Practice guidelines for performance of the routine mid-trimester fetal ultrasound scan

A Mathematical Model to Predict Human Microcephaly

BACKGROUND

Microcephaly (MiC) is defined as head circumference (HC) dimensions smaller than the normal standards.

OBJECTIVE

To detect MiC with a mathematical formula.

MATERIALS AND METHODS

The 0 to 5 years head HC percentile data for girls and boys reported by the World Health Organization were used. To assess early childhood, these growth standards are available on its website for international use. Mathematical formulas best estimating the 3rd percentile curves were defined using basic regression analysis methods.

RESULTS

The mathematical models obtained as a result of logarithmic regression analysis with the highest coefficient of determination values (R2 = 0.991 for girls; R2 = 0.991 for boys) were identified as the best model. The formulas of HC = 34.025 + 3.283 ∗ ln (age as months), and HC = 35.475 + 3.14 ∗ ln (age as months) were determined for girls and boys, respectively. A limitation of these formulas is that they do not provide the HC at birth (ln (0) = undetermined).

CONCLUSION

Microcephaly can be estimated using the mathematical formulas with a calculator without using percentile scales, mobile applications, software, or the Internet.

A Matter of Time: Does Gestational Age Affect the Duration of the Fetal Anatomic Survey?

OBJECTIVE

To assess the average duration of detailed fetal anatomic surveys in pregnancy in relation to gestational age (GA) and the maternal body mass index (BMI) to determine optimal timing of the examination.

METHODS

This was a retrospective cohort study of gravidae presenting for detailed fetal anatomic examinations between January 1, 2010, and June 30, 2017. After excluding examinations expected to have longer duration (ie, multifetal, major fetal anomalies), there were a total of 6522 examinations performed between GAs of 18 weeks 0 days and 22 weeks 0 days. Women were grouped by BMI, and results were analyzed by logistic regression.

RESULTS

Gravidae of normal weight (BMI, 18.5-24.9 kg/m² ) had a decrease of 47.47 seconds of the examination time with each increasing week of gestation (P = .036). Overweight (BMI, 25-29.9 kg/m² ) gravidae similarly had a decrease of 66.31 seconds of the examination time with each additional week of gestation (P = .017). Underweight (BMI, 8.5 kg/m² ) and obese (BMI, ≥30 kg/m² ) gravidae did not have differences in the examination time with increasing GA. Increases in suboptimal examinations were noted with an increasing BMI (P < .001). There was a decreased frequency of suboptimal examinations in obese gravidae with a BMI of 40 kg/m² or higher with increasing GA (P = .037).

CONCLUSIONS

The duration of detailed fetal anatomic examinations decreased with increasing GA in normal-weight and overweight gravidae but not in obese gravidae. Performing the anatomy scan earlier in class I and II obese gravidae (BMI, 30-40 kg/m² ) may enable improved pregnancy management options without increasing the examination duration or likelihood of a suboptimal evaluation.

Prenatal diagnosis of isolated lateral facial cleft by ultrasonography and three-dimensional printing: A case report

BACKGROUND

Lateral facial clefts are atypical with a low incidence in the facial cleft spectrum. With the development of ultrasonography (US) prenatal screening, such facial malformations can be detected and diagnosed prenatally rather than at birth. Although three-dimensional US (3DUS) can render the fetus' face via 3D reconstruction, the 3D images are displayed on two-dimensional screens without field depth, which impedes the understanding of untrained individuals. In contrast, a 3D-printed model of the fetus' face helps both parents and doctors develop a more comprehensive understanding of the facial malformation by creating more interactive aspects. Herein, we present an isolated lateral facial cleft case that was diagnosed via US combined with a 3D-printed model.

CASE SUMMARY

A 31-year-old G2P1 patient presented for routine prenatal screening at the 22^nd wk of gestation. The coronal nostril-lip section of two-dimensional US (2DUS) demonstrated that the fetus' bilateral oral commissures were asymmetrical, and left oral commissure was abnormally wide. The left oblique-coronal section showed a cleft at the left oral commissure which extended to the left cheek. The results of 3DUS confirmed the cleft. Furthermore, we created a model of the fetal face using 3D printing technology, which clearly presented facial malformations. The fetus was diagnosed with a left lateral facial cleft, which was categorized as a No. 7 facial cleft according to the Tessier facial cleft classification. The parents terminated the pregnancy at the 24^th wk of gestation after parental counseling.

CONCLUSION

In the diagnostic course of the current case, in addition to the traditional application of 2D and 3DUS, we created a 3D-printed model of the fetus, which enhanced diagnostic evidence, benefited the education of junior doctors, improved parental counseling, and had the potential to guide surgical planning.

Analysis of maturation features in fetal brain ultrasound via artificial intelligence for the estimation of gestational age

BACKGROUND

Optimal prenatal care relies on accurate gestational age dating. After the first trimester, the accuracy of current gestational age estimation methods diminishes with increasing gestational age. Considering that, in many countries, access to first trimester crown rump length is still difficult owing to late booking, infrequent access to prenatal care, and unavailability of early ultrasound examination, the development of accurate methods for gestational age estimation in the second and third trimester of pregnancy remains an unsolved challenge in fetal medicine.

OBJECTIVE

This study aimed to evaluate the performance of an artificial intelligence method based on automated analysis of fetal brain morphology on standard cranial ultrasound sections to estimate the gestational age in second and third trimester fetuses compared with the current formulas using standard fetal biometry.

STUDY DESIGN

Standard transthalamic axial plane images from a total of 1394 patients undergoing routine fetal ultrasound were used to develop an artificial intelligence method to automatically estimate gestational age from the analysis of fetal brain information. We compared its performance-as stand alone or in combination with fetal biometric parameters-against 4 currently used fetal biometry formulas on a series of 3065 scans from 1992 patients undergoing second (n=1761) or third trimester (n=1298) routine ultrasound, with known gestational age estimated from crown rump length in the first trimester.

RESULTS

Overall, 95% confidence interval of the error in gestational age estimation was 14.2 days for the artificial intelligence method alone and 11.0 when used in combination with fetal biometric parameters, compared with 12.9 days of the best method using standard biometrics alone. In the third trimester, the lower 95% confidence interval errors were 14.3 days for artificial intelligence in combination with biometric parameters and 17 days for fetal biometrics, whereas in the second trimester, the 95% confidence interval error was 6.7 and 7, respectively. The performance differences were even larger in the small-for-gestational-age fetuses group (14.8 and 18.5, respectively).

CONCLUSION

An automated artificial intelligence method using standard sonographic fetal planes yielded similar or lower error in gestational age estimation compared with fetal biometric parameters, especially in the third trimester. These results support further research to improve the performance of these methods in larger studies.

Success rate to complete optimal 20 + 2 ISUOG planes for foetal ultrasonographic structural screening during early second trimester pregnancy in Thailand

Objective

To compare the success rates of obtaining optimal 20 + 2 (2 overview + 20 planes) International Society of Ultrasound in Obstetrics and Gynaecology (ISUOG) planes for foetal ultrasound structural screening between pregnant women at gestational age (GA) 18–20 weeks and 20–22 weeks 6 days

Methods

A prospective descriptive study was conducted. Singleton pregnant women at GA 18–22 weeks + 6 days attending antenatal clinic between December 2019 and March 2020 were invited to participate in the study. Women whose foetuses had obvious structural anomalies were excluded. The ultrasound screening using 20 + 2 ISUOG protocol was performed by 21 operators who had completed the online ISUOG basic training programme with an experience of ultrasound scanning of at least 30 cases. The success rates of achieving optimal planes between GA 18–20 weeks and 20–22 weeks 6 days were compared using Chi-square test. Common suboptimal planes in the ultrasound scan were also presented.

Results

Optimal 20 + 2 ISUOG planes were successfully assessed in 97/126 (77%) and 112/126 (88.9%) patients in the group with a GA < 20 weeks and in the group with a GA ≥ 20 weeks, respectively. Overall success rate was 82.9%. The success rate for the GA < 20 weeks group was significantly lower than that for the GA ≥ 20 weeks group. The group with a GA ≥ 20 weeks had a 1.2 times higher success rate than the group with a GA < 20 weeks. The most common suboptimal planes were the facial planes, especially the median facial profile, and foetal thoracic planes.

Conclusions

We prefer to perform foetal structural screening using US with the 20 + 2 ISUOG protocol at a GA 20 to 22 weeks and 6 days with the aim reducing the need for repeat scans.

A Prenatal Ultrasound Scanning Approach: One-Touch Technique in Second and Third Trimesters

This study was aimed at evaluating the performance of the innovative technique Smart Fetus (SF) developed to recognize the planes and obtain the basic biometric measurements of fetuses automatically. This prospective study included 1005 uncomplicated singleton pregnancies undergoing routine examinations. For every pregnancy, planes, including the transverse section of the thalami, transverse section of the abdomen and longitudinal section of the femur, were acquired, and standard biometric measurements, including biparietal diameter, head circumference, abdominal circumference and femur length, were obtained using SF and traditional ultrasound technique (TUT). The accuracy, reproducibility and time required for the analysis of SF were compared with those of TUT. In 998 of 1005 cases (99.30%), SF successfully acquired the sections and made all measurements. The agreement between the techniques was high for all measurements. The time to obtain sections and measure biometric parameters or solely measure biometric parameters was significantly shorter with SF than with TUT. No significant differences were found in SF repeated measurements obtained by two independent observers. The SF technique helped in the acquisition of reliable standard sections and biometric measurements and saved time. It might serve as a novel ultrasound scanning approach and improve workflow efficiency.

The role of fetal echocardiogram after detection of extracardiac anomalies in utero (fetal echocardiogram for extracardiac malformations)

OBJECTIVE

We aimed to investigate the utility of comprehensive screening fetal echocardiography (FE) for patients diagnosed with any type of fetal extracardiac malformation (ECM) at a single multidisciplinary fetal center.

