Utilidad de la ecografía morfológica precoz en la aplicación de cribado de cromosomopatías mediante DNA fetal en sangre materna

OBJETIVOS: Confirmar que la ecografía morfológica precoz tiene una capacidad diagnóstica para malformaciones estructurales fetales mayor del 80%, en el grupo de alto riesgo sometido a un test combinado como método de cribado de cromosomopatías. Reducir la realización de ténicas invasivas de un 5% al 3% manteniendo una tasa de detección de cromosomatías del 85%, al aplicar el test combinado asociado a un test prenatal no invasivo mediante DNA fetal en sangre materna. MATERIAL Y MÉTODOS: Estudio observacional prospectivo, realizado entre enero de 2013 y diciembre de 2016. Se aplicó una ecografía morfológica precoz asociada al test prenatal no invasivo, en aquellos casos de alto riesgo en el cribado combinado de cromosomopatías del primer trimestre. En primer lugar se realiza un cribado combinado de primer trimestre entre las 11-13+6 semanas de gestación como método de cribado de trisomía 21,18 y 13. Asociamos como método de rescate un doble test. En casos de resultado mayor 1/270 se informa como riesgo bajo y continuamos el control de la gestación. Si obtenemos un cribado combinado por encima de 1/270, se informa a la gestante de un riesgo alto de trisomía 21 y 18 y se oferta la realización de una técnica invasiva. A éstas gestantes como alternativa a la técnica invasiva se les ofrece un test prenatal no invasivo. Se informa a la gestante y se obtiene un consentimiento por escrito. En pacientes con un cribado combinado mayor de 1/10, se indica directamente la realización una técnica invasiva, al tratarse de un grupo de muy alto riesgo. Si el resultado es menor o igual a 1/270 la paciente es sometida a una ecografía morfológica precoz, lo que permite detectar malformaciones mayores o traslucencia nucal por encima de 3,5 mm, siendo éstas pacientes clasificadas de nuevo como de muy alto riesgo, indicándose por tanto la técnica invasiva. RESULTADOS: Hemos analizado 12.650 gestaciones con una prevalencia de cromosomopatías del 0,5% (en total 64 casos, de los cuales, 49 casos corresponden a trisomía 21, es decir, un 76,5%). La cobertura del cribado de cromosomopatías es de un 98,5% (12.461 gestantes). El test combinado presenta una sensibilidad para trisomía 21 del 85,1 % (40/47 casos) y para todas las cromosomopatías del 85,2% (52/61). Con una tasa de falsos positivos del 4% (483/12.088). La ecografía morfológica precoz se ha realizado a 645 gestantes de las cuales el 85,2% (550) fueron concluyentes, presentando dificultad la evaluación del SNC y el corazón. La ecografía morfológica precoz ha presentado una sensibilidad para las malformaciones estructurales del 89,6% (52/58). El modelo de cribado basado en primer paso con test combinado o doble test y como segundo paso la ecografía morfológica precoz asociada al Test Prenatal No Invasivo o técnica invasiva, presenta una sensibilidad global de un 90,6% (57/64), para T21 de 91,8% (45/49), con una tasa de realización de técnica invasiva del 3,1% (382/12.282)

A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation.

