OBJECTIVE:To describe the sonographic cervical changes induced by Dilapan-S (DS) during cervical ripening at term and to explore their association with mode of birth. METHODS:This prospective observational study included singleton pregnancies with an unfavorable cervix (Bishop score ≤4) undergoing induction of labor at term (>37 weeks). DS was inserted under direct visualization and left in place for 12-16 h. Ultrasonographic assessment of cervical length (CL), posterior cervical angle (PCA), and fetal occiput position was performed before DS insertion and at rod removal. The exposures of interest were CL, PCA and fetal occiput position measured at the time of DS removal; the corresponding changes between insertion and removal (delta values) were examined as secondary exposures. The primary outcome was mode of birth, defined as vaginal birth (spontaneous or operative) versus cesarean delivery; vaginal birth was modelled as the event and cesarean delivery was the reference category. The secondary outcome was the induction-to-delivery interval, analysed in women who gave birth vaginally. Maternal age, body mass index (BMI), parity and Bishop score at DS removal were considered a priori as potential confounders. RESULTS:Among 37 women who underwent cervical ripening with DS, 28 (75.7%, 95% CI 59.9-86.6) gave birth vaginally. All 11 multiparous women delivered vaginally, in every case by spontaneous vaginal delivery (100%, 95% CI 74.1-100), compared with 17 of 26 nulliparous women (65.4%, 95% CI 46.2-80.6; risk difference 34.6%, 95% CI 4.6-53.8; p = 0.036). The median induction-to-delivery interval was 27.0 h (IQR 24.8-30.0) among women who gave birth vaginally. All cervical sonographic parameters changed significantly after DS placement, while fetal head position did not. CL at DS removal was significantly shorter in women who delivered vaginally than in those who underwent cesarean section (21.3 vs 26 mm; median difference -6.1 mm, 95% CI -12.8 to -0.1; p = 0.047) and correlated significantly with the induction-to-delivery interval (r = 0.604, 95% CI 0.30-0.80; p = 0.0006). No other sonographic variable was significantly associated with the induction-to-delivery interval. In the prespecified multivariable model fitted with Firth penalised likelihood, cervical length at Dilapan-S removal showed a consistent association with vaginal delivery (adjusted OR 0.919; 95% CI, 0.807-0.989; p = 0.032), with similar findings after adjustment for parity (adjusted OR, 0.899; 95% CI, 0.777-0.991; p = 0.030) and in the cervical length-only model (adjusted OR, 0.923; 95% CI, 0.832-0.964; p = 0.004). CONCLUSION:DS induces measurable sonographic changes in cervical length and posterior cervical angle. Shorter CL at the time of dilator removal was associated with vaginal birth and with a shorter induction-to-delivery interval. These findings should be regarded as hypothesis-generating rather than predictive; they require confirmation in larger studies.

Background: Gestational diabetes mellitus (GDM) and periodontitis (PD) are chronic inflammatory conditions that may share metabolic and immune pathways. Evidence suggests an association between them, although results across studies remain inconsistent. This systematic review and meta-analysis evaluated the relationship between GDM and PD and examined whether GDM influences key periodontal parameters. Methods: A systematic search of PubMed/MEDLINE, Scopus, Web of Science, and Embase was conducted up to August 2025 following PRISMA guidelines. Observational studies comparing periodontal status in pregnant women with and without GDM were included. Periodontal status was assessed using probing pocket depth (PPD), clinical attachment loss (CAL), and bleeding on probing (BOP). Study quality was evaluated with the Newcastle-Ottawa Scale, and random-effects models were applied to estimate pooled associations. Results: Fifteen studies involving about 3800 pregnant women met the criteria. A significant association was found between GDM and PD (Odds Ratio [OR] 2.10; 95% Confidence Interval [CI] 1.64-2.69). No significant association emerged between GDM and gingivitis. Women with GDM showed increased BOP and higher PPD, indicating greater periodontal inflammation, while CAL did not significantly differ between groups. Conclusions: The findings support a significant association between GDM and periodontitis, suggesting that gestational hyperglycemia may enhance periodontal inflammation and early tissue changes. Incorporating periodontal screening into prenatal care may benefit maternal oral and metabolic health. Further longitudinal and interventional studies are needed to clarify causality and to explore whether periodontal therapy may help reduce risks linked to GDM.

