Publications by authors named "Elisa Montaguti"

25 Publications

  • Page 1 of 1

Fetal speckle-tracking echocardiography: a comparison between two-dimensional and electronic spatio-temporal image correlation (e-STIC) technique.

J Matern Fetal Neonatal Med 2021 Apr 6:1-7. Epub 2021 Apr 6.

Department of Medical and Surgical Sciences, Obstetric Unit, University of Bologna and IRCCS Azienda Ospedaliero-Universitaria S.Orsola-Malpighi, Bologna, Italy.

Background: Speckle tracking technology has been applied to assess ventricular deformation throughout the cardiac cycle. An electronic four dimensional probe that allows rapid acquisition of electronic spatio-temporal image correlation volumes (eSTIC) has been recently introduced.

Objectives: The aim of our study was to investigate whether e-STIC acquisition improves deformation analyses reproducibility.

Study Design: We recruited fetuses between 20 and 40 weeks of gestation. We obtained a 2D video clip and an e-STIC volume of a four-chamber view. We focused on left ventricular global strain (LV-GS) and left ventricular ejection fraction (LV-FE). Intraobserver, interobserver and intermethod agreement were assessed by means of intraclass correlation coefficient (ICC) and illustrated by Bland-Altman plots. Systematic differences between measurements were assessed using a paired t-test.

Results: The mean difference between LV-GS values obtained with e-STIC and 2D analysis was -0.10 (95% CI -2.28, 2.08). No systematic differences were found between the two techniques for LV-GS values (-value = .927). The mean difference between LV-FE values obtained with e-STIC and 2D analysis was 7.55 (95% CI 4.16, 10.95; -value <.001). The inter-rater reliability of LV-GS was moderate-to-substantial for both e-STIC and 2D. The inter-rater reliability of LV-FE obtained via e-STIC was superior to that obtained via 2D analysis. The intra-rater reliability of LV-GS obtained with e-STIC was superior to that obtained with 2D analysis (ICC 0.857; 95% IC 0.761-0.917). The intra-rater reliability of LV-FE obtained via e-STIC was superior to that obtained via 2D analysis (ICC 0.647; IC 0.51-0.783).

Conclusions: e-STIC seems to be a better technique than 2D analysis for intra-rater reliability of LV-GS. 4D acquisition might improve intrinsic limitations of speckle tracking echocardiography.
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http://dx.doi.org/10.1080/14767058.2021.1906855DOI Listing
April 2021

A case of lobar holoprosencephaly: brain and facial typical features.

Am J Obstet Gynecol 2021 Mar 30. Epub 2021 Mar 30.

Obstetric Unit, Department of Medical and Surgical Sciences, University of Bologna and IRCCS Azienda Ospedaliero-Universitaria S.Orsola-Malpighi.

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http://dx.doi.org/10.1016/j.ajog.2021.03.030DOI Listing
March 2021

Condensation Ultrasound measurement of the Sylvian fossa during second trimester is feasible and reproducible; a shallow fissure is associated with malformations of cortical development, microcephaly or both.

Am J Obstet Gynecol MFM 2021 Mar 21:100357. Epub 2021 Mar 21.

Obstetric Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy.

Background: Abnormal sulcation of the brain is frequently associated with severe malformations, but the prenatal diagnosis is challenging, especially in early pregnancy.

Objectives: The aim of our study was to investigate the value of Sylvian fossa sonographic biometry in the diagnosis of cerebral malformation in the second trimester of gestation.

Study Design: We prospectively established the normal values of the Sylvian fossa depth in a cohort of non-consecutive patients, with singleton pregnancies and normal fetuses between 18+0 and 23+0 weeks of gestation. For each patient, a coronal view of the fetal brain, with a clear visualization of the anterior complex and the Sylvian fissure, was acquired by one sonologist, who also measured the depth of the fossa. Reproducibility for each parameter was assessed by a second sonologist using stored images. We also retrospectively acquired the same measurements in second trimester fetuses with central nervous system anomalies.

Results: in 103 fetuses with a normal sonogram, the mean depth of the Sylvian fossa was 3.9 ± 0.8 mm (3-6). Inter-observer reproducibility analysis demonstrated good results. Eleven of 31 fetuses with cerebral malformations had a Sylvian fossa depth < - 2 z-scores and these were found to have malformations of cortical development, lissencephaly in particular, and/or microcephaly.

Conclusion: Sonographic measurement of the Sylvian fossa during second trimester is feasible and reproducible. A shallow Sylvian fossa is associated with malformations of cortical development, microcephaly or both.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100357DOI Listing
March 2021

Maternal hemodynamic assessment by USCOM device in the first trimester of pregnancy.

J Matern Fetal Neonatal Med 2021 Feb 14:1-7. Epub 2021 Feb 14.

Obstetric Unit, Department of Medical and Surgical Sciences, University of Bologna and IRCCS Azienda Ospedaliero-Universitaria S.Orsola-Malpighi, Bologna, Italy.

Background: Preeclampsia is a main obstetric disease and could be caused by the inability of the woman hemodynamic system to face the cardiovascular effort required by gestation.

Objective: The aim of the present study is to evaluate the correlation between maternal hemodynamic parameters detected by UltraSonic Cardiac Output Monitor (USCOM) and ultrasound or biochemical parameters in women during the first-trimester screening of chromosomal abnormalities.

