G. Centini

Cervical ripening and induction of labor by prostaglandin E2: a comparison between intracervical gel and vaginal pessary

Objective: To compare the effectiveness and safety of two formulations of prostaglandin (PG) E2 (gel and pessary) for induction of labor. Primary outcomes were cervical ripening, initiation/ duration of labor, and type of delivery. Study design: A total of 115 women with singleton gestations were consecutively enrolled and assigned to receive intracervical PGE2 (dinoprostone 0.5 mg) by gel (n = 66) or PGE2 (dinoprostone 10 mg) by intravaginal pessary (n = 49). Results: Independently from parity, the vaginal pessary induced successful cervical ripening with a slightly higher but not statistically significant occurrence of vaginal delivery with respect to gel induction. The mean time interval from induction to vaginal delivery did not differ between groups, despite being shorter for the pessary group in inducation-delivery intervals > 12 h. No significant differences were found between the groups with respect to patients who required a second course of PGE2 (9% vs. 2%), as well as oxytocin (11% vs. 13%) induction. No significant difference was found in the incidence of uterine hyperstimulation and other adverse reactions in nulliparas, or in fetal and neonatal outcome. Conclusion: Independently from parity, both PGE2 administration routes appeared to be effective in achieving cervical ripening, initiation of labor and optimal type of delivery, and showed the same incidence of side-effects.

A case of cervical pregnancy.

A cervical pregnancy diagnosed by transvaginal ultrasonography and successfully treated by aspiration and curettage is disucssed.

First trimester three‐dimensional transvaginal imaging of alobar holoprosencephaly associated with proboscis and hypotelorism (ethmocephaly) in a 46,XX fetus

ABSTRACT  A 19‐year‐old woman was scanned at 10+6 weeks gestation by 2D‐3D ultrasound. The fetus had a crown‐rump length of 40.9 mm, with the cephalic pole occupied by a single cystic cavity measuring 10.6 × 7.7 × 6.8 mm and severe hypotelorism associated with mid‐facial hypoplasia. 3D ultrasound confirmed the malformations seen on the 2D scan and enabled the visualization of a proboscis and a low‐set right ear. Fetal karyotyping was performed by chorionic villus sampling. Due to major fetal malformations of the fetus, the patient opted for termination of pregnancy. First trimester sonographic diagnosis of holoprosencephaly relies on bilateral visualization of choroid plexuses in what has been called the ‘butterfly’ sign. Differential diagnosis between holoprosencephaly and hydranencephaly may be difficult in the first trimester of pregnancy. However, midline structures such as falx cerebri, interhemispheric fissure and third ventricle are present in hydranencephaly and are absent in alobar holoprosencephaly, and thalami are never fused in hydranencephaly. 3D ultrasound has demonstrated an increased definition of anatomical abnormalities of malformations, compared with 2D ultrasound, and has proven to be crucial in the decision‐making process of parents and in later prenatal counseling, especially in this case where necroscopy examination was refused by the parents. Images obtained by 3D ultrasound gave detailed insight into this ventral midline anomaly, depicting much of the disordered prosencephalic development.

Amniotic fluid urocortin, CRF, oestriol, dehydroepiandrosterone sulfate and cortisol concentrations at mid-trimester: putative relationship with preterm delivery

OBJECTIVE Stress-related peptide and steroid hormones are involved in the pathogenesis of preterm delivery, even though their clinical usefulness as predictive markers of preterm delivery remains unclear. The present study evaluated whether mid-trimester amniotic fluid concentrations of stress-related peptides, that is corticothophin-releasing factor (CRF) and urocortin (Ucn) and feto-placental steroids (oestriol, DHEA-S and cortisol) correlated with preterm delivery. STUDY DESIGN It is a retrospective case-control study. Healthy women (n=130) undergoing amniocentesis at mid-gestation for genetic indications, of whom 15 had a preterm delivery (cases) and 115 delivered at term (controls). CRF, urocortin, cortisol, DHEA-S and oestriol concentrations were measured by specific and sensitive immunoenzymatic assays. RESULTS Amniotic fluid urocortin concentrations in the cases (0.50+/-0.07 ng/ml) (M+/-SD) were significantly lower (P<0.0001) than in the control group (0.90+/-0.26 ng/ml), while CRF concentrations did not differ between the cases (1.52+/-0.39 ng/ml) and control group (1.64+/-0.68 ng/ml). Amniotic fluid cortisol (17.71+/-3.72 ng/ml vs. 17.32+/-3.17 ng/ml), DHEA-S (0.16+/-0.06 ng/ml vs. 0.17+/-0.09 ng/ml) and oestriol (4.68+/-1.95 ng/ml vs. 4.79+/-1.84 ng/ml) concentrations were similar in the two groups. CONCLUSIONS The low amniotic fluid concentrations of urocortin at mid-trimester may be a signal of predisposition to preterm delivery, while the unchanged CRF and steroid hormones concentrations in women delivering preterm suggest that this mechanisms are not yet activated at mid-trimester.

Prenatal Diagnosis of Severe Epignathus in a Twin: Case Report and Review of the Literature

A prenatal ultrasound diagnosis of epignathus in a dichorionic-diamniotic twin pregnancy is reported. A complex mass protruding from the fetal face was seen at week 19. Amniocentesis resulted in a 46,XX fetus with elevated alpha-fetoprotein (α-FP). An increase in tumor size and severe polyhydramnios ensued. Selective feticide performed at 22 weeks led to untreatable uterine contractions with iatrogenic abortion and early neonatal mortality of the healthy cotwin. Without development of polyhydramnios and tumor growth, weekly scan and transvaginal cervical assessment would have been carried out and cesarean section planned at around 32 weeks. Necroscopy and histology aided the ultrasound-based prenatal diagnosis.

