Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study.
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SUBMITTER: Knights S
PROVIDER: S-EPMC10079042 | biostudies-literature | 2023 Apr
REPOSITORIES: biostudies-literature
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Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study.
Knights Samantha S Prasad Smriti S Kalafat Erkan E Dadali Anahita A Sizer Pam P Harlow Francoise F Khalil Asma A
PLoS medicine 20230406 4
<h4>Background</h4>Accurate knowledge of fetal presentation at term is vital for optimal antenatal and intrapartum care. The primary objective was to compare the impact of routine third trimester ultrasound or point-of-care ultrasound (POCUS) with standard antenatal care, on the incidence of overall and proportion of all term breech presentations that were undiagnosed at term, and on the related adverse perinatal outcomes.<h4>Methods and findings</h4>This was a retrospective multicentre cohort s ...[more]
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Project description:BackgroundBreech presentation at term contributes significantly to cesarean section (CS) rates worldwide. External cephalic version (ECV) is a safe procedure that reduces term breech presentation and associated CS. A principal barrier to ECV is failure to diagnose breech presentation. Failure to diagnose breech presentation also leads to emergency CS or unplanned vaginal breech birth. Recent evidence suggests that undiagnosed breech might be eliminated using a third trimester scan. Our aim was to evaluate the impact of introducing a routine 36-week scan on the incidence of breech presentation and of undiagnosed breech presentation.Methods and findingsWe carried out a population-based cohort study of pregnant women in a single unit covering Oxfordshire, United Kingdom. All women delivering between 37+0 and 42+6 weeks gestational age, with a singleton, nonanomalous fetus over a 4-year period (01 October 2014 to 30 September 2018) were included. The mean maternal age was 31 years, mean BMI 26, 44% were nulliparous, and 21% were of non-white ethnicity. Comparisons between the 2 years before and after introduction of routine 36-week scan were made for 2 primary outcomes of (1) the incidence of breech presentation and (2) undiagnosed breech presentation. Secondary outcomes related to ECV, mode of birth, and perinatal outcomes. Relative risks (RRs) with 95% confidence intervals (CIs) are reported. A total of 27,825 pregnancies were analysed (14,444 before and 13,381 after). A scan after 35+0 weeks was performed in 5,578 (38.6%) before, and 13,251 (99.0%) after (p < 0.001). The incidence of breech presentation at birth did not change significantly (2.6% and 2.7%) (RR 1.02; 95% CI 0.89, 1.18; p = 0.76). The rate of undiagnosed breech before labour reduced, from 22.3% to 4.7% (RR 0.21; 95% CI 0.12, 0.36; p < 0.001). Vaginal breech birth rates fell from 10.3% to 5.3% (RR 0.51; 95% CI 0.30, 0.87; p = 0.01); nonsignificant increases in elective CS rates and decreases in emergency CS rates for breech babies were seen. Neonatal outcomes were not significantly altered. Study limitations include insufficient numbers to detect serious adverse outcomes, that we cannot exclude secular changes over time which may have influenced our results, and that these findings are most applicable where a comprehensive ECV service exists.ConclusionsIn this study, a universal 36-week scan policy was associated with a reduction in the incidence but not elimination of undiagnosed term breech presentation. There was no reduction in the incidence of breech presentation at birth, despite a comprehensive ECV service.
