Publications by authors named "Tullio Ghi"

121 Publications

Sonographic knowledge of occiput position to decrease failed operative vaginal delivery: a systematic review and meta-analysis of randomized controlled trials.

Am J Obstet Gynecol 2021 Sep 4. Epub 2021 Sep 4.

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

Objective: To assess the efficacy of ultrasound assessment of fetal occiput position prior to operative vaginal delivery (OVD) in decreasing failed OVD.

Data Sources: The search was conducted using MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library as electronic databases from the inception of each database to April 2021. No restrictions for language or geographic location were applied.

Study Eligibility Criteria: Selection criteria included randomized controlled trails (RCTs) of pregnant women randomized to either sonographic or clinical digital diagnosis of fetal occiput position during the second stage of labor prior to OVD.

Study Appraisal And Synthesis Methods: The primary outcome was failed OVD, defined as a failed fetal OVD (vacuum or forceps) extraction requiring a CD, or forceps after failed vacuum. The summary measures were reported as relative risk (RR) or as mean difference (MD) with 95% confidence intervals (CI) using the random effects model of DerSimonian and Laird. I-squared (Higgins I2) greater than 0% was used to identify heterogeneity.

Results: Four RCTs including 1,007 women with singleton term cephalic fetuses randomized to either sonographic (n=484) or clinical digital (n=523) diagnosis of occiput position during the second stage of labor before OVD. Prior to OVD, fetal occiput was diagnosed as anterior in 63.5% vs 69.5% in the sonographic vs clinical digital diagnosis groups, respectively (p=0.04). There was no significant difference in the rate of failed OVD between sonographic and clinical diagnosis of occiput position (9.9% vs 8.2%; RR 1.14, 95% CI 0.77-1.68). Women randomized to sonographic diagnosis of occiput position had a significantly lower rate of occiput position discordance between pre-OVD and birth evaluation, compared to those randomized to clinical diagnosis (2.3% vs 17.7%; RR 0.16, 95% CI 0.04-0.74, p=0.02). There were no significant differences in any of the other secondary obstetric and perinatal outcomes assessed.

Conclusions: Sonographic knowledge of occiput position before OVD does not seem to be associated with an effect on the incidence of failed OVD, despite better sonographic accuracy in the occiput position diagnosis compared to clinical assessment. Perhaps future studies should evaluate how a more accurate sonographic diagnosis of occiput position or other parameters can lead to a more safe and effective OVD technique.
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http://dx.doi.org/10.1016/j.ajog.2021.08.057DOI Listing
September 2021

Occiput-spine angle and prediction of cesarean delivery in protracted active phase of labor: occiput position does matter.

Am J Obstet Gynecol 2021 Aug 12. Epub 2021 Aug 12.

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

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http://dx.doi.org/10.1016/j.ajog.2021.08.009DOI Listing
August 2021

Ultrasound versus routine care before instrumental vaginal delivery: A systematic review and meta-analysis.

Acta Obstet Gynecol Scand 2021 Jul 27. Epub 2021 Jul 27.

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

Introduction: The objective was to report the role of intrapartum ultrasound examination in affecting maternal and perinatal outcome in women undergoing instrumental vaginal delivery.

Material And Methods: MEDLINE, Embase, CINAHL, Google Scholar and ClinicalTrial.gov databases were searched. Inclusion criteria were randomized controlled trials comparing ultrasound assessment of fetal head position vs routine standard care (digital examination) before instrumental vaginal delivery (either vacuum or forceps). The primary outcome was failed instrumental delivery extraction followed by cesarean section. Secondary outcomes were postpartum hemorrhage, 3rd or 4th degree perineal lacerations, episiotomy, prolonged hospital stay, Apgar score<7 at 5 min, umbilical artery pH <7.0 and base excess greater than -12 mEq, admission to neonatal intensive care unit (NICU), shoulder dystocia, birth trauma, a composite score of adverse maternal and neonatal outcome and incorrect diagnosis of fetal head position. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB-2). The quality of evidence and strength of recommendations were assessed using the Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. Head-to-head meta-analyses using a random-effect model were used to analyze the data and results are reported as relative risk with their 95% confidence intervals.

Results: Five studies were included (1463 women). There was no difference in the maternal, pregnancy or labor characteristics between the two groups. An ultrasound assessment prior to instrumental vaginal delivery did not affect the cesarean section rate compared with standard care (p = 0.805). Likewise, the risk of composite adverse maternal outcome (p = 0.428), perineal lacerations (p = 0.800), postpartum hemorrhage (p = 0.303), shoulder dystocia (p = 0.862) and prolonged stay in hospital (p = 0.059) were not different between the two groups. Composite adverse neonatal outcome was not different between the women undergoing and those not undergoing ultrasound assessment prior to instrumental delivery (p = 0.400). Likewise, there was no increased risk with abnormal Apgar score (p = 0.882), umbilical artery pH < 7.2 (p = 0.713), base excess greater than -12 (p = 0.742), admission to NICU (p = 0.879) or birth trauma (p = 0.968). The risk of having an incorrect diagnosis of fetal head position was lower when ultrasound was performed before instrumental delivery, with a relative risk of 0.16 (95% confidence interval 0.1-0.3; I :77%, p < 0.001).

