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Alobar holoprosencephaly (HPE) is easily detected during a first-trimester screening examination, conversely, recognizing the lesser varieties may be difficult even in the second trimester.To describe the imaging findings of a cohort of fetuses with holoprosencephaly (HPE) and to elucidate the appearances of the different anatomical varieties.We reviewed medical records and stored images of pregnant women referred to our clinic because of a diagnosis or the suspicion of various forms of HPE. We reported the imaging characteristics, the presence of other associated anomalies, magnetic resonance findings, karyotype and autoptic examinations when available.Alobar forms show great distortion of normal brain anatomy, with a single ventricle detectable during the first trimester of pregnancy. Extracerebral, face and karyotype abnormalities are often associated. In semilobar and lobar forms the septum pellucidum is typically absent in axial planes, with fused frontal horns, while posterior fossa is often normal. At multiplanar neurosonogram, anomalies involving corpus callosum and cortex development can be detected. Face abnormalities are mild in lobar forms: receding forehead, various degrees of hypotelorism and the presence of a single central maxillary incisor are reported.The alobar forms are detectable since the first trimester, with a peculiar single ventricle and extremely frequent extracerebral and karyotype abnormalities. The semilobar and lobar forms are more challenging and the diagnosis is easily missed in a mid-trimester screening exam unless a careful evaluation of both

OBJECTIVE Hypertensive pulmonary edema is a fatal condition unless early and properly diagnosed and managed. Central blood pressure (cBP) has been proven to be more associated with adverse cardiovascular events. We aimed to study the correlation between cBP and heart damage in patients with Hypertensive pulmonary edema. METHODS We included 50 patients admitted to the emergency department in a university hospital for hypertensive pulmonary edema, 27 women and 23 men aged 50 to 70 years. We excluded patients with suspected acute coronary syndrome, significant valvular heart disease, and pericardial diseases. We measured cBP non-invasively from pulse wave analysis of the brachial artery. Brain natriuretic peptide (BNP) and cBP were repeatedly measured for every patient. RESULTS The median BNP levels of patients significantly decreased from 284 pg/ml (232-352.5) to 31.5 pg/ml (24-54) on discharge, P < 0.001. We found a significant correlation between admission BNP and central SBP (cSBP), urea, creatinine, arterial blood gases parameters, and left ventricular end-diastolic diameter (LVEDD). Concurrently, BNP at discharge was correlated with age, central DBP (cDBP), urea, creatinine, LVEDD, partial oxygen pressure (pO2), and oxygen saturation (SO2). Delta BNP was correlated with cSBP, peripheral SBP, urea, creatinine, pO2, and SO2. Linear regression analysis revealed that creatinine, and cSBP, were independent predictors of admission BNP, while urea and cDBP were the independent predictors of discharge BNP. CONCLUSION This simple, noninvasive method of cBP measurement was significantly associated with the extent of myocardial damage in patients presenting with hypertensive pulmonary edema.

BackgroundMyocarditis is a highly heterogeneous disorder with a challenging diagnostic work-up. We aimed to focus on the possible diagnostic workup for this condition in settings where endomyocardial biopsy as a gold standard is not always feasible, detect the etiologic cardiotropic viruses in our locality, and follow the clinical course in patients admitted with clinically suspected myocarditis.MethodsThis is a prospective observational study. We recruited patients with clinically suspected myocarditis presenting at a university hospital from October 1st, 2020 until March 31st, 2021. All Patients had a diagnostic coronary angiography and were included only if they had a non-obstructive coronary artery disease. All patients also had cardiac magnetic resonance imaging (CMR) with contrast. Sera were obtained from all suspected patients for detection of antibodies against viruses using enzyme-linked immunosorbent assay, and viral genomes using polymerase chain reaction (PCR), and reverse transcription–PCR. Endomyocardial biopsy was done for patients with a typical CMR picture of myocarditis.ResultsOut of 2163 patients presenting to the hospital within the 6 months, only 51 met the inclusion criteria. Males represented 73%, with a mean age of 39 ± 16 years. CMR showed an ischemic pattern in 4 patients and thus they were excluded. We classified patients into two categories based on CMR results: group A (CMR-positive myocarditis), 12 patients (25.5%), and group B (CMR-negative myocarditis), 35 (74.5%) patients. On serological analysis, 66% of patients (n = 31/47) showed antibodies against the common cardiotropic viruses. Parvovirus B19 IgM in 22 patients (47%) and coxsackievirus IgM in 16 (34%) were the most observed etiologies. Regarding the outcome, 42.5% of patients recovered left ventricular ejection fraction and three patients died at 6 months’ clinical follow-up.ConclusionPatients with Clinically suspected myocarditis represented 2.2% of total hospital admissions in 6 months. CMR is only a good positive test for the diagnosis of acute myocarditis. Parvovirus B19 and coxsackievirus were the most common pathogens in our locality.Trial registration: Clinical trial registration no., NCT04312490; first registration: 18/03/2020. First recruited case 01/10/2020. URL:https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0009O3D&selectaction=Edit&uid=U0002DVP&ts=2&cx=9zdfin.

