Publications by authors named "Maria Gaia Dodaro"

10 Publications

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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

Brain death in pregnancy: a systematic review focusing on perinatal outcomes.

Am J Obstet Gynecol 2021 Feb 16. Epub 2021 Feb 16.

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

Objective: Brain death (BD) during pregnancy might justify in select cases maternal somatic support to obtain fetal viability and maximize perinatal outcome. This study is a systematic review of the literature on cases of brain death in pregnancy with attempt to prolong pregnancy to assess perinatal outcomes.

Data Sources: We performed a systematic review of the literature using Ovid MEDLINE, Scopus, PubMed (including Cochrane database), and CINHAIL from inception to April 2020.

Study Eligibility Criteria: Relevant articles describing any case report of maternal brain death were identified from the aforementioned databases without any time, language, or study limitations. Studies were deemed eligible for inclusion if they described at least 1 case of maternal brain death.

Methods: Only cases of brain death in pregnancy with maternal somatic support aimed at maximizing perinatal outcome were included. Maternal management strategy, diagnosis, clinical course, fetal monitoring, delivery, and fetal and neonatal outcome data were collected. Mean, range, standard deviation, and percentage calculations were used as applicable.

Results: After exclusion, 35 cases of brain death in pregnancy were analyzed. The mean gestational age at diagnosis of brain death was at 20.2±5.3 weeks, and most cases (68%) were associated with maternal intracranial hemorrhage, subarachnoid hemorrhage, and hematoma. The most common maternal complications during the study were infections (69%) (eg, pneumonia, urinary tract infection, sepsis), circulatory instability (63%), diabetes insipidus (56%), thermal variability (41%), and panhypopituitarism (34%). The most common indications for delivery were maternal cardiocirculatory instability (38%) and nonreassuring fetal testing (35%). The mean gestational age at delivery was 27.2±4.7 weeks and differed depending on the gestational age at diagnosis of brain death. Most deliveries (89%) were via cesarean delivery. There were 8 cases (23%) of intrauterine fetal demise in the second trimester of pregnancy (14-25 weeks), and 27 neonates (77%) were born alive. Of the 35 cases of brain in pregnancy, 8 neonates (23%) were described as "healthy" at birth, 15 neonates (43%) had normal longer-term follow-up (>1 month to 8 years; mean, 20.3 months), 2 neonates (6%) had neurologic sequelae (born at 23 and 24 weeks of gestation), and 2 neonates (6%) died (born at 25 and 27 weeks of gestation). Mean birth weight was 1,229 grams, and small for gestational age was present in 17% of neonates. The rate of live birth differed by gestational age at diagnosis of brain death: 50% at <14 weeks, 54.5% at 14 to 19 6/7 weeks, 91.7% at 20 to 23 6/7 weeks, 100% at 24 to 27 6/7 weeks, and 100% at 28 to 31 6/7 weeks.

Conclusion: In 35 cases of brain death in pregnancy at a mean gestation age of 20 weeks, maternal somatic support aimed at maximizing perinatal outcome lasted for about 7 weeks, with 77% of neonates being born alive and 85% of these infants having a normal outcome at 20 months of life. The data of this study will be helpful in counseling families and practitioners faced with such rare and complex cases.
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http://dx.doi.org/10.1016/j.ajog.2021.01.033DOI Listing
February 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

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

Longitudinal Changes of Subpubic Arch Angle throughout Pregnancy.

Gynecol Obstet Invest 2020 20;85(1):100-106. Epub 2019 Nov 20.

Academic Department of System Medicine, Tor Vergata University Hospital, Rome, Italy.

Objective: The objective of this study is to assess whether the subpubic arch angle (SPA) changes throughout pregnancy.

Materials And Methods: We recruited a group of nulliparous women in the first trimester of pregnancy. Each woman was assessed 3 times throughout pregnancy, once per each trimester, by measuring SPA using a recently described highly reproducible three-dimensional transperineal ultrasound (linear reconstruction with contrast enhancement technique; OmniView-volume contrast imaging). Repeated measures analysis of variance was used to study SPA changes during pregnancy.

Results: Overall, 97 women were included in the final analysis. SPA increased progressively and significantly (F = 27.824, p < 0.001) from the first to the second trimester (121.8 ± 8.7 vs. 123.5 ± 8.4°, p = 0.01) and from the second to the third trimester (123.5 ± 8.4 vs. 125.3 ± 8.1°, p = 0.01).

Conclusion: SPA width increases progressively but slightly during pregnancy. Although this finding is interesting, the extremely small difference detected is unlikely to be clinically significant.
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http://dx.doi.org/10.1159/000504096DOI Listing
May 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

Fundal pressure in the second stage of labor: time to face the invisible enemy.

J Matern Fetal Neonatal Med 2019 Oct 13:1-2. Epub 2019 Oct 13.

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

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http://dx.doi.org/10.1080/14767058.2019.1677600DOI 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

The use of ultrasound in the evaluation of postpartum paravaginal hematomas.

Am J Obstet Gynecol MFM 2019 03 7;1(1):82-88. Epub 2019 Mar 7.

Department of Medical and Surgical Sciences, Obstetric and Gynecologic Unit, University of Bologna, Bologna, Italy.

Background: Paravaginal hematoma can be a severe postpartum complication. Diagnosis is challenging because signs and symptoms are often nonspecific. Most of the available literature about diagnostic imaging in these cases focuses on the use of computed tomography or magnetic resonance imaging, and there are very limited data on the use of sonography.

Objective: The purpose of this study was to evaluate the usefulness of sonography in the diagnosis of paravaginal hematomas from a review of our own experience.

Study Design: This was a retrospective study that included patients with postpartum paravaginal hematoma after vaginal delivery who underwent transabdominal or transperineal ultrasound in our University Hospital in Bologna from 2014-2016. Ultrasound features, dimensions, and relationship with other pelvic organs of the paravaginal hematoma were obtained. Information on patients' characteristics, symptoms, mode of delivery, treatment, and outcomes were recorded.

Results: We retrieved 11 cases of paravaginal hematoma after vaginal delivery in which ultrasound scanning was performed. The indications for ultrasound evaluation after delivery were pelvic and/or perianal pain, swelling of the vulva, and urinary retention, frequently in combination. The hematomas were always clearly visualized by sonography performed either transabdominally or transperineally with a full bladder as hypoechoic collections posterior to the vagina. The lesions were found to range in size of 4-10 cm. All patients underwent surgical treatment that consisted of incision of the hematoma and identification and ligature of any feeding vessels; packing was necessary in 8 cases (73%), and drainage was necessary in 5 cases (45%); however, 4 patients (36%) required reintervention.

Conclusion: Transabdominal (performed with a full bladder) or transperineal sonography can visualize paravaginal hematomas effectively after vaginal delivery. We suggest that in cases of otherwise unexplained postpartum pelvic and perianal pain, swelling of the vulva, and/or urinary retention, ultrasound can be considered as the first-line imaging tool.
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http://dx.doi.org/10.1016/j.ajogmf.2019.03.002DOI Listing
March 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