To assess sonographically the degree of fetal head deflexion during the 1st of labour and to evaluate the reproducibility of this parameter. In a non consecutive series of women during the 1st stage of labour with the fetus in occiput anterior position, the angle between the occipital bone and the cervical spine of the fetus (occiput-spine angle or OSA) was measured by 2D ultrasound by operator A (Fig 1). The sonographic picture was stored in the archive of the machine and the measurement was repeated at distance by the same examiner and by a different one (operator B). The intra- and interobserver reproducibility of this measurement was assessed by means of intraclass correlation coefficient. Overall 33 women in the first stage of labour were included in the study group. The OSA was measured at a mean cervical dilatation of 4.0 ± 0.9 cm and showed a mean value of 128.7 ± 12.5°. OSA measurements showed excellent intra- and interobserver agreement (intraobserver 0.87, 95% CI 0.75 - 0.93; interobserver 0.82, 95% CI 0.67-0.91). Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

To compare the policy of prenatal diagnosis versus first trimester screening of trisomy 21 among pregnant women of advanced age. A retrospective study was conducted on patients aged ≥35 divided in two groups: patients who requested first trimester combined test and only in case of screen positive result underwent invasive testing (group A); patients undergoing CVS or amniocentesis as first investigation (group B). The following outcome variables were compared: antenatal detection of trisomy 21, occurrence of trisomy 21 at birth, miscarriage rate, hospitals' costs. 4527 women were included. Of these, 534 (11.80%) underwent T21 screening whereas 3993 (88.20%) requested primary invasive testing. In group A, 64 combined test were positive (11.99%) and 8 trisomy 21 cases were diagnosed (1.50%); the loss of euploid fetuses after invasive procedure was 4.55% (2/44). No false negative case was observed. In group B 57 cases of trisomy 21 were diagnosed (1.43%), and pregnancy loss rate of chromosomally normal fetuses was 0.45 % (17/3806). The estimated cost was respectively 67.720 € for the primary screening vs 1.996.500 € for direct prenatal diagnosis. First trimester screening of trisomy 21 is highly accurate and cost saving among women ≥35.

Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

The objectives of this study were firstly to assess the longitudinal changes of various sonographic parameters of fetal head progression in relation to length of active second stage of labor, and secondly to compare ultrasound findings obtained longitudinally among fetuses with persistent occiput posterior (OP) vs those with persistent occiput anterior (OA) position.

ABSTRACTObjectivesTo assess the intermethod agreement between two‐dimensional (2D) and three‐dimensional (3D) transperineal ultrasound methods in measuring a new index of fetal head station (the fetal head–symphysis distance (HSD)) in active labor, and to assess potential factors that may affect their agreement.MethodsHSD was measured by transperineal ultrasound in 86 women in active labor, once using a 2D and once using a 3D technique. 2D images were acquired first in 43 cases and 3D images were acquired first in the other 43 women. Intermethod agreement between 2D and 3D methods was analyzed by means of intraclass correlation coefficient (ICC) and Bland–Altman analysis. In addition, potential factors affecting the intermethod reproducibility were investigated including fetal occiput position, order of acquisition, fetal head station, stage of labor, maternal body mass index and use of epidural analgesia, using the ANOVA test to check for systematic bias and Levene's test for homoscedasticity.ResultsGood agreement was demonstrated between 2D and 3D measurements of HSD (ICC, 0.949 (95% CI, 0.914–0.984)). No evidence of systematic difference was shown between the two methods (average difference ± SD = 0.03 ± 2.29 mm; P = 0.888). The only factor that had a significant effect on systematic difference between 2D and 3D methods was order of acquisition (P = 0.042); the first observation was higher regardless of the method used. Fetal head station had a significant effect on the homogeneity between the two methods (P = 0.004) with a better 2D–3D agreement obtained at lower head stations (SD of differences: 1.63 vs 2.59 mm).ConclusionsThere is very good agreement between 2D and 3D methods of assessing HSD. Agreement is better in lower fetal head stations. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

