K. Kalache

Transperineal ultrasound imaging in prolonged second stage of labor with occipitoanterior presenting fetuses: how well does the ‘angle of progression’ predict the mode of delivery?

To compare the angle of progression on transperineal ultrasound imaging between different modes of delivery in prolonged second stage of labor with occipitoanterior fetal position.

Associated Malformations and Chromosomal Defects in Congenital Diaphragmatic Hernia

In order to determine the frequency of associated malformations and chromosomal defects in patients with congenital diaphragmatic hernia (CDH) our experiences with CDH during the last 8 years (1985-1993) were reviewed. During the study period, 33 fetuses (prenatal group) with CDH were examined at our level III ultrasound department. In the same period 11 neonates (postnatal group) were admitted to our pediatric surgical unit after postnatal diagnosis of a CDH. Those cases had not been suspicious for CDH during prenatal level I scan. In 24 (72.7%) of the cases with CDH seen prenatally, at least one or more extradiaphragmatic malformations could be detected. Most of them affected the cardiovascular, skeletal, genitourinary and nervous system. Six (18.1%) fetuses had chromosomal abnormalities, especially trisomy 18. In contrast to these findings just 4 of the 11 babies (36.3%) seen postnatally had associated malformations and all of them had a normal chromosome set. Survival rate of fetuses with CDH and associated anomalies (7.1%) was poor, in contrast to those with an isolated CDH (43.7%). Prenatal ultrasound investigations being suspect for CDH should encourage the clinician to make further diagnostical efforts. This includes detailed ultrasound examination and cytogenetic analysis. Associated malformations as well as chromosomal defects are often present in affected patients.

Measurement of fetal head descent using the 'angle of progression' on transperineal ultrasound imaging is reliable regardless of fetal head station or ultrasound expertise.

To assess whether ultrasound experience or fetal head station affects the reliability of measurement of fetal head descent using the angle of progression on intrapartum ultrasound images obtained by a single experienced operator, and to determine reliability of measurements when images were acquired by different operators with variable ultrasound experience.

Right aortic arch with vascular ring and aberrant left subclavian artery: prenatal diagnosis assisted by three‐dimensional power Doppler ultrasound

The prenatal detection of a right-sided aortic arch achieved mainly by targeted visualization of the threevessel and three vessels and trachea (3VT) view, with or without color Doppler, has been discussed recently in this journal1–4. Two typical forms of a right aortic arch can be distinguished5,6. In one condition a vascular ring is found around the trachea, the so-called U-sign prenatally (Figure 1)2,3. The trachea and esophagus are entrapped between the right aortic arch and the left ductus arteriosus and this abnormality is often an isolated incidental finding prenatally2. In the other condition, both the aorta and ductus arteriosus lie to the right of the trachea without a vascular ring. This condition is very commonly associated with cardiac anomalies5. The branching pattern of the great vessels arising from the aortic arch in both conditions is of major interest in pediatric cardiology5,6. The right aortic arch without a vascular ring usually exhibits mirror image branching of the arteries with the left innominate (brachiocephalic) artery arising first followed by the right common carotid and right subclavian artery6. By contrast, the right aortic arch with vascular ring very often has an association with an aberrant left subclavian artery. The left common carotid arises first from the aortic arch, followed by the right common carotid, right subclavian artery, and finally a retroesophageal vessel segment from which the left subclavian artery arises and the ductus arteriosus connects. The retroesophageal (and retrotracheal) vessel segment is known as the diverticulum of Kommerell. In other words, the left subclavian artery is connected ventrally to the ductus arteriosus arising from the left pulmonary artery, and dorsally through the Kommerell’s diverticulum to the descending aorta. In postnatal life, after closure of the ductus arteriosus, blood enters the left subclavian artery via the descending aorta and Kommerell’s diverticulum4. Prenatal assessment of a right-sided aortic arch and its branching pattern requires scanning in such planes as a transverse 3VT view (Figure 1), oblique cephalad Left

Pulmonary arterial Doppler velocimetry in fetuses with lung hypoplasia.

OBJECTIVE The aim of the study was to examine Doppler flow velocity waveforms in the main stems of the pulmonary arteries in fetuses with autopsy-proven lung hypoplasia and to find out whether in these conditions typical patterns can be found. STUDY DESIGN Doppler spectra were derived from the main stem of the right or left pulmonary artery in fetuses at high-risk for lung-hypoplasia. The following Doppler parameters were analyzed and compared to reference ranges: peak systolic velocity, acceleration time, time velocity integral, end-systolic reverse flow, pulsatility index (PI). Pulmonary hypoplasia was found in nine cases at autopsy after termination of pregnancy (19-23 weeks). According to etiology, three groups were considered: (A) bilateral renal malformations (n=4), (B) congenital diaphragmatic hernia (n=2), and (C) miscellaneous malformations including heart defects (n=3). RESULTS The following Doppler parameters were found: normal values in end-systolic reversal flow in all cases, decreased peak systolic velocity and acceleration time in 3/9, decreased time velocity integral in 4/9 and increased pulsatility index in 6/9. Considering the etiology of pulmonary hypoplasia the pulsatility index was found to be the most sensitive, since all fetuses in groups A and B had an abnormal PI. CONCLUSIONS Human fetuses with renal malformations and diaphragmatic hernia associated with lung hypoplasia show as early as 19-23 weeks of gestation an abnormal Doppler spectrum in the main stems of the pulmonary arteries. Increased PI is the best parameter to detect flow abnormality in this condition. Since the Doppler spectrum depends on cardiac anatomy and function, PI in lung hypoplasia seems to be reliable only when cardiac defects are absent.