OBJECTIVES Deep infiltrating endometriosis (DIE) is associated with chronic pelvic pain, dyspareunia and pelvic floor muscle hypertonia. The primary aim of this study was to evaluate the effect of pelvic floor physiotherapy (PFP) on the area of levator ani hiatus during Valsalva maneuver, assessed using transperineal ultrasound, in women with DIE suffering from superficial dyspareunia. METHODS This was a randomized controlled trial of 34 nulliparous women diagnosed with DIE and associated superficial dyspareunia. After an initial clinical examination, all patients underwent three-dimensional/four-dimensional (3D/4D) transperineal ultrasound to measure the levator hiatal area (LHA) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, and were asked to rate their pain symptoms using a numerical rating scale (NRS). Eligible women were assigned randomly (1:1 ratio) to no intervention (control group, 17 women) or treatment with five individual sessions of PFP (study group, 17 women). Four months after the first examination, all women underwent a second evaluation of pain symptoms and LHA on transperineal ultrasound. The primary outcome measure was the percentage change in LHA on maximum Valsalva maneuver between the baseline and follow-up examinations. The percentage changes in pain symptoms between the two examinations, including superficial and deep dyspareunia, dysmenorrhea, chronic pelvic pain, dysuria and dyschezia, were also evaluated. RESULTS Thirty women, comprising 17 in the study group and 13 in the control group, completed the study and were included in the analysis. The percentage change in LHA on maximum Valsalva maneuver between the two examinations was higher in the study group than in the control group (20.0 ± 24.8% vs -0.5 ± 3.3%; P = 0.02), indicating better pelvic floor muscle relaxation. After PFP treatment, the NRS score for superficial dyspareunia remained almost unchanged in the control group (median change in NRS (Δ-NRS), 0 (interquartile range (IQR), 0-0)) while a marked reduction was observed in the study group (median Δ-NRS, -3 (IQR, -4 to -2); P

Preeclampsia is a main obstetric disease and could be caused by the inability of the woman hemodynamic system to face the cardiovascular effort required by gestation. The aim of the present study i...

Purpose of review Fetal central nervous system malformations are among the most common congenital anomalies. Whereas simple axial views are sufficient for basic fetal brain examination, other important views are essential for a more detailed examination, which are sometimes challenging to obtain. Three-dimensional ultrasound can be helpful in obtaining standardized and reproducible images of many difficult fetal brain views. The aim of the present review is to explore the most recent evidence on the utility and technique of three-dimensional ultrasound in the examination of the fetal brain, with particular emphasis on the brain views that benefit from three-dimensional ultrasound. Recent findings The article describes the various techniques of acquisition and analyses of three-dimensional ultrasound volumes of the fetal brain and their usefulness in the assessment of normal and abnormal fetal brain anatomy. Three-dimensional ultrasound has also permitted the application of many new technologies, such as artificial intelligence and deep machine learning. Recently, thanks to high-quality three-dimensional ultrasound, fetal cortical development can be assessed quantitatively and reliably. Summary Three dimensional ultrasound can help as a complementary tool to two-dimensional ultrasound in the assessment of the fetal brain development and malformations. In addition, it paves the way for the application of promising technologies in the evaluation of fetal brain. Video abstract A video summarizing the findings of the article. The video illustrates the various approaches and techniques applied for the examination of the fetal brain using three-dimensional ultrasound. Furthermore, the advantages and future perspectives of the application of three-dimensional ultrasound in the examination of the fetal brain are discussed, http://links.lww.com/COOG/A74.

Using transperineal 3D/4D ultrasound, we evaluated the prevalence of the various categories of a 4-point pelvic contraction scale among women affected by ovarian endometriosis (OE), deep infiltrating endometriosis (DIE), and healthy controls.This prospective study was conducted on nulliparous women scheduled for surgery to remove endometriosis, and nulliparous healthy volunteers who did not show any clinical or sonographic signs of endometriosis, who served as controls. Patients were subjected to 3D/4D transperineal ultrasound obtaining measurements of the antero-posterior diameter (APD), both at rest and during maximal pelvic floor muscle (PFM) contraction (PFMC). The difference of APD from rest to maximal PFMC was then calculated as percent change from baseline (ΔAPD) and patients were thus categorized using the 4-point pelvic contraction scale.One hundred sixty-four patients were considered for the study. Mean difference in APD between relaxed state and maximal PFMC was 23.3 ± 7.9% (range 2.4-40.0) in controls, 20.5 ± 9.0% (range 0.0-37.3) in patients with OE, and 14.6 ± 10.4% (range 0.0-37.1) in patients with DIE (F-test = 19.5, P-value.001). A significant negative correlation was found between the contraction scale and dyspareunia (rs = -0.17, P = .032), and it appeared to be stronger among patients with DIE (rs = -0.20, P = .076).PFM function in endometriotic patients could be assessed reliably through this 4-point scale. The rapid identification of women suffering from PFM dysfunction, along with deep dyspareunia, could enable gynecologists to offer them additional therapies, such as PFM rehabilitation.