In the last decade, the use of ultrasound in labor has been the subject of much research. Suggested applications include confirmation of fetal viability, identification of fetal presentation and assessment of fetal occiput position and head descent. Nevertheless, it is not clear whether this has changed the practice of caregivers outside the research context; and if it has, it is not clear how. In order to assess this, we performed a survey in April 2012 among participants on courses on prenatal medicine and obstetric ultrasound at the Department of Obstetrics and Gynecology of the Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. Participants whose duties included management of labor were invited to answer an online questionnaire. In total, 264 attending physicians completed the questionnaire. The most relevant results are displayed in Table 1. According to our survey, the most popular application of ultrasound in labor was for assessment of fetal occiput position (Table 1). This finding is not surprising given that transabdominal sonographic identification of fetal occiput position is easy to achieve through visualization of anatomical landmarks, such as fetal orbits and the spine, as well as requiring minimal time123. Furthermore, a number of studies have demonstrated the superiority of ultrasound over digital examination for this aim, and are consistent and unequivocal in their support of its use as the gold standard for this clinically important variable123. Sonographic assessment of fetal head position can offer extremely valuable information in certain clinical situations, for instance before instrumental delivery, whereas it seems to be a poor predictor of mode of delivery3, 4. On the other hand, ultrasound was less widely used among survey participants for the assessment of fetal head station and progression (Table 1). We suggest three main obstacles to the application of sonography for this purpose. The first is accessibility to ultrasound equipment; less than half of the participants had an ultrasound machine permanently stationed in their delivery suite. The second obstacle is the absence of convincing data on the utility of ultrasound for this purpose. Lastly, the complexity of the sonographic parameters suggested so far may partially impede the implementation of ultrasound for evaluation of the progression of labor in clinical practice. We acknowledge that more detailed questions about each intrapartum ultrasound parameter would have been useful, however the main goal of this survey was not a comparison between individual parameters. We do also recognize a potential bias in our data. As the chief subject of our courses is ultrasound in obstetrics, the participants who answered the questionnaire are likely to be more experienced in ultrasound than other personnel working in the labor ward. Our survey provides original data on the current use of ultrasonography in the labor ward from the key perspective of the caregiver. It suggests that the publication of more convincing, clinically applicable data and the development of less complex sonographic methods, as encouraged in a recent Opinion article in this Journal3, would promote wider use of intrapartum sonography, especially for the assessment of fetal head descent. A. Youssef*†, T. Ghi†, E. E. Awad‡, E. Maroni†, E. Montaguti†, N. Rizzo† and G. Pilu† †Department of Obstetrics and Gynecology, Sant'Orsola Malpighi Hospital, University of Bologna, Via Massarenti 13, 40138 Bologna, Italy; ‡Department of Obstetrics and Gynecology, El-Shatby Hospital, University of Alexandria, Egypt *Correspondence. (e-mail: [email protected])

To compare the accuracy of transabdominal (TA) vs transperineal (TP) approach in the sonographic assessment of fetal occiput position during the second stage of labor A series of nulliparous low-risk women at term with uncomplicated singleton pregnancy attending the labour ward of our University hospital were prospectively recruited for the purpose of this study. During the second stage of labor patients were evaluated first by TP and than by TA ultrasound to determine the fetal occiput position by an expert operator blinded to clinical evaluation. The following criteria allowed occiput position recognition at TP approach: thalami and choroid plexus orientation and fetal head shape. The occiput position was labelled as anterior, posterior or transverse (right or left) and the agreement between the two techniques was assessed. Overall 54 patients were recruited in the study group. Ultrasound examination was performed at 40.9±17.2 minutes from the beginning of the active pushing. At transperineal approach, the fetal occiput was diagnosed as anterior in 36 (66.7%), posterior in 10 (18.5%) and transverse in 8 (14.8%) fetuses and in all cases the occiput position was subsequently confirmed at TA approach. Ultrasound TP examination is accurate in the diagnosis of fetal occiput position during the second stage of labor.

ABSTRACT Objectives To assess the reproducibility of measurement of a new sonographic index of fetal head station in labor, the fetal head–symphysis distance (HSD), using three‐dimensional ultrasound, and its correlation with digital assessment of fetal head descent and with the angle of progression (AoP). Methods Three‐dimensional (3D) ultrasound volumes were acquired from 47 nulliparous women in active labor following assessment of fetal head station with digital examination. The HSD (the distance between the lower edge of the pubic symphysis and the nearest point of the fetal skull) was measured independently by two operators in order to evaluate intra‐ and interobserver reproducibility. The correlation between HSD, AoP and fetal head station was evaluated using regression analysis. Using 3D tomographic ultrasound imaging (TUI), measurements of the HSD were obtained in different parasagittal planes to evaluate the influence of inaccurate alignment of the probe with the midline of the pelvis. Results Measurement of HSD showed high intraobserver (intraclass correlation coefficient (ICC) = 0.995; 95% CI, 0.991–0.997) and interobserver (ICC = 0.991; 95% CI, 0.984–0.995) reliability. In addition, a high correlation was demonstrated between mid‐sagittal and parasagittal HSD measurements. HSD showed significant negative correlation with both fetal head station and AoP. Conclusion Fetal HSD is a simple and reliable method for the assessment of fetal head descent in labor. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