Methods: This was a prospective observational study with 162 women enrolled during the first-trimester ultrasound, recording demographic, biochemical and ultrasound data, including the pulsatility index of uterine arteries (UTPI). Hemodynamic indices were obtained using the USCOM system. We also analyzed the outcomes of pregnancy of those women who delivered in our clinic.

Results: As for the correlation between biochemical and ultrasound parameters, pregnancy-associated plasma protein A (PAPP-A) relates inversely with the mean UTPI ( -0.298,  < .001). We also reported a statistically significant correlation between the mean UTPI and the maternal haemodynamic parameters detected by USCOM (higher values of mean UTPI are associated with lower values of indexed cardiac output, CO, and higher indexed peripheral resistances, TVR). When comparing women with higher UTPI and TVR or lower CO to patients who had regular values of these parameters, we noticed that between these groups there were significant differences in all the remaining hemodynamic parameters, including inotropy index and stroke volume, as well as in the biochemical values of PAPP-A. Analyzing postpartum data, if we combine the onset of hypertensive disorders and fetal growth restriction, the most predictive parameter is indexed TVR.

Conclusion: Our study confirmed the correlation between PAPP-A and placental function, expressed through the determination of the pulsatility index of the uterine arteries. Moreover, we found a clear correlation between biochemical markers, placental function and maternal hemodynamics, since the first trimester of pregnancy. The inclusion of maternal hemodynamic evaluation could be useful in the screening protocols of preeclampsia. If we combine the onset of hypertensive disorders and of fetal growth restriction, the most predictive parameter is indexed total vascular resistances.
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http://dx.doi.org/10.1080/14767058.2021.1887129DOI Listing
February 2021

Usefulness of USCOM® evaluation in women with chronic hypertension who developed severe preeclampsia with low platelets and elevated liver enzymes.

J Matern Fetal Neonatal Med 2021 Jan 17:1-4. Epub 2021 Jan 17.

Obstetric Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Bologna, Italy.

Cardiovascular changes that occur during pregnancy have been recently described and are matter of debate; during gestation we observe an increase in cardiac output and a reduction of peripheral total vascular resistance (TVR). In pregnancies complicated by hypertensive disorders, instead, these changes are lacking, with a persisting low cardiac output and high peripheral resistances. In this case report, we observed that in patients with chronic hypertension TVR are high, while the cardiac output is able to face the needs of pregnancy. The increase in TVR before the decision to deliver, due to bad blood pressure control despite therapy, may precede the alterations in blood tests (platelet decreasing and high liver enzymes). This data may be useful for monitoring patients with chronic hypertension and identifying those at higher risk of developing HELLP/severe preeclampsia.
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http://dx.doi.org/10.1080/14767058.2021.1873269DOI Listing
January 2021

Prenatal diagnosis of congenital heart defects and voluntary termination of pregnancy.

Am J Obstet Gynecol MFM 2020 11 15;2(4):100207. Epub 2020 Aug 15.

Obstetric Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy.

Background: The prenatal diagnosis of an isolated congenital heart defect is a matter of concern for parents. The decision of whether to terminate the pregnancy according to the different types of congenital heart defects has not been investigated yet.

Objective: This study aimed to evaluate the frequency of voluntary termination of pregnancy after the prenatal diagnosis of a congenital heart defect in a tertiary care center.

Study Design: This was a retrospective study of patients who were referred to our center from January 2013 to December 2019, underwent fetal echocardiography, and were counseled by a perinatologist and a pediatric cardiologist. The following data were collected: prenatal diagnosis, including genetic testing; gestational age at diagnosis; and outcome of pregnancy. The diagnoses were stratified retrospectively according to the type of congenital heart defect and its severity (low complexity, moderate complexity, and high complexity) by a perinatologist and a pediatric cardiologist.

Results: Of 704 women who received a diagnosis of fetal congenital heart defect, 531 (75.4%) were seen before 23 weeks' gestation, which is the upper limit imposed for the termination of pregnancy by the Italian legislation. Congenital heart defects were apparently isolated in 437 of 531 cases (82.3%). Overall, 108 of 531 patients (20.3%) requested a termination of pregnancy. The rate of termination of pregnancy was found to vary according to the severity of congenital heart defects: low complexity, 0%; moderate complexity, 12.1%, and high complexity, 33.2% (P<.001). The presence or absence of associated anomalies or the ethnicity of the couples was not found to have an influence on women's decisions.

Conclusion: In our population, the decision to terminate a pregnancy after the diagnosis of a fetal congenital heart defect is influenced by the surgical complexity of the congenital heart defect itself. However, most patients, including those with the most severe forms of congenital heart defect, decided to continue the pregnancy.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100207DOI Listing
November 2020

Obstetric anal sphincter injuries: strategies for prevention, diagnosis, and management.

Minerva Obstet Gynecol 2021 Feb 30;73(1):74-81. Epub 2020 Nov 30.