To assess the correlation between fetal head regression and levator ani muscle (LAM) co-activation under Valsalva maneuver.This study was a secondary analysis of a prospective cohort study on the association between the angle of progression (AoP) and labor outcome. We scanned a group of nulliparous women at term before the onset of labor at rest and under maximum Valsalva maneuver. In addition to the previously calculated AoP, in the present study, we measured the anteroposterior diameter of LAM hiatus (APD) on each ultrasound image. LAM co-activation was defined as APD at Valsalva less than that at rest, whereas fetal head regression was defined as AoP at Valsalva less than that at rest. We calculated the correlation between the two phenomena. Finally, we examined various labor outcomes according to the presence, absence, or co-existence of these two phenomena.We included 469 women. A total of 129 (27.5%) women presented LAM co-activation while 50 (10.7%) showed head regression. Only 15 (3.2%) women showed simultaneous head regression and LAM co-activation. Women with coexisting LAM co-activation and head regression had the narrowest AoP at Valsalva in comparison with other study groups (In nulliparous women at term before the onset of labor fetal head regression and LAM co-activation at Valsalva are two distinct phenomena that uncommonly coexist.

The novel coronavirus disease (COVID-19) is a challenge to every health system. Unfortunately, it is unlikely that this pandemic will disappear soon. No health system, with its present resources and workflow, is capable enough to deal with a full-blown wave of this pandemic. Acquisition of specific new skills may be fundamental in delivering appropriate health care for our patients. The gold standard for diagnosis of the COVID-19 infection is real-time reverse transcription polymerase chain reaction. Radiological investigations (chest X-ray or high-resolution computerized tomography [CT]) can be helpful both for diagnosis and management, but they have many limitations. Ultrasound has been suggested as a reliable and accurate tool for assessing the lungs in COVID-19 patients. Lung ultrasound (LUS) can show specific signs of inter-stitial pneumonia, which is characteristic of COVID-19 pulmonary infection. In addition, nonradiologist specialists with experience in ultrasound can be trained on LUS with a relatively rapid learning curve. In pregnancy, LUS can be particularly useful due to the avoidance of exposure to ionizing radiation. In this review, we present the advantages, techniques, and limitations of the use of LUS during the COVID-19 pandemic, with specific focus on pregnancy.

Background: Growth differentiation factor 15 (GDF15) gene expression level is a novel biomarker that reflects inflammation and oxidative stress in patients with acute coronary syndrome and those complicated with type 2 diabetes mellitus (T2DM). Growth differentiation factor 15 high levels could be a reliable sensitive biomarker for the prediction of acute coronary syndrome. Patients and Methods: This Cross-sectional/case-control study was conducted at the Cardiology Department, Assiut University during the period from January 2018 to December 2019, and patients were selected with the exclusion of any inflammatory or autoimmune disease. Results: Growth differentiation factor 15 gene expression was significantly higher in acute coronary syndrome patients compared to the controls (p-value

The current COVID-19 pandemic is a challenge to every health system over the globe. Unfortunately, it is likely that this emergency will not disappear soon. No health system, with its present resources and work flow is ready to deal with a full-blown wave of this pandemic. Rapid acquisition of specific new skills may be fundamental in delivering appropriate health care for our patients. COVID-19 infection is classically diagnosed by real time reverse transcription polymerase chain reaction and radiological investigations (X-ray or high-resolution computerized tomography). These techniques are not without limitations. Ultrasound has been suggested as a reliable and accurate tool for assessing the lungs in patients with suspected pneumonia. Obstetricians and gynecologists are usually familiar with the use of ultrasound. Lung ultrasound can show specific signs of interstitial pneumonia, which is characteristic of COVID-19 pulmonary infection. We believe that extensive and rapid training of healthcare providers on the application of ultrasound in the detection of characteristic pulmonary signs of COVID-19 infection, in addition to proper care and handling of their ultrasound machines, is feasible and may be critical in order to provide appropriate management especially of the obstetric patient in the coming period. We present a systematic approach to lung examination, simplified to encourage its adoption by obstetricians and gynecologists, together with an example of a recent pregnant woman with COVID-19 infection, in which lung ultrasound was useful in the management.