Conclusions: Although ultrasound examination was associated with a lower rate of incorrect diagnoses of fetal head position and station, but this did not translate to any improvement of maternal or neonatal outcomes.
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http://dx.doi.org/10.1111/aogs.14236DOI Listing
July 2021

Intrapartum ultrasound and evidence-based medicine: a necessary but challenging marriage.

Authors:
Tullio Ghi

Am J Obstet Gynecol MFM 2021 Jul 21:100428. Epub 2021 Jul 21.

Unit of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Parma, Parma, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.ajogmf.2021.100428DOI Listing
July 2021

Antepartum evaluation of the obstetric conjugate at transabdominal 2D ultrasound: A feasibility study.

Acta Obstet Gynecol Scand 2021 Oct 26;100(10):1917-1923. Epub 2021 Jul 26.

Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy.

Introduction: The obstetric conjugate represents the shortest anteroposterior diameter of the birth canal and it reflects the capacity of the pelvic inlet to allow the passage and the engagement of the fetal head. The antepartum evaluation of this parameter may be attempted at digital examination to predict the risk of cephalopelvic disproportion, but the accuracy of clinical pelvimetry is notoriously poor. The aim of our study was to describe the sonographic measurement of the obstetric conjugate at transabdominal 2D-ultrasound and to assess its reproducibility.

Material And Methods: This is a prospective cohort study conducted at a tertiary University hospital. A non-consecutive series of pregnant women with uncomplicated singleton pregnancies attending the antenatal clinic for routine booking from 34 weeks of gestation onward were included. The ultrasound probe was longitudinally placed above the level of the symphysis and the interpubic fibrocartilaginous disk was visualized. Then the promontory was identified as the most prominent segment of the sacral vertebral column. The obstetric conjugate was measured as the distance between the inner edge of the interpubic disk and the promontory. The inter- and intraobserver repeatability of this measurement was calculated using the intraclass correlation coefficient (ICC) and the Bland-Altman method.

Results: In all, 119 women were considered eligible for the study; of these, 111/119 (93.3%) women were included in the analysis with a median gestational age of 36.0 (35.0-37.0) weeks. The mean obstetric conjugate measurement was 11.4 ± 0.93 mm for the first operator and 11.4 ± 0.91 mm for the second operator. The overall interobserver ICC was 0.95 (95% [confidence interval] CI 0.92-0.96) and the overall intraobserver ICC was 0.97 (95% CI 0.96-0.98). Limits of agreement ranged from -0.84 to 0.80 for interobserver measures and from -0.64 to 0.62 for intraobserver measures. The degree of reliability was also analyzed for women with a body mass index ≥30 and for women with a gestational age ≥37 weeks. The inter- and intraobserver ICCs were respectively 0.97 (95% CI 0.90-0.98) and 0.98 (0.95-0.99) in the former group and 0.96 (95% CI 0.93-0.98) and 0.97 (95% CI 0.95-0.98) in the latter group.

Conclusions: Our study demonstrated that among pregnant women at term gestation, sonographic measurement of the obstetric conjugate is feasible and reproducible.
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http://dx.doi.org/10.1111/aogs.14226DOI Listing
October 2021

Asynclitism in the second stage of labor: prevalence, associations, and outcome.

Am J Obstet Gynecol MFM 2021 09 1;3(5):100437. Epub 2021 Jul 1.

Department of Obstetrics and Gynecology, Kwong Wah Hospital, Hong Kong SAR, China (Drs Hung, Chan, and Lau).

Background: Fetal head asynclitism may affect labor progress, increase the need for obstetrical intervention, and even be associated with difficult or failed instrumental delivery. However, there is limited evidence on the true prevalence and associations of asynclitism when diagnosed by transperineal ultrasound in the second stage of labor.

Objective: This study aimed to examine the prevalence and outcome of asynclitism in the second stage of labor in a regional hospital in Hong Kong.

Study Design: This is a prospective cohort study involving 92 term nulliparous women with singleton pregnancy in the second stage of labor, recruited from December 2019 to December 2020. Transperineal ultrasound was performed and asynclitism was diagnosed if there was asymmetry of intracranial structures on the transverse plane. To assess the fetal head station, the head perineum distance was measured at rest and on pushing, and the mode of delivery was recorded. Relationship between asynclitism and fetal head position, and between head perineum distance and the mode of delivery, were evaluated with chi-squared tests and Mann-Whitney U tests.

Results: The prevalence of asynclitism was 15% (14 of 92), of which 12 were anterior asynclitism and 2 were posterior asynclitism. The prevalence of asynclitism was less common in occiput anterior compared with nonocciput anterior position (6.7% vs 53%, P<.01). Women with asynclitism were associated with smaller delta head perineum distance (head perineum distance at rest minus that at pushing) than women without asynclitism (median [interquartile range], 0.68 cm [0.85 cm] vs 0.91 cm [0.71 cm]; P=.01). Eventually, there was a trend of more operative deliveries in women with asynclitism (43%, or 6 of 14 women) than in women without asynclitism (27%, or 21 of 78 women), although this difference was not statistically significant (P=.22).

Conclusion: The prevalence of asynclitism at transperineal ultrasound was rather common in nulliparous women at second stage of labor and seemed more commonly associated with nonocciput anterior position.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100437DOI Listing
September 2021

COVID-19 in pregnancy: where are we now?

J Perinat Med 2021 Jul 30;49(6):637-642. Epub 2021 Jun 30.

