T. Arcangeli

Intrapartum transperineal ultrasound assessment of fetal head progression in active second stage of labor and mode of delivery

To compare longitudinal changes in angle of progression (AoP) and midline angle (MLA) during the active second stage of labor according to the mode of delivery.

Intrapartum three‐dimensional ultrasonographic imaging of face presentations: report of two cases

The term ‘right aortic arch’ (RAA) refers to a congenital abnormal position of the aortic arch, that is, to the right of the trachea, with or without an abnormal branching pattern, and is one of the least frequently prenatally diagnosed cardiac abnormalities1–3. The main clue for the detection of RAA in large population studies and small case series has been absence of the normal ‘V’shaped confluence of the ductal and aortic arches (both to the left of the trachea) in the axial three vessels and trachea (3VT) view1–7, as a RAA and left ductus form an abnormal ‘U’-shape. Reviewing papers that have evaluated the associated conditions and outcomes of the different types of RAA, its occurrence with a right ductus arteriosus (RDA) has been reported with severe cardiac anomalies (tetralogy of Fallot, pulmonary atresia with ventricular septal defect, common arterial trunk)3,7,8 and high rates of 22q11 deletions7,9,10. We describe here a case of RAA with a RDA in which the heart was normal. This was easily recognizable in the 3VT view from the first trimester onwards, independent of the angle of insonation. Sonographic evaluations and image acquisitions were performed transabdominally using a Voluson 730 ultrasound machine (GE Medical Systems, Zipf, Austria). A 31-yearold low-risk pregnant woman, gravida 1 para 0, attended for first-trimester screening at our center. A cardiac transverse sweep showed an anatomically and functionally normal fetal heart, but a right-sided aortic arch and a V-shaped confluence with a patent RDA were observed on the 3VT view (Figure 1). Offline analysis by examiners experienced in fetal echocardiography resulted in similar conclusions. Invasive tests ruled out karyotype and 22q11 abnormalities. During the second and third trimesters normal views of the fetal heart were found on the standard axial approach (situs, area, axis, cardiac chambers, emergence of great vessels) (Figures 2a–c and Videoclip S1) and, in accordance with previous findings, an RAA and patent RDA were identified as a V-shaped

Mode of delivery in the preterm gestation and maternal and neonatal outcome.

Objective. To determine if the mode of delivery in preterm gestations is associated with changes in maternal and neonatal outcome. Methods. A retrospective cohort study that included all singleton deliveries occurring after spontaneous onset of labour between 25 + 0 and 32 + 6 weeks of gestation. Cases of early preterm delivery were identified from clinical records and classified according to the mode of delivery. The following outcomes were derived for each case and compared between caesarean and vaginal deliveries: perinatal death, cranial findings compatible with haemorrhage or white matter disease in the neonate, new-onset of maternal severe anaemia or pyrexia. Results. From 1990 to 2007, 109 cases of spontaneous preterm labour were retrospectively selected, including 50 (45.8%) caesarean sections and 59 (54.2%) vaginal deliveries. Perinatal death occurred in 10 infants (9.1%), whereas among survivors abnormal cerebral findings were detected in 20, including 6 cases with haemorrhage, 12 with white matter findings and 2 with both. At multiple logistic regression, a birthweight lower than 1100 g was the only predictor of all adverse outcomes, whereas male sex increased the risk of white matter findings. Caesarean section compared to vaginal delivery conferred a higher risk of maternal complications (23/50 or 46% vs. 6/59 or 10.2%; OR: 11.9, CI 95%: 4.2–333; p < 0.0005). Conclusions. In severely premature infants born after spontaneous onset of labour, the risk of adverse perinatal outcome does not seem to depend upon the mode of delivery, whereas the risk of maternal complications is significantly increased after Caesarean section.

Three‐dimensional sonographic imaging of fetal bilateral cleft lip and palate in the first trimester

The introduction of three-dimensional (3D) ultrasound imaging has greatly improved the prenatal assessment of fetal face anomalies. We report a case of bilateral cleft lip and palate that was suspected on two-dimensional (2D) ultrasound examination during a routine first-trimester scan. The use of 3D ultrasonography enabled a more accurate depiction of the defect. A 30-year-old Caucasian primigravida attended the ultrasound department of our university hospital at 12 weeks’ gestation for nuchal translucency assessment. The ultrasound scan was performed transabdominally using a Voluson 730 Pro (GE Healthcare, Milan, Italy). Fetal biometry was compatible with the date of the woman’s last menstrual period (crown–rump length, 64 mm) and nuchal translucency was within the normal range (1.6 mm). On 2D imaging a bilateral facial cleft was suspected owing to the bulging of the premaxilla in the mid-sagittal plane of the fetal face (Figure 1). No additional anomalies were noted. Three-dimensional ultrasound assessment was carried out in order to achieve a more accurate depiction of the defect. On multiplanar imaging a cleft extending to the palate on either side was confirmed (Figure 2a). The surfacerendered coronal image of the fetal face confirmed the presence of the bilateral cleft lip and a premaxillary protrusion (Figure 2b). After counseling the couple opted for termination of pregnancy, which was carried out by forceps and curettage without fetal karyotyping. A bilateral cleft lip and palate was confirmed visually in the aborted fetus, although a systematic postmortem assessment was not feasible owing to the early gestational age and to the procedure-related specimen disruption. In expert hands 2D ultrasound examination is accurate in the prenatal detection and classification of facial clefts, leading to a correct assessment of both laterality and involvement of the palate in the vast majority of cases1–3. In our case a correct diagnosis of the defect was achieved by 2D ultrasound examination at 12 weeks of gestation. This is extremely unusual; the prenatal diagnosis of facial clefts during the second trimester is common but only a