OBJECTIVE:To evaluate whether crown-rump length (CRL) measured at 11-14 weeks is associated with the risk of large-for-gestational-age (LGA) neonates in uncomplicated pregnancies. METHODS:This prospective study included 333 singleton pregnancies undergoing first-trimester ultrasound screening. CRL was measured according to standardized criteria, and gestational age was confirmed or reassigned based on CRL when discrepancies with last menstrual period exceeded 7 days. The primary outcome was the occurrence of LGA neonates, defined according to INTERGROWTH-21st standards. Multivariate regression and receiver operating characteristic (ROC) curve analyses were performed to assess the predictive value of CRL. RESULTS:CRL was significantly associated with the risk of LGA neonates. ROC curve analysis demonstrated a modest discriminative performance, with an area under the curve (AUC) of 0.665 (95% CI: 0.547-0.784). The optimal CRL cut-off showed a sensitivity of 63.6% and specificity of 69.3%, with a high negative predictive value (96.4%). CONCLUSIONS:First-trimester CRL is associated with fetal overgrowth but shows limited predictive accuracy when used alone. Its clinical utility may lie in contributing to combined predictive models rather than serving as a standalone screening tool.

Diffusion-weighted imaging (DWI) has been adopted to study placentas of women infected by SARS-CoV-2, highlighting the microstructural deterioration of the tissues using the Intravoxel Incoherent Motion model (IVIM). However, unlike the results obtained on placental histology, no perfusion impairment was observed. We used the Two-perfusion IVIM model to investigate the placenta's perfusion compartments. DWIs of n = 12 patients affected by SARS-CoV-2 and n = 20 gestational age-matched pre-pandemic healthy subjects were acquired at 1.5 T scanner with 10 b values. The maternal and fetal placentae were investigated. Differences in the two groups were evaluated using Welch’s t test. The placental fetal side showed higher values of D and lower values of f2 (relative to the trophoblast compartment) in SARS-CoV-2 patients. D2* was higher on the maternal side of SARS-CoV-2 patients. Higher values of D reflect damage to the tissue, while the lower f2 parameter suggested an impairment of the exchange between mother and fetus. The higher values of D2* in the maternal side of SARS-CoV-2 placentas may be due to a decreased capillaries’ size caused by the infiltration of lymphocytes in the decidua basalis. These results further confirm the potential of the two-perfusion IVIM model in detecting placental dysfunction.

Ischemic heart failure remains a major clinical challenge, underscoring the need to better understand post-infarction immune mechanisms and identify new therapeutic targets. Both innate and adaptive immunity contribute to adverse cardiac remodeling following myocardial infarction (MI), yet the role of cytotoxic cells such as natural killer (NK) cells remains poorly defined. Here, we show that after acute MI in mice, NK cells are recruited to the ischemic myocardium in a CCR2-dependent manner and become activated. Activated NK cells locally release granzyme B, promoting cardiomyocyte apoptosis, adverse ventricular remodeling, and impaired cardiac function. Genetic deletion or pharmacological depletion of NK cells reduces cardiomyocyte death, attenuates inflammation, limits myocardial injury, and improves cardiac function. In contrast, NK cell activation using an anti-NKG2A monoclonal antibody exacerbates ischemic heart failure. We further demonstrate that NK cells regulate bone marrow myelopoiesis through local GM-CSF production. Finally, we identify a distinct NK cellular and transcriptomic signature in human ischemic heart tissue at early stages. Together, these findings reveal a detrimental role for NK cells following acute MI and highlight NK cells as potential therapeutic targets to limit adverse cardiac remodeling.

