Ultrasound changes in quadriceps femoris thickness in women with normal pregnancy and bedridden women due to risk of preterm labor

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Design and Study Subjects

We performed two studies: a longitudinal study of changes in quadriceps femoris muscle thickness in women with normal pregnancy, both during pregnancy and the postpartum period (Study 1), and a prospective comparative study on quadriceps femoris muscle thickness during pregnancy and the postpartum period in women with normal pregnancy and women treated for bedridden BPD (study 2) between June 2014 and March 2016. The ethics committee of the The study was reviewed and approved by Tokushima University Hospital (approval number 2037-1) and written informed consent was obtained from all participants. All experimental protocols were designed according to the ethical principles of the Declaration of Helsinki and performed according to ethical guidelines for medical and health research involving human subjects.

Study 1

The study population consisted of 26 pregnant women aged 23 to 40 years. We recruited participants from the outpatient clinic of the Obstetrics and Gynecology Department of Tokushima University Hospital between June 2014 and March 2016 for the longitudinal study. Women with hypertensive disorders of pregnancy, diabetes mellitus, gestational diabetes mellitus, maternal complications requiring medication, severe fetal malformations diagnosed before birth, and those prescribed bed rest for any other reason were excluded. All of the women included had singleton pregnancies lasting 37 weeks or more. Muscle thickness of the proximal, middle, and distal rectus femoris and vastus intermedius muscles was measured by ultrasound at 11–13, 26, 30, and 35 weeks gestation, and at 3–5 days and 1 month postpartum. . We used food frequency questionnaire software (Excel Eiyoukun FFQg version 3.0; Kenpousha, Tokyo, Japan) to assess calorie and protein intake of outpatients35. Physical activity was assessed with the Japanese version of the International Physical Activity Questionnaire (IPAQ), which was used to assess physical activity in different domains36.37. Each domain assesses walking, with moderate and vigorous physical activity performed for at least 10 min each day per week. Using the IPAQ, we calculated an average metabolic equivalent score (MET) for total physical activity performed per week in MET min/week38.

Muscle thickness measurement

The position of participants during ultrasound measurements, and the choice of site for limb measurements were the same as those described in a previous study.9. We measured muscle thicknesses from the quadriceps femoris to the anterior aspect of the right leg using a real-time B-mode ultrasound imaging device (Hi Vision Preirus; Hitachi, Tokyo, Japan) with a probe 7.5 MHz Linear Array (EUP-L74M ). To improve acoustic coupling without compressing the dermal surface, a water-soluble transmission gel was placed on the scan head. The transducer was held perpendicular to the skin surface. Images were captured, stored on the hard drive of the ultrasound system, and then muscle thickness was measured using screen calipers (Fig. 3). All measurements were performed with the participants in the supine position, meaning full (passive) extension at the knee and elbow joints. Mean muscle thickness was calculated as the average of five consecutive measurements from each muscle site, and all measurements were performed by the same experienced researcher.

picture 3

Ultrasound image of the rectus femoris and the vastus intermedius.

Ultrasonic measurement sites

The quadriceps femoris muscle is subdivided into four distinct muscles in front of the thigh: vastus lateralis, located in the lateral superficial part; vastus medialis, located in the medial superficial part; rectus femoris, located in the middle superficial part; and the vastus intermedius, located between the vastus lateralis and the vastus medialis, in the deep part of the front of the thigh. We measured the muscle thickness of the rectus femoris and the vastus intermedius separately at the proximal, intermediate and distal points. These points were determined as follows: proximal point, on the anterior surface, 25% proximal to the point between the antero-superior iliac spine and the superior pole of the patella; intermediate point, on the anterior surface halfway between the antero-superior iliac spine and the superior pole of the patella; distal point, on the anterior surface, 75% distal to the point between the antero-superior iliac spine and the superior pole of the patella (Fig. 4).

Figure 4
number 4

Ultrasound measurement sites on the rectus femoris (A) and vast intermediate (B). Proximal point, on the anterior surface, 25% proximal to the point between the antero-superior iliac spine and the superior pole of the patella; intermediate point, on the anterior surface halfway between the antero-superior iliac spine and the superior pole of the patella; distal point, on the anterior surface, 75% downstream of the point between the antero-superior iliac spine and the superior pole of the patella.

Study 2

We recruited 15 pregnant women who were admitted to our hospital at less than 30 weeks gestation and treated with bed rest for BPD. We compared the muscle thickness of these women with that of the 26 normal pregnant women included in Study 1. Cases with regular objective uterine contractions and/or significant cervical changes (dilation and/or effacement and/or cervical length short) were diagnosed as BPD. The 15 women with BPD were treated with bed rest and ambulation limited to bathroom privileges, and intravenous ritodrine hydrochloride. Bed rest and intravenous ritodrine hydrochloride were continued until 35–36 weeks gestation. The food supplement in the hospital included 626 mg of calcium, 1145 mg of phosphorus, 7 μg of vitamin D and 2000 kcal/day on average. Women with hypertensive disorders of pregnancy, diabetes mellitus, gestational diabetes mellitus, maternal complications requiring medication, severe fetal malformations diagnosed before birth, and those who had received treatment with glucocorticoids or magnesium sulfate were excluded from the study. All women had singleton pregnancies lasting 35 weeks or more. We measured muscle thickness at the same six sites as in the study 1 at 30 and 35 weeks of pregnancy, then at 3-5 days and 1 month after delivery. We used the same frequency questionnaire software as in Study 1 for outpatients, and we calculated the protein and calorie intake of hospital meals given to inpatients. Physical activity was assessed using the same questionnaire as in Study 1.

Test-retest reliability of ultrasonic measurements

To assess the reliability of muscle thickness measurements, the observer performed two sets of ultrasound measurements on 17 pregnant and postpartum women who did not participate in Study 1 and Study 2. Two sets of measurements were were taken at 30 minute intervals. In each series, five measurements were taken at the six muscle sites. The investigator was blinded to the results of the measurements displayed on the ultrasound system during the tests, and the order of the measurement sites was randomized to avoid memory bias. Intraclass correlation coefficients for the proximal point of the rectus femoris muscle, the intermediate point of the rectus femoris muscle, the distal point of the rectus femoris muscle, the proximal point of the vastus intermedius, the intermediate point of the vastus intermedius and the distal point of the vastus intermedius were 0.95, 0.99, 0.99, 0.99, 0.99, and 0.99, respectively. Intra-rater test-retest reliability was considered high for all measures. Inter-rater test-retest reliability was also high for all measures, with intraclass correlation coefficients for the proximal point of the rectus femoris muscle, the intermediate point of the rectus femoris muscle, the distal point of the rectus femoris muscle, the proximal point of the vastus intermedius muscle, the intermediate point of the vastus intermedius muscle and the distal point of the vastus intermedius muscle, i.e. 0.77, 0.7, 0.75, 0.87, 0.99 and 0.84, respectively.

statistical analyzes

Data were expressed as mean ± standard deviation, medians and IQR, and proportions (%). Fisher’s exact test, Student’s t test and Mann-Whitney U test were used for statistical analysis of baseline characteristics. Differences in muscle thickness between the groups were compared by Student’s t-test (in the cross-sectional study) or repeated measures ANOVA (in the longitudinal study), while multiple comparisons in the study longitudinal were performed using the paired t test. test with Bonferroni’s post-hoc correction. All statistical analyzes were performed with EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for R (R Foundation for Statistical Computing, Vienna, Austria). Specifically, it is a modified version of R commander designed to add the statistical functions frequently used in biostatistics.39. All p values ​​were two-sided and α was set at a significance level of 0.05.

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