A national survey on current practice of ultrasound in labor ward

OBJECTIVES

Use of ultrasonography has been suggested as an accurate adjunct to clinical evaluation of fetal position and station during labor. There are no available reports concerning its actual use in delivery wards. The aim of this survey was to evaluate the current practice regarding the use of ultrasonography during labor.

METHODS

A questionnaire was sent to members of the Italian Society of Ultrasound in Obstetrics and Gynecology employed in delivery wards. The qFeuestionnaire was made up of 22 questions evaluating participant characteristics and the current use of ultrasound in labor in their hospital of employment. The answers were grouped according to participant characteristics.

RESULTS

A total of 200 participants replied. Ultrasound was considered useful before an operative vaginal delivery by 59.6 % of respondents, while 51.8 and 52.5 % considered it useful in the management of prolonged first and second stages of labor, respectively. The major indication for ultrasound use during labor was the assessment of fetal occiput position. The major difficulties in its application were the perceived lack of training and the complexity of the ultrasound equipment use. Participants that reported fewer difficulties were those employed in hospitals with a higher number of deliveries or having delivery units with more years of experience using ultrasound in labor, or those who had attended specific training courses.

CONCLUSIONS

The results indicate that, despite the reported evidence of a higher accuracy of ultrasound compared to clinical evaluation in assessing fetal position and station, its use is still limited, even amongst maternal-fetal medicine practitioners specialized in ultrasonography.

Mosaic derivative chromosomes at chorionic villi (CV) sampling are expression of genomic instability and precursors of cryptic disease-causing rearrangements: report of further four cases

Mosaic chromosomal anomalies arising in the product of conception and the final fetal chromosomal arrangement are expression of complex biological mechanisms. The rescue of unbalanced chromosome with selection of the most viable cell line/s in the embryo and the unfavourable imbalances in placental tissues was documented in our previous paper and in the literature. We report four additional cases with mosaic derivative chromosomes in different feto-placental tissues, further showing the instability of an intermediate gross imbalance as a frequent mechanism of de novo cryptic deletions and duplications. In conclusion we underline how the extensive remodeling of unbalanced chromosomes in placental tissues represents the 'backstage' of de novo structural rearrangements, as the early phases of a long selection process that the genome undergo during embryogenesis.

The "Preeclampsia and Hypertension Target Treatment" study: a multicenter prospective study to evaluate the effectiveness of the antihypertensive therapy based on maternal hemodynamic findings

BACKGROUND

Despite major advances in the pharmacologic treatment of hypertension in the nonpregnant population, treatments for hypertension in pregnancy have remained largely unchanged over the years. There is recent evidence that a more adequate control of maternal blood pressure is achieved when the first given antihypertensive drug is able to correct the underlying hemodynamic disorder of the mother besides normalizing the blood pressure values.

OBJECTIVE

This study aimed to compare the blood pressure control in women receiving an appropriate or inappropriate antihypertensive therapy following the baseline hemodynamic findings.

STUDY DESIGN

This was a prospective multicenter study that included a population of women with de novo diagnosis of hypertensive disorders of pregnancy. A noninvasive assessment of the following maternal parameters was performed on hospital admission via Ultrasound Cardiac Output Monitor before any antihypertensive therapy was given: cardiac output, heart rate, systemic vascular resistance, and stroke volume. The clinician who prescribed the antihypertensive therapy was blinded to the hemodynamic evaluation and used as first-line treatment a vasodilator (nifedipine or alpha methyldopa) or a beta-blocker (labetalol) based on his preferences or on the local protocols. The first-line pharmacologic treatment was retrospectively considered hemodynamically appropriate in either of the following circumstances: (1) women with a hypodynamic profile (defined as low cardiac output [≤5 L/min] and/or high systemic vascular resistance [≥1300 dynes/second/cm2]) who were administered oral nifedipine or alpha methyldopa and (2) women with a hyperdynamic profile (defined as normal or high cardiac output [>5 L/min] and/or low systemic vascular resistances [<1300 dynes/second/cm2]) who were administered oral labetalol. The primary outcome of the study was to compare the occurrence of severe hypertension between women treated with a hemodynamically appropriate therapy and women treated with an inappropriate therapy.

RESULTS

A total of 152 women with hypertensive disorders of pregnancy were included in the final analysis. Most women displayed a hypodynamic profile (114 [75.0%]) and received a hemodynamically appropriate treatment (116 [76.3%]). The occurrence of severe hypertension before delivery was significantly lower in the group receiving an appropriate therapy than in the group receiving an inappropriately treated (6.0% vs 19.4%, respectively; P=.02). Moreover, the number of women who achieved target values of blood pressure within 48 to 72 hours from the treatment start was higher in the group who received an appropriate treatment than in the group who received an inappropriate treatment (70.7% vs 50.0%, respectively; P=.02).

CONCLUSION

In pregnant individuals with de novo hypertensive disorders of pregnancy, a lower occurrence of severe hypertension was observed when the first-line antihypertensive agent was tailored to the correct maternal hemodynamic profile.

Assessment of the cerebroplacental ratio and uterine arteries in low-risk pregnancies in early labour for the prediction of obstetric and neonatal outcomes

BACKGROUND

The evidence-based management of human labor includes the antepartum identification of patients at risk for intrapartum hypoxia. However, available evidence has shown that most of the hypoxic-related complications occur among pregnancies classified at low-risk for intrapartum hypoxia, thus suggesting that the current strategy to identify the pregnancies at risk for intrapartum fetal hypoxia has limited accuracy.

OBJECTIVE

To evaluate the role of the combined assessment of the cerebroplacental ratio (CPR) and uterine arteries (UtA) Doppler in the prediction of obstetric intervention (OI) for suspected intrapartum fetal compromise (IFC) within a cohort of low-risk singleton term pregnancies in early labor.

METHODS

Prospective multicentre observational study conducted across four tertiary Maternity Units between January 2016 and September 2019. Low-risk term pregnancies with spontaneous onset of labor were included. A two-step multivariable model was developed to assess the risk of OI for suspected IFC. The baseline model included antenatal and intrapartum characteristics, while the combined model included antenatal and intrapartum characteristics plus Doppler anomalies such as CPR MoM < 10th percentile and mean UtA Doppler PI MoM ≥ 95th percentile. Predictive performance was determined by receiver-operating characteristics curve analysis.

RESULTS

804 women were included. At logistic regression analysis, CPR MoM < 10th percentile (aOR 1.269, 95 % CI 1.188-1.356, P < 0.001), mean UtA PI MoM ≥ 95th percentile (aOR 1.012, 95 % CI 1.001-1.022, P = 0.04) were independently associated with OI for suspected IFC. At ROC curve analysis, the combined model including antenatal characteristics plus abnormal CPR and mean UtA PI yielded an AUC of 0.78, 95 %CI(0.71-0.85), p < 0.001, which was significantly higher than the baseline model (AUC 0.61, 95 %CI(0.54-0.69), p = 0.007) (p < 0.001). The combined model was associated with a 0.78 (95 % CI 0.67-0.89) sensitivity, 0.68 (95 % CI 0.65-0.72) specificity, 0.15 (95 % CI 0.11-0.19) PPV, and 0.98 (0.96-0.99) NPV, 2.48 (95 % CI 2.07-2.97) LR + and 0.32 (95 % CI 0.19-0.53) LR- for OI due to suspected IFC.

CONCLUSIONS

A predictive model including antenatal and intrapartum characteristics combined with abnormal CPR and mean UtA PI has a good capacity to rule out and a moderate capacity to rule in OI due to IFC, albeit with poor predictive value.

