Ultrasound in Obstetrics & Gynecology最新文献

Objective: To determine consensus, using Delphi methodology, on the critical procedural steps for intravascular intrauterine transfusion (IUT) for the treatment of fetal anemia.

Methods: We conducted a two-part Delphi survey of international experts in fetal intervention. The first round of the survey proposed 32 potentially critical steps for the IUT procedure. Participants were asked to rate all steps on a Likert scale ranging from 1 (not important) to 5 (absolutely essential). We calculated the mean Likert score and 95% CI for all steps. Procedural steps were determined to be critical if the lower bound of the 95% CI was ≥ 3.0 and were excluded if the upper bound of the 95% CI was ≤ 3.5. In the second round of the survey, participants were asked specific questions regarding parameters associated with the procedural steps determined to be critical in the first round.

Results: Overall, 49 individuals from 24 different countries (six continents) participated in both rounds of the Delphi survey. The median length of experience in fetal medicine was 21 (range, 4-38) years. The median number of IUT procedures performed annually per respondent was 20 (range, 2-80). Of the 32 proposed procedural steps, 20 were determined to be critical and 12 non-critical procedural steps were excluded. Respondents indicated that an individual should perform a median of 20 (range, 10-50) IUT procedures during training to attain competency, and that the median number of IUT procedures required annually to maintain competency was 10 (range, 5-20). There was marked variation between respondents in how they performed the following critical IUT procedural steps: preparation of donor blood, preoperative medication, maternal anesthesia, site chosen for cordocentesis, use of fetal paralysis, method for determining fetal hematocrit, postoperative care and decision to schedule a subsequent IUT.

Conclusions: The findings of this international Delphi survey can be used to standardize the approach to performing IUT. An experienced fetal interventionist should perform the procedure, and in centers in which IUT is performed infrequently, referral to a more experienced center should be considered. Calculating the specific volume of blood to transfuse at the start of the procedure and undertaking continuous fetal heart-rate monitoring once the gestational-age threshold for viability is reached were ranked highest in the intra- and postoperative phases of the procedure, respectively. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Objective: To determine whether the sonographic appearance of levator ani muscle avulsion after vaginal birth can improve significantly over the first few years postpartum.

Methods: This was a retrospective study of women seen in the context of two prospective perinatal imaging studies. All subjects had undergone an interview, clinical examination and four-dimensional translabial ultrasound on average 4.3 months and 3.1 years postpartum. Volume datasets were analyzed at a later date, with the examiner blinded against all other data. The number of abnormal slices at both timepoints was compared using the Mann-Whitney U-test. Patients in whom findings had changed over time were reviewed separately, in parallel, in order to reduce the impact of differences in slice location and imaging settings. The symmetry test was used to analyze changes between the two postnatal visits.

Results: Of 1148 women recruited originally, 315 attended at least two postnatal visits. Forty-two were excluded, leaving 273 women for the final analysis. The mean time of first follow-up was 4.3 (range, 2.6-9.8) months after their first birth and the mean time of last follow-up was 3.1 (range, 1.4-8.0) years postpartum. Cohen's κ for the category of avulsion (normal, partial avulsion and full avulsion) at the two assessments was 0.89, with agreement in 97% (264/273) of cases. At the first visit, full levator ani muscle avulsion was diagnosed in 20, partial avulsion in 32 and no avulsion in 221 women. While seven partial avulsions appeared sonographically normal at the second visit, there were no statistically significant changes in avulsion category between visits (P = 0.4).

Conclusions: Tomographic pelvic floor imaging obtained 3-10 months after childbirth may be used as a proxy for long-term outcomes. Ultrasound findings at a mean of 3.1 years postpartum showed 97% agreement with findings obtained on imaging at a mean of 4.3 months postpartum. There was a non-significant reduction in abnormal slices at the second follow-up visit, affecting at most 3/12 slices. This may be explained by compensatory hypertrophy of the remaining intact muscle. Sonographic normalization of full levator ani muscle avulsion was not observed. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Objective: To establish a normal reference interval for amniotic sac diameter (ASD) between 7 + 0 and 9 + 6 weeks' gestation and its relative size in relation to gestational sac diameter (GSD) and the embryo crown-rump length (CRL).