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

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http://dx.doi.org/10.1515/jpm-2021-0309DOI Listing
July 2021

First assessment of bone mineral density in healthy pregnant women by means of Radiofrequency Echographic Multi Spectrometry (REMS) technology.

Eur J Obstet Gynecol Reprod Biol 2021 Aug 15;263:44-49. Epub 2021 Jun 15.

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

Objective: The maternal bone structure is the largest calcium reserve for the fetus during pregnancy, and this is claimed to lead to a bone mineral density (BMD) reduction in pregnant women. The primary outcome of the present work was to assess the BMD in a group of healthy pregnant women.

Study Design: In this prospective case - control observational study, a non-consecutive group of pregnant women with uncomplicated pregnancy at or >37 weeks were enrolled at the unit of Obstetrics and Gynecology, University of Parma, from February to December 2020. The study subjects were submitted to a sonographic examination of the proximal femur with Radiofrequency Echographic Multi Spectrometry (REMS) technology to quantify the BMD of the femur. The BMD values obtained in the study group were compared with those of a control group of non-pregnant women matched for age, ethnicity and pre-pregnant body mass index (BMI).

Results: Overall, 78 pregnant women at 39.1 ± 1.5 weeks were assessed. Compared with non-pregnant women, the femoral BMD values measured in pregnancy using REMS were significant lower (0.769 ± 0.094 g/cm vs 0.831 ± 0.101 g/cm, p = 0.0001) with a mean BMD reduction of 8.1%. The femoral neck BMD presented a positive correlation with the pre-pregnant BMI (p = 0.0004) and a negative correlation with the maternal age (p < 0.0001). In addition, a lower femoral neck BMD in Caucasian ethnicity compared with non-Caucasian was noted (p < 0.0001).

Conclusion: In this exploratory and proof of concept study, for the first time, a decreased BMD has been objectively demonstrated in pregnant compared with non-pregnant women by means of REMS technology. New studies are required to assess the longitudinal changes of maternal bone density throughout the pregnancy.
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http://dx.doi.org/10.1016/j.ejogrb.2021.06.014DOI Listing
August 2021

Three-Dimensional Sonographic Evaluation of the Position of the Fetal Conus Medullaris at First Trimester.

Fetal Diagn Ther 2021 9;48(6):464-471. Epub 2021 Jun 9.

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

Objective: The objective of this study was to assess the position of the conus medullaris (CM) at the first trimester 3D ultrasound in a cohort of structurally normal fetuses.

Methods: This was a multicenter prospective study involving a consecutive series of structurally normal fetuses between 11 and 13 weeks of gestation (CRL between 45 and 84 mm). All fetuses were submitted to 3D transvaginal ultrasound using a sagittal view of the spine as the starting plane of acquisition. At offline analysis, the position of the CM was evaluated by 2 independent operators with a quantitative and a qualitative method: (1) the distance between the most caudal part of the CM and the distal end of the coccyx (CMCd) was measured; (2) a line perpendicular to the fetal spine joining the tip of the CM to the anterior abdominal wall was traced to determine the level of this line in relation to the umbilical cord insertion (conus to abdomen line, CAL). Interobserver agreement for the CCMd was evaluated. Linear regression analysis was used to determine the association between the CMCd and CRL, and a normal range was computed based on the best-fit model. The absence of congenital anomalies was confirmed in all cases after birth.

Results: In the study period between December 2019 and March 2020, 143 fetuses were recruited. In 130 fetuses (90.9%), the visualization of the CM was feasible. The mean value of the CMCd was 1.09 ± 0.16 cm. The 95% limits of agreement for the interobserver variability in measurement of the CMCd were 0.24 and 0.26 cm. The interobserver variability based on the intra-class correlation coefficient (ICC) for the CCMd was good (ICC = 0.81). We found a positive linear relationship between the CCMd and CRL. In all these fetuses, the CAL encountered the abdominal wall at or above the level of the cord insertion.

Conclusion: In normal fetuses, the assessment of the CM position is feasible at the first trimester 3D ultrasound with a good interobserver agreement. The CM level was never found below the fetal umbilical cord insertion, while the CMCd was noted to increase according to the gestational age, confirming the "ascension" of the CM during fetal life.
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http://dx.doi.org/10.1159/000516516DOI Listing
June 2021

Manual rotation of persistent occiput posterior position: more research is warranted.

Am J Obstet Gynecol MFM 2021 May 6:100387. Epub 2021 May 6.

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

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http://dx.doi.org/10.1016/j.ajogmf.2021.100387DOI Listing
May 2021

Monitoring fetal well-being in labor in late fetal growth restriction.

Minerva Obstet Gynecol 2021 Aug 5;73(4):453-461. Epub 2021 May 5.

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

Late-onset fetal growth restriction (FGR) accounts for approximately 70-80% of all cases of FGR secondary to uteroplacental insufficiency. It is associated with an increased incidence of adverse antepartum and perinatal events, which in most instances result from hypoxic insults either present at the onset of labor or supervening during labor as a result of uterine contractions. Labor represents a stressful event for the fetoplacental unit being uterine contractions associated with an up-to 60% reduction of the uteroplacental perfusion. Intrapartum fetal heart rate monitoring by means of cardiotocography (CTG) currently represents the mainstay for the identification of fetal hypoxia during labor and is recommended for the fetal surveillance during labor in the case of FGR or other conditions associated with an increased risk of intrapartum hypoxia. In this review we discuss the potential implications of an impaired placental function on the intrapartum adaptation to the hypoxic stress and the role of the CTG and alternative techniques for the intrapartum monitoring of the fetal wellbeing in the context of FGR secondary to uteroplacental insufficiency.
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http://dx.doi.org/10.23736/S2724-606X.21.04819-XDOI Listing
August 2021

Intrapartum sonographic assessment of the fetal head flexion in protracted active phase of labor and association with labor outcome: a multicenter, prospective study.

