Factors affecting feasibility and quality of second-trimester ultrasound scans in obese pregnant women

The Impact of Overweight and Obesity on Pregnancy: A Narrative Review of Physiological Consequences, Risks and Challenges in Prenatal Care, and Early Intervention Strategies

BACKGROUND

While substantial literature exists on the intersection of overweight/obesity (OWO) and pregnancy, much of it focuses on specific aspects, making it difficult to maintain an overview of clinically relevant factors for optimal care of OWO women throughout pregnancy.

OBJECTIVES

To provide a comprehensive synthesis of the existing literature, covering the full spectrum of clinically relevant information needed to manage OWO women from preconception to birth.

METHODS

For this narrative review a literature search was conducted on PubMed in January 2025. Eligible studies included full-text English articles with data from human subjects, with no restrictions on publication date.

FINDINGS

The impact of OWO on pregnancy is multifaceted, encompassing four interrelated themes: physiological consequences, emerging risks, challenges in prenatal care, and intervention strategies. OWO women exhibit differences in metabolic and inflammatory pathways compared to normal-weight women, reflected in altered laboratory tests. When managing gestational diabetes and preeclampsia, obesity-related characteristics must be considered. Clinicians need to be alert of obesity-mediated fetal complications, including overgrowth, malformations, stillbirth, and preterm birth, while navigating challenges in ultrasound measurements. Interventions during the preconception and prenatal periods provide key opportunities to optimize maternal weight and reduce the risk of long-term disease development.

CONCLUSION

The review's insights enhance clinical practice and call on researchers and policymakers to prioritize strategies that offer early counseling for obese pregnant women. These initiatives aim to optimize outcomes for both mother and child and contribute to combating the global obesity crisis.

Comparative analysis of quality scores images between second- and third-trimester ultrasound scan

OBJECTIVES

To evaluate whether the quality scores validated for second-trimester ultrasound scan can be used for third-trimester ultrasound scan.

METHODS

Prospective multicenter ancillary study using data from the RECRET study. Nulliparous women, with no reported history, with second- and third-trimester ultrasound examinations performed by the same ultrasonographer and using the same ultrasound machine were recruited. The global score and the individual score of each ultrasound image were compared between second- and third-trimester ultrasound scan. The sample size was calculated for a non-inferiority (one-sided) paired Student t test.

RESULTS

103 women with 1606 anonymized ultrasound images were included. The median term at second- and third-trimester ultrasound scan was 22.2 weeks gestation (22.0-22.7) and 31.6 weeks gestation (30.7-34.7), respectively. The mean global score of ultrasound images was comparable between the second- and the third-trimester ultrasound examination (32.37 ± 2.62 versus 31.80 ± 3.27, p = 0.13). Means scores for each biometric parameters i.e. head circumference, abdominal circumference, and femur diaphysis length were comparable. The scores for the four-chamber view (5.11 ± 0.91 versus 5.36 ± 0.75, p = 0.02) and the spine (4.18 ± 1.17 versus 5.22 ± 1.02, p < 0.001) were significantly lower in the third trimester compared to the second trimester. The score for the kidney image was significantly higher for third trimester images compared to second trimester images (4.73 ± 0.51 versus 4.32 ± 0.67, p < 0.001.

CONCLUSIONS

Biometrics parameters quality scores images previously validated for the second trimester ultrasound scan can be also used for the third trimester scan. However, anatomical quality scores images performances may vary between the second and the third trimester scan.

The application of high-performance ultrasound probes increases anatomic depiction in obese patients

This study evaluated the impact of obesity on abdominal ultrasound diagnostics and assessed effect of high-performance ultrasound probes increased imaging quality. Lean and obese subjects (n = 40; 58% female) were categorized according to body mass index (BMI, 21 to 48 kg/m2). A highly standardized ultrasound examination of the abdomen was performed by trained examiners using three different probes in randomized order (standard probe versus two high-performance probes). Quality of B-mode and duplex ultrasound were assessed using a custom scoring approach for depiction of liver and kidney anatomy and vascularization. Across probes, imaging quality of hepatic and kidney anatomy was inversely related with BMI (P < 0.03, r < - 0.35). Age, sex, and BMI explained 51% of the variance within the ultrasound quality score, with β = - 0.35, P < 0.0001 for BMI. Compared to the standard probe, high-performance probes allowed for a better depiction of kidney and liver anatomy in subjects above BMI 35 kg/m2 (n = 20, all P < 0.05), resulting in a less pronounced deterioration of imaging quality with increased BMI (all P < 0.05). In conclusion the study shows that obesity impairs ultrasound imaging quality of abdominal anatomy. The application of high-performance probes can increase anatomic depiction in obese patients.Registration number of the German Registry of Clinical Studies: DRKS00023498.