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, PA, USA -

Obstetric anal sphincter injuries (OASIS) are one of the most common causes of anal incontinence (AI) in women of reproductive age and can have a significant impact on quality of life. However, many women do not report symptoms to their physicians because of embarrassment and shame. Therefore, prevention and diagnosis of the tear is essential. Diagnostic strategies have evolved considerably in recent years, with an increase in prevalence of OASIS as a consequence. The use of 3D endoanal (3D-EAUS) and 4D transperineal ultrasound (4D-TPUS), in addition to standard clinical examination have enhanced the detection of OASIS. Once identified, adequate repair by a skilled practitioner and optimal postpartum management should be ensured in order to reduce the risk of anal incontinence. This review presents the available evidence on strategies for prevention, diagnosis, and management of OASIS.
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http://dx.doi.org/10.23736/S0026-4784.20.04668-7DOI Listing
February 2021

The role of a new three-dimensional ultrasound technique in the diagnosis of levator ani muscle avulsion.

Neurourol Urodyn 2020 01 25;39(1):455-463. Epub 2019 Nov 25.

Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy.

Aims: To evaluate the intermethod agreement between the tomographic ultrasound imaging (TUI), considered as the gold standard, and the OmniView-VCI in the diagnosis of levator ani muscle (LAM) avulsion and in the measurement of levator-urethral gap (LUG).

Methods: We acquired dynamic 4D transperineal ultrasound volumes from 114 women. Each data set was analyzed on maximal pelvic floor contraction by TUI and OmniView-VCI techniques to check for LAM avulsion. Moreover, we measured LUG using both TUI and OmniView-VCI, twice by an operator and once by another to assess intraobserver and interobserver reproducibility. Reproducibility and intermethod agreement were studied by means of intraclass correlation coefficient (ICC) and Cohen's kappa coefficient.

Results: In the diagnosis of ani levator avulsion, the two techniques showed a good agreement (Cohen's κ = 0.691, 95% confidence interval [CI], 0.522-0.860; P < .001); we also reported a good intraobserver and interobserver agreement (Cohen's κ = 0.738, 95% CI, 0.597-0.879; P < .001, and Cohen's κ = 0.864, 95% CI, 0.750-0.978; P < .001, respectively). LUG measurements by OmniView-VCI technique showed high intraobserver (ICC 0.895; 95% CI, 0.866-0.918) and interobserver (ICC 0.821; 95% CI, 0.774-0.858) reproducibility. High intermethod agreement was demonstrated between the two methods (ICC 0.813; 95% CI, 0.764-0.853). The area under the receiver-operating characteristic curve of LUG in predicting avulsion was 0.931 (0.868-0.994, 95% CI; P < .001) with 24 mm showing the best sensitivity (82%) and specificity (97%).

Conclusions: OmniView-VCI is a reliable method for LUG measurement and for levator avulsion diagnosis.
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http://dx.doi.org/10.1002/nau.24236DOI Listing
January 2020

Reliability of transperineal ultrasound for the assessment of the angle of progression in labor using parasagittal approach versus midsagittal approach.

J Matern Fetal Neonatal Med 2019 Oct 23:1-6. Epub 2019 Oct 23.

Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna , Bologna , Italy.

To assess the inter-method agreement between midsagittal (msAoP) and parasagittal (psAoP) measurements of the angle of progression (AoP) during labor. In addition, we aimed to evaluate the correlation between AoP measurements by both midsagittal and parasagittal approaches with the mode of delivery. We recruited a nonconsecutive series of women in active labor with a singleton uncomplicated term pregnancy with fetuses in vertex presentation. Women underwent transperineal ultrasound in the absence of uterine contractions or maternal pushing to measure both msAoP and psAoP. The inter-method agreement between the two acquisitions was then assessed. Lastly, both measurements were compared between women who had a vaginal delivery versus those who underwent cesarean section (CS). Overall, 151 women were included in the study. We found an excellent agreement between msAoP and psAoP (ICC 0.935; 95% CI 0.912-0.953,  < .001). On the other hand, psAoP overestimated the measurements in comparison with msAoP (101.2 ± 15.6 versus 98.2 ± 16.0,  < .001). There was a significant correlation between both methods of AoP assessment and duration of the active second stage of labor and AoP measured by either method was significantly wider in patients who delivered vaginally compared to those who had a CS. Our data showed a significant difference in the measured angle between the psAoP and the originally described msAoP. The automated measurements of AoP that have been introduced are designed using the parasagittal visualization of the more echogenic pubic arch, rather than the hypoechogenic pubic symphysis. We think that in the light of our data, care should be taken before applying data from midsagittal measurement in centers using the parasagittal automated approach.
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http://dx.doi.org/10.1080/14767058.2019.1678143DOI Listing
October 2019

Dynamic changes of fetal head descent at term before the onset of labor correlate with labor outcome and can be improved by ultrasound visual feedback.

J Matern Fetal Neonatal Med 2019 Aug 8:1-8. Epub 2019 Aug 8.

a Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna , Bologna , Italy.