Am J Obstet Gynecol 2021 08 4;225(2):171.e1-171.e12. Epub 2021 Mar 4.

Obstetrics and Gynecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy. Electronic address:

Background: To date, no research has focused on the sonographic quantification of the degree of flexion of the fetal head in relation to the labor outcome in women with protracted active phase of labor.

Objective: This study aimed to assess the relationship between the transabdominal sonographic indices of fetal head flexion and the mode of delivery in women with protracted active phase of labor.

Study Design: Prospective evaluation of women with protracted active phase of labor recruited across 3 tertiary maternity units. Eligible cases were submitted to transabdominal ultrasound for the evaluation of the fetal head position and flexion, which was measured by means of the occiput-spine angle in fetuses in nonocciput posterior position and by means of the chin-to-chest angle in fetuses in occiput posterior position. The occiput-spine angle and the chin-to-chest angle were compared between women who had vaginal delivery and those who had cesarean delivery. Cases where obstetrical intervention was performed solely based on suspected fetal distress were excluded.

Results: A total of 129 women were included, of whom 43 (33.3%) had occiput posterior position. Spontaneous vaginal delivery, instrumental delivery, and cesarean delivery were recorded in 66 (51.2%), 17 (13.1%), and 46 (35.7%) cases, respectively. A wider occiput-spine angle was measured in women who had vaginal delivery compared with those submitted to cesarean delivery owing to labor dystocia (126±14 vs 115±24; P<.01). At the receiver operating characteristic curve, the area under the curve was 0.675 (95% confidence interval, 0.538-0.812; P<.01), and the optimal occiput-spine angle cutoff value discriminating between cases of vaginal delivery and those delivered by cesarean delivery was 109°. A narrower chin-to-chest angle was measured in cases who had vaginal delivery compared with those undergoing cesarean delivery (27±33 vs 56±28 degrees; P<.01). The area under the curve of the chin-to-chest angle in relation to the mode of delivery was 0.758 (95% confidence interval, 0.612-0.904; P<.01), and the optimal cutoff value discriminating between vaginal delivery and cesarean delivery was 33.0°.

Conclusion: In women with protracted active phase of labor, the sonographic demonstration of fetal head deflexion in occiput posterior and in nonocciput posterior fetuses is associated with an increased incidence of cesarean delivery owing to labor dystocia. Such findings suggest that intrapartum ultrasound may contribute in the categorization of the etiology of labor dystocia.
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http://dx.doi.org/10.1016/j.ajog.2021.02.035DOI Listing
August 2021

Management of Infants with Brief Resolved Unexplained Events (BRUE) and Apparent Life-Threatening Events (ALTE): A RAND/UCLA Appropriateness Approach.

Life (Basel) 2021 Feb 22;11(2). Epub 2021 Feb 22.

Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy.

Unexpected events of breath, tone, and skin color change in infants are a cause of considerable distress to the caregiver and there is still debate on their appropriate management. The aim of this study is to survey the trend in prevention, decision-making, and management of brief resolved unexplained events (BRUE)/apparent life-threatening events (ALTE) and to develop a shared protocol among hospitals and primary care pediatricians regarding hospital admission criteria, work-up and post-discharge monitoring of patients with BRUE/ALTE. For the study purpose, a panel of 54 experts was selected to achieve consensus using the RAND/UCLA appropriateness method. Twelve scenarios were developed: one addressed to primary prevention of ALTE and BRUE, and 11 focused on hospital management of BRUE and ALTE. For each scenario, participants were asked to rank each option from '1' (extremely inappropriate) to '9' (extremely appropriate). Results derived from panel meeting and discussion showed several points of agreement but also disagreement with different opinion emerged and the need of focused education on some areas. However, by combining previous recommendations with expert opinion, the application of the RAND/UCLA appropriateness permitted us to drive pediatricians to reasoned and informed decisions in term of evaluation, treatment and follow-up of infants with BRUE/ALTE, reducing inappropriate exams and hospitalisation and highlighting priorities for educational interventions.
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http://dx.doi.org/10.3390/life11020171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7926945PMC
February 2021

Fetal heart rate pattern in term or near-term cerebral palsy: looking at the data in the right perspective.

Am J Obstet Gynecol 2021 07 1;225(1):106. Epub 2021 Mar 1.

University of Parma (Università degli Studi di Parma), Parma, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.ajog.2021.02.031DOI Listing
July 2021

Intrapartum ultrasound before instrumental vaginal delivery: Clinical benefits are difficult to demonstrate.

Acta Obstet Gynecol Scand 2021 05 5;100(5):988-989. Epub 2021 Feb 5.

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

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http://dx.doi.org/10.1111/aogs.14082DOI Listing
May 2021

Usefulness of an Intrapartum Ultrasound Simulator (IUSim™) for Midwife Training: Results from an RCT.

