To examine the association between sonographic fetal head position before labour induction and outcome of induction of labour, specifically left occipito-anterior (LOA) and occiput posterior (OP) fetal position and vaginal delivery within 24 hours. This is a retrospective cohort study retrieved data from a computerized database for previous clinical trials using a prospectively determined method of induction. The study cohort consisted of 371 women with singleton pregnancies who were scheduled for induction of labour at ≥ 37 weeks. Immediately before induction, all women enrolled in this study underwent a transabdominal ultrasound to determine fetal occiput position. The clinical parameters studied were maternal age, height, weight, fetal gender, cervical length, Bishop score and birthweight. Primary outcome measure was vaginal delivery within 24 hours and secondary outcome included mode of delivery. Successful vaginal delivery occurred in 310 of the 371 (83.5%) women and this was within 24 hours of induction in 253 (68.1%) women. Univariate and multivariate analyses showed no evidence of difference in odds ratio (OR) of vaginal delivery within 24 hours for fetuses in the LOA position when compared with all other positions. Similarly, there is no evidence of the OP position being associated with vaginal delivery within 24 hours. However, logistic regression indicated that maternal weight, cervical length and Bishop score were independent predictors of vaginal delivery within 24 hours. In terms of the likelihood of Caesarean delivery as the outcome variable, very similar results of univariate and multivariate analyses were obtained. Our study showed that LOA and OP position before induction of labour do not appear to be associated with outcome of induction of labour. Therefore, in clinical practice, ultrasonography for assessing fetal position before induction has a limited value in predicting outcome of labour induction.

To determine whether sonographic short cervix at mid-trimester is associated with an increased risk of the development of histologic chorioamnionitis and funisitis in asymptomatic women who subsequently had spontaneous preterm delivery (<37.0 weeks). This is a retrospective cohort study of 135 consecutive women with spontaneous preterm delivery before 37 weeks who underwent routine cervical length assessment between 19 and 25 weeks of gestation. Two groups of women were identified and compared: those with a mid-trimester sonographically short cervix and those without evidence of cervical shortening. Women with multiple gestation, cerclage, and indicated preterm delivery without labour were excluded. The placentas were examined histologically after delivery. The data were analyzed at cutoff cervical lengths of 25, 20, and 15 mm to define a short cervix. A short mid-trimester cervical length (<2.5 cm) was found in 9.6% (13/135) of women with spontaneous preterm delivery. Maternal demographic characteristics were not significantly different between the two groups. Women with mid-trimester cervical shortening had significantly higher rates of both histologic chorioamnionits and funisitis, as compared to women without mid-trimester cervical shortening. In multivariable linear regression, both a short cervix and histologic chorioamnionitis were significantly associated with gestational age at birth. In asymptomatic women at mid-trimester who subsequently delivered prematurely, a short cervix is associated with an increased risk of subsequent histologic chorioamnionitis and funisitis. Both a short cervix and histologic chorioamnionitis were independently associated with gestational age at birth. These data suggest that earlier gestational age at birth associated with a short mid-trimester cervix is not merely due to intra-uterine infection.

Numerous studies emphasized increased risk of spontaneous fetal loss as well as perinatal mortality in multifetal pregnancies. However, surveillance strategies and interventions have been rapidly developed as well. The natural course of twin gestations and higher order multifetal pregnancies may have changed currently. Therefore, we evaluated recent data to determine up-to-dated clinical implications of spontaneous fetal loss rates in singletons, twins, and triplets. A retrospective cohort study was conducted in pregnant women who visited Seoul National University Hospital before 12 weeks of gestation and delivered from January 2006 to March 2014 (n = 1834). We excluded cases who underwent selective fetal reduction, termination of pregnancy (n = 150). Total 1684 cases of singleton (n = 1387), twin (n = 209), and triplet (n = 88) were used for analysis. Fetal loss was defined as spontaneous abortion or stillbirth. Fetal loss rate was 10.8% in singleton pregnancies, 12.0% in twin pregnancies, and 12.5% in triplet pregnancies, which was not different among the groups. In twins, patients with monochorionic twins were at higher risk for fetal loss than those with dichorionic twins (15.4% vs. 6.8%, p = 0.021). In triplet pregnancies, fetal loss rate was 16.7% in monochorionic triplets, 10.3% in dichorionic triplets, and 3.9% in trichorionic triplets (p = 0.033). This study showed no significant difference of fetal loss rate among singleton, twin, and triplet pregnancies. Throughout gestation, fetal loss rate was significantly higher in monochorionic fetuses in both twins and triplets. The result of our data can be effectively used for counseling for women with multifetal pregnancy and for deciding the intensity of fetal surveillance as well.