Forceps delivery is associated with a high rate of levator ani muscle (LAM) trauma (avulsion) at 35%-65% whereas data on avulsion rates after vacuum delivery vary greatly. Nevertheless, a common characteristic of all previous studies carried out to evaluate the association between instrumental deliveries (forceps and vacuum) and LAM avulsion, is the fact that characteristics of the instrumentation have not been described or evaluated. The objective of this study is to compare the rate of LAM avulsion between forceps and vacuum deliveries according to the characteristics of the instrumentation. Prospective, observational study, including 263 nulliparous women, who underwent an instrumental delivery with either Malmström vacuum or Kielland forceps. The characteristics of the instrumentation, position (anterior position and other position) and height of the fetal head at the moment of instrumentation (low instrumentation [vertex at +2 station] and mid-instrumentation [head is involved but leading part above +2 station]) were assessed. Evaluation of LAM avulsion was performed at 6 months postpartum by three-/four-dimensional transperineal ultrasound. Using the multi-view mode, a complete avulsion was diagnosed when the abnormal muscle insertion was identified in all three central slices, that is, in the plane of minimal hiatal dimensions and the 2.5-mm and 5.0-mm slices cranial to this one. To detect a 30% or 15% difference in the LAM injury rate, with 80% power and 5% α-error, we needed, respectively 42 and 99 women per study group. In all, 263 nulliparous individuals have been evaluated (162 vacuum deliveries, 101 forceps deliveries). Instrumentation in an occipito-anterior position was more frequent in vacuum deliveries (75.3% vs 56.4%, P = .002), whereas other positions were more frequent in the forceps deliveries group (24.7% vs 43.6%). No statistically significant differences were noted regarding the height of the fetal head at the moment of instrumentation. No statistically significant differences were found in the presence of LAM avulsion (41.4% vs 38.6%) between vacuum and forceps deliveries. The univariate analysis of the crude odds ratio was 1.17, 95% CI 0.67-1.98, P = .70 for the avulsion of the LAM and the multivariate of the adjusted OR 0.90, 95% CI; 0.53-1.55, P = .71. We consider that, in our population, LAM avulsion rate should not be a factor taken into account when choosing the type of instrumentation (Malmström vacuum or Kielland forceps) in an operative delivery

Pelvic floor rehabilitation in patients with levator ani muscle avulsion

Objective: To determine if physiotherapy treatment applied to patients with levator ani muscle (LAM) avulsion identified after a vaginal delivery, reduces the LAM hiatus area. Material and Methods: A prospective observational study of 52 nulliparous (26 in the experimental and 26 in the control group). We included patients with LAM avulsion, diagnosed by 3-4D/transperineal ultrasound performed 3 months after delivery. Patients in the experimental group underwent a program of pelvic floor exercises, assisted by biofeedback and lumbopelvic stabilization exercises. Assessment of LAM was carried out at 6 and 9 months postpartum, using 3-4D/transperineal ultrasound, and taking the following measurements: levator hiatus area at rest, during Valsalva and at maximum contraction; LAM area, and thickness of right and left LAM. Results: Patients in the experimental group presented a reduction in the levator hiatus area at rest (17.0, 15.7, 15.9 cm2 ), during Valsalva (23.0, 20.8, 19.9 cm2 ) and at maximum contraction (15.6, 14.4 and 13.5 cm2 ), in comparison with patients in the control group, who presented a levator hiatus area at rest of 17.4, 17.2 and 16.8 cm2 , during Valsalva of 21.0, 20.8 and 20.3 cm2 , and at maximum contraction of 16.6, 16.1 and 15.6 cm2 , at 1, 6 and 9 months postpartum respectively (P < 0.05). However, no changes were appreciated in the successive examinations regarding LAM area between study groups: experimental 9.5, 8.9, 9.6 cm2 versus 8.9, 9.0, 9.2 cm2 in the control group. Conclusions: Physiotherapy treatment based on pelvic floor exercises with lumbopelvic stabilization exercises in patients with LAM avulsion reduces the levator hiatus area at rest, during Valsalva and at maximum contraction