Using transvaginal ultrasounds for the identification of follicle-like structures ≥10 mm in a multi-center randomized contraceptive clinical trial of three 84-day oral ulipristal acetate regimens

PURPOSE

We examine the use of transvaginal sonography in imaging ovarian follicles among non-pregnant reproductive-aged women enrolled in a contraceptive clinical trial.

METHODS

Ten sites conducted a clinical trial comparing three oral ulipristal acetate regimens for ovulation inhibition. Enrollees underwent twice weekly transvaginal sonography and hormonal blood testing throughout treatment and until the second menses post-treatment. The primary outcome of the present analysis was success in identifying follicles ≥10 mm in a subgroup of sonograms performed at times of likely follicular activity (estradiol <100 pg/ml and progesterone >3 ng/ml). Secondarily, an overall analysis assessed all sonograms regardless of timing.

RESULTS

At times of likely follicular activity, 135 women underwent 969 sonograms. The proportion of sonograms without follicles ≥10 mm ranged from 8.3% to 46.3% when stratified by site (p = .01). The odds of no follicle among higher-body mass index (BMI) women were 1.91 times those among lower-BMI women after controlling for site and treatment arm (95% CI: 1.13, 3.22). Results were similar for the overall population.

CONCLUSION

Sonographers were less likely to identify follicles for higher-BMI women and results varied by site. Machine quality slightly impacted sonogram results, but did not sufficiently explain site differences.

Protocol for the e-POWUS Project: multicentre blinded-randomised controlled trial of ultrasound speed choice to improve sonography quality in pregnant women with obesity

INTRODUCTION

During pregnancy, maternal obesity increases the risk of fetal abnormalities. Despite advances in ultrasound imaging, the assessment of fetal anatomy is less thorough among these women. Currently, the construction of ultrasound images uses a conventional ultrasound propagation velocity (1540 m/s), which does not correspond to the slower speed of propagation in fat tissue.The main objective of this randomised study is to compare the completeness of fetal ultrasonography according to whether the operator could choose the ultrasound velocity (1420, 1480 or 1540 m/s) or was required to apply the 1540 m/s velocity.

METHODS AND ANALYSIS

This randomised trial is an impact study to compare a diagnostic innovation with the reference technique. The trial inclusion criteria require that a pregnant woman with obesity be undergoing a fetal morphology examination by ultrasound from 20⁺⁰ to 25⁺⁰ gestational weeks.Randomisation will allocate women into two groups. The first will be the 'modulable speed' group, in which operators can choose the speed of ultrasound propagation to be considered for the morphological analysis: 1420, 1480 or 1540 m/s. In the second 'conventional speed' group, operators will perform the morphological examination with the ultrasound speed fixed at 1540 m/s. The adjudication committee, two independent experts, will validate the completeness of each examination and the quality of the images.

ETHICS AND DISSEMINATION

This research protocol does not change the standard management. The only possible impact is an improvement of the ultrasound examination by improving the quality of the image and the completeness of morphological examination. The Agence du Médicament et produits de santé approved this study (2018-A03478-47). The anonymised data will be available on request from the principal investigator. Results will be reported in peer-reviewed journals and at scientific meetings.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (http://www.clinicaltrials.gov) Registry (NCT04212234).

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.

ACR Appropriateness Criteria® Second and Third Trimester Screening for Fetal Anomaly

The Appropriateness Criteria for the imaging screening of second and third trimester fetuses for anomalies are presented for fetuses that are low risk, high risk, have had soft markers detected on ultrasound, and have had major anomalies detected on ultrasound. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

An Automated ALARA Method for Ultrasound: An Obstetric Ultrasound Feasibility Study

OBJECTIVES

Ultrasound users are advised to observe the ALARA (as low as reasonably achievable) principle, but studies have shown that most do not monitor acoustic output metrics. We developed an adaptive ultrasound method that could suggest acoustic output levels based on real-time image quality feedback using lag-one coherence (LOC).

METHODS

Lag-one coherence as a function of the mechanical index (MI) was assessed in 35 healthy volunteers in their second trimester of pregnancy. While imaging the placenta or the fetal abdomen, the system swept through 16 MI values ranging from 0.15 to 1.20. The LOC-versus-MI data were fit with a sigmoid curve, and the ALARA MI was selected as the point at which the fit reached 98% of its maximum.

