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Angle of progression measurements of fetal head at term: a systematic comparison between open magnetic resonance imaging and transperineal ultrasound
Christian Bamberg, MD; Saskia Scheuermann, MD; Christina Fotopoulou, PhD; Torsten Slowinski, MD; Anna M. Dckelmann, MD; Ulf Teichgrber, PhD; Florian Streitparth, MD; Wolfgang Henrich, PhD; Joachim W. Dudenhausen, PhD; Karim D. Kalache, PhD
OBJECTIVE: During labor, transperineal sonography is increasingly RESULTS: The angles of progression measured by transperineal ultrasound

used to evaluate fetal head descent. The aim of this study was to compare the angle of progression assessed by open magnetic resonance imaging (MRI) vs transperineal ultrasound.
STUDY DESIGN: A total of 31 pregnant women at term ( 37 weeks), who were not in labor, underwent MRI in an open 1.0-T system. A midsagittal plane of the maternal pelvis was stored. Immediately after, without changing the supine position, a transperineal ultrasound was performed. The angle of progression was measured ofine by transperineal ultrasound and MRI.

(mean, 79.05 degrees; SD 11.44) and MRI (mean, 80.48 degrees; SD 11.06) correlated signicantly (P .001). The intraclass correlation coefcient between the 2 methods was 0.89 (95% condence interval, 0.780.94).
CONCLUSION: The angle of progression measurements obtained by

transperineal ultrasound and open MRI showed very good agreement. Key words: angle of progression, labor, open magnetic resonance imaging, translabial ultrasound, transperineal ultrasound, ultrasonography

Cite this article as: Bamberg C, Scheuermann S, Fotopoulou C, et al. Angle of progression measurements of fetal head at term: a systematic comparison between open magnetic resonance imaging and transperineal ultrasound. Am J Obstet Gynecol 2012;206:161.e1-5.

arious studies have shown that vaginal palpation of fetal head station is highly subjective, examiner dependent, and thus not accurately reliable,1,2 even though it is the standard practice used to determine labor progress in all delivery units around the world.3 Neverthe-

From the Departments of Obstetrics (Drs Bamberg, Scheuermann, Dckelmann, Henrich, Dudenhausen, and Kalache), Gynecology (Dr Fotopoulou), Nephrology (Dr Slowinski), and Radiology (Drs Teichgrber and Streitparth), Charit University Hospital, Berlin, Germany.
Received April 18, 2011; revised Aug. 18, 2011; accepted Oct. 19, 2011. This project was supported by a public grant from TSB (Technologiestiftung Berlin) Zufunftsfonds Berlin. The authors report no conict of interest. Reprints: Christian Bamberg, MD, Department of Obstetrics, Charit University Hospital, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany. christian.bamberg@charite.de. 0002-9378/$36.00 2012 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.10.867

less, during labor, transperineal sonography is becoming an established method for evaluating labor progress4-6 and the success rate of vacuum extraction.7 Barbera et al8 were the rst to use transperineal ultrasound to measure the angle between the maternal symphysis pubis and the leading part of the fetal skull (angle of progression). There is growing evidence suggesting the angle of progression may constitute a suitable, objective tool to evaluate labor progress. The goal of this study was to study the agreement in assessing angle of progression between open magnetic resonance (MR) imaging (MRI) (the gold standard) and transperineal ultrasound in women at term, who were not in labor. To our knowledge, this is the rst study describing MRI evaluation of the angle of progression.

M ATERIALS AND M ETHODS

From January 2009 through September 2009, we prospectively evaluated women at term from our antenatal care unit. Inclusion criteria were a live singleton pregnancy of 37 completed weeks with a fetus in an occiput anterior position. The

fetal head position was diagnosed by transabdominal ultrasound as previously described by Akmal et al.9 Exclusion criteria were known fetal abnormalities, preterm ruptured membranes, active labor demonstrated by regular uterine contractions, and contraindications to the use of MRI. The study protocol was approved by the local medical ethics committee. Informed consent was obtained from all patients. All 31 healthy patients underwent MRI examination and, subsequently, a transperineal ultrasound. MRI was performed in a 1.0-T open high-eld MR scanner with a vertical magnetic eld orientation (Panorama; Philips Healthcare, Best, The Netherlands) using a body coil. Pregnant patients were examined with an empty bladder, in a supine decubitus position, with appropriate padding. A T1-weighted fast spin-echo sequence was obtained using the following settings: time of echo, 19 milliseconds; time of repetition, 790 milliseconds; and thickness, 3 mm. The total individual study time was 30 minutes in all cases. MRIs were analyzed ofine (Figure 1, A); on the basis of a midsagittal slice orientation, the angle of progression was mea161.e1