Relationship between fetal head station established using an open magnetic resonance imaging scanner and the angle of progression determined by transperineal ultrasound

We investigated the correlation between the angle of progression measured by transperineal ultrasound and fetal head station measured by open magnetic resonance imaging (MRI), the gold standard, in pregnant women at full term.

Human birth observed in real-time open magnetic resonance imaging

OBJECTIVE Knowledge about the mechanism of labor is based on assumptions and radiographic studies performed decades ago. The goal of this study was to describe the relationship between the fetus and the pelvis as the fetus travels through the birth canal, using an open magnetic resonance imaging (MRI) scanner. STUDY DESIGN The design of the study used a real-time MRI series during delivery of the fetal head. RESULTS Delivery occurred by progressive head extension. However, extension was a very late movement that was observed when the occiput was in close contact with the inferior margin of the symphysis pubis, occurring simultaneously with gliding downward of the fetal head. CONCLUSION This observational study shows, for the first time, that birth can be analyzed with real-time MRI. MRI technology allows assessment of maternal and fetal anatomy during labor and delivery.

Correlation of midtrimester amniotic fluid cytokine concentrations with adverse pregnancy outcome in terms of spontaneous abortion, preterm birth, and preeclampsia

Objective: To assess midtrimester amniotic fluid concentrations of three major proinflammatory cytokines (IL-6, IL-8, and TNF-α) in asymptomatic pregnancies with adverse outcomes. Methods: A prospective follow up study at the Charité University Hospital, Berlin, Germany of women with uncomplicated singleton pregnancies at second trimester and amniocentesis. Concentrations of IL-6, IL-8, and TNF-α were measured by enzyme-linked immunosorbent assay following amniotic fluid assessment by midtrimester amniocentesis performed from gestation days 15 weeks 0 days up to 20 weeks 6 days. Values from normal pregnancies were compared to those from pregnancies having adverse outcomes of spontaneous abortion, preterm delivery, preeclampsia, or eclampsia. Main outcome measure IL-6, IL-8 and TNF-α in relation to adverse pregnancy outcome. Results: A total of 298 consecutive patients were evaluated. Median patient age was 35 years (range 19–43). Controls consisted of 273 women who delivered without further complications after 37 weeks gestation. The range values of IL-6, IL-8, and TNF-α in the control group were 4.9–2620 pg/mL, 36.2–5843 pg/mL, and 8.0–28.2 pg/mL, respectively. Patients with adverse pregnancy outcome (n = 25) were classified into three groups: spontaneous abortion group (n = 4), preterm delivery group (n = 17), and preeclampsia/eclampsia group (n = 4). There were no significant differences in IL-6, IL-8, and TNF-α between controls and study groups, regardless of the type of complication (p > 0.05). Conclusion: Midtrimester amniotic fluid concentrations of the proinflammatory cytokines IL-6, IL-8, and TNF-α are not predictive of adverse pregnancy outcome in terms of spontaneous abortion, preterm delivery or preeclampsia/eclampsia in our study population.

Three‐dimensional ultrasound in evaluating the fetus

In recent years three‐dimensional (3D) ultrasound has made a place in clinical practice and has become a major field of research in obstetrics. In this article we will review the diagnostic performance of the most widely used 3D ultrasound applications in the assessment of fetal anomalies, explain the technique to gain correct 3D images and offer some practical advice for their efficient use. Examples are given to demonstrate the applicability and vividness of 3D in daily routine. Copyright

Impact of intrapartal ultrasound to assess fetal head position and station on the type of obstetrical interventions at full cervical dilatation

Objectives: Recent ultrasound studies have shown that it is feasible to objectively and reproducibly assess fetal head position and station within the pelvis. We sought to evaluate the impact of this new approach on decision making by physicians in a cohort of women with a prolonged second stage of labor. Methods: This was a retrospective cohort study that included all women with fetuses in cephalic presentation, who were diagnosed with a prolonged second stage of labor, and who delivered in a 1-year period. We compared a group of women (n = 121) with a prolonged second stage of labor who underwent intrapartal ultrasound prior to obstetrical intervention (Group A, n = 43) with a group of women for whom the delivery modus was decided upon after clinical digital examination alone (Group B, n = 78). Results: There were no significant differences in maternal and neonatal morbidity between both groups. The rate of second-stage cesarean section was significantly higher (p < 0.50) in Group B without ultrasound compared to Group A with ultrasound prior to operative delivery (20/78 vs. 7/43). Seven patients in Group A delivered spontaneously, but none of the patients in Group B had spontaneous deliveries. Conclusions: Intrapartal ultrasound in patients with a prolonged second stage of labor may change obstetrical practice by reducing the number of second stage cesarean section without increasing maternal and neonatal morbidity.