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To evaluate the role of the cervical sliding sign (CSS) in the prediction of the outcome of induction of labor (IOL).Two-center prospective observational cohort study involving a non-consecutive series of uncomplicated singleton term pregnancies, planned for IOL, with a fetus in cephalic presentation and unfavorable cervix as defined by a Bishop score ≤ 6. The Bishop score was evaluated by transvaginal digital examination and the cervical length and CSS by transvaginal ultrasound. The presence of CSS was defined as the sliding of the anterior cervical lip on the posterior one under gentle pressure of the transvaginal probe. The primary outcome of the study was successful vaginal delivery within 24 h. The secondary outcome was the induction-to-active-labor time. The interobserver agreement for the CSS was also evaluated.Over a period of 12 months, 179 women were included. The CSS was found in 86 (48.0 %) patients and was associated with an increased likelihood of vaginal delivery within 24 h (60/86 or 69.8 % vs 27/93 or 29.0 %, P 0.001) and a shorter induction-to-active-labor time (954 ± 618 min vs 1416 ± 660 min, P 0.001). Multivariable regression analysis showed that the CSS was an independent predictor of vaginal delivery within 24 h (aOR 5.37, 95 % CI 2.26-12.75) and shorter induction-to-active-labor time interval (HR 1.81, 95 % CI 1.19-2.74). The interobserver variability based on intraclass correlation coefficient for the CSS was excellent (ICC = 0.90).In women undergoing IOL with an unfavorable cervix, the CSS is associated with a higher frequency of vaginal delivery within 24 h and a shorter induction-to-active-labor time.

These practice guidelines follow the mission of the World Association of Perinatal Medicine in collaboration with the Perinatal Medicine Foundation, bringing together groups and individuals throughout the world, with the goal of improving the ultrasound assessment of the fetal Central Nervous System (CNS) anatomy. In fact, this document provides further guidance for healthcare practitioners for the evaluation of the fetal CNS during the mid-trimester ultrasound scan with the aim to increase the ability in evaluating normal fetal anatomy. Therefore, it is not intended to establish a legal standard of care. This document is based on consensus among perinatal experts throughout the world, and serves as a guideline for use in clinical practice.

Most brain abnormalities are present in the first trimester, but only a few are detected so early in gestation. According to current recommendations for first-trimester ultrasound, the fetal head structures that should be visualized are limited to the cranial bones, the midline falx and the choroid-plexus-filled ventricles. Using this basic approach, almost all cases of acrania, alobar holoprosencephaly and cephalocele are detected. However, the majority of other fetal brain abnormalities remain undiagnosed until the midtrimester. Such anomalies would be potentially detectable if the sonographic study were to be extended to include additional anatomic details not currently included in existing guidelines. The aim of this review article is to describe how best to assess the normal fetal brain by first-trimester expert multiplanar neurosonography and to demonstrate the early sonographic findings that characterize some major fetal brain abnormalities. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

It has been happened a significant increase of critically severe pneumonia cases in northern Italy by the end of February 2020 with consequent overcrowding of intensive care units (ICU). Due to the COVID-19 fast outbreak, a strict quarantine was imposed in the areas with the higher number of affected cases. The WHO declared COVID-19 a pandemic, with over 50 countries on the 10th of March. By the 10th of March Italy was the second most affected country after China, with more than nine thousand confirmed cases and more than 460 deaths, becoming the most affected in April.

Objectives The early identification of women with preterm premature rupture of membranes (p-PROM) who are at higher risk of imminent delivery remains challenging. The aim of our study was to evaluate if an increased echogenicity of the amniotic membranes may represent a sonographic marker of impending delivery in women with p-PROM. Methods This was a prospective study including women with singleton pregnancies and diagnosis of p-PROM between 22 and 37 gestational weeks. A sonographic examination was performed within 24 h from the hospital admission and the appearance of the amniotic membranes close to the internal os was specifically evaluated. The membranes were defined as hyperechoic when their echogenicity was similar to that of the fetal bones or normoechoic in the other cases. The primary aim of the study was to compare the admission to spontaneous onset of labor interval and the pregnancy outcome between the cases of p-PROM with and without hyperechoic membranes. Results Overall, 45 women fulfilled the inclusion criteria with similar characteristics at admission. In women with hyperechoic membranes, the admission to spontaneous onset of labor interval was significantly shorter (11.5 [5.3–25.0] vs. 3.0 [1.5–9.0] p=0.04) compared to women with normo-echoic membranes. At binomial logistic regression after adjustment for GA at hospital admission, the presence of hyperechoic membranes was found as the only independent predictor of spontaneous onset of labor ≤72 h (aOR: 6.1; 95% CI: 1.0–36.9) Conclusions The presence of hyperechoic membranes is associated with a 6-fold higher incidence of spontaneous onset of labor within 72 h independently from the gestational age at p-PROM.