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FIGURE 1

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sured by 1 radiologist, in the same way described for the transperineal approach (see below), who was blinded to the ultrasound results. Transperineal ultrasound studies were performed immediately after the MRI examinations without changing the womens posture. We opted for this approach to avoid any fetal head movements between the MRI examination and the transperineal ultrasound study. A Voluson 730 Expert system equipped with a 4- to 7-MHz transabdominal 3-dimensional transducer (GE Healthcare, Milwaukee, WI) was used. A single experienced observer with 10 years clinical ultrasound practice quantied the angle of progression using the method described by our group.6 Briey, the probe was covered with a sterile glove and placed on the midsagittal plane on the perineum. First, small lateral movements of the probe were made until an image was obtained that did not contain shadows from the pubic rami and showed a midsagittal view with clear visualization of the pubic symphysis and fetal skull. The probe was then displaced laterally until the pubic ramus was clearly visualized within the symphyseal capsular tissue. Care was taken to project the acoustic shadow generated by the pubic ramus above the presenting part of the fetal skull by tilting the transducer. Two to 3 images were recorded for ofine measurement of the angle of progression (the angle between a line placed through the midline of the pubic symphysis along the pubic ramus and a line running from the inferior apex of the symphysis tangentially to the most anterior part of the fetal skull) (Figure 1, B). The sonographer was blinded to the MRI data. All results are presented in raw numbers, rates, medians and ranges, or means SD according to the underlying distribution. Data were rst tested for normality and equal variance (Kolmogorov-Smirnov test). We used paired t test to compare the relationship of the angles of progression measured by transperineal ultrasound and open MRI. The intraclass correlation coefcient (ICC); 95% condence interval (CI) for the ICC and the BlandAltman method for assessing agreement, including calculation of the average discrepancy between measurements (bias);

Images in same woman

Angles of progression measured by A, open magnetic resonance imaging, and B, transperineal ultrasound.
Bamberg. Angles of progression measured by transperineal ultrasound and open MRI. Am J Obstet Gynecol 2012.

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TABLE

FIGURE 2
Value [range] 29.5 38.3 5.3 [1838] 1.6 [3741]

Maternal and pregnancy characteristics of study population

Characteristic Maternal age, y Parity Gestational age at enrollment, wk Nulliparous

.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................

Box and whiskers plot shows distribution of angle of progression measured by transperineal ultrasound and MRI

18 (58) 13 (42)

Multiparous

Maternal height, cm

..............................................................................................................................................................................................................................................

163.9 74.9 39.2

7.7 [143186]

Maternal weight at enrollment, kg Gestational age at delivery, wk Mode of delivery Spontaneous Instrumental Cesarean Birthweight, g
Data are presented as mean

.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................

10.9 [5691] 1.0 [3741]

18 (58) 4 (13) 9 (29)

3284
SD or as total number (%).

513 [22404180]
MRI, magnetic resonance imaging. Bamberg. Angles of progression measured by transperineal ultrasound and open MRI. Am J Obstet Gynecol 2012.

..............................................................................................................................................................................................................................................

Bamberg. Angles of progression measured by transperineal ultrasound and open MRI. Am J Obstet Gynecol 2012.

the 95% limits of agreement; and the SD of bias were generated to illustrate the differences between angles of progression measured by open MRI and transperineal ultrasound. Statistical analysis was performed using software (SPSS 16.0; SPSS Inc, Chicago, IL). Software (GraphPad Prism, version 4.0 for Mac OSX; GraphPad Software, San Diego, CA) was also used for graphing. For all tests, P .005 was considered statistically signicant.

distribution. The angles of progression measured by transperineal ultrasound (mean, 79.05 degrees; SD 11.44) and MRI (mean, 80.48 degrees; SD 11.06) correlated signicantly (P .001) (Figures 2 and 3). The intraclass correlation was 0.89 (95% CI, 0.78 0.94). Figure 4 shows a Bland-Altman graph, comparing the angle of progression differences between transperineal ultrasound and open MRI. The mean difference was 1.4 degrees 6.75 SD with 95% limits of agreement from 14.9 to 12 degrees.

R ESULTS
During the study period, 31 patients were enrolled and included in this analysis. The mean age was 29 years (range, 18 38), whereas the median gravidity was 2 (range, 15) and median parity was 1 (range, 0 2). Detailed maternal and pregnancy-related characteristics are summarized in the Table. The majority of the evaluated patients (58%) had a spontaneous vaginal delivery, whereas 9 patients (29%) underwent a cesarean section. The mean birthweight was 3284 513 g for full-term newborns. All attempts to measure angles of progression with transperineal ultrasound and open MRI were successful. The values of the angles of progression measured by both methods showed a normal