METHODS

We retrospectively reviewed all patients presenting to our referral center for FE due to a prenatal diagnosis of ECM (January 2013-December 2018).

RESULTS

Among 641 patients with ≥1 ECM referred for FE, 78 (12.2%) had CHD diagnosed at 25.6 ± 0.5 weeks. The frequency of CHD by type of ECM ranged from 35.1% for craniofacial to 9.8% for thoracic. Increasing number of fetal ECMs was strongly associated with CHD: odds ratio 2.01 (95% confidence interval: 1.06-3.69) for two ECMs, 9.57 (2.00-49.05) for three ECMs, and 11.68 (3.84-37.15) for more than three ECMs. Of fetuses with ECM and an abnormal genetic finding, 33.3% had CHD as compared to 10.9% of those without (p < 0.0001). Obstetric anatomy sonogram detected 43.6% of CHD.

CONCLUSION

CHD was commonly diagnosed among fetuses with any type of ECM at our center but was not always detected on obstetric sonogram. As the presence of CHD may impact decision-making and perinatal care, patients with a diagnosis of any fetal ECM should be considered for FE.

Ultrasound Patterns in the First Trimester Diagnosis of Congenital Heart Disease

Congenital heart disease (CHD) is the most common birth defect, with a reported prevalence of 5–12 per 1000 live births. Very recently, the American Institute of Ultrasound in Medicine published a guideline recommending the use of the four-chamber and the three-vessel and trachea views to screen for CHD in the first trimester of pregnancy. Our aim is to present abnormal image patterns that are seen in the four-chamber, three-vessel, and trachea views of the fetal heart in the first trimester and to describe their association with specific CHD types. We used a total of 29 cases of CHD from the archives of Filantropia Hospital and the Maternal and Child Health Institute (INSMC) fetal medicine units. We selected cases with a clear and well-documented diagnosis of the CHD type. We identified a series of repeating color doppler flow patterns seen in the four-chamber, three-vessel, and trachea views of the studied cases. Our observations could be developed into a diagnosis algorithm to orientate the examiner to the most likely type of CHD in individual cases.

Diagnostic accuracy of ultrasound screening for fetal structural abnormalities during the first and second trimester of pregnancy in low‐risk and unselected populations

This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows:

The main objectives of this review are to assess the diagnostic accuracy of first‐ and second‐trimester fetal anomaly screening in low‐risk pregnant women, and to compare overall performance of single‐ and two‐stage screening approaches with regards to the number of cases detected before birth, as well as the proportion of false positive diagnoses.

The use of methotrexate in conservative treatment of placenta accreta spectrum disorders

Aim of the study: This article reports on a series of patients with placenta accreta spectrum (PAS) disorder who were treated conservatively with Methotrexate (MTX) administration with or without embolization. We investigate whether there is a place for MTX in conservative treatment of PAS.Methods: We present a single-center retrospective case series of five patients. In all patients, diagnosis was unexpected and not made prenatally.Conclusion: The benefits should be weighed against the possible drug toxicity. Today high-quality evidence is lacking. PAS covers a broad spectrum of pathology, standardization in prenatal and postnatal diagnosis can help to compare evidence on treatment.

Diagnosis of central nervous system abnormalities: comparison of prenatal neurosonography and foetal magnetic resonance imaging findings

Magnetic resonance imagining (MRI) is gradually becoming the more preferred imaging modality in the evaluation of central nervous system (CNS) abnormalities rather than foetal ultrasonography (USG). The aim of this study was to compare the findings of prenatal neurosonography and foetal MRI. The study was a retrospective study analysing the records of 160 pregnant women who underwent both foetal MRI and USG due to suspicion of CNS abnormalities between 2008 and 2019. Indications for applying foetal MRI were neurosonography and foetal MRI findings. When the compatibility between MRI and USG results was examined in CNS abnormalities, it was found fully compatible in 61.3% of cases, partially compatible in 24.53% of cases, and not compatible in 14.5% of cases. When comparing prenatal neurosonography and foetal MRI findings, additional findings were reported in 16.9% of cases, and no additional finding was reported in 66.8% of cases. While normal anatomical findings were reported in 8.8% of the cases in MRI, the diagnosis made by neurosonography changed in 7.5%. Foetal MRI has more advantages than USG both in imaging the CNS abnormalities in more detail and in determining the accompanying additional anomalies.IMPACT STATEMENTWhat is already known on this subject: USG is a safe, practical and cost-effective primary imaging method that is widely used for foetal anomaly screening. However, there may sometimes be difficulties in evaluating the foetal brain structures due to foetal position which is unsuitable for imaging, extremely obese with a high body mass index, oligohydramnios and ossified foetal skull. For this reason, magnetic resonance imaging (MRI) is used as the most commonly used imaging method after USG in the evaluation of foetal anatomy, especially CNS.What do the results of this study add?: In our study, we saw that foetal MRI has more advantages than neurosonography in both seeing CNS abnormalities in more detail and recognising additional anomalies that may accompany.What are the implications of these findings for clinical practice and/or further research?: We have seen that besides neurosonography, foetal MRI can provide important information that can affect the clinical approach in pregnancy management by increasing the correct diagnosis in pregnancies with congenital CNS abnormalities. MRI: it is the best secondary imaging modality that can aid diagnosis in addition to neurosonography in the diagnosis of CNS abnormalities and in suspected cases. Therefore, foetal MRI should be used more widely in prenatal diagnosis.

Prenatal diagnosis of isolated clubfoot: Diagnostic accuracy and long-term postnatal outcomes

OBJECTIVE

To evaluate concordance between prenatal and postnatal diagnosis of congenital talipes equinovarus (cTEV), rates of surgery and postnatal outcomes in relation to the prenatal classification of severity.

STUDY DESIGN

This is a retrospective observational cohort study on fetuses with a prenatal diagnosis of cTEV between 2004 and 2018. All cases of isolated cTEV in singleton pregnancies were included. Postnatally, the Ponseti method was applied. Children were followed-up postnatally for at least two years, with a specific focus on neurodevelopmental outcome.

RESULTS

The cohort included 81 fetuses with a prenatal diagnosis of cTEV confirmed postnatally in 86.4% of cases. Concordance between prenatal and postnatal assessment was good for both laterality and degree of severity (k = 0.61 and 0.66, respectively). The average Pirani score, number of casts and rates of Achilles tendon tenotomy were higher for III degree cTEV (p < 0.001). Within this group only, the rate of relapse was 11% and the rates of major surgery was 6%. The postnatal outcome was normal in 68.6% newborns, while 14% of cases had a diagnosis of minor additional findings and 17% had an impairment of neurological development. None of the outcome was statistically correlated to the prenatal assessment of laterality or degree.

CONCLUSIONS

The accuracy of prenatal ultrasound for isolated cTEV is 86% with a false positive diagnosis of 14%. The grade of cTEV assigned prenatally correlates to postnatal severity and longer orthopedic rehabilitation in terms of number of casts and need of surgery. The assessment of the correlation between cTEV and neurological impairment requires further prospective studies on larger cohorts.

Prenatal diagnosis of genetic aberrations in fetuses with short femur detected by ultrasound: A prospective cohort study

OBJECTIVES

To investigate the genetic aberrations in fetuses with short femur and explore the relationships with respect to degree of femoral shortening and the initial diagnostic gestational age GA.

METHODS

Singleton pregnancies with fetal short femur who consented to amniocentesis and to single nucleotide polymorphism (SNP) array and Sanger sequencing for G380R mutations in FGFR3 gene were enrolled in this 5-year period prospective study. Clinical follow-up assessments were performed after birth.

RESULTS

Of a total of 161 fetuses, the prevalence of genetic aberrations was 16.2% (26/161), comprised of 65.4% (17/26) with chromosomal abnormalities and 34.6% (9/26) with G380R mutations. All fetuses with chromosomal abnormalities had FL 2-4SDs below GA. Fewer chromosomal abnormalities were detected in fetuses with short femurs presenting in the third trimester. Significantly more FGFR3 mutations were detected in fetuses with FL below -4SDs. All fetuses with FL 2-4SDs below GA diagnosed as achondroplasia were between 22 and 24 gestational weeks, and all of those diagnosed in third trimester had FL below -4SDs.

CONCLUSION

In this small cohort study, we demonstrated that different degrees of femur shortness may be attributed to different genetic aberrations. SNP array should be regarded as the first-tier test for fetuses with FL 2-4SDs below GA. The prognoses for fetuses with FL 2-4SDs below GA was significantly better than those with FL below 4SDs.

Applications of Advanced Ultrasound Technology in Obstetrics

Over the years, there have been several improvements in ultrasound technologies including high-resolution ultrasonography, linear transducer, radiant flow, three-/four-dimensional (3D/4D) ultrasound, speckle tracking of the fetal heart, and artificial intelligence. The aims of this review are to evaluate the use of these advanced technologies in obstetrics in the midst of new guidelines on and new techniques of obstetric ultrasonography. In particular, whether these technologies can improve the diagnostic capability, functional analysis, workflow, and ergonomics of obstetric ultrasound examinations will be discussed.

Prediction of non-reassuring fetal status and umbilical artery acidosis by the maternal characteristic and ultrasound prior to induction of labor

Objective

To investigate the predictive value of pre-induction digital examination, sonographic measurements and parity for the prediction of non-reassuring fetal status and cord arterial pH < 7.2 prior to the induction of labor (IOL).

Method

This was a prospective observational study, including 384 term pregnancies undergoing IOL. Before the IOL, the Bishop score (BS) by digital examination, sonographic Doppler parameters and the estimated fetal weight (EFW) was assessed. The fetal cord arterial was sampled to measure the pH at delivery. Multivariate logistic regression analysis was performed to identify independent predictors of non-reassuring fetal status and low cord arterial pH.