RESULTS

In this study, the ALARA MI values were between 0.35 and 1.03, depending on the acoustic window. Compared to a default MI of 0.8, the pilot acquisitions suggested a lower ALARA MI 80% of the time. The contrast, contrast-to-noise ratio, generalized contrast-to-noise ratio, and LOC all followed sigmoidal trends with an increasing MI. The R2 of the fit was statistically significantly greater for LOC than the other metrics (P < .017).

CONCLUSIONS

These results suggest that maximum image quality can be achieved with acoustic output levels lower than the US Food and Drug Administration limits in many cases, and an automated tool could be used in real time to find the ALARA MI for specific imaging conditions. Our results support the feasibility of an automated, LOC-based implementation of the ALARA principle for obstetric ultrasound.

Delay of Fetal Anatomy Ultrasound Assessment Based on Maternal Body Mass Index Does Not Reduce the Rate of Inadequate Visualization

OBJECTIVES

To determine whether delay of initial anatomy ultrasound based on the maternal body mass index (BMI) reduces the rate of inadequate visualization compared to standard timing at 18^0/7 to 19^6/7 weeks.

METHODS

A retrospective study of singleton anatomy assessments was conducted at a tertiary care center in the 2-year period before (A, 2012-2014) and after (B, 2014-2016) protocol initiation. Assessments in period B were scheduled on the basis of the BMI in the first trimester: lower than 25 kg/m² , 18^0/7 to 19^6/7 weeks; 25 to 29.9 kg/m² , 19^0/7 to 20^6/7 weeks; 30 to 34.9 kg/m² , 20^0/7 to 21^6/7 weeks; 35 to 39.9 kg/m² , 21^0/7 to 22^6/7 weeks; and 40 kg/m² or higher, 22^0/7 to 23^6/7 weeks. In period A, assessments were scheduled between 18^0/7 and 19^6/7 weeks. The rate of inadequate visualization and repeated assessments in periods A and B were compared. Multivariable logistic regression, per-protocol, and BMI subgroup analyses were completed.

RESULTS

In total, 3491 pregnancies in period A and 3672 in period B were included. In period B, 74% were scheduled per protocol; however, this rate decreased for higher-BMI categories (52% for BMI ≥40 kg/m² ). The inadequate visualization rate was slightly higher in period B versus A (16.9% versus 15.0%; P = .03) and exceeded 35% for a BMI of 40 kg/m² or higher, with or without delay. After adjusting for maternal age and fetal presentation, period B had small increased odds of inadequate visualization versus period A (adjusted odds ratio, 1.2; 95% confidence interval, 1.02-1.38). Repeated assessment rates were similar in periods B and A (14.0% versus 13.1%; P = .25).

CONCLUSIONS

In pregnancies with obesity, a protocol delaying the initial assessment beyond 19^6/7 weeks based on the maternal BMI does not reduce the rate of inadequate visualization.

Impact of ultrasound speed choice on the quality of the second-trimester fetal ultrasound examination in obese women

PURPOSE

The purpose of this study was to assess the impact of the free choice of ultrasound propagation velocity on ultrasound image construction to improve the completion rate and anatomical quality of fetal second-trimester ultrasound examination in obese women.

MATERIALS AND METHODS

This repeated cross-sectional single-center study retrospectively collected second-trimester ultrasound images of 88 obese women. During the first period, ultrasound examinations were performed in 44 women (mean age, 31.4±5.9 [SD] years; range: 21.1 - 45.3 years) applying only the standard 1540m/s tissue ultrasound velocity (group 1). During the second period, ultrasound examinations were performed in other 44 women (mean age, 31.4±5.1 [SD] years; range: 20.6 - 41.6 years) with the operator free to choose among three available velocity settings (1420m/s, 1480m/s or 1540m/s) for the scanning planes for the morphological images (group 2). All women underwent mid-trimester ultrasound examination at 20 to 24 gestational weeks. Two observers assessed the examinations in both groups for completeness, quality, and duration of fetal ultrasound examinations.

RESULTS

No differences in age (P>0.99), body mass index (P=0.67), prevalence of previous cesarean delivery (P=0.30) or gestational age at the second-trimester scan (P=0.20) were found between the two groups. The mean cumulative duration of these ultrasound examinations was longer in group 1 than in group 2 (for both the complete (P=0.04) and incomplete (P=0.03) examinations). The quality of the anatomic images according to Salomon's criteria was less often acceptable in group 1 (5/44, 11.4%) than in group 2 (15/44, 34.1%) (P=0.02).

