: PMC10877423 DOI: 10.1016/j.xagr.2024.100312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
OBJECTIVE This study aimed to systematically review the worldwide second-stage cesarean delivery rate concerning pre-second-stage cesarean delivery and assisted vaginal birth rates. DATA SOURCES PubMed, Medline Ovid, EBSCOhost, Embase, Scopus, and Google Scholar were queried from inception to February 2023, with the following terms: "full dilatation," "second stage," and "cesarean," with their word variations. Furthermore, an additional cohort of 353,434 cases from our recently published study was included. STUDY ELIGIBILITY CRITERIA Only original studies that provided sufficient information on the number of pre-second-stage cesarean deliveries, second-stage cesarean deliveries, and vaginal births were included for the calculation of different modes of delivery. Systemic reviews, meta-analyses, or case reports were excluded. METHODS Study identification and data extraction were independently performed by 2 authors. Selected studies were categorized on the basis of parity, study period, and geographic regions for comparison. RESULTS A total of 25 studies were included. The overall pre-second-stage cesarean delivery rate, the second-stage cesarean delivery rate, and the second-stage cesarean delivery-to-assisted vaginal birth ratio were 17.94%, 2.65%, and 0.19, respectively. Only 5 studies described singleton, term, cephalic presenting pregnancies of nulliparous women, and their second-stage cesarean delivery rates were significantly higher than those studies with cohorts of all parity groups (4.50% vs 0.83%; P<.05). In addition, the second-stage cesarean delivery rate showed a secular increase across 2009 (0.70% vs 1.05%; P<.05). Moreover, it was the highest among African studies (5.14%) but the lowest among studies from East Asia and South Asia (0.94%). The distributions of second-stage cesarean delivery rates of individual studies and subgroups were shown with that of pre-second-stage cesarean delivery and assisted vaginal birth using the bubble chart. CONCLUSION The overall worldwide pre-second-stage cesarean delivery rate was 17.94%, the second-stage cesarean delivery rate was 2.65%, and the second-stage cesarean delivery-to-assisted vaginal birth ratio was 0.19. The African studies had the highest second-stage cesarean delivery rate (5.14%) and second-stage cesarean delivery-to-assisted vaginal birth ratio (1.88), whereas the studies from East Asia and South Asia were opposite (0.94% and 0.11, respectively).
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Affiliation(s)
- Lin Tai Linus Lee
- Department of Obstetrics and Gynaecology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong (Dr Lee)
| | - Christopher Pak Hey Chiu
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong (Dr Chiu, Ms Chan, and Prof Leung)
| | - Man Kee Teresa Ma
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong (Dr Ma)
| | - Lee Ting Kwong
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong (Drs Kwong and So)
| | - Man Wai Catherine Hung
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Kowloon, Hong Kong (Drs Hung and Lau)
| | - Yuen Yee Yannie Chan
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Lai Chi Kok, Hong Kong (Dr Chan)
| | - Eunice Joanna Wong
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong (Drs Kwong and So)
- Department of Obstetrics and Gynaecology, United Christian Hospital, Kwun Tong, Hong Kong (Dr Wong)
| | - Theodora Hei Tung Lai
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, Pok Fu Lam, Hong Kong (Dr Lai)
| | - Oi Ka Chan
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong (Dr Chiu, Ms Chan, and Prof Leung)
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Lai Chi Kok, Hong Kong (Dr Chan)
| | - Po Lam So
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong (Drs Kwong and So)
| | - Wai Lam Lau
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Kowloon, Hong Kong (Drs Hung and Lau)
| | - Tak Yeung Leung
- Department of Obstetrics and Gynaecology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong (Dr Lee)
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong (Dr Chiu, Ms Chan, and Prof Leung)
| | - Hong Kong College of Obstetricians and Gynaecologists Research Group
- Department of Obstetrics and Gynaecology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong (Dr Lee)
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong (Dr Chiu, Ms Chan, and Prof Leung)
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong (Dr Ma)
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong (Drs Kwong and So)
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Kowloon, Hong Kong (Drs Hung and Lau)
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Lai Chi Kok, Hong Kong (Dr Chan)
- Department of Obstetrics and Gynaecology, United Christian Hospital, Kwun Tong, Hong Kong (Dr Wong)