OBJECTIVES:To compare cardiac function in fetuses with and without fetal growth restriction (FGR). METHODS:Medline and Embase databases were searched. Inclusion criteria were pregnancies complicated compared to those non-complicated by FGR, defined according to the Delphi criteria. The following cardiovascular parameters were assessed. Markers of cardiac geometry and morphology, including the left and right sphericity index (SI). Markers primarily affecting the systolic function, including right (TAPSE) and left (MAPSE) cardiac output (CO), atrioventricular plane displacement, and peak systolic velocity of the aorta and pulmonary arteries. Markers primarily affecting the diastolic function, including the mitral and tricuspid E/A ratio. Markers of global cardiac function, including left and right isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT) ejection time (ET), and myocardial performance index (MPI). Random-effect meta-analyses were used to analyze the data. RESULTS:Fifteen studies were included. Fetuses affected by FGR had a smaller right SI (MD -0.23, 95% CI 0.44 to -0.01; p: 0.04) and left (MD: -0.20, 95% CI -0.33 to -0.05) compared to those not affected. There was no difference in left (p = 0.179) and right (p = 0.068) CO between fetuses affected and those not affected by FGR. Fetuses with FGR had shorter MAPSE (MD: -0.91 mm, 95% CI: -1.25 to -0.57; p < 0.001) and TAPSE (MD: -1.09 mm, 95% CI: -1.23 to -0.96; p < 0.001), while there was no difference in mitral (p = 0.832) and tricuspid (p = 0.504) E/A ratio. Left MPI was higher (MD: 0.09, 95% CI 0.04 to 0.14; p < 0.001) in fetuses with FGR compared with controls. CONCLUSION:FGR is associated with significant changes in fetal cardiac geometry and function.

Operative vaginal delivery (OVD) via vacuum extraction is a fundamental component of modern obstetric management, yet it carries specific risks of failure and maternal–fetal complications, such as cup detachment, cephalohematoma, and intracranial hemorrhage. The success and safety of the procedure rely heavily on the correct application of the vacuum cup over the “flexion point” of the fetal head. Traditional identification of this landmark via digital examination is often hindered by caput succedaneum and cranial molding, leading to high rates of diagnostic error, particularly in dystocic labor, due to fetal head malpositions and malpresentation. Intrapartum ultrasound (ITU) has demonstrated superior accuracy compared to clinical examination in assessing fetal head position and station and internal rotation. This expert commentary and technical proposal analyzes the current literature regarding vacuum extraction application and failures, focusing on the predictive value of ITU parameters (e.g., Angle of Progression, Midline Angle, Head-Symphysis Distance) and the impact of ITU on cup placement and delivery outcomes. Furthermore, we propose a novel technique: the “Ultrasound Flexion Point” (UFP). This method utilizes translabial ultrasound to identify the specific intersection of the fetal midline and the biparietal diameter as an objective sonographic proxy for the classical flexion point. By providing spatial orientation guidance immediately before the procedure, this technique aims to guide the operator in aligning the cup’s notch with the sonographically identified target zone, using the midline angle as orientation reference, thereby potentially minimizing paramedian or deflexing applications and reducing the incidence of vacuum detachment and associated neonatal trauma. This expert commentary and technical proposal synthesizes current evidence and proposes a protocol requiring prospective validation through randomized controlled trials.

INTRODUCTION:To report the prevalence of chromosomal anomalies in fetuses with a nuchal translucency (NT) between 3.0 and 3.4 mm and to assess the incremental yield of invasive prenatal diagnosis over cell-free DNA (cfDNA) in these fetuses. MATERIAL AND METHODS:MEDLINE, EMBASE, and The Cochrane Library were searched. Inclusion criteria encompassed fetuses with an NT between 3.0 and 3.4 mm undergoing prenatal invasive testing or postnatal genetic assessment. The observed outcomes included common trisomies such as Trisomy 21, 18, and 13, sex chromosomal anomalies (SCAs), rare autosomal anomalies, copy number variants detected by chromosomal microarray (CMA), and single-gene disorders. We also reported the rate of anomalies potentially detectable by cfDNA. Finally, we planned to perform a subgroup analysis involving cases with isolated NT between 3.0 and 3.4 mm, including only cases undergoing detailed first-trimester ultrasound assessment. A random-effects meta-analysis of proportions was utilized to analyze the data. RESULTS:Seventeen studies (7007 fetuses) were included. In fetuses with NT measurements between 3.0 and 3.4 mm, chromosomal anomalies were identified in 13.1% (95% CI 9.3-17.3). Common trisomies included Trisomy 21 at 8.0% (95% CI 5.1-11.5), Trisomy 18 at 1.0% (95% CI 0.6-1.7), and Trisomy 13 at 0.52% (95% CI 0.2-1.0) of all chromosomal anomalies. SCAs occurred in 0.58% (95% CI 0.4-0.8), while rare autosomal trisomies and pathogenic or likely pathogenic copy number variants (CNVs) were found in 0.27% (95% CI 0.1-0.6) and 2.5% (95% CI 1.3-3.9), respectively. Additionally, single-gene disorders detected via NGS/WES were reported in 5.7% (95% CI 3.3-8) of cases with NT between 3.0 and 3.4 mm. When examining only fetuses with an isolated NT between 3.0 and 3.4 mm, all chromosomal anomalies were identified in 12.4% (95% CI 7.9-17.7). CONCLUSIONS:Fetuses with an NT between 3.0 and 3.4 mm showed a high rate of chromosomal anomalies and CNVs, most of which could potentially be detected through cfDNA.

