Intrapartum fetal head position II: comparison between transvaginal digital examination and transabdominal ultrasound assessment during the second stage of labor.

OBJECTIVE: To test the null hypothesis that no correlation exists between transvaginal digital examination compared with the gold standard technique of transabdominal suprapubic ultrasound assessment of fetal head position during the second stage of labor. A secondary objective was to compare the performance of attending physicians vs. senior residents in depicting fetal head position by transvaginal digital examination in comparison with ultrasound assessment. METHODS: Consecutive patients in the second-stage of labor at term with normal singleton cephalic-presenting fetuses and ruptured membranes were included. Transvaginal digital examinations were performed by either attending physicians or senior residents and were followed immediately by transverse suprapubic transabdominal sonographic assessments performed by a single sonographer. Examiners were blinded to each other's findings. Power analysis dictated sample size. Exact binomial confidence intervals around observed rates were compared with chi 2 and Cohen's kappa-tests. Logistic regression was applied. P < 0.05 was considered significant throughout. RESULTS: One hundred and twelve patients were studied. The absolute error of transvaginal digital examinations was recorded in 65% of patients (95% confidence interval, 56-74%). Parity, pelvic station, combined spinal epidural anesthesia, length of first or second stages of labor, use of oxytocin augmentation, gestational age, mode of delivery, birth weight, and examiner experience did not significantly affect examination accuracy. Stratification, when the transvaginal digital examination was recorded as correct if occurring within +/- 45 degrees of the ultrasound assessment, reduced the error of the transvaginal digital examinations to 39% (95% confidence interval, 30-49%). Independent variables again did not affect examination accuracy in this assessment modality. Rates of agreement between the two methods for attending physicians compared with residents were not significantly different. The overall degrees of agreement were 40% (95% confidence interval, 26-55%) and 68% (95% confidence interval, 53-80%) (kappa = 0.25 and 0.30) for the absolute agreement and +/- 45 degrees assessment modalities, respectively, for attending physicians, and 31% (95% confidence interval, 20-44%) and 55% (95% confidence interval, 42-68%) (kappa = 0.14 and 0.12) for senior residents. CONCLUSION: Using ultrasound assessment as the gold standard, our data demonstrate a high rate of error (65%) in transvaginal digital determination of fetal head position during the second stage of labor. The performance of senior residents in transvaginal digital examinations did not differ significantly from that of attending physicians. Intrapartum ultrasound increases the accuracy of fetal head position assessment during the second stage of labor.     

Intrapartum assessment of fetal head engagement: comparison between transvaginal digital and transabdominal ultrasound determinations.

OBJECTIVE: To test the null hypothesis that no correlation exists between transvaginal digital examination and the gold standard technique of intrapartum transabdominal ultrasound determination of fetal head engagement, and secondarily to compare the performance of attending physicians and senior residents in depicting fetal head engagement by transvaginal digital examination. METHODS: Two hundred and twenty-two consecutive patients in labor > 37 weeks' gestation with normal singleton cephalic-presenting fetuses and with either ruptured or intact membranes were included. Of these, 119 were nulliparous and 103 were multiparous. Transvaginal digital examinations were performed by either attending physicians or senior residents and were followed immediately by transverse suprapubic sonographic assessments by a single sonographer. The fetal head was considered engaged on transvaginal digital examination if the leading part of the fetal head was positioned at least at maternal ischial spine station 0, and on transverse suprapubic ultrasound if the fetal biparietal diameter was below the maternal pelvic inlet. Examiners were blinded to each other's findings and the effect of examiner experience on the rate of agreement between the two techniques was assessed. The effect of several other independent variables upon the rate of agreement between the two modalities was also assessed. RESULTS: Overall, transvaginal digital examinations were consistent with ultrasound determinations with a raw percent agreement rate of 85.6% (95% confidence interval (CI), 80.8-90.3); kappa = 69.5% (95% CI, 59.4-73.9; P < 0.001). When stratified according to parity, the raw percent agreement rate for nulliparous patients was 81.5% (95% CI, 73.4-88.0); kappa = 60.7% (95% CI, 45.9-64.1; P < 0.001), and for multiparous patients it was 90.3% (95% CI, 84.1-95.9); kappa = 80.4% (95% CI, 63.0-87.5; P < 0.001). Maternal age, gravidity, maternal body mass index, gestational age, cervical dilatation, effacement, membrane status, ischial spine station of the fetal head, fetal head position at ultrasound assessment, birth weight and mode of delivery did not significantly affect rate of agreement. Parity did not affect examination consistency in multiparous patients, but in the whole group increasing parity increased the rate of agreement between modalities. Presence of combined spinal epidural anesthesia significantly increased the rate of agreement in the complete group and among multiparous but not among nulliparous patients. CONCLUSION: These data demonstrate a high rate of agreement (85.6%) between ultrasound determination and transvaginal digital assessment of fetal head engagement. Examiner experience had no effect. These data support the use of intrapartum transabdominal assessment of fetal head engagement.     