Results

Forty four cases (11.5%) had non-reassuring fetal status, and 76 cases (19.8%) had fetal cord arterial pH < 7.2. In the non-reassuring fetal status group, the incidence of cord arterial pH < 7.2 was significantly higher than that in the normal fetal heart rate group (χ² = 6.401, p = 0.011). Multivariate analysis indicated that significant independent predictors of non-reassuring fetal status were nulliparity (adjusted odds ratio [AOR]: 3.746, p = 0.003), EFW < 10^th percentile (AOR: 3.764, p = 0.003) and cerebroplacental ratio (CPR) < 10^th centile (AOR:4.755, p < 0.001). In the prediction of non-reassuring fetal status, the performance of the combination of nulliparity and EFW < 10th percentile was improved by the addition of CPR < 10th percentile (AUC: 0.681, (95%CI: 0.636 to 0.742) vs 0.756, (95%CI:0.713 to 0.795)), but the difference was not significant (DeLong test: z = 1.039, p = 0.053).. None of the above variables were predictors of cord arterial pH < 7.2.

Conclusion

The risk of fetal acidosis has increased in cases of non-reassuring fetal status. Nulliparity, small for gestational age and CPR < 10th centile are independent predictors for non-reassuring fetal status in term fetuses, though the addition of CPR < 10th centile could not significantly improve the screening accuracy.

Esophageal atresia and tracheoesophageal fistula: prenatal sonographic manifestation from early to late pregnancy

OBJECTIVE

Esophageal atresia and/or tracheoesophageal fistula (EA/TEF) remains one of the most frequently missed congenital anomalies prenatally. The aim of our study was to elucidate the sonographic manifestation of EA/TEF throughout pregnancy.

METHODS

This was a retrospective study of data obtained from a tertiary center over a 12-year period. The prenatal ultrasound scans of fetuses with EA/TEF were assessed to determine the presence and timing of detection of three principal signs: small/absent stomach and worsening polyhydramnios, both of which were considered as 'suspected' EA/TEF, and esophageal pouch, which was considered as 'detected' EA/TEF. We assessed the yield of the early (14-16 weeks' gestation), routine mid-trimester (19-26 weeks) and third-trimester (≥ 27 weeks) anomaly scans in the prenatal diagnosis of EA/TEF.

RESULTS

Seventy-five cases of EA/TEF with available ultrasound images were included in the study. A small/absent stomach was detected on the early anomaly scan in 3.6% of fetuses scanned, without a definitive diagnosis. On the mid-trimester scan, 19.4% of scanned cases were suspected and 4.3% were detected. On the third-trimester anomaly scan, 43.9% of scanned cases were suspected and 33.9% were detected. An additional case with an esophageal pouch was detected on magnetic resonance imaging (MRI) in the mid-trimester and a further two were detected on MRI in the third trimester. In total, 44.0% of cases of EA/TEF in our cohort were suspected, 33.3% were detected and 10.7% were suspected but, eventually, not detected prenatally.

CONCLUSIONS

Prenatal diagnosis of EA/TEF on ultrasound is not feasible before the late second trimester. A small/absent stomach may be visualized as early as 15 weeks' gestation. Polyhydramnios does not develop before the mid-trimester. An esophageal pouch can be detected as early as 22 weeks on a targeted scan in suspected cases. The detection rates of all three signs increase with advancing pregnancy, peaking in the third trimester. The early and mid-trimester anomaly scans perform poorly as a screening and diagnostic test for EA/TEF. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Agent With Warm Start and Adaptive Dynamic Termination for Plane Localization in 3D Ultrasound

Accurate standard plane (SP) localization is the fundamental step for prenatal ultrasound (US) diagnosis. Typically, dozens of US SPs are collected to determine the clinical diagnosis. 2D US has to perform scanning for each SP, which is time-consuming and operator-dependent. While 3D US containing multiple SPs in one shot has the inherent advantages of less user-dependency and more efficiency. Automatically locating SP in 3D US is very challenging due to the huge search space and large fetal posture variations. Our previous study proposed a deep reinforcement learning (RL) framework with an alignment module and active termination to localize SPs in 3D US automatically. However, termination of agent search in RL is important and affects the practical deployment. In this study, we enhance our previous RL framework with a newly designed adaptive dynamic termination to enable an early stop for the agent searching, saving at most 67% inference time, thus boosting the accuracy and efficiency of the RL framework at the same time. Besides, we validate the effectiveness and generalizability of our algorithm extensively on our in-house multi-organ datasets containing 433 fetal brain volumes, 519 fetal abdomen volumes, and 683 uterus volumes. Our approach achieves localization error of 2.52mm/10.26^° , 2.48mm/10.39^° , 2.02mm/10.48^° , 2.00mm/14.57^° , 2.61mm/9.71^° , 3.09mm/9.58^° , 1.49mm/7.54^° for the transcerebellar, transventricular, transthalamic planes in fetal brain, abdominal plane in fetal abdomen, and mid-sagittal, transverse and coronal planes in uterus, respectively. Experimental results show that our method is general and has the potential to improve the efficiency and standardization of US scanning.

Fetal cardiac filling and ejection time fractions by pulsed-wave Doppler: reference ranges and potential clinical application

OBJECTIVES

Fetal cardiac function can be evaluated using a variety of parameters. Among these, cardiac cycle time-related parameters, such as filling time fraction (FTF) and ejection time fraction (ETF), are promising but rarely studied. We aimed to report the feasibility and reproducibility of fetal FTF and ETF measurements using pulsed-wave Doppler, to provide reference ranges for fetal FTF and ETF, after evaluating their relationship with heart rate (HR), gestational age (GA) and estimated fetal weight (EFW), and to evaluate their potential clinical utility in selected fetal conditions.

METHODS

This study included a low-risk prospective cohort of singleton pregnancies and a high-risk population of fetuses with severe twin-twin transfusion syndrome (TTTS), aortic stenosis (AoS) or aortic coarctation (CoA), from 18 to 41 weeks' gestation. Left ventricular (LV) and right ventricular inflow and outflow pulsed-wave Doppler signals were analyzed, using valve clicks as landmarks. FTF was calculated as: (filling time/cycle time) × 100. ETF was calculated as: (ejection time/cycle time) × 100. Intraclass correlation coefficients (ICC) were used to evaluate the intra- and interobserver reproducibility of FTF and ETF measurements in low-risk fetuses. The relationships of FTF and ETF with HR, GA and EFW were evaluated using multivariate regression analysis. Reference ranges for FTF and ETF were then constructed using the low-risk population. Z-scores of FTF and ETF in the high-risk fetuses were calculated and analyzed.

RESULTS

In total, 602 low-risk singleton pregnancies and 54 high-risk fetuses (nine pairs of monochorionic twins with severe TTTS, 16 fetuses with AoS and 20 fetuses with CoA) were included. Adequate Doppler traces for FTF and ETF could be obtained in 95% of low-risk cases. Intraobserver reproducibility was good to excellent (ICC, 0.831-0.905) and interobserver reproducibility was good (ICC, 0.801-0.837) for measurements of all timing parameters analyzed. Multivariate analysis of FTF and ETF in relation to HR, GA and EFW in low-risk fetuses identified HR as the only variable predictive of FTF, while ETF was dependent on both HR and GA. FTF increased with decreasing HR in low-risk fetuses, while ETF showed the opposite behavior, decreasing with decreasing HR. Most recipient twins with severe TTTS showed reduced FTF and preserved ETF. AoS was associated with decreased FTF and increased ETF in the LV, with seemingly different patterns associated with univentricular vs biventricular postnatal outcome. The majority of fetuses with CoA had FTF and ETF within the normal range in both ventricles.

CONCLUSIONS

Measurement of FTF and ETF using pulsed-wave Doppler is feasible and reproducible in the fetus. The presented reference ranges account for associations of FTF with HR and of ETF with HR and GA. These time fractions are potentially useful for clinical monitoring of cardiac function in severe TTTS, AoS and other fetal conditions overloading the heart. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Fetal US and MRI in detection of craniospinal anomalies with postnatal correlation: single-center experience

Background/aim

To reveal the contribution of magnetic resonance imaging (MRI) to ultrasound (US) in prenatal diagnosis of fetal craniospinal anomalies by retrospectively comparing the prenatal and postnatal findings.

Materials and methods

After institutional review board approval, between January 2010 and May 2020, 301 pregnant women, which had a gestational age between 19–37 weeks (mean 26.5 ± 6.1 weeks), diagnosed with cranial and spinal anomalies on fetal US and later on imaged with MRI were evaluated, and in 179 of those cases prenatal imaging findings were compared with postnatal findings.

Results

A total of 191 fetal craniospinal anomalies were detected in 179 pregnant women. MRI and US diagnosis were completely correct in 145 (75.9%) and 112 (58.6%), respectively. Diagnostic performance of MRI was significantly higher than that of the US (p < 0.05). Both prenatal MRI and US findings were concordant with postnatal diagnosis in 53% of the cases. In 28.7% cases, prenatal MRI contributed to US by either changing the wrong US diagnosis (8.9%), demonstration of additional findings (14%), or confirming the suspicious US diagnosis (5.8%).

Conclusion

Due to its high resolution and multiplanar imaging capability, fetal MRI contributes significantly to US in the correct prenatal diagnosis of craniospinal anomalies. This contribution especially is significant in neural tube defects, cortical malformations, and ischemic-hemorrhagic lesions.