Preterm birth (PTB) remains a significant public health concern despite advances in obstetric and neonatal care. Risk screening methods have modest predictive power, primarily because they rely on clinical risk factors that are not present in most women who experience a PTB. Unlike a single disease entity, PTB is a heterogeneous syndrome caused by various genetic, clinical, and environmental factors, and therefore, cannot be predicted by a single marker or risk indicator. For this reason, current risk assessment methods must be shifted from purely clinical indicators to ones that can also capture the underlying biology of the process. This expert opinion piece discusses the current state of risk screening in Europe and the importance of using a 'syndromic' rather than a 'single disease' view of PTB to guide future risk screening. A validated maternal serum biomarker test, marketed in the United States under the tradename PreTRM®, is also discussed as a tool that could potentially help address key shortcomings of risk screening methods, and thereby aid efforts to mitigate PTB, neonatal morbidity and mortality, and their associated costs.

OBJECTIVE:To determine whether uterine tachysystole is associated with adverse neonatal and maternal outcomes. DATA SOURCES:A search strategy for PubMed (National Library of Medicine) was created, and the medical librarian translated the search for every database. The search strategy was peer reviewed by another medical librarian following the Peer Review of Electronic Search Strategies checklist. The databases included in this search were PubMed, Embase.com, Cochrane CENTRAL, CINAHL Ultimate, and Scopus; a combination of key words and subject headings was used. METHODS OF STUDY SELECTION:Trials of nulliparous or multiparous parturients exposed to uterine tachysystole were included. Included studies compared individuals with and those without uterine tachysystole. TABULATION INTEGRATION AND RESULTS:Two reviewers independently extracted data and assessed risk of bias. Random-effect head-to-head meta-analyses reporting summary odds ratios (ORs) with 95% CIs were performed. The random-effects model of DerSimonian and Laird was used. Values of I 2 (Higgins I 2) greater than 50% were used to identify heterogeneity. The coprimary outcome was Apgar score below 7 at 5 minutes and umbilical arterial pH less than 7.10. Of 10,719 studies screened, five met the inclusion criteria with 68,412 individuals. Of these, 7,412 (10.9%) were exposed to uterine tachysystole, and 60,857 (89.1%) were unexposed. The likelihood of the coprimary outcomes was similar: Apgar score below 7 at 5 minutes (OR 1.11, 95% CI, 0.65-1.89) and umbilical arterial pH less than 7.10 (OR 1.38, 95% CI, 0.34-5.25). Nonsignificant differences were reported between the two groups for cesarean delivery (OR 0.68, 95% CI, 0.27-1.73), for Apgar score below 3 at 5 minutes (OR 0.46, 95% CI, 0.17-1.23), and for neonatal seizures (0.23% vs 0.17%, OR 1.27, 95% CI, 0.50-3.21). CONCLUSION:Observational studies do not report significant differences in the likelihood of adverse neonatal outcomes and cesarean delivery among individuals exposed compared with those not exposed to uterine tachysystole during labor. Additional data, from either interventional trials or observational studies with better characterization of the interventions and outcomes, on uterine tachysystole and adverse outcomes are needed. SYSTEMATIC REVIEW REGISTRATION:PROSPERO, CRD42024560155.

