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Objective: Our aim was to assess diagnostic accuracy in the prediction of small for gestational age (SGA <10th centile) and fetal growth restricted (FGR) (SGA <3rd centile) fetuses using three different sonographic methods in pregnancies at increased risk of fetal growth restriction: 1) fetal abdominal circumference (AC) z-scores, 2) estimated fetal weight (EFW) z-scores according to postnatal reference standard; 3) EFW z-scores according to a prenatal reference standard., Methods: Singleton pregnancies at increased risk of fetal growth restriction seen in two university hospitals between 2014 and 2015 were studied retrospectively. EFW was calculated using formulas proposed by the INTERGROWTH-21st project and Hadlock; data derived from publications by the INTEGROWTH-twenty-first century project and Hadlock were used to calculate z-scores (AC and EFW). The accuracy of different methods was calculated and compared., Results: The study group included 406 patients. Prenatal standard EFW z-scores derived from INTERGROWTH-21st project and Hadlock and co-workers performed similarly and were more accurate in identifying SGA infants than using AC z-scores or a postnatal reference standard. The subgroups analysis demonstrated that EFW prenatal standard was more or similarly accurate compared to other methods across all subgroups, defined by gestational age and birth weight., Conclusions: Prenatal standard EFW z-scores derived from either INTERGROWTH-21 st project or Hadlock and co-workers publications demonstrated a statistically significant advantage over other biometric methods in the diagnosis of SGA fetuses., (© 2022. The Author(s).)

Objective: To investigate the association between application of fundal pressure during the second stage of labor (Kristeller maneuver) and the risk of levator ani muscle (LAM) injury., Methods: This was a prospective case-control study of women recruited immediately after their first vaginal delivery in our university hospital between March 2014 and September 2016. Women who underwent the Kristeller maneuver were recruited as cases. For each case, a control (no Kristeller) was recruited matched for body mass index, use of epidural analgesia, duration of second stage of labor and birth weight. All women were invited to undergo four-dimensional (4D) transperineal ultrasound (TPU) 3-6 months postpartum. The main outcome measure was the presence of LAM avulsion on 4D-TPU. TPU results were compared between cases and controls. Multivariate logistic regression analysis was performed to identify independent risk factors for LAM avulsion., Results: During the study period, 134 women in the Kristeller maneuver group and 128 women in the control group underwent TPU assessment. Women who underwent the Kristeller maneuver had a higher prevalence of LAM avulsion than did controls (38/134 (28.4%) vs 18/128 (14.1%); P = 0.005). In addition, women in the Kristeller-maneuver group had a larger hiatal area on maximum Valsalva maneuver and a greater increase in hiatal area from rest to maximum Valsalva. On multivariate logistic regression analysis, use of the Kristeller maneuver was the only independent factor associated with LAM avulsion (odds ratio, 2.5 (95% CI, 1.29-4.51))., Conclusion: The Kristeller maneuver is associated with an increased risk of LAM avulsion when applied in women during their first vaginal delivery. This should be taken into account when deciding to use fundal pressure to accelerate the second stage of labor and when counseling women following childbirth. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.)

Objective: To investigate the usefulness of visual biofeedback using transperineal ultrasound to improve coached pushing during the active second stage of labor in nulliparous women., Methods: This was a randomized controlled trial of low-risk nulliparous women in the active second stage of labor. Patients were allocated to either coached pushing aided by visual demonstration on transperineal ultrasound of the progress of the fetal head (sonographic coaching) or traditional coaching. Patients in both groups were coached by an obstetrician for the first 20 min of the active second stage of labor and, subsequently, the labor was supervised by a midwife. Primary outcomes were duration of the active second stage and increase in the angle of progression at the end of the coaching process. Secondary outcomes included the incidence of operative delivery and complications of labor., Results: Forty women were recruited into the study. Those who received sonographic coaching had a shorter active phase of the second stage (30 min (interquartile range (IQR), 24-42 min) vs 45 min (IQR, 39-55 min); P = 0.01) and a greater increase in the angle of progression (13.5° (IQR, 9-20°) vs 5° (IQR, 3-9.5°); P = 0.01) in the first 20 min of the active second stage of labor than did those who had traditional coaching. No differences were found in the secondary outcomes between the two groups., Conclusion: Our preliminary data suggest that transperineal ultrasound may be a useful adjunct to coached pushing during the active second stage of labor. Further studies are required to confirm these findings and better define the benefits of this approach. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.)