Fetal Diagn Ther 2021 9;48(2):120-127. Epub 2020 Dec 9.

Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy,

Introduction: We conducted a randomized study to determine whether a training session on a dedicated simulator (IUSim™) would facilitate the midwives in learning the technique of transperineal intrapartum ultrasound.

Methods: Following a 30-min multimedia presentation including images and videos on how to obtain and measure the angle of progression (AoP) and the head-perineum distance (HPD), 6 midwives with no prior experience in intrapartum ultrasound were randomly split into 2 groups: 3 of them were assigned to the "training group" and 3 to the "control group." The midwives belonging to the former group were taught to measure the 2 sonographic parameters during a 3-h practical session conducted on IUSim™ under the supervision of an expert obstetrician. In the following 3 months, all the 6 midwives were asked to independently perform transperineal ultrasound during their clinical practice and to measure on the acquired images either the AoP or the HPD. The sonographic images were examined in blind by the teaching obstetrician who assigned a 0-3 score to the image quality (IQS) and to the measurement quality (MQS).

Results: A total of 48 ultrasound images (24 patients) from 5 midwives were acquired and included in the study analysis. A midwife of the "training group" declined participation after the practical session. Independently from the randomization group, the image quality score (IQS + MQS) was significantly higher for the HPD compared with the AoP (2.5 ± 0.66 vs. 1.79 ± 1.14; p = 0.01). In the training group, the MQS of either AoP (2.66 ± 0.5 vs.1.46 ± 1.45. p = 0.038) and the HPD (2.9 ± 0.33 vs. 1.87 ± 0.83 p = 0.002) was significantly higher in comparison with the control group, while the IQS of both measurements was comparable between the 2 groups (1.91 ± 1.24 vs. 2.25 ± 0.865; p = 0.28).

Conclusion: The use of a dedicated simulator may facilitate the midwives in learning how to measure the AoP and the HPD on transperineal ultrasound images.
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http://dx.doi.org/10.1159/000512047DOI Listing
December 2020

Up to date management of labor.

Authors:
Tullio Ghi

Minerva Obstet Gynecol 2021 02 4;73(1):4-5. Epub 2020 Dec 4.

Department of Medicine and Surgery, University of Parma, Parma, Italy -

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http://dx.doi.org/10.23736/S0026-4784.20.04742-5DOI Listing
February 2021

Impact of ultrasound guided training in the diagnosis of the fetal head position during labor: A prospective observational study.

Eur J Obstet Gynecol Reprod Biol 2021 Jan 20;256:308-313. Epub 2020 Nov 20.

Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy. Electronic address:

Objectives: To assess whether the additional training with transabdominal ultrasound may improve the accuracy of the transvaginal digital examination in the assessment of the fetal head position during the active stage of labor.

Methods: Prospective observational study involving 2 residents in their 1 st year of training in Obstetrics with no prior experience in neither transvaginal digital examination nor ultrasound. Women with term, cephalic presenting fetus and active labor with cervical dilation ≥ 8 cm and ruptured membranes were included. In the preliminary phase of the study, the resident A ("blinded") was assigned to assess the fetal head position by transvaginal digital examination, while the resident B ("unmasked") performed transvaginal digital examination following transabdominal ultrasound, which was considered to be the gold standard to determine the fetal head position. After 50 examinations independently performed by each resident in the training phase, a post-training phase of the study was carried out to compare the accuracy of each resident in the diagnosis of fetal head position by digital assessment. The occiput position was eventually confirmed by ultrasound performed by the main investigator.

Results: Over a 6 months period, 90 post-training vaginal examinations were performed by each resident. The number of incorrect diagnoses of head position was higher for the "blinded" resident compared with the "unmasked" resident subjected to the ultrasound training (28/90 or 31.1 % vs 15/90 or 16.7 % p = 0.02). For both residents a wrong diagnosis was more likely with non-OA vs OA fetuses but this difference was statistically significant for the "blinded" Resident (10/20 or 50 % vs 18/70 or 25.7 % p = 0.039) but not for the "unmasked" Resident (5/18 or 27.9 % vs 10/72 or 13.9 % p = 0.16).

Conclusion: The addition of transabdominal ultrasound as a training tool in the determination of the fetal head position during labor seems to improve the accuracy of the transvaginal digital examination in unexperienced residents.
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http://dx.doi.org/10.1016/j.ejogrb.2020.11.053DOI Listing
January 2021

STAN: a reappraisal of its clinical usefulness.

Minerva Obstet Gynecol 2021 Feb 30;73(1):34-44. Epub 2020 Nov 30.

Department of Medicine and Surgery, University of Parma, Parma, Italy -

The automatic analysis of fetal ECG in labor has been introduced as an adjunct of traditional cardiotocography with the aim to improve the identification of fetuses with intrapartum hypoxia. Several randomized controlled trials and meta-analyses have produced conflicting results, with the most recent randomized controlled trial not demonstrating any improvement in either neonatal outcomes or reduction in operative birth rates. The objective of this review article is to present the state of art about the use of STAN technology in labor ward.
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http://dx.doi.org/10.23736/S0026-4784.20.04690-0DOI Listing
February 2021

Intrapartum Doppler ultrasound: where are we now?

Minerva Obstet Gynecol 2021 Feb 20;73(1):94-102. Epub 2020 Nov 20.