OBJECTIVE To evaluate the performance of a new ultrasound technique for the automatic assessment of the change in head-perineum distance (delta-HPD) and angle of progression (delta-AoP) during the active phase of the second stage of labor. METHODS This was a prospective observational cohort study including singleton term pregnancies with fetuses in cephalic presentation during the active phase of the second stage of labor. In each patient, two videoclips of 10 s each were acquired transperineally, one in the axial and one in the sagittal plane, between rest and the acme of an expulsive effort, in order to measure HPD and AoP, respectively. The videoclips were processed offline and the difference between the acme of the pushing effort and rest in HPD (delta-HPD) and AoP (delta-AoP) was calculated, first manually by an experienced sonographer and then using a new automatic technique. The reliability of the automatic algorithm was evaluated by comparing the automatic measurements with those obtained manually, which was considered as the reference gold standard. RESULTS Overall, 27 women were included. A significant correlation was observed between the measurements obtained by the automatic and the manual methods for both delta-HPD (intraclass correlation coefficient (ICC) = 0.97) and delta-AoP (ICC = 0.99). The high accuracy provided by the automatic algorithm was confirmed by the high values of the coefficient of determination (r2 = 0.98 for both delta-HPD and delta-AoP) and the low residual errors (root mean square error = 1.2 mm for delta-HPD and 1.5° for delta-AoP). A Bland-Altman analysis showed a mean difference of 0.52 mm (limits of agreement, -1.58 to 2.62 mm) for delta-HPD (P = 0.034) and 0.35° (limits of agreement, -2.54 to 3.09°) for delta-AoP (P = 0.39) between the manual and automatic measurements. CONCLUSIONS The automatic assessment of delta-AoP and delta-HPD during maternal pushing efforts is feasible. The automatic measurement of delta-AoP appears to be reliable when compared with the gold standard manual measurement by an experienced operator. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

To evaluate the accuracy and reliability of a new ultrasound technique for the automatic assessment of the head-perineum distance (HPD) during childbirth.HPD was measured on a total of 40 acquisition sessions in 30 laboring women both automatically by an innovative algorithm and manually by trained sonographers, assumed as gold standard.A significant correlation was found between manual and automatic measurements (Intra-CC = 0.994). High values of the coefficient of determination (The automatic algorithm for the assessment of the HPD represents a reliable technique.

Objectives To compare the sonographic signs of spina bifida obtained on axial and sagittal views of the fetal head between 11 and 13+6 weeks of gestation. Methods This was a retrospective study including 27 cases of spina bifida and 1003 randomly selected controls. Indirect markers of spina bifida were evaluated on stored ultrasound images. Intracranial translucency (IT), ratio between the brainstem and the brainstem-occipital bone distance (BS/BSOB), and maxillo-occipital (MO) line were assessed on sagittal view, whereas biparietal diameter (BPD), BPD to abdominal circumference ratio (BPD/AC), and aqueduct to occipital bone (aqueduct of Sylvius [AoS]) distance were measured on the axial plane. Reference ranges were developed, and cases of spina bifida were examined in relation to the reference range. Results On the sagittal view, detection rates for IT below the fifth percentile, BS/BSOB above the 95th percentile, and an abnormal MO line were 52.3%, 96.3%, and 96.3%, respectively. On the axial view, detection rates for BPD, BPD/AC, and AoS below the fifth percentile were 66.7%, 70.4%, and 77.8%, respectively. Conclusion The MO line and the BS/BSOB ratio appear to be the best indirect ultrasound markers of spina bifida and can be easily obtained during the routine first-trimester scan.

Introduction The obstetric conjugate represents the shortest anteroposterior diameter of the birth canal and it reflects the capacity of the pelvic inlet to allow the passage and the engagement of the fetal head. The antepartum evaluation of this parameter may be attempted at digital examination to predict the risk of cephalopelvic disproportion, but the accuracy of clinical pelvimetry is notoriously poor. The aim of our study was to describe the sonographic measurement of the obstetric conjugate at transabdominal 2D-ultrasound and to assess its reproducibility. Material and methods This is a prospective cohort study conducted at a tertiary University hospital. A non-consecutive series of pregnant women with uncomplicated singleton pregnancies attending the antenatal clinic for routine booking from 34 weeks of gestation onward were included. The ultrasound probe was longitudinally placed above the level of the symphysis and the interpubic fibrocartilaginous disk was visualized. Then the promontory was identified as the most prominent segment of the sacral vertebral column. The obstetric conjugate was measured as the distance between the inner edge of the interpubic disk and the promontory. The inter- and intraobserver repeatability of this measurement was calculated using the intraclass correlation coefficient (ICC) and the Bland-Altman method. Results In all, 119 women were considered eligible for the study; of these, 111/119 (93.3%) women were included in the analysis with a median gestational age of 36.0 (35.0-37.0) weeks. The mean obstetric conjugate measurement was 11.4 ± 0.93 mm for the first operator and 11.4 ± 0.91 mm for the second operator. The overall interobserver ICC was 0.95 (95% [confidence interval] CI 0.92-0.96) and the overall intraobserver ICC was 0.97 (95% CI 0.96-0.98). Limits of agreement ranged from -0.84 to 0.80 for interobserver measures and from -0.64 to 0.62 for intraobserver measures. The degree of reliability was also analyzed for women with a body mass index ≥30 and for women with a gestational age ≥37 weeks. The inter- and intraobserver ICCs were respectively 0.97 (95% CI 0.90-0.98) and 0.98 (0.95-0.99) in the former group and 0.96 (95% CI 0.93-0.98) and 0.97 (95% CI 0.95-0.98) in the latter group. Conclusions Our study demonstrated that among pregnant women at term gestation, sonographic measurement of the obstetric conjugate is feasible and reproducible.