Objectives: To compare the efficiency of electronic spatiotemporal image correlation (eSTIC) with that of conventional STIC to acquire four-dimensional (4D) fetal cardiac volumes of diagnostic quality., Methods: This was a randomized controlled trial of 100 patients in mid-gestation with normal sonograms. In half of the cases, STIC volumes of the fetal heart were obtained with a conventional mechanical 4D probe and in the remaining cases eSTIC volumes were obtained with an electronic 4D probe. Examinations were kept within the timeframe allotted for a standard examination of fetal anatomy, and a maximum of two attempts were made at obtaining a 4D cardiac volume. Datasets were stored on a computer and subsequently analyzed and categorized as being of optimal, satisfactory or inadequate quality, depending on whether or not it was possible to perform an extended basic cardiac examination, including obtaining a three vessels and trachea view, as well as a clear reconstruction of both the aortic and ductal arches in the sagittal plane., Results: The eSTIC volume datasets were more frequently of optimal or satisfactory diagnostic quality compared with conventional STIC (94% vs 76%, P < 0.0001). Failure to obtain an eSTIC volume of adequate quality was in all cases the consequence of an unfavorable position of the fetus., Conclusions: Compared with a standard mechanical probe, the electronic 4D probe facilitates acquisition of sonographic cardiac volumes in mid-trimester fetuses. In our hands, eSTIC volumes of optimal or satisfactory diagnostic quality, allowing a detailed offline evaluation of the fetal heart, were obtained in more than 90% of cases within the time frame of a standard examination of fetal anatomy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.)

Objective: To determine whether the subpubic arch angle (SPA) measured by three-dimensional ultrasound is associated with the fetal occiput position at delivery and the mode of delivery., Methods: Nulliparous women with an uncomplicated singleton pregnancy at ≥ 37 weeks' gestation were recruited from two tertiary centers between September 2013 and August 2015. All women underwent a three-dimensional transperineal ultrasound examination and the SPA was measured using the previously validated Oblique View Extended Imaging software. Data on the outcome of labor were obtained prospectively in all cases and the correlations between SPA and the fetal occiput position at delivery and the incidence of operative delivery were investigated., Results: Overall, 368 women were included in the study. Fetal position at delivery was occiput anterior in 339 (92.1%) cases and occiput posterior (OP) in 29 (7.9%) cases. A significantly narrower SPA was found in the OP group compared with the occiput anterior group (104.4 ± 16.8° vs 116.4 ± 11.9°; P < 0.0001). The SPA was significantly narrower in women requiring obstetric intervention compared with in women with a spontaneous vaginal delivery. From multivariable logistic regression analysis, SPA and maternal height appeared to be significant predictors of both the fetal occiput position at delivery and the risk of operative delivery. The best cut-off value of SPA for predicting an OP position at delivery was 90.5°., Conclusion: A narrow SPA is associated with a higher risk of persistent OP position at delivery and of operative delivery. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.)

We report on the sonographic appearance of a new type of fetal head malposition in labor that has not been previously described systematically. In some circumstances, the fetal lie is characterized by a lateral orientation of the head with respect to the trunk and, on suprapubic ultrasound, a transverse section of the fetal chest together with the facial profile can be seen on the same image. These sonographic findings were documented in five cases of first-stage labor arrest. This report illustrates how, in these circumstances, ultrasound might be helpful in clarifying the precise cause of obstructed labor., (Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.)

Objectives: To assess the intermethod agreement between two-dimensional (2D) and three-dimensional (3D) transperineal ultrasound methods in measuring a new index of fetal head station (the fetal head-symphysis distance (HSD)) in active labor, and to assess potential factors that may affect their agreement., Methods: HSD was measured by transperineal ultrasound in 86 women in active labor, once using a 2D and once using a 3D technique. 2D images were acquired first in 43 cases and 3D images were acquired first in the other 43 women. Intermethod agreement between 2D and 3D methods was analyzed by means of intraclass correlation coefficient (ICC) and Bland-Altman analysis. In addition, potential factors affecting the intermethod reproducibility were investigated including fetal occiput position, order of acquisition, fetal head station, stage of labor, maternal body mass index and use of epidural analgesia, using the ANOVA test to check for systematic bias and Levene's test for homoscedasticity., Results: Good agreement was demonstrated between 2D and 3D measurements of HSD (ICC, 0.949 (95% CI, 0.914-0.984)). No evidence of systematic difference was shown between the two methods (average difference ± SD = 0.03 ± 2.29 mm; P = 0.888). The only factor that had a significant effect on systematic difference between 2D and 3D methods was order of acquisition (P = 0.042); the first observation was higher regardless of the method used. Fetal head station had a significant effect on the homogeneity between the two methods (P = 0.004) with a better 2D-3D agreement obtained at lower head stations (SD of differences: 1.63 vs 2.59 mm)., Conclusions: There is very good agreement between 2D and 3D methods of assessing HSD. Agreement is better in lower fetal head stations., (Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.)

