Objective
To evaluate the level of agreement between ultrasound measurements to evaluate fetal head position and progress of labor by attending midwives and obstetricians after appropriate training.
...Methods
In this prospective study, women in the first stage of labor giving birth to a single baby in cephalic presentation at our Obstetric Unit between March 2018 and December 2019 were invited to participate; 109 women agreed. Transperineal and transabdominal ultrasound was independently performed by a trained midwife and an obstetrician. Two paired measurements were available for comparisons in 107 cases for the angle of progression (AoP), in 106 cases for the head‐to‐perineum distance (HPD), in 97 cases for the cervical dilatation (CD), and in 79 cases for the fetal head position.
Results
We found a good correlation between the AoP measured by obstetricians and midwives (intra‐class correlation coefficient ICC = 0.85; 95% confidence interval CI 0.80–0.89). There was a moderate correlation between the HPD (ICC = 0.75; 95% CI 0.68–0.82). There was a very good correlation between the CD measured (ICC = 0.94; 95% CI 0.91–0.96). There was a very good level of agreement in the classification of the fetal head position (Cohen's κ = 0.89; 95% CI 0.80–0.98).
Conclusions
Ultrasound assessment of fetal head position and progress of labor can effectively be performed by attending midwives without previous experience in ultrasound.
Synopsis
Ultrasound assessment of fetal head position and progress of labor can effectively be performed by attending midwives without previous experience on ultrasound.
Objective
We describe transvaginal color Doppler, HDlive, and HDlive Silhouette features of an umbilical cord cyst (UCC) before 11 weeks of gestation.
Methods
In this cohort study, 135 transvaginal ...dating scans were performed at 7 to 10 + 6 weeks of gestation, and 17 UCCs were identified (12.6%). UCC was evaluated using color Doppler, HDlive, and HDlive Silhouette. The clinical characteristics, pregnancy courses, and outcomes were also investigated.
Results
UCC location was on the fetal side in six cases, at the free loop in 10 cases, and on the placental side in one case. There were seven single and 10 multiple cysts. Cyst diameters ranged from 3.3 to 11.3 mm (mean, 5.6; standard deviation, ±2.1). Blood flow inside the cyst was noted in three cases (17.6%). HDlive clearly showed the spatial relationships among UCC, the umbilical cord, midgut herniation, yolk sac, and embryo. Location of UCC could be clearly identified with HDlive. HDlive Silhouette showed central cysts inside UCCs in seven cases (41.2%). HDlive Silhouette also clearly demonstrated the sac of midgut herniation in the umbilical cord in 12 cases (70.6%). All UCCs resolved before 15 weeks (mean, 11.1 weeks; standard deviation, ±1.5). All fetuses with UCCs showed good neonatal outcomes.
Conclusion
The incidence of UCC was high compared with that in previous reports. Color Doppler, HDlive, and HDlive Silhouette may provide information on the nature and origin of UCCs before 11 weeks of gestation. UCC before 11 weeks of gestation may be a common, transient, and benign finding.
Synopsis
An umbilical cord cyst before 11 weeks of gestation is a common, transient, and benign finding in utero.
Objective
To measure condition‐specific detection rates for 14 physical conditions screened for by the NHS fetal anomaly screening programme (FASP) fetal anomaly (FA) ultrasound scan.
Design
...Retrospective audit of 12 694 diagnoses across a 3‐year national cohort.
Setting
All English NHS and crown‐dependency hospital trusts providing maternity services.
Population
Pregnancies booked for maternity services with an expected date of delivery between 1 April 2017 and 31 March 2020 and at least one diagnosis of a condition screened for by FASP.
Methods
Active multi‐source ascertainment, linkage, audit and validation of clinical information to identify the subset of diagnoses meeting the condition‐specific positivity threshold for the FA scan.
Main outcome measure
The accuracy of the FA scan compared with diagnostic reference standards.