Comparison of transvaginal digital examination with intrapartum sonography to determine fetal head position before instrumental delivery.

OBJECTIVE: To investigate the accuracy of intrapartum transvaginal digital examination in defining the position of the fetal head before instrumental delivery. PATIENTS AND METHODS: In 64 singleton pregnancies undergoing instrumental delivery the fetal head position was determined by transvaginal digital examination by the attending obstetrician. Immediately after or before the clinical examination, the fetal head position was determined by transabdominal ultrasound by a trained sonographer who was not aware of the clinical findings. The digital examination was considered to be correct if the fetal head position was within +/- 45 degrees of the ultrasound finding. The accuracy of the digital examination was examined in relation to maternal and fetal characteristics. RESULTS: Digital examination failed to define the correct fetal head position in 17 (26.6%) cases. In 12 of 17 (70.6%) errors the difference was >/= 90 degrees and in five (29.4%) the difference was between 45 degrees and 90 degrees. The accuracy of vaginal digital examination was 83% for occiput-anterior and 54% for occiput-lateral + occiput-posterior positions. Logistic regression analysis demonstrated significant independent contributions in explaining the variance in the accuracy of vaginal examination for the station of the fetal head, the position of the fetal head and the experience of the examining obstetrician. CONCLUSIONS: Digital examination during instrumental delivery fails to identify the correct fetal head position in about one quarter of cases.     

Transvaginal sonographic measurement of cervical length vs. Bishop score in labor induction at term: tolerability and prediction of Cesarean delivery.

OBJECTIVES: To compare transvaginal sonography for cervical length measurement and digital examination for Bishop score assessment in women undergoing labor induction at term, to assess their tolerability (in terms of pain) and ability to predict need for Cesarean delivery. METHODS: A prospective study was performed on 249 women admitted for labor induction. Cervical length was measured using transvaginal ultrasound examination. A 10-point visual analog scale (VAS) for procedure-related pain was obtained. Bishop score was determined just before labor induction and another pain score was obtained. Delivery outcome was recorded. Analyses were by t-test, Fisher's exact test, receiver-operating characteristics (ROC) curves and multivariate logistic regression. RESULTS: Transvaginal sonography was significantly less painful than digital examination for Bishop score assessment (mean difference in VAS score 3.46; P<0.001). Analyses of the ROC curves for cervical length and Bishop score indicated that both were predictors of Cesarean delivery (area under the curve 0.611 vs. 0.607; P=0.012 vs. P=0.015, respectively) with optimal cut-offs for predicting Cesarean delivery of >20 mm for cervical length and Bishop score20 mm (AOR 3.4; 95% CI, 1.4-8.1; P=0.006) were independent predictors of Cesarean delivery. CONCLUSIONS: Transvaginal sonography for cervical length measurement is better tolerated than digital examination for Bishop score assessment. Both cervical length and Bishop score are useful predictors of the need for Cesarean delivery following labor induction. A cervical length>20 mm at labor induction at term is an independent predictor of Cesarean delivery.     

The role of ultrasound and fetal fibronectin in predicting the length of induced labor when the cervix is unfavorable.