In neonates with single ventricle congenital heart disease, several clinical findings of neonates such as systemic outflow obstruction and ventricular systolic dysfunction are known risk factors for adverse outcomes. The objective of this study was to determine if the antenatal ultrasound findings and cord blood biomarkers for heart failure can predict neonatal mortality in single ventricle congenital heart disease. A total of 44 cases of single ventricle congenital heart disease were enrolled. The presence of antenatal ultrasound findings suggesting systemic outflow obstruction (ascending aorta < 2.5 percentile) or ventricular dysfunction (the presence of cardiomegaly or hydrops) were evaluated, and the total number of abnormal findings was converted to a numeric score, which was named as “cardiac profile score”. In addition, N-terminal pro-B-type natriuretic peptide (NT pro-BNP) and cardiac troponin T (cTnT) was measured in cord blood which was taken at the time of delivery. The rate of neonatal mortality (within 28 days after birth) was 27% (12/44). The antenatal ultrasound findings of systemic outflow obstruction or ventricular dysfunction were detected more frequently and the cord blood concentrations of NT pro-BNP and cTnT were elevated in cases who are destined to neonatal death. The presence of either abnormal ultrasound findings (cardiac profile score ≥ 2) or elevated concentrations of NT pro-BNP or cTnT was associated with the risk of neonatal death (neonatal death risk: 6% in cases without these finding vs. 41% in cases with at least one of these findings, p < 0.05). The antenatal ultrasound findings and cord blood biomarkers for heart failure can predict neonatal death in single ventricle congenital heart disease. OC02.05: Table 1.

To evaluate whether an increased sonographic cervical length at mid-trimester is associated with an increased risk of failed labour induction and to compare cervical length measurements at mid-trimester and at the time of induction of labour. This is a retrospective cohort study including 518 singleton pregnant women who underwent cervical length screening between 19 and 24 weeks of gestations and underwent induction of labour at 33 completed weeks of gestations or later. Ultrasound measurements of the cervical length were performed both at mid-trimester and at the time of induction. Primary outcome was induction failed. A multivariate analysis was conducted, with control for known confounding factors associated with the failed induction of labour. Labor induction failed in 23.9 %. Women failed to induce labour had significantly longer cervical lengths at mid-trimester and at labour induction, a higher proportion of nulliparity and a higher body mass index, and earlier gestational age at induction than those who induced labour successfully. Multivariate analysis demonstrated that cervical length at mid-trimester was significantly associated with failed induction of labour after adjustment for body mass index, gestational age at induction and parity. The area under curve for the cervical length at labour induction was a significantly larger than that for the cervical length at mid-trimester. However, neither cervical length at mid-trimester nor cervical length at the time of induction was associated with the risk of Caesarean delivery in univariate and multivariate analysis. Increased cervical length at mid-trimester is independently associated with an increased risk of failed labour induction. However, cervical length at mid-trimester appeared to have a less predictive value for the risk of failed induction than that at the time of induction.