Results
FA scan detection rates were: anencephaly 96.3% (95% confidence interval CI 81.7–99.3%), atrioventricular septal defect: 69.2% (95% CI 65.8–72.4%), bilateral renal agenesis: 98.7% (95% CI 95.4–99.6%), cleft lip: 89.5% (95% CI 87.8–90.9%), congenital diaphragmatic hernia: 60.8% (95% CI 56.5–65%), Edwards syndrome: 73.8% (95% CI 67.5–79.3%), exomphalos: 59.4% (95% CI 49.4–68.7%), gastroschisis: 88.6% (95% CI 79–94.1%), hypoplastic left heart syndrome: 92.7% (95% CI 90–94.8%), lethal skeletal dysplasia: 93.2% (95% CI 88.6–96%), Patau syndrome: 82.3% (95% CI 72.4–89.1%), spina bifida: 93.8% (95% CI 91.8–95.3%), tetralogy of Fallot: 75.4% (95% CI 72.1–78.4%) and transposition of the great arteries: 84.9% (95% CI 81.7–87.5%).
Conclusions
The performance of the FA scan is above the expectations set in 2010 for most conditions. For the remaining conditions, the majority of fetuses and babies affected are detected before the FA scan.
Fetal interventions are often key to fetal survival and growth; however, they can often have complications causing significant morbidity and mortality. This case highlights not only a complication of ...fetal surgery, but also a very unusual diagnosis. We present the case of a male fetus who was diagnosed with urethral atresia and subsequently underwent 2 vesicoamniotic shunt placements. At birth, he was diagnosed with Megacystis Microcolon Intestinal Hypoperistalsis Syndrome and was noted to have rectovesical and vesicocutaneous fistulae likely iatrogenically created from shunt placement. While fetal interventions are often required, a multidisciplinary team approach is often necessary as complications occur.
Babies born large-for-gestational age have an increased risk of adverse health outcomes, including birth injuries, childhood obesity, and cardiometabolic disorders. However, little work has been done ...to characterize patterns of fetal growth among large-for-gestational age births, which may further elucidate high- and low-risk subgroups.
This study aimed to identify subgroups of large-for-gestational age births based on trajectories of fetal growth derived from prenatal ultrasound measurements and explore differences in sociodemographic, pregnancy, and birth outcome characteristics across subgroups.
This study identified and described trajectories of fetal growth among large-for-gestational age births (n=235) in the LIFECODES Fetal Growth Study. Ultrasound measurements of fetal growth in middle to late pregnancy were abstracted from health records. Group-based multi-trajectory modeling was applied to measurements of head circumference, abdominal circumference, and femur length z-scores to identify multivariate trajectories of fetal growth. Moreover, sociodemographic variables, pregnancy characteristics, and birth outcomes based on trajectory membership were summarized.
This study identified 4 multivariate trajectories of fetal growth among large-for-gestational age births: catch-up growth (n=28), proportional abdominal circumference–to–femur length growth (n=67), disproportional abdominal circumference–to–femur length growth (n=96), and consistently large (n=44). Fetuses in the “catch-up growth” group exhibited small relative sizes in midpregnancy (ie, below average head circumference, abdominal circumference, and femur length z-scores) and large relative sizes in late pregnancy. Growth among these births was driven by increases in relative abdominal circumference and head circumference sizes. Participants who delivered births assigned to this group were less likely to have normal glucose control (40% vs 65%–75%) and more likely to have pregestational diabetes mellitus (36% vs 10%–17%) than other large-for-gestational age subgroups. In addition, the babies in this trajectory group were more likely to have macrosomia (86% vs 67%–73%) and to be admitted to the neonatal intensive care unit (32% vs 14%–21%) than other large-for-gestational age subgroups. In contrast, babies in the “consistently large” group had the largest relative size for all growth parameters throughout gestation and experienced a lower risk of adverse birth outcomes than other large-for-gestational age subgroups.
This study characterized several trajectories of fetal growth among large-for-gestational age births, which were related to different pregnancy characteristics and the distribution of adverse birth outcomes. Although the number of individuals within some trajectories was small, a subgroup that exhibited a catch-up growth phenotype during gestation was identified, which may be uniquely associated with exposure to pregestational diabetes mellitus and a higher risk of admission to the neonatal intensive care unit. These results have highlighted that the risk of adverse outcomes may not be evenly distributed across all large-for-gestational age births.