Sonographic evaluation of fetal scrotum, testes and epididymis

External male genitalia have rarely been evaluated on fetal ultrasound. Apart from visualization of the penis for fetal sex determination, there are no specific instructions or recommendations from scientific societies. This study aimed to review the current knowledge about prenatal diagnosis of the scrotum and internal structures, with discussion regarding technical aspects and clinical management. We conducted an article search in Medline, EMBASE, Scopus, Google Scholar, and Web of Science databases for studies in English or Spanish language that discussed prenatal scrotal pathologies. We identified 72 studies that met the inclusion criteria. Relevant data were grouped into sections of embryology, ultrasound, pathology, and prenatal diagnosis. The scrotum and internal structures show a wide range of pathologies, with varying degrees of prevalence and morbidity. Most of the reported cases have described incidental findings diagnosed via striking ultrasound signs. Studies discussing normative data or management are scarce.

Fetal intracranial structures: differences in size according to sex

OBJECTIVES

We aimed to compare gender difference on sizes of some structures in the brain of normal male and female fetuses between 20 and 22 week gestations.

METHODS

A total of 300 female and 300 male singleton pregnancies with low risk were included in the study. Biparietal diameter, head circumference, transcerebellar diameter, cisterna magna, nuchal fold thickness, anterior and posterior horn of lateral ventricles, length and width of cavum septum pellucidum were measured transabdominally. Mean±SD values were calculated and comparison of measurements were done between male and female fetuses. Kolmogorov-Smirnov and independent samples t-test were used for statistical analysis. A value of p<0.05 were accepted as statistically significant.

RESULTS

We determined statistically significant difference in sizes of some structures of the brain of male and female fetuses. Mean±SD value of cavum septi pellucidi width was 3.38±0.61 and 3.85±0.96 in female and males, respectively (p<0.05). Male fetuses were also found to have larger anterior (1.92±0.30 vs. 1.58±0.26, p<0.0001) and posterior horn of lateral ventricles (6.00±0.87 vs. 5.53±1.17, p<0.05).

CONCLUSIONS

Difference in sizes of some structures of the brain starts in fetal life. This finding may be important in evaluating the intracranial structures more precisely. These results may also give a contribution to the understanding physiological and pathologic differences between males and females.

Fetal growth standards for Chinese twin pregnancies

Background

The common use of singleton fetal growth standard to access twin growth might lead to over-monitoring and treatment. We aimed to develop fetal growth standards for Chinese twins based on ultrasound measurements, and compare it with Zhang’s and other twin fetal growth charts.

Methods

A cohort of uncomplicated twin pregnancies were prospectively followed in 2014–2017. Smoothed estimates of fetal growth percentiles for both monochorionic (MC) and dichorionic (DC) twins were obtained using a linear mixed model. We also created growth charts for twins using a model-based approach proposed by Zhang et al. Our twin standards were compared with Hadlock’s (singleton) in predicting adverse perinatal outcomes.

Results

A total of 398 twin pregnancies were included, with 214 MC and 582 DC live-born twins. The MC twins were slightly lighter than the DC twins, with small differences throughout the gestation. Our ultrasound-based fetal weight standards were comparable to that using Zhang’s method. Compared with previous references/standards from the US, Brazil, Italy and UK, our twins had very similar 50th percentiles, but narrower ranges between the 5th and 95th or 10th and 90th percentiles. Compared with the Hadlock’s standard, the risks of neonatal death and adverse perinatal outcomes for small for gestational age (SGA) versus non-SGA were substantially elevated using our standards.

Conclusions

A normal fetal growth standard for Chinese twins was created. The differences between MC and DC twins were clinically insignificant. The 50th weight percentiles of the Chinese twins were identical to those in other races/ethnicities but the ranges were markedly narrower. Our standard performed much better than the Hadlock’s in predicting low birth weight infants associated with adverse perinatal outcomes in twin pregnancies. The present study also indicated that Zhang’s method is applicable to Chinese twins, and other areas may use Zhang’s method to generate their own curves for twins if deemed necessary.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03926-y.

Swedish intrauterine growth reference ranges for estimated fetal weight

Fetal growth restriction is a strong risk factor for perinatal morbidity and mortality. Reliable standards are indispensable, both to assess fetal growth and to evaluate birthweight and early postnatal growth in infants born preterm. The aim of this study was to create updated Swedish reference ranges for estimated fetal weight (EFW) from gestational week 12-42. This prospective longitudinal multicentre study included 583 women without known conditions causing aberrant fetal growth. Each woman was assigned a randomly selected protocol of five ultrasound scans from gestational week 12 + 3 to 41 + 6. Hadlock's 3rd formula was used to estimate fetal weight. A two-level hierarchical regression model was employed to calculate the expected median and variance, expressed in standard deviations and percentiles, for EFW. EFW was higher for males than females. The reference ranges were compared with the presently used Swedish, and international reference ranges. Our reference ranges had higher EFW than the presently used Swedish reference ranges from gestational week 33, and higher median, 2.5th and 97.5th percentiles from gestational week 24 compared with INTERGROWTH-21st. The new reference ranges can be used both for assessment of intrauterine fetal weight and growth, and early postnatal growth in children born preterm.

Cardiac axis evaluation as a screening method for detecting cardiac abnormalities in the first trimester of pregnancy

Congenital cardiac abnormalities refer to especially anatomic malformations of the heart that normally occur during fetal heart development, before eight weeks after conception. Aim: The aim is to investigate the association between cardiac axis and congenital heart abnormalities for a potential underline clinical application of cardiac axis evaluation during detection by abnormalities at the time of first trimester ultrasound. It is known that aneuploids can be associated in almost half of cases with cardiac abnormalities, so the angle of the cardiac axis could be a potential indirect marker for the detection of aneuploids in the first trimester of pregnancy. Being easy to obtain, from the cross-section at the chest level with the visualization of the four chambers, does not require additional sections to those provided in the current guides, we aim to prove its usefulness in diagnosing aneuploids and congenital cardiac abnormalities along with the translucent nuchal flow, at the level of the venous duct and the presence of tricuspid regurgitation. Conclusions: Cardiac axis has a higher value for the detection of congenital cardiac abnormalities with respect to the nuchal translucency, tricuspid regurgitation and inverted A wave at the level of the venous duct.

Recognition of Fetal Facial Ultrasound Standard Plane Based on Texture Feature Fusion

In the process of prenatal ultrasound diagnosis, accurate identification of fetal facial ultrasound standard plane (FFUSP) is essential for accurate facial deformity detection and disease screening, such as cleft lip and palate detection and Down syndrome screening check. However, the traditional method of obtaining standard planes is manual screening by doctors. Due to different levels of doctors, this method often leads to large errors in the results. Therefore, in this study, we propose a texture feature fusion method (LH-SVM) for automatic recognition and classification of FFUSP. First, extract image's texture features, including Local Binary Pattern (LBP) and Histogram of Oriented Gradient (HOG), then perform feature fusion, and finally adopt Support Vector Machine (SVM) for predictive classification. In our study, we used fetal facial ultrasound images from 20 to 24 weeks of gestation as experimental data for a total of 943 standard plane images (221 ocular axial planes, 298 median sagittal planes, 424 nasolabial coronal planes, and 350 nonstandard planes, OAP, MSP, NCP, N-SP). Based on this data set, we performed five-fold cross-validation. The final test results show that the accuracy rate of the proposed method for FFUSP classification is 94.67%, the average precision rate is 94.27%, the average recall rate is 93.88%, and the average F1 score is 94.08%. The experimental results indicate that the texture feature fusion method can effectively predict and classify FFUSP, which provides an essential basis for clinical research on the automatic detection method of FFUSP.

Outcome-based comparison of SMFM and ISUOG definitions of fetal growth restriction

OBJECTIVE

The recent international guidelines by the Society for Maternal-Fetal Medicine (SMFM) and the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) differ in their definitions of fetal growth restriction (FGR). Our aim was to compare the performance of the two definitions in predicting neonatal small-for-gestational age (SGA) and composite adverse neonatal outcome (ANO).

METHODS

This was a secondary analysis of data from a prospective study of women referred for fetal growth ultrasound examination between 26 + 0 and 36 + 6 weeks' gestation. The SMFM and ISUOG guidelines were used to define pregnancies with FGR. The SMFM definition of FGR is estimated fetal weight (EFW) or abdominal circumference (AC) < 10^th percentile. The ISUOG-FGR definition follows the Delphi consensus criteria and includes either EFW or AC < 3^rd percentile or EFW or AC < 10^th percentile combined with abnormal Doppler findings or a decrease in growth centiles. The primary outcome was the prediction of neonatal SGA, defined as birth weight < 10^th percentile, and a composite of ANO, which was defined as one or more of: Grade-III or -IV intraventricular hemorrhage, respiratory distress syndrome, neonatal death, cord blood pH < 7.1, seizures and admission to the neonatal intensive care unit. Test characteristics (sensitivity, specificity, positive predictive value (PPV), negative predictive value and positive (LR+) and negative likelihood ratios) and area under the receiver-operating-characteristics curve were determined. The association between FGR detected by each definition and selected adverse outcomes was assessed using logistic regression analysis.

RESULTS

Of the 1054 pregnancies that met the inclusion criteria, 137 (13.0%) and 55 (5.2%) were defined as having FGR by the SMFM and ISUOG definitions, respectively. Composite ANO and SGA neonate each occurred in 139 (13.2%) pregnancies. For the prediction of neonatal SGA, the SMFM-FGR definition had a higher sensitivity (54.7%) than did the ISUOG definition (28.8%). The ISUOG-FGR definition had higher specificity (98.4% vs 93.3%), LR+ (18.0 vs 8.2) and PPV (72.7% vs 55.5%) than did the SMFM definition for the prediction of a SGA neonate. The SMFM- and ISUOG-FGR definitions had similarly poor performance in predicting composite ANO, with sensitivities of 15.1% and 10.1%, respectively.