| S-EPMC7810318 | biostudies-literature
Project description:OBJECTIVES:To investigate the effectiveness of routine ultrasonography in the third trimester in reducing adverse perinatal outcomes in low risk pregnancies compared with usual care and the effect of this policy on maternal outcomes and obstetric interventions. DESIGN:Pragmatic, multicentre, stepped wedge cluster randomised trial. SETTING:60 midwifery practices in the Netherlands. PARTICIPANTS:13 046 women aged 16 years or older with a low risk singleton pregnancy. INTERVENTIONS:60 midwifery practices offered usual care (serial fundal height measurements with clinically indicated ultrasonography). After 3, 7, and 10 months, a third of the practices were randomised to the intervention strategy. As well as receiving usual care, women in the intervention strategy were offered two routine biometry scans at 28-30 and 34-36 weeks' gestation. The same multidisciplinary protocol for detecting and managing fetal growth restriction was used in both strategies. MAIN OUTCOME MEASURES:The primary outcome measure was a composite of severe adverse perinatal outcomes: perinatal death, Apgar score <4, impaired consciousness, asphyxia, seizures, assisted ventilation, septicaemia, meningitis, bronchopulmonary dysplasia, intraventricular haemorrhage, periventricular leucomalacia, or necrotising enterocolitis. Secondary outcomes were two composite measures of severe maternal morbidity, and spontaneous labour and birth. RESULTS:Between 1 February 2015 and 29 February 2016, 60 midwifery practices enrolled 13 520 women in mid-pregnancy (mean 22.8 (SD 2.4) weeks' gestation). 13 046 women (intervention n=7067, usual care n=5979) with data based on the national Dutch perinatal registry or hospital records were included in the analyses. Small for gestational age at birth was significantly more often detected in the intervention group than in the usual care group (179 of 556 (32%) v 78 of 407 (19%), P<0.001). The incidence of severe adverse perinatal outcomes was 1.7% (n=118) for the intervention strategy and 1.8% (n=106) for usual care. After adjustment for confounders, the difference between the groups was not significant (odds ratio 0.88, 95% confidence interval 0.70 to 1.20). The intervention strategy showed a higher incidence of induction of labour (1.16, 1.04 to 1.30) and a lower incidence of augmentation of labour (0.78, 0.71 to 0.85). Maternal outcomes and other obstetric interventions did not differ between the strategies. CONCLUSION:In low risk pregnancies, routine ultrasonography in the third trimester along with clinically indicated ultrasonography was associated with higher antenatal detection of small for gestational age fetuses but not with a reduced incidence of severe adverse perinatal outcomes compared with usual care alone. The findings do not support routine ultrasonography in the third trimester for low risk pregnancies. TRIAL REGISTRATION:Netherlands Trial Register NTR4367.
| S-EPMC6792062 | biostudies-literature
Project description:ObjectivesOperators performing fetal growth scans are usually aware of the gestational age of the pregnancy, which may lead to expected-value bias when performing biometric measurements. We aimed to evaluate the incidence of expected-value bias in routine fetal growth scans and assess its impact on standard biometric measurements.MethodsWe collected prospectively full-length video recordings of routine ultrasound growth scans coupled with operator eye tracking. Expected value was defined as the gestational age at the time of the scan, based on the estimated due date that was established at the dating scan. Expected-value bias was defined as occurring when the operator looked at the measurement box on the screen during the process of caliper adjustment before saving a measurement. We studied the three standard biometric planes on which measurements of head circumference (HC), abdominal circumference (AC) and femur length (FL) are obtained. We evaluated the incidence of expected-value bias and quantified the impact of biased measurements.ResultsWe analyzed 272 third-trimester growth scans, performed by 16 operators, during which a total of 1409 measurements (354 HC, 703 AC and 352 FL; including repeat measurements) were obtained. Expected-value bias occurred in 91.4% of the saved standard biometric plane measurements (85.0% for HC, 92.9% for AC and 94.9% for FL). The operators were more likely to adjust the measurements towards the expected value than away from it (47.7% vs 19.7% of measurements; P < 0.001). On average, measurements were corrected by 2.3 ± 5.6, 2.4 ± 10.4 and 3.2 ± 10.4 days of gestation towards the expected gestational age for the HC, AC, and FL measurements, respectively. Additionally, we noted a statistically significant reduction in measurement variance once the operator was biased (P = 0.026). Comparing the lowest and highest possible estimated fetal