Objective: To compare longitudinal changes in angle of progression (AoP) and midline angle (MLA) during the active second stage of labor according to the mode of delivery., Methods: A three-dimensional transperineal ultrasound volume was acquired in a series of nulliparous women at the beginning of the active second stage (T1) and every 20 min thereafter (T2, T3, T4, T5 and T6). Following delivery, all ultrasound volumes were analyzed and AoP and MLA were measured., Results: Among 71 women included in the study, 58 underwent spontaneous vaginal delivery (group A) and 13 underwent operative delivery (group B) (eight by vacuum extraction and five by Cesarean section). When compared with Group B, Group A had a wider AoP only at T1 (140.0 ± 20.2° vs. 122.9 ± 16.7°; P = 0.010) and T2 (149.7 ± 20.7° vs. 126.9 ± 17.5°; P = 0.006). MLA was narrower in group A only at T3 (21.2 ± 11.7° vs. 40.8 ± 27.9°; P = 0.043), T4 (18.2 ± 15.0° vs. 47.4 ± 29.6°; P = 0.020) and T5 (18.3 ± 6.0° vs. 34.7 ± 4.2°; P = 0.034). On stepwise forward multiple logistic regression analysis, both AoP and MLA were independently associated with operative delivery (OR = 0.955 and OR = 1.018, respectively)., Conclusion: Ultrasonographic assessment of fetal head descent in the second stage of labor may play a role in the prediction of the mode of delivery., (Copyright © 2013 ISUOG. Published by John Wiley & Sons, Ltd.)

Objectives: To evaluate pregnancy outcome in patients with increased uterine artery (UtA) pulsatility at 34 weeks' gestation as an isolated finding., Methods: Normotensive women attending at 34 weeks' gestation for fetal growth assessment were enrolled in the study if fetal growth was appropriate for age and mean UtA pulsatility index (PI) was persistently above the 95(th) centile for gestational age. Patients were excluded with any of the following conditions: multiple pregnancy, sonographic suspicion of fetal anomaly or fetal growth restriction, history of chronic maternal disease, hypertensive disorder or diabetes in the current pregnancy or one or more adverse events in their past obstetric history. The control group consisted of age- and body mass index-matched low-risk women attending at 34 weeks with normal uterine artery Doppler since the midtrimester., Results: Sixty-six normotensive patients with normal fetal growth and increased UtA-PI at 34 weeks were included in the study group. Women with abnormal Doppler findings compared with controls showed significantly lower gestational age at delivery (38.2 ± 1.6 vs. 38.9 ± 1.3 weeks, P = 0.006), birth weight (2942 ± 583 vs. 3404 ± 469 g, P < 0.001), birth-weight Z-score (-0.61 ± 1.07 vs. 0.19 ± 1.05, P < 0.001) and increased risk of a small-for-gestational-age (SGA) newborn (13/66 vs. 1/66, P < 0.001). The occurrence of late pre-eclampsia (3/66 vs. 0/66, P = 0.24), admission to the neonatal intensive care unit (6/66 vs. 4/66, P = 0.74), rate of induction of labor (16/66 vs. 14/66, P = 0.83) and rate of Cesarean section due to fetal distress (6/66 vs. 3/66, P = 0.49) were comparable between the two groups., Conclusion: Increased UtA-PI as an isolated finding at 34 weeks' gestation is associated with an increased risk of delivering an SGA neonate., (Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd.)

Objectives: To evaluate the accuracy of three-dimensional (3D) ultrasound in fetal gender assignment in the first trimester., Methods: A series of pregnant women attending at 11 to 13 + 6 weeks for the nuchal translucency (NT) scan were enrolled into the study. An ultrasound volume of each fetus was obtained and stored for offline analysis. On the reconstructed mid-sagittal plane, the angle between the genital tubercle and an imaginary line passing tangentially through the fetal back (genital angle) was estimated and a receiver-operating characteristics (ROC) curve was constructed to determine the best cut-off for genital angle in fetal male gender determination. Fetal gender was subsequently ascertained in all cases. To calculate the interobserver variability, a second operator repeated the measurements., Results: There were 85 cases included in the study. The genital angle in males was significantly higher than that in females (51.2 ± 11.3° (n = 36) vs. 18.9 ± 4.1 (n = 49), P < 0.001). The ROC curve revealed the estimated genital angle to have a high degree of accuracy in fetal gender determination (area under the curve ± SE = 1.000 ± 0.001). The best cut-off for male gender determination was found to be between 27° and 29° (sensitivity, 100%; specificity, 98.0%). There was a high degree of correlation between the two operators (r(2) = 0.998; coefficient of variation = 5.4%)., Conclusions: 3D ultrasound is a highly accurate and reproducible tool for fetal gender assignment prior to 14 weeks of gestation., (Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd.)