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, Pok Fu Lam, Hong Kong (Dr Lai)
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Cornthwaite K, Bahl R, Winter C, Wright A, Kingdom J, Walker KF, Tydeman G, Briley A, Schmidt-Hansen M, Draycott T. Management of Impacted Fetal Head at Caesarean Birth: Scientific Impact Paper No. 73. BJOG 2023; 130:e40-e64. [PMID: 37303275 DOI: 10.1111/1471-0528.17534] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Over one-quarter of women in the UK have a caesarean birth (CB). More than one in 20 of these births occurs near the end of labour, when the cervix is fully dilated (second stage). In these circumstances, and when labour has been prolonged, the baby's head can become lodged deep in the maternal pelvis making it challenging to deliver the baby. During the caesarean birth, difficulty in delivery of the baby's head may result - this emergency is known as impacted fetal head (IFH). These are technically challenging births that pose significant risks to both the woman and baby. Complications for the woman include tears in the womb, serious bleeding and longer hospital stay. Babies are at increased risk of injury including damage to the head and face, lack of oxygen to the brain, nerve damage, and in rare cases, the baby may die from these complications. Maternity staff are increasingly encountering IFH at CB, and reports of associated injuries have risen dramatically in recent years. The latest UK studies suggest that IFH may complicate as many as one in 10 unplanned CBs (1.5% of all births) and that two in 100 babies affected by IFH die or are seriously injured. Moreover, there has been a sharp increase in reports of babies having brain injuries when their birth was complicated by IFH. When an IFH occurs, the maternity team can use different approaches to help deliver the baby's head at CB. These include: an assistant (another obstetrician or midwife) pushing the head up from the vagina; delivering the baby feet first; using a specially designed inflatable balloon device to elevate the baby's head and/or giving the mother a medicine to relax the womb. However, there is currently no consensus for how best to manage these births. This has resulted in a lack of confidence among maternity staff, variable practice and potentially avoidable harm in some circumstances. This paper reviews the current evidence regarding the prediction, prevention and management of IFH at CB, integrating findings from a systematic review commissioned from the National Guideline Alliance.
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Gq Peak A, Barwise E, Walker KF. Techniques for managing an impacted fetal head at caesarean section: A systematic review. Eur J Obstet Gynecol Reprod Biol 2023; 281:12-22. [PMID: 36525940 DOI: 10.1016/j.ejogrb.2022.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
A complication arising at caesarean birth when the baby's head is deeply engaged in the pelvis and may be difficult to deliver, is known as an 'impacted fetal head'. This obstetric emergency occurs in 16% of second stage caesarean sections. Multiple techniques are described in the literature to manage the complication but there is no consensus regarding which technique results in the best maternal and neonatal outcomes. The objective of this review is to determine which technique for managing impacted fetal head at caesarean section has the best maternal and neonatal outcomes. A literature search of three electronic databases was conducted in November 2021. Studies directly comparing two methods for the management of impacted fetal head at caesarean section in the second stage were included. Systematic reviews, meta-analyses, case-control studies, and studies not fitting the search criteria were excluded. Data was extracted in Covidence and meta-analysis of the six most commonly reported outcomes was conducted using RevMan 5.4. In total, 16 studies (3344women) were included. 13 studies (2506women) compared the push method with reverse breech extraction. meta-analysis showed that risk of extension of the uterine incision, blood transfusion, bladder injury, postpartum haemorrhage, NICU admission and Apgar score <7 at 5 min were significantly higher with the push method compared with reverse breech extraction. Three studies (838women) compared the push method with Patwardhan's technique. meta-analysis of studies comparing the push method with Patwardhan's technique found no significant differences between the two groups in any of the six maternal or neonatal outcomes. Evidence derived from small, inadequately powered studies suggests reverse breech extraction is associated with better outcomes than the push method. The method which produces the best outcomes is still unknown as not all methods have been tested. Further high quality, adequately powered RCTs are warranted for definitive conclusions to be drawn and to ameliorate the paucity of evidence on how best to manage this complication.