Background: Congenital cytomegalovirus (cCMV) infection is a leading cause of neonatal morbidity. This retrospective study aimed to evaluate the efficacy of valacyclovir in reducing vertical transmission after primary maternal CMV infection and to assess the diagnostic performance of amniocentesis and prenatal imaging. Methods: Eighty-two pregnant women with confirmed primary CMV infection were included. Maternal CMV serology and viral DNA were assessed in blood and urine, with standardized prenatal care including serial ultrasound examinations and fetal MRI when indicated. Amniocentesis was offered to confirm fetal infection. Valacyclovir (8 g/day) was administered before 24 weeks' gestation, and neonatal infection was diagnosed by CMV DNA detection in urine at birth. Statistical analyses were performed using SPSS version 27.0. Results: Most infections (62.2%) were diagnosed in the first trimester. Valacyclovir was administered in 97.6% of cases, and amniocentesis was performed in 81.7%, with CMV DNA detected in 19.4%. Among 74 live births, 23% of neonates were CMV-positive and 6.8% symptomatic. Seven infected neonates had negative amniocentesis (false-negative rate, 13.2%). Prenatal ultrasound and MRI failed to detect abnormalities in symptomatic cases. Conclusions: Valacyclovir may reduce, but does not eliminate, the risk of cCMV transmission. Negative amniocentesis does not fully exclude fetal infection, highlighting postnatal follow-up.

Although international recommendations strongly support regular physical activity during pregnancy due to the improved maternal and fetal outcomes, adherence to physical activity remains low, particularly in early gestation. Understanding activity patterns during the first trimester is crucial, as behaviors established in this phase often persist throughout pregnancy. To describe physical activity levels and adherence to international recommendations among low-risk pregnant women in the first trimester, using the Italian version of the Pregnancy Physical Activity Questionnaire (PPAQ). This cross-sectional observational study includes 498 low-risk singleton pregnant women between 11+3 and 13+6 weeks’ gestation, recruited at the University Hospital of Naples Federico II, Italy, between January 2022 and December 2023. Participants completed the Italian version of the PPAQ. Total energy expenditure was expressed in MET-h/week, and women were classified as exercisers (≥ 150 mines/week of moderate-intensity activity) or non-exercisers. Participants reported a median of 11.5 (IQR 8.2–15.0) h/week of total activity, corresponding to 155.7 (102.6–241.7) METs-h/week. While 51

Purpose To develop and validate an anatomy-aware, two-stage, end-to-end deep learning pipeline for fetal brain abnormality automated detection on standardized second-trimester brain US images. Materials and Methods This retrospective multicenter study included 319 fetal brain images (218 normal, 101 abnormal) between 19 weeks ± 0 and 23 weeks ± 6 of gestation from nine international fetal medicine centers, each with paired standard transventricular and transcerebellar axial plane images acquired at second-trimester US between January 2010 and December 2022. Abnormalities were confirmed by neonatal imaging or autopsy. Images were annotated for six key brain regions by two experienced fetal medicine specialists. An anatomy-aware, two-stage deep learning pipeline was developed, consisting of a You Only Look Once version 5-based object detector followed by a classification network using a Mini-ResNet feature extractor within a HexaNet architecture. The pipeline classified each image as normal or abnormal. Object detection performance was evaluated using mean average precision at an intersection-over-union threshold of 0.5 (mAP@0.5). Classification performance was assessed using the area under the receiver operating characteristic curve, sensitivity, specificity, and F1 score. Results The object detection model achieved a mAP@0.5 of 0.93 (95% CI: 0.90, 0.96) on the test dataset. The classification model achieved an area under the receiver operating characteristic curve of 0.96 (95% CI: 0.90, 1.00), a sensitivity of 87% (95% CI: 67, 100 [13 of 15]), a specificity of 91% (95% CI: 79, 100 [29 of 32]), and an F1 score of 0.84 (95% CI: 0.67, 0.96) for distinguishing normal from abnormal fetal brain images. Conclusion The developed model achieved high diagnostic performance for the detection of brain anomalies at routine fetal second-trimester US. Keywords: Artificial Intelligence, Machine Learning, Fetal Neurology, Neurosonography, Fetal Brain Malformation, YOLOv5, Neural Networks Supplemental material is available for this article. © RSNA, 2026 See also commentary by Rafful in this issue.