Division of Maternal and Fetal Medicine, Cristo Re Hospital, Tor Vergata University, Rome, Italy.

Intrapartum hypoxic events most commonly occur in low-risk pregnancies with appropriately grown fetuses. Continuous intrapartum monitoring by means of cardiotocography has not demonstrated a reduction in the frequency of adverse perinatal outcome but has been linked with an increase in the caesarean section rate, particularly among women considered at low risk. Available data from the literature suggests that abnormalities in the uterine artery Doppler and in the ratio between fetal cerebral and umbilical Doppler (i.e. cerebroplacental ratio [CPR]) are associated with conditions of subclinical placental function occurring in fetuses who have failed to achieve their growth potential regardless of their actual size. In this review we summarize the available evidence on the use of intrapartum Doppler ultrasound for the fetal surveillance during labor and the identification of the fetuses at risk of intrapartum distress.
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http://dx.doi.org/10.23736/S0026-4784.20.04698-5DOI Listing
February 2021

Hyperechoic amniotic membranes in patients with preterm premature rupture of membranes (p-PROM) and pregnancy outcome.

J Perinat Med 2021 Mar 22;49(3):311-318. Epub 2020 Oct 22.

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

Objectives: The early identification of women with preterm premature rupture of membranes (p-PROM) who are at higher risk of imminent delivery remains challenging. The aim of our study was to evaluate if an increased echogenicity of the amniotic membranes may represent a sonographic marker of impending delivery in women with p-PROM.

Methods: This was a prospective study including women with singleton pregnancies and diagnosis of p-PROM between 22 and 37 gestational weeks. A sonographic examination was performed within 24 h from the hospital admission and the appearance of the amniotic membranes close to the internal os was specifically evaluated. The membranes were defined as hyperechoic when their echogenicity was similar to that of the fetal bones or normoechoic in the other cases. The primary aim of the study was to compare the admission to spontaneous onset of labor interval and the pregnancy outcome between the cases of p-PROM with and without hyperechoic membranes.

Results: Overall, 45 women fulfilled the inclusion criteria with similar characteristics at admission. In women with hyperechoic membranes, the admission to spontaneous onset of labor interval was significantly shorter (11.5 [5.3-25.0] vs. 3.0 [1.5-9.0] p=0.04) compared to women with normo-echoic membranes. At binomial logistic regression after adjustment for GA at hospital admission, the presence of hyperechoic membranes was found as the only independent predictor of spontaneous onset of labor ≤72 h (aOR: 6.1; 95% CI: 1.0-36.9).

Conclusions: The presence of hyperechoic membranes is associated with a 6-fold higher incidence of spontaneous onset of labor within 72 h independently from the gestational age at p-PROM.
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http://dx.doi.org/10.1515/jpm-2020-0223DOI Listing
March 2021

Hemodynamic findings in normotensive women with small-for-gestational-age and growth-restricted fetuses.

Acta Obstet Gynecol Scand 2021 05 29;100(5):876-883. Epub 2020 Nov 29.

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

Introduction: Fetal growth restriction (FGR) in most instances is a consequence of primary placental dysfunction due to inadequate trophoblastic invasion. Maternal cardiac maladaptation to pregnancy has been proposed as a possible determinant of placental insufficiency and impaired fetal growth. This study aimed to compare the maternal hemodynamic parameters between normotensive women with small-for-gestational-age (SGA) and FGR fetuses and to evaluate their correlation with neonatal outcome.

Material And Methods: An observational cohort study including singleton pregnancies referred to our tertiary care center due to fetal smallness. At the time of diagnosis, fetuses were classified as SGA or FGR according to the Delphi consensus criteria, and pregnant women underwent hemodynamic assessment using a cardiac output monitor. A group of women with singleton uncomplicated pregnancies ar ≥35 weeks of gestation were recruited as controls. Cardiac output, systemic vascular resistance, stroke volume, and heart rate were measured and compared among the three groups (controls vs FGR vs SGA). The correlation between antenatal findings and neonatal outcome was also evaluated by multivariate logistic regression analysis.

Results: A total of 51 women with fetal smallness were assessed at 34.8 ± 2.6 weeks. SGA and FGR were diagnosed in 22 and 29 cases, respectively. The control group included 61 women assessed at 36.5 ± 0.8 weeks of gestation. Women with FGR had a lower cardiac output Z-score (respectively, -1.3 ± 1.2 vs -0.4 ± 0.8 vs -0.2 ± 1.0; P < .001) and a higher systemic vascular resistance Z-score (respectively, 1.2 ± 1.2 vs 0.2 ± 1.1 vs -0.02 ± 1.2; P < .001) compared with both SGA and controls, whereas no difference in the hemodynamic parameters was found between women with SGA and controls. The incidence of neonatal intensive care unit admission did not differ between SGA and FGR fetuses (18.2% vs 41.4%; P = .13), but FGR fetuses had a longer hospitalization compared with SGA fetuses (14.2 ± 17.7 vs 4.5 ± 1.6 days; P = .02). Multivariate analysis showed that the cardiac output Z-score at diagnosis (P = .012) and the birthweight Z-score (P = .007) were independent predictors of the length of neonatal hospitalization.