Background
Stillbirth affects 2.6 million pregnancies worldwide each year. Whilst the majority of cases occur in low‐ and middle‐income countries, stillbirth remains an important clinical issue for ...high‐income countries (HICs) ‐ with both the UK and the USA reporting rates above the mean for HICs. In HICs, the most frequently reported association with stillbirth is placental dysfunction. Placental dysfunction may be evident clinically as fetal growth restriction (FGR) and small‐for‐dates infants. It can be caused by placental abruption or hypertensive disorders of pregnancy and many other disorders and factors
Placental abnormalities are noted in 11% to 65% of stillbirths. Identification of FGR is difficult in utero. Small‐for‐gestational age (SGA), as assessed after birth, is the most commonly used surrogate measure for this outcome. The degree of SGA is associated with the likelihood of FGR; 30% of infants with a birthweight < 10th centile are thought to be FGR, while 70% of infants with a birthweight < 3rd centile are thought to be FGR. Critically, SGA is the most significant antenatal risk factor for a stillborn infant. Correct identification of SGA infants is associated with a reduction in the perinatal mortality rate. However, currently used tests, such as measurement of symphysis‐fundal height, have a low reported sensitivity and specificity for the identification of SGA infants.
Objectives
The primary objective was to assess and compare the diagnostic accuracy of ultrasound assessment of fetal growth by estimated fetal weight (EFW) and placental biomarkers alone and in any combination used after 24 weeks of pregnancy in the identification of placental dysfunction as evidenced by either stillbirth, or birth of a SGA infant. Secondary objectives were to investigate the effect of clinical and methodological factors on test performance.
Search methods
We developed full search strategies with no language or date restrictions. The following sources were searched: MEDLINE, MEDLINE In Process and Embase via Ovid, Cochrane (Wiley) CENTRAL, Science Citation Index (Web of Science), CINAHL (EBSCO) with search strategies adapted for each database as required; ISRCTN Registry, UK Clinical Trials Gateway, WHO International Clinical Trials Portal and ClinicalTrials.gov for ongoing studies; specialist and conference proceeding resources (British Library’s ZETOC and Web of Science Conference Proceedings Citation Index). Search last conducted in Ocober 2016.
Selection criteria
We included studies of pregnant women of any age with a gestation of at least 24 weeks if relevant outcomes of pregnancy (live birth/stillbirth; SGA infant) were assessed. Studies were included irrespective of whether pregnant women were deemed to be low or high risk for complications or were of mixed populations (low and high risk). Pregnancies complicated by fetal abnormalities and multi‐fetal pregnancies were excluded as they have a higher risk of stillbirth from non‐placental causes. With regard to biochemical tests, we included assays performed using any technique and at any threshold used to determine test positivity.
Data collection and analysis
We extracted the numbers of true positive, false positive, false negative, and true negative test results from each study. We assessed risk of bias and applicability using the QUADAS‐2 tool. Meta‐analyses were performed using the hierarchical summary ROC model to estimate and compare test accuracy.
Main results
We included 91 studies that evaluated seven tests — blood tests for human placental lactogen (hPL), oestriol, placental growth factor (PlGF) and uric acid, ultrasound EFW and placental grading and urinary oestriol — in a total of 175,426 pregnant women, in which 15,471 pregnancies ended in the birth of a small baby and 740 pregnancies which ended in stillbirth. The quality of included studies was variable with most domains at low risk of bias although 59% of studies were deemed to be of unclear risk of bias for the reference standard domain. Fifty‐three per cent of studies were of high concern for applicability due to inclusion of only high‐ or low‐risk women.
Using all available data for SGA (86 studies; 159,490 pregnancies involving 15,471 SGA infants), there was evidence of a difference in accuracy (P < 0.0001) between the seven tests for detecting pregnancies that are SGA at birth. Ultrasound EFW was the most accurate test for detecting SGA at birth with a diagnostic odds ratio (DOR) of 21.3 (95% CI 13.1 to 34.6); hPL was the most accurate biochemical test with a DOR of 4.78 (95% CI 3.21 to 7.13). In a hypothetical cohort of 1000 pregnant women, at the median specificity of 0.88 and median prevalence of 19%, EFW, hPL, oestriol, urinary oestriol, uric acid, PlGF and placental grading will miss 50 (95% CI 32 to 68), 116 (97 to 133), 124 (108 to 137), 127 (95 to 152), 139 (118 to 154), 144 (118 to 161), and 144 (122 to 161) SGA infants, respectively. For the detection of pregnancies ending in stillbirth (21 studies; 100,687 pregnancies involving 740 stillbirths), in an indirect comparison of the four biochemical tests, PlGF was the most accurate test with a DOR of 49.2 (95% CI 12.7 to 191). In a hypothetical cohort of 1000 pregnant women, at the median specificity of 0.78 and median prevalence of 1.7%, PlGF, hPL, urinary oestriol and uric acid will miss 2 (95% CI 0 to 4), 4 (2 to 8), 6 (6 to 7) and 8 (3 to 13) stillbirths, respectively. No studies assessed the accuracy of ultrasound EFW for detection of pregnancy ending in stillbirth.