C OMMENT
In this study, we showed there was very good agreement between measurements of the angle of progression obtained by transperineal ultrasound and open MRI. Transperineal ultrasound is a novel technique, which is increasingly being used to evaluate fetal head descent during labor.4-6,10 This method was established because digital vaginal examination of head station during labor is operator dependent and poorly reproducible.11-13 Barbera et al4 measured the angle of progression in 88 laboring patients in the second stage of labor and found an angle 120 degrees was always associated with a subsequent spontaneous delivery. We previously reported that measuring the

angle of progression could assist in the obstetricians decision to attempt a vaginal delivery or cesarean section. An angle of progression of 120 degrees in an occiput anterior fetal position was associated with a 90% probability of successful vaginal delivery.6 Very recently, our group showed a signicant correlation between the angle of progression observed by transperineal ultrasound and the distance between the leading bone edge of the fetal cranium and the maternal ischial spines depicted by open MRI.14 Based on statistical assumption, station 0 would correspond to a 120-degree angle of progression. In this evaluation, we showed angle of progression measurements at term can be accurately assessed by transperineal ultrasound as it presents a highly statistically signicant correlation with equivalent MRI measurements, which are reproducible and not examiner dependent. However, several limitations of our study must be addressed. Results are based on a relatively small number of enrolled patients. None of the women in this investigation were in labor, and none of the fetal heads were engaged. The average angle of progression was about 80 degrees, which correlates from our previous published data to 161.e3

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FIGURE 3

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a fetal head station 3-4 cm above the level of the ischial spines.14 The fundamental premise that has been used to label station is that the rst part of the birth canal is straight and the second part below the interspinous level has a curvilinear trajectory.15 In this model, an increased angle of progression up to 120 degrees would correspond to a proportional descent in fetal head station until head engagement. We are aware that most published angles of progression were acquired during labor.4-6 It is yet to be shown if these ndings can be correlated to patients in labor. Further investigation into this aspect would help to resolve this issue. Although, Dietz and Lanzarone16 established the pubic symphysis as a landmark for transperineal ultrasound before labor and examined its reproducibility. Even if it would have added strength to the study having 2 observers, the reproducibility of transperineal ultrasound has been reported and found to be good. Molina et al17 showed the angle of progression is the most reliable ultrasound parameter to assess fetal head descent. In 50 women in the second stage of labor, 2 experts performed 3-dimensional volume acquisition of the fetal head by transperineal sonography and compared the results of head direction, angle of midline, progression distance, and angle of progression. The angle of progression had the highest ICC for the same observer (0.94) and 2 different (0.84) observers. Furthermore, these measurements had the smallest limits of agreement in the Bland-Altman test for the intraobserver and interobserver variability, respectively.17 These ndings are very similar to those of Dckelmann et al18 who used a 2-dimensional ultrasound system to examine the angle of progression in 24 women in prolonged second stage of labor and reported that the ICC of separate images acquired by 2 experienced sonographers was 0.82 (95 CI, 0.70 0.89). The mean differences in the angle of progression measurements between an observer with 10 years ultrasound experience vs an observer with 5 years experience were similar and small. In clinical settings, measurement comparisons of 2 different methods are often

Scatterplot of angles of progression measured by 2 different methods, linear regression model ts curve best

Bamberg. Angles of progression measured by transperineal ultrasound and open MRI. Am J Obstet Gynecol 2012.

FIGURE 4

Bland-Altman diagram shows good agreement for ofine analysis of angle of progression between open MRI and transperineal US

Solid line represents mean and dotted line

MRI, magnetic resonance imaging; US, ultrasound.

1.96 SD.

Bamberg. Angles of progression measured by transperineal ultrasound and open MRI. Am J Obstet Gynecol 2012.

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needed to determine whether they agree sufciently. The use of correlation is misleading. Data that are in poor agreement can produce quite high correlations, and the test of signicance is inappropriately to the question of agreement. Bland and Altman19,20 devised a simple, but informative, way of graphing the comparison of 2 assay methods. Therefore, we used the limits of agreement approach and Bland-Altman graphing of the difference between the methods against their mean.19,20 The 2 methods had very similar results on average, and the difference between the means was only 1.4 degrees. In 95% of subjects, the angles lie between 14.9 and 12 degrees. The differences between measurements remained stable as the average angle of progression increased. Open MRI systems were designed to allow better patient access and to increase patient comfort.21 The higher eld strength ( 1.0 T) in combination with an open conguration of the magnet is therefore desirable to obtain high MRI quality.22 We used a T1-weighted fast spin-echo sequence with a midsagittal view for assessment of the fetal head station and for measurement of the angle of progression. As mentioned by Paltieli and Nizard,23 ultrasound measurements of angle of progression use the non-bony pubic symphysis landmark, whereas computed tomography derived data are obtained by considering bony landmarks. A strict midsagittal section has the advantage of obtaining an image without an acoustic shadow from the pubic ramus. This view allows clear visualization of the presenting part but might present a challenge when dening the long axis of the symphysis. We suggest slightly displacing the probe until the pubic ramus is clearly visualized within the symphyseal capsular tissue.24 In conclusion, to conrm the validity of the angle of progression measurement by transperineal ultrasound, we have now tested this method by comparing it to MRI (the gold standard). From practical and clinical points of view, the discrepancy between the 2 methods is very small. Further conrmation studies are needed to validate transperineal ultrasound imaging measurements of the angle of progression in the assessment of labor. Clinical trials demonstrating benets of the use of this technique in practical obstetrics are warranted. We propose that transperineal ultrasound measurement of the angle of progression can be clinically benecial in laboring patients. f
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