Prenatal vs postnatal diagnosis of 22q11.2 deletion syndrome: cardiac and noncardiac outcomes through 1 year of age

BACKGROUND

The 22q11.2 deletion syndrome is the most common microdeletion syndrome and is frequently associated with congenital heart disease. Prenatal diagnosis of 22q11.2 deletion syndrome is increasingly offered. It is unknown whether there is a clinical benefit to prenatal detection as compared with postnatal diagnosis.

OBJECTIVE

This study aimed to determine differences in perinatal and infant outcomes between patients with prenatal and postnatal diagnosis of 22q11.2 deletion syndrome.

STUDY DESIGN

This was a retrospective cohort study across multiple international centers (30 sites, 4 continents) from 2006 to 2019. Participants were fetuses, neonates, or infants with a genetic diagnosis of 22q11.2 deletion syndrome by 1 year of age with or without congenital heart disease; those with prenatal diagnosis or suspicion (suggestive ultrasound findings and/or high-risk cell-free fetal DNA screen for 22q11.2 deletion syndrome with postnatal confirmation) were compared with those with postnatal diagnosis. Perinatal management, cardiac and noncardiac morbidity, and mortality by 1 year were assessed. Outcomes were adjusted for presence of critical congenital heart disease, gestational age at birth, and site.

RESULTS

A total of 625 fetuses, neonates, or infants with 22q11.2 deletion syndrome (53.4% male) were included: 259 fetuses were prenatally diagnosed (156 [60.2%] were live-born) and 122 neonates were prenatally suspected with postnatal confirmation, whereas 244 infants were postnatally diagnosed. In the live-born cohort (n=522), 1-year mortality was 5.9%, which did not differ between groups but differed by the presence of critical congenital heart disease (hazard ratio, 4.18; 95% confidence interval, 1.56-11.18; P<.001) and gestational age at birth (hazard ratio, 0.78 per week; 95% confidence interval, 0.69-0.89; P<.001). Adjusting for critical congenital heart disease and gestational age at birth, the prenatal cohort was less likely to deliver at a local community hospital (5.1% vs 38.2%; odds ratio, 0.11; 95% confidence interval, 0.06-0.23; P<.001), experience neonatal cardiac decompensation (1.3% vs 5.0%; odds ratio, 0.11; 95% confidence interval, 0.03-0.49; P=.004), or have failure to thrive by 1 year (43.4% vs 50.3%; odds ratio, 0.58; 95% confidence interval, 0.36-0.91; P=.019).

CONCLUSION

Prenatal detection of 22q11.2 deletion syndrome was associated with improved delivery management and less cardiac and noncardiac morbidity, but not mortality, compared with postnatal detection.

Correlation between intrapartum CTG findings and interleukin-6 levels in the umbilical cord arterial blood: A prospective cohort study

OBJECTIVE

to investigate the correlation between the intrapartum CardioTocoGraphic (CTG) findings "suggestive of fetal inflammation" ("SOFI") and the interleukin (IL)-6 level in the umbilical arterial blood.

STUDY DESIGN

prospective cohort study conducted at a tertiary maternity unit and including 447 neonates born at term.

METHODS

IL-6 levels were systematically measured at birth from a sample of blood taken from the umbilical artery. The intrapartum CTG traces were retrospectively reviewed by two experts who were blinded to the postnatal umbilical arterial IL-6 values as well as to the neonatal outcomes. The CTG traces were classified into "suggestive of fetal inflammation (SOFI)" and "no evidence of fetal inflammation (NEFI) according to the principles of physiologic interpretation the CTG traces. The CTG was classified as "SOFI" if there was a persistent fetal heart rate (FHR) increase > 10 % compared with the observed baseline FHR observed at the admission or at the onset of labor without any preceding repetitive decelerations. The occurrence of Composite Adverse Outcome (CAO) was defined as Neonatal Intensive Care Unit (NICU) or Special Care Baby Unit (SCBU) admission due to one or more of the following: metabolic acidaemia, Apgar score at 5 min ≤ 7, need of neonatal resuscitation, respiratory distress, tachypnoea/polypnea, jaundice requiring phototherapy, hypotension, body temperature instability, poor perinatal adaptation, suspected or confirmed early neonatal sepsis.

MAIN OUTCOME MEASURES

To compare the umbilical IL-6 values between the cases with intrapartum CTG traces classified as "SOFI" and those classified as "NEFI"; to assess the correlation of umbilical IL-6 values with the neonatal outcome.

RESULTS

43 (9.6 %) CTG traces were categorized as "SOFI"; IL-6 levels were significantly higher in this group compared with the "NEFI" group (82.0[43.4-325.0] pg/ml vs. 14.5[6.8-32.6] pg/mL; p <.001). The mean FHR baseline assessed 1 h before delivery and the total labor length showed an independent and direct association with the IL-6 levels in the umbilical arterial blood (p <.001 and p = 0.005, respectively). CAO occurred in 33(7.4 %) cases; IL-6 yielded a good prediction of the occurrence of the CAO with an AUC of 0.72 (95 % CI 0.61-0.81).

CONCLUSION

Intrapartum CTG findings classified as "SOFI" are associated with higher levels of IL-6 in the umbilical arterial blood.

Real-time ultrasound to assist during a vaginal breech delivery

We report a novel application of intrapartum sonography, herein used to assist the internal podalic version and the vaginal delivery of a transverse-lying second twin. Following the vaginal delivery of the first cephalic twin, the internal podalic version was performed under continuous ultrasound vision, leading to the uncomplicated breech delivery of a healthy neonate.

Pattern of recurrence in endometrial cancer. The murderer always returns to the scene of the crime

BACKGROUND

Endometrial cancer recurrence occurs in about 18 % of patients. This study aims to analyze the pattern recurrence of endometrial cancer and the relationship between the initial site of primary disease and the relapse site in patients undergoing surgical treatment.

METHODS

We retrospectively reviewed all surgically treated patients with endometrial cancer selecting those with recurrence. We defined primary site disease as uterus, lymph nodes, or peritoneum according to pathology analysis of the surgical specimen. The site of recurrence was defined as vaginal cuff, lymph nodes, peritoneum, and parenchymatous organs. Our primary endpoint was to correlate the site of initial disease with the site of recurrence.

RESULTS

The study enrolled 1416 patients. The overall recurrence rate was 17,5 % with 248 relapses included in the study. An increase of 9.9, 5.7, and 5.7 times in the odds of relapse on the lymph node, peritoneum, and abdominal parenchymatous sites respectively was observed in case of nodal initial disease (p < 0.001). A not significant difference in odds was observed in terms of vaginal cuff relapse (OR 0.9) between lymph node ad uterine primary disease (p = 0.78). An increasing OR of 8.7 times for nodal recurrences, 46.6 times for peritoneum, and 23.3 times for parenchymatous abdominal recurrences were found in the case of primary peritoneal disease (p < 0.001).

CONCLUSION

Endometrial cancer tends to recur at the initial site of the disease. Intraoperative inspection of the adjacent sites of primary disease and targeted instrumental examination of the initial sites of disease during follow-up are strongly recommended.

Maternal Hemodynamics from Preconception to Delivery: Research and Potential Diagnostic and Therapeutic Implications: Position Statement by Italian Association of Pre-Eclampsia and Italian Society of Perinatal Medicine

OBJECTIVE

 The Italian Association of Preeclampsia (AIPE) and the Italian Society of Perinatal Medicine (SIMP) developed clinical questions on maternal hemodynamics state of the art.

STUDY DESIGN

 AIPE and SIMP experts were divided in small groups and were invited to propose an overview of the existing literature on specific topics related to the clinical questions proposed, developing, wherever possible, clinical and/or research recommendations based on available evidence, expert opinion, and clinical importance. Draft recommendations with a clinical rationale were submitted to 8th AIPE and SIMP Consensus Expert Panel for consideration and approval, with at least 75% agreement required for individual recommendations to be included in the final version.