Objective: Inflammation of the chorioamniotic membranes (histologic chorioamnionitis) is a risk factor for adverse neonatal outcome. Labor has many common features with inflammatory processes; therefore, an important question is whether the frequency of histologic chorioamnionitis in spontaneous labor at term is higher than that of women in labor after induction. This study was conducted to address this question.Study design: The frequency of histologic chorioamnionitis was compared between patients who delivered after the spontaneous onset of labor versus those who delivered after induction of labor at term in singleton gestations (>= 37 weeks). Patients in whom uterotonic agents were used during the latent phase of labor were excluded.Results: (1) The overall frequency of histologic chorioamnionitis was 20.2% (107/531); (2) histologic chorioamnionitis was significantly more frequent in women who delivered after the spontaneous onset of labor than in those who underwent induction of labor (24.3% [81/333] versus 13.1% [26/198], p < 0.005). This difference remained significant after adjusting for parity, gestational age at delivery, total duration of labor, the interval from rupture of membranes to delivery and the mode of delivery.Conclusion: Histologic chorioamnionitis is more common in women who delivered after the spontaneous onset of labor than in those who underwent induction of labor at term. (C) 2010 Elsevier Ltd. All rights reserved.

Objectives In polyhydramnios, amniotic fluid (AF) volume can be increased not only as a result of increased fetal urine production, but also due to several other factors, including impairment of both fetal swallowing and gastrointestinal (GI) absorption of AF. Our aim was to evaluate whether measurement of the fetal urine production rate (UPR) can be used to differentiate the causes of increased AF volume.Methods This cross-sectional study included 54 pregnant women with an increased amniotic fluid index (AFI), defined as AFI >= 18 cm, divided into two groups according to the presence of fetal anomalies that are associated with impairment of fetal swallowing or decreased GI absorption of AF (Group 1, n = 14) or the absence of fetal anomalies (Group 2, n = 40). The control group included 96 normal pregnancies with normal AFI (8 <= AFI < 18 cm) (Group 3). Fetal UPR was obtained by serial bladder volume measurements (two to four times, with a median interval of 5 min between each) using the rotational method of Virtual Organ Computer-aided AnaLysis (VOCAL (TM)) with three-dimensional ultrasound. To adjust for fetal weight (Wt) and gestational age (GA), UPR_Wt and UPR_SD were calculated using the following formulae: UPR_Wt = measured UPR/estimated fetal weight and UPR_SD = (measured UPR - mean UPR for each GA)/SD of UPR for each GA.Results The AFI was increased significantly in Groups 1 and 2 compared with Group 3. However, the median fetal UPR in Group 1 did not differ from that of Group 3, in contrast to the higher median fetal UPR in Group 2 compared with Groups 1 and 3; this difference remained significant after adjusting for GA and estimated fetal weight in terms of UPR_SD and UPR_Wt. In Groups 2 and 3, AFI and UPR had a positive correlation in terms of UPR, UPR_SD and UPR_Wt.Conclusions Our findings that fetal UPR is significantly increased in cases with increased AFI without fetal anomalies, but not in those with increased AFI and fetal anomalies involving decreased GI absorption of AF, might be used to differentiate causes of increased AF volume. In the absence of fetal anomalies, AFI and fetal UPR correlate positively. Copyright (C) 2010 ISUOG. Published by John Wiley & Sons, Ltd.

Tuberous sclerosis is associated with facial angiofibroma, epilepsy, mental retardation, renal cysts, multiple and bilateral angiomyolipomas of the kidney, and rhabdomyoma of the heart. The variable manifestations of tuberous sclreosis are not easily detected during the fetal life except the cardiac rhabdomyoma. We report a case of prenatally diagosed tuberous sclerosis with variable manifestations of fetal heart, brain, and bialteral kidneys. A 39 year-old woman was referred for further evalaution of porencephaly at 34 gestational weeks. Ultrasound examination revealed left sided porencephaly and multiple tiny subependymal harmatomas with a large echogenic mass suggesting giant cell astrocystoma in the fetal brain. Multiple variable sized rhabdomyomas were detected in the fetal heart. There were several tiny cysts and echogenic spots of angiomaylipomas in the bilateral fetal kidneys. At 39 gestational weeks, Cesarean section was performed because of arrest of descent after spontaneous onset of labor. Echocardiography of neonate revealed multiple rhabdomyomas and arrhythmia. Fundoscopy revealed retinal harmatomas. Brain MRI of baby revealed a subependymal giant cell astrocytoma and multiple tiny subependymal hamartomas with hemiventriculomegaly. Multiple tiny cysts and angiomylipomas were detected in both kidneys on the kidney ultrasound exam.