The aim of the study was to evaluate the dynamic changes of angle of progression (AoP) before the onset of labor and their correlation with labor outcome and to investigate the effect of visual feedback using transperineal ultrasound on maternal pushing. We recruited a group of low-risk nulliparous women with singleton pregnancy at term. We measured AoP at rest, during pelvic floor contraction and Valsalva maneuver (before and after visual feedback). We compared AoP between women who delivered vaginally (VD) and those who underwent a cesarean section (CS). We also assessed the correlation between AoP and labor durations. Overall, 222 women were included in the study; 129 (58.1%) had spontaneous VD, 35 (15.8%) had instrumental delivery, and 58 (26.1%) underwent CS. In comparison with rest, AoP decreased at PFMC ( < .001) and increased at first Valsalva ( < .001). AoP increased further significantly at Valsalva after visual feedback ( < .001). Women with VD had wider AoP at rest ( = .020), during Valsalva maneuver before ( = .024), and after visual feedback ( = .037). At cox regression analysis, wider AoP was associated with shorter first, second, and active second stages. Wider AoP at rest and under Valsalva is associated with vaginal delivery, the shorter interval to delivery, and shorter labor duration in nulliparous women at term. The accuracy of AoP in the prediction of cesarean delivery is modest and is unlikely to be clinically applicable in isolation for the prediction of the mode of delivery.
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http://dx.doi.org/10.1080/14767058.2019.1651266DOI Listing
August 2019

Dynamic 2-dimensional transperineal ultrasound evaluation in labor room as a screening tool for anal sphincter injuries and anal incontinence in primiparous women.

Am J Obstet Gynecol MFM 2019 08 21;1(3):100037. Epub 2019 Aug 21.

Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Italy.

Background: Early repair of obstetric anal sphincter injuries is crucial in the prevention of anal incontinence, but the diagnostic accuracy of the clinical examination after delivery is poor. Endoanal ultrasound imaging is now regarded as the gold standard for diagnosing anal sphincter injuries, and it improves the diagnosis of these lacerations. Four-dimensional transperineal ultrasound imaging has been proposed as an effective and less invasive alternative to endoanal ultrasound imaging in the diagnosis of anal sphincter injuries.

Objective: The purpose of this study was to evaluate the feasibility and accuracy of the assessment of anal sphincter contraction by dynamic 2-dimensional transperineal ultrasound imaging immediately after delivery and its correlation with anal incontinence at the 4-month follow-up evaluation.

Study Design: A nonconsecutive series of nulliparous women with low-risk singleton term pregnancies were recruited in the labor room after vaginal delivery for the purpose of this study from January 2017 to July 2017. All enrolled patients had a clinical examination of the perineum by the caregiver that was repeated by an experienced research fellow. For each patient, a further dynamic 2-dimensional transperineal ultrasound imaging were carried out. Before the perineal repair, the women were asked to contract the anal sphincter during 2-dimensional transperineal ultrasound imaging; they were divided in 2 groups according to the sonographic findings: women with sonographic evidence of anal sphincter contraction (group A) and women with no evidence of contraction at ultrasound imaging (group B). A follow-up examination of anal sphincter integrity with 4-dimensional transperineal ultrasound imaging was carried out 4 months after delivery. At this time, the levator ani integrity was evaluated with the use of 4-dimensional transperineal ultrasound imaging, as previously described.

Results: Over the study period 69 women were enrolled. In 55 women (80%), there was evidence of proper anal sphincter contraction (group A); in 14 cases (20%), it was not possible to identify anal sphincter contraction with dynamic 2-dimensional transperineal ultrasound imaging (group B). Obstetric anal sphincter injuries that were detected through clinical examination were significantly more frequent in group B than in group A (13/14 [93%] vs 7/55 [12%]; P<.001). At the 4-month postpartum follow up, the previously recognized obstetric anal sphincter injuries were found to be repaired correctly; a third-degree perineal tear that had not been reported previously was diagnosed by 4-dimensional transperineal ultrasound imaging . Anal incontinence was reported in 8 of 69 patients (11%); it was more frequent in group B when compared with group A (4/14 [29%] vs 4/55 [7%]; P=.047).

Conclusion: Dynamic 2-dimensional transperineal ultrasound imaging is a feasible technique and a useful supporting tool for the assessment of anal sphincter integrity in the labor room before suturing. Anal incontinence at the 4-month follow-up evaluation is more frequent among women with no evidence of anal sphincter contraction at dynamic 2-dimensional transperineal ultrasound imaging after delivery.
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http://dx.doi.org/10.1016/j.ajogmf.2019.100037DOI Listing
August 2019

Contraction of the levator ani muscle during Valsalva maneuver (coactivation) is associated with a longer active second stage of labor in nulliparous women undergoing induction of labor.

Am J Obstet Gynecol 2019 02 12;220(2):189.e1-189.e8. Epub 2018 Oct 12.

Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy. Electronic address:

Background: The Valsalva maneuver is normally accompanied by relaxation of the levator ani muscle, which stretches around the presenting part, but in some women the maneuver is accompanied by levator ani muscle contraction, which is referred to as levator ani muscle coactivation. The effect of such coactivation on labor outcome in women undergoing induction of labor has not been previously assessed.

Objective: The aim of the study was to assess the effect of levator ani muscle coactivation on labor outcome, in particular on the duration of the second and active second stage of labor, in nulliparous women undergoing induction of labor.

Study Design: Transperineal ultrasound was used to measure the anteroposterior diameter of the levator hiatus, both at rest and at maximum Valsalva maneuver, in a group of nulliparous women undergoing induction of labor in 2 tertiary-level university hospitals. The correlation between anteroposterior diameter of the levator hiatus values and levator ani muscle coactivation with the mode of delivery and various labor durations was assessed.