OBJECTIVE The "Fetal Brain Tutor 4us" (FBTApp) is a recently developed application for interactive multiplanar navigation through the normal fetal brain. The purpose of this work was to assess its impact on normal anatomy learning. METHODS A multiple-choice quiz (MCQ) was administered to first-year resident doctors in Obstetrics and Gynecology in two separate sessions, before and 2 weeks after downloading the FBTApp. For each MCQ, the junior trainee was asked to use one out of five items to label a specific cerebral structure on an ultrasound image of a normal midtrimester fetal brain. Six sonographic images of the fetal brain on each of the three scanning planes (axial, sagittal, and coronal) were shown to the participants at either session. The results of the two sessions were analysed and compared. RESULTS Overall, 216 questions were administered to the trainees in the 2-week study, 108 before and 108 after the use of the FBTApp. From the first to the second sessions, a significant increase of correct answers was noted (from 47/108 or 43% to 77/108 or 71%, P

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.

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.

Objective: The objective of this study was to assess the position of the conus medullaris (CM) at the first trimester 3D ultrasound in a cohort of structurally normal fetuses. Methods: This was a multicenter prospective study involving a consecutive series of structurally normal fetuses between 11 and 13 weeks of gestation (CRL between 45 and 84 mm). All fetuses were submitted to 3D transvaginal ultrasound using a sagittal view of the spine as the starting plane of acquisition. At offline analysis, the position of the CM was evaluated by 2 independent operators with a quantitative and a qualitative method: (1) the distance between the most caudal part of the CM and the distal end of the coccyx (CMCd) was measured; (2) a line perpendicular to the fetal spine joining the tip of the CM to the anterior abdominal wall was traced to determine the level of this line in relation to the umbilical cord insertion (conus to abdomen line, CAL). Interobserver agreement for the CCMd was evaluated. Linear regression analysis was used to determine the association between the CMCd and CRL, and a normal range was computed based on the best-fit model. The absence of congenital anomalies was confirmed in all cases after birth. Results: In the study period between December 2019 and March 2020, 143 fetuses were recruited. In 130 fetuses (90.9%), the visualization of the CM was feasible. The mean value of the CMCd was 1.09 ± 0.16 cm. The 95% limits of agreement for the interobserver variability in measurement of the CMCd were 0.24 and 0.26 cm. The interobserver variability based on the intra-class correlation coefficient (ICC) for the CCMd was good (ICC = 0.81). We found a positive linear relationship between the CCMd and CRL. In all these fetuses, the CAL encountered the abdominal wall at or above the level of the cord insertion. Conclusion: In normal fetuses, the assessment of the CM position is feasible at the first trimester 3D ultrasound with a good interobserver agreement. The CM level was never found below the fetal umbilical cord insertion, while the CMCd was noted to increase according to the gestational age, confirming the “ascension” of the CM during fetal life.

Objective To evaluate the usefulness of a Doppler technology highly sensitive for low-velocity flow in the antenatal imaging of the torcular herophili (TH) in the second trimester of pregnancy. Design Prospective study. Setting Referral Fetal Medicine Unit. Population Non-consecutive series of singleton pregnancies submitted to antenatal neurosonogram between 20 and 28 weeks of gestation. Methods A midsagittal section of the fetal brain was obtained by insonating through the anterior fontanelle, then the MV-Flow™ and LumiFlow™ presets were selected to visualise the TH as the posterior confluence of the superior sagittal sinus and the straight sinus. Main outcome measures Evaluation of the anatomic relationship of the TH with the 'transpalatal line' joining the upper bony palate to the fetal skull. Results A total of 99 pregnant women were recruited, including one fetus with open spina bifida, one with Dandy-Walker malformation (DWM) and two with Blake's pouch cysts. In normal fetuses, the TH appeared to lie on or just below the 'transpalatal line'. In the cases of Blake's pouch cyst, the position of the TH appeared normal if compared with controls, whereas in DWM a supra-elevated position of the TH in respect of the transpalatal line was demonstrated. Finally, in the fetus with Chiari II malformation the TH was identified below the 'transpalatal plane'. Conclusions Prenatal ultrasound visualisation of the TH by means of newly developed Doppler technologies characterised by high sensitivity for low-velocity flow is feasible and allows the indirect evaluation of the insertion of cerebellar tentorium in the second trimester. Tweetable abstract Prenatal imaging of the torcular herophili using a Doppler technology highly sensitive for low-velocity flow.