The mitral valve surgery decision is made mainly according to echocardiographic (ECHO) criteria. As the asymptomatic patients are still candidates for surgery in some situations, this makes the accurate assessment of mitral regurgitation (MR) severity and cardiac dimensions even more important. We aimed to compare ECHO and cardiac magnetic resonance imaging (CMR) in the assessment of MR severity and cardiac dimensions. In this prospective study, we included all patients with more than mild MR by ECHO and referred to our university hospital from 1st of April 2017 and 1st of April 2019. Exclusion criteria were critically ill patients, presence of other valve lesions, planned revascularization, pregnancy and contraindication for CMR. All patients had full history taking, examination, body surface area, and ECG. MR severity and left atrial and left ventricular dimensions were assessed in 50 patients with both 2D-ECHO and CMR in the same day. There were no significant differences in baseline clinical characteristics between moderate (24 patients) and severe MR (26 patients) groups. Poor degree of agreement was present between CMR and ECHO assessment for MR severity (same degree of MR only in 36% (18/50 patients) with kappa grade = 0.19). Furthermore, ECHO overestimated grades of MR compared to CMR (severe MR in 52% vs. 38.4%, p = 0.01 respectively). Based on the etiology of MR, primary (30 patients) vs. secondary MR (20 patients) showed the same dis-agreement between CMR and ECHO assessment of MR severity. Left atrial and ventricular dimensions showed good agreement between CMR and ECHO. Our results suggest that CMR could be more accurate than ECHO in assessing the severity of MR especially in severe cases that need surgery.

Dysphagia is a distressing symptom during and after radiotherapy treatment in head and neck cancer (HNC) patients. The objective of this prospective study was to investigate whether swallowing sparing intensity modulated radiotherapy (SW-IMRT) reduces the occurrence of swallowing dysfunction compared to the standard IMRT (ST-IMRT). We randomized, planned, and treated patients with HNC who needed whole neck irradiation using the simultaneous integrated boost (SIB) IMRT technique. Doses of 70, 60, and 54 Gy (over 33 daily fractions) were prescribed to the primary tumor, high-risk and low-risk regions, respectively. The postoperative cases received 60 and 54 Gy (over 30 daily fractions) to the high-risk planning target volume (PTV) and low-risk PTV. We contoured organs at risk related to swallowing dysfunction (SWOARs) in all cases. In the ST-IMRT group, parotids only were spared. In the SW-IMRT group, parotids and SWOARs outside the high-risk PTV were spared. Assessment of dysphagia included clinical and instrumental evaluation. One hundred forty-six patients ended their radiotherapy treatment. Dose distribution showed comparable PTV coverage and no difference in parotid glands sparing between the two groups. SWOARs dose reduction with SW-IMRT differs according to tumor location and its overlap with SWOARs. Using different assessment methods, SW-IMRT was associated with a lower occurrence of dysphagia up to one year after treatment. There was no difference between the two groups regarding acute dysphagia (p = 0.262), overall survival (p = 0.811), and disease-free survival (p = 0.876). SW-IMRT is significantly better than ST-IMRT regarding a physician-rated and objective assessment of swallowing dysfunction at short- and long-term post-treatment follow-up.

Objective To assess the association between sonographic findings at transperineal ultrasound (TPU) and chronic constipation (CC) in women with endometriosis. Methods An observational prospective cohort study was performed by enrolling all women with endometriosis scheduled for surgery between September 2019 and October 2020. Women underwent TPU at rest and during Valsalva maneuver evaluating levator-hiatal-area (LHA), antero-posterior diameter (APD), and levator ani muscle (LAM) coactivation. Ultrasound findings were compared between women with and without CC in the whole study population, and subsequently in two subgroups (only ovarian endometriosis and deep infiltrating endometriosis [DIE]). Results In all, 87 women were enrolled: 29 (33%) with CC and 58 (67%) without CC. Women with endometriosis and CC showed a smaller LHA during Valsalva, less LHA and APD enlargement from rest to maximum Valsalva, and a higher prevalence of LAM coactivation compared with women without CC. In the ovarian subgroup, women with CC had smaller LHA at Valsalva, less enlargement of LHA and APD from rest to maximum Valsalva, and higher prevalence of LAM coactivation compared with non-CC patients. In the DIE subgroup, TPU did not significantly differ between CC and non-CC patients. Conclusion TPU signs of pelvic floor muscle hypertonia are more frequent in endometriosis patients with CC compared with those without constipation, particularly in women affected by isolated ovarian endometriosis.

Aims The primary aim of the present study was to assess the association between levator ani muscle (LAM) integrity and function on the one hand, and the risk of urinary incontinence (UI) on the other. A secondary objective was to assess the association between fundal pressure in the second stage of labor (Kristeller maneuver) and the risk of postpartum UI. Methods In this prospective cohort study, women underwent a clinical and transperineal ultrasound examination at rest, at pelvic floor muscle contraction (PFMC), and at Valsalva maneuver 3-6 months after their first vaginal delivery. LAM avulsion and levator hiatal area (LHA) were evaluated. In addition, women were interviewed about the presence of UI, whether stress (SUI) or urgency (UUI). Results Overall, data of 244 women were analyzed. SUI was reported in 50 (20.5%), while UUI was reported in 19 (7.8%) women. Women who reported SUI had a higher prevalence of LAM avulsion and less proportional reduction in LHA from rest to a maximum contraction in comparison to women with no SUI. Women who reported UUI had a greater LHA at rest, during contraction, and during maximal Valsalva in comparison to women without UUI. No significant association was found between the Kristeller maneuver and the incidence of any UI. Conclusion Levator ani avulsion and less proportional reduction of LHA with PFMC appear to be associated with a higher risk of postpartum urinary stress incontinence.