Methods: This was a prospective, cross-sectional study of consecutive women presenting to the Early Pregnancy Unit, University College Hospital, London, UK, between August 2022 and June 2023. We included live, normally sited, singleton pregnancies with a normal 20-week anomaly scan. We collected 120 cases per gestational week, from 7 + 0 to 9 + 6 weeks' gestation, totaling 360 cases. We performed an inter- and intraobserver variability assessment in the measurement of mean ASD in 30 patients. Regression analyses were used to establish reference intervals for GSD and CRL, ASD and CRL, GSD and ASD, and GSD/ASD ratio and CRL. A fitted regression line was calculated, along with a 90% prediction interval and R² value.

Results: There was good interobserver agreement (mean ± SD difference, 0.007 ± 1.105 mm (95% limits of agreement (LoA), -2.160 to 2.174 mm)) and good intraobserver agreement for Observer A (mean ± SD difference, -0.080 ± 0.741 mm (95% LoA, -1.532 to 1.372 mm)) and Observer B (mean ± SD difference, -0.014 ± 0.919 mm (95% LoA, -1.814 to 1.786 mm)) in the measurement of mean ASD. Regression analyses showed a statistically significant association between each pair of values (P < 0.001 for all). There was a significant quadratic association between mean GSD and CRL (R² = 56%), mean GSD and ASD (R² = 60%) and GSD/ASD ratio and CRL (R² = 68%), and a significant cubic association between mean ASD and CRL (R² = 90%). The regression equations were used to quantify the values of ASD and GSD/ASD ratios for a range of CRL values and gestational ages.

Conclusion: Our study has produced comprehensive reference intervals for amniotic sac size in early pregnancy, which could be used in routine clinical practice. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Objective: Hemoglobin (Hb) Bart's disease is a severe manifestation of alpha-thalassemia, resulting in fetal tissue hypoxia and severe anemia. There is limited research available on assessing speckle-tracking analysis of the fetal heart as a response to fetal anemia caused by Hb Bart's disease. This study aimed to assess the diagnostic performance of fetal cardiac measurements derived from speckle-tracking analysis to identify fetuses with Bart's anemia between 17 and 24 weeks of gestation.

Methods: This prospective cohort study included 115 women with singleton pregnancies at risk for fetal Hb Bart's disease who underwent either amniocentesis or cordocentesis at Siriraj Hospital, Bangkok, Thailand, in the period between January 2019 and January 2021. Speckle-tracking analysis of the fetal heart was performed in the four-chamber view (4CV), assessing ventricular size and shape, ventricular contractility and left ventricular function, prior to invasive prenatal testing. Logistic regression analysis was used to determine significant cardiac predictors and calculate the probability of a fetus having Hb Bart's anemia.

Results: Among the cohort, 38 (33.0%) fetuses were diagnosed with Hb Bart's disease, and of these, nine (23.7%) cases exhibited fetal hydrops. In comparison to the control group, affected fetuses displayed enlargement of the 4CV, with a globular shape of the right ventricular chamber. Additionally, there were significant reductions in both global and longitudinal left ventricular contractility in non-hydropic affected fetuses compared with the controls. At mid-gestation, no significant differences were observed in transverse contractility or left ventricular function, except for the ejection fraction, between the two groups. Based on logistic regression analysis, combined cardiac measurements derived from speckle-tracking analysis, as a function of head circumference, could differentiate non-hydropic fetuses with Hb Bart's anemia from unaffected fetuses, achieving a sensitivity of 100%, specificity of 98.7% and overall accuracy of 99.1%.

Conclusions: Speckle-tracking analysis of the fetal heart has the potential to accurately identify early fetal cardiac changes during the second trimester in individuals with Bart's anemia. These findings not only offer a novel predictive marker for Hb Bart's anemia, but also help address the question of the underlying mechanisms of heart failure associated with fetal anemia. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.