David M. Sherer

Abstract Objective To test the null hypothesis that no correlation exists between transvaginal digital examination compared with the gold standard technique of transabdominal suprapubic ultrasound assessment of fetal head position during the second stage of labor. A secondary objective was to compare the performance of attending physicians vs. senior residents in depicting fetal head position by transvaginal digital examination in comparison with ultrasound assessment. Methods Consecutive patients in the second‐stage of labor at term with normal singleton cephalic‐presenting fetuses and ruptured membranes were included. Transvaginal digital examinations were performed by either attending physicians or senior residents and were followed immediately by transverse suprapubic transabdominal sonographic assessments performed by a single sonographer. Examiners were blinded to each other's findings. Power analysis dictated sample size. Exact binomial confidence intervals around observed rates were compared with χ 2 and Cohen's κ‐tests. Logistic regression was applied. P < 0.05 was considered significant throughout. Results One hundred and twelve patients were studied. The absolute error of transvaginal digital examinations was recorded in 65% of patients (95% confidence interval, 56–74%). Parity, pelvic station, combined spinal epidural anesthesia, length of first or second stages of labor, use of oxytocin augmentation, gestational age, mode of delivery, birth weight, and examiner experience did not significantly affect examination accuracy. Stratification, when the transvaginal digital examination was recorded as correct if occurring within ±45° of the ultrasound assessment, reduced the error of the transvaginal digital examinations to 39% (95% confidence interval, 30–49%). Independent variables again did not affect examination accuracy in this assessment modality. Rates of agreement between the two methods for attending physicians compared with residents were not significantly different. The overall degrees of agreement were 40% (95% confidence interval, 26–55%) and 68% (95% confidence interval, 53–80%) (κ = 0.25 and 0.30) for the absolute agreement and ±45° assessment modalities, respectively, for attending physicians, and 31% (95% confidence interval, 20–44%) and 55% (95% confidence interval, 42–68%) (κ = 0.14 and 0.12) for senior residents. Conclusion Using ultrasound assessment as the gold standard, our data demonstrate a high rate of error (65%) in transvaginal digital determination of fetal head position during the second stage of labor. The performance of senior residents in transvaginal digital examinations did not differ significantly from that of attending physicians. Intrapartum ultrasound increases the accuracy of fetal head position assessment during the second stage of labor. Copyright © 2002 ISUOG

OBJECTIVE: To test the null hypothesis that no correlation exists between transvaginal digital and the gold standard technique of transabdominal suprapubic ultrasound assessments of fetal head position during labor. A secondary objective was to compare the performance of attending physicians vs. senior residents in depicting fetal head position by transvaginal digital examination in comparison with ultrasound, respectively. METHODS: Consecutive patients in active labor at term with normal singleton cephalic-presenting fetuses were included. All participants had ruptured membranes, cervical dilation > or = 4 cm and fetal head at ischial spine station -2 or lower. Transvaginal sterile digital examinations were performed by either senior residents or attending physicians and followed immediately by transverse suprapubic transabdominal ultrasound assessments. Examiners were blinded to each other's findings. Power-analyses dictated number of subjects required. Statistical analyses included Chi-square, Cohen's Kappa test and logistic regression analysis. P < 0.05 was considered statistically significant. RESULTS: One hundred and two patients were studied (n = 102). In only 24% of patients (n = 24), transvaginal digital examinations were consistent with ultrasound assessments (P = 0.002, 95% confidence interval, 16-33). Logistic regression revealed that cervical effacement (P = 0.03) and ischial spine station (P = 0.01) significantly affected the accuracy of transvaginal digital examination. Parity, gestational age, combined spinal epidural anesthesia, cervical dilation, birth weight and examiner experience did not significantly affect accuracy of the examination. The accuracy of the transvaginal digital exams was increased to 47% (n = 48) (95% confidence interval, 37-57) when fetal head position at transvaginal digital examination was recorded as correct if reported within +/- 45 degrees of the ultrasound assessment. The rate of agreement between the two assessment methods for attending physicians vs. residents was 58% vs. 33%, respectively (P = 0.02) with the +/- 45 degrees analysis. CONCLUSIONS: Using ultrasound assessment as the gold standard, our data demonstrate an overall high rate of error (76%) in transvaginal digital determination of fetal head position during active labor, consistent with the null hypothesis. Attending physicians exhibited an almost two-fold higher success rate in depicting correct fetal head position by physical examination vs. residents in the +/- 45 degrees analysis. Intrapartum ultrasound increases the accuracy of fetal head position assessment during active labor and may serve as an educational tool for physicians in training.

Hyperemesis gravidarum or pernicious vomiting of pregnancy affects between 0.3% and 2% of all pregnant patients. The objective of this paper is to review current literature pertaining to epidemiology, etiology, symptomatology, complications, treatment, and perinatal outcome of patients with hyperemesis gravidarum. We performed a MEDLINE search of the English literature from 1966 through January 2000 utilizing the keywords: hyperemesis gravidarum, nausea and vomiting, and pregnancy. Current data pertaining to epidemiology, etiology, clinical manifestations, differential diagnosis, complications, various treatment modalities, subsequent perinatal outcome and recent developments are presented. Review of the literature supports that hyperemesis gravidarum is a multifactorial disease in which pregnancy-induced hormonal changes associated with concurrent gastrointestinal dysmotility and possible Helicobacter pylori infection function as contributing factors. Therapeutic key elements are mainly supportive in conjunction with antiemetic medication. It appears perinatal outcome is unaffected.

BACKGROUND: In the United States, hyperemesis gravidarum is the most common cause of hospitalization during the first half of pregnancy and is second only to preterm labor for hospitalizations in pregnancy overall. In approximately 0.3-3% of pregnancies, hyperemesis gravidarum is prevalent and this percentage varies on account of different diagnostic criteria and ethnic variation in study populations. Despite extensive research in this field, the mechanism of the disease is largely unknown. Although cases of mortality are rare, hyperemesis gravidarum has been associated with both maternal and fetal morbidity. The current mainstay of treatment relies heavily on supportive measures until improvement of symptoms as part of the natural course of hyperemesis gravidarum, which occurs with progression of gestational age. However, studies have reported that severe, refractory disease manifestations have led to serious adverse outcomes and to termination of pregnancies. SUMMARY: Despite extensive research in the field, the pathogenesis of hyperemesis gravidarum remains unknown. Recent literature points to a genetic predisposition in addition to previously studied factors such as infectious, psychiatric, and hormonal contributions. Maternal morbidity is common and includes psychological effects, financial burden, clinical complications from nutritional deficiencies, gastrointestinal trauma, and in rare cases, neurological damage. The effect of hyperemesis gravidarum on neonatal health is still debated in literature with conflicting results regarding outcomes of birth weight and prematurity. Available therapy options remain largely unchanged in the past several decades and focus on parenteral antiemetic medications, electrolyte repletion, and nutritional support. Most studies of therapeutic options do not consist of randomized control studies and cross-study analysis is difficult due to considerable variation of diagnostic criteria. Key Messages: Hyperemesis gravidarum carries a significant burden on maternal health and US health care. Most published research on pathogenesis is observational and suggests multifactorial associations with hyperemesis gravidarum. Precise, strictly defined criteria for clinical diagnosis are likely to benefit meta-analyses of further research studies regarding pathogenesis as well as therapeutic options.