To evaluate the diagnostic accuracy of a new ultrasound sign, intracervical lakes (ICL), in predicting the presence of placenta accreta spectrum (PAS) disorder and delivery outcome in patients with placenta previa or low-lying placenta.This was a retrospective multicenter study of women with placenta previa or low-lying placenta at ≥ 26 weeks' gestation, who were referred to three Italian tertiary units from January 2015 to September 2018. The presence of ICL, defined as tortuous anechoic spaces within the cervix which appeared to be hypervascular on color Doppler, was evaluated on ultrasound images obtained at the time of referral. The primary aim was to explore the diagnostic accuracy of ICL in detecting the presence and depth of PAS disorder. The secondary aim was to explore the accuracy of this sign in predicting total estimated blood loss, antepartum bleeding, major postpartum hemorrhage at the time of Cesarean section and need for Cesarean hysterectomy. The diagnostic accuracy of ICL in combination with typical sonographic signs of PAS disorder, was assessed by computing summary estimates of sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios and diagnostic odds ratios (DOR).A total of 332 women with placenta previa or low-lying placenta were included in the analysis, with a median maternal age of 33.0 (interquartile range, 29.0-37.0) years. ICL were noted in 15.1% of patients. On logistic regression analysis, the presence of ICL was associated independently with major postpartum hemorrhage (odds ratio (OR), 3.3 (95% CI, 1.6-6.5); P 0.001), Cesarean hysterectomy (OR, 7.0 (95% CI, 2.1-23.9); P 0.001) and placenta percreta (OR, 2.8 (95% CI, 1.3-5.8); P ≤ 0.01), but not with the presence of any PAS disorder (OR, 1.6 (95% CI, 0.7-3.5); P = 0.2). Compared with the group of patients without ultrasound signs of PAS disorder, the presence of at least one typical sonographic sign of PAS disorder in combination with ICL had a DOR of 217.2 (95% CI, 27.7-1703.4; P 0.001) for placenta percreta and of 687.4 (95% CI, 121.4-3893.0; P 0.001) for Cesarean hysterectomy.ICL may represent a marker of deep villus invasion in women with suspected PAS disorder on antenatal sonography and anticipate the occurrence of severe maternal morbidity. Copyright © 2019 ISUOG. Published by John WileySons Ltd.Los espacios intracervicales como marcador ecográfico de trastornos del espectro de la placenta acreta en pacientes con placenta previa o placenta baja OBJETIVO: Evaluar la precisión del diagnóstico de un nuevo indicio de ultrasonido, los espacios intracervicales (EIC), para predecir la presencia de trastornos del espectro de la placenta acreta (EPA) y el resultado del parto en pacientes con placenta previa o placenta baja. MÉTODOS: Este fue un estudio multicéntrico retrospectivo de mujeres con placenta previa o placenta baja a ≥ 26 semanas de gestación, que se remitieron a tres unidades terciarias italianas desde enero de 2015 a septiembre de 2018. Se evaluó la presencia de EIC, definida como espacios anecoicos tortuosos dentro del cuello uterino que parecían ser hipervasculares en el Doppler a color, en imágenes de ecografías obtenidas en el momento de la remisión. El objetivo principal fue estudiar la precisión del diagnóstico mediante EIC en la detección de la presencia y la profundidad de un trastorno del EPA. El objetivo secundario fue explorar la precisión de este indicador para predecir la pérdida total estimada de sangre, la hemorragia antes del parto, la hemorragia puerperal importante en el momento de la cesárea y la necesidad de una histerectomía por cesárea. La precisión diagnóstica de EIC, en combinación con los indicios ecográficos típicos de los trastornos del EPA, se evaluó calculando estimaciones estadísticas descriptivas de la sensibilidad, la especificidad, los valores predictivos positivos y negativos, los cocientes de verosimilitud positivos y negativos y las razones de momios del diagnóstico (RMD). RESULTADOS: En el análisis se incluyó un total de 332 mujeres con placenta previa o placenta baja, con una mediana de la edad materna de 33,0 años (rango intercuartil, 29,0-37,0). Se observaron EIC en el 15,1% de las pacientes. En el análisis de regresión logística, la presencia de EIC se asoció de forma independiente con la hemorragia puerperal grave (razón de momios (RM), 3,3 (IC 95%, 1,6-6,5); P0,001), la histerectomía por cesárea (RM, 7,0 (IC 95%, 2,1-23,9); P0,001) y la placenta percreta (RM, 2,8 (IC 95%, 1,3-5,8); P≤0,01), pero no con la presencia de ningún trastorno del EPA (RM, 1,6 (IC 95%, 0,7-3,5); P=0,2). En comparación con el grupo de pacientes sin indicios de ultrasonido de algún trastorno del EPA, la presencia de al menos un indicio ecográfico típico de trastorno del EPA en combinación con EIC tuvo una RMD de 217,2 (IC 95%, 27,7-1703,4; P0,001) para la placenta percreta y de 687,4 (IC 95%, 121,4-3893,0; P0,001) para la histerectomía por cesárea. CONCLUSIÓN: Los EIC pueden representar un marcador de invasión profunda de las vellosidades en mujeres con sospecha de algún trastorno del EPA basado en la ecografía prenatal y anticipar la presencia de una morbilidad materna grave.作为胎盘增生频谱紊乱超声征象的前置胎盘或低位胎盘患者宫颈内血池 目标: 评估一种新型超声征象宫颈内血池(ICL)在预测前置胎盘或低位胎盘患者胎盘增生频谱(PAS)紊乱和分娩结果中的诊断准确性。 方法: 这是一项针对2015年1月至2018年9月间，转诊至意大利三家三级医院的妊娠满26周前置胎盘或低位胎盘女性患者的回顾性多中心研究。评估转诊时获得的超声图像确定是否存在ICL，即彩色多普勒超声检测显示宫颈内出现血管增生的迂曲无回声间隙。首要目的是研究ICL在检测PAS紊乱及其深度时的诊断准确性。次要目的是研究该征象在估计剖宫产预计总失血量、产前出血、产后大出血，以及是否需要进行剖宫产子宫切除术时的准确性。计算敏感性、特异性、阳性和阴性预测值、阳性和阴性似然比和诊断比值比(DOR)汇总估算，以此评估ICL结合典型PAS紊乱超声征象的诊断准确性。 结果: 总共分析了332名前置胎盘或低位胎盘女性患者，孕产妇年龄中位数为33.0岁(四分位间距29.0 - 37.0)。发现15.1%的病患出现ICL。逻辑回归分析表明ICL与产后大出血(比值比OR 3.3 (95% CI, 1.6-6.5); P0.001))、剖宫产子宫切除术(OR, 7.0 (95% CI, 2.1-23.9); P0.001)以及植入胎盘(OR, 2.8 (95% CI, 1.3-5.8); P≤0.01)独立相关，但与任何PAS紊乱无关(OR, 1.6 (95% CI, 0.7-3.5); P=0.2)。对照未出现PAS紊乱超声征象的病患组，(植入胎盘中)至少一种典型的PAS紊乱超声征象结合ICL的DOR为217.2 (95% CI, 27.7-1703.4; P0.001)，剖宫产子宫切除术为687.4 (95% CI, 121.4-3893.0; P0.001)。 结论: ICL可能是一种产前超声检测中显示疑似PAS紊乱的孕产妇深绒毛浸润标志物，可以预测重度孕产妇疾病发病率。.