The indications for induction of labor have been consistently on the rise. These indications are mainly medical (maternal or fetal) or social or related to convenience or maternal preferences. With the increase in the prevalence of these indications, the incidence rates of induction of labor are expected to rise continuously. This poses a substantial workload and financial burden on maternity healthcare systems. Failure rates of induction of labor are relatively high, especially when considering the maternal, fetal, and neonatal risks associated with emergency cesarean deliveries in cases of failure. Therefore, it is essential for obstetricians to carefully select women who are eligible for induction of labor, particularly those with no clinical contraindication and who have a reasonable chance of ending up with a successful noncomplicated vaginal delivery. Ultrasound has an established role in the various areas of obstetrical care. It is available, accessible, easy to perform, and acceptable to the patient. In addition, the learning curve for skillful obstetrical ultrasound scanning is rather easy to fulfill. Ultrasound has always had an important role in the assessment of maternal and fetal well-being. Indeed, it has been extensively explored as a reliable, reproducible, and objective tool in the management of labor. In this review, we aimed to provide a comprehensive update on the different applications and uses of ultrasound before induction of labor for the prediction of its success and the potential improvement of its health-related maternal and fetal outcomes.

Hypertensive disorders are quite common, complicating about 10% of pregnancies, while preeclampsia occurs in 2-8% of cases. The most recognized etiopathogenetic factor for the development of preeclampsia is deficient remodeling of the spiral arteries during trophoblastic invasion. Recently, some authors speculated about the "cardiovascular origin of preeclampsia"; in particular, they postulate that placental dysfunction is not the primum movens of preeclampsia, but it could be caused by a failure of the maternal cardiovascular system to adapt to the pregnancy itself. Moreover, several studies have also shown that developing preeclampsia in pregnancy is associated with an increased risk of cardiovascular disease later in life. Due to the importance of this pathology, it would be crucial to have an effective screening in order to implement a prophylaxis; for this purpose, it could be useful to have an accurate and noninvasive device for the assessment of maternal hemodynamic variables. USCOM

Preeclampsia is a main obstetric disease and could be caused by the inability of the woman hemodynamic system to face the cardiovascular effort required by gestation.The aim of the present study is to evaluate the correlation between maternal hemodynamic parameters detected by UltraSonic Cardiac Output Monitor (USCOMThis was a prospective observational study with 162 women enrolled during the first-trimester ultrasound, recording demographic, biochemical and ultrasound data, including the pulsatility index of uterine arteries (UTPI). Hemodynamic indices were obtained using the USCOMAs for the correlation between biochemical and ultrasound parameters, pregnancy-associated plasma protein A (PAPP-A) relates inversely with the mean UTPI (Our study confirmed the correlation between PAPP-A and placental function, expressed through the determination of the pulsatility index of the uterine arteries. Moreover, we found a clear correlation between biochemical markers, placental function and maternal hemodynamics, since the first trimester of pregnancy. The inclusion of maternal hemodynamic evaluation could be useful in the screening protocols of preeclampsia. If we combine the onset of hypertensive disorders and of fetal growth restriction, the most predictive parameter is indexed total vascular resistances.

Objectives To evaluate the strength of association between maternal and pregnancy characteristics and the risk of adverse perinatal outcomes in pregnancies with laboratory confirmed COVID-19. Methods Secondary analysis of a multinational, cohort study on all consecutive pregnant women with laboratory-confirmed COVID-19 from February 1, 2020 to April 30, 2020 from 73 centers from 22 different countries. A confirmed case of COVID-19 was defined as a positive result on real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay of nasal and pharyngeal swab specimens. The primary outcome was a composite adverse fetal outcome, defined as the presence of either abortion (pregnancy loss before 22 weeks of gestations), stillbirth (intrauterine fetal death after 22 weeks of gestation), neonatal death (death of a live-born infant within the first 28 days of life), and perinatal death (either stillbirth or neonatal death). Logistic regression analysis was performed to evaluate parameters independently associated with the primary outcome. Logistic regression was reported as odds ratio (OR) with 95% confidence interval (CI). Results Mean gestational age at diagnosis was 30.6±9.5 weeks, with 8.0% of women being diagnosed in the first, 22.2% in the second and 69.8% in the third trimester of pregnancy. There were six miscarriage (2.3%), six intrauterine device (IUD) (2.3) and 5 (2.0%) neonatal deaths, with an overall rate of perinatal death of 4.2% (11/265), thus resulting into 17 cases experiencing and 226 not experiencing composite adverse fetal outcome. Neither stillbirths nor neonatal deaths had congenital anomalies found at antenatal or postnatal evaluation. Furthermore, none of the cases experiencing IUD had signs of impending demise at arterial or venous Doppler. Neonatal deaths were all considered as prematurity-related adverse events. Of the 250 live-born neonates, one (0.4%) was found positive at RT-PCR pharyngeal swabs performed after delivery. The mother was tested positive during the third trimester of pregnancy. The newborn was asymptomatic and had negative RT-PCR test after 14 days of life. At logistic regression analysis, gestational age at diagnosis (OR: 0.85, 95% CI 0.8–0.9 per week increase; p Conclusions Early gestational age at infection, maternal ventilatory supports and low birthweight are the main determinants of adverse perinatal outcomes in fetuses with maternal COVID-19 infection. Conversely, the risk of vertical transmission seems negligible.