weight (using the smallest and largest biased HC, AC and FL measurements), we noted that the discordance, in percentage terms, was 10.1% ± 6.5%, and that in 17% (95% CI, 12-21%) of the scans, the fetus could be considered as small-for-gestational age or appropriate-for-gestational age if using the smallest or largest possible measurements, respectively. Similarly, in 13% (95% CI, 9-16%) of scans, the fetus could be considered as large-for-gestational age or appropriate-for-gestational age if using the largest or smallest possible measurements, respectively.ConclusionsDuring routine third-trimester growth scans, expected-value bias frequently occurs and significantly changes standard biometric measurements obtained. © 2019 the Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
| S-EPMC7079033 | biostudies-literature
Project description:BackgroundMedical literature supports planned cesarean delivery for breech presentation at term because of observed reductions in neonatal morbidity and mortality compared with vaginal breech delivery.ObjectiveThis study aimed to compare perinatal outcomes of singleton pregnancies with breech presentation at term according to the different delivery protocols of 2 teaching hospitals, where vaginal breech delivery (protocol 1) or cesarean delivery (protocol 2) is routinely offered, respectively.Study designA retrospective matched cohort study was conducted between January 2015 and May 2021. A total of 1079 women were eligible for analysis. After matching for possible confounding factors, the final analysis was performed on 257 patients in each group. The primary outcomes were a composite of adverse obstetrical outcomes and a composite of neonatal adverse outcomes.ResultsOverall, 1079 women were eligible for analysis. After matching for possible confounding factors, the final analysis was performed on 257 patients in each group. The composite of adverse obstetrical outcomes was similar in the 2 groups (24.1% vs 24.5%; P=1.000); however, the composite of neonatal adverse outcomes was significantly higher for protocol 1 (17.9% vs 1.2%; P<.001). No neonatal death or birth trauma was reported in either group. The rates of neonatal intensive care unit admission (4.3% vs 0.4%; P=.004), respiratory distress at birth (17.5% vs 1.2%; P<.001), and Apgar scores of <7 after 5 minutes (5.8% vs 0.4%; P<.001) were significantly higher for protocol 1.ConclusionShort-term, nonsevere adverse neonatal outcomes were significantly increased in the protocol 1 group. These must be balanced against the possible negative effects of cesarean delivery on long-term infant and maternal health.
| S-EPMC9758336 | biostudies-literature
Project description:IntroductionFetal growth restriction is associated with adverse perinatal outcome and the clinical management of these pregnancies is a challenge. The aim of this study was to investigate the potential of cerebroplacental ratio (CPR) to predict adverse perinatal outcome in high-risk pregnancies in the third trimester. Another aim was to study whether the CPR has better predictive value than its components, middle cerebral artery (MCA) pulsatility index (PI) and umbilical artery (UA) PI.Material and methodsThe study was a retrospective cohort study including 1573 singleton high-risk pregnancies with Doppler examinations performed at 32+0 to 40+6 gestational weeks at Lund University Hospital and the University Hospital of Malmö between 29 December 1994 and 31 December 2017. Receiver operating characteristics (ROC) curves were used to investigate the predictive value of the gestational age-specific z-scores for CPR, UA PI and MCA PI, respectively, for the primary outcome "perinatal asphyxia/mortality" and the secondary outcomes "birthweight small for gestational age (SGA)" and two composite outcomes: "appropriate for gestational age/large for gestational age liveborn infants with neonatal morbidity" and "SGA liveborn infants with neonatal morbidity."ResultsThe performance in predicting perinatal asphyxia/mortality was poor for all three variables and did not differ significantly. The ROC area under curve (AUC) was 0.56, 0.55 and 0.53 for CPR, UA PI and MCA PI z-scores, respectively. The ROC AUC for CPR z-scores to predict SGA was 0.73, significantly higher than that for either UA PI or MCA PI (P < .001). The ability of CPR and the MCA PI to predict appropriate for gestational age/large for gestational age infant morbidity and SGA infant morbidity was similar and significantly better than UA PI (P < .001).ConclusionsIn the present study, none of the three Doppler measures proved to be useful in predicting perinatal asphyxia and mortality. CPR and MCA PI were equally good in predicting neonatal morbidity, especially in SGA pregnancies, and both were significantly better predictors than the UA PI. CPR had a high predictive value for SGA at birth, better than that of its two components, UA PI and MCA PI.