Introduction Fetal overgrowth is an acknowledged risk factor for abnormal labor course and maternal and perinatal complications. The objective of this study was to evaluate whether the use of antenatal ultrasound-based customized fetal growth charts in fetuses at risk for large-for-gestational age (LGA) allows a better identification of cases undergoing caesarean section due to intrapartum dystocia. Material and methods An observational study involving four Italian tertiary centers was carried out. Women referred to a dedicated antenatal clinic between 35 and 38 weeks due to an increased risk of having an LGA fetus at birth were prospectively selected for the study purpose. The fetal measurements obtained and used for the estimation of the fetal size were biparietal diameter, head circumference, abdominal circumference and femur length, were prospectively collected. LGA fetuses were defined by estimated fetal weight (EFW) >95th centile either using the standard charts implemented by the World Health Organization (WHO) or the customized fetal growth charts previously published by our group. Patients scheduled for elective caesarean section (CS) or for elective induction for suspected fetal macrosomia or submitted to CS or vacuum extraction (VE) purely due to suspected intrapartum distress were excluded. The incidence of CS due to labor dystocia was compared between fetuses with EFW >95th centile according WHO or customized antenatal growth charts. Results Overall, 814 women were eligible, however 562 were considered for the data analysis following the evaluation of the exclusion criteria. Vaginal delivery occurred in 466 (82.9 %) women (435 (77.4 %) spontaneous vaginal delivery and 31 (5.5 %) VE) while 96 had CS. The EFW was >95th centile in 194 (34.5 %) fetuses according to WHO growth charts and in 190 (33.8 %) by customized growth charts, respectively. CS due to dystocia occurred in 43 (22.2 %) women with LGA fetuses defined by WHO curves and in 39 (20.5 %) women with LGA defined by customized growth charts (p 0.70). WHO curves showed 57 % sensitivity, 72 % specificity, 24 % PPV and 91 % NPV, while customized curves showed 52 % sensitivity, 73 % specificity, 23 % PPV and 91 % NPV for CS due to labor dystocia. Conclusions The use of antenatal ultrasound-based customized growth charts does not allow a better identification of fetuses at risk of CS due to intrapartum dystocia.