CONCLUSION

Free choice of ultrasound velocity improves the overall performance of fetal second-trimester ultrasound examinations in obese women.

Incoherent Clutter Suppression Using Lag-One Coherence

The lag-one coherence (LOC), derived from the correlation between the nearest-neighbor channel signals, provides a reliable measure of clutter which, under certain assumptions, can be directly related to the signal-to-noise ratio of individual channel signals. This offers a direct means to decompose the beamsum output power into contributions from speckle and spatially incoherent noise originating from acoustic clutter and thermal noise. In this study, we applied a novel method called lag-one spatial coherence adaptive normalization (LoSCAN) to locally estimate and compensate for the contribution of spatially incoherent clutter from conventional delay-and-sum (DAS) images. Suppression of incoherent clutter by LoSCAN resulted in improved image quality without introducing many of the artifacts common to other adaptive imaging methods. In simulations with known targets and added channel noise, LoSCAN was shown to restore native contrast and increase DAS dynamic range by as much as 10-15 dB. These improvements were accompanied by DAS-like speckle texture along with reduced focal dependence and artifact compared with other adaptive methods. Under in vivo liver and fetal imaging conditions, LoSCAN resulted in increased generalized contrast-to-noise ratio (gCNR) in nearly all matched image pairs ( N = 366 ) with average increases of 0.01, 0.03, and 0.05 in good-, fair-, and poor-quality DAS images, respectively, and overall changes in gCNR from -0.01 to 0.20, contrast-to-noise ratio (CNR) from -0.05 to 0.34, contrast from -9.5 to -0.1 dB, and texture μ/σ from -0.37 to -0.001 relative to DAS.

Identification of newborns with birthweight ≥ 4,500g: Ultrasound within one- vs. two weeks of delivery

OBJECTIVE

Our objective was to compare the diagnostic characteristics of sonographic estimated fetal weight (SEFW) done within 7 versus 8-14 days before delivery for detection of fetal macrosomia (birthweight ≥ 4500 g).

STUDY DESIGN

We performed a multicenter, retrospective cohort study of all non-anomalous singletons with SEFW ≥ 4000 g by Registered Diagnostic Medical Sonographers conducted within 14 days of delivery. Cohorts were grouped by time interval between ultrasound and delivery: 0-7 days versus 8-14 days. The detection rate (DR) and false positive rate (FPR) for detection of birthweight (BW) ≥ 4500 g were compared between groups with subgroup analysis for diabetic women. Area under the receiver operator curve (AUC) was calculated to analyze all possible SEFW cutoffs within our cohort.

RESULTS

A total of 330 patients met inclusion criteria with 250 (75.8 %) having SEFW within 7 days and 80 (24.2 %) with SEFW 8-14 days prior to delivery. The rate of macrosomia was 15.1 % (N = 51). The DR for macrosomia was significantly higher when SEFW was performed within 7 days of delivery compared to 8-14 days among non-diabetic (73.0 % vs 7.1 %; p < 0.001) and diabetic women (76.5 % vs 16.7 %; p = 0.02). There was no significant change in FPR in either group. The AUC for detection of macrosomia was significantly higher when SEFW was performed within 7 days versus 8-14 days (0.89 vs 0.63; p < 0.01).

CONCLUSION

With SEFW ≥ 4000 g, the detection of BW ≥ 4500 g is significantly higher when the sonographic examination is within 7 days of birth irrespective of maternal diabetes.

Detailed Fetal Anatomic Ultrasound Examination Duration and Association With Body Mass Index

OBJECTIVE

To evaluate the association of the duration of the detailed fetal anatomic ultrasound examination with maternal body mass.

METHODS

This was a retrospective chart review of patients presenting to our clinic for detailed fetal anatomic examinations between January 1, 2010, and June 30, 2017. After excluding multifetal pregnancies and other examinations expected to have a longer duration, a total of 6,522 examinations were performed between 18 0/7 and 22 0/7 weeks of gestation. Results were analyzed using analysis of variance and Student's t-test.

RESULTS

Mean (SD) body mass index (BMI) was 29.3 (±7.7), and mean examination time was 51.5 (±10.4) minutes. We found that mean examination time was 48.8 (±9.6) minutes for patients with normal BMIs, 50.6 (±10.0) minutes for overweight patients, 52.2 (±10.4) minutes for patients with class I obesity, 54.6 (±10.3) minutes for patients with class II obesity, and 57.7 (±10.3) minutes for patients with class III obesity (P<.001). The duration of the detailed fetal anatomic ultrasound examination increased continuously with BMI (r=0.285, P<.001).