| S-EPMC8049045 | biostudies-literature
Project description:BackgroundMoxibustion, acupuncture and other acupoint stimulations are commonly used for the correction of breech presentation. This systematic review aims to evaluate the efficacy and safety of moxibustion and other acupoint stimulations to treat breech presentation.MethodsWe included randomized controlled trials (RCTs) and controlled clinical trials (CCTs) on moxibustion, acupuncture or any other acupoint stimulating methods for breech presentation in pregnant women. All searches in PubMed, the Cochrane Library (2008 Issue 2), China National Knowledge Information (CNKI), Chinese Scientific Journal Database (VIP) and WanFang Database ended in July 2008. Two authors extracted and analyzed the data independently.ResultsTen RCTs involving 2090 participants and seven CCTs involving 1409 participants were included in the present study. Meta-analysis showed significant differences between moxibustion and no treatment (RR 1.35, 95% CI 1.20 to 1.51; 3 RCTs). Comparison between moxibustion and knee-chest position did not show significant differences (RR 1.30, 95% CI 0.95 to 1.79; 3 RCTs). Moxibustion plus other therapeutic methods showed significant beneficial effects (RR 1.36, 95% CI 1.21 to 1.54; 2 RCTs). Laser stimulation was more effective than assuming the knee-chest position plus pelvis rotating. Moxibustion was more effective than no treatment (RR 1.29, 95% CI 1.17 to 1.42; 2 CCTs) but was not more effective than the knee-chest position treatment (RR 1.22, 95% CI 1.11 to 1.34; 2 CCTs). Laser stimulation at Zhiyin (BL67) was more effective than the knee-chest position treatment (RR 1.30, 95% CI 1.10 to 1.54; 2 CCTs,).ConclusionMoxibustion, acupuncture and laser acupoint stimulation tend to be effective in the correction of breech presentation.
| S-EPMC2663768 | biostudies-literature
Project description:IntroductionFetal growth restriction is a major risk factor for adverse perinatal outcome. As most of the growth-restricted fetuses are small for gestational age (SGA), an efficient antenatal screening method for SGA fetuses would have a major impact on perinatal health. The aim of this study was to compare the SGA prediction rate achieved with third-trimester routine ultrasound estimation of fetal weight (EFW) with that obtained using ultrasound examination on indication. The secondary aim was to evaluate the clinical outcome in relation to the SGA screening method.Material and methodsDuring 1995-2009, two perinatal centers in southern Sweden offered routine ultrasound examination at 32-34 gestational weeks to 99 265 women with singleton pregnancies. Of these, 59 452 (60%) underwent the ultrasound examination. The other population, comprising 24 868 pregnancies, was cared for in another three centers that used a risk-based method with ultrasound examinations on indication only. Of them, 5792 (23%) underwent ultrasound examination at 32-36 gestational weeks. The deviation in the EFW from the expected one was expressed as the EFW z-score, SGA EFW being defined as the EFW z-score less than -2. SGA prediction ability was assessed by receiver operating characteristic (ROC) curves. Crude and adjusted risk ratios were calculated for selected variables of perinatal outcome when comparing the populations.ResultsThe SGA prediction ability for routine ultrasound was high, area under the ROC curve was 0.90 (95% CI 0.89-0.91). For an EFW z-score of -1, the sensitivity was 67.3% and specificity was 90.5% among routinely screened pregnancies; corresponding numbers in the ultrasound on indication population were 34.3% and 96.6%. The screened population had a lower risk of preterm birth, birthweight z-score less than -3, and Apgar score less than 7 at 5 min with adjusted risk ratios 0.87 (95% CI 0.82-0.92), 0.75 (95% CI 0.61-0.92), and 0.77 (95% CI 0.68-0.87), respectively. No difference in perinatal mortality was detected. There were no differences in perinatal outcome between the two subcohorts of infants born SGA.ConclusionsThird-trimester routine ultrasound improves the detection of SGA antenatally compared with ultrasound performed on indication, but no convincing improvement in perinatal outcome was identified.
| S-EPMC9564549 | biostudies-literature
Project description:Mirror artifacts are produced by the reflection of ultrasound waves after they propagate through a structure and encounter a strong and smooth interface capable of acting as a mirror. Ultrasound waves bounce back and forth between the mirroring interface and the reflective object and then eventually return to the transducer. The typical display of the mirror artifact consists of two similar structures separated and at similar distances from the reflective interface. We report a mirror artifact in a patient with a singleton gestation at 18 weeks. The image was interpreted as consistent with a twin gestation using transabdominal and transvaginal ultrasound. The differential diagnosis consisted of an abdominal heterotopic pregnancy. The presence of synchronized but opposite movements of both fetuses, and the blurred image of the second fetus, suggested a mirror artifact. The reflective surface was created by the interface located between a distended rectosigmoid filled with gas and the posterior uterine wall. Mirror artifacts can lead to diagnostic errors. This case illustrates how a distended rectosigmoid colon can generate an image that simulates either a twin gestation or an abdominal heterotopic pregnancy.