Results: In total, 138 women were included in the analysis. Larger anteroposterior diameter of the levator hiatus at Valsalva was associated with a shorter second stage (r = -0.230, P = .021) and active second stage (r = -0.338, P = .001) of labor. Women with levator ani muscle coactivation had a significantly longer active second stage duration (60 ± 56 vs 28 ± 16 minutes, P < .001). Cox regression analysis, adjusted for maternal age and epidural analgesia, demonstrated an independent significant correlation between levator ani muscle coactivation and a longer active second stage of labor (hazard ratio, 2.085; 95% confidence interval, 1.158-3.752; P = .014). There was no significant difference between women who underwent operative delivery (n = 46) when compared with the spontaneous vaginal delivery group (n = 92) as regards anteroposterior diameter of the levator hiatus at rest and at Valsalva maneuver, nor in the prevalence of levator ani muscle coactivation (10/46 vs 15/92; P = .49).

Conclusion: Levator ani coactivation is associated with a longer active second stage of labor.
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http://dx.doi.org/10.1016/j.ajog.2018.10.013DOI Listing
February 2019

The Effect of Chorionicity on Maternal Cardiac Adaptation to Uncomplicated Twin Pregnancy: A Prospective Longitudinal Study.

Fetal Diagn Ther 2019 17;45(6):394-402. Epub 2018 Aug 17.

Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy.

Objective: The objective of this study was to longitudinally evaluate maternal echocardiographic findings in uncomplicated twin gestations according to chorionicity.

Methods: Healthy women with twin pregnancy were assessed with transthoracic echocardiography across the first, second, and third trimesters. Cardiac findings were compared within each group and between monochorionic (MC) and dicho-rionic (DC) pregnancies.

Results: Overall, 19 MC and 48 DC uncomplicated twin pregnancies were included. In the MC group, no significant maternal haemodynamic changes were documented across gestation, with the exception of a decrease in ejection fraction. Compared to DC pregnancies, in the MC set lower cardiac output (second and third trimester, p = 0.001 and p = 0.006, respectively) and higher total vascular resistance (first trimester, p = 0.032) were observed. Regarding the diastolic function in MC twins, significantly higher values were observed for mitral E/A ratio (third trimester, p = 0.014), septal mitral E1/A1 ratio (third trimester, p = 0.030), lateral mitral E1 (second and third trimester, p = 0.014 and p = 0.029, respectively), and E1/A1 ratio (third trimester, p = 0.006).

Conclusions: Maternal cardiac adaptation in twin pregnancy seems to differ significantly according to chorionicity. In particular, in MC pregnancies the impairment of diastolic function is less pronounced, presumably due to the lower circulating volume.
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http://dx.doi.org/10.1159/000490462DOI Listing
January 2020

Automated 3D ultrasound measurement of the angle of progression in labor.

J Matern Fetal Neonatal Med 2018 Jan 23;31(2):141-149. Epub 2017 Jan 23.

a Department of Obstetrics and Gynecology , Sant'Orsola Malpighi University Hospital, University of Bologna , Bologna , Italy.

Objectives: To assess the feasibility and reliability of an automated technique for the assessment of the angle of progression (AoP) in labor by using three-dimensional (3D) ultrasound.

Methods: AoP was assessed by using 3D transperineal ultrasound by two operators in 52 women in active labor to evaluate intra- and interobserver reproducibility. Furthermore, intermethod agreement between automated and manual techniques on 3D images, and between automated technique on 3D vs 2D images were evaluated.

Results: Automated measurements were feasible in all cases. Automated measurements were considered acceptable in 141 (90.4%) out of the 156 on the first assessments and in all 156 after repeating measurements for unacceptable evaluations. The automated technique on 3D images demonstrated good intra- and interobserver reproducibility. The 3D-automated technique showed a very good agreement with the 3D manual technique. Notably, AoP calculated with the 3D automated technique were significantly wider in comparison with those measured manually on 3D images (133 ± 17° vs 118 ± 21°, p = 0.013).

Conclusions: The assessment of the angle of progression through 3D ultrasound is highly reproducible. However, automated software leads to a systematic overestimation of AoP in comparison with the standard manual technique thus hindering its use in clinical practice in its present form.
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http://dx.doi.org/10.1080/14767058.2016.1277701DOI Listing
January 2018

Automated Measurement of the Angle of Progression in Labor: A Feasibility and Reliability Study.

Fetal Diagn Ther 2017 3;41(4):293-299. Epub 2016 Sep 3.

Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy.

Objectives: The aim of this paper was to assess the feasibility and reliability of a new automated method for the measurement of the angle of progression (AoP) in labor.

Methods: AoP was assessed using two-dimensional transperineal ultrasound by two operators in 52 women in active labor to evaluate intra- and interobserver reproducibility. The intermethod agreement between automated and manual techniques was analyzed by means of the intraclass correlation coefficient and Bland-Altman method.

Results: Automated measurements were feasible in all cases. Automated assessments correctly depicted the pubic symphysis and fetal head in 133 (85.3%) out of 156 on first assessments and in all 156 after repeating measurements once in case of incorrect first evaluation. The automated technique showed good intra- and interobserver reproducibility and very good agreement with the manual technique. AoP measured by the automated method were significantly wider than those done by the manual technique (119 ± 20° vs. 130 ± 20°, p = 0.005).