To assess the intermethod agreement between two- (2D) and three dimensional (3D) transperineal ultrasound methods in measuring a new index of fetal head station (the fetal head-symphysis distance; HSD) in active labor, and to assess potential factors that may affect the agreement between the latter two methods. The fetal head-symphysis distance was measured by transperineal ultrasound in 86 women in active labor once using 2D and once using 3D technique. 2D images were acquired first in 43 women and 3D images were acquired first in the other 43 women. Intermethod agreement between 2D and 3D methods was analyzed by means of intraclass correlation coefficient and Bland-Altman method. In addition, potential factors affecting the intermethod reproducibility were investigated including fetal occiput position, order of acquisition, fetal head station, stage of labor, maternal BMI and epidural analgesia using ANOVA test to check for systematic bias and Levene's test for homoscedasticity. A good agreement was demonstrated between 2D and 3D measurements of HSD (ICC 0.949, 95% CI: 0.914 to 0.984). No evidence of systematic difference was shown between the two methods (average difference±SD: 0.04±2.29 mm, P = 0.888. The order of acquisition was the unique factor that had a significant effect (P = 0.042) on systematic difference between 2D and 3D (the first observation was higher independently of the methods used), while fetal head station had a significant effect (P = 0.004) on the homogeneity between the two methods with a better 2D-3D agreement obtained in lower head stations (SD of differences: 1.63 vs. 2.59 mm). HSD assessment using 2D and 3D methods have a good agreement. Both methods can be used interchangeably for the assessment of HSD. The agreement was better in lower fetal head stations.

Objective 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. Methods A three-dimensional transperineal ultrasound volume was acquired in a series of nulliparous women at the beginning of the active second stage (T1) and every 20 min thereafter (T2, T3, T4, T5 and T6). Following delivery, all ultrasound volumes were analyzed and AoP and MLA were measured. Results Among 71 women included in the study, 58 underwent spontaneous vaginal delivery (Group A) and 13 underwent operative delivery (Group B) (eight by vacuum extraction and five by Cesarean section). When compared with Group B, Group A had a wider AoP only at T1 (140.0 +/- 20.2 degrees vs 122.9 +/- 16.7 degrees; P = 0.010) and T2 (149.7 +/- 20.7 degrees vs 126.9 +/- 17.5 degrees; P = 0.006). MLA was narrower in Group A only at T3 (21.2 +/- 11.7 degrees vs 40.8 +/- 27.9 degrees; P = 0.043), T4 (18.2 +/- 15.0 degrees vs 47.4 +/- 29.6 degrees; P = 0.020) and T5 (18.3 +/- 6.0 degrees vs 34.7 +/- 4.2 degrees; P = 0.034). On stepwise forward multiple logistic regression analysis, both AoP and MLA were independently associated with operative delivery (OR = 0.955 and OR = 1.018, respectively). Conclusion Ultrasonographic assessment of fetal head descent in the second stage of labor may play a role in the prediction of the mode of delivery. Copyright. (C) 2013 ISUOG. Published by John Wiley & Sons, Ltd.

The use of transperineal intrapartum ultrasound assessment has been introduced in recent years to complement traditional digital evaluation, with the aim of providing an objective evaluation of fetal head descent1−5. Despite an increasing number of studies on the subject, the application of this method in everyday clinical practice remains difficult, probably because of the technical difficulty in obtaining most of the sonographic parameters that have been suggested thus far6,7. However, Eggebø et al. have proposed a measurement that is simply obtained, i.e. the distance between the fetal skull and the perineum on transperineal ultrasound (the head–perineum distance (HPD))3 (Figure 1a). More recently we have proposed another simple index of fetal head station inspired by the obstetric literature, i.e. the distance between the lower edge of the maternal symphysis pubis and the fetal skull, along the infrapubic line (the fetal head–symphysis distance (HSD)) (Figure 1b)8. We studied HSD with threedimensional ultrasound which gave us the opportunity to measure both HPD and HSD retrospectively using the volume datasets we had stored (Figure 2). As shown in Figure 3, we found good correlation between the two measurements (Pearson’s r coefficient, 0.826; P < 0.001),