Background: Occiput posterior position is the most frequent cephalic malposition, and its persistence at delivery is associated with a higher risk of maternal and perinatal morbidity. Diagnosis and management of occiput posterior position remain a clinical challenge. This is partly caused by our inability to predict fetuses who will spontaneously rotate into occiput anterior from those who will have persistent occiput posterior position. The angle of progression, measured with transperineal ultrasound, represents a reliable tool for the evaluation of fetal head station during labor. The relationship between the persistence of occiput posterior position and fetal head station in the second stage of labor has not been previously assessed. Objective: This study aimed to evaluate the role of fetal head station, as measured by the angle of progression, in the prediction of persistent occiput posterior position and the mode of delivery in the second stage of labor. Study Design: We recruited a nonconsecutive series of women with posterior occiput position diagnosed by transabdominal ultrasound in the second stage of labor. For each woman, a transperineal ultrasound was performed to measure the angle of progression at rest. We compared the angle of progression between women who delivered fetuses in occiput anterior position and those with persistent occiput posterior position at delivery. Receiver operating characteristics curves were performed to evaluate the accuracy of the angle of progression in the prediction of persistent occiput posterior position. Finally, we performed a multivariate logistic regression to determine independent predictors of persistent occiput posterior position. Results: Overall, 63 women were included in the analysis. Among these, 39 women (62%) delivered in occiput anterior position, whereas 24 (38%) delivered in occiput posterior position (persistent occiput posterior position). The angle of progression was significantly narrower in the persistent occiput posterior position group than in women who delivered fetuses in occiput anterior position (118.3°±12.2° vs 127.5°±10.5°; P=.003). The area under the receiver operating characteristics curve was 0.731 (95% confidence interval, 0.594–0.869) with an estimated best cutoff range of 121.5° (sensitivity of 72% and specificity of 67%). On logistic regression analysis, the angle of progression was found to be independently associated with persistence of occiput posterior position (odds ratio, 0.942; 95% confidence interval, 0.889–0.998; P=.04). Finally, women who underwent cesarean delivery had significantly narrower angle of progression than women who had a vaginal delivery (113.5°±8.1 vs 128.0°±10.7; P

The mechanism of labor requires positional changes of the presenting fetal part in the maternal pelvis. One of the cardinal movements of labor is fetal head descent in the birth canal. Fetal head descent leads to its engagement in the birth canal. This is usually defined when the largest fetal head diameter (biparietal diameter) passes through the pelvic inlet [1]. Since this is impossible to diagnose directly, many indirect signs, usually by digital examination, are used as a proxy to engagement. Assessing fetal head descent is of utmost importance in labor.

Objective: To assess the feasibility and reliability of transperineal ultrasound in the assessment of fetal breech descent in the birth canal, by measuring the breech progression angle (BPA). Methods: Women with a singleton pregnancy with the fetus in breech presentation between 34 and 41 weeks' gestation were recruited. Transperineal ultrasound images were acquired in the midsagittal view for each woman, twice by one operator and once by another. Each operator measured the BPA after anonymization of the transperineal ultrasound images. BPA was defined as the angle between a line running along the long axis of the pubic symphysis and another line extending from the most inferior portion of the pubic symphysis tangentially to the lowest recognizable fetal part in the maternal pelvis. Each operator was blinded to all other measurements performed for each woman. Intra- and interobserver reproducibility of BPA measurement was evaluated using the intraclass correlation coefficient (ICC). To investigate the presence of any bias, intra- and interobserver agreement was also analyzed using Bland–Altman analysis. Student's t-test and Levene's W0 test were used to investigate whether a number of different clinical factors had an effect on systematic differences and homogeneity, respectively, between BPA measurements. Results: Overall, 44 women were included in the analysis. BPA was measured successfully by both operators on all images. Both intra- and interobserver agreement analyses showed excellent reproducibility in BPA measurement, with ICCs of 0.88 (95% CI, 0.80–0.93) and 0.83 (95% CI, 0.71–0.90), respectively. The mean difference between measurements was 0.4° (95% CI, −1.4 to 2.2°) for intraobserver repeatability and −0.4° (95% CI, −2.6 to 1.8°) for interobserver repeatability. The upper limits of agreement were 12.0° (95% CI, 8.9–15.1°) and 13.6° (95% CI, 9.9–17.3°) for intra- and interobserver repeatability, respectively. The lower limits of agreement were −11.2° (95% CI, −14.3 to −8.1°) and −14.4° (95% CI, −18.2 to −10.7°) for intra- and interobserver repeatability, respectively. No systematic difference between BPA measurements was found on either intra- or interobserver agreement analysis. None of the clinical factors examined (maternal body mass index, maternal age, gestational age at the ultrasound scan and parity) showed a statistically significant effect on intra- or interobserver reliability. Conclusions: BPA represents a new feasible and highly reproducible measurement for the evaluation of fetal breech descent in the birth canal. Future studies assessing its usefulness in the prediction of successful external cephalic version and breech vaginal delivery are needed. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