Objectives: To explore the association of uterine arteries (UA) waveform analysis with brachial artery flow-mediated dilation (BAFMD) in the prediction of preeclampsia in high-risk pregnancies.Methods: UA waveforms were recorded using Pulsed Doppler ultrasonography in 33 women at 22-24 weeks of gestation with high risk factors for preeclampsia (PE).Mean Pulsatility Index (PI) of both UA were registered.At the same time, brachial artery diameter was evaluated in basal and after stress conditions using Color Doppler; BAFMD was expressed as percent change in diameter from baseline.The onset of PE was divided in early (before 34 weeks of gestation) or late (after 34 weeks).Logistic regression models were developed, and their predictive ability assessed using ROC curves.Results: The prevalence of PE in the studied group was 24% (8/33), 5 early and 3 late-onset.Mean UA-PI and BAFMD values of cases without PE were lower, but not significant, than those developing PE (mean difference (MD): -0.39 (95% CI: -0.90-0.13)and -4.41% (95% CI: -16.1-7.3)respectively).Area under ROC curve for mean UA-PI was of 0.70 (95% CI: 0.41-0.99%),and for BAFMD of 0.59 (95% CI: 0.37-0.80).Logistic regression analysis was only significant for mean UA-PI (P = 0.034), and adding BAFMD did not improve the prediction.For early-onset PE, there were significant higher values in mean UA-PI (MD: 0.56 (95% CI: 0.19-0.94)),and higher BAFMD results but not significant (MD: 8.8% (95% CI: -4.6-22.2%)).Area under ROC curve for mean UA-PI was of 0.79 (95% CI: 0.44-1), and for BAFMD of 0.69 (95% CI: 0.46-0.91).Logistic regression analysis was only significant for mean UA-PI (P = 0.02), multivariate regression analysis combining UA-PI and BAFMD did not get better the prediction of early-onset PE.Conclusions: Although there is a trend of higher BAFMD in pregnancies with PE, the test in the second trimester did not improve the capacity for prediction of PE that provides the UA by itself.

Objective: The aim of this study was assessment the accuracy of sonographic estimation of fetal weight at 34–37 weeks and 37–40 weeks of gestation. Materials and methods: In this prospective cross sectional study 120 well dated pregnant women who were perceived to be at low risk of obstetrics complications or fetal abnormality, were enrolled. Two ultrasound measurements were made on each fetus, first at 34–37 and the next at 37–40 weeks. Measurements of fetal biparietal diameter (BPD), abdominal circumference and femoral length were all taken by a single sonographer using standardized techniques. Birth weight was measured immediately after birth, always using the same scales and techniques of measurements for each newborn. The ultrasound measurements were used in four different formula (Aoki, campell and Wilkin, Shepard and Hadlock formulas) to calculate estimated birth weight. The estimates were adjusted for weight gain between scan and delivery by adding 25 grams per day. Results: There were fewer errors in predicting true birth weight in sonograms obtained between 34–37 weeks than sonograms obtained between 37–40 weeks. And the greatest accuracy was obtained with the Aoki formula. The differences were less than 120 grams and although not clinically significant but were statistically significant. Conclusion: Sonography obtained between 34 and 37 weeks gestation provided comparable and slight more accurate prediction of birth weight. So for prediction of birth weight a single sonography obtained between 34–37 weeks’ gestation is better than serial sonography or sonographies taken late in pregnancy.

