Factors that influence the development of avulsion of the levator ani muscle in eutocic deliveries: 3–4D transperineal ultrasound study

Introduction: Levator ani muscle (LAM) lesions are the most frequent injuries of the pelvic floor during delivery. Ten to 36% of women report this lesion during their first delivery. Many risk factors have been proposed but very few evaluate the aspects that can influence during natural vaginal delivery.

Method: A prospective observational trial was conducted involving 74 primiparous women following vaginal delivery. Maternal, fetal and obstetric characteristics were analyzed. A transperineal three or four-dimensional (3D–4D) ultrasound was offered six months after delivery in order to evaluate avulsions and anomalies of the hiatus.

Results: Seventy four women were included, three of them did not show up for ultrasound evaluation. Sixty two (87.3%) demonstrated no avulsion in comparison with nine (12.7%) who did. Five of these lesions were unilateral and four bilateral. Mean newborn weight was 3193?g in the “no avulsion group” versus 3470?g in the “avulsion” group (p=0.025).

Discussion: According to the results, the most important risk factor established, for avulsion during natural childbirth, was the newborn weight. This contrasts with many other authors who have established that birth weight has no impact on these lesions.

Conclusions: The most important factor intervening in the avulsion of LAM during natural vaginal delivery is the newborn weight. Patients with diagnosed avulsions present an enlarged urogenital hiatus during valsalva and maximal contraction.     

Can we predict levator ani muscle avulsion in instrumental deliveries through intrapartum transperineal ultrasound?

Introduction: To determine whether intrapartum translabial ultrasound (ITU) is useful for the prediction of levator ani muscle (LAM) avulsions in instrumental deliveries (vacuum and forceps).

Materials and methods: Prospective, observational study, including (1/2016???5/2016) 77 nulliparous women, with singleton pregnancies of ≥37 weeks of gestation and with cephalic presentation, who required vacuum or forceps instrumentation to complete the delivery. The ITU parameters evaluated were Angle of Progression (AoP), Progression Distance (PD), Head Direction (HD), and Midline Angle (MLA), both at rest and with maternal push. Evaluation of LAM avulsion was performed at 6 months postpartum with 3–4D transperineal ultrasound. Complete avulsion was defined as an abnormal insertion of LAM in the lower pubic branch identified in all three central slices.

Results: Data from 48 nulliparous women were finally included in the study (34 vacuum and 14 forceps). We observed no difference in obstetric parameters between the two study groups (group with avulsion of LAM ?14 cases, 29.2%???and group without avulsion of LAM ?34 cases, 70.8%). The “LAM avulsion group” had an AoP and a PD of 136.7?±?22.4 and 43.5?±?15.6, respectively, versus 141.6?±?21.3 and 47.2?±?16.8 recorded in the group without avulsion (NS), respectively. We obtained a ROC curve for AoP and PD with a push of 0.66 (95% CI, 0.28–1.00) and 0.57 (95% CI, 0.39–0.75), respectively.

Conclusions: ITU is not a useful technique to predict the occurrence of LAM avulsion in instrumental deliveries with vacuum or forceps.     

Gestational sac volume by 3D-sonography at 7–10 weeks of pregnancy using the VOCAL method

Purpose  Establish normative data for gestational sac volume (GSV) between 7 and 10 weeks gestation using three-dimensional ultrasonography (3DUS). Methods  A cross-sectional study involving 74 normal pregnancies was performed to assess GSV between 7 and 10 weeks gestation. All measurements were performed using an endocavitary volumetric transducer. The virtual organ computer-aided analysis (VOCAL) method was used for volumetric calculations, with a 30° rotation angle. To analyze the correlation between GSV and gestational age, regression models were constructed and adjustments were made using the determination coefficient (R ²). For each week the mean, median, standard-deviation, minimum and maximum GSV values were calculated. The method proposed by Royston and Wright was used to calculate the reference intervals according to crown-rump length (CRL). The interclass correlation coefficient (ICC) and Bland–Altman graph were used to evaluate intraobserver variability. Results  There was a high correlation between GSV and gestational age (R ² = 0.816). Mean GSV increased from 8.50 cm³ at 7 weeks to 44.35 cm³ at 10 weeks. There was also a significant correlation between GSV and CRL (R ² = 0.693) with mean GSV increasing from 5.00 to 50.28 cm³ for CRL between 9 and 40 mm. Intraobserver variability was excellent with an ICC = 0.9997 (95% CI, 0.9994–0.9998), with an average difference between measurements of 0.5 cm³. Conclusions  There is a correlation between GSV and CRL and this is a reproducible first trimester parameter. Reference limits for GSV using 3DUS were generated for pregnancies between 7 and 10 weeks.     