WOS:000613461600006 PubMed ID: 32926494 Objectives To evaluate the maternal and perinatal outcomes of pregnancies affected by SARS-CoV-2 infection. Methods This was a multinational retrospective cohort study including women with a singleton pregnancy and laboratory-confirmed SARS-CoV-2 infection, conducted in 72 centers in 22 different countries in Europe, the USA, South America, Asia and Australia, between 1 February 2020 and 30 April 2020. Confirmed SARS-CoV-2 infection was defined as a positive result on real-time reverse-transcription polymerase chain reaction (RT-PCR) assay of nasopharyngeal swab specimens. The primary outcome was a composite measure of maternal mortality and morbidity, including admission to the intensive care unit (ICU), use of mechanical ventilation and death. Results In total, 388 women with a singleton pregnancy tested positive for SARS-CoV-2 on RT-PCR of a nasopharyngeal swab and were included in the study. Composite adverse maternal outcome was observed in 47/388 (12.1%) women; 43 (11.1%) women were admitted to the ICU, 36 (9.3%) required mechanical ventilation and three (0.8%) died. Of the 388 women included in the study, 122 (31.4%) were still pregnant at the time of data analysis. Among the other 266 women, six (19.4% of the 31 women with first-trimester infection) had miscarriage, three (1.1%) had termination of pregnancy, six (2.3%) had stillbirth and 251 (94.4%) delivered a liveborn infant. The rate of preterm birth before 37 weeks' gestation was 26.3% (70/266). Of the 251 liveborn infants, 69/251(27.5%) were admitted to the neonatal ICU, and there were five (2.0%) neonatal deaths. The overall rate of perinatal death was 4.1% (11/266). Only one (1/251, 0.4%) infant, born to a mother who tested positive during the third trimester, was found to be positive for SARS-CoV-2 on RT-PCR. Conclusions SARS-CoV-2 infection in pregnant women is associated with a 0.8% rate of maternal mortality, but an 11.1% rate of admission to the ICU. The risk of vertical transmission seems to be negligible. (C) 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Sir, We read with interest the paper written by Hasegawa and colleagues analyzing the obstetric factors associated with uterine rupture [1]. The authors found that fundal pressure in the second stage (Kristeller’s maneuver) was applied in approximately one every four women with uterine rupture, and in one every three women with rup- ture on unscarred uterus. Kristeller’s maneuver remains one of the most contro- versial and underreported obstetric practices [2,3]. Very little evidence exist on the benefits and safety of the Kristeller’s maneuver. Recently, the World Health Organization issued a document stating fundal pressure in the second stage is not recommended [4]. The authors developing the document declared to have “serious con- cerns about the potential for harm to mother and baby with this procedure” [4]. In addition to these concerns, one of the main problems in research performed on the maneuver is that it is frequently unreported. In a recent study published by our group on Kristeller’s maneuver, we found that in 90% of cases it is not reported in the women’s file [5]. We believe that under- or the total absence of reporting of the maneuver is as challenging and risky as the maneuver itself. Over the past 5 years, in our University Hospital we aimed at reducing the rate of Kristeller’s maneuver and to increase its reporting using a systematic approach. This approach included conducting research to investigate the risks of the maneuver on the pelvic floor, increasing caregivers’ awareness on the con- cerns and evidence regarding the maneuver, and audit- ing the incidence of the application of the maneuver and the rate of its reporting over time.

Fundal pressure in the second stage of labor, also known as Kristeller maneuver, gets the name from its creator, Samuel Kristeller, who was born in Poland in 1820 and died in Berlin in 1900 [1] (Fig. 54.1). In 1867, Kristeller published a study in which he described an obstetric maneuver that could help women in the second stage of labor to push out the fetus by pressing many times the uterus for a short time toward the horizontal axis of the birth canal [1]. In the original procedure, the patient laid in supine position, and the operator placed his hands on the fundus and sides of the uterus. Combining downward pressure with the palms on the fundus with lateral pressure by means of the fingers, the uterus was brought into correct relation with the pelvic axis, and the fetus was forced down into the canal of birth [2].

