Monitoring fetal well-being in labor in late fetal growth restriction

Late-onset fetal growth restriction (FGr) accounts for approximately 70-80% of all cases of FGr secondary to uteroplacental insufficiency. It is associated with an increased incidence of adverse antepartum and perinatal events, which in most instances result from hypoxic insults either present at the onset of labor or supervening during labor as a result of uterine contractions. labor represents a stressful event for the fetoplacental unit being uterine contractions associated with an up-to 60% reduction of the uteroplacental perfusion. intrapartum fetal heart rate monitoring by means of cardiotocography (CTG) currently represents the mainstay for the identification of fetal hypoxia during labor and is recommended for the fetal surveillance during labor in the case of FGr or other conditions associated with an increased risk of intrapartum hypoxia. in this review we discuss the potential implications of an impaired placental function on the intrapartum adaptation to the hypoxic stress and the role of the ctG and alternative techniques for the intrapartum monitoring of the fetal wellbeing in the context of FGR secondary to uteroplacental insufficiency

First-trimester fetal neurosonography: technique and diagnostic potential

Most of the brain abnormalities are present in fact also at first trimester but only a few of these are detected at such early stage. According to the current recommendations for the 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 usually detected, however the majority of the other abnormalities of the fetal central nervous system remain undiagnosed until midtrimester. Such anomalies are potentially detectable if the sonographic study is extended to additional anatomic details which are not currently included in the existing guidelines. The aim of this review article is to describe how to assess the normal fetal brain at first trimester expert multiplanar neurosonography and to demonstrate the early sonographic findings which characterize some major fetal brain abnormalities. This article is protected by copyright. All rights reserved

Sars-CoV-2 in pregnancy: Why is it better than expected?

Since the outbreak of Coronavirus disease in December 2019, information specific to pregnancy remains limited and controversial. Based on data from previous reports, it has been noticed that contrary to prior pandemics such as SARS, MERS and H1N1 and although pregnancy is usually considered as a condition of high susceptibility to viral infections, new SARS-CoV2 infection seems to have a more benign clinical course when affecting pregnant women. We speculate that during pregnancy the physiological “silencing” of the Th1 pro-inflammatory response may blunt the cytokines storm which is thought to play a key-role in the pathogenesis of the severe complications of Covid-19

Persistent organochlorine compounds in fetal and maternal tissues: evaluation of their potential influence on several indicators of fetal growth and health

Some organochlorine compounds, such as polychlorinated biphenyls (PCBs), have a tendency to bioaccumulate in humans and predators at the top of the food chain. We have recently confirmed the transplacental transfer of these compounds and the present study has been designed on the same material with the aim of investigating their potential health effects on newborns from 70 pregnant women, resident in a Northern Italy industrial town. Organochlorine compounds [namely, p,p'-dichlorodiphenyltrichloroethane (p,p'-DDT), p,p'-dichlorodiphenyldichloroethene (p,p'-DDE), hexachlorobenzene (HCB), and PCBs] have been analyzed both in cord and maternal serum, placenta, and maternal subcutaneous adipose tissue by GC-MSD. p,p'-DDT levels in the adipose tissue resulted significantly (p<0.05) related to birth length. Mothers of neonates born by preterm programmed caesarean delivery showed significantly (p<0.005 for both) higher serum p,p'-DDE serum concentrations and p,p'-DDT levels in the adipose tissue, as compared to mothers delivering at term

Report of a series of healthy term newborns from convalescent mothers with covid-19

Background: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmittable virus associated with a significantly increased risk of complications among the infected population. Few data are available for the outcome of pregnancy complicated by serious respiratory disease due to SARS-CoV-2 infection. Aim: We herein report a series of four neonates whose mothers had recovered from new coronavirus 2019 disease (COVID-19) diagnosed in the third trimester of pregnancy. Methods: Pregnant women with documented COVID-19 infection during their pregnancy, who gave birth in Parma Hospital, University of Parma, Italy, in March and April 2020, during the peak of incidence of COVID-19 in Italy. Clinical records and laboratory tests were retrospectively reviewed. Results: All neonates were delivered at term in good conditions without congenital COVID-19 infection. Conclusions: Findings from our series of cases indicated that adverse effects on foetuses from pregnancies complicated by COVID-19 infection in late pregnancy are unlikely

Prenatal visualisation of the torcular herophili by means of a Doppler technology highly sensitive for low-velocity flow in the expert assessment of the posterior fossa: a prospective study

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&nbsp;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

Conservative treatment for hypervascularised placental polyp with secondary haemoperitoneum: A case report