CONCLUSIONS

The SMFM definition of FGR is associated with a higher detection rate for SGA neonates but at the cost of some reduction in specificity. The ISUOG-FGR definition has a higher specificity, LR+ and PPV for the prediction of neonatal SGA. Both definitions of FGR performed poorly in predicting a composite ANO. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

First-Trimester Cranial Ultrasound Markers of Open Spina Bifida

OBJECTIVES

To evaluate cranial ultrasound markers during a first-trimester routine ultrasound examination for screening for open spina bifida (OSB).

METHODS

Midsagittal and axial images of the fetal head obtained from fetuses with spina bifida and unaffected control fetuses at 11 weeks to 13 weeks 6 days were analyzed retrospectively. The observed markers of the posterior brain included the 4- versus 3-line view, the brain stem (BS)-to-brain stem-occipital bone (BSOB) distance ratio (BS/BSOB), the position relationship between the maxillo-occipital (MO) line and the midbrain-BS junction, and the crash sign status.

RESULTS

This study included 9 OSB cases, 2 closed spina bifida (CSB) cases, and 200 unaffected controls. Eight of 9 OSB cases had informative midsagittal views of the head. The 3-line view (abnormal) and BS/BSOB greater than 1 (abnormal) were observed in 87.5% (7 of 8) and 100% (8 of 8), respectively. The midbrain-BS junction was below or nearly on the MO line (abnormal) in 100% (8 of 8). Seven of the cases had informative axial views of the head. The crash sign (abnormal) was observed in 85.7% (6 of 7). A 3-line view was seen in all of the cases that had a positive crash sign. Neither of the 2 cases of CSB and none of the controls had any of the 4 first-trimester intracranial ultrasound markers of OSB.

CONCLUSIONS

The 4 first-trimester intracranial ultrasound markers investigated in this study appear to be very good markers of OSB, especially a BS/BSOB greater than 1 and an abnormal MO line. The crash sign and 3-line view were observed in the same fetus. In our study, these ultrasound findings were not helpful in CSB.

Predicting cesarean delivery for failure to progress as an outcome of labor induction in term singleton pregnancy

BACKGROUND

Induction of labor is one of the most common interventions in modern obstetrics, and its frequency is expected to continue to increase. There is inconsistency as to how failed induction of labor is defined; however, the majority of studies define success as the achievement of vaginal delivery. Induction of labor in nulliparous women poses an additional challenge with a 15% to 20% incidence of failure, ending in emergency operative deliveries. The Bishop score has been traditionally used before decisions for induction of labor. Nonetheless, it is subjective and prone to marked interobserver variation. Several studies have been conducted to find alternative predictors, yet a reliable, objective method still remains to be introduced and validated. Hence, there is still a need for the development of new predictive tools to facilitate informed decision making, optimization of resources, and minimization of potential risks of failure. Furthermore, a peripartum transperineal ultrasound scan has been proven to provide objective, noninvasive assessment of labor.

OBJECTIVE

This study aimed to assess the feasibility of developing and validating an objective and reproducible model for the prediction of cesarean delivery for failure to progress as an outcome of labor induction in term singleton pregnancies.

STUDY DESIGN

This was a prospective observational cohort study conducted in Cairo University Hospitals and University of Bologna Hospitals between November 2018 and November 2019. We recruited 382 primigravidae with singleton term pregnancies in cephalic presentation. All patients had baseline Bishop scoring together with various transabdominal and transperineal ultrasound assessments of the fetus, maternal cervix, and pelvic floor. The managing obstetricians were blinded to the ultrasound scan findings. The method and indication of induction of labor, the total duration of stages of labor, mode of birth, and neonatal outcomes were all recorded. Women who had operative delivery for fetal distress or indications other than failure to progress in labor were excluded from the final analysis, leaving a total of 344 participants who were randomly divided into 243 and 101 pregnancies that constituted the model development and cross-validation groups, respectively.

RESULTS

It was possible to perform transabdominal and transperineal scans and assess all the required parameters on all study participants. Univariate and multivariate analyses were used for selection of potential predictors and model fitting. The independent predictive variables for cesarean delivery included maternal age (odds ratio, 1.12; P=.003), cervical length (odds ratio, 1.08; P=.04), angle of progression at rest (odds ratio, 0.9; P=.001), and occiput posterior position (odds ratio, 5.7; P=.006). We tested the performance of the prediction model on our cross-validation group. The calculated areas under the curve for the ability of the model to predict cesarean delivery were 0.7969 (95% confidence interval, 0.71-0.87) and 0.88 (95% confidence interval, 0.79-0.97) for the developed and validated models, respectively.

CONCLUSION

Maternal age and sonographic fetal occiput position, angle of progression at rest, and cervical length before labor induction are very good predictors of induction outcome in nulliparous women at term.

Reduced fetal growth velocity precedes antepartum fetal death

OBJECTIVES

To determine whether decreased fetal growth velocity precedes antepartum fetal death and to evaluate whether fetal growth velocity is a better predictor of antepartum fetal death compared to a single fetal biometric measurement at the last available ultrasound scan prior to diagnosis of demise.

METHODS

This was a retrospective, longitudinal study of 4285 singleton pregnancies in African-American women who underwent at least two fetal ultrasound examinations between 14 and 32 weeks of gestation and delivered a liveborn neonate (controls; n = 4262) or experienced antepartum fetal death (cases; n = 23). Fetal death was defined as death diagnosed at ≥ 20 weeks of gestation and confirmed by ultrasound examination. Exclusion criteria included congenital anomaly, birth at < 20 weeks of gestation, multiple gestation and intrapartum fetal death. The ultrasound examination performed at the time of fetal demise was not included in the analysis. Percentiles for estimated fetal weight (EFW) and individual biometric parameters were determined according to the Hadlock and Perinatology Research Branch/Eunice Kennedy Shriver National Institute of Child Health and Human Development (PRB/NICHD) fetal growth standards. Fetal growth velocity was defined as the slope of the regression line of the measurement percentiles as a function of gestational age based on two or more measurements in each pregnancy.

RESULTS

Cases had significantly lower growth velocities of EFW (P < 0.001) and of fetal head circumference, biparietal diameter, abdominal circumference and femur length (all P < 0.05) compared to controls, according to the PRB/NICHD and Hadlock growth standards. Fetuses with EFW growth velocity < 10^th percentile of the controls had a 9.4-fold and an 11.2-fold increased risk of antepartum death, based on the Hadlock and customized PRB/NICHD standards, respectively. At a 10% false-positive rate, the sensitivity of EFW growth velocity for predicting antepartum fetal death was 56.5%, compared to 26.1% for a single EFW percentile evaluation at the last available ultrasound examination, according to the customized PRB/NICHD standard.

CONCLUSIONS

Given that 74% of antepartum fetal death cases were not diagnosed as small-for-gestational age (EFW < 10^th percentile) at the last ultrasound examination when the fetuses were alive, alternative approaches are needed to improve detection of fetuses at risk of fetal death. Longitudinal sonographic evaluation to determine growth velocity doubles the sensitivity for prediction of antepartum fetal death compared to a single EFW measurement at the last available ultrasound examination, yet the performance is still suboptimal. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Confined placental mosaicism and the association with pregnancy outcome and fetal growth: a review of the literature

BACKGROUND

Chromosomal mosaicism can be detected in different stages of early life: in cleavage stage embryos, in blastocysts and biopsied cells from blastocysts during preimplantation genetic testing for aneuploidies (PGT-A) and later during prenatal testing, as well as after birth in cord blood. Mosaicism at all different stages can be associated with adverse pregnancy outcomes. There is an onward discussion about whether blastocysts diagnosed as chromosomally mosaic by PGT-A should be considered safe for transfer. An accurate diagnosis of mosaicism remains technically challenging and the fate of abnormal cells within an embryo remains largely unknown. However, if aneuploid cells persist in the extraembryonic tissues, they can give rise to confined placental mosaicism (CPM). Non-invasive prenatal testing (NIPT) uses cell-free (cf) DNA released from the placenta in maternal blood, facilitating the detection of CPM. In literature, conflicting evidence is found about whether CPM is associated with fetal growth restriction (FGR) and/or other pregnancy outcomes. This makes counselling for patients by clinicians challenging and more knowledge is needed for clinical decision and policy making.

OBJECTIVE AND RATIONALE

The objective of this review is to evaluate the association between CPM and prenatal growth and adverse pregnancy outcomes. All relevant literature has been reviewed in order to achieve an overview on merged results exploring the relation between CPM and FGR and other adverse pregnancy outcomes.

SEARCH METHODS

The following Medical Subject Headings (MESH) terms and all their synonyms were used: placental, trophoblast, cytotrophoblast, mosaicism, trisomy, fetal growth, birth weight, small for gestational age and fetal development. A search in Embase, PubMed, Medline Ovid, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases was conducted. Relevant articles published until 16 July 2020 were critically analyzed and discussed.

OUTCOMES

There were 823 articles found and screened based on their title/abstract. From these, 213 articles were selected and full text versions were obtained for a second selection, after which 70 publications were included and 328 cases (fetuses) were analyzed. For CPM in eight different chromosomes (of the total 14 analyzed), there was sufficient evidence that birth weight was often below the 5th percentile of fetal growth standards. FGR was reported in 71.7% of CPM cases and preterm birth (<37 weeks of delivery) was reported in 31.0% of cases. A high rate of structural fetal anomalies, 24.2%, in cases with CPM was also identified. High levels of mosaicism in CVS and presence of uniparental disomy (UPD) were significantly associated with adverse pregnancy outcomes.