Vaginal birth is the major cause of pelvic floor damage. The development of transperineal ultrasound has improved our understanding of the relationship between vaginal birth and pelvic floor dysfunction. The female pelvic floor dimensions and function can be assessed reliably in pregnant women. Maternal pushing associated with pelvic floor muscle relaxation is the central requirement of vaginal birth. Many studies have evaluated the role of the pelvic floor on labor outcomes. Smaller levator hiatal dimensions and incomplete or absent levator ani muscle relaxation seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Here, we presented an overview of the current knowledge of the correlation between female pelvic floor dimension and function, as assessed by transperineal ultrasound, and labor outcome.

Obstetric anal sphincter injuries (OASIS) are one of the most common causes of anal incontinence (AI) in women of reproductive age and can have a significant impact on quality of life. However, many women do not report symptoms to their physicians because of embarrassment and shame. Therefore, prevention and diagnosis of the tear is essential. Diagnostic strategies have evolved considerably in recent years, with an increase in prevalence of OASIS as a consequence. The use of 3D endoanal (3D-EAUS) and 4D transperineal ultrasound (4D-TPUS), in addition to standard clinical examination have enhanced the detection of OASIS. Once identified, adequate repair by a skilled practitioner and optimal postpartum management should be ensured in order to reduce the risk of anal incontinence. This review presents the available evidence on strategies for prevention, diagnosis, and management of OASIS.

Background Induction of labor is one of the most common interventions in modern obstetrics, and its frequency is expected to continue to increase. There is inconsistency as to how failed induction of labor is defined; however, the majority of studies define success as the achievement of vaginal delivery. Induction of labor in nulliparous women poses an additional challenge with a 15% to 20% incidence of failure, ending in emergency operative deliveries. The Bishop score has been traditionally used before decisions for induction of labor. Nonetheless, it is subjective and prone to marked interobserver variation. Several studies have been conducted to find alternative predictors, yet a reliable, objective method still remains to be introduced and validated. Hence, there is still a need for the development of new predictive tools to facilitate informed decision making, optimization of resources, and minimization of potential risks of failure. Furthermore, a peripartum transperineal ultrasound scan has been proven to provide objective, noninvasive assessment of labor. Objective This study aimed to assess the feasibility of developing and validating an objective and reproducible model for the prediction of cesarean delivery for failure to progress as an outcome of labor induction in term singleton pregnancies. Study Design This was a prospective observational cohort study conducted in Cairo University Hospitals and University of Bologna Hospitals between November 2018 and November 2019. We recruited 382 primigravidae with singleton term pregnancies in cephalic presentation. All patients had baseline Bishop scoring together with various transabdominal and transperineal ultrasound assessments of the fetus, maternal cervix, and pelvic floor. The managing obstetricians were blinded to the ultrasound scan findings. The method and indication of induction of labor, the total duration of stages of labor, mode of birth, and neonatal outcomes were all recorded. Women who had operative delivery for fetal distress or indications other than failure to progress in labor were excluded from the final analysis, leaving a total of 344 participants who were randomly divided into 243 and 101 pregnancies that constituted the model development and cross-validation groups, respectively. Results It was possible to perform transabdominal and transperineal scans and assess all the required parameters on all study participants. Univariate and multivariate analyses were used for selection of potential predictors and model fitting. The independent predictive variables for cesarean delivery included maternal age (odds ratio, 1.12; P=.003), cervical length (odds ratio, 1.08; P=.04), angle of progression at rest (odds ratio, 0.9; P=.001), and occiput posterior position (odds ratio, 5.7; P=.006). We tested the performance of the prediction model on our cross-validation group. The calculated areas under the curve for the ability of the model to predict cesarean delivery were 0.7969 (95% confidence interval, 0.71–0.87) and 0.88 (95% confidence interval, 0.79–0.97) for the developed and validated models, respectively. Conclusion Maternal age and sonographic fetal occiput position, angle of progression at rest, and cervical length before labor induction are very good predictors of induction outcome in nulliparous women at term.

Aim The aim of the present study was to evaluate the correlation between the proportional change of anteroposterior diameter (APD) of levator hiatus from rest to maximum Valsalva maneuver in nulliparous women at term and labor outcome. Methods We prospectively recruited nulliparous women at term before the onset of labor. Women underwent a two-dimensional transperineal ultrasound, measuring the APD of the levator hiatus at rest and under maximum Valsalva's maneuver. APD change from rest to maximum Valsalva was described both in terms of absolute figures and proportional change. Correlation of APD change with the mode of delivery and with labor durations was assessed. Results Overall, 486 women were included in the analysis. No significant association between change in APD and the mode of delivery. We found a significant negative correlation between change of APD from rest to Valsalva and the duration of active second stage both in terms of absolute change (Pearson's r = -0.138, P = .009) and in terms of proportional change (Pearson's r = -0.154, P = .004). Survival outcomes based on Cox-regression model showed that APD was independently associated with the duration of active second stage of labor after adjusting for epidural analgesia, maternal age and body mass index (hazard ratio, 1.008; 95% confidence interval, 1.001-1.016; P = .04) CONCLUSION: Women with higher increase of the anteroposterior diameter of the levator hiatus from rest to Valsalva have a shorter active second stage of labor.