To assess the association between confined placental mosaicism (CPM) and adverse pregnancy outcome. A retrospective cohort study was carried out evaluating the outcome of pregnancies with and without CPM involving a rare autosomal trisomy (RAT) or tetraploidy. Birthweight, gestational age at delivery, fetal growth restriction (FGR), Apgar score, neonatal intensive care admission, preterm delivery, and hypertensive disorders of pregnancy were considered. Overall 181 pregnancies with CPM and 757 controls were recruited. Outcome information was available for 69% of cases (n = 124) and 62% of controls (n = 468). CPM involving trisomy 16 (T16) was associated with increased incidence of birthweight

Objectives:The primary objective was to quantify the risk of perinatal mortality in non‐anomalous monochorionic monoamniotic (MCMA) twin pregnancies complicated by birth‐weight (BW) discordance. The secondary objectives were to investigate the effect of inpatientvsoutpatient fetal monitoring on the risk of mortality in weight‐discordant MCMA twin pregnancies, and to explore the predictive accuracy of BW discordance for perinatal mortality. Methods:This analysis included data on 242 MCMA twin pregnancies (484 fetuses) from three major research collaboratives on twin pregnancy (MONOMONO, STORK and NorSTAMP). The primary outcomes were the risks of intrauterine (IUD), neonatal (NND) and perinatal (PND) death, according to weight discordance at birth from ≥ 10% to ≥ 30%. The secondary outcomes were the association of inpatientvsoutpatient fetal monitoring with the risk of mortality in weight‐discordant pregnancies, and the accuracy of BW discordance in predicting mortality. Logistic regression and receiver‐operating‐characteristics‐curve analyses were used to analyze the data. Results:The risk of IUD was significantly increased in MCMA twin pregnancies with BW discordance ≥ 10% (odds ratio (OR), 2.2; 95% CI, 1.1–4.4;P= 0.022) and increased up to an OR of 4.4 (95% CI, 1.3–14.4;P= 0.001) in those with BW discordance ≥ 30%. This association remained significant on multivariate logistic regression analysis for BW‐discordance cut‐offs ≥ 20%. However, weight discordance had low predictive accuracy for mortality, with areas under the receiver‐operating‐characteristics curve of 0.60 (95% CI, 0.46–0.73), 0.52 (95% CI, 0.33–0.72) and 0.57 (95% CI, 0.45–0.68) for IUD, NND and PND, respectively. There was no difference in the risk of overall IUD, single IUD, double IUD, NND or PND between pregnancies managed as an inpatient compared with those managed as an outpatient, for any BW‐discordance cut‐off. Conclusions:MCMA twin pregnancies with BW discordance are at increased risk of fetal death, signaling a need for increased levels of monitoring. Despite this, the predictive accuracy for mortality is low; thus, detection of BW discordance alone should not trigger intervention, such as iatrogenic delivery. The current data do not demonstrate an advantage of inpatient over outpatient management in these cases. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

These guidelines follow the mission of the World Association of Perinatal Medicine, which brings together groups and individuals throughout the world with the goal of improving outcomes of maternal, fetal and neonatal (perinatal) patients. Guidelines for auditing, evaluation, and clinical care in perinatal medicine enable physicians diagnose, treat and follow-up of COVID-19-exposed pregnant women. These guidelines are based on quality evidence in the peer review literature as well as the experience of perinatal expert throughout the world. Physicians are advised to apply these guidelines to the local realities which they face. We plan to update these guidelines as new evidence become available.

