Ana Fernández-Palacín

Utility of intrapartum transperineal ultrasound to predict cases of failure in vacuum extraction attempt and need of cesarean section to complete delivery

Abstract Objectives: We aim to evaluate the predictive capacity of intrapartum transperineal ultrasound (ITU) to predict cases of failure in fetal extraction in operative deliveries with vacuum. Prospective, observational study performed on 61 nulliparous women, ≥37 weeks, singleton pregnancies at full dilatation who underwent transperineal ultrasound before placement of vacuum to complete fetal extraction. Working on the transperineal longitudinal plane, we evaluated the following: Angle of Progression (AoP), Progression Distance (PD) and head direction. In the transverse plane, midline angle (MLA) and head–perineum distance were assessed. Vacuum extractions were classified as easy (EG) (three or less vacuum pulls), difficult (DG) (more than three vacuum pulls) or impossible (IG) (delivery completed by cesarean section). Occipito-posterior presentations were not evaluated. Results: Fifty-two patients were studied (26-EG, 19-DG and 7-IG). No differences in obstetric, intrapartum or neonatal characteristics were observed between study groups, with the following exceptions: weight at birth (3147u2009g-EG, 3523u2009g-DG and 3588u2009g-IG) and number of vacuum pulls (1.4-EG, 4.4-DG and 4.1-IG; pu2009<u20090.0005). The AoP pushing was 133.1°u2009±u200913.6-EG, 112.8°u2009±u200912.8-DG and 99.1°u2009±u20098.9-IG (pu2009<u20090.0005); “head-up” direction was identified in 84.6% of EG, 36.8% of DG and 28.6% of IG (pu2009<u20090.001); PD were 37.0u2009±u200910.4u2009mm, 33.3u2009±u200923.3u2009mm and 20.8u2009±u20099.5u2009mm (pu2009<u20090.0005); MLA were 35.0°u2009±u200919.6, 55.3°u2009±u200924.4 and 76.0°u2009±u200923.2 (pu2009=u20090.003); and head–perineum distances were 41.8u2009±u20096.6u2009mm, 49.2u2009±u20099.8u2009mm and 48.0u2009±u20093.4u2009mm (pu2009=u20090.072), respectively. Conclusion: We have observed that the presence of an AoP with pushing <105°, a PD <25u2009mm, a “head-down” direction and a >45° MLA are very unfavorable ITU parameters which can be used to identify cases of high risk of fetal extraction failure in vacuum-assisted deliveries.

Intrapartum transperineal ultrasound as a predictor of instrumentation difficulty with vacuum-assisted delivery in primiparous women

Abstract Objectives: To assess the capability of different intrapartum transperineal ultrasound parameters to predict the difficulty of vacuum extraction. This is a prospective observational study performed between 04/2012 and 03/2013 on 72 primiparous-women, ≥37-weeks with singleton pregnancies at full dilatation that underwent transperineal ultrasound before vacuum placement for foetal extraction. Working in a transperineal longitudinal plane we evaluated: progression-angle, progression-distance and head direction; in a transverse plane: midline-angle and head-perineum distance. The vacuum extractions were classified as easy-group (EG) (≤3 vacuum pulls), difficult/impossible-group (DG)(≥4 pulls). Occiput-posterior presentations were not assessed. Results: Fifty-two (52) patients were studied (26 patients per study group). No differences were observed in obstetric, neonatal or intrapartum characteristics between the study groups, with the following exceptions: new-born (NB) weight (3147u2009g versus 3540u2009g) and the number of vacuum pulls (1.4 EG versus 4.3 DG; pu2009<u20090.0005). The progression angle was 133.1° (123°–143°) in EG and 109.2° (97.2°–121.2°) in DG (pu2009<u20090.0005); up direction of foetal head was 88% versus 34.5% (pu2009<u20090.0005); progression distance was 37u2009mm (26.6–47.4) versus 29.9u2009mm (8.8–51; pu2009=u20090.003); midline angle was 35° (15.4°–54.6°) versus 59.7° (34.5°–84.9°; pu2009=u20090.0005); head-perineum distance was 41.9u2009mm (35.2–48.6) versus 48.9u2009mm (40.5–57.3; pu2009=u20090.017). The area under the Receiver Operating Characteristic (ROC) curve for the progression angle was 0.9 (95%CI, 0.82–0.99), and the midline angle was 0.8 (95%CI, 0.67–0.92). Conclusion: If previous to the placement of the vacuum cup the progression angle is ≤120°, the foetal head direction is horizontal or down, and the midline angle is ≥35°, there is an 85% chance that the delivery will require more than 4 vacuum pulls.