| S-EPMC3973438 | biostudies-literature
Project description:IntroductionIn both Canada and the United States, workload measurement for anatomic pathology is mainly based on complexity and clinical significance of specimens, with gross examination being a considerable contributor. While Pathologists' Assistants (PAs) play an increasing role in gross examination, there is little known regarding the time required for PAs to complete grossing tasks. This information is essential for effective staffing and workload management in pathology laboratories. The objective of our study was to determine the time required for PAs to gross second and third trimester singleton placentas in a large tertiary hospital with a significant perinatal pathology service.Materials and methodsFor our study, 7 certified PAs each grossed a minimum of 10 second and third trimester singleton placentas using a standard placental grossing protocol, an electronic laboratory information system, and voice recognition dictation software. Placental specimens requiring photography, sampling for ancillary studies, or immediate pathologist's consultation were excluded. We calculated average and standard deviation of grossing times for each PA, overall average grossing time, and 95% confidence interval using a mixed linear regression model. We analyzed the impact of PA job experience, degree obtained, and number of blocks prepared on overall average in a multivariate analysis.ResultsThe mean grossing times for each PA ranged from 11.0 (standard deviation [sd] = 2.0) to 17.8 (sd = 4.5) minutes. The overall average grossing time was 14.5 minutes, with a 95% confidence interval of 11.7 to 17.3 minutes. In multivariate analysis, an increase in the number of blocks prepared was significantly associated with longer overall average grossing time. If 4 blocks were prepared consistently, the model predicted a slightly lower overall average of 13.3 minutes, with a 95% confidence interval of 10.9 to 15.7 minutes.DiscussionTo our knowledge, our study is the first to objectively report time required for PAs to perform gross examinations of routine second and third trimester singleton placentas. The methodology of our study is replicable and can be applied to other specimen types and laboratory settings. Previously, estimated grossing times for specimens were primarily based on retrospective surveys, which were susceptible to recall errors and subjectivity. However, our study demonstrates objective data collection is achievable. Furthermore, the data collected from this study offer valuable insights into the accuracy of previous and current pathology workload models for second and third trimester singleton placentas.
| S-EPMC10685689 | biostudies-literature
Project description:BackgroundCervical dilatation curves are widely used to describe normal and abnormal labor progression for cephalic presentation. Labor curves for breech presentations have never been described.ObjectivesThe aims of this study were to examine the pattern of labor progression in women with a breech presentation and to determine whether the type of breech or parity can influence the speed of cervical dilatation.Study designWe analyzed the labor data from 349 women with a term, singleton, and breech fetus after spontaneous onset of labor in 2010-2018. Cesarean deliveries were excluded. The patterns of labor progression were described by examining the relationship between the elapsed times from the full dilatation and cervical dilatation stages. Average labor curves were developed using repeated-measures analysis with 3rd degree polynomial modeling. The results were interpreted according to parity and the type of breech.ResultsThe first stage of labor progression was divided into a latency phase from 0 to 5 cm of dilatation and an active phase from 5 to 10 cm. In the active phase, the median speed of cervical dilatation was 1.67 cm/h [1.25, 2.61] (2 cm/h for multipara and 1.54 cm/h for nullipara). The difference by parity was significant in the active phase (p< 0.05). The cervical dilatation rate from 3 cm to 10 cm did not significantly differ between the complete and frank breeches (1.56 cm/h vs 1.75 cm/h, p = 0.48). However, the median cervical dilatation rate from 8 cm to complete dilatation was faster for complete breeches (1.92 cm/h versus 1.33 cm/h, p = 0.045).ConclusionAs with cephalic presentation, the first stage of labor progression for breech presentation can be divided into a latent and active phase. Labor progression should be interpreted with respect to parity, and women should be informed that the type of breech does not seem to influence the cervical dilatation rate when there is adequate management.
| S-EPMC8920216 | biostudies-literature