Online learning for 3D/4D transperineal ultrasound of the pelvic floor

Introduction. To evaluate the feasibility of an online learning process for performing and analyzing 3D/4D transperineal ultrasound imaging of the pelvic floor. Materials and methods: A prospective study was conducted with 20 patients. The learning process of three inexperienced examiners (IEs) performing and analyzing 3D/4D transperineal ultrasound volumes was evaluated. The learning process for the IEs was conducted online by an expert examiner (EE); no face-to-face tutoring was provided. The IEs’ competency and analysis of the volumes were estimated using the intraclass correlation coefficient (ICC). Results: The interobserver analysis of the levator hiatus dimensions provided by the EE and those from each IE (for the 20 studied cases) had ICCs ranging from 0.81 to 0.96. The dimensions of the levator hiatus performed by the IEs for the first 10 patients showed ICCs ranging from 0.55 to 0.9. However, when the IEs proceeded with the next 10 patients, they obtained ICCs ranging from 0.81 to 0.96. Conclusions: Conducting 3D/4D transperineal ultrasound of the pelvic floor is a technique that can be learned online in a short period of time. A learning programme designed specifically for this purpose provides excellent reliability

Evaluation of isolated urinary stress incontinence 2 according to the type of lesion on the levator ani muscle 3 using 3-4d transperineal ultrasound 36 months post-partum

Introduction Vaginal delivery can lead to pelvic floor disorders. Many authors have described pelvic floor injuries that can predict future defects such as urinary incontinence and pelvic organ prolapse. We propose the assessment of urinary stress incontinence and its association with levator ani muscle (LAM) microtrauma (>20% in the levator hiatus area during Valsalva) and macrotraumas (avulsion) identified by 3/4D transperineal ultrasound (3D-TpUS) 36 months post-partum. Materials and methods This was a prospective observational study including 168 nulliparous women. All patients included were nulliparous with singleton gestation in cephalic presentation, at ≥37 weeks and were recruited on the first day after delivery. Thirty-six months after delivery, 3D-TpUS was carried out to identify LAM lesions (macro or micro). Clinical assessment of urinary stress incontinence (USI) was based on the ICIQ-UI-SF test; a simple stress test and urodynamic test were carried out in the same visit. Results A total of 105 nulliparous women were studied (51 spontaneous deliveries [SpD] and 54 vacuum-assisted deliveries [VD]). Microtraumas were identified in 35.3% of SpD and 20.4% of VD. Macrotraumas (avulsion) were identified in 9.8% of SpD and 35.2% of VD (p = 0.006). No differences were found in USI between study groups or in relation to the identification of LAM defects (19.2% in the no lesion group, 25% in the macrotrauma and 13.8% in the microtrauma groups; p = not significant). Nor were significant differences found in the results from the different study groups in the International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF) test (12.7±2.2 in the no lesion group, 12.5±4.2 in the macrotrauma and 13.25±4.8 in the microtrauma groups; p = NS). Conclusion No difference was observed in USI between patients with and without LAM lesions (microtrauma or macrotrauma) 36 months post-delivery

Influence of difficulty of instrumentation with vacuum on the rate of levator ani muscle avulsion identified by 3–4 d transperineal ultrasound

Objectives: Evaluation of the influence of difficulty of instrumentation with vacuum on the rate of levator ani muscle (LAM) avulsions. Materials and methods: Prospective observational study with 86 nulliparous women with at term gestation who required instrumentation with vacuum to complete fetal extraction. After every delivery, each explorer reported the number of vacuum tractions needed to complete fetal extraction, as well as the subjective complexity of the instrumentation. LAM avulsion rate was assessed by 3D–4D transperineal ultrasound evaluation 6 months after delivery. Results: Seventy nine cases were evaluated and classified as either “easy” delivery (below three vacuum tractions; n = 49) or “difficult” delivery (three or more vacuum tractions; n = 30). No differences in obstetric characteristics were observed between study groups, with the following exceptions: fetal head circumference (34.8 ± 2.7 versus 35.2 ± 1.1; p = .013) and fetal weight at birth (3260 ± 421 versus 3500 ± 421; p = .016). No statistically significant differences between study groups were observed in LAM avulsion rate (36.7 versus 30%) and levator hiatus area (cm2) at rest (18.44 ± 3.95 versus 17.75 ± 3.90). Conclusions: The number of vacuum tractions needed to complete fetal extraction is not associated to a higher LAM avulsion rate nor with differences in levator hiatus area