Objectives: To assess the role of fetal magnetic resonance imaging (MRI) in detecting associated anomalies in fetuses presenting with mild or moderate isolated ventriculomegaly (VM) undergoing multiplanar ultrasound evaluation of the fetal brain. Methods: This was a multicenter, retrospective, cohort study involving 15 referral fetal medicine centers in Italy, the UK and Spain. Inclusion criteria were fetuses affected by isolated mild (ventricular atrial diameter, 10.0–11.9 mm) or moderate (ventricular atrial diameter, 12.0–14.9 mm) VM on ultrasound, defined as VM with normal karyotype and no other additional central nervous system (CNS) or extra-CNS anomalies on ultrasound, undergoing detailed assessment of the fetal brain using a multiplanar approach as suggested by the International Society of Ultrasound in Obstetrics and Gynecology guidelines for the fetal neurosonogram, followed by fetal MRI. The primary outcome of the study was to report the incidence of additional CNS anomalies detected exclusively on prenatal MRI and missed on ultrasound, while the secondary aim was to estimate the incidence of additional anomalies detected exclusively after birth and missed on prenatal imaging (ultrasound and MRI). Subgroup analysis according to gestational age at MRI (< 24 vs ≥ 24 weeks), laterality of VM (unilateral vs bilateral) and severity of dilatation (mild vs moderate VM) were also performed. Results: Five hundred and fifty-six fetuses with a prenatal diagnosis of isolated mild or moderate VM on ultrasound were included in the analysis. Additional structural anomalies were detected on prenatal MRI and missed on ultrasound in 5.4% (95% CI, 3.8–7.6%) of cases. When considering the type of anomaly, supratentorial intracranial hemorrhage was detected on MRI in 26.7% of fetuses, while polymicrogyria and lissencephaly were detected in 20.0% and 13.3% of cases, respectively. Hypoplasia of the corpus callosum was detected on MRI in 6.7% of cases, while dysgenesis was detected in 3.3%. Fetuses with an associated anomaly detected only on MRI were more likely to have moderate than mild VM (60.0% vs 17.7%; P < 0.001), while there was no significant difference in the proportion of cases with bilateral VM between the two groups (P = 0.2). Logistic regression analysis showed that lower maternal body mass index (adjusted odds ratio (aOR), 0.85 (95% CI, 0.7–0.99); P = 0.030), the presence of moderate VM (aOR, 5.8 (95% CI, 2.6–13.4); P < 0.001) and gestational age at MRI ≥ 24 weeks (aOR, 4.1 (95% CI, 1.1–15.3); P = 0.038) were associated independently with the probability of detecting an associated anomaly on MRI. Associated anomalies were detected exclusively at birth and missed on prenatal imaging in 3.8% of cases. Conclusions: The incidence of an associated fetal anomaly missed on ultrasound and detected only on fetal MRI in fetuses with isolated mild or moderate VM undergoing neurosonography is lower than that reported previously. The large majority of these anomalies are difficult to detect on ultrasound. The findings from this study support the practice of MRI assessment in every fetus with a prenatal diagnosis of VM, although parents can be reassured of the low risk of an associated anomaly when VM is isolated on neurosonography. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Objectives To introduce a new sonographic marker of intrathoracic liver herniation in fetuses with left-sided congenital diaphragmatic hernia (CDH). Methods In a consecutive series of fetuses with isolated CDH, an ultrasound volume of the fetal abdomen was acquired. On this volume, offline calculation of the angle formed by the midline of the abdomen (joining the center of the vertebral body to the abdominal insertion of the umbilical cord) and a second line joining the center of the vertebral body to the intra-abdominal convexity of the umbilical vein was carried out to give the umbilical vein deviation angle (UVDA). The UVDA was measured in a group of normal fetuses selected as controls. At follow-up, the presence of liver herniation was investigated in all cases of CDH. UVDA values were compared between the CDH group and controls, and between CDH ‘liver-up’ vs ‘liver-down’ cases. A receiver–operating characteristics (ROC) curve was constructed to identify a cut-off value of the UVDA with the highest accuracy in predicting liver herniation in the CDH group. Results Between 2009 and 2015, 22 cases of left-sided CDH were included in the study group, of which nine cases had liver herniation. Eighty-eight normal fetuses were recruited as controls. The UVDA was significantly higher in the cases vs controls (15.25 ± 7.91° vs 7.68 ± 1.55°; P

OBJECTIVES Outlet ventricular septal defects (VSDs) are usually suspected on the five-chamber view of the fetal heart; however, postnatal confirmation occurs only in a small number of cases. The aim of this study was to evaluate if the systematic assessment of the short axis view may improve the prediction of prenatally detected outlet VSDs. METHODS Cases where isolated outlet VSD was suspected on the five-chamber view were assessed by using the short axis scanning plane for confirmation of the defect. Postnatal assessment was performed within 2 weeks from birth at our Paediatric Cardiology Unit. RESULTS An outlet VSD was suspected at five-chamber view in 23 fetuses. Postnatal confirmation of the VSD occurred in 14 cases where the defect was prenatally detected both on the five chamber and the short axis views. VSDs were not confirmed at postnatal assessment only in two cases where outlet VSD was suspected on both views, whereas all the seven cases with a suspected VSD on the five-chamber view only turned out to be false positives. CONCLUSION The short axis view of the fetal heart seems useful in confirming the presence of outlet VSDs. © 2016 John Wiley & Sons, Ltd.

A comprehensive assessment of the fetal brain is among the most difficult tasks of antenatal ultrasound. A specific expertise is required to obtain in particular the non-axial planes of the fetal head and to assess the sonographic appearance of the cerebral structures at different gestational ages in order to rule out the presence of intracranial anomalies (1). Multiplanar neurosonography is far more sensitive than the standard axial approach in the antenatal detection of fetal brain malformations and it is recommended in cases at high risk for CNS anomalies (2,3).