RESULTS

 More and more evidence in literature underlines the relationship between maternal and fetal hemodynamics, as well as the relationship between maternal cardiovascular profile and fetal-maternal adverse outcomes such as fetal growth restriction and hypertensive disorders of pregnancy. Experts agreed on proposing a classification of pregnancy hypertension, complications, and cardiovascular states based on three different hemodynamic profiles depending on total peripheral vascular resistance values: hypodynamic (>1,300 dynes·s·cm-5), normo-dynamic, and hyperdynamic (<800 dynes·s·cm-5) circulation. This differentiation implies different therapeutical strategies, based drugs' characteristics, and maternal cardiovascular profile. Finally, the cardiovascular characteristics of the women may be useful for a rational approach to an appropriate follow-up, due to the increased cardiovascular risk later in life.

CONCLUSION

 Although the evidence might not be conclusive, given the lack of large randomized trials, maternal hemodynamics might have great importance in helping clinicians in understanding the pathophysiology and chose a rational treatment of patients with or at risk for pregnancy complications.

KEY POINTS

· Altered maternal hemodynamics is associated to fetal growth restriction.. · Altered maternal hemodynamics is associated to complicated hypertensive disorders of pregnancy.. · Maternal hemodynamics might help choosing a rational treatment during hypertensive disorders..

Fetal face shape analysis from prenatal 3D ultrasound images

3D ultrasound imaging of fetal faces has been predominantly confined to qualitative assessment. Many genetic conditions evade diagnosis and identification could assist with parental counselling, pregnancy management and neonatal care planning. We describe a methodology to build a shape model of the third trimester fetal face from 3D ultrasound and show how it can objectively describe morphological features and gestational-age related changes of normal fetal faces. 135 fetal face 3D ultrasound volumes (117 appropriately grown, 18 growth-restricted) of 24-34 weeks gestation were included. A 3D surface model of each face was obtained using a semi-automatic segmentation workflow. Size normalisation and rescaling was performed using a growth model giving the average size at every gestation. The model demonstrated a similar growth rate to standard head circumference reference charts. A landmark-free morphometry model was estimated to characterize shape differences using non-linear deformations of an idealized template face. Advancing gestation is associated with widening/fullness of the cheeks, contraction of the chin and deepening of the eyes. Fetal growth restriction is associated with a smaller average facial size but no morphological differences. This model may eventually be used as a reference to assist in the prenatal diagnosis of congenital anomalies with characteristic facial dysmorphisms.

Longitudinal changes of the femoral bone mineral density from first to third trimester of pregnancy: bone health assessment by means of non-ionizing REMS technology

BACKGROUND

Throughout the pregnancy, there is a substantial transfer of calcium from the maternal skeleton to the fetus, which leads to a transient net reduction of the maternal bone mineral density.

AIMS

To assess longitudinally the changes in the bone mineral density at the femoral neck between the first and third trimester of pregnancy in a cohort of healthy participants using Radiofrequency Echographic Multi Spectrometry (REMS) technology.

METHODS

Prospective, cohort study conducted at the University hospital of Parma, Italy between July 2022 and February 2023. We recruited healthy participants with an uncomplicated singleton pregnancy before 14 completed weeks of gestation. All included participants were submitted to a sonographic examination of the femoral neck to assess the bone mineral density (and the corresponding Z-score values) using REMS at 11-13 and 36-38 weeks of pregnancy. The primary outcome was the change in the bone mineral density values at the maternal femoral neck between the first and third trimester of pregnancy.

RESULTS

Over a period of 7 months, a total of 65 participants underwent bone mineral density measurement at the femoral neck at first and third trimester of the pregnancy using REMS. A significant reduction of the bone mineral density at the femoral neck (0.723 ± 0.069 vs 0.709 ± 0.069 g/cm2; p < 0.001) was noted with a mean bone mineral density change of - 1.9 ± 0.6% between the first and third trimester of pregnancy. At multivariable linear regression analysis, none of the demographic or clinical variables of the study population proved to be independently associated with the maternal bone mineral density changes at the femoral neck.

CONCLUSIONS

Our study conducted on a cohort of healthy participants with uncomplicated pregnancy demonstrates that there is a significant reduction of bone mineral density at femoral neck from early to late gestation.

Prediction of persistent occiput posterior position by sonographic assessment of fetal head attitude at start of second stage of labor: prospective study

OBJECTIVES

To evaluate the relationship between the attitude of the fetal head quantified by means of the chin-to-chest angle (CCA) in fetuses in occiput posterior (OP) position at the beginning of the second stage of labor, and persistent OP position at birth.

METHODS

This was a single-center, prospective observational study conducted at the University Hospital of Parma, Parma, Italy. We included singleton pregnancies at term with fetuses in the OP position at the beginning of the second stage of labor. The fetal head position, station by means of angle of progression and head-to-perineum distance, and attitude by means of CCA were assessed using transabdominal or transperineal ultrasound. The primary outcome was persistent OP position at birth.

RESULTS

Between January and July 2022, 76 women were included in the study. There were 48 (63.2%) spontaneous rotations of the fetal head and spontaneous vaginal delivery occurred in all. Among the 28 (36.8%) fetuses that did not rotate spontaneously into an occiput anterior position, eight (28.6%) had a spontaneous vaginal delivery, while operative vaginal delivery and Cesarean delivery was performed in 11 (39.3%) and nine (32.1%) cases, respectively. Multivariable logistic regression analysis showed that the CCA (adjusted odds ratio (aOR), 2.15 (95% CI, 1.22-3.78); P = 0.008) and nulliparity (aOR, 0.20 (95% CI, 0.06-0.76); P = 0.02) were associated independently with persistent OP position at birth. Moreover, the CCA showed an area under the receiver-operating-characteristics curve of 0.69 (95% CI, 0.56-0.82); P = 0.005) for the prediction of persistent OP position. The optimal cut-off value of the CCA was 36.5°, and was associated with a sensitivity of 0.82 (95% CI, 0.63-0.94), specificity of 0.50 (95% CI, 0.35-0.65), positive predictive value of 0.49 (95% CI, 0.34-0.64), negative predictive value of 0.83 (95% CI, 0.64-0.94), positive likelihood ratio of 1.64 (95% CI, 1.18-2.29) and negative likelihood ratio of 0.36 (95% CI, 0.15-0.83).

CONCLUSIONS

Our data show that, within a population of women with fetal OP position at the beginning of the second stage of labor, the sonographic fetal head attitude measured by means of the CCA might help in the identification of fetuses at risk of persistent OP position. Such findings can be useful for patient counseling when OP position is diagnosed at full cervical dilatation. Further studies should investigate if the CCA might select patients who may benefit from manual rotation of the fetal head. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Infectious Complications in Laparoscopic Gynecologic Oncology Surgery within an ERAS-Compliant Setting

Minimally Invasive Surgery (MIS) represents a safe and feasible option for the surgical treatment of gynecologic malignancies, offering benefits, including reduced blood loss, lower complications, and faster recovery, without compromising oncological outcomes in selected patients. MIS is widely accepted in early-stage gynecologic malignancies, including endometrial cancer, cervical tumors measuring 2 cm or less, and early-stage ovarian cancer, considering the risk of surgical spillage. Despite its advantages, MIS does not rule out the possibility of adverse events such as postoperative infections. This retrospective study on 260 patients undergoing laparoscopic surgery at Parma University Hospital for gynecologic malignancies explores the incidence and risk factors of postoperative infectious complications. The Clavien-Dindo classification was used to rank postoperative surgical complications occurring 30 days after surgery and Enhanced Recovery After Surgery (ERAS) recommendations put into practice. In our population, 15 (5.8%) patients developed infectious complications, predominantly urinary tract infections (9, 3.5%). Longer surgical procedures were independently associated with higher postoperative infection risk (p = 0.045). Furthermore, C1 radical hysterectomy correlated significantly with infectious complications (p = 0.001, OR 3.977, 95% CI 1.370-11.544). In conclusion, compared to prior research, our study reported a lower rate of infectious complications occurrence and highlights the importance of adopting infection prevention measures.

Is the fetus fit for labor? Introducing fast-and-frugal trees (FFTrees) to simplify triage of women for STAN monitoring: An interobserver agreement comparison with traditional classification

INTRODUCTION

It is a shortcoming of traditional cardiotocography (CTG) classification table formats that CTG traces are frequently classified differently by different users, resulting in poor interobserver agreements. A fast-and-frugal tree (FFTree) flow chart may help provide better concordance because it is straightforward and has clearly structured binary questions with understandable "yes" or "no" responses. The initial triage to determine whether a fetus is suitable for labor when utilizing fetal ECG ST analysis (STAN) is very important, since a fetus with restricted capacity to respond to hypoxic stress may not generate STAN events and therefore may become falsely negative. This study aimed to compare physiology-focused FFTree CTG interpretation with FIGO classification for assessing the suitability for STAN monitoring.

MATERIAL AND METHODS

A retrospective study of 36 CTG traces with a high proportion of adverse outcomes (17/36) selected from a European multicenter study database. Eight experienced European obstetricians evaluated the initial 40 minutes of the CTG recordings and judged whether STAN was a suitable fetal surveillance method and whether intervention was indicated. The experts rated the CTGs using the FFTree and FIGO classifications at least 6 weeks apart. Interobserver agreements were calculated using proportions of agreement and Fleiss' kappa (κ).

RESULTS

The proportions of agreement for "not suitable for STAN" were for FIGO 47% (95% confidence interval [CI] 42%-52%) and for FFTree 60% (95% CI 56-64), ie a significant difference; the corresponding figures for "yes, suitable" were 74% (95% CI 71-77) and 70% (95% CI 67-74). For "intervention needed" the figures were 52% (95% CI 47-56) vs 58% (95% CI 54-62) and for "expectant management" 74% (95% CI 71-77) vs 72% (95% CI 69-75). Fleiss' κ agreement on "suitability for STAN" was 0.50 (95% CI 0.44-0.56) for the FIGO classification and 0.57 (95% CI 0.51-0.63) for the FFTree classification; the corresponding figures for "intervention or expectancy" were 0.53 (95% CI 0.47-0.59) and 0.57 (95% CI 0.51-0.63).

CONCLUSIONS

The proportion of agreement among expert obstetricians using the FFTree physiological approach was significantly higher compared with the traditional FIGO classification system in rejecting cases not suitable for STAN monitoring. That might be of importance to avoid false negative STAN recordings. Other agreement figures were similar. It remains to be shown whether the FFTree simplicity will benefit less experienced users and how it will work in real-world clinical scenarios.

Mode of delivery and peripartum outcome in women with heart disease according to the ESC guidelines: an Italian multicenter study

INTRODUCTION

The European Society of Cardiology (ESC) guidelines (GL) provide indications on the mode of delivery in women with heart disease. However available data suggests that the rate of Cesarean Delivery (CD) is high and widely variable among such patients. In this study, we aimed to investigate the degree of adherence to the ESC recommendations among women delivering in four tertiary maternity services in Italy and how this affects the maternal and neonatal outcomes.

MATERIAL AND METHODS

Retrospective multicenter cohort study including pregnant women with heart disease who gave birth between January 2014 and July 2020. Composite adverse maternal outcome (CAM) was defined by the occurrence of one or more of the following: major postpartum hemorrhage, thrombo-embolic or ischemic event, de novo arrhythmia, heart failure, endocarditis, aortic dissection, need for re-surgery, sepsis, maternal death. Composite Adverse Neonatal outcome (CAN) was defined as cord arterial pH <7.00, APGAR <7 at 5 min, admission to the intensive care unit, and neonatal death. We compared the incidence of CAM and CAN between the cases with planned delivery in accordance (group "ESC consistent") or in disagreement (group "ESC not consistent") with the ESC GL.

RESULTS

Overall, 175 women and 181 liveborn were included. A higher frequency of CAN was found when delivery was not planned accordingly to the ESC guidelines [("ESC consistent" 9/124 (7.2%) vs "ESC not consistent" 13/57 (22.8%) p = 0.002 OR 3.74 (CI 95% 1.49-9.74) , while the occurrence of CAM was comparable between the two groups. At logistic regression analysis, the gestational age at delivery was the only parameter independently associated with the occurrence of CAN (p = 0.006).

CONCLUSION

Among pregnant women with heart disease, deviating from the ESC guidelines scheduling cesarean delivery does not seem to improve maternal outcomes and it is associated with worse perinatal outcomes, mainly due to lower gestational age at birth.

The "cortical invagination sign": a midtrimester sonographic marker of unilateral cortical focal dysgyria in fetuses with complete agenesis of the corpus callosum

BACKGROUND

Agenesis of the corpus callosum is associated with several malformations of cortical development. Recently, features of focal cortical dysgyria have been described in fetuses with agenesis of the corpus callosum.

OBJECTIVE

This study aimed to describe the "cortical invagination sign," a specific sonographic feature of focal cortical dysgyria, which is consistently seen at midtrimester axial brain ultrasound in fetuses with complete agenesis of the corpus callosum.

STUDY DESIGN

This was a retrospective analysis of prospectively collected data from 2018 to 2021, including patients referred to 5 fetal medicine centers in the second trimester of pregnancy (19 0/7 to 22 0/7 weeks of gestation) with suspected complete agenesis of the corpus callosum. All cases with the diagnosis of complete agenesis of the corpus callosum were submitted to an axial sonographic assessment of the fetal brain on the transventricular plane. In this scanning section, the mesial profile of both cerebral hemispheres at the level of the frontal-parietal cortex was investigated. In this area, the operator looked for an abnormal invagination of the cortical surface along the widened interhemispheric fissure, which was referred to as the "cortical invagination sign." All fetuses were submitted to dedicated antenatal magnetic resonance imaging to reassess the ultrasound findings. Cases with additional brain anomalies, which did not involve the cortex, were excluded. The final diagnosis was confirmed at postnatal brain magnetic resonance imaging or postmortem examination, for cases undergoing termination of pregnancy. The primary outcome of this study was to evaluate the presence and laterality of the "cortical invagination sign" in fetuses with complete agenesis of the corpus callosum at antenatal ultrasound and magnetic resonance imaging.

RESULTS

During the study period, 64 cases of complete agenesis of the corpus callosum were included; of those cases, 50 (78.1%) resulted in termination of pregnancy, and 14 (21.9%) resulted in a live birth. The "cortical invagination sign" was detected at ultrasound in 13 of 64 cases (20.3%) and at targeted brain magnetic resonance imaging in 2 additional cases (23.4%), all of which were electively terminated. Moreover, the "cortical invagination sign" was found to be exclusively unilateral and on the left cerebral hemisphere in all the cases. There was a predominant number, although nonsignificant, of male fetuses (80.0% of cases; P=.06) in the group of complete agenesis of the corpus callosum with the "cortical invagination sign."

CONCLUSION

The "cortical invagination sign" is a specific marker of focal cortical dysgyria, which seems to characterize at midtrimester of pregnancy in a large group of fetuses with complete agenesis of the corpus callosum. The etiology, pathophysiology, and prognostic significance of this finding remain to be elucidated.

Association of umbilical vein flow with abnormal fetal growth and adverse perinatal outcome in low-risk population: multicenter prospective study

OBJECTIVES

To investigate the relationship of umbilical vein flow (UVF) measured close to term with abnormal fetal growth and adverse perinatal outcome in a cohort of pregnancies at low risk of placental insufficiency.

METHODS

This was a prospective multicenter observational study conducted across two tertiary maternity units. Patients with a singleton appropriate-for-gestational-age fetus between 35 and 38 weeks' gestation were included. Pregnancies at higher risk of placental insufficiency or with fetal anomalies were excluded. At ultrasound examination, the abdominal circumference (AC), umbilical vein diameter and peak velocity of the umbilical vein were measured, and, using these variables, a new variable, UVF/AC, was calculated. The primary outcome was the occurrence of severely stunted fetal growth, defined as a greater than 40-percentile drop between estimated fetal weight at the third-trimester ultrasound and birth weight between the third-trimester ultrasound and delivery. The occurrence of adverse perinatal outcome, defined as one of the following: neonatal acidosis (umbilical artery pH < 7.15 and/or base excess > 12 mmol/L) at birth, 5-min Apgar score < 7, neonatal resuscitation or neonatal intensive care unit admission, was analyzed as a secondary outcome.

RESULTS

Between April 2021 and March 2023, 365 women were included in the study. The mean UVF/AC at enrolment was 6.4 ± 2.6 mL/min/cm, and 35 (9.6%) cases were affected by severely stunted fetal growth. Severely stunted fetal growth was associated with a lower mean UVF/AC (5.4 ± 2.6 vs 6.5 ± 2.6 mL/min/cm; P = 0.02) and a higher frequency of UVF/AC < 10th percentile (8/35 (22.9%) vs 28/330 (8.5%); P = 0.01). Moreover, UVF/AC showed an area under the receiver-operating-characteristics curve (AUC) of 0.65 (95% CI, 0.55-0.75; P = 0.004) in predicting the occurrence of severely stunted fetal growth, and the optimal cut-off value of UVF/AC for discriminating between normal and severely stunted fetal growth was 7.2 mL/min/cm. This value was associated with a sensitivity and specificity of 0.77 (95% CI, 0.60-0.90) and 0.33 (95% CI, 0.28-0.39), and positive and negative predictive values of 0.11 (95% CI, 0.07-0.15) and 0.93 (95% CI, 0.87-0.97), respectively. Regarding the occurrence of adverse perinatal outcome, this was associated independently with maternal age (adjusted odds ratio (aOR), 0.93 (95% CI, 0.87-0.99); P = 0.04), UVF/AC Z-score (aOR, 0.53 (95% CI, 0.30-0.87); P = 0.01) and augmentation of labor (aOR, 2.69 (95% CI, 1.28-5.69); P = 0.009). UVF/AC showed an AUC of 0.65 (95% CI, 0.56-0.73; P = 0.005) in predicting the occurrence of adverse perinatal outcome, and the optimal cut-off value of UVF/AC for discriminating between normal and adverse perinatal outcome was 6.7 mL/min/cm. This value was associated with a sensitivity and specificity of 0.70 (95% CI, 0.54-0.83) and 0.40 (95% CI, 0.34-0.45), and positive and negative predictive values of 0.14 (95% CI, 0.09-0.19) and 0.91 (95% CI, 0.85-0.95), respectively.

CONCLUSIONS

Our data demonstrate an association between reduced UVF close to term, severely stunted fetal growth and adverse perinatal outcome in a cohort of low-risk pregnant women, with a moderate ability to rule out and a poor ability to rule in either outcome. Further studies are needed to establish whether the assessment of UVF can improve the identification of fetuses at risk of subclinical placental insufficiency and adverse perinatal outcome. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Optimal Management for Stage IVB Endometrial Cancer: A Systematic Review

(1) Background: Endometrial cancer (EC) is a common gynecological malignancy, often diagnosed at an early stage with a high overall survival rate. Surgical treatment is the primary approach, guided by pathological and molecular characteristics. Stage IVB EC, characterized by intra and/or extra-abdominal metastasis, presents a significant challenge with no clear consensus on optimal management. (2) Methods: A systematic literature review was conducted from January to May 2023, covering studies from 2000 to 2023. Eligible studies included retrospective case series, prospective trials, and randomized clinical trials. (3) Results: Of 116 studies identified, 21 were deemed relevant: 7 on primary surgery, 10 on neoadjuvant chemotherapy (NACT), and 4 on adjuvant treatment. Notably, the impact of residual tumor after primary surgery was a critical factor affecting survival. The use of NACT followed by interval debulking surgery showed promise, particularly in cases deemed unresectable. Adjuvant treatment, combining radiotherapy and chemotherapy, demonstrated improved survival but lacked consensus regarding its role. (4) Conclusions: Stage IVB EC poses a complex challenge with limited evidence to guide management. Optimal cytoreduction remains crucial, and NACT should be considered for unresectable cases. Multimodality adjuvant therapy may benefit patients, even with disease spread beyond the pelvis. Future advances in molecular classification and targeted therapies are expected to enhance treatment strategies.

Hysteroscopic endometrial tumor localization and sentinel lymph node mapping. An upgrade of the hysteroscopic role in endometrial cancer patients

INTRODUCTION

Given the growing interest in sentinel node mapping (SLN) biopsy in Endometrial Cancer (EC) patients, many efforts have been made to maximize the SLN bilateral detection rate. However, at present, no previous research assessed the potential correlation between primary EC location in the uterine cavity and SLN mapping. In this context, this study aims to investigate the possible role of intrauterine EC hysteroscopic localization in predicting SLN nodal placement.

MATERIALS AND METHODS

EC patients surgically treated from January 2017 to December 2021 were retrospectively analyzed. All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and SLN mapping. During hysteroscopy, the location of the neoplastic lesion was described as follows: uterine fundus (comprising the most cranial portion of the uterine cavity up to the tubal ostium including the cornual areas), corpus uteri (from the tubal ostium to the inner uterine orifice), and diffuse (when the tumor invades more than 50% of the uterine cavity).

RESULTS

Three hundred ninety patients met the inclusion criteria. The tumor pattern diffused to the whole uterine cavity was statistically associated with SLN uptake on common iliac lymph nodes (OR 2.4, 95%CI 1-5.8, p = 0.05). Patients'age is an independent factor associated with SLN failure (OR: 0.95, 95%CI 0.93-0.98, p < 0.001).

CONCLUSIONS

The study showed a statistically significant association between EC hysteroscopically spread throughout the whole uterine cavity and SLN uptake at the common iliac lymph nodes. Furthermore, patient age negatively affected the SLN detection rate.

Normal and abnormal appearance of fetal ganglionic eminence on second-trimester three-dimensional ultrasound

OBJECTIVES

To describe the appearance and size of the ganglionic eminence (GE) in normal fetuses on midtrimester three-dimensional (3D) neurosonography and to report on the association between GE alterations (cavitation or enlargement) and malformation of cortical development (MCD).

METHODS

This was a prospective multicenter cohort study of normal fetuses and a retrospective analysis of pathological cases with MCD. From January 2022 to June 2022, patients attending our tertiary centers for an expert fetal brain scan were recruited for the purpose of the study. A 3D volume of the fetal head, starting from the sagittal plane, was acquired in apparently normal fetuses using a transabdominal or transvaginal approach. Stored volume datasets were then evaluated independently by two expert operators. Two measurements (longitudinal diameter and transverse diameter) of the GE in the coronal view were obtained twice by each operator. Intra- and interobserver measurement variation was calculated. Reference ranges for GE measurements were calculated in the normal population. A previously stored volume dataset of 60 cases with MCD was also analyzed independently by the two operators using the same method in order to assess if GE abnormalities (cavitation or enlargement) were present. Postnatal follow-up was obtained in all cases.

RESULTS

In the study period, 160 normal fetuses between 19 and 22 weeks of gestation were included in the study. The GE was visible in the coronal plane on 3D neurosonography in 144 (90%) cases and was not clearly visible in the remaining 16 (10%) cases. The intra- and interobserver agreement was almost perfect for the longitudinal diameter, with an intraclass correlation coefficient (ICC) of 0.90 (95% CI, 0.83-0.93) and 0.90 (95% CI, 0.86-0.92), respectively, and substantial for the transverse diameter, with an ICC of 0.80 (95% CI, 0.70-0.87) and 0.64 (95% CI, 0.53-0.72), respectively. A retrospective analysis of 50 cases with MCD in the second trimester showed that GE enlargement was present in 12 cases and GE cavitation was present in four cases.

CONCLUSIONS

Systematic assessment of the GE in fetuses at 19-22 weeks of gestation is feasible on 3D neurosonography, with good reproducibility in normal cases. Cavitation or enlargement of the GE can be demonstrated in fetuses with MCD. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prenatal and Neonatal Bone Health: Updated Review on Early Identification of Newborns at High Risk for Osteopenia

Bone health starts with maternal health and nutrition, which influences bone mass and density already in utero. The mechanisms underlying the effect of the intrauterine environment on bone health are partly unknown but certainly include the 'foetal programming' of oxidative stress and endocrine systems, which influence later skeletal growth and development. With this narrative review, we describe the current evidence for identifying patients with risk factors for developing osteopenia, today's management of these populations, and screening and prevention programs based on gestational age, weight, and morbidity. Challenges for bone health prevention include the need for new technologies that are specific and applicable to pregnant women, the foetus, and, later, the newborn. Radiofrequency ultrasound spectrometry (REMS) has proven to be a useful tool in the assessment of bone mineral density (BMD) in pregnant women. Few studies have reported that transmission ultrasound can also be used to assess BMD in newborns. The advantages of this technology in the foetus and newborn are the absence of ionising radiation, ease of use, and, above all, the possibility of performing longitudinal studies from intrauterine to extrauterine life. The use of these technologies already in the intrauterine period could help prevent associated diseases, such as osteoporosis and osteopenia, which are characterised by a reduction in bone mass and degeneration of bone structure and lead to an increased risk of fractures in adulthood with considerable social repercussions for the related direct and indirect costs.

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.

Use of artificial intelligence and deep learning in fetal ultrasound imaging

Deep learning is considered the leading artificial intelligence tool in image analysis in general. Deep-learning algorithms excel at image recognition, which makes them valuable in medical imaging. Obstetric ultrasound has become the gold standard imaging modality for detection and diagnosis of fetal malformations. However, ultrasound relies heavily on the operator's experience, making it unreliable in inexperienced hands. Several studies have proposed the use of deep-learning models as a tool to support sonographers, in an attempt to overcome these problems inherent to ultrasound. Deep learning has many clinical applications in the field of fetal imaging, including identification of normal and abnormal fetal anatomy and measurement of fetal biometry. In this Review, we provide a comprehensive explanation of the fundamentals of deep learning in fetal imaging, with particular focus on its clinical applicability. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Effect of the "shoulder-up" bundle on the incidence of spontaneous perineal injury after vaginal delivery: comparison of 2 historic cohorts after propensity score matching

BACKGROUND

Perineal injury following vaginal delivery represents a major cause of long-term maternal morbidity, and its prevention is among the priorities of modern obstetrical practice.

OBJECTIVE

This study aimed to investigate whether the systematic implementation of a bundle of maneuvers to prevent perineal injury (ie, the "shoulder-up" bundle) may reduce the rate of spontaneous perineal tears in women delivering at a single tertiary maternity unit.

STUDY DESIGN

This was a single-center retrospective intervention study including all vaginal deliveries between April 1, 2020 and March 31, 2022. On March 1, 2021, a bundle focused on perineal injury prevention in vaginal deliveries was implemented and introduced as a standard of care. The "shoulder-up" bundle includes the addition of a hands-on technique for the delivery of the posterior shoulder, which is slowly lifted up under the direct visualization of the perineal body, immediately after the disengagement of the anterior shoulder. The labor ward staff underwent dedicated training to acquire expertise on the "shoulder-up" bundle. Little changes in terms of medical and midwifery staffing were recorded during the study period. The incidence of spontaneous second-degree or higher perineal tears was compared between the patients who gave birth before the clinical implementation of the bundle (standard-care group) and those who were delivered following the implementation of the bundle (shoulder-up group). A 1:1 propensity score matching of the 2 groups was done for the variables that proved to be independently associated with the perineal outcome.

RESULTS

From April 1, 2020 to March 31, 2022, 3671 patients had a vaginal birth at our tertiary care unit (1786 in the standard-care group and 1885 in the "shoulder-up" group) and were enrolled in the study population. Of these, 1191 (32.4%) had a spontaneous second-degree or higher perineal tear. At univariate analysis, nulliparity (59.6% vs 39.1%; P<.001), higher gestational age at delivery (39.8±1.28 vs 39.4±1.97 weeks; P<.001), epidural analgesia (40.6% vs 31.2%; P<.001), vacuum-assisted delivery (9.6% vs 4.0%; P<.001), and birthweight >4 kg (11.0% vs 6.3%; P<.001) were independently associated with the perineal outcome. Following propensity score matching for the above cited factors, the 1703 patients of each group were compared. A significant increase in the rate of intact perineum (71.0% vs 64.1%; P=.014) and a reduction in the incidence of second- (27.2% vs 32.9%; P=.006) and third to fourth-degree perineal tears (1.3% vs 3.0%; P<.001) was demonstrated in the "shoulder-up" group. Among the subgroup of patients undergoing vacuum-assisted delivery, a borderline significant reduction in the rate of obstetrical anal sphincter injury (10.4% vs 2.9%; P=.052) was also observed.

CONCLUSION

Our study showed that the clinical implementation of the "shoulder-up" bundle at vaginal delivery is associated with a significant reduction in the incidence of spontaneous second-degree or higher perineal tears.

Pathophysiological interpretation of fetal heart rate tracings in clinical practice

The onset of regular, strong, and progressive uterine contractions may result in both mechanical (compression of the fetal head and/or umbilical cord) and hypoxic (repetitive and sustained compression of the umbilical cord or reduction in uteroplacental oxygenation) stresses to a human fetus. Most fetuses are able to mount effective compensatory responses to avoid hypoxic-ischemic encephalopathy and perinatal death secondary to the onset of anaerobic metabolism within the myocardium, culminating in myocardial lactic acidosis. In addition, the presence of fetal hemoglobin, which has a higher affinity for oxygen even at low partial pressures of oxygen than the adult hemoglobin, especially increased amounts of fetal hemoglobin (ie, 180-220 g/L in fetuses vs 110-140 g/L in adults), helps the fetus to withstand hypoxic stresses during labor. Different national and international guidelines are currently being used for intrapartum fetal heart rate interpretation. These traditional classification systems for fetal heart rate interpretation during labor are based on grouping certain features of fetal heart rate (ie, baseline fetal heart rate, baseline variability, accelerations, and decelerations) into different categories (eg, category I, II, and III tracings, "normal, suspicious, and pathologic" or "normal, intermediary, and abnormal"). These guidelines differ from each other because of the features included within different categories and because of their arbitrary time limits stipulated for each feature to warrant an obstetrical intervention. This approach fails to individualize care because the "ranges of normality" for stipulated parameters apply to the population of human fetuses and not to the individual fetus in question. Moreover, different fetuses have different reserves and compensatory responses and different intrauterine environments (presence of meconium staining of amniotic fluid, intrauterine inflammation, and the nature of uterine activity). Pathophysiological interpretation of fetal heart rate tracing is based on the application of the knowledge of fetal responses to intrapartum mechanical and/or hypoxic stress in clinical practice. Both experimental animal studies and observational human studies suggest that, just like adults undertaking a treadmill exercise, human fetuses show predictable compensatory responses to a progressively evolving intrapartum hypoxic stress. These responses include the onset of decelerations to reduce myocardial workload and preserve aerobic metabolism, loss of accelerations to abolish nonessential somatic body movements, and catecholamine-mediated increases in the baseline fetal heart rate and effective redistribution and centralization to protect the fetal central organs (ie, the heart, brain, and adrenal glands), which are essential for intrauterine survival. Moreover, it is essential to incorporate the clinical context (progress of labor, fetal size and reserves, presence of meconium staining of amniotic fluid and intrauterine inflammation, and fetal anemia) and understand the features suggestive of fetal compromise in nonhypoxic pathways (eg, chorioamnionitis and fetomaternal hemorrhage). It is important to appreciate that the timely recognition of the speed of onset of intrapartum hypoxia (ie, acute, subacute, and gradually evolving) and preexisting uteroplacental insufficiency (ie, chronic hypoxia) on fetal heart rate tracing is crucial to improve perinatal outcomes.

Optimizing the management of acute, prolonged decelerations and fetal bradycardia based on the understanding of fetal pathophysiology

Any acute and profound reduction in fetal oxygenation increases the risk of anaerobic metabolism in the fetal myocardium and, hence, the risk of lactic acidosis. On the contrary, in a gradually evolving hypoxic stress, there is sufficient time to mount a catecholamine-mediated increase in the fetal heart rate to increase the cardiac output and redistribute oxygenated blood to maintain an aerobic metabolism in the fetal central organs. When the hypoxic stress is sudden, profound, and sustained, it is not possible to continue to maintain central organ perfusion by peripheral vasoconstriction and centralization. In case of acute deprivation of oxygen, the immediate chemoreflex response via the vagus nerve helps reduce fetal myocardial workload by a sudden drop of the baseline fetal heart rate. If this drop in the fetal heart rate continues for >2 minutes (American College of Obstetricians and Gynecologists' guideline) or 3 minutes (National Institute for Health and Care Excellence or physiological guideline), it is termed a prolonged deceleration, which occurs because of myocardial hypoxia, after the initial chemoreflex. The revised International Federation of Gynecology and Obstetrics guideline (2015) considers the prolonged deceleration to be a "pathologic" feature after 5 minutes. Acute intrapartum accidents (placental abruption, umbilical cord prolapse, and uterine rupture) should be excluded immediately, and if they are present, an urgent birth should be accomplished. If a reversible cause is found (maternal hypotension, uterine hypertonus or hyperstimulation, and sustained umbilical cord compression), immediate conservative measures (also called intrauterine fetal resuscitation) should be undertaken to reverse the underlying cause. In reversible causes of acute hypoxia, if the fetal heart rate variability is normal before the onset of deceleration, and normal within the first 3 minutes of the prolonged deceleration, then there is an increased likelihood of recovery of the fetal heart rate to its antecedent baseline within 9 minutes with the reversal of the underlying cause of acute and profound reduction in fetal oxygenation. The continuation of the prolonged deceleration for >10 minutes is termed "terminal bradycardia," and this increases the risk of hypoxic-ischemic injury to the deep gray matter of the brain (the thalami and the basal ganglia), predisposing to dyskinetic cerebral palsy. Therefore, any acute fetal hypoxia, which manifests as a prolonged deceleration on the fetal heart rate tracing, should be considered an intrapartum emergency requiring an immediate intervention to optimize perinatal outcome. In uterine hypertonus or hyperstimulation, if the prolonged deceleration persists despite stopping the uterotonic agent, then acute tocolysis is recommended to rapidly restore fetal oxygenation. Regular clinical audit of the management of acute hypoxia, including the "the onset of bradycardia to delivery interval," may help identify organizational and system issues, which may contribute to poor perinatal outcomes.

Correlation between bituberous diameter and mode of delivery in a cohort of low-risk nulliparous women

OBJECTIVE

The aim our study was to evaluate the association between the antepartum clinical measurement of the Bituberous Diameter (BTD) and the occurrence of unplanned obstetrical intervention (UOI) due to labor dystocia, including either operative vaginal delivery or caesarean section in a cohort of low-risk, nulliparous at term.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Tertiary maternity care.

INTERVENTIONS

With the women lying in lithotomic the distance between two ischial tuberosities was assessed using a tape measure during the routine antenatal booking between 37 and 38 weeks of gestation.

MEASUREMENTS AND FINDINGS

Overall, 116 patient were included, and of these 23(19.8%) were submitted to an UOI due to labor dystocia. Compared to women that had a spontaneous vaginal delivery, women submitted to an UOI had a shorter BTD (8.25 + 0.843 vs 9.60 + 1.12, p < 0.001), a higher frequency of epidural analgesia (21/23 or 91.3% vs 50/93 or 53.8%; p = 0.002) and of augmentation of labor (14/23 or 60.9% vs 19/93 or 20.4%; p < 0.001) as well as a longer first [455 (IQR 142-455 min vs 293 (IQR 142-455) min] and second stages of labor [129 (IQR 85-155) min vs 51 (IQR 27-78) min]. Multivariable logistic regression showed that the BTD (aOR 0.16, 95% CI 0.04-0.60; p = 0.007) and the length of the second stage of labor (aOR 6.83, 95% CI 2.10-22.23; p = 0.001) were independently associated with UOI. When evaluating the diagnostic accuracy of the BTD for the prediction of UOI due to labor dystocia, the BTD showed an AUC of 0.82 (95 %CI 0.73-0.91; p < 0.001) with an optimal cut-off value of 8.6 cm (78.3% (95 %CI 56.3-92.5) sensitivity, 77.4% (95 %CI 67.6-85.4) specificity, 46.2% (95% CI 30.1-62.8) PPV, 93.5% (95% CI 85.5-97.9) NPV, 3.5 (95% CI 2.3-5.4) positive LR, and 0.28 (95% CI 0.13-0.61) negative LR. A significant inverse correlation between the length of the second stage of labour and the BTD in patients that had a vaginal delivery was also demonstrated (Spearman's rho = -0.24, p = 0.01).

KEY CONCLUSIONS

Our study suggests that antepartum clinical assessment of the BTD might be used as a reliable predictor of UOI due to labor dystocia in low-risk, nulliparous women at term gestation.

IMPLICATIONS FOR PRACTICE

Antenatal identification of women at higher risk for labor dystocia might trigger some interventions during the second stage of labor, such as maternal position shifting, to increase the pelvic capacity and potentially improve outcomes or might prompt a referral of the patient to a district hospital prior to the onset of labor.

Do Exophytic and Endophytic Patterns in Borderline Ovarian Tumors Have Different Prognostic Implications? A Large Multicentric Experience

Borderline ovarian tumor (BOT) accounts for 15-20% of all epithelial ovarian tumors. Concerns have arisen about the clinical and prognostic implications of BOT with exophytic growth patterns. We retrospectively reviewed all cases of BOT patients surgically treated from 2015 to 2020. Patients were divided into an endophytic pattern (with intracystic tumor growth and intact ovarian capsule) and an exophytic pattern (with tumor growth outside the ovarian capsule) group. Among the 254 patients recruited, 229 met the inclusion criteria, and of these, 169 (73.8%) belonged to the endophytic group. The endophytic group showed more commonly an early FIGO stage than the exophytic group (100.0% vs. 66.7%, p < 0.001). Furthermore, tumor cells in peritoneal washing (20.0% vs. 0.6%, p < 0.001), elevated Ca125 levels (51.7% vs. 31.4%, p = 0.003), peritoneal implants (0 vs. 18.3%, p < 0.001), and invasive peritoneal implants (0 vs. 5%, p = 0.003) were more frequently observed in the exophytic group. The survival analysis showed 15 (6.6%) total recurrences, 9 (5.3%) in the endophytic and 6 (10.0%) patients in the exophytic group (p = 0.213). At multivariable analysis, age (p = 0.001), FIGO stage (p = 0.002), fertility-sparing surgery (p = 0.001), invasive implants (p = 0.042), and tumor spillage (p = 0.031) appeared significantly associated with recurrence. Endophytic and exophytic patterns in borderline ovarian tumors show superimposable recurrence rates and disease-free survival.