Semilobar holoprosencephaly with associated cyclopia and radial aplasia: first trimester diagnosis by means of integrating 2D–3D ultrasound

Introduction  Holoprosencephaly (HPE) is commonly associated with facial malformations. We present a case of semilobar HPE associated with distal limb defect which was detected at 12 weeks of gestation. Case  The fetus had a crown-rump length of 60 mm (12 weeks–4 days), had nuchal translucency thickness of 1.5 mm. Initial two-dimensional (2D) ultrasound revealed the absence of nasal bone, decreased BPD and abnormal profile. Transvaginal 2D ultrasound was effective in the detection of HPE (partially absence of the interhemispheric fissure, fused thalami, the choroid plexuses were not visualized bilateraly: absent ‘butterfly’ sign), cylopia, absence of the nose and unilateral radial aplasia. Three dimensional (3D) ultrasound provided a better visualization of the associated anomalies. The necropsy result confirmed the sonographic findings: the diagnosis was semilobar HPE, cyclopia, absence of the nose, and the absence of the radius and the thumb in the left arm. Discussion  Transvaginal 2D sonographic examination is effective in detection of the cases with HPE at first trimester. Fetal morphological study through 3D ultrasound may facilitate the diagnosis of associated anomalies.     

Comparing the detection rate of postpartum diabetes in early and 4–12 week postpartum screening tests in women with gestational diabetes mellitus: A systematic review and meta-analysis

Gestational Diabetes Mellitus (GDM) is one of the critical risk factors for diabetes mellitus (DM). An early postpartum test done in the first few postpartum days can increase the screening rate in women with GDM. Therefore, this systematic review and meta-analysis aimed to combine and analyze data from different studies reporting the detection rate of postpartum diabetes in early and 4–12 week postpartum screening tests in women with GDM. ProQuest, Web of Science, EMBASE, PubMed, Cochrane, and Scopus were searched for English articles from January 1985 to January 2021. Two independent reviewers selected the eligible studies, and the outcomes of interest were extracted. The quality of studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for diagnostic test accuracy studies. Sensitivity and specificity, negative likelihood ratio (NLR), and positive likelihood ratio (PLR) were calculated for the early postpartum oral glucose tolerance test (OGTT). Of 1944 initially identified articles, four studies were included. The sensitivity and specificity of the early test were 74% and 56%, respectively, and the PLR and NLR were calculated as 1.7 and 0.4, respectively. The sensitivity of the early test was higher than the specificity. Based on this sensitivity and specificity, normal cases could be distinguished from abnormal cases, including diabetes and glucose intolerance. Early postpartum OGTT can be advised before hospital discharge. Early testing is a practical option in patients with GDM. Further studies are required to evaluate the early test detection rate for DM and glucose intolerance separately.     

Prenatal diagnosis and molecular cytogenetic characterization of a de novo deletion of 4q34.1→qter associated with low PAPP-A and low PlGF in the first-trimester maternal serum screening,congenital heart defect on fetal ultrasound and a false negative non-invasive prenatal testing (NIPT) result

ObjectiveWe present prenatal diagnosis and molecular cytogenetic characterization of a de novo deletion of 4q34.1→qter associated with low pregnancy associated plasma protein-A (PAPP-A) and low placental growth factor (PlGF) in the first-trimester maternal serum screening, congenital heart defect (CHD) on fetal ultrasound and a false negative non-invasive prenatal testing (NIPT) result.Case ReportA 40-year-old, primigravid woman underwent amniocentesis at 20 weeks of gestation because of advanced maternal age. This pregnancy was conceived by in vitro fertilization (IVF) and embryo transfer (ET). First-trimester maternal serum screening at 12 weeks of gestation revealed low PAPP-A [0.349 multiples of the median (MoM)] and low PlGF (0.299 MoM) and showed a risk for fetal trisomy 21 and trisomy 13. However, NIPT detected no genomic imbalance and a normal result. Nevertheless, level II ultrasound revealed ventricular septal defect, single umbilical artery and a small brain midline cyst. Amniocentesis revealed a karyotype of 46,XX,del(4)(q34.1) and a 17.8-Mb deletion of 4q34.1q.35.2 on array comparative genomic hybridization (aCGH) analysis. The parental karyotypes were normal. The pregnancy was terminated at 23 weeks of gestation, and a malformed fetus was delivered with craniofacial dysmorphism. Postnatal cytogenetic analysis of the placenta confirmed the prenatal diagnosis. There was a 17.8-Mb deletion of 4q34.1q.35.2 encompassing the genes of HAND2, SORBS2 and DUX4. Polymorphic DNA marker analysis on the parental bloods and cord blood showed a paternal origin of the deletion.ConclusionAn abnormal first-trimester maternal serum screening result along with abnormal fetal ultrasound should alert the possibility of fetal aneuploidy, and amniocentesis is indicated even in the presence of a normal NIPT result.