Communication in the neonatal intensive care unit: a continuous challenge

Aim: Communication between the healthcare team and the parents in Neonatal Intensive Care Unit (NICU) is very important, and may affect both trust in medical team and the health of premature babies. The aim of this study is to confirm that a good relationship with families can be obtained if all the healthcare team adopts a good common communication scheme. Methods: We have implemented a communication strategy that works through three stages: (1) Training in Communication: a course about general problems with communication for medical and nursing staff. (2) Communicative Algorithm: various guidelines to follow during the most common scenarios in the NICU. (3) Communicative Case Sheet: a notebook used to record any problem or discomfort that occurs during communication. We applied the strategy for a 12 months trial period. Results: A Systemic Counselling Institute of Medical Psychology tested families’ satisfaction at the end of the period. The test showed that in 75% of cases, satisfaction with communication was very good and in the remaining 25%, parents perceived communication as good, but improvable. Conclusion: In NICU, communication between the members of the team and the newborn’s parents may be improved by specific tools.

Accuracy of fetal gender determination in the first trimester using three-dimensional ultrasound

To evaluate the accuracy of three‐dimensional (3D) ultrasound in fetal gender assignment in the first trimester.

Neonatal hypoxic-ischemic encephalopathy in apparently low risk pregnancies: Retrospective analysis of the last five years at the University of Bologna

Objective. To provide recent figures on the occurrence of neonatal hypoxic-ischemic encephalopathy (NHIE) from a Teaching Hospital. Study Design. A retrospective case–control study was conducted in a tertiary level university hospital with more than 3000 deliveries annually. Twenty-four cases of NHIE that occurred in apparently low-risk pregnancies were analysed and compared to a group of controls for the most common labor variables. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Results. Of 15,371 apparently low-risk deliveries, 24 cases of NHIE were observed (0.16%), with perinatal death or cerebral palsy occurring in nine of these cases (0.06%). The following intra-partum variables were significantly more common in cases than in controls: stained amniotic fluid (OR: 7.50; 95% CI:1.77–31.79), maternal fever (none in the control group), abnormal CTG (OR: 253.0; 95% CI: 26.70–2397), persistent occiput posterior (OR: 15.67; 95% CI: 2.25–104.53) and operative delivery (OR: 3.98; 95% CI: 1.39–11.33). Conclusion. The incidence of NHIE is considerably low in a Tertiary care Centre.

Significance of uteroplacental Doppler at midtrimester in patients with favourable obstetric history

Objective: To reassess the usefulness of midtrimester uterine Doppler in low-risk multiparous women. Methods: We prospectively recruited low-risk pregnant women at 20–22 weeks attending our clinic. Among those, women with a favourable obstetric history (group A) were distinguished from nulliparous (group B) and of each group we measured uterine artery Doppler (pulsatility index (PI)). We evaluated the accuracy of uterine artery Doppler in the prediction of preeclampsia and small for gestational age (SGA) neonates. Results: Between January 2009 and October 2010, 382 women were included in the study of which 147 in group A and 235 in group B. Overall, 26/382 (6.8%) women presented preeclampsia and SGA occurred in 59/382 (15.4%) cases. In our population, at a 10% false positive rate (FPR) uterine artery Doppler showed a detection rate (DR) of 19.2% for preeclampsia and of 37.3% for SGA, with a higher sensitivity for SGA neonates delivered ≤ vs. >34 weeks (87% vs. 29.4%). The univariable receiver operating characteristics (ROC) curve by uterine artery PI yielded a significant prediction only for SGA in nulliparous women (areas under the curve (AUC) of 0.70; 95% CI 0.60–0.79). Conclusions: Our data confirmed that midtrimester uterine artery Doppler is not an efficient strategy in anticipating the risk of pregnancy complications among low-risk multiparous women.

The descent of the fetal head is not modified by mobile epidural analgesia: a controlled sonographic study

The aim of our study was to assess the sonographic indices of fetal head progression obtained by three‐dimensional ultrasound during the second stage of labor in women with and without mobile epidural analgesia. Sonographic volume data sets were obtained with a transperineal approach every 20 min from the beginning of the active second stage until delivery. The ultrasound parameters were calculated off‐line from each volume and compared between women with and without epidural analgesia. All the sonographic measurements of the fetal head descent were comparable at each time interval between the two groups. This observation suggests that mobile epidural analgesia is not likely to affect the dynamics of the second stage of labor.

Three-dimensional ultrasound is an accurate and reproducible technique for fetal crown-rump length measurement

The aim of the study was to evaluate the accuracy and reproducibility of fetal crown‐rump length (CRL) measurement using three‐dimensional ultrasound (3DUS).