Neonatal porencephaly in very low birth weight infants: Ultrasound timing of asphyxial injury and neurodevelopmental outcome at two years of age

Objective. To investigate and diagnose the timing of asphyxial injury leading to cerebral cavitation with subsequent developing of neonatal porencephaly in the preterm VLBW infant. All newborns underwent careful neurodevelopmental outcome at 2 years of corrected age. Methods. 250 consecutive VLBW infants (mean gestational age of 28 weeks and mean birthweight of 1150 g) have been study by means of weekly neonatal transfontanellae ultrasonography. Periventricular white matter necrosis was diagnosed when echolucencies were visible after day 3 from birth. Results. Twelve cases of neonatal porencephaly were diagnosed by ultrasound. The timing of asphyxial insult leading to cerebral cavitation seems to have occurred in 33% of neonates during the antepartum period, in 42% during the peripartum period (antepartum + neonatal period) and 25% in the remaining neonatal period. Periventricular-intraventricular hemorrhage (PVH-IVH) was found in all cases and in 50% a severe IVH (grade III-IV) was diagnosed within 7 days neonatal period. Nine infants had evidence of cerebral palsy at 2 years neurological outcome. Conclusions. The ultrasound criteria of cerebral cavitation have been priorly selected in order to assure that the damage may have occurred before delivery. A comprehensive prenatal study of fetal brain, integrating ultrasound with high-velocity MRI, is also advocate. This will lead to a more detailed understanding of the underlying cerebral condition that is of critical importance for the clinician in planning the time and mode of delivery and have great deal with further medico-legal consideration.

4D vs 2D ultrasound-guided amniocentesis

The aim of this study was to assess the effectiveness of 4D sonography (US) to guide amniocentesis when compared with standard 2D US, and to evaluate the impact this new method may have on needle placement, the number of needle insertions performed, and duration of the procedure.

Acrania-Anencephaly Associated with Hypospadias. Prenatal Ultrasound and MRI Diagnosis and Molecular Folate Metabolism Pathway Analysis

Acrania may occur as a single isolated malformation or associated with extracranial defects. Hypospadias is one of the most common congenital abnormalities of the genitalia frequently missed on prenatal sonograms. Second trimester two- and three-dimensional ultrasound and MRI diagnosis with necropsy and folate metabolism pathway analysis. The mechanisms leading to closure of both neural and urethral tubes, are far from being demonstrated, and molecular studies of this very rare association are lacking although it might be based on a common genetic mechanism, leading to a disturbed development pathway at the molecular level.

Sonographic Imaging of the Fetal Hard Palate During the Second-Trimester Pregnancy Scan Setting the Standard for 3D Sonography in a Training Program

Cleft lip and cleft palate are among the more common congenital abnormalities, representing the fourth most common birth defect in the United States, with an incidence of 1 in 700 live births. The study of fetal secondary palate has reached new potential due to new 3D applications— namely, tomographic sonography imaging and volume contrast imaging (VCI). The aim of this review is to describe the 3D sonographic setting for a systematic study of the fetal secondary palate during second-trimester pregnancy. Sonographers can easily achieve appropriate training in 3D scanning of the fetal face under expert tutoring. The sonographic study of the fetal secondary palate should become an integral part of the second-trimester scan. Technically, the axial and coronal sections are those that better display the 3D reconstruction, especially when the fetus is facing the transducer (profile section). The use of static VCI may enhance tomographic sonography imaging of the fetal secondary palate and should therefore be integrated in this target examination.

Can 3D Ultrasound and Doppler Angiography of Great Arteries Be Included in Second Trimester Ecocardiographic Examination? A Prospective Study on Low‐Risk Pregnancy Population

The introduction of new applications such as the spatiotemporal image correlation (STIC) and the tomographic ultrasound imaging (TUI) has greatly enhanced the study of cardiac and vessels anatomy. The aim of our study was to assess the feasibility of including real‐time volumetric 3D reconstruction of heart anatomy and Doppler angiography of great vessels during routine second trimester pregnancy scan, in a low‐risk population. Visualization of the pulmonary veins, ductus venosus and inferior vena cava was significantly superior with 3D ultrasound. Therefore, STIC makes it possible to store heart beats for a mean time of 10 s, to replay acquired volumes in slow motion, to study the heart atrium along three axes and retrace volumetric image storage inversely from the apex to the base of the heart, making reconstruction of the four‐chamber view and great artery outflow tract much easier and faster. Furthermore, the use of digital communication allow operators to store and send volume of images that can be postprocessed by external consultant specialists worldwide. Although 3D echocardiography is less time‐consuming and independent of fetal positioning in utero when compared with 2D it may be premature to include 3D and 3D Doppler angiography among routine examination. However, the study of the outflow tracts by 2D echocardiography should be implemented in order to improve the diagnostic accuracy of CHDs. At present, only “targeted” cases in which a routine 2D scan has raised diagnostic doubts should undergo a second level sonography for a thorough 2D‐3D examination of cardiac and vessels anatomy.