Conclusions: Different maternal hemodynamic profiles characterize women with SGA or FGR fetuses. Furthermore, a negative correlation was found between the maternal cardiac output and the length of neonatal hospitalization.
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http://dx.doi.org/10.1111/aogs.14026DOI Listing
May 2021

Intrapartum fetal heart rate between 150 and 160 bpm at or after 40 weeks and labor outcome.

Acta Obstet Gynecol Scand 2021 03 1;100(3):548-554. Epub 2020 Nov 1.

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

Introduction: A baseline fetal heart rate between 110 and 160 bpm is considered normal. However, among normal fetuses the average baseline heart rate has been shown to diminish progressively and the 90th centile of the fetal heart rate at 40 weeks of gestation has been consistently found at around 150 bpm. The aim of our study was to assess the labor and neonatal outcome of fetuses at 40 gestational weeks or beyond, whose intrapartum baseline fetal heart rate was between 150 and 160 bpm.

Material And Methods: Retrospective cohort study including singleton pregnancies with spontaneous onset of labor, gestational age between 40 and 42 weeks, category I CTG trace according to the FIGO guidelines 2015 with baseline fetal heart rate between 110 and 160 bpm during the first 60 minutes of active labor. Exclusion criteria were maternal hyperpyrexia at admission, fetal arrhythmias, maternal tachycardia (>110 bpm) and uterine tachysystole (>5 contractions/10 minutes). The following outcomes were compared between fetuses with a baseline ranging between 110 and 149 bpm and those with a baseline ranging between 150 and 160 bpm: incidence of meconium-stained amniotic fluid, intrapartum hyperpyrexia, mode of delivery, Apgar at 5 minutes <7, arterial pH <7.1 and Neonatal Intensive Care Unit admission, incidence of a composite adverse neonatal outcome.

Results: In all, 1004 CTG traces were included in the analysis, 860 in Group 110-149 bpm and 144 in Group 150-160 bpm. Group 150-160 bpm had a significantly higher incidence of meconium-stained amniotic fluid (odds ratio [OR] 2.6; 95% CI 1.8-3.8), maternal intrapartum hyperpyrexia (OR 4.7; 95% CI 1.1-14.6), urgent/emergent cesarean section for suspected fetal distress (OR 13.4; 95% CI 3.3-54.3), Apgar <7 at 5th min (OR 9.13; 95% CI 1.5-55.1) and neonatal acidemia (OR 3.5; 95% CI 1.5-55.1). Logistic regression including adjustiing for potential confounders showed that fetal heart rate between 150 and 160 bpm is an independent predictor of meconium-stained amniotic fluid (adjusted odds ratio [aOR] 2.2; 95% CI 1.5-3.3), cesarean section during labor for fetal distress (aOR 10.7; 95% CI 2.9-44.6), neonatal acidemia (aOR 2.6; 95% CI 1.1-6.7) and adverse composite neonatal outcome (aOR 2.6; 95% CI 1.2-5.6).

Conclusions: In fetuses at 40 weeks or beyond, an intrapartum fetal heart rate baseline ranging between 150 and 160 bpm seems associated with a higher incidence of labor complications.
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http://dx.doi.org/10.1111/aogs.14024DOI Listing
March 2021

Sars-CoV-2 in pregnancy: Why is it better than expected?

Eur J Obstet Gynecol Reprod Biol 2020 Sep 24;252:476-478. Epub 2020 Jul 24.

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

Since the outbreak of Coronavirus disease in December 2019, information specific to pregnancy remains limited and controversial. Based on data from previous reports, it has been noticed that contrary to prior pandemics such as SARS, MERS and H1N1 and although pregnancy is usually considered as a condition of high susceptibility to viral infections, new SARS-CoV2 infection seems to have a more benign clinical course when affecting pregnant women. We speculate that during pregnancy the physiological "silencing" of the Th1 pro-inflammatory response may blunt the cytokines storm which is thought to play a key-role in the pathogenesis of the severe complications of Covid-19.
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http://dx.doi.org/10.1016/j.ejogrb.2020.07.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7378463PMC
September 2020

Automatic measurement of head-perineum distance during intrapartum ultrasound: description of the technique and preliminary results.

J Matern Fetal Neonatal Med 2020 Jul 29:1-6. Epub 2020 Jul 29.

Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy.

Objectives: To evaluate the accuracy and reliability of a new ultrasound technique for the automatic assessment of the head-perineum distance (HPD) during childbirth.

Methods: HPD was measured on a total of 40 acquisition sessions in 30 laboring women both automatically by an innovative algorithm and manually by trained sonographers, assumed as gold standard.

Results: A significant correlation was found between manual and automatic measurements (Intra-CC = 0.994). High values of the coefficient of determination (=0.98) and low residual errors: RMSE = 2.01 mm (4.9%) were found.

Conclusion: The automatic algorithm for the assessment of the HPD represents a reliable technique.
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http://dx.doi.org/10.1080/14767058.2020.1799974DOI Listing
July 2020

Current use and performance of the different fetal growth charts in the Italian population.

Eur J Obstet Gynecol Reprod Biol 2020 Sep 29;252:323-329. Epub 2020 Jun 29.

Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Via Gramsci 14, 43125 Parma, Italy. Electronic address:

Objectives: The choice of growth charts impacts on screening, diagnosis and clinical management of fetal growth abnormalities. The objectives of the study were to evaluate: 1) the clinical practice at a national level among tertiary referral centers in the use of fetal biometric growth charts; and 2) the impact on fetal growth screening of existing national and international growth charts.