Conclusions: Automated assessment AoP is feasible and reproducible. However, measurements performed by the automated software are significantly different from those resulting from the previously published manual technique. In the light of our data, the automated technique does not seem ready yet for clinical use, and the AoP should be exclusively measured by the previously suggested manual technique.
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http://dx.doi.org/10.1159/000448947DOI Listing
March 2018

Reply.

Am J Obstet Gynecol 2016 Mar 1;214(3):414-5. Epub 2015 Dec 1.

Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

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http://dx.doi.org/10.1016/j.ajog.2015.11.010DOI Listing
March 2016

Subpubic Arch Angle and Mode of Delivery in Low-Risk Nulliparous Women.

Fetal Diagn Ther 2016 11;40(2):150-5. Epub 2015 Nov 11.

Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy.

Objective: To assess whether subpubic arch angle (SPA) measurement before labor onset can predict labor outcome among low-risk pregnant women.

Methods: 3D ultrasound volume was transperineally acquired from a series of nulliparous women with uncomplicated pregnancy at term before the onset of labor. SPA was measured offline using Oblique View Extended Imaging (OVIX) on each volume performed by an investigator not involved in the clinical management. Labor outcome was prospectively investigated in the whole study group.

Results: Overall, 145 women were enrolled in the study. Of these, 83 underwent spontaneous vaginal delivery, whereas obstetric intervention was performed in 62 cases (Cesarean section in 40 and vacuum extraction in 22). The SPA appeared to be significantly narrower in the women submitted to obstetric intervention compared with those undergoing spontaneous vaginal delivery (116.8 ± 10.3° vs. 123.7 ± 9.6°, p < 0.01). At multivariate analysis SPA and maternal age were identified as independent predictors of the mode of delivery. On the other hand, the duration of labor did not show a significant relationship with SPA.

Conclusions: In low-risk nulliparous women at term gestation, SPA measurement obtained by 3D ultrasound before the onset of labor seems to predict the likelihood of an obstetric intervention but not the duration of labor.
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http://dx.doi.org/10.1159/000441517DOI Listing
February 2017

Maternal cardiac evaluation during uncomplicated twin pregnancy with emphasis on the diastolic function.

Am J Obstet Gynecol 2015 Sep 5;213(3):376.e1-8. Epub 2015 May 5.

Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

Objective: The objective of the study was to evaluate the longitudinal changes in maternal systolic and diastolic function in a series of women carrying an uncomplicated twin pregnancy.

Study Design: A series of women carrying a twin pregnancy underwent standard M-mode, 2-dimensional color Doppler, and tissue Doppler transthoracic echocardiography during the first (11-13 weeks), the second (20-23 weeks), the third (28-32 weeks) trimesters, and the postpartum (6 months after delivery).

Results: From January 2012 to September 2013, 30 women with an uncomplicated twin pregnancy were included in this prospective study. All the pregnancies were diamniotic including 24 dichorionic and 6 monochorionic sets. Overall, 60 live births were observed with a mean gestational age at delivery of 37 ± 1 weeks and a mean birthweight of 2532 ± 313 g. During pregnancy a significant worsening of left ventricle systolic function expressed by ejection fraction, fractional shortening and S1 longitudinal contractility decrease was observed. These findings also persisted at postpartum assessment. Regarding diastolic function, our data showed a significant progressive reduction of pulsed Doppler E-wave velocity and an increase of A-wave from the first to the third trimester. Similar changes were documented for tissue Doppler E1 and A1 peak velocities assessed at the level of the mitral and tricuspid annulus. After delivery diastolic findings returned to values comparable with those obtained in the first trimester.

Conclusion: In uncomplicated twin gestations, significant changes in maternal systolic and diastolic function occur from the first to the third trimester. Moreover, although diastolic parameters normalize after pregnancy, a relative systolic dysfunction seems to persist after delivery.
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http://dx.doi.org/10.1016/j.ajog.2015.05.003DOI Listing
September 2015

A New Method to Measure the Subpubic Arch Angle Using 3-D Ultrasound.

Fetal Diagn Ther 2015 8;38(3):195-9. Epub 2015 Apr 8.

Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy.

Objectives: The aim of this study was to assess the reproducibility of both a new contrast-enhancing technique (Oblique View eXtended Imaging, OVIX; Samsung) and the recently reported 3-D multiplanar technique (MPT) in the measurement of the subpubic angle (SPA) among a group of women at term gestation. In addition, we aimed to study the intermethod agreement between the OVIX technique and MPT.

Methods: We acquired a transperineal 3-D ultrasound volume from 155 women with a singleton uncomplicated term pregnancy before the onset of labor. Each 3-D dataset was analyzed by the MPT and OVIX algorithm. The angle formed by the lower edges of the pubic rami (SPA) was measured twice by an operator and once by another operator for each technique in order to assess intra- and interobserver reproducibility. Reproducibility and intermethod agreement were studied by means of the intraclass correlation coefficient (ICC) and Bland-Altman method.

Results: SPA measurements performed with OVIX showed high intraobserver [ICC 0.912, 95% confidence interval (CI) 0.882-0.935] and good interobserver (ICC 0.791, 95% CI 0.724-0.844) agreement, while those measured with MPT showed moderate intraobserver (ICC 0.573, 95% CI 0.457-0.670) and good interobserver (ICC 0.640, 95% CI 0.537-0.724) agreement. Whereas the intermethod analysis showed good agreement between the MPT and the OVIX techniques (ICC 0.614, 95% CI 0.414-0.757), the SPA measured by MPT were significantly wider than those measured by OVIX (125 ± 12 vs. 120 ± 11°, p = 0.006).