OBJECTIVE: To compare cervical clinical data, ultrasound parameters and fetal fibronectin assessment in the prediction of the duration of induced labor when the cervix is unfavorable. METHODS: This was a prospective study of 90 pregnant women with a Bishop score /= 27 mm (P = 0.002 and P = 0.005). CONCLUSION: Cervical dilatation as assessed by digital examination is the best predictor of the duration of the latent phase and of that of the whole of labor. Ultrasound measurement of cervical length is not more accurate at predicting the duration of labor than are clinical data.     

产时超声对产程评估的应用价值

目的评价产时超声在分娩过程中评估产程的应用价值。 方法选取2020年3月至6月在西安大兴医院产科行阴道试产的临产孕妇120例，由超声经会阴测量宫颈口扩张大小、胎头进展角（AoP）及胎头会阴距离（HPD），由经验丰富的助产医师经阴道触诊判断宫颈口扩张大小和胎先露最低点位置，2组人员评估过程中数据保持互盲，采用Pearson相关分析超声判断的宫颈口扩张大小与阴道触诊的宫颈口扩张大小的相关性，分析超声测量的AoP和HPD与胎先露最低点位置关系，使用受试者操作特征（ROC）曲线评估AoP和HPD预测自然分娩的效能。 结果阴道触诊宫颈口与超声检查宫颈口大小成正相关（r=0.904，P＜0.001）。随着胎头位置的下降，AoP逐渐增大，HPD逐渐减小。AoP预测自然分娩的ROC曲线下面积为0.699，敏感度为75%，特异度为60%，截点值为96.5°；HPD预测自然分娩的ROC曲线下面积为0.624，敏感度为48%，特异度为80%，截点值为36.5 mm。 结论超声评估宫颈口扩张大小与阴道触诊结果基本符合，产时超声检测参数AoP和HPD可用于评估胎头下降位置，对预测分娩方式具有可行性。     

经会阴三维超声评估产程进展参数研究

目的探讨经会阴三维超声测量产程进展度数、胎头下降距离评估产程进展的可行性。方法选取2010年12月至2011年1月于我院行阴道试产的孕妇100例。其中经阴道分娩82例(自然分娩75例,阴道助产7例),剖宫产18例。于产程中对孕妇行经会阴三维超声检查,测量产程进展度数、胎头下降距离。采用线性回归分析分析产程进展度数、胎头下降距离与内诊检查胎先露最低点位置的关系;应用受试者操作特性曲线(ROC曲线)分析产程进展度数、胎头下降距离与孕妇分娩方式的关系;采用两独立样本t检验分析经阴道分娩和剖宫产孕妇产程进展度数变化速度、胎头下降速度差异。结果线性回归分析显示,产程进展度数、胎头下降距离均与内诊检查胎先露最低点位置呈明显的线性关系,线性回归方程分别为:Y产程进展度数=-6.747X+0.057(R2=0.582,P<0.001),Y胎头下降距离=-2.121X+0.074(R2=0.605,P<0.001)。ROC曲线分析显示,产程进展度数>125.5°,胎头下降距离>39.5mm时,孕妇经阴道分娩的可能性较大。经阴道分娩孕妇第一产程活跃期产程进展度数变化速度为(19.3±15.4)°/h,胎头下降速度为(14.6±12.2)cm/h,均高于剖宫产孕妇的(2.4±4.8)°/h、(2.7±4.7)cm/h,且差异均有统计学意义(t值分别为9.896、6.766,P均为0.000)。结论经会阴三维超声可用于产程进展监测。经会阴三维超声测量产程进展度数、胎头下降距离可为临床提供一个相对客观、简便、准确的评估产程进展的参考指标。     