In polyhydramnios amniotic fluid (AF) volume is increased not only by increased fetal urine production but also by other factors, including impairment of fetal swallowing, reabsorption by the intestine and several other factors. We undertook this study to evaluate whether measurement of the fetal urine production rate (UPR) in fetuses with polyhydramnios can be used to differentiate the causes of polyhydramnios. We enrolled 22 women with an increased amniotic fluid index, which was defined as AFI > 18, including five cases of anomaly associated with decreased gastrointestinal absorption of amniotic fluid (Group 1) and 17 cases of unknown cause (Group 2). Group 1 consisted of two cases of duodenal atresia, two of cleft lip and palate and one of esophageal atresia. After matching for gestational age (GA) and estimated fetal weight, we also enrolled 22 women of normal AFI (10⩽AFI⩽18, control). Fetal bladder volume was measured using a rotational method of VOCAL (Virtual Organ Computer-aided AnaLysis) with 3D ultrasound and fetal UPR was calculated from serial measurement of bladder volume. To adjust for GA, each percentile value and SD ratio of UPR (UPR_SD) was calculated according to each GA. Previous published data from 154 normal pregnancies was used to calculate mean and SD values of UPR for each GA and each percentile value. (UPR_SD = (estimated UPR − mean UPR of each GA)/SD of UPR of each GA.) AFI was greatest in Group 1, whereas fetal urine production was mostly increased in Group 2 (Table). This result suggests that measurement of fetal UPR may be used in differentiation of the causes of polyhydramnios.

Amniotic fluid index (AFI) is generally used to evaluate AF volume and to predict abnormal perinatal outcome. But its use is limited in both extreme sides, oligohydramnios and polyhydramnios. Particularly if AFI is within borderline range of oligohydramnios, its clinical meaning becomes more obscure. We undertook this study to compare usefulness of fetal urine production rate (UPR) with that of AFI in borderline oligohydramnios for prediction of abnormal perinatal outcome. We enrolled 17 pregnant women with borderline oligohydramnios, which was defined as 5 ⩽ AFI ⩽ 10. Fetal bladder volume was measured using a rotational method of VOCAL (Virtual Organ Computer-aided AnaLysis) with 3D ultrasound and fetal UPR was calculated from serial measurement of bladder volume. To adjust GA, each standard deviation ratio of UPR(UPR_SD) was calculated according to each GA. Previous published data from normal 154 pregnancies was used to get mean UPR and SD of UPR of each GA and each percentile value. (UPR_SD = (estimated UPR—mean UPR of each GA)/SD of UPR of each GA) Fetuses with decreased urine production had worse perinatal outcome in terms of low birth weight, Cesarean section rate for fetal distress. But comparing perinatal outcomes between cases with more decreased AFI (5 ⩽ AFI < 8) and those with less decreased AFI (8 ⩽ AFI ⩽ 10) did not show any significant difference. Decreased fetal urine production is associated with adverse perinatal outcome, suggesting better clinical usefulness of fetal UPR than AFI in borderline oligohydramnios.

OBJECTIVES:Measurement of fetal urine production may provide a means of evaluating amniotic fluid volume, which is difficult to measure directly, and predicting fetal hypoxia. Although there have been some reports on fetal urine production, most of these have used two-dimensional (2D) ultrasonography to measure bladder volume. Three-dimensional (3D) ultrasonography is, however, known to be superior to 2D ultrasonography in some organ volume measurements. Thus, we undertook this study to measure bladder volumes using 3D ultrasonography and to establish a nomogram of fetal urine production rate (UPR) according to gestational age (GA). METHODS:One hundred and fifty-four women with a normal singleton pregnancy at 24 to 40 weeks' gestation were enrolled in this cross-sectional study. The women had no medical or obstetric complications affecting amniotic fluid volume. Fetal bladder volume was measured using 3D ultrasound imaging and Virtual Organ Computer-aided AnaLysis (VOCAL) with a rotational angle of 30 degrees and manual surface tracing technique. Bladder volume was measured two or three times within a 5-10-min interval and fetal UPR was calculated from serial measurements. When measurements were performed more than twice, we used the mean rate of calculated UPRs. UPR was then plotted against GA to establish the nomogram. RESULTS:Fetal UPR increased with GA from a median value of 7.3 mL/h at 24 weeks' gestation to 71.4 mL/h at term, and could be calculated from GA using the formula: Ln(UPR) = - 6.29582 + (0.43924 x GA) + (0.000432 x GA2), r2 = 0.63, P = 0.0046. Growth percentiles of UPR according to age are presented. CONCLUSIONS:Fetal UPR can be easily measured by 3D ultrasound assessment of bladder volume. This modality may be a promising alternative to conventional methods of amniotic fluid volume measurement such as amniotic fluid index and single deepest pocket, and might be an alternative option for predicting fetal hypoxia.