Abstract Introduction Most of the studies reporting the outcome of the surviving twin after single intra‐uterine fetal death (sIUFD) focused on uncomplicated pregnancies or those affected by twin‐to‐twin transfusion syndrome, while there is a paucity of data for those complicated by twin anemia polycythemia sequence (TAPS). The aim of this systematic review was to report perinatal outcomes in monochorionic diamniotic (MCDA) twin pregnancies complicated by TAPS after sIUFD, according to gestational age at fetal loss and the presence of pregnancy‐related comorbidities. Material and Methods MEDLINE, EMBASE, and The Cochrane Library were searched for studies reporting the outcome of monochorionic twin pregnancies complicated by TAPS experiencing single IUFD. The primary outcome was the occurrence of co‐twin IUFD. Secondary outcomes were neonatal death (NND), preterm birth (PTB) <34, <32, and <28 weeks of gestation, cerebral abnormalities detected at follow‐up prenatal ultrasound, fetal magnetic resonance imaging (MRI) or postnatal imaging (ultrasound or MRI), and adverse neurodevelopmental outcome. Random‐effects meta‐analysis of proportions was used to analyze the data, and results were reported as pooled proportions or odd ratios (OR) with 95% CI. Results Eleven studies (83 twin pregnancies affected by TAPS, either spontaneous or post‐laser, and complicated by single IUFD) were included in the systematic review and 10 (78 pregnancies) in the meta‐analysis. Co‐twin IUFD occurred in 4.9% (95% CI 1.1–11.3) after a single IUFD in pregnancies affected by TAPS, while there was no case of NND. PTB, either spontaneous or iatrogenic, occurred in 80.4% (95% CI 44.3–99.5) <34 weeks, and 50.0% (95% CI 16.3–83.7) <28 weeks of cases. Intra‐uterine transfusion was required in 8.0% (95% CI 0.9–38.3). Cerebral anomalies at follow‐up ultrasound or fetal MRI were reported in 15.0% (95% CI 8.2–78.3) and 11.4% (95% CI 2.4–55.7) of cases, while anomalies at post‐natal imaging in 9.4% (95% CI 5.6–57.6) of cases. It was not possible to perform a meaningful pooled data synthesis on the observed outcomes according to the type and staging of TAPS and according to the donor or recipient twin. Conclusions The occurrence of co‐twin death after single IUFD in pregnancies complicated by TAPS appears low, while cerebral abnormalities detected either pre‐ or post‐natally occur in 10–15% of cases. Further evidence is needed to elucidate the long‐term neurological and neurodevelopmental risk of these children.

OBJECTIVE:To develop standardised Objective Structured Assessment of Technical Skills (OSATS) forms for major obstetric emergencies, thereby improving the quality and consistency of obstetric simulation training. DESIGN AND SETTING:A panel of national experts with extensive experience in teaching Gynaecology and Obstetrics, simulation training, and the clinical management of labour complications and peripartum emergencies. POPULATION AND METHODS:A Delphi process with four iterative rounds was conducted to create, evaluate, revise, and finalise OSATS checklists for 11 obstetric emergencies. Each OSATS form was rated using a Likert scale (0-9), refined according to expert feedback, and validated through structured discussions. MAIN OUTCOME MEASURES:The creation and approval of OSATS forms for shoulder dystocia, vacuum delivery, assisted breech delivery, third- and fourth-degree laceration repair, external cephalic version, abnormal CTG management, postpartum haemorrhage, non-cephalic second twin delivery, reverse breech extraction at caesarean section, maternal collapse and forceps application. RESULTS:Consensus was achieved for all emergencies with good to excellent ratings: shoulder dystocia (82%), external cephalic version (94%), vacuum delivery (75%), abnormal CTG management (42%), postpartum haemorrhage (96%), reverse breech extraction (72%), maternal collapse (94%), forceps application (76%), non-cephalic second twin delivery (96%), assisted breech delivery (94%) and third- and fourth-degree laceration repair (82%). CONCLUSION:The Delphi study successfully developed consensus-based OSATS forms, addressing the need for standardised assessments in obstetric simulation training. These tools enhance training quality, identify skill gaps and improve clinical preparedness. This study was supported by AGUI (Associazione Ginecologi Universitari Italiani).