A limited number of studies have addressed the role of intrapartum ultrasound in the prediction of the mode of delivery in women with prolonged second stage of labor.The objective of the study was to evaluate the role of transabdominal and transperineal sonographic findings in the prediction of spontaneous vaginal delivery among nulliparous women with prolonged second stage of labor.This was a 2-center prospective study conducted at 2 tertiary maternity units. Nulliparous women with a prolonged active second stage of labor, as defined by active pushing lasting more than 120 minutes, were eligible for inclusion. Transabdominal ultrasound to evaluate the fetal head position and transperineal ultrasound for the measurement of the midline angle, the head-perineum distance, and the head-symphysis distance were performed in between uterine contractions and maternal pushes. At transperineal ultrasound the angle of progression was measured at rest and at the peak of maternal pushing effort. The delta angle of progression was defined as the difference between the angle of progression measured during active pushing at the peak of maternal effort and the angle of progression at rest. The sonographic findings of women who had spontaneous vaginal delivery vs those who required obstetric intervention, either vacuum extraction or cesarean delivery, were evaluated and compared.Overall, 109 were women included. Spontaneous vaginal delivery and obstetric intervention were recorded in 40 (36.7%) and 69 (63.3%) patients, respectively. Spontaneous vaginal delivery was associated with a higher rate of occiput anterior position (90% vs 53.2%, P.0001), lower head-perineum distance and head-symphysis distance (33.2 ± 7.8 mm vs 40.1 ± 9.5 mm, P = .001, and 13.1 ± 4.6 mm vs 19.5 ± 8.4 mm, P.001, respectively), narrower midline angle (29.6° ± 15.3° vs 54.2° ± 23.6°, P.001) and wider angle of progression at the acme of the pushing effort (153.3° ± 19.8° vs 141.8° ± 25.7°, P = .02) and delta-angle of progression (17.3° ± 12.9° vs 12.5° ± 11.0°, P = .04). At logistic regression analysis, only the midline angle and the head-symphysis distance proved to be independent predictors of spontaneous vaginal delivery. More specifically, the area under the curve for the prediction of spontaneous vaginal delivery was 0.80, 95% confidence interval (0.69-0.92), P.001, and 0.74, 95% confidence interval (0.65-0.83), P = .002, for the midline angle and for the head-symphysis distance, respectively.Transabdominal and transperineal intrapartum ultrasound parameters can predict the likelihood of spontaneous vaginal delivery in nulliparous women with prolonged second stage of labor.

Objective To evaluate the feasibility of antenatal direct visualization of normal and abnormal fetal esophagus using three-dimensional ultrasound (3D-US) with Crystal Vue rendering technology. Methods Between February and April 2018, 3D-US volumes were collected from a non-consecutive series of singleton pregnancies, referred for clinically indicated detailed prenatal ultrasound at 19-28 weeks' gestation to one of two fetal medicine units in Italy. 3D volumes were acquired from a midsagittal section of the fetal thorax and upper abdomen with the fetus lying in supine position. Postprocessing with multiplanar mode was applied to orientate the volume and identify the esophagus. The region of interest was angled by approximately 30° to the spine and its thickness was adjusted in order to optimize visualization of the intrathoracic and intra-abdominal course of the esophagus. Crystal Vue software was used for image rendering of the fetal trunk in the coronal plane. Postnatal follow-up was available in all cases. Results During the study period, 91 pregnancies met the inclusion criteria and were recruited. The study cohort included two pregnancies with suspicion of esophageal atresia due to suboptimal visualization of the stomach. Of the 89 cases with normal stomach on two-dimensional (2D) imaging, 3D-US with Crystal Vue rendering technology allowed direct evaluation of the whole course of the esophagus in 74 (83.1%). In the two cases with small or absent stomach bubble on 2D imaging, esophageal atresia was demonstrated antenatally on 3D Crystal Vue imaging and was confirmed postnatally. The mean time required for offline postprocessing and visualization of the esophageal anatomy was 4 min. Conclusions Using 3D-US with Crystal Vue rendering, it is possible to visualize antenatally the normal fetal esophagus and demonstrate presence of esophageal atresia. This should facilitate prenatal counseling and management of cases with suspected esophageal atresia. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Objective To assess the risk of 22q11.2 deletion in fetuses with a prenatal diagnosis of right aortic arch without intracardiac anomalies (RAA-no ICA). Methods This was a retrospective study of all fetuses with RAA-no ICA diagnosed prenatally at three referral centers, between 2004 and 2014. A detailed sonographic examination was performed in each case, including visualization of the thymus and of the head and neck vessels to identify the presence of an aberrant left subclavian artery (ALSA). Karyotyping and fluorescence in situ hybridization analysis for diagnosis of 22q11.2 deletion were always offered either prenatally or postnatally. Clinical and echocardiographic examinations were performed in livebirths and a postmortem examination in cases of termination of pregnancy. Results During the study period, 85 fetuses were diagnosed prenatally with RAA-no ICA. Genetic or clinical data were not available for three cases and these were excluded from analysis. 22q11.2 deletion was found in 7/82 cases (8.5% (95% CI, 3.8–17.3%)). The thymus was small or non-visualized in all seven cases and additional abnormal sonographic findings were present in four. Conclusion 22q11.2 deletion is present in a clinically significant proportion of fetuses with a prenatal diagnosis of RAA-no ICA. In such cases, a detailed sonographic examination, with assessment of the thymus in particular, may be useful to further define the level of risk for 22q11.2 deletion. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.