Study Design: A questionnaire was sent to 14 Italian tertiary referral centers to explore biometric reference growth charts used in clinical practice. National and international (Intergrowth-21st and World Health Organization) fetal growth charts were tested on a large national cohort of low risk women with singleton uneventful pregnancy derived from a retrospective cross-sectional multicenter study (21 centers). The percentage of fetuses with biometric measurements below and above the 10th and 90th percentile for each biometric parameter and gestational week were calculated for each growth chart. The percentile curves of the study population were calculated by non-linear quantile regressions.

Results: Twelve Italian centers (86 %) answered to the questionnaire showing a wide discrepancy in the use of growth charts for fetal biometry. The cohort included 7347 pregnant women. By applying Intergrowth-21st growth charts the percentage of fetuses with head circumference, abdominal circumference and femur length below the 10th centile was 3.9 %, 3.6 % and 2.3 %, and above the 90th centile 29.9 %, 32.5 % and 46 %, respectively. The percentages for the World Health Organization growth charts for head and abdominal circumferences and femur length were: below the 10th centile 6.3 %, 7.2 % and 5.3 %, and above 90th centile 22.8 %, 21.3 % and 31.9 %, respectively.

Conclusions: The wide discrepancy in clinical use of fetal growth charts in Italian centers warrants the adoption of an uniform set of charts. Our data suggest that immediate application into clinical practice of international growth charts might result into an under-diagnosis of small for gestational age fetuses and, especially, in an over-diagnosis of large for gestational age fetuses with major consequences for clinical practice. On these grounds, there is an urgent need for a nationwide study for the prospective evaluation of international growth charts and, if needed, the construction and adoption of methodologically robust national growth charts.
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http://dx.doi.org/10.1016/j.ejogrb.2020.06.059DOI Listing
September 2020

Letter to Editor with regard to the article "Hybrid simulation for obstetrics training: A systematic review".

Eur J Obstet Gynecol Reprod Biol 2020 08 12;251:278-279. Epub 2020 May 12.

Division of Maternal Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy.

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http://dx.doi.org/10.1016/j.ejogrb.2020.03.046DOI Listing
August 2020

Report of a series of healthy term newborns from convalescent mothers with COVID-19.

Acta Biomed 2020 May 11;91(2):251-255. Epub 2020 May 11.

.

Background: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmittable virus associated with a significantly increased risk of complications among the infected population. Few data are available for the outcome of pregnancy complicated by serious respiratory disease due to SARS-CoV-2 infection.

Aim: We herein report a series of four neonates whose mothers had recovered from new coronavirus 2019 disease (COVID-19) diagnosed in the third trimester of pregnancy.

Methods: pregnant women with documented COVID-19 infection during their pregnancy, who gave birth in Parma Hospital, University of Parma, Italy, in March and April 2020, during the peak of incidence of COVID-19 in Italy. Clinical records and laboratory tests were retrospectively reviewed.

Results: All neonates were delivered at term in good conditions without congenital COVID-19 infection.

Conclusions: Findings from our series of cases indicated that adverse effects on foetuses from pregnancies complicated by COVID-19 infection in late pregnancy are unlikely.
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http://dx.doi.org/10.23750/abm.v91i2.9743DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7569646PMC
May 2020

Evaluation of the uterine scar stiffness in women with previous Cesarean section by ultrasound elastography: A cohort study.

Clin Imaging 2020 Aug 31;64:53-56. Epub 2020 Mar 31.

Department of Obstetrics and Gynecology, University of Parma, Italy. Electronic address:

Purpose: To evaluate by means of elastography if the quantitative assessment of the cesarean scar elasticity is feasible using as reference the surrounding intact myometrium and to investigate if the cesarean scar stiffness is influenced by the clinical characteristics of the previous cesarean delivery.

Methods: Prospective study including women with a previous Cesarean Section (CS) ≥ 37 weeks' gestation performed 12-15 months before. By transvaginal ultrasound two regions of interest (ROI) were selected: uterine scar (Region 1) and surrounding myometrium (Region 2). Strain index (SI) for each ROI was calculated and the Strain Ratio (SR) was defined as Region 1 SI/Region 2 SI. The primary outcome was to compare SR among women who were grouped in accordance to presence of previous vaginal delivery, CS during labor, type of suture or pyrexia during post-partum. The secondary outcome of this study was to evaluate the correlation between SR and maternal, neonatal and labor characteristics.

Results: 68 women were included. The mean SR was 1.8 ± 0.7 thus indicating an increased stiffness of the uterine scar compared to the surrounding myometrium. No significant differences were found in terms of SR according to presence of previous VD, CS during labor, type of suture or pyrexia during post-partum period. Strain Ratio was not correlated to maternal characteristics nor to labor and neonatal outcome.

Conclusions: Evaluation of uterine scar stiffness is feasible by using elastography. The stiffness of the uterine scar is higher than that of the surrounding myometrium and is not correlated to maternal and labor characteristics.
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http://dx.doi.org/10.1016/j.clinimag.2020.03.006DOI Listing
August 2020

Evaluation of the cerebroplacental ratio in early labor in low-risk population.

Am J Obstet Gynecol 2020 08 2;223(2):302-303. Epub 2020 Apr 2.

Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.ajog.2020.03.026DOI Listing
August 2020
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