Susana Santo

Human factors affecting the interpretation of fetal heart rate tracings: an update.

Purpose of review Human factors can have an important impact on cardiotocography (CTG) interpretation and management decisions, and therefore may directly affect obstetrical outcomes. Recent findings It has been well demonstrated that there is wide observer disagreement over CTG interpretation, particularly in the evaluation of variability, decelerations, and overall tracing classification. The reasons behind this are still incompletely understood, but poor reproducibility can have a profound impact on the technologys accuracy and on its efficacy. Some scientific societies have recently revised their guidelines for CTG interpretation, but no up-to-date universally accepted recommendation exists. In spite of some approximation between the major guideline sets, important differences still exist between them, and they remain complex and prone to memory decay. Regular training in CTG interpretation appears to result in increased knowledge, better observer agreement, and improved quality of care. Computer analysis has also been developed, but remains heavily dependent on staff to confirm interpretation and to decide clinical management. Summary An international consensus, comprising simpler and more objective interpretation guidelines, together with regular staff training, and improved decision support systems seem to be the way forward for this technology.

Prenatal ultrasonographic diagnosis of vein of Galen aneurysms – report of two cases

Aneurysms of the vein of Galen (AVG) represent less than 1% of all intracranial arteriovenous malformations. Two cases of prenatal diagnosis made by color Doppler ultrasonography at 32 weeks of gestation are reported. Both cases presented with antenatal mild cardiomegaly and both developed severe cardiac failure in the neonatal period. Embolization was unsuccessful and both infants died. These cases highlight the need for a careful evaluation of the time and mode of delivery; embolization must be performed after a fully informed decision.

Agreement and accuracy using the FIGO, ACOG and NICE cardiotocography interpretation guidelines

One of the limitations reported with cardiotocography is the modest interobserver agreement observed in tracing interpretation. This study compared agreement, reliability and accuracy of cardiotocography interpretation using the International Federation of Gynecology and Obstetrics, American College of Obstetrics and Gynecology and National Institute for Health and Care Excellence guidelines.

Fetal bronchopulmonary malformations

Abstract Introduction: Fetal body tumors are rare, but the ability to diagnose them has improved over recent years. Most masses discovered in the chest results from fetal bronchopulmonary malformations, such as congenital cystic adenomatoid malformation and bronchopulmonary sequestration. Congenital cystic adenomatoid malformation and bronchopulmonary sequestration have a reported incidence of 50% and 33% of all prenatally diagnosed lung lesions, respectively. Material and methods: Retrospective analysis of the congenital cystic adenomatoid malformation and bronchopulmonary sequestration cases diagnosed or surveilled at our department, between January 2003 and March 2013. Prenatal examination, evolution, management and patient outcome were analyzed. Results: A total of 918 fetal malformations were diagnosed at our hospital, 17 of them representing fetal bronchopulmonary malformations. The majority were diagnosed during the second trimester and stabilized or regressed during the third trimester of pregnancy. The pregnancies and deliveries had no other relevant findings or complications, except in three cases. Nine children required surgery. All of the children are healthy and have a normal development, with regular surveillance by the pediatricians. Discussion: The majority of these fetal lung masses are isolated findings that partially regress during intrauterine life. With adequate postnatal surveillance and eventual surgery the prognosis is good.

Prenatal ultrasonographic diagnosis of abdominal cystic lymphangioma: A case report

Abdominal lymphangioma is a rare tumor of the lymphatic vessels. A case of an abdominal cystic lymphangioma identified at 22 weeks of gestation is reported. Ultrasonographic monitoring showed a progressive increase of mass size during the gestation. Pregnancy was terminated at 38 weeks and the newborn was submitted to a laparotomy with resection of all cystic structures. At the present time the infant is three years old and is doing well.

Labor Induction with 25-μg Misoprostol Vaginal Capsules

Aim: To evaluate the success rate and the safety profile of labor induction with a new misoprostol formulation – vaginal capsules of 25 μg of misoprostol. Methods: Labor induction was performed in 250 singleton term pregnancies; 149 (59.6%) were nulliparous. Vaginal capsules of 25 μg of misoprostol were placed in the posterior vaginal fornix every 6 h. Success rate, contractility and fetal heart rate abnormalities and fetal outcomes were evaluated. Results: The success rate of labor induction was 97.6%. The average number of vaginal administrations was 1.5. The mean interval between induction and active labor was 10 h and 20 min and the average length of labor was 15 h and 35 min. The cesarean section rate was 18.8%. There were 15 cases of tachysystole, 3 cases of hypertonus and 1 case of hyperstimulation syndrome. There were no adverse neonatal outcomes. Conclusions: This study allowed to conclude that labor induction with vaginal capsules of 25 μg of misoprostol is associated with an excellent success rate and safety profile.

Mueller-Hillis maneuver and angle of progression: Are they correlated?

Objective: Mueller-Hillis maneuver (MHM) and angle of progression (AOP) measured by transperineal ultrasound have been used to assess fetal head descent during the second stage of labor. We aimed to assess whether AOP correlates with MHM in the second stage of labor. Method: A prospective observational study including women with singleton pregnancy in the second stage of labor was performed. The AOP was measured immediately after the Mueller-Hillis maneuver. A receiver-operating characteristics (ROC) curve analysis was performed to determine the best discriminatory AOP cut-off for the identification of a positive MHM. A p-value less than 0.05 was considered statistically significant. Results: One hundred and sixty-six (166) women were enrolled in the study and 81.3% (n=135) had a positive MHM. The median AOP was 143º (106º to 210º). The area under the curve for the prediction of a positive maneuver was 0.619 (p=0.040). Derived from the ROC curve, an AOP of 138.5º had the best diagnostic performance for the identification of a positive MHM (specificity of 65% and a sensitivity of 67%). Conclusion: An AOP of 138º seems to be associated with a positive MHM in the second stage of labor.

Maternal and neonatal immediate effects of sequential delivery

Objective: To evaluate the immediate maternal and neonatal outcomes associated with sequential instrumental delivery (vaccum plus forceps) compared with the use of one instrument only (forceps or vaccum). Study design: A longitudinal observational study was carried out, including all instrumental deliveries performed in term singleton pregnancies, in vertex presentation, at station level 0 or +1. According to the type of the instruments, the deliveries were divided in three groups: the vaccum group, the forceps group and the sequential group. Immediate maternal and neonatal outcomes were evaluated. Results: A total of 275 instrumental deliveries were performed: 126 (45.5%) vaccum assisted deliveries, 62 (22.6%) forceps assisted deliveries and 87 (31.6%) sequential deliveries. Regarding maternal morbidity, there was a significant difference between the three groups (p < 0.001), with a higher rate of complications in the sequential group. The type of instrument was the only factor associated with significant maternal morbidity. The rate of immediate neonatal morbidity was 4.4% and there was no significant association with the instrument type or with other identifiable factors. Conclusion: Sequential delivery is associated with a higher maternal morbidity and it seems not to increase neonatal morbidity.