WIDER IMPLICATIONS

Based on the literature, the advice to clinicians is to monitor fetal growth intensively from first trimester onwards in case of CPM, especially when chromosome 2, 3, 7, 13, 15, 16 and 22 are involved. In addition to this, it is advised to examine the fetuses thoroughly for structural fetal anomalies and raise awareness of a higher chance of (possibly extreme) premature birth. Despite prematurity in nearly a fifth of cases, the long-term follow-up of CPM life borns seems to be positive. More understanding of the biological mechanisms behind CPM will help in prioritizing embryos for transfer after the detection of mosaicism in embryos through PGT-A.

Prenatal chromosomal microarray analysis in 2466 fetuses with ultrasonographic soft markers: a prospective cohort study

BACKGROUND

Soft markers are nonspecific findings detected by ultrasonography during the second trimester that are often transient and nonpathologic but may imply an increased risk of underlying fetal aneuploidy. However, large-scale prospectively stratified studies focusing on the prevalence of chromosomal aberrations, including copy number variants, in fetuses with different types of isolated soft markers have rarely been published in the literature.

OBJECTIVE

This study aimed to investigate clinical outcomes in fetuses with isolated soft markers by single nucleotide polymorphism array with long-term follow-up and to propose a diagnostic algorithm based on specific types of soft markers.

STUDY DESIGN

The prevalence of fetal isolated soft markers was 13.2% (7869 of 59,503). A total of 2466 fetuses with ultrasonographic soft markers during the second trimester, which were subjected to single nucleotide polymorphism array with long-term follow-up, were selected in this prospective study over a 5-year period. Soft markers were categorized into 12 groups. The demographic profile and chromosomal microarray analysis detection results were analyzed and compared among different groups.

RESULTS

The overall prevalence of chromosomal aberrations in fetuses with soft markers was 4.3% (107 of 2466), which comprised 40.2% with numeric chromosomal abnormalities, 48.6% with pathogenic copy number variants, and 11.2% with likely pathogenic copy number variants. The incidence of numeric chromosomal abnormalities was significantly higher in multiple soft markers (5.5% vs 1.5%; P=.001) and the thickened nuchal fold group (8.3% vs 1.7%; P=.024). Meanwhile, the incidence of pathogenic copy number variants was significantly higher in multiple soft markers (5.5% vs 2.4%; P=.046) and the short femur length group (6.6% vs 2.2%; P<.0001). The incidences of pathogenic copy number variants in fetuses with isolated echogenic intracardiac focus, enlarged cisterna magna, choroid plexus cysts, echogenic bowel, or single umbilical artery were lower than 1.5%. The normal infant rate in fetuses without chromosomal aberrations was 91.7%; however, it was significantly lower in the mild ventriculomegaly (86.2% vs 93.0%; P<.0001) and short femur length groups (71.4% vs 93.6%; P<.0001).

CONCLUSION

The potential chromosomal aberrations and clinical prognoses varied widely among different types of isolated soft markers. Pathogenic copy number variants are more often present in specific soft markers, especially when multiple soft markers are found. Thus, a specific soft marker type-based prenatal genetic testing algorithm was proposed.

Antenatal counselling of congenital surgical anomalies: A decade of experience in a local tertiary centre

AIM

This study reviewed the experience of a tertiary paediatric surgery and obstetric centre on prenatal counselling of congenital surgical anomalies and to explore the role of paediatric surgeons on perinatal outcomes of antenatally detected anomalies.

METHODS

A retrospective analysis of all antenatal consultations and subsequent medical records after birth were performed between 2009 and 2018. Data including timing of consultations, gestations at birth, birthweight, impact on obstetrics management, neonatal mortality and need of surgery were included.

RESULTS

A total of 256 fetuses were diagnosed to have congenital surgical anomalies on antenatal ultrasound. The most common were urogenital (31%) and thoracic (30%) anomalies. Twelve of the 256 (4.7%) had multiple anomalies. The mean gestation at referral was 23 ± 5 weeks. The majority (85.4%) were born at term. Mode and timing of delivery was altered in 7% of patients. Four received fetal intervention after surgical consultation. Termination of pregnancy rate was 5.4% (n = 14). Neonatal death was reported in 7.8% of the cohort.

CONCLUSION

Congenital surgical anomalies had a significant impact on perinatal outcome as well as morbidity in later infancy and childhood. A multidisciplinary approach in managing pregnancy with these anomalies should be implemented. Combined-specialty consultations and counselling deliver valuable information for parents.

Ultrasound in the prediction of birthweight discordance in dichorionic twins

INTRODUCTION

Large birthweight discrepancy has been identified as a risk factor for perinatal morbidity and mortality in twin pregnancies. However, it remains unclear whether such discordance can be predicted by various biological indices with specific cut-off values, and how these depend on the gestational age. We aimed to determine the most effective way to predict large birthweight discordance at various gestational ages.

MATERIAL AND METHODS

A retrospective cohort study of dichorionic twins, live-born between 2008 and 2018, was conducted. Discordances in biparietal diameter, head circumference, humerus and femur length, abdominal circumference, and estimated fetal weight were calculated-([larger twin - smaller twin] / larger twin) × 100%-and compared between those with and without a large birthweight discordance (≥20%). Receiver operating characteristic curves were constructed to analyze the predictive characteristics of each parameter.

RESULTS

Of 598 dichorionic twin pregnancies included, 83 (13.9%) had a birthweight discordance ≥20%. Group differences in biparietal diameter and head circumference discordance were the earliest to emerge (before 20 weeks of gestation), but became insignificant after 36 weeks, followed by humerus and femur length, estimated fetal weight discordance (after 20 weeks), and abdominal circumference discordance (after 28 weeks). The best predictors (with cut-off values) were discordance in biparietal diameter ≥7.8% at <20 weeks, head circumference ≥4.5% at 20-23⁺⁶  weeks, humerus length ≥4.5% at 24-27⁺⁶  weeks, and estimated fetal weight discordance (≥11.6% at 28-31⁺⁶  weeks, ≥10.5% at 32-35⁺⁶  weeks, and ≥15.0% ≥36 weeks), with sensitivity and specificity of 52%-77% and 69%-82%, respectively.

CONCLUSIONS

Different predictors and cut-off values may be useful for predicting large inter-twin birthweight discordance in dichorionic twins at different gestational ages. It is more accurate to use biparietal diameter and head circumference discordance in the early second trimester, humerus length discordance in the late second trimester, and estimated fetal weight discordance in the third trimester.

Vasa praevia with meandering fetal vessels despite placental and umbilical cord insertion on the same side of the uterine wall: A case report

Vasa praevia with meandering fetal vessels is extremely rare, and it is difficult to diagnose this prenatally. When cesarean section is performed, a change in the site of uterine incision may be required for a safe delivery.

Resting Energy Expenditure, Fetal Biometric Parameters by Ultrasound, and Birthweight in Chinese Pregnant Women With Gestational Diabetes Mellitus

OBJECTIVES

To explore the relationships between resting energy expenditure (REE) according to indirect calorimetry, fetal biometric parameters by ultrasound, and birthweight in gestational diabetes mellitus (GDM).

METHODS

Sixty-five women with GDM and 60 in the control group were enrolled. The REE, birthweight, and fetal biometric parameters according to ultrasound, including biparietal diameter, head circumference, abdominal circumference (AC), and femur length, were measured.

RESULTS

The AC at 29 to 32 weeks and 37 to 40 weeks was larger in the GDM than in the control group (P < 0.01), birthweight was higher in the GDM than in the control group (P < 0.01), and women in the GDM group had higher REE than those in the control group at all stages of pregnancy (P < 0.01). In the control group, all fetal biometric parameters were correlated with birthweight at 37 to 40 weeks (r = 0.418, 0.678, 0.741, and 0.635 for biparietal diameter, head circumference, AC, and femur length, respectively, P < 0.05); however, in the GDM group, only AC was correlated with birthweight at 37 to 40 weeks (r = 0.707; P < 0.05). In the GDM group, REE was correlated with birthweight at all three stages of pregnancy (r = 0.369, 0.381, and 0.446 for 21 to 24, 29 to 32, and 37 to 40 weeks, respectively, P < 0.05), and REE was correlated with AC at 37 to 40 weeks (r = 0.431; P < 0.05).

CONCLUSIONS

REE is correlated with birthweight in women with GDM from the middle to the end of pregnancy. REE by indirect calorimetry might be potential index for medical nutrition therapy in GDM.

Frontal lobe growth is impaired in fetuses with congenital heart disease

OBJECTIVES

The primary objective of this study was to assess whether fetuses with congenital heart disease (CHD) have smaller frontal brain areas compared with normal controls. The secondary objective was to evaluate whether there are any differences in frontal brain area between cases with different types of CHD, grouped according to their impact on hemodynamics.

METHODS

This was a retrospective cross-sectional study, including 421 normal fetuses and 101 fetuses with isolated CHD evaluated between 20 and 39 gestational weeks at our fetal medicine and surgery unit in the period January 2016-December 2019. The study group was subdivided, according to the CHD hemodynamics, as follows: (1) hypoplastic left heart syndrome and other forms of functionally univentricular heart defect; (2) transposition of the great arteries; (3) conotruncal defects and other CHDs with large shunts; (4) right ventricular outflow tract obstruction, without a hypoplastic right ventricle; (5) left outflow tract obstruction; (6) others. The transventricular axial view of the fetal head was used as the reference view, on which the frontal lobe anteroposterior diameter (FAPD) and the occipitofrontal diameter (OFD) were measured, assuming the former to be representative of the area of the frontal lobes. The FAPD/OFD ratio was then calculated as FAPD/OFD × 100. These two variables (FAPD and FAPD/OFD ratio) were then evaluated and compared between the study and control groups. Adjustment for gestational age, both via multiple linear regression and by using a-posteriori matching based on the propensity score, was employed.