Authors' conclusions
Biochemical markers of placental dysfunction used alone have insufficient accuracy to identify pregnancies ending in SGA or stillbirth. Studies combining U and placental biomarkers are needed to determine whether this approach improves diagnostic accuracy over the use of ultrasound estimation of fetal size or biochemical markers of placental dysfunction used alone. Many of the studies included in this review were carried out between 1974 and 2016. Studies of placental substances were mostly carried out before 1991 and after 2013; earlier studies may not reflect developments in test technology.
This study aimed to compare the prognostic accuracy of intrapartum transperineal ultrasound measures of fetal descent before operative vaginal birth in predicting complicated or failed procedures.
We ...performed a predefined systematic search in Medline, Embase, CINAHL, and Scopus from inception to June 10, 2022.
We included studies assessing the following intrapartum transperineal ultrasound measures before operative vaginal birth to predict procedure outcome: angle of progression, head direction, head-perineum distance, head-symphysis distance, midline angle, and/or progression distance.
Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate meta-analysis was used to pool sensitivities and specificities into summary receiver operating characteristic curves for each intrapartum transperineal ultrasound measure. Subgroup analyses were performed for measures taken at rest vs with pushing and prediction of failed vs complicated operative vaginal birth.
Overall, 16 studies involving 2848 women undergoing attempted operative vaginal birth were included. The prognostic accuracy of intrapartum transperineal ultrasound measures taken at rest to predict failed or complicated operative vaginal birth was high for angle of progression (area under the receiver operating characteristic curve, 0.891; 9 studies) and progression distance (area under the receiver operating characteristic curve, 0.901; 3 studies), moderate for head direction (area under the receiver operating characteristic curve, 0.791; 6 studies) and head-perineum distance (area under the receiver operating characteristic curve, 0.747; 8 studies), and fair for midline angle (area under the receiver operating characteristic curve, 0.642; 4 studies). There was no study with sufficient data to assess head-symphysis distance. Subgroup analysis showed that measures taken with pushing tended to have a higher area under the receiver operating characteristic curve for angle of progression (0.927; 4 studies), progression distance (0.930; 2 studies), and midline angle (0.903; 3 studies), with a similar area under the receiver operating characteristic curve for head direction (0.802; 4 studies). The prediction of failed vs complicated operative vaginal birth tended to be less accurate for angle of progression (0.837 4 studies vs 0.907 6 studies) and head direction (0.745 3 studies vs 0.810 5 studies), predominantly because of lower specificity, and was more accurate for head-perineum distance (0.812 6 studies vs 0.687 2 studies).
Angle of progression, progression distance, and midline angle measured with pushing demonstrated the highest prognostic accuracy in predicting complicated or failed operative vaginal birth. Overall, the measurements seem to perform better with pushing than at rest.
Objective To improve the interpretation of future studies in women who are initially diagnosed with a pregnancy of unknown location (PUL), we propose a consensus statement with definitions of ...population, target disease, and final outcome. Design A review of literature and a series of collaborative international meetings were used to develop a consensus for definitions and final outcomes of women initially diagnosed with a PUL. Result(s) Global differences were noted in populations studied and in the definitions of outcomes. We propose to define initial ultrasound classification of findings into five categories: definite ectopic pregnancy (EP), probable EP, PUL, probable intrauterine pregnancy (IUP), and definite IUP. Patients with a PUL should be followed and final outcomes should be categorized as visualized EP, visualized IUP, spontaneously resolved PUL, and persisting PUL. Those with the transient condition of a persisting PUL should ultimately be classified as nonvisualized EP, treated persistent PUL, resolved persistent PUL, or histologic IUP. These specific categories can be used to characterize the natural history or location (intrauterine vs. extrauterine) of any early gestation where the initial location is unknown. Conclusion(s) Careful definition of populations and classification of outcomes should optimize objective interpretation of research, allow objective assessment of future reproductive prognosis, and hopefully lead to improved clinical care of women initially identified to have a PUL.
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