Intrapartum translabial ultrasound with pushing used to predict the difficulty in vacuum-assisted delivery of fetuses in non-occiput posterior position

Abstract Objective: Our aim is to evaluate the capacity of intrapartum translabial ultrasound (ITU) with pushing in the prediction of difficulty of fetal extraction in vacuum assisted deliveries. Prospective, observational study performed (2/2015–8/2015) on 75 nulliparous women, ≥37 weeks with singleton pregnancies at full dilatation who had ITU-with-pushing performed, previous to vacuum-placement for fetal extraction. Working on the translabial sagittal-plane, we assessed: Angle-Progression (AoP), Progression-Distance (PD) and Head-Direction (HD); in the axial plane we evaluated: Midline-Angle (MLA) and Head-Perineum-Distance (HPD). Vacuum extractions were classified as easy-difficulty (ED) (≤3 vacuum-pulls), difficult-unsuccessful (DD) (>3 vacuum-pulls). We did not assess occipito-posterior-presentations. Results: Seventy nulliparous were studied (44-ED,26-DD). We observed no differences in obstetric, neonatal or intrapartum characteristics between the two study groups, with the following exceptions: newborn weight (3272u2009±u2009438u2009g versus 3540u2009±u2009372u2009g; pu2009=u20090.011) and number of vacuum-pulls (1.4-ED-vs-4.4-DD; pu2009<u20090.0005). AoP-pushing was 143.9°u2009±u200914.6° in ED and 115.1°±u200912.9° in DD (pu2009<u20090.0005); Head-Up was 79.5% versus 38.4% (pu2009<u20090.0005); PD-Pushing was 42.7u2009±u200911.3u2009mm versus 30.4u2009±u20099.8u2009mm (pu2009<u20090.0005); MLA-Pushing was 27.6°±u200926.6° versus 57.5°±26.5°(p=0.025); HPD-Pushing was 40.8u2009±u200910.0u2009mm versus 47.4u2009±u200910.9u2009mm (pu2009=u20090.039). Conclusion: We identified that the presence of an AoP-Pushingu2009>u2009128° predicts an Easy-Vacuum-Delivery (≤3 Vacuum-Pulls) in u2009>85% of cases (Sen 80%–FPR 9.3%).

Factors that influence the development of avulsion of the levator ani muscle in eutocic deliveries: 3–4D transperineal ultrasound study

Abstract Introduction: Levator ani muscle (LAM) lesions are the most frequent injuries of the pelvic floor during delivery. Ten to 36% of women report this lesion during their first delivery. Many risk factors have been proposed but very few evaluate the aspects that can influence during natural vaginal delivery. Method: A prospective observational trial was conducted involving 74 primiparous women following vaginal delivery. Maternal, fetal and obstetric characteristics were analyzed. A transperineal three or four-dimensional (3D–4D) ultrasound was offered six months after delivery in order to evaluate avulsions and anomalies of the hiatus. Results: Seventy four women were included, three of them did not show up for ultrasound evaluation. Sixty two (87.3%) demonstrated no avulsion in comparison with nine (12.7%) who did. Five of these lesions were unilateral and four bilateral. Mean newborn weight was 3193u2009g in the “no avulsion group” versus 3470u2009g in the “avulsion” group (p=0.025). Discussion: According to the results, the most important risk factor established, for avulsion during natural childbirth, was the newborn weight. This contrasts with many other authors who have established that birth weight has no impact on these lesions. Conclusions: The most important factor intervening in the avulsion of LAM during natural vaginal delivery is the newborn weight. Patients with diagnosed avulsions present an enlarged urogenital hiatus during valsalva and maximal contraction.