To describe sonographic parameters of fetal head progression among fetuses with occiput posterior position (OP) persisting from the beginning of the second stage to head delivery. A series of nulliparous low-risk women at term (37 + 0–42 + 0) attending the labour ward of our University hospital were prospectively recruited for the purpose of this study. Fetal head position was determined by transabdominal ultrasound at the beginning of active second stage. A volume dataset was acquired by translabial ultrasound every 40 minutes from the beginning of the active pushing until delivery (T1, T2, T3, etc). A list of sonographic parameters were derived from offline analysis of each volume and compared at each time interval between patients with OP (Group A) and OA (Group B) position at delivery, including angle of progression, midline angle and head direction. Cases of OP who converted to OA during the second stage were excluded from final analysis. Overall 71 patients were recruited in the study group, including 7 (9.9%) fetuses persisting in OP position at delivery from the beginning of the second stage. At longitudinal sonographic evaluation head direction was significantly different between the two groups at T1 (92.57 + 19.2 vs. 111.73 + 16.9, P = 0.011) and T2 (87.00 + 30.6 vs. 119.92 + 16.1, P = 0.028) whereas no difference was noted thereafter. The other sonographic parameters appeared comparable at each time interval. In fetuses persisting in OP position vs those delivered in OA position, fetal head direction assessed by intrapartum translabial ultrasound seems to be different at early phases of the second stage.

Objectives: To evaluate the predictive value of maternal weight, Bishop score, and sonographically measured cervical length at 37 weeks’ gestation for predicting the risk of intrapartum Cesarean delivery in parous women with prior vaginal delivery. Methods: This prospective observational study recruited parous women with singleton pregnancies with previous vaginal delivery at 37 weeks’ gestation. Transvaginal ultrasound for measurement of the cervical length was performed and the Bishop score was determined by digital examination. The data collected at enrollment included maternal weight, height and age. A regression model was constructed with control for known intraand post-partum confounders. Results: Five hundred twenty women were analyzed; 6 women (1.2%) underwent Cesarean delivery in labor. Based on univariate analysis, the maternal weight at 37 weeks was significantly associated with the risk for intrapartum cesarean delivery in parous women, whereas cervical length, Bishop score, maternal age and height at 37 weeks, epidural anesthesia, labor induction, and birth weight were not associated. Multiple logistic regression demonstrated that only maternal weight at 37 weeks provided a significant contribution in predicting intrapartum cesarean delivery. To predict cesarean delivery in labor, the best cut-off value of maternal weight was 72.4 kg, with a sensitivity of 83.3% and a specificity of 79.8%. Conclusions: Maternal weight at 37 weeks’ gestation independently predicted the risk of intrapartum Cesarean delivery in parous women with prior vaginal delivery. However, the sonographic measurement of the cervical length and Bishop score were not predictive of Cesarean delivery.

To compare the longitudinal changes of the angle of progression (AoP) and the midline angle (MLA) as evaluated by three-dimensional (3DUS) intrapartum transperineal ultrasound (ITU) during the active second stage according to the mode of delivery. A 3DUS ITU volume was acquired in a series of nulliparous women at the beginning of the active second stage (T1) and every 20 minutes thereafter (T2, T3, etc.). Following delivery, all 3DUS volumes were analysed and both AoP and MLA were measured. Both parameters were then compared between women who underwent spontaneous vaginal delivery (SVD, Group A) and those who underwent operative delivery (Group B). ROC curves were subsequently constructed for both parameters at different scan intervals to estimate their accuracy to predict SVD. Among 71 women included in the study, 58 women underwent SVD, 8 were delivered by vacuum extraction and 5 underwent cesarean delivery. When compared with group B, group A had a significantly wider AoP only at T1 (140.9 ± 20.2° vs. 122.9 ± 16.7°, P = 0.01) and T2 (149.7 ± 20.7° vs. 126.9 ± 17.5°, P = 0.006). The ROC curves revealed an AUC ± SE of 0.731 ± 0.077 at T1 and of 0.785 ± 0.080 at T2. On the other hand, MLA was narrower in Group A only at T3 (21.2 ± 11.7° vs. 40.8 ± 27.9°, P = 0.043), T4 (18.2 ± 15.0° vs. 47.4 ± 29.6°, P = 0.020) and T5 (18.25 ± 6.0° vs. 34.7 ± 4.2°, P = 0.034). ROC curves yielded an AUC at T3 of 0.750 ± 0.044, at T4 of 0.880 ± 0.089 and T5 of 1.000 ± 0.000. On stepwise forward multiple logistic regressions both AoP and MLA were associated with the spontaneous vaginal delivery (OR (exponential beta) 1.047 and 0.983 respectively)). Ultrasonographic assessment of fetal head descent in the second stage may play a role in the prediction of the mode of delivery.