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Affiliation(s)
- Amelia Gq Peak
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
| | - Elena Barwise
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
| | - Kate F Walker
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
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Rada MP, Ciortea R, Măluțan AM, Prundeanu I, Doumouchtsis SK, Bucuri CE, Blaga LD, Mihu D. Maternal and neonatal outcomes associated with delivery techniques for impacted fetal head at cesarean section: a systematic review and meta-analysis. J Perinat Med 2022; 50:446-456. [PMID: 35119802 DOI: 10.1515/jpm-2021-0572] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/11/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Late first-stage or second-stage cesarean section is commonly associated with fetal head impaction, leading to maternal and neonatal complications. This situation requires safe delivery techniques, but the optimal management remains controversial. The aim of this meta-analysis was to compare maternal and neonatal outcomes associated with delivery techniques via cesarean section. METHODS An electronic search of three databases, from inception to June 2021, was conducted. Cohort and randomised comparative studies on maternal and neonatal outcomes associated with techniques to deliver an impacted fetal head during cesarean section were included. The methodological quality of the primary studies was assessed. Review Manager 5.4 was used for statistical analyses. RESULTS Nineteen articles, including 2,345 women were analyzed. Three fetal extraction techniques were identified. Meta-analyses showed that the "pull" technique carries lower risks as compared to the "push" technique and the "Patwardhan" technique is safer compared to the "push" or the "push and pull" technique. CONCLUSIONS In the absence of robust evidence to support the use of a specific technique, the choice of the obstetrician should be based on best available evidence. Our study suggests that the "pull", as well as the "Patwardhan" technique represent safe options to deliver an impacted fetal head.
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Affiliation(s)
- Maria Patricia Rada
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Răzvan Ciortea
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andrei Mihai Măluțan
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ioana Prundeanu
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Stergios K Doumouchtsis
- Department of Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, Epsom, UK.,Laboratory of Experimental Surgery and Surgical Research N. S. Christeas, Athens University Medical School, Athens, Greece.,St George's University of London, London, UK.,American University of the Caribbean, School of Medicine, Pembroke Pines, Florida, USA.,School of Medicine, Ross University, Miramar, FL, USA
| | - Carmen Elena Bucuri
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Dr. Constantin Papilian Military Emergency Clinical Hospital, Cluj-Napoca, Romania
| | - Ligia Daniela Blaga
- Department of Neonatology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dan Mihu
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Di Girolamo R, Galliani C, Buca D, Liberati M, D'Antonio F. Outcomes of second stage cesarean section following the use of a fetal head elevation device: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2021; 262:1-6. [PMID: 33984724 DOI: 10.1016/j.ejogrb.2021.04.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To explore maternal and perinatal outcomes of women undergoing full dilatation cesarean section (CS) who had compared to those who did not have application of fetal head elevation device (FHED). MATERIAL AND METHODS Pubmed, Embase, Cinahl, Clinical Trial.Gov and Google Scholar databases were searched. Inclusion criteria were studies exploring maternal and perinatal outcomes in women having compared to those not having FHED at full dilatation CS. The outcomes explored were: hysterotomy to delivery time (sec), mean estimated blood loss (ml), blood loss > 1000 mL, need for blood transfusion, uterine incision extension, operative complications, need for re-operation, urinary retention, hospital re-admission, length of in hospital stay, Apgar score < 3 at 1 min, Apgar score < 7 at 5 min, neonatal arterial Ph, arterial pH < 7.1, admission to neonatal intensive care unit (NICU), neonatal sepsis, need for neonatal endotracheal intubation, neonatal death. Random effect head-to-head meta-analyses combining summary mean difference (MD), and odd ratio (OR) were used to analyze the data. RESULTS Ten studies (1326 women) were included. The mean time from hysterotomy to delivery was lower in women having compared to those not having FHED (MD: -52.26 s, 95 % CI -55.2 to -34.94, p < 0.001). Women who had FHED had also a lower mean estimated blood loss (MD: -130.82 mL, 95 % CI -130.1 to -381.0; p < 0.001) and a shorter stay in the hospital (MD: -0.884 h, 95 % CI -1.07 to -0.70; p < 0.001) compared to controls. Pregnant women having FHED at full dilatation CS had a lower risk of uterine incision extension (OR: 0.50, 95 % CI 0.3 to 0.9; p = 0.02), need for blood transfusion (OR: 0.39, 95 % CI 0.2 to 0.7; p = 0.04) and operative complications (OR: 0.44, 95 % CI 0.2 to 0.9; p = 0.03) compared to controls, while there was no difference in the other maternal outcomes between the two groups. When exploring perinatal outcome, women who received FHED had higher mean arterial pH values (MD: 0.617, 95 % CI 0.43 to 0.88; p < 0.001) and a lower risk of neonatal sepsis (OR: 0.10, 95 % CI 0.01 to 0.99; p = 0.05) and admission to NICU (OR: 0.63, 95 % CI 0.5 to 0.9; p = 0.008) compared to controls. CONCLUSION Application of FHED at full dilatation CS seems to be associated with improvement in some maternal and neonatal outcomes.
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Affiliation(s)
- Raffaella Di Girolamo
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - Carmen Galliani
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - Danilo Buca
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - Marco Liberati
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - Francesco D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy.
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