Intra and interobserver variability of intrapartum transperineal ultrasound measurements with contraction and pushing

Abstract The aim of this study was to evaluate the inter- and intraobserver correlation of the different intrapartum-transperineal-ultrasound-parameters(ITU) (angle of progression (AoP), progression-distance (PD), head-direction (HD), midline-angle (MLA) and head-perineum distance (HPD)) with contraction and pushing. We evaluated 28 nulliparous women at full dilatation under epidural analgesia. We performed a transperineal ultrasound evaluating AoP and PD in the longitudinal plane, and MLA and HPD in the transverse plane. Interclass correlation coefficients (ICC) with 95% CIs and Bland–Altman analysis were used to assess intra- and interobserver measurement’s repeatability. The ICC of the ITU for the same observer was adequate for all the parameters (pu2009<u2009.005) AoP 0.98 (95%CI, 0.96–0.99), PD 0.98 (95%CI, 0.97–0.99), MLA 0.99 (95%CI, 0.97–0.99), HPD 0.96 (95%CI, 0.88–0.99). The ICC of the ITU for interobserver was: AoP 0.93 (95%CI, 0.79–0.98), PD 0.92 (95%CI, 0.76–0.97), MLA 0.77 (95%CI, 0.42–0.92), HPD 0.47 (95%CI, −0.12–0.8). The HD had an interobserver correlation of 0.53 (95%CI, 0.1–0.9) (Kappa C). The mean difference of the AoP was 2.42°, of the PD 1u2009mm and 0.28° MLA (Bland–Altman test). ITU has an adequate intra- and interobserver correlation for its use with contraction and pushing under epidural analgesia. Impact statement What is already known on this subject: The intrapartum transperineal ultrasound parameters can be used with contraction and pushing under epidural analgesia. What the results of this study add to what we know: ITU may be used to evaluate the difficulty of instrumental delivery/to evaluate the difficulty of instrumentation in vaginal operative deliveries and this study concludes that ITU is reproducible during uterine contraction with pushing. What the implications are of these findings for clinical practice and/or further research: Therefore, ITU could be used without difficulty with an adequate intra- and interobserver correlation for the prediction of instrumentation difficulty in operative vaginal deliveries.

Levator ani muscle injuries associated with vaginal vacuum assisted delivery determined by 3/4D transperineal ultrasound

Abstract Objectives: To determine the rate of pelvic floor trauma, levator ani muscle (LAM) avulsion as well as the mean difference in levator hiatus area, after normal vaginal deliveries (NVD) and vacuum assisted deliveries (VD), assessed with three-dimensional transperineal ultrasound (3D-TpUS). Materials and methods: Prospective observational study with 151 nulliparous women with NVD or VD at ≥37 weeks between 9-2012 and 6-2013. 3D-TpUS was performed six months after every patient’s delivery, during which LAM, anteroposterior diameter, transverse diameter and levator hiatus area were assessed. Results: A total of 146 nulliparous were studied, comprising 73 NVD and 73 VD. No differences in obstetric, intrapartum or neonatal characteristics were observed between study groups, with the following exceptions: maternal age (28.1u2009±u20095.4 versus 30.4u2009±u20095.5; pu2009=u20090.008, ORu2009=u20091.1) and episiotomy rate (35.6% versus 97.3%; pu2009=u20090.011, ORu2009=u20094.3). LAM avulsion rate was 9.6% in NVD versus 34.2% in VD (pu2009=u20090.001, OR 3.99), while levator hiatus area at rest was 16.5u2009±u20093.2 versus 18.2u2009±u20093.9 (pu2009=u20090.016). Conclusions: Vacuum assisted deliveries present a higher rate of LAM avulsion, as well as a greater increase in levator hiatal area than in NVD.

Intrapartum transperineal ultrasound used to predict cases of complicated operative (vacuum and forceps) deliveries in nulliparous women

The objective of this study was to investigate the predictive value of intrapartum transperineal ultrasound in the identification of complicated operative (vacuum or forceps) deliveries in nulliparous women.

Early fetal morphological evaluation (11–13 + 6 weeks) accomplished exclusively by transabdominal imaging and following routine midtrimester fetal ultrasound scan recommendations. Since when can it be performed?

Abstract Objectives: To establish the best timing for the realization of first-trimester-morphologic-evaluation, following routine midtrimester fetal-ultrasound-scan-recommendations (RFUSR), by performing exclusive transabdominal exploration, and to determine the sensitivity of the mentioned scan for diagnosis of major structural abnormalities. Method: Prospective observational study with 512 pregnant women with singleton gestations (438 low-risk, 74 high-risk) was conducted. Early fetal morphological evaluation (EFME) is performed in line with RFUSR (18–22 weeks) (ISUOG 2010) and a check-list structured evaluation was followed, between 11–13u2009+u20096 weeks. Its performance is assessed in the correct identification of normal fetal anatomy, and its effectiveness in the detection of structural defects Results: Five hundred and four pregnant women were evaluated, of which, 58.3% EFME are considered complete fetal anatomical surveys. Complete fetal anatomical surveys scans rise from 23.1% at 11–11u2009+u20096 weeks to 63.8% at 13u2009+u20093–13 weeks, with a clear turning point at 12u2009+u20096–13u2009+u20093 weeks (63.8%) (pu2009<u2009.05). From 12u2009+u20096–13u2009+u20093 weeks only renal (26.3%) and cardiac assessments (31.6%) present an inconclusive evaluation greater than 20%. Body mass index (23.9 versus 29.8) and estimated fetal weight (63 versus 86.7u2009g) influence EMFE’s ability of identifying fetal structures (pu2009<u2009.05). EMFE presents sensitivity for the identification of structural malformations of 83.3% (20/24). Conclusions: From 12u2009+u20096 weeks of gestation onwards, a complete fetal morphological evaluation can be performed in 63.8% of cases following the routine midtrimester fetal ultrasound scan recommendations (ISUOG’s 20 weeks scan).

Can we predict levator ani muscle avulsion in instrumental deliveries through intrapartum transperineal ultrasound

Abstract Introduction: To determine whether intrapartum translabial ultrasound (ITU) is useful for the prediction of levator ani muscle (LAM) avulsions in instrumental deliveries (vacuum and forceps). Materials and methods: Prospective, observational study, including (1/2016u2009−u20095/2016) 77 nulliparous women, with singleton pregnancies of ≥37 weeks of gestation and with cephalic presentation, who required vacuum or forceps instrumentation to complete the delivery. The ITU parameters evaluated were Angle of Progression (AoP), Progression Distance (PD), Head Direction (HD), and Midline Angle (MLA), both at rest and with maternal push. Evaluation of LAM avulsion was performed at 6 months postpartum with 3–4D transperineal ultrasound. Complete avulsion was defined as an abnormal insertion of LAM in the lower pubic branch identified in all three central slices. Results: Data from 48 nulliparous women were finally included in the study (34 vacuum and 14 forceps). We observed no difference in obstetric parameters between the two study groups (group with avulsion of LAM −14 cases, 29.2%u2009−u2009and group without avulsion of LAM −34 cases, 70.8%). The “LAM avulsion group” had an AoP and a PD of 136.7u2009±u200922.4 and 43.5u2009±u200915.6, respectively, versus 141.6u2009±u200921.3 and 47.2u2009±u200916.8 recorded in the group without avulsion (NS), respectively. We obtained a ROC curve for AoP and PD with a push of 0.66 (95% CI, 0.28–1.00) and 0.57 (95% CI, 0.39–0.75), respectively. Conclusions: ITU is not a useful technique to predict the occurrence of LAM avulsion in instrumental deliveries with vacuum or forceps.

In vivo confocal microscopy indicates an inverse relationship between the sub-basal corneal plexus and the conjunctivalisation in patients with limbal stem cell deficiency

Background/aims Limbal stem cell deficiency (LSCD) is characterised by a marked decrease in limbal stem cells. It is classified primarily using subjective slit-lamp observations. In vivo confocal microscopy (IVCM) can non-invasively provide objective information on the condition of the limbal niche, the corneal epithelial basal cell density and the corneal sub-basal nerve plexus density (SND). We here used IVCM to evaluate changes in SND to improve LSCD classification. Methods We evaluated and classified 38 patients (76 eyes, 44 with LSC and 32 control eyes) using the Rama, López-García and Deng (clinical and confocal) classifications and evaluated the concordance of the confocal and clinical classifications. We constructed a logistic regression model using multivariate analysis to correlate different degrees of conjunctivalisation with IVCM parameters and used receiver operating characteristic (ROC) curve analysis to establish the SND cut-off value with maximum diagnostic sensitivity and specificity. Results The classification systems correlated moderately at best (kappa, 0.449). The corneal SND of cases (6469±6295u2009µm/mm2) was less (p<0.001) than in controls (20911±4142u2009µm/mm2). The SND, but not basal cell density, played a protective role against conjunctivalisation (OR, 0.069; 95% CI 0.008–0.619; p=0.01). An SND cut-off value of 17u2009215u2009µm/mm2 yielded a sensitivity and specificity of 95.5% and 90.6%, respectively, for LSCD diagnosis. Conclusion The density of the corneal sub-basal nerve plexus was inversely related to conjunctivalisation in LSCD. Further studies are needed to verify this and to elucidate the directionality between these factors.