To assess the changes in the angle of progression (AP), progression distance (PD), and midline angle (MLA) in nulliparous women according to the length of the active second stage. A series of nulliparous low-risk women at term (37 + 0–42 + 0) attending the labour ward of our University hospital were prospectively recruited for the purpose of this study. A volume dataset was acquired by translabial ultrasound every 20 minutes from the beginning of the active pushing until delivery (T1, T2, T3, etc). A list of sonographic parameters were derived from offline analysis of each volume, including the angle of progression (PA), progression distance (PD) and midline angle (MLA). All parameters were compared at each time interval between patients who delivered within 60 minutes from the beginning of active second stage of labour (Group A) and those who remained undelivered by that time (Group B). Overall 71 patients were recruited in the study group. Spontaneous vaginal delivery was achieved in 58 (81.7%) cases, whereas vacuum and caesarean section were performed respectively in 8 (11.3%) and 5 (7%) cases. Delivery was achieved within 60 minutes from the beginning of active second stage in 44 (62%) patient. In Group A compared to Group B the AP and PD where significantly greater at T1 (PA: 143.89 + 20.505 vs. 125.33 + 15.008, P < 0.0001; PD 43.95 + 14.074 vs. 34.96 + 13.137, P = 0.008) and T2 (PA: 157.28 + 21.082 vs. 134.33 + 16.509, P < 0.0001; PD: 54 + 16.472 vs. 41.04 + 14.227, P = 0.004) whereas no difference concerning MLA was noted. In the second stage of labor, the longitudinal changes of AoP and PD seem to be significantly different among patients undergoing delivery prior to vs after 60 minutes from the active pushing.

to introduce the fetal head-symphysis pubis distance (HSD) as a novel sonographic parameter for the assessment of fetal head station in labor; to assess its repeatability using three-dimensional ultrasound (3DUS) and to evaluate its correlation with digital examination. A series of 47 US volumes was translabially acquired from nulliparous women in active labor after digital examination and stored for offline analysis. HSD (distance between the lower border symphysis pubis and the nearest point of the fetal skull along a line passing perpendicular to the long axis of SP and tangential to its lower border) was measured in the midsagittal plane by two operators blinded to the results of clinical evaluation. Angle of progression was also measured in each volume dataset. Intra- and interobserver repeatability for HSD was determined. Lastly, HSD was measured on the left and right parasagittal planes. Regression analysis was used to estimate the correlation between HSD with the fetal head station at digital examination and AoP. HSD showed high intra- and inter-observer repeatability (see table). HSD showed significant correlation with digital examination (Spearman rank correlation coefficient − 0.918) and with angle of progression (Pearson correlation coefficient (r) = − 0.826). Furthermore, HSD showed a high repeatability on parasagittal measurements. OP18.05: Table 1. Intra and interobserver repeatability and correlation of midsagittal with left and right paradagittal (5 mm) measurements of the fetal head-symphysis pubis distance Fetal head-symphysis pubis distance is a new simple and reliable sonographic parameter for the assessment of fetal head descent in labor.

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

To test prospectively the accuracy of 3D ultrasound (3DUS) in the determination of fetal gender at 11–13 + 6 weeks. A series of women attending at 11–13 + 6 weeks for the nuchal translucency (NT) scan were enrolled into the study. Exclusion criteria included: suspected fetal abnormality, NT > 95th centile, subsequent miscarriage or genital malformation at birth. An ultrasound volume of each fetus was obtained and analyzed online measuring the angle between the genital tubercle a line passing through the fetal back (genital angle) on the midsagittal plane. The assignment to male or female was performed using the previously published cut-off (27–29°) and was registered following volume analysis. A second volume was then acquired, quality checked, stored and the genital angle was subsequently re-calculated. Fetal gender was ascertained in all cases following birth. Fetal gender assignment accuracy according to the initial, lower and higher angle was calculated. Cases with wrong fetal assignment were individually analyzed. Overall, 95 cases were included in the analysis. Following online genital angle calculation fetal gender assignment was possible in all but one woman (98.9%) in which the angle fell inside the cut-off (28°). The assigned gender was correct in 90 of the 95 cases (94.7%). Among the 5 cases with wrong fetal gender assignment 2 cases were < 12 weeks and two cases had an angle calculated from the second volume which fell inside the cut-off (undetermined gender). Using the narrower and higher angle the accuracy of fetal gender determination was 93.7% and 96.8% respectively. 3DUS is a highly accurate tool for fetal gender assignment in the first trimester. A second look may have a role in reducing the margin of error in fetal gender determination. In case of discrepancy the wider angle seems to perform better.