RESULTS

In normal fetuses, FAPD showed a linear positive correlation with gestational age. In fetuses with CHD, the FAPD was shorter than in normal fetuses from the 20^th  gestational week onwards, with the difference increasing after 30 gestational weeks. FAPD/OFD ratio was significantly smaller in fetuses with CHD than in normal fetuses (P < 0.0001) at all gestational ages, with no apparent differences among the various CHD categories, all of which had smaller FAPD/OFD ratio compared with controls.

CONCLUSIONS

Fetuses with CHD have a shorter FAPD and a smaller FAPD/OFD ratio compared with normal fetuses. This impaired growth of the frontal area of the brain seems to occur in all types of CHD, regardless of their impact on hemodynamics. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound screening for fetal anomalies in a single center: diagnostic performances twenty years after the Eurofetus Study

PURPOSE

To establish the accuracy of ultrasound in detecting fetal anomalies looking at the concordance between prenatal and postnatal diagnosis.

MATERIALS AND METHODS

Retrospective analysis of concordance between prenatal and postnatal/autoptic diagnosis of fetuses with congenital abnormalities. Data are from a single center (Policlinico di Modena); all fetuses included were born between 2017 and 2018 and with a follow-up of at least 6 months. We included all deliveries (including perinatal deaths) and termination of pregnancy (TOP) for fetal indication. We calculated sensibility, sensitivity, Positive and Negative Likelihood Ratio, positive and negative predictive value of ultrasound.

RESULTS

During the study period 5920 deliveries, including perinatal deaths, and 28 TOP for fetal indication were registered at our center. The prevalence of congenital malformations was 2.6% (153/5920). At least one ultrasound was performed in our center in 1250 women delivering in our unit. All 28 TOP had the anomaly scan performed in our center. Among the total 1278 women scanned in our unit, there were 128 (10%) suspicious scans. In 5/128 (3.9%) cases we diagnosed a false alarm; in 8/128 (6.2%) cases an evolutive malformation with in-utero regression. The prenatal diagnosis was confirmed in 77 (60.2%) cases at birth and in 28/128 (21.9%) at postmortem analysis while there were 10/128 false positive (7.8%). Among the 153 congenital malformations diagnosed at birth, the anomaly scan was performed in our Prenatal Medicine Unit in 92 (60.1%) fetuses. Among these, there were 15 false negatives (9.8%) while in 77/92 (83.7%) the malformation at birth agreed with the sonographic diagnosis. Sensitivity and specificity of ultrasound were 87.5% (IC95 80.2-92.8%) and 99.1% (IC95 98.4-99.6%) respectively with a Positive Likelihood Ratio and Negative Likelihood Ratio of 101.3 (IC95 54.5-188.5) and 0.13 (IC95 0.08-0.2); Positive Predictive Value and Negative Predictive Value were 91.3% (IC95 85-95.1%) and 98.7(IC95 98-99.2%).

CONCLUSION

Anomaly scan in pregnancy allows the diagnosis of congenital malformations with a sensibility of 87.5% and specificity of 99.1%. The main limitations of this study are its retrospective design and that it was conducted in a single referral center.

Predicting fetal weight by three-dimensional limb volume ultrasound (AVol/TVol) and abdominal circumference

BACKGROUND

Fetal weight is an important parameter to ensure maternal and child safety. The purpose of this study was to use three-dimensional (3D) limb volume ultrasound combined with fetal abdominal circumference (AC) measurement to establish a model to predict fetal weight and evaluate its efficiency.

METHODS

A total of 211 participants with single pregnancy (28-42 weeks) were selected between September 2017 and December 2018 in the Beijing Obstetrics and Gynecology Hospital of Capital Medical University. The upper arm (AVol)/thigh volume (TVol) of fetuses was measured by the 3D limb volume technique. Fetal AC was measured by two-dimensional ultrasound. Nine cases were excluded due to incomplete information or the interval between examination and delivery >7 days. The enrolled 202 participants were divided into a model group (134 cases, 70%) and a verification group (68 cases, 30%) by mechanical sampling method. The linear relationship between limb volume and fetal weight was evaluated using Pearson Chi-squared test. The prediction model formula was established by multivariate regression with data from the model group. Accuracy of the model formula was evaluated with verification group data and compared with traditional formulas (Hadlock, Lee2009, and INTERGROWTH-21st) by paired t-test and residual analysis. Receiver operating characteristic curves were generated to predict macrosomia.

RESULTS

AC, AVol, and TVol were linearly related to fetal weight. Pearson correlation coefficient was 0.866, 0.862, and 0.910, respectively. The prediction model based on AVol/TVol and AC was established as follows: Y = -481.965 + 12.194TVol + 15.358AVol + 67.998AC, R2adj = 0.868. The scatter plot showed that when birth weight fluctuated by 5% (i.e., 95% to 105%), the difference between the predicted fetal weight by the model and the actual weight was small. A paired t-test showed that there was no significant difference between the predicted fetal weight and the actual birth weight (t = -1.015, P = 0.314). Moreover, the residual analysis showed that the model formula's prediction efficiency was better than the traditional formulas with a mean residual of 35,360.170. The combined model of AVol/TVol and AC was superior to the Lee2009 and INTERGROWTH-21st formulas in the diagnosis of macrosomia. Its predictive sensitivity and specificity were 87.5% and 91.7%, respectively.

CONCLUSION

Fetal weight prediction model established by semi-automatic 3D limb volume combined with AC is of high accuracy, sensitivity, and specificity. The prediction model formula shows higher predictive efficiency, especially for the diagnosis of macrosomia.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03002246; https://clinicaltrials.gov/ct2/show/NCT03002246?recrs=e&cond=fetal&draw=8&rank=67.

Analysis of an obstetrics point-of-care ultrasound training program for healthcare practitioners in Zanzibar, Tanzania

Background

A point-of-care ultrasound education program in obstetrics was developed to train antenatal healthcare practitioners in rural Zanzibar. The study group consisted of 13 practitioners with different training backgrounds: physicians, clinical officers, and nurse/midwives. Trainees received an intensive 2-week antenatal ultrasound course consisting of lectures and hands-on practice followed by 6 months of direct supervision of hands-on scanning and bedside education in their clinical practice environments. Trainees were given a pre-course written exam, a final exam at course completion, and practical exams at 19 and 27 weeks. Trainees were expected to complete written documentation and record ultrasound images of at least 75 proctored ultrasounds. The objective of this study was prospectively to analyze the success of a longitudinal point-of-care ultrasound training program for antepartum obstetrical care providers in Zanzibar.

Results

During the 6-month course, trainees completed 1338 ultrasound exams (average 99 exams per trainee with a range of 42–128 and median of 109). Written exam scores improved from a mean of 33.7% (95% CI 28.6–38.8%) at pre-course assessment to 77.5% (95% CI 71–84%) at course completion (P < 0.0001). Practical exam mean scores improved from 71.2% at course midpoint (95% CI 62.3–80.1%) to 84.7% at course completion (95% Cl 78.5–90.8%) (P < 0.0005). Eight of the 13 trainees completed all training requirements including 75 proctored ultrasound exams.

Conclusion

Trainees improved significantly on all measures after the training program. 62% of the participants completed all requirements. This relatively low completion rate reflects the challenges of establishing ultrasound capacity in this type of setting. Further study is needed to determine trainees’ long-term retention of ultrasound skills and the impact of the program on clinical practice and health outcomes.

Associations between molybdenum exposure and ultrasound measures of fetal growth parameters: A pilot study

Previous studies have suggested the association of molybdenum (Mo) exposure with some adverse outcomes. However, limited epidemiological studies have been performed to explore the association between maternal Mo exposure level and fetal growth. This study recruited 220 pregnant women during their second trimester. The mother's urinary Mo concentration was measured by inductively coupled plasma mass spectrometry (ICP-MS). The fetal biometric parameters, including head circumference (HC), biparietal diameter (BPD), femur diaphysis length (FL), and abdominal circumference (AC) were assessed by prenatal ultrasound. Estimated fetal weight (EFW) was evaluated using the formula of Hadlock. Multivariable linear regression models were applied to estimate the relationships between Mo level and fetal biometric parameters, and potential confounders were adjusted. A one-unit increment in natural-logarithm transformed urinary Mo level was significantly associated with reductions in fetal AC of -0.34 cm (95%CI: -0.63, -0.04), and was negatively related to EFW (β = -18.2, 95%CI: -40.5, 4.2). Furthermore, when participants were stratified by copper (Cu) level, the results showed that the magnitude of negative association between Mo and AC (β = -0.55, 95%CI: -1.13, 0.04) was greater in pregnant women with Cu level below median value, comparing with those with Cu level above median value (β = -0.08, 95%CI: -0.57, 0.42), and a similar pattern was found for EFW, although the interaction between Mo and Cu was not significant. Our data suggested an inverse association of maternal urinary Mo level with fetal AC and EFW during the second trimester of pregnancy. These associations might be stronger in pregnant women with relatively lower Cu levels.

Visualization of the fetal anus by prenatal ultrasound for the diagnosis of anorectal malformations: is it feasible?

PURPOSE

The goal of this study was to determine the feasibility of identifying the anal dimple (AD) on routine prenatal ultrasound. Using the presence, absence, appearance, and location of the anal dimple as an indirect sign for possible underlying anorectal malformations (ARM), we hypothesize that evaluation of the anal dimple as part of the fetal anatomic survey may increase the sensitivity in detecting less severe ARMs.

METHODS

In a prospective longitudinal observational study, pregnant women who underwent prenatal ultrasound (US) at the Colorado Fetal Care Center between January 2019 and 2020 were enrolled. The variables recorded included gestational age, singleton versus multiple pregnancy, gender of the fetus, visualization of the AD, and reason for non-visualization of the AD.