To evaluate the performance of the fetal renal pelvic anteroposterior diameter (APD) to predict postnatal significant uropathy. One hundred and thirty cases (207 renal units) who were found to have fetal renal pelvic dilatation, defined as the presence of the fetal renal pelvic APD ≥ 4 mm before 33 weeks and/or ≥ 7 mm after 33 weeks were identified and reviewed retrospectively. On the basis of postnatal diagnosis, renal units were divided into four groups: spontaneous resolution (n = 43); minimal uropathy, that is, ‘pelvic dilatation without caliceal dilatation’ (n = 45); significant uropathy, defined as ‘pelvicaliceal dilatation’, treated with conservative management (n = 90); significant uropathy required surgery (n = 29). From ROC curve, multiple thresholds were analyzed for the fetal renal pelvic APD for predicting postnatal significant uropathy and the need for surgery. Significant uropathy was diagnosed in 119 (57%) renal units. The most common renal pathology was ureteropelvic junction (UPJ) obstruction (56/119, 47%) and the next was hydronephrosis (51/119, 43%). The most common uropathy requiring surgical intervention was UPJ obstruction (22/29, 76%). In predicting postnatal significant uropathy, sensitivity and specificity for the 11 mm of cut-off value before 33 weeks were 83% and 67% (p < 0.001), and for the 16 mm after 33 weeks were 77% and 70% (p < 0.001), respectively. A value of 16 mm or more at diagnosis showed 75% of sensitivity and 83% of specificity in predicting the need for surgery (p < 0.001). Moreover, there was a significant correlation between the fetal renal pelvic APD before delivery and delivery-to-operation interval (correlation coefficient − 0.425, p < 0.05). The incidence of postnatal surgery in female fetuses was higher than in male (9/25 vs 19/105, p < 0.05). The results of this study suggest that the fetal renal pelvic APD is of value in predicting postnatal significant uropathy and the need for postnatal surgery.

Reflex redistribution of cardiac output caused by fetal hypoxia increases blood flow to fetal brain, heart but decreases fetal renal blood flow, resulting in decreased urine production and ultimately, oligohydramnios. Because of difficulty in measuring actual amniotic fluid volume, direct measurement of fetal urine production may be another option to evaluate amniotic fluid volume and to predict fetal hypoxia. Although there are some reports about fetal urine production, most of them used 2D ultrasound to measure bladder volume. It is well known that 3D US is superior to 2D US especially in volume measurement. We undertook this study to measure bladder volume with 3D US and establish normogram of hourly fetal urine production rate (HFUPR) according to gestational age (GA). We enrolled 173 women with a normal singleton pregnancy at 24 to 40 weeks gestation. They had no medical or obstetric complications affecting amniotic fluid volume. Fetal bladder volume was measured using a rotational method of VOCAL (Virtual Organ Computer-aided AnaLysis) with 3D US. HFUPR was calculated from serial measurement of bladder volume, and plotted against gestational age. HFUPR can be calculated from GA. ln(HFUPR) = −6.5563 + 0.4622 × (GA) − 0.0048 × (GA)2 (r2 = 0.678, p < 0.001) Normal values of HFUPR versus gestational age HFUPR can be easily measured with 3D US and may be a promising alternative to conventional methods such as amniotic fluid index (AFI) or single deepest pocket.