Conclusions: OVIX is a reliable technique for SPA measurement. MPT overestimates the SPA in comparison with OVIX. Further studies are needed to assess its clinical utility.
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http://dx.doi.org/10.1159/000380947DOI Listing
September 2016

Sequential analysis of the normal fetal fissures with three-dimensional ultrasound: a longitudinal study.

Prenat Diagn 2015 May;35(5):493-9

Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy.

Objective: To perform a sequential analysis of the main cortical fissures in normal fetuses using 3D ultrasound.

Methods: A cohort of patients with uncomplicated singleton pregnancies underwent three consecutive transabdominal scans at 19-21, 26-28 and 30-34 weeks. Volumes of the fetal head were acquired and searched in the multiplanar mode for the following cortical fissures: sylvian, parieto-occipital, calcarine, hippocampus and cingulate. A qualitative analysis of these sulci was performed in each volume by an experienced operator (A) and a trainee (B). By placing the dot on the sulcus in one plane, it was evaluated whether it was visible also in other planes.

Results: Fifty patients were included in the study. At 19-21 weeks, the sylvian and parieto-occipital sulci were visualized on at least one plane by both operators in all cases. At 26-28 weeks, all fissures were visualized by both operators on at least one plane, with no significant difference between the performances of the two operators. At 30-34 weeks, a mild overall decline in the accuracy of identification of all the cerebral fissures was observed.

Conclusions: 3D multiplanar mode allows a systematic evaluation of the cortical fissures in normal fetuses since midtrimester.
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http://dx.doi.org/10.1002/pd.4565DOI Listing
May 2015

A new simple technique for 3-dimensional sonographic assessment of the pelvic floor muscles.

J Ultrasound Med 2015 Jan;34(1):65-72

Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy (A.Y., E.M., O.S., L.C., G.P., T.G., G.P., N.R.); and Department of Obstetrics and Gynecology, El-Shatby Maternity Hospital, Alexandria University, Alexandria, Egypt (E.E.A.).

Objectives: The purpose of this study was to assess the reproducibility of a new technique for 3-dimensional (3D) pelvic floor sonography: OmniView combined with Volume Contrast Imaging (VCI; GE Healthcare, Kretz Ultrasound, Zipf, Austria) for pelvic hiatal area measurement. In addition, we aimed to study the intermethod agreement between the new technique and the standard 3D rendering method.

Methods: We acquired a static 3D sonographic transperineal volume from 124 nulliparous asymptomatic women and 118 women with symptoms of pelvic floor dysfunction. Each 3D data set was analyzed by the OmniView-VCI technique to measure the pelvic hiatal area twice by one operator and once by another to assess intraobserver and interobserver reproducibility. The first operator later measured the hiatal area using the 3D rendering method to evaluate intermethod agreement. Reproducibility and intermethod agreement were studied by the intraclass correlation coefficient and Bland-Altman method.

Results: Hiatal area measurements by the OmniView-VCI technique showed high intraobserver and interobserver reproducibility in both asymptomatic and symptomatic women. In addition, high agreement was shown between the new technique and 3D rendering in both groups. No systematic differences were noted in any of the reliability studies performed. The new technique took slightly less time to calculate the hiatal area than the standard rendering method in both asymptomatic and symptomatic women.

Conclusions: OmniView-VCI is a reliable method for pelvic hiatal area measurement. Further studies are needed to assess its reliability under contraction and the Valsalva maneuver and to evaluate its usefulness and reproducibility for diagnosis of levator ani lesions.
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http://dx.doi.org/10.7863/ultra.34.1.65DOI Listing
January 2015

Fetal head-symphysis distance and mode of delivery in the second stage of labor.

Acta Obstet Gynecol Scand 2014 Oct 13;93(10):1011-7. Epub 2014 Aug 13.

Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

Objective: To evaluate whether the fetal head-symphysis distance measured by three-dimensional transperineal ultrasound during the active second stage predicts operative delivery.

Design: Prospective observational study.

Setting: University hospital, Bologna, Italy.

Population: Seventy-one nulliparous women at term in active second stage of labor.

Methods: We acquired a series of sonographic volumes at the beginning of the active second stage (T1) and every 20 min thereafter (T2, T3, T4, T5, T6) until delivery. All volumes were retrospectively analyzed and head-symphysis distance was measured for each acquisition. We compared head-symphysis distance between women with spontaneous vaginal delivery and those with operative delivery. Receiver operator characteristic curves were constructed to estimate the accuracy of head-symphysis distance in the prediction of operative delivery. Logistic regression was used to identify independent variables associated with operative delivery.

Main Outcome Measures: Operative delivery (vacuum or cesarean).

Results: Of the women included, 81.7% had a spontaneous vaginal delivery and 18.3% underwent operative delivery. Women with spontaneous vaginal delivery had shorter head-symphysis distance than women in the operative delivery group at T1 (p < 0.001), T2 (p < 0.001) and T3 (p = 0.025), whereas no significant differences were recorded thereafter. Receiver operator characteristic curves revealed accuracy values of 81.0%, 87.9% and 77.6% in the prediction of operative delivery at T1, T2 and T3, respectively. At multivariate logistic regression head-symphysis distance and epidural analgesia were the only independent predictors of operative delivery among ultrasonographic, maternal and intrapartum variables.