RESULTS

A total of 900 ultrasounds were performed, evaluating 1044 fetuses, in 372 different pregnant women. Gestational ages ranged from 16 to 38 weeks. The AD was visualized in 612 fetuses (58.6%) and not seen in 432 (41.4%). The two most common reasons for non-visualization were extremes in gestational age (n = 155; 36%) and fetal position (n = 152; 35.3%). The optimal gestational age range for AD visualization was 28-33 weeks + 6 days, with 78.1% visualization rate.

CONCLUSION

Visualization of the anal dimple by ultrasound is feasible and may aid in the detection of less severe ARMs, ultimately impacting pregnancy management and family counseling. The optimal timing for anal dimple visualization is late second and third trimester.

Routine first-trimester ultrasound screening using a standardized anatomical protocol

BACKGROUND

First-trimester ultrasound scans were introduced to China for nearly 20 years. The ability of first-trimester ultrasound screening to detect different malformations was variable. A recent systematic review concluded that the use of a standardized anatomic protocol was the most crucial factor to improve the sensitivity of first-trimester ultrasound screening for anomalies. Standardized sectional scans have long been used for routine anatomy screening during the second trimester. However, during the first trimester, most of the previous studies have described the observation of anatomic structures but have not specified clearly the standard sectional views.

OBJECTIVE

We aimed to determine the performance of routine first-trimester scans using a standardized anatomic protocol for detecting structural abnormalities in China.

STUDY DESIGN

This was a large retrospective study involving 59,063 sequential unselected pregnancies. Scans at 11 to 13⁺⁶ weeks were performed in a single center during a 7-year span. All fetuses were examined following a predefined protocol for standardized views.

RESULTS

From October 2008 to December 2015, first-trimester scans were performed in 53,349 pregnant women with available outcome. Of these, there were 1578 (3%) pregnancies that presented with at least 1 fetal structural abnormality. The detection rate for first-trimester screening was 43.1% (95% confidence interval, 40.6%-45.5%). Routine first-trimester scans detected 95.6% of abdominal wall defects, 66.3% of nervous system defects, 33.8% of limbs and skeleton malformations, 30.8% of facial abnormalities, 21.2% of urogenital abnormalities, 18.4% of thoracic and lung abnormalities, and 4.1% of gastrointestinal tract abnormalities. During the first trimester, 37.7% of cardiac defects were identified and included 57.9% of major cardiac defects and 2.6% of mild cardiac defects. A robust high detection rate for anencephaly, exencephaly, cephalocele, holoprosencephaly, exomphalos, gastroschisis, Pentalogy of Cantrell, sirenomelia, and body stalk anomaly was achieved during routine first-trimester scans.

CONCLUSION

A standardized anatomic protocol is advised when performing routine first-trimester ultrasound screening. It is recommended that screening for severe structural abnormalities should be extended to the first trimester.

Comparison of the Accuracy of INTERGROWTH-21 and Hadlock Ultrasound Formulae for Fetal Weight Prediction

OBJECTIVE

To compare the accuracy of INTERGROWTH-21 (IG-21) versus Hadlock1 formulae for birth weight prediction on third-trimester ultrasound in a North American population.

METHODS

This single-centre retrospective cohort study included all pregnant patients who had a third-trimester ultrasound between 34⁰ and 36⁶ weeks gestation and delivered a term singleton at our maternal-fetal medicine reference centre between April 1 and July 30, 2019. Estimated ultrasound fetal weight was calculated with both Hadlock1 and IG-21 formulae for each fetus, then reported on a centile curve to adjust for gestational age at delivery, and compared with the actual birth weight.

RESULTS

The cohort included 600 women. The IG-21 formula had a comparable accuracy to Hadlock1 with mean absolute percentage errors (MAPEs) of 8.64 and 8.86, respectively (P = 0.191). Success rate, defined by a <10% discrepancy range of the actual birth weight, was significantly higher for IG-21 than for Hadlock1 (67.5% vs. 64.3%; P = 0.044).

CONCLUSION

Our results do not support the superiority of IG-21 to Hadlock1. There is a need for continued research to improve birth weight prediction with the ultimate objective of increasing the detection of small for gestation age and macrosomic fetuses.

Fetal biometry in ultrasound: A new approach to assess the long-term impact of simulation on learning patterns

CONTEXT

Simulation-based education (SBE) has demonstrated its acceptability and effectiveness in improving ultrasound training. Because of the high cost of its implementation (investment in equipment and supervision), a pragmatic assessment of the transfer of skills learned in SBE to clinical practice and the identification of its optimal scheduling conditions have been requested to optimize its input.

OBJECTIVES

To quantify the long-term impact of simulation-based education (SBE) on the adequate performance of ultrasound fetal biometry measurements (I). The secondary objective was to identify the temporal patterns that enhanced SBE input in learning (II).

METHODS

Trainees were arbitrarily assigned to a 6-month course in obstetric ultrasound with or without an SBE workshop. In the SBE group, the workshop was implemented 'before' or at an 'early' or a 'late-stage' of the course. Those who did not receive SBE were the control group. The ultrasound skills of all trainees were prospectively collected, evaluated by calculating the delta between OSAUS (Objective Structured Assessment of Ultrasound Skills) scores before and after the course (I). Concomitantly, the accuracy of trainees' measurements was assessed throughout the course by verifying their correlation with the corresponding measurements by their supervisors. The percentage of trainees able to perform five consecutive sets of correct measurements in the control group and in each SBE subgroup were compared (II).

RESULTS

The study included 61 trainees (39 SBE and 22 controls). Comparisons between groups showed no significant difference in the quantitative assessment of skill enhancement (difference in the pre- and post-internship OSAUS score: 1.09 ± 0.87 in the SBE group and 0.72 ± 0.98 in the control group) (I). Conversely, the predefined acceptable skill level was reached by a significantly higher proportion of trainees in the 'early' SBE subgroup (74%, compared with 30% in the control group, P<0.01)(II).

CONCLUSIONS

The quantitative assessment does not support the existence of long-term benefits from SBE training, although the qualitative assessment confirmed SBE helped to raise the minimal level within a group when embedded in an 'early' stage of a practical course.

Maternal asthma and early fetal growth, the MAESTRO study

BACKGROUND

Several maternal conditions can affect fetal growth, and asthma during pregnancy is known to be associated with lower birth weight and shorter gestational age.

OBJECTIVE

In a new Swedish cohort study on maternal asthma exposure and stress during pregnancy (MAESTRO), we have assessed if there is evidence of early fetal growth restriction in asthmatic women or if a growth restriction might come later during pregnancy.

METHODS

We recruited women from eight antenatal clinics in Stockholm, Sweden. Questionnaires on background factors, asthma status and stress were assessed during pregnancy. The participants were asked to consent to collection of medical records including ultrasound measures during pregnancy, and linkage to national health registers. In women with and without asthma, we studied reduced or increased growth by comparing the second-trimester ultrasound with first-trimester estimation. We defined reduced growth as estimated days below the 10th percentile and increased growth as days above the 90th percentile. At birth, the weight and length of the newborn and the gestational age was compared between women with and without asthma.

RESULTS

We enrolled 1693 participants in early pregnancy and collected data on deliveries and ultrasound scans in 1580 pregnancies, of which 18% of the mothers had asthma. No statistically significant reduced or increased growth between different measurement points were found when women with and without asthma were compared; adjusted odds ratios for reduced growth between first and second trimester 1.11 95% CI (0.63-1.95) and increased growth 1.09 95% CI (0.68-1.77).

CONCLUSION AND CLINICAL RELEVANCE

In conclusion, we could not find evidence supporting an influence of maternal asthma on early fetal growth in the present cohort: Although the relatively small sample size, which may enhance the risk of a type II error, it is concluded that a potential difference is likely to be very small.

We Need to Improve Prenatal Screening Practices in Primary Obstetric Care: A Representative Data from a Fetal Medicine Unit in Coastal Karnataka

Background

The present observational data from the fetal medicine unit aim to identify gaps in prenatal screening modalities employed in the primary obstetric care population in coastal Karnataka.

Methods

A retrospective observational study of all referrals to Fetal Medicine unit is over 2 years. For each fetal abnormality, we reviewed the literature to note the range of gestational age at which the abnormality should almost always be diagnosed. Taking this as standard, the gestational age at which each of these problems was diagnosed and referred was noted down. They were compared and analysed to understand the efficiency of prenatal screening practices in the referral population. The final perinatal outcome was also noted down in order to assess the impact on perinatal mortality/morbidity.

Results

A total of 277 cases were referred to fetal medicine unit. Two hundred twenty-eight cases (82.31%) were low risk pregnancies. Among 277 cases, 200 (72.2%) had structural abnormalities, 7 (2.5%) chromosomal/ genetic abnormalities, 61 (22.02%) isolated soft markers, and 9 (3.2%) twin-related problems. Detection rate of structural abnormalities was 33% at 14 weeks and 52.22% at 20 weeks, considering those anomalies usually diagnosed by these gestational age windows. The primary reason for delayed diagnosis was non-performance of ultrasound “on time”, rather than missed diagnosis. Fifty-three per cent (106 out of 200) of all the fetal structural abnormalities were diagnosed beyond 20 weeks. Average gestational age at mid-trimester anomaly scan in this group was between 20 and 24 weeks. Sixty-one patients were referred due to isolated soft markers, 30 beyond 20 weeks. Eighty per cent of them did not have any aneuploidy screening in pregnancy.

Conclusion

Practice of fetal medicine hugely depends upon appropriate prenatal screening practices in the referral population. There is an urgent need to bring in standard protocols for Prenatal Screening across all the primary obstetric care providers, both in the public and private sectors. Considering the huge burden of delayed prenatal diagnosis in our country, the proposed revision of MTP bill is a welcome change in fast-growing field of fetal diagnosis and therapy.