CONCLUSION

We found that the duration of detailed fetal anatomic examinations increased with BMI. Examinations for gravid patients with class III obesity lasted 8.9 minutes longer than those for gravid patients with normal BMIs; examinations for gravid patients with BMIs of 50 or higher lasted 13.5 minutes longer. This information may be useful for fetal ultrasound examination scheduling.

Is Bigger Really Better? Comparison of Ultraportable Handheld Ultrasound with Standard Point-of-Care Ultrasound for Evaluating Safe Site Identification and Image Quality prior to Pleurocentesis

BACKGROUND

Pleural effusions remain a common medical problem which often requires diagnostic pleurocentesis to determine the underlying cause. Pleurocentesis is a frequently performed procedure worldwide with improved safety using ultrasound (US) technology.

OBJECTIVES

This prospective, single-center study evaluated the use of an ultraportable handheld (UPHH) US compared with standard point-of-care (SPOC) US in determining a safe site for pleurocentesis. In addition, US image quality and factors impacting on image quality were assessed using both UPHH and SPOC US.

METHODS

Paired US assessments were performed by thoracic physicians using UPHH and SPOC US on patients with unilateral pleural effusions to determine a safe site for pleurocentesis (defined as >2 cm of pleural fluid, >2 cm from a solid organ/diaphragm, and <7 cm chest wall depth). Distance measurements for key structures and image quality scores (using a 5-point Likert rating scale) were obtained at the time of US assessment. Factors affecting image quality were analyzed using univariate analysis.

RESULTS

In 52 of the 54 included patients (96.3%), UPHH US was able to identify a safe site for pleurocentesis. Distance measurements between UPHH and SPOC US were not statistically different (all <0.5 cm with values of p > 0.05), but image quality was reduced in UPHH compared with SPOC US by 1 point on a 5-point Likert rating scale (p < 0.002). Increasing body mass index was associated with a reduction in image quality in both UPHH and SPOC US (all p < 0.01).

CONCLUSIONS

Although image quality was lower in UPHH than SPOC US, a safe site was found in 96.3% of patients, which suggests that UPHH US may be a useful tool for diagnostic pleuro-centesis when SPOC US is not available (http://www.anzctr.org.au/, Australia New Zealand Clinical Trials Registry, No. ACTRN12618001592235).

Antenatal diagnosis of absence of septum pellucidum

The absence of septum pellucidum (ASP) is a rare disease, which affects the structure of the brain. It is either isolated or associated with various congenital brain malformations. The diagnosis of ASP can be performed by second-trimester ultrasound. When the ASP is isolated, prenatal counseling is optimistic regarding neurological outcome, but there is a 20% risk of septo-optic dysplasia in the neonate.

Should an Early Anatomy Ultrasound Scan Be Offered Routinely to Obese Pregnant Women?

OBJECTIVE

The primary objective of this study was to determine whether an early anatomic scan (EAS), either on its own or in combination with the routine transabdominal scan (R-TAS), would improve overall completion rates of the fetal anatomic survey in the obese pregnant woman. The study's secondary objectives were to compare patients' and sonographers' satisfaction with EAS versus R-TAS.

METHODS

A prospective observational study was carried out over a 2.5-year period including consecutive pregnant women with a pre-pregnancy BMI ≥30 kg/m² who consented at a dating ultrasound appointment to undergo EAS at 15 ± 1 GA in addition to the second trimester R-TAS. Anatomic structures were categorized as normal, not well seen, or abnormal by using the institutional 26-item anatomic standardized reporting template. Examination completion and study duration were recorded. Neonatal follow-up was performed to evaluate for any missed diagnoses. Patients' and sonographers' satisfaction questionnaires were completed.

RESULTS

A total of 120 pregnant women completed the study. Visualization of all anatomic components was complete in 14% at EAS and in 61% at R-TAS (combined completion rate, 90%). Mean scan time was 30.4 minutes at EAS and 51 minutes at R-TAS. No missed diagnoses of structural anomalies were identified at neonatal follow-up. EAS and R-TAS differed in terms of sonographers' reports of difficult or suboptimal scans (9% vs. 58%), well-seen anatomy (85% vs. 78%), and good visibility (44% vs. 12%). Most sonographers expressed a preference for performing EAