Ultrasound feedback training increases trainee accuracy in vaginal assessment of fetal head position in labor

OBJECTIVE

To evaluate the impact of an immediate ultrasound feedback intervention on trainee accuracy in vaginal-examination-based assessment of fetal head position.

METHODS

This was a prospective cohort study conducted at a single tertiary care center. Six third-year and six fourth-year residents in an obstetrics and gynecology residency training program were the study subjects. The third-year residents underwent a training intervention in which they assessed fetal head position by transvaginal digital examination and then received immediate feedback through ultrasound demonstration of the actual position. All examinations were performed in women with a singleton gestation ≥ 35 weeks and cervical dilation ≥ 8 cm, following rupture of membranes. The comparison groups were third-year residents before, during and after training and fourth-year residents who were not exposed to the training intervention. The primary outcome was the difference in accuracy of fetal-head-position assessment on vaginal examination by third-year residents before and after ultrasound feedback training. Univariate and multivariate analyses were performed to identify factors associated with digital examination accuracy.

RESULTS

Overall, 390 examinations were performed. The accuracy of fetal-head-position assessments of third-year residents was 55% (53/96) before training, 65% (74/114) during training and 70% (63/90) after training, while that of fourth-year residents who did not undergo training was 52% (47/90) (P = 0.04). Fourth-year residents who did not undergo ultrasound training demonstrated similar baseline accuracy to that of third-year residents pretraining (52% (47/90) vs 55% (53/96), P = 0.68), but had significantly lower accuracy than had the third-year residents post-training (52% (47/90) vs 70% (63/90); P = 0.01). Multivariable analysis revealed a positive association between ultrasound feedback training and the ability to assess accurately fetal head position. After adjusting for the variables included in the final model, examinations performed by third-year residents pretraining and those performed by fourth-year residents who did not undergo training were less likely to be accurate than those performed by third-year residents post-training (adjusted odds ratio, 0.48 (95% CI, 0.26-0.91) and 0.42 (95% CI, 0.22-0.80), respectively).

CONCLUSION

Immediate ultrasound feedback training increased trainee accuracy in vaginal assessment of fetal head position in labor. Its integration into obstetric training programs should be considered. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Breech presentation at delivery: a marker for congenital anomaly?

OBJECTIVE

To determine whether congenital anomalies are associated with breech presentation at the time of birth.

STUDY DESIGN

A population-based, retrospective cohort study was conducted among 460,147 women with singleton live births using the Missouri Birth Defects Registry, which includes all defects diagnosed during the first year of life. Maternal and obstetric characteristics and outcomes between breech and cephalic presentation groups were compared using χ(2)-square statistic and Student's t-test. Multivariable binary logistic regression analysis was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULT

At least one congenital anomaly was more likely present among infants breech at birth (11.7%) than in those with cephalic presentation (5.1%), whether full-term (9.4 vs 4.6%) or preterm (20.1 vs 11.6%). The relationship between breech presentation and congenital anomaly was stronger among full-term births (aOR 2.09, CI 1.96, 2.23, term vs 1.40, CI 1.26, 1.55, preterm), but not in all categories of anomalies.

CONCLUSION

Breech presentation at delivery is a marker for the presence of congenital anomaly. Infants delivered breech deserve special scrutiny for the presence of malformation.

Neonatal pulmonary hypoplasia and perinatal mortality in patients with midtrimester rupture of amniotic membranes--a critical analysis

OBJECTIVE

We sought to critically assess the risk factors for neonatal pulmonary hypoplasia and perinatal death in patients with preterm rupture of the amniotic membranes from 15 to 28 weeks' gestation.

STUDY DESIGN

This was a prospective cohort study. The study patients had preterm rupture of the amniotic membranes at 15 to 28 weeks' gestation and were without fetal anomalies, multiple gestation, and oligohydramnios before rupture of the membranes. The amniotic fluid volume index was determined at admission and weekly afterward until delivery.

RESULTS

The incidence of pulmonary hypoplasia was 12.9% (21/163). The overall perinatal mortality rate was 54% (88/163). Logistic regression analysis revealed the following: (1) Gestational age at rupture of the membranes, the latency period, and either the initial or the average amniotic fluid index have significant influence on the development of pulmonary hypoplasia; (2) gestational age at rupture of the membranes and latency period are significant factors in predicting perinatal death.

CONCLUSIONS

In this large population of patients with rupture of membranes at 15 to 28 weeks' gestation, gestational age at rupture of the membranes, latency period, and amniotic fluid index were important independent predictors of neonatal pulmonary hypoplasia. In addition, gestational age at rupture of the membranes and latency period were important independent determinants of perinatal death. Expectant management of patients with preterm rupture of the amniotic membranes during this gestational age interval was associated with improved perinatal survival, even though it may increase the risk of pulmonary hypoplasia.

Attempted vaginal birth after cesarean section: a multicenter comparison of outpatient prostaglandin E(2) gel with expectant management

Objective: To compare the clinical effectiveness and safety of outpatient administration of an intracervical prostaglandin (PG) E(2) gel with expectant management for women with an unfavorable cervix who wish to attempt a vaginal birth after cesarean section.Study Design: This outpatient study was a randomized, multicenter investigation involving pregnant women at term with one previous low transverse cesarean section. Each had an unfavorable cervix (Bishop score </=4) and was a candidate for vaginal delivery. Those randomly assigned to receive the gel, rather than expectant management, were given a 0.5 mg dose of PGE(2) (Prepidil) intracervically at 39 weeks gestation. This cervical ripening treatment was repeated at weekly office visits for up to 3 doses.Results: Of the 294 cases, 143 received the gel while 151 underwent expectant management. No differences between the two groups were found for maternal demographics, race, parity, or predose Bishop score. The rates of repeat cesarean section did not differ (P =.68) with use of the gel (61, 42%) or with expectant therapy (48, 45%). The onset of active labor, the duration of labor among those delivering vaginally, and the 1-minute and 5-minute Apgar scores were not different between the two groups. No uterine rupture was apparent, and adverse effects during labor were as likely to occur in the two groups.Conclusions: Although its safety was confirmed for outpatient use and for persons with a prior cesarean delivery, intracervical prostaglandin E(2) gel did not improve the chance of a vaginal birth after a cesarean delivery.

Maternal floor infarction of the placenta: prenatal diagnosis and clinical significance

OBJECTIVE

To determine whether maternal floor infarction can be diagnosed prenatally.

METHODS

We reviewed the charts of 13 patients with maternal floor infarction confirmed histopathologically to determine the frequency of increased placental echogenicity, fetal growth restriction (FGR), and oligohydramnios. Subsequently, we applied these criteria prospectively to diagnose maternal floor infarction in three cases.

RESULTS

Twelve of the 13 pregnancies reviewed retrospectively resulted in small for gestational age infants, of which eight were stillbirths. Fetal growth restriction and oligohydramnios were evident on ultrasound in five pregnancies and a placental abnormality was noted in four; two patients exhibited this complete triad of sonographic abnormalities. Three patients were identified prospectively with maternal floor infarction based on sonographic findings and electively delivered live preterm infants.

CONCLUSIONS

Maternal floor infarction is a placental condition with profound risk for FGR and stillbirth. Antenatal diagnosis may improve the perinatal outcome with this condition.

Chronic anemia in pregnant ewes: maternal and fetal effects

To examine maternal and fetal responses to a sustained reduction in maternal hematocrit during days 110-138 of ovine gestation, 22 ewes and their singleton fetuses were instrumented. By repetitive exchange transfusions, the hematocrit in 12 ewes was decreased from 28.1 +/- 0.8 (baseline, day 110) to 14.0 +/- 0.7% (day 117) and maintained at that level. Anemic ewes demonstrated a transient increase in heart rate from 99 +/- 4 to 116 +/- 4 beats/min and a sustained increase in cardiac output from 117 +/- 8 to 153 +/- 11 ml.min-1.kg-1 compared with control animals. Uterine blood flow steadily increased in control animals from 868 +/- 100 (day 110) to 1,410 +/- 177 ml/min (day 138) but failed to increase in the anemic ewes. Uterine oxygen delivery fell from 83 +/- 10 to 39 +/- 4 ml/min with production of anemia and remained low in the anemic ewes. Arterial PO2 and oxygen content in the fetuses of anemic ewes fell transiently below control values (19.9 +/- 0.8 vs. 23.4 +/- 1.0 mmHg and 5.3 +/- 0.3 vs. 6.8 +/- 0.4 ml/dl, respectively) but did not persist. Fetal weights at 138 days gestation were lower in the anemic group (2,596 +/- 329 vs. 4,313 +/- 132 g). We conclude that chronic maternal anemia results in a decreased uterine blood flow as well as decreased uterine oxygen delivery. The fetus responds with decreased growth but does not develop sustained hypoxia or acidosis.

Prenatal diagnosis of recurrent Larsen syndrome: further definition of a lethal variant

Larsen syndrome is characterized by multiple congenital joint dislocations and flattened facies. Some cases have been familial, with both autosomal dominant and recessive patterns of inheritance. Reports of a form of Larsen syndrome, lethal in the neonatal period, are reviewed. We present a family in which recurrence of the syndrome was diagnosed prenatally, but a lethal outcome again resulted despite preparation for anticipated perinatal complications. Because of the wide clinical variation and the lack of a known metabolic defect, delineation between the various forms of Larsen syndrome is difficult. While the lethal variant appears to be a combination of the Larsen phenotype and pulmonary hypoplasia, other features noted in the lethal cases, such as abnormal palmar creases and laryngotracheomalacia, are also seen in patients with Larsen syndrome who survive.

Maternal hyponatremia and the syndrome of hemolysis, elevated liver enzymes, and low platelet count

A patient with the syndrome of hemolysis, elevated liver enzymes, and low platelet count and hyponatremia is described. Hyponatremia could explain the central nervous system symptoms sometimes seen in cases of toxemia.