Conclusions: Ultrasonographic measurement of head-symphysis distance in the second stage of labor can be used to predict operative delivery.
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http://dx.doi.org/10.1111/aogs.12454DOI Listing
October 2014

Prenatal diagnosis versus first-trimester screening of trisomy 21 among pregnant women aged 35 or more.

J Matern Fetal Neonatal Med 2015 Apr 26;28(6):674-8. Epub 2014 Jun 26.

Department of Obstetrics and Gynaecology, Sant'Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy.

Objective: To compare the policy of prenatal diagnosis versus first trimester screening of trisomy 21 among pregnant women of advanced age.

Methods: A retrospective study was conducted on patients aged ≥35 divided in two groups: patients who requested first trimester combined test and only in case of screen-positive result underwent invasive testing (group A); patients undergoing chorionic villous sampling or amniocentesis as first investigation (group B). The following outcome variables were compared: antenatal detection of trisomy 21, occurrence of trisomy 21 at birth, miscarriage rate, hospitals' costs.

Results: 4527 women were included. Of these, 534 (11.80%) underwent T21 screening whereas 3993 (88.20%) requested primary invasive testing. In group A, 64 combined test were positive (11.99%) and 8 trisomy 21 cases were diagnosed (1.50%); the loss of euploid fetuses after invasive procedure was 4.55% (2/44). No false-negative case was observed. In group B 57 cases of trisomy 21 were diagnosed (1.43%), and pregnancy loss rate of chromosomally normal fetuses was 0.45% (17/3806). The estimated cost was, respectively, 67.720€ for the primary screening versus 1.996.500€ for direct prenatal diagnosis.

Conclusion: First trimester screening of trisomy 21 is highly accurate and cost saving among women ≥35.
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http://dx.doi.org/10.3109/14767058.2014.928852DOI Listing
April 2015

Post-partum evaluation of maternal cardiac function after severe preeclampsia.

J Matern Fetal Neonatal Med 2014 May 18;27(7):696-701. Epub 2013 Sep 18.

Department of Obstetrics and Gynecology and.

Objective: To evaluate the post-partum maternal cardiac function in patients with history of severe preeclampsia.

Methods: A series of women with previous singleton pregnancy complicated by severe preeclampsia underwent transthoracic echocardiography at 6-12 months from delivery. A group of women with previous uncomplicated pregnancy was selected as controls.

Results: Sixteen women with history of severe preeclampsia were enrolled in the study group whereas 18 patients were selected as controls. In the study group systolic (p=0.002) and diastolic blood pressure (p=0.044) were significantly higher. Significant differences were observed in systolic left ventricular (LV) parameters, such as cardiac output (p=0.034), LV mass indexed to BSA (p=0.024) and longitudinal contraction, expressed by tissue Doppler (TD) S1 wave, which resulted relatively impaired in former preeclamptic women (p=0.049). As regards as diastolic parameters, pulsed Doppler A-wave velocity was increased (p=0.036). TD E-wave velocity was significantly lower in study group (p<0.001) and E/E1 ratio (E=peak early diastole transmitral wave velocity/E1=peak early diastolic velocity at mitral valve annulus at TD) was higher respect to controls (p<0.001).

Conclusions: LV contractility and diastolic function, although within normal reference ranges, show slight but significant impairment among women who experienced a severe preeclampsia. TD seems to be a sensible tool to identify these precocious signs of potential LV dysfunction.
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http://dx.doi.org/10.3109/14767058.2013.834325DOI Listing
May 2014

Significance of uteroplacental Doppler at midtrimester in patients with favourable obstetric history.

J Matern Fetal Neonatal Med 2013 Feb 29;26(3):299-302. Epub 2012 Oct 29.

Department of Obstetrics and Gynaecology, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

Objective: To reassess the usefulness of midtrimester uterine Doppler in low-risk multiparous women.

Methods: We prospectively recruited low-risk pregnant women at 20-22 weeks attending our clinic. Among those, women with a favourable obstetric history (group A) were distinguished from nulliparous (group B) and of each group we measured uterine artery Doppler (pulsatility index (PI)). We evaluated the accuracy of uterine artery Doppler in the prediction of preeclampsia and small for gestational age (SGA) neonates.

Results: Between January 2009 and October 2010, 382 women were included in the study of which 147 in group A and 235 in group B. Overall, 26/382 (6.8%) women presented preeclampsia and SGA occurred in 59/382 (15.4%) cases. In our population, at a 10% false positive rate (FPR) uterine artery Doppler showed a detection rate (DR) of 19.2% for preeclampsia and of 37.3% for SGA, with a higher sensitivity for SGA neonates delivered ≤ vs. >34 weeks (87% vs. 29.4%). The univariable receiver operating characteristics (ROC) curve by uterine artery PI yielded a significant prediction only for SGA in nulliparous women (areas under the curve (AUC) of 0.70; 95% CI 0.60-0.79).

Conclusions: Our data confirmed that midtrimester uterine artery Doppler is not an efficient strategy in anticipating the risk of pregnancy complications among low-risk multiparous women.
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http://dx.doi.org/10.3109/14767058.2012.733757DOI Listing
February 2013