Objective: We describe the first case to our knowledge of hypervascularised placental polyp (HPP) presenting with acute pelvic pain and hemoperitoneum. Case Report: A 33 years-old woman with a history of medical abortion three months earlier came to our attention complaining acute pelvic pain and vaginal bleeding. Transvaginal (TV) and transabdominal (TA) ultrasound (US) demonstrated a highly vascular intrauterine lesion and intra-abdominal free fluid consistent with a diagnosis of haemoperitoneum. Emergency laparoscopy yielded no intra-abdominal bleeding and was followed by bilateral selective embolization of the uterine arteries due to persistent vaginal bleeding. Hysteroscopy and pathology findings were consistent with a final diagnosis of HPP. Conclusion: HPP may occur months or years after pregnancy or abortion and the clinical picture of abnormal vaginal bleeding associated with acute abdominal pain and haemoperitoneum should warrant to consider HPP among the differential diagnosis. Clinical and imaging findings need to be considered when planning the conservative management of HPP. Our experience suggests that uterine artery embolization is a safe and effective for the conservative treatment of highly vascularized HPP. (www. actabiomedica.it)

Current use and performance of the different fetal growth charts in the Italian population

Objectives: The choice of growth charts impacts on screening, diagnosis and clinical management of fetal growth abnormalities. The objectives of the study were to evaluate: 1) the clinical practice at a national level among tertiary referral centers in the use of fetal biometric growth charts; and 2) the impact on fetal growth screening of existing national and international growth charts. Study design: A questionnaire was sent to 14 Italian tertiary referral centers to explore biometric reference growth charts used in clinical practice. National and international (Intergrowth-21st and World Health Organization) fetal growth charts were tested on a large national cohort of low risk women with singleton uneventful pregnancy derived from a retrospective cross-sectional multicenter study (21 centers). The percentage of fetuses with biometric measurements below and above the 10th and 90th percentile for each biometric parameter and gestational week were calculated for each growth chart. The percentile curves of the study population were calculated by non-linear quantile regressions. Results: Twelve Italian centers (86 %) answered to the questionnaire showing a wide discrepancy in the use of growth charts for fetal biometry. The cohort included 7347 pregnant women. By applying Intergrowth-21st growth charts the percentage of fetuses with head circumference, abdominal circumference and femur length below the 10th centile was 3.9 %, 3.6 % and 2.3 %, and above the 90th centile 29.9 %, 32.5 % and 46 %, respectively. The percentages for the World Health Organization growth charts for head and abdominal circumferences and femur length were: below the 10th centile 6.3 %, 7.2 % and 5.3 %, and above 90th centile 22.8 %, 21.3 % and 31.9 %, respectively. Conclusions: The wide discrepancy in clinical use of fetal growth charts in Italian centers warrants the adoption of an uniform set of charts. Our data suggest that immediate application into clinical practice of international growth charts might result into an under-diagnosis of small for gestational age fetuses and, especially, in an over-diagnosis of large for gestational age fetuses with major consequences for clinical practice. On these grounds, there is an urgent need for a nationwide study for the prospective evaluation of international growth charts and, if needed, the construction and adoption of methodologically robust national growth charts

Antepartum evaluation of the obstetric conjugate at transabdominal 2D ultrasound: A feasibility study

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&nbsp;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&nbsp;±&nbsp;0.93&nbsp;mm for the first operator and 11.4&nbsp;±&nbsp;0.91&nbsp;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&nbsp;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

Usefulness of an Intrapartum Ultrasound Simulator (IUSim™) for Midwife Training: Results from an RCT

Introduction: We conducted a randomized study to determine whether a training session on a dedicated simulator (IUSim™) would facilitate the midwives in learning the technique of transperineal intrapartum ultrasound. Methods: Following a 30-min multimedia presentation including images and videos on how to obtain and measure the angle of progression (AoP) and the head-perineum distance (HPD), 6 midwives with no prior experience in intrapartum ultrasound were randomly split into 2 groups: 3 of them were assigned to the "training group"and 3 to the "control group."The midwives belonging to the former group were taught to measure the 2 sonographic parameters during a 3-h practical session conducted on IUSim™ under the supervision of an expert obstetrician. In the following 3 months, all the 6 midwives were asked to independently perform transperineal ultrasound during their clinical practice and to measure on the acquired images either the AoP or the HPD. The sonographic images were examined in blind by the teaching obstetrician who assigned a 0-3 score to the image quality (IQS) and to the measurement quality (MQS). Results: A total of 48 ultrasound images (24 patients) from 5 midwives were acquired and included in the study analysis. A midwife of the "training group"declined participation after the practical session. Independently from the randomization group, the image quality score (IQS + MQS) was significantly higher for the HPD compared with the AoP (2.5 ± 0.66 vs. 1.79 ± 1.14; p = 0.01). In the training group, the MQS of either AoP (2.66 ± 0.5 vs.1.46 ± 1.45. p = 0.038) and the HPD (2.9 ± 0.33 vs. 1.87 ± 0.83 p = 0.002) was significantly higher in comparison with the control group, while the IQS of both measurements was comparable between the 2 groups (1.91 ± 1.24 vs. 2.25 ± 0.865; p = 0.28). Conclusion: The use of a dedicated simulator may facilitate the midwives in learning how to measure the AoP and the HPD on transperineal ultrasound images