Long-term survival outcomes in high-risk endometrial cancer patients undergoing sentinel lymph node biopsy alone versus lymphadenectomy

OBJECTIVE

Endometrial cancer is the most common gynecologic neoplasm. To date, international guidelines recommend sentinel lymph node biopsy for low-risk neoplasms, while systematic lymphadenectomy is still considered for high-risk cases. This study aimed to compare the long-term survival of high-risk patients who were submitted to sentinel lymph node biopsy alone versus systematic pelvic lymphadenectomy.

METHODS

Patients with high-risk endometrial cancer according to the 2021 European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology risk classification were retrospectively analyzed. The primary aim of the study was to compare the long-term overall survival and disease-free survival of high-risk endometrial cancer patients undergoing sentinel lymph node biopsy versus systematic lymphadenectomy. A supplementary post-hoc survival analysis of cases with nodal metastasis was performed to compare sentinel lymph node and lymphadenectomy survival outcomes in this subset of patients.

RESULTS

The study enrolled 237 patients with histologically proven high-risk endometrial cancer. Patients were followed up for a median of 31 months (IQR 18-40). During the follow-up, 38 (16.0%) patients had a recurrence, and 19 (8.0%) patients died. Disease-free survival (85.2% vs 82.8%; p=0.74) and overall survival (91.3% vs 92.6%; p=0.62) were not different between the sentinel lymph node alone and lymphadenectomy groups. Furthermore, neither overall survival (96.1% vs 91.4%; p=0.43) nor disease-free survival (83.7% vs 76.4%; p=0.46) were different among sentinel lymph node alone and lymphadenectomy groups in patients with nodal metastasis.

CONCLUSIONS

Sentinel lymph node mapping alone in high-risk endometrial cancer appears to be an oncologically safe technique over a long observational time. Systematic lymphadenectomy in this population does not offer a survival advantage.

The time has come for a paradigm shift in obstetrics' medico-legal litigations

Cerebral Palsy (CP) represents the most common neuromuscular disability in childhood and it is caused by a multiplicity of factors. Intrapartum fetal surveillance is still a controversial issue: even though intrapartum hypoxia alone plays a minimal role in causing neonatal cerebral damage, obstetricians face a large number of medical malpractice litigations for alleged birth mismanagement. The cardinal driver of CP litigation is Cardiotocography (CTG): despite its suboptimal performance in reducing the occurrence of intrapartum brain injury, its ex post interpretation is widely used to evaluate the liability of the labor ward personnel in trials and, based on this, most caregivers are convicted. This article takes cue from a recent acquittal verdict by the Italian Supreme Court of Cassation to challenge the role of intrapartum CTG as a medico-legal proof of malpractice. Because of its low specificity and poor inter- and intra-observer agreement, intrapartum CTG traces do not meet the Daubert criteria and, lastly, they should be weighed with caution in the context of a courtroom trial.

Head-to-perineum distance measured transperineally as a predictor of failed midcavity vacuum-assisted delivery

BACKGROUND

During the second stage of labor, in case of a need for a fetal extraction at midcavity, the choice of attempting the procedure between operative vaginal delivery and cesarean delivery is difficult. Moreover, guidelines on this subject are not clear.

OBJECTIVE

This study aimed to identify antenatal and intrapartum parameters associated with a failed midcavity vacuum-assisted delivery and its association with maternal and neonatal adverse outcomes.

STUDY DESIGN

This was a single-center, retrospective, cohort study conducted at a tertiary maternity hospital in France from January 2010 to December 2020. Women with singleton pregnancies under epidural analgesia with nonanomalous cephalic presenting fetuses and gestational ages at ≥37 weeks of gestation, who were submitted to midcavity vacuum-assisted delivery, were included. Following the American College of Obstetricians and Gynecologists definition, midcavity was defined as the presenting part of the fetus (ie, the fetal head) found at stations 0 and +1. For research purposes, all patients were submitted to transperineal ultrasound to evaluate the head-to-perineum distance, however, this measurement did not affect the decision to perform a midcavity vacuum-assisted delivery. The primary outcome of the study was failed midcavity vacuum-assisted delivery leading to cesarean delivery or the use of a different instrument to achieve vaginal delivery.

RESULTS

Overall, 951 cases of midcavity vacuum-assisted delivery were included in this study. Failed midcavity vacuum-assisted delivery occurred in 242 patients (25.4%). Factors independently associated with failed midcavity vacuum-assisted delivery included maternal height (adjusted odds ratio, 0.96; 95% confidence interval, 0.94-0.99; P=.002), duration of the active phase of the first stage of labor (adjusted odds ratio, 1.11; 95% confidence interval, 1.05-1.17; P<.001), nonocciput anterior fetal head position (adjusted odds ratio, 1.47; 95% confidence interval, 1.06-2.04; P=.02), z score of the head-to-perineum distance (adjusted odds ratio, 1.23; 95% confidence interval, 1.05-1.43; P=.01), and birthweight of >4000 g (adjusted odds ratio, 2.04; 95% confidence interval, 1.28-3.26; P=.003). Women submitted to a failed midcavity vacuum-assisted delivery were more likely to have a major postpartum hemorrhage (7.1% vs 2.0%; P<.001), whereas neonates were more likely to have an umbilical artery pH of <7.1 (30.5% vs 19.8%; P=.001), be admitted to the neonatal intensive care unit (9.6% vs 4.7%; P=.005), and have a severe caput succedaneum (14.9% vs 0.7%; P<.001). Subgroup analysis on all patients with a fetal head station of 0 found that the head-to-perineum distance was the only independent variable associated with failed midcavity vacuum-assisted delivery (adjusted odds ratio, 1.66; 95% confidence interval, 1.29-2.12; P<.001). The area under the receiving operating characteristic curve of the head-to-perineum distance in this subgroup population was 0.67 (95% confidence interval, 0.60-0.73; P<.001), and the optimal cutoff point of the head-to-perineum distance measurement discriminating between failed and successful midcavity vacuum-assisted deliveries was 55 mm. It was associated with a 0.90 (95% confidence interval, 0.83-0.95) sensitivity, 0.19 (95% confidence interval, 0.14-0.25) specificity, 0.36 (95% confidence interval, 0.30-0.42) positive predictive value, and 0.80 (95% confidence interval, 0.66-0.90) negative predictive value.

CONCLUSION

Study data showed that a high fetal head station, measured using the head-to-perineum distance, and a nonocciput anterior position of the fetal head are independently associated with failed midcavity vacuum-assisted delivery. The result supported the systematic assessment of the sonographic head station and position before performing a midcavity vacuum-assisted delivery.

An update on maternal cardiac hemodynamics in fetal growth restriction and pre-eclampsia

Pre-eclampsia and fetal growth restriction (FGR) have been long related to primary placental dysfunction, caused by abnormal trophoblast invasion. Nevertheless, emerging evidence has led to a new hypothesis for the origin of pre-eclampsia and FGR. Suboptimal maternal cardiovascular adaptation has been shown to result in uteroplacental hypoperfusion, ultimately leading to placental hypoxic damage with secondary dysfunction. In this review, we summarize current evidence on maternal cardiac hemodynamics in FGR and pre-eclampsia. We also discuss the different approaches for antihypertensive treatment according to the hemodynamic phenotype observed in pre-eclampsia and FGR.

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.