孕期宫颈超声报告的质量现况分析

目的评估不同年资以及是否有专业背景的超声医师孕期宫颈超声检查的报告质量。 方法从超声医学影像工作站导出并选择2019年1月1日至12月31日北京协和医院经会阴与经阴道超声孕期检查宫颈的超声报告624份。检查医师分为第1年住院医师（G1组）、第2~3年住院医师（G2组）和专业医师（G3组）。参考加拿大妇产科医师协会母胎医学专业委员会指南,由2位工作经验＞10年的超声医师对上述图文报告进行评估,分为符合、不符合,通过χ²检验或Fisher精确检验进行组间比较。 结果满足入选标准与排除标准的624份宫颈超声检查报告中,经会阴超声检查507份（81.2%,507/624）,经阴道超声检查117份（18.8%,117/624）。G1组、G2组、G3组检查医师人数分别为：16名、33名、13名。经会阴超声检查,G1组、G2组、G3组的总报告数分别为90份、326份、91份,其符合率分别为74.4%（67/90）、85.9%（280/326）、86.8%（79/91）,G1与G2组、G1与G3组比较,差异有统计学意义（χ²=6.678,P=0.010;χ²=4.438,P=0.035）,G2与G3组比较,差异无统计学意义（P＞0.05）。经阴道超声检查,G1+G2组、G3组的总报告数分别为44份、73份,其符合率分别为75.0%（33/44）、91.8%（67/73）,2组比较差异有统计学意义（χ²=6.225,P=0.013）。相同年资医师经会阴与经阴道宫颈超声检查的符合率之间比较,差异无统计学意义（P＞0.05）。 结论经阴道超声宫颈检查专业组医师符合率较高,经会阴超声检查符合率随着年资增高而增高。病例积累和标准化专业培训是提高孕期宫颈超声检查的有效途径。     

Ultrasound simulators: experience with the SonoTrainer and comparative review of other training systems.

Ultrasound has become indispensable in prenatal diagnosis. Ultrasound training, however, still lacks proper quality assessment and control. Moreover, most fetal anomalies which must be diagnosed during pregnancy are extremely rare. Ultrasound simulators could provide an opportunity to overcome this dilemma. This review summarizes the potential benefits of simulator-based ultrasound training, briefly describes the properties of a variety of ultrasound simulators that have been developed for various applications including prenatal diagnosis, and presents the SonoTrainer sonography simulation system which makes it possible to run a real-time simulation of a complete prenatal ultrasound examination. We evaluated the system for the training of first- and second-trimester screening for both normal and pathological findings and found that physicians who received theoretical training and were additionally trained with the simulator (T + S) significantly improved their skills in measurements of nuchal translucency thickness (NT) and crown-rump length (CRL) as compared with colleagues who only underwent theoretical instruction (T) [mean +/- SD NT deviation: 0.31 +/- 0.1 mm (T + S) vs. 0.62 +/- 0.2 mm (T), P < 0.05; mean +/- SD CRL deviation: 1.48 +/- 2.0 mm (T + S) vs. 3.27 +/- 2.5 (T), P < 0.05]. Simulator-based training enabled physicians to diagnose rare fetal anomalies in the second trimester with a sensitivity of 86% and a specificity of 100%. In a study in which second-trimester scans including fetal anomalies were presented to physicians, 96% of the participants subjectively estimated their training effect as being good. We therefore conclude that simulator-based training would provide an ideal educational tool to test, improve and monitor a physician's or technician's ultrasound skills in detecting fetal anomalies.     

Cervical assessment at 22 and 27 weeks for the prediction of spontaneous birth before 34 weeks in twin pregnancies: is transvaginal sonography more accurate than digital examination?

OBJECTIVES: This study compared the accuracy of ultrasound cervical assessment (cervical length and cervical index) and digital examination (Bishop score and cervical score) in the prediction of spontaneous birth before 34 weeks in twin pregnancies. METHODS: In a prospective multicenter study, digital examination and transvaginal sonography were performed consecutively in twin pregnancies attending for routine sonography at either 22 weeks (175 women) or 27 weeks (153 women). The digital examination took place first, and the Bishop score and cervical score (cervical length minus cervical dilatation) were calculated. Ultrasound measurements were then made of cervical length and funnel length to yield the cervical index (1 + funnel length/cervical length). The association between each variable and delivery before 34 weeks was tested by the Mann-Whitney U-test. The receiver-operating characteristics (ROC) curves of the ultrasound and digital indicators were determined for both gestational age periods, and the areas under the ROC curves compared. The best cut-off values for each indicator were used to determine predictive values for delivery before 34 weeks. RESULTS: The median gestational age at delivery among the women included in the 22-week examination period was 36.0 (range, 21-40) weeks; 10.9% (19) gave birth spontaneously before 34 weeks. The median cervical length was 40 (range, 6-65) mm. All four parameters were predictors of delivery before 34 weeks. The areas under the ROC curves for cervical index, cervical length, Bishop score and cervical score did not differ significantly. The median gestational age at delivery among the women in the 27-week examination period was 36.0 (range, 27-40) weeks; 9.2% (14) gave birth spontaneously before 34 weeks. The median cervical length was 35 (range, 1-57) mm. All parameters except the Bishop score were predictors of delivery before 34 weeks. The likelihood ratio of the positive and negative tests for cervical length < or = 25 mm was 5.4 (range, 3.2-9.0) and 0.3 (range, 0.1-0.7), respectively, compared with 2.3 (range, 1.3-4.2) and 0.6 (range, 0.3-1.1), respectively, for cervical score < or = 1. The area under the curve for the cervical index was significantly larger than that for the Bishop score (P = 0.008) or cervical score (P = 0.02). CONCLUSION: Transvaginal sonography predicted spontaneous delivery before 34 weeks better than digital examination at the 27-week but not the 22-week examination.     

经阴道超声对11~14孕周胎儿结构异常的诊断价值

目的探讨经阴道彩色超声检查在11～14孕周诊断胎儿结构异常的价值.方法对75例11～14孕周有高危妊娠病史或经腹检查不满意以及经腹检查怀疑胎儿有异常的孕妇进行了经阴道彩色超声检查,并与胎儿引产结果对照.结果在75例受检胎儿中,发现胎儿结构异常12例,随访9例,除1例足内翻漏诊外,均与阴道彩超检查结果符合.结论经阴道彩超检查对早期诊断胎儿结构异常有重要临床应用价值.     

Sonographic measurement of cervical length in preterm prelabor amniorrhexis.

OBJECTIVE: To determine whether sonographic measurement of cervical length in pregnancies complicated by preterm prelabor amniorrhexis helps distinguish between those women who deliver within 7 days and those who do not. METHODS: In 101 women with singleton pregnancies presenting with preterm prelabor amniorrhexis at 24-36 (median, 32) weeks of gestation cervical length was measured by transvaginal ultrasound. Exclusion criteria were active labor defined by the presence of cervical dilatation of > or = 3 cm and iatrogenic delivery for fetal or maternal indication when not in active labor. The clinical management was determined by the attending obstetrician. The primary outcome of the study was delivery within 7 days of presentation. RESULTS: Delivery within 7 days of presentation occurred in 58/101 (57%) pregnancies. Logistic regression analysis demonstrated that significant independent contribution in the prediction of delivery within 7 days was provided by cervical length (odds ratio (OR) = 0.91, 95% CI 0.86-0.96, P = 0.001), gestation at presentation (OR = 1.35, 95% CI 1.14-1.59, P = 0.001) and presence of contractions at presentation (OR = 3.07, 95% CI 1.05-8.92, P = 0.039) with no significant independent contribution from ethnic origin, maternal age, body mass index, parity, previous history of preterm delivery, cigarette smoking, vaginal bleeding or the administration of tocolytics, antibiotics or steroids. CONCLUSION: In women with preterm prelabor amniorrhexis prediction of delivery within 7 days is provided by cervical length, gestation and presence of contractions at presentation.     

Multicenter screening for pre-eclampsia and fetal growth restriction by transvaginal uterine artery Doppler at 23 weeks of gestation.

OBJECTIVE: To determine the value of transvaginal color Doppler assessment of the uterine arteries at 23 weeks of gestation in predicting the subsequent development of pre-eclampsia and fetal growth restriction. PATIENTS AND METHODS: Women with singleton pregnancies attending for routine ultrasound examination at 23 weeks in any one of seven hospitals underwent Doppler assessment of the uterine arteries. The presence of an early diastolic notch in the waveform was noted, and the mean pulsatility index of the two arteries was calculated. Screening characteristics in the prediction of pre-eclampsia and the delivery of a low birth-weight infant were calculated. RESULTS: Doppler examination of the uterine arteries was attempted in 8335 consecutive singleton pregnancies, satisfactory waveforms were obtained from both vessels in 8202 (98.4%) cases and complete outcome data were available in 7851 (95.7%) of these. The mean gestational age was 23 (range, 22-24) weeks. The mean uterine artery pulsatility index did not change significantly with gestation (r = -0.0078; P = 0.483); the median value was 1.04 and the 95th centile was 1.63. In 9.3% of cases early diastolic notches in the waveform from both uterine arteries were present and in an additional 11.1% of cases there were notches unilaterally. Pre-eclampsia with fetal growth restriction occurred in 42 (0.5%) cases, pre-eclampsia without fetal growth restriction in 71 (0.9%) and fetal growth restriction without pre-eclampsia in 698 (8.9%). The sensitivity of increased pulsatility index above the 95th centile (1.63) for pre-eclampsia with fetal growth restriction was 69%, for pre-eclampsia without fetal growth restriction was 24%, for fetal growth restriction without pre-eclampsia was 13%, for pre-eclampsia irrespective of fetal growth restriction was 41% and for fetal growth restriction irrespective of pre-eclampsia was 16%. The sensitivity of fetal growth restriction defined by the 5th rather than the 10th centile was higher (19% vs. 16%). The sensitivity for both pre-eclampsia and fetal growth restriction was inversely related to the gestational age at delivery; when delivery occurred before 32 weeks, the sensitivity for all cases of pre-eclampsia with fetal growth restriction, pre-eclampsia without fetal growth restriction and fetal growth restriction without pre-eclampsia increased to 93%, 80% and 56%, respectively. The sensitivity of bilateral notches in predicting pre-eclampsia and/or fetal growth restriction was similar to that of increased pulsatility index but the screen-positive rate with notches (9.3%) was much higher than that with increased pulsatility index (5.1%). CONCLUSIONS: A one-stage color Doppler screening program at 23 weeks identifies most women who subsequently develop severe pre-eclampsia and/or fetal growth restriction.     

Examination of fetal nasal bone and repeatability of measurement in early pregnancy.

OBJECTIVE: To evaluate the examination and measurement of fetal nasal bone at 10-14 weeks of gestation. METHODS: The study included 501 fetuses in 496 consecutive pregnant women attending for the routine first-trimester ultrasound examination. The presence or absence of the fetal nasal bone was determined in the mid-sagittal plane and the length was measured by one of four examiners (measurement A; n = 501). A second measurement was taken by the same examiner (B, n = 300) and a different examiner repeated the measurement (C, n = 200) whenever possible. Measurements were made to the nearest 0.1 mm. The duration of one hundred consecutive examinations was recorded, as was that of another 100 consecutive routine first-trimester examinations without measuring the nasal bone. RESULTS: The median nasal bone length was 1.6 (0.8-2.4) mm, the median gestational age was 12 (10-14) weeks and the median crown-rump length (CRL) was 63 (32-90) mm. The fetal profile was examined in all 501 cases and the fetal nasal bone was present in all but one case (99.8%). No transvaginal scans were needed for the examination of nasal bone only. The average time for the sonographic examination (8.3 min) was not significantly different from the average time for first-trimester scans in which the fetal nasal bone was not measured (8.0 min). The fetal nasal bone length increased from 1.1 mm at a CRL of 35 mm to 2.1 mm at a CRL of 90 mm (nasal bone = 0.016 x CRL + 0.619, P < 0.001, r = 0.655). The repeatability coefficient for intraobserver measurements was 0.080 mm and the coefficient for interobserver measurements was similar (0.083 mm). CONCLUSIONS: The nasal bone can be detected from 10 weeks of gestation onwards. Consistent visualization and repeatable measurement of fetal nasal bone can be performed by an experienced sonographer in the first trimester without extending the length of time required for scanning or introducing the need for transvaginal sonography.     

Prediction of labor and delivery by transperineal ultrasound in pregnancies with prelabor rupture of membranes at term.

OBJECTIVE: To evaluate whether engagement of the fetal head or cervical length in women with premature rupture of membranes (PROM) at term, are associated with time from PROM to delivery or need for operative delivery. METHODS: A transperineal ultrasound examination was performed in 152 women with a single live fetus in cephalic presentation after PROM (at > 37 gestational weeks). The shortest distance from the outer bony limit of the fetal skull to the skin surface of the perineum was measured in a transverse view, and the cervical length was measured in a sagittal view. The time from PROM to delivery was tested in a Cox regression analysis with ultrasound measurements, parity, maternal age, body mass index and birth weight as possible predictive factors. RESULTS: The head-perineal distance was associated with the time from PROM to delivery (log rank test, P < 0.001). Thirty-six hours after PROM, 32% (95% CI, 15-49) of women with a short head-perineal distance (< 45 mm) and 43% (95% CI, 24-62) of women with a long distance (> or = 45 mm) were still in labor. Women with a short head-perineal distance had fewer Cesarean sections, less use of epidural analgesia and a shorter time in active labor, and their babies had a higher pH in the umbilical artery. The measured cervical length was not associated independently with time to delivery. CONCLUSION: Transperineal ultrasound measurements of fetal head engagement may help clinicians to predict the course of labor in women with PROM.     

The natural history of adnexal cysts incidentally detected at transvaginal ultrasound examination in postmenopausal women.

OBJECTIVE: To determine the natural history of adnexal cysts incidentally detected at transvaginal ultrasound examination and judged to be benign in postmenopausal women. METHODS: One hundred and thirty-four postmenopausal women referred for ultrasound examination and found to have an adnexal cyst judged to be benign and not causing any symptoms were followed with transvaginal ultrasound at 3, 6 and 12 months, and then every 12 months. The referring physician treated the patient at his/her own discretion. RESULTS: One hundred and sixty cysts were found, 121 (76%) being unilocular and 39 more complicated. Seventy-two cysts (45%) had a largest diameter of 3-19 mm and 88 (55%) had a largest diameter of 20-80 mm. Median follow-up time was 3 (range, 0.3-8) years. In twelve women (9%) the cysts were removed during follow-up, all their cysts (n = 14) being benign. The indication to operate was a change in cyst morphology or increased cyst size in five (4%) women. In 39 (29%) women, the cysts disappeared; in 18 (13%), new cysts developed; and, in 65 (49%), the number of cysts and their location remained unchanged. Regression of cysts was observed in 54% (33/61) of women < 60 years vs. in 8% (6/73) of those > or = 60 years (P = 0.0001). Ultrasound findings remained unchanged in 34% (21/61) of women < 60 years vs. in 77% (56/73) of those > or = 60 years (P = 0.0001). CONCLUSIONS: The results support conservative management of adnexal cysts incidentally detected at transvaginal ultrasound examination and judged to be benign in postmenopausal women. Whether such cysts need to be followed-up at all and, if they do, how often and for how long, remains an open question.     

Does ultrasound examination when the cervix is unfavorable improve the prediction of failed labor induction?

OBJECTIVE: To compare the Bishop score, ultrasound cervical parameters and fetal fibronectin assessment for predicting failed labor induction when the cervix is unfavorable. METHOD: A prospective observational study was performed in 106 consecutive pregnant women with a Bishop score < or =5 undergoing labor induction. Assessment of fetal fibronectin and ultrasound measurement of cervical length, cervical wedging and cervical lip areas were performed. The relationship between these parameters and failure of labor induction was determined. RESULTS: Failure of labor induction was defined as failure to reach a cervical dilatation of > or =5 cm, and it occurred in 16 patients (15.1%). Induction failure was associated with low Bishop scores before (P = 0.004) and 6 h after the start of induction (P = 0.007), increased clinical cervical length (P = 0.02) and increased ultrasound anterior cervical lip area (P = 0.04). The logistic regression model identified the Bishop score before induction (odds ratio = 2.25; 95% CI, 1.30-3.91; P = 0.003) and the clinical cervical length (odds ratio = 3.95; 95% CI, 1.3-11.7; P = 0.01) as being independent predictors of failed induction. To predict an induction failure, the best Bishop score cut-off value was 4, with a sensitivity of 87.5%, a specificity of 45.6%, a likelihood ratio of 1.58, a positive predictive value of 22.2% and a negative predictive value of 95.4%. CONCLUSION: Compared with the Bishop score, cervical length by ultrasound is not a better predictor for the outcome of labor induction in an unfavorable cervix. Nevertheless, the Bishop score appears to be of poor predictive value for failed induction of labor.     

基于虚拟超声模型评价超声住院医师操作技能培训效果

目的探讨应用虚拟超声模型评价超声住院医师操作技能培训效果的价值。 方法选取在北京协和医院超声医学科参加住院医师规范化培训的2019级住院医师11人,应用虚拟超声模型考核腹部器官的7个正常超声切面和3个病例切面的显示,完成病灶最大切面的长径与短径共6个测量值的测量,并与高年资医师的测量值进行比较。经过2个月门诊实践练习后,再次应用虚拟超声模型进行考核。练习前后分别记为G0M组和G2M组（G,Group;M,Month）。应用Mann-Whitney U检验比较2组检查用时的差异,应用单样本t检验比较住院医师测量值与高年资医师测量值的差异,应用χ²检验（Fisher精确概率法）比较切面合格率和完成率的组间差异。 结果G0M组获取7个正常超声切面的合格率为59.46%（44/74）,检查用时为（8.18±2.96）min。G2M组71.43%的切面合格率均提高,合格率达到88.31%（68/77）,检查用时下降为（5.45±1.57）min,与G0M组相比差异均具有统计学意义（χ²=44.101,P＜0.001;t=-2.698,P=0.014）。G2M组对3个病例切面的完成率较G0M组提高,但组间差异无统计学意义（P均＞0.05）。G2M组对病例1和病例2的检查用时较G0M组减少［1.00（2.00,1.00）min vs 3.00（4.00,2.00）min;2.00（2.00,1.00）min vs 2.50（3.00,2.00）min］,2组间差异具有统计学意义（Z=-3.089、-2.061,P=0.002、0.039）。G2M组对病例3长径的测量准确性较G0M组下降,与高年资医师比较［（8.42±0.88）cm vs 9.45 cm］,差异具有统计学意义（t=-3.097,P=0.021）。 结论虚拟超声模型可用于评价超声住院医师初学阶段和练习期间的操作技能培训效果。     

经阴道超声对11~14孕周胎儿结构异常的诊断价值

目的 探讨经阴道彩色超声检查在11～14孕周诊断胎儿结构异常的价值。方法 对75例11～14孕周有高危妊娠病史或经腹检查不满意以及经腹检查怀疑胎儿有异常的孕妇进行了经阴道彩色超声检查，并与胎儿引产结果对照。结果 在75例受检胎儿中，发现胎儿结构异常12例，随访9例，除1例足内翻漏诊外，均与阴道彩超检查结果符合。结论 经阴道彩超检查对早期诊断胎儿结构异常有重要临床应用价值。     

Transvaginal ultrasonography for cervical assessment before induction of labor.

OBJECTIVE: To evaluate the value of ultrasonographic cervical assessment in predicting the outcome of labor induction and to compare its performance against the Bishop score. METHODS: The Bishop score was determined by digital examination, and transvaginal ultrasonography was performed in 105 women at 37 to 42 weeks' gestation scheduled for labor induction. Ultrasonographic parameters evaluated were cervical length, the presence of funneling, funnel width, and funnel length and were blinded to managing physicians. The primary outcome was the occurrence of active labor within 2 days (successful labor induction). The interval from the onset of induction to active labor (duration of induction) was the secondary outcome. Statistical analysis was performed by the chi2 test, Wilcoxon rank sum test, Pearson correlation, receiver operating characteristic curves, logistic regression, Cox proportional hazards model, and generalized Wilcoxon test for survival data. RESULTS: Induction of labor was successful in 93 women (89%). The area under the receiver operating characteristic curve for cervical length was greater than that of the Bishop score in predicting a successful labor induction (z = 2.18; P < .05). A cervical length of 3.0 cm or less had sensitivity of 75% (70 of 93) and specificity of 83% (10 of 12). Multiple logistic regression analysis showed a significant relationship between successful labor induction and cervical length but not the Bishop score (odds ratio = 0.24; 95% confidence interval, 0.096-0.59; P = .002). Only parity and cervical length had a significantly independent relationship with the duration of induction. CONCLUSIONS: Cervical length measured by transvaginal ultrasonography is a useful and independent predictor of successful labor induction and the duration of induction and provides better predictability of successful labor induction than the Bishop score does.