Federico Migliorelli

Definition of Failed Induction of Labor and Its Predictive Factors: Two Unsolved Issues of an Everyday Clinical Situation.

Objective: The objectives of this review were to identify the predictive factors of induction of labor (IOL) failure or success as well as to highlight the current heterogeneity regarding the definition and diagnosis of failed IOL. Materials and Methods: Only studies in which the main or secondary outcome was failed IOL, defined as not entering the active phase of labor after 24 h of prostaglandin administration ± 12 h of oxytocin infusion, were included in the review. The data collected were: study design, definition of failed IOL, induction method, IOL indications, failed IOL rate, cesarean section because of failed IOL and predictors of failed IOL. Results: The database search detected 507 publications. The main reason for exclusion was that the primary or secondary outcomes were not the predetermined definition of failed IOL (not achieving active phase of labor). Finally, 7 studies were eligible. The main predictive factors identified in the review were cervical status, evaluated by the Bishop score or cervical length. Discussion: Failed IOL should be defined as the inability to achieve the active phase of labor, considering that the definition of IOL is to enter the active phase of labor. A universal definition of failed IOL is an essential requisite to analyze and obtain solid results and conclusions on this issue. An important finding of this review is that only 7 of all the studies reviewed assessed achieving the active phase of labor as a primary or secondary IOL outcome. Another conclusion is that cervical status remains the most important predictor of IOL outcome, although the value of the parameters explored up to now is limited. To find or develop predictive tools to identify those women exposed to IOL who may not reach the active phase of labor is crucial to minimize the risks and costs associated with IOL failure while opening a great opportunity for investigation. Therefore, other predictive tools should be studied in order to improve IOL outcome in terms of health and economic burden.

Quantitative Analysis of the Cervical Texture by Ultrasound and Correlation with Gestational Age

Objectives: Quantitative texture analysis has been proposed to extract robust features from the ultrasound image to detect subtle changes in the textures of the images. The aim of this study was to evaluate the feasibility of quantitative cervical texture analysis to assess cervical tissue changes throughout pregnancy. Methods: This was a cross-sectional study including singleton pregnancies between 20.0 and 41.6 weeks of gestation from women who delivered at term. Cervical length was measured, and a selected region of interest in the cervix was delineated. A model to predict gestational age based on features extracted from cervical images was developed following three steps: data splitting, feature transformation, and regression model computation. Results: Seven hundred images, 30 per gestational week, were included for analysis. There was a strong correlation between the gestational age at which the images were obtained and the estimated gestational age by quantitative analysis of the cervical texture (R = 0.88). Discussion: This study provides evidence that quantitative analysis of cervical texture can extract features from cervical ultrasound images which correlate with gestational age. Further research is needed to evaluate its applicability as a biomarker of the risk of spontaneous preterm birth, as well as its role in cervical assessment in other clinical situations in which cervical evaluation might be relevant.

Mid‐trimester sonographic cervical consistency index to predict spontaneous preterm birth in a low‐risk population

To investigate the effectiveness of mid‐trimester sonographic cervical consistency index (CCI) for the prediction of spontaneous preterm birth (sPTB) in low‐risk pregnancies and to compare its performance with that of mid‐trimester sonographic cervical‐length (CL) measurement.

Contribution of Amniotic Fluid along Gestation to the Prediction of Perinatal Mortality in Women with Early Preterm Premature Rupture of Membranes

Introduction: To evaluate the largest vertical pocket (LVP) of amniotic fluid as a time-dependent factor to predict perinatal mortality in women with early preterm premature rupture of membranes (EPPROM). Material and Methods: Observational cohort study of singleton pregnancies with EPPROM <24 weeks. Termination of pregnancy (TOP) was considered if the LVP was <2 cm at 7 days. The maternal and neonatal characteristics of ongoing pregnancies were recorded. Prediction of perinatal mortality was estimated based on the influence of the LVP as a time-dependent factor after adjustment for maternal age, prior invasive procedure, and gestational age at EPPROM. Results: Of 104 women, 39 requested TOP. Neonatal survival to discharge was 40%, increasing to 74% if pregnancies achieved 24 weeks. LVP at admission <1 cm, latency to delivery, and gestational age at delivery were independent predictors of perinatal mortality. When evaluating the LVP at different time points of gestation, the highest perinatal mortality risk was established at 2 weeks (odds ratio 14.67, p < 0.001) after membrane rupture, being 5.75 (p = 0.05) the week after and 10.93 (p = 0.037) beyond 2 weeks of EPPROM. Discussion: When LVP measurement, gestational age at EPPROM, maternal age, and prior invasive procedure were considered, we found that the worst prognosis related to perinatal mortality was at 2 weeks after EPPROM.

Cervical consistency index and risk of cesarean delivery after induction of labor at term: Cervical consistency index and induction of labor

To evaluate the association between the cervical consistency index (CCI) and the risk of Cesarean delivery after planned induction of labor (IOL) at term.

Clinical Feasibility of Quantitative Ultrasound Texture Analysis: A Robustness Study Using Fetal Lung Ultrasound Images

To compare the robustness of several methods based on quantitative ultrasound (US) texture analysis to evaluate its feasibility for extracting features from US images to use as a clinical diagnostic tool.

Clinical and Sonographic Model to Predict Cesarean Delivery after Induction of Labor at Term

Objective: To develop a model combining clinical and sonographic features to predict the risk of cesarean delivery after the induction of labor (IOL). Methods: We designed a prospective observational study involving women admitted for IOL. The main outcome was defined as cesarean delivery due to failed IOL or arrest of labor. Several clinical and ultrasonographic variables were collected. Seventy percent of the sample was used to build the predictive model, using stepwise logistic regression, while the remaining sample was used for validation. The final model was estimated and calibrated using all participants. Results: We analyzed 477 pregnancies. The main outcome occurred in 102/477 (21.4%) women. The final model included previous vaginal delivery (odds ratio [OR] 0.088; 95% confidence interval [CI] 0.04–0.21), height (OR 0.904; 95% CI 0.87–0.94), body mass index before delivery (OR 1.084; 95% CI 1.02–1.15), ultrasonographic estimated fetal weight (OR 3.965; 95% CI 2.18–7.22), and ultrasonographic cervical length (OR 1.065; 95% CI 1.04–1.09) as predictors. Area under the receiver operating characteristics curve was 0.826 (95% CI 0.78–0.87). For a 5% false-positive rate, the sensitivity, specificity, and positive and negative likelihood ratios were 44.1%, 94.9%, 8.7, and 0.59, respectively. Conclusion: Our model combining clinical and ultrasonographic features might offer individualized counseling regarding risk of cesarean delivery to women who are candidates for IOL.

Contents Vol. 41, 2017

R. Achiron, Tel Hashomer N.S. Adzick, Philadelphia, PA L. Allan, London A.A. Baschat, Baltimore, MD K.J. Blakemore, Baltimore, MD T.-H. Bui, Stockholm F.A. Chervenak, New York, NY T. Chiba, Tokyo R. Chmait, Los Angeles, CA F. Crispi, Barcelona J.E. De Lia, Milwaukee, WI J.A. Deprest, Leuven G.C. Di Renzo, Perugia J.W. Dudenhausen, Berlin N.M. Fisk, Brisbane, QLD A.W. Flake, Philadelphia, PA U. Gembruch, Bonn M.R. Harrison, San Francisco, CA J.C. Hobbins, Denver, CO L.K. Hornberger, Edmonton, AB E.R.M. Jauniaux, London M.P. Johnson, Philadelphia, PA J.-M. Jouannic, Paris P.M. Kyle, London O. Lapaire, Basel S. Lipitz, Tel Hashomer E. Llurba, Barcelona G. Malinger, Tel Aviv G. Mari, Detroit, MI M. Martinez-Ferro, Buenos Aires A. McLennan, Sydney, NSW K.J. Moise, Houston, TX F. Molina, Granada K.H. Nicolaides, London L. Otaño, Buenos Aires Z. Papp, Budapest R.A. Quintero, Miami, FL G. Ryan, Toronto, ON J. Rychik, Philadelphia, PA H. Sago, Tokyo W. Sepulveda, Santiago P. Stone, Auckland D.V. Surbek, Bern B.J. Trudinger, Westmead, NSW Y. Ville, Paris J.M.G. van Vugt, Nijmegen Clinical Advances and Basic Research

Successful Fetoscopic Surgery to Release a Complete Obstruction of the Urethral Meatus in a Case of Congenital Megalourethra

We report the successful use of fetoscopy to treat a case of severe low urinary tract obstruction (LUTO) secondary to a congenital megalourethra. A second trimester male fetus presented at 21 weeks of gestation with massive dilatation of the penile urethra. In addition, bilateral hydronephrosis, an enlarged and hypertrophic bladder, with progressive oligohydramnios were found, suggesting poor prognosis. Extensive counselling was performed and, after the approval from the local ethics committee and informed consent, patients accepted fetal therapy by fetoscopy. The procedure consisted in fetoscopic identification of the tip of the penis and confirmation of the complete absence of the urethral meatus. Thereafter, under combined endoscopic and ultrasound guidance a perforation of the tip of the penis was performed with contact diode laser, until an opening into the urethra was achieved. After the operation, resolution of the cystic penile dilation, with reduction of the penile size, and normalization of the amniotic fluid volume were observed. The pregnancy continued uneventfully and a normal male infant was born at term at the local hospital. The baby was developing normally with normal renal function at 6 months of age. Our report demonstrates that fetoscopic decompression of a distal urethra obstruction can achieve neonatal survival in the rare event of congenital megalourethra.