Measurement of fetal head descent using the 'angle of progression' on transperineal ultrasound imaging is reliable regardless of fetal head station or ultrasound expertise

OBJECTIVES

To assess whether ultrasound experience or fetal head station affects the reliability of measurement of fetal head descent using the angle of progression on intrapartum ultrasound images obtained by a single experienced operator, and to determine reliability of measurements when images were acquired by different operators with variable ultrasound experience.

METHODS

One experienced obstetrician performed 44 transperineal ultrasound examinations of women at term and in prolonged second stage of labor with the fetus in the occipitoanterior position. Three midwives without ultrasound experience, three obstetricians with < 5 years' experience and three obstetricians with > 10 years' experience measured fetal head descent based on the angle of progression in the images obtained. The angle of progression was measured by two obstetricians in independent ultrasound examinations of 24 laboring women at term with the fetus in the cephalic position to allow assessment of the reliability of image acquisition. Intraclass correlation coefficients (ICCs) with 95% confidence interval (CI) were used to evaluate interobserver reliability and Bland-Altman analysis was used to assess interobserver agreement.

RESULTS

In total, 444 measurements were performed and compared. Interobserver reliability with respect to offline image analysis was substantial (overall ICC, 0.72; 95% CI, 0.63-0.81). ICCs were 0.82 (95% CI, 0.70-0.89), 0.81 (95% CI, 0.71-0.88) and 0.61 (95% CI, 0.43-074) for observers with > 10 years', < 5 years' and no ultrasound experience, respectively. There were no significant differences between ICCs among observer groups according to ultrasound experience. Fetal head station did not affect reliability. Bland-Altman analysis indicated reasonable agreement between measurements obtained by two different operators with > 10 years' and < 5 years' ultrasound experience (bias, -1.09 degrees ; 95% limits of agreement, -8.76 to 6.58). The reliability of measurement of the angle of progression following separate image acquisition by two experienced operators was similar to the reliability of offline image analysis (ICC, 0.86; 95% CI, 0.70-0.93).

CONCLUSIONS

Measurement of the angle of progression on transperineal ultrasound imaging is reliable regardless of fetal head station or the clinician's level of ultrasound experience.

Transperineal ultrasound imaging in prolonged second stage of labor with occipitoanterior presenting fetuses: how well does the 'angle of progression' predict the mode of delivery?

OBJECTIVES

To compare the angle of progression on transperineal ultrasound imaging between different modes of delivery in prolonged second stage of labor with occipitoanterior fetal position.

METHODS

We prospectively evaluated 41 women at term (>or= 37 weeks) with failure to progress in the second stage of labor. Only cases with occipitoanterior fetal position were included in the final analysis. These cases were classified into three groups: Cesarean section for failure to progress, vacuum extraction for failure to progress, and spontaneous delivery following prolonged second stage of labor. Transperineal ultrasound examination was performed just before digital examination and subsequent delivery. The angle between a line placed through the midline of the pubic symphysis and a line running from the inferior apex of the symphysis tangentially to the fetal skull (the so-called 'angle of progression') was measured offline by an observer blinded to the mode of delivery.

RESULTS

There were 26 cases with occipitoanterior fetal position (Cesarean section, n = 5; vacuum extraction, n = 16; spontaneous delivery, n = 5). Logistic regression analysis showed a strong relationship between the angle of progression and the need for Cesarean delivery (R(2) measure of fit = 55%, likelihood ratio chi-square P < 0.0001). When the angle of progression was 120 degrees , the fitted probability of either an easy and successful vacuum extraction or spontaneous vaginal delivery was 90%.

CONCLUSIONS

This is the first report to document a strong relationship between an objective ultrasound marker (angle of progression) and the mode of delivery following prolonged second stage of labor with occipitoanterior fetal position. A predictive model using this parameter would allow better decision making regarding operative delivery for obstructed labor.

Ets-1 is up-regulated together with its target gene products matrix metalloproteinase-2 and matrix metalloproteinase-9 in atypical and anaplastic meningiomas

AIMS

Matrix metalloproteinases (MMPs) are a pivotal enzyme system involved in extracellular matrix (ECM) degradation and are considered to be important in the development and invasion of human tumours. Little is known about the regulation of MMPs in meningioma development and prognosis. The transcription factor Ets-1 is the main regulator of several MMPs, including MMP-2 and -9. The aim of this study was to determine the relationship between the expression of Ets-1, MMP-2 and -9 and the malignant potential of meningiomas.

METHODS AND RESULTS

Seventy-four meningiomas of different histological grades were investigated immunohistochemically. Up-regulation of Ets-1, MMP-2 and MMP-9 expression was observed in atypical and anaplastic meningiomas. Invasive meningiomas showed increased immunohistochemical expression of these proteins compared with non-invasive meningiomas. We also observed a correlation between the expression of Ets-1 and of its target genes MMP-2 and MMP-9.

CONCLUSIONS

Ets-1 may be involved in the transcriptional regulation of MMP-2 and MMP-9 as well as in the invasive process in meningiomas. Evaluation of these expressions might be of prognostic value for meningiomas.

The transcription factor Ets-1 is expressed in human amniochorionic membranes and is up-regulated in term and preterm premature rupture of membranes

OBJECTIVE

The major tensile strength of fetal membranes is provided by their extracellular matrix (ECM) components. The transcription factor Ets-1 is a critical mediator of ECM remodelling. The purpose of this study was to examine whether Ets-1 is expressed in human fetal membranes and whether it is implicated in premature membrane rupture.

STUDY DESIGN

Amniochorionic membranes from 52 women in the following categories were analyzed for Ets-1 expression: preterm and term premature rupture of membranes, preterm and term labor and delivery, and preterm and term cesarean sections without previous onset of labor. Ets-1 protein was localized with the use of immunohistochemistry. Ets-1 levels were determined with a histoscore.

RESULTS

Ets-1 protein was localized to the trophoblast as well as to the stromal layers. Ets-1 protein expression was up-regulated in the stroma of term and preterm prematurely ruptured membranes.

CONCLUSION

Ets-1 is expressed in human fetal membranes and its expression is up-regulated with premature rupture of membranes, suggesting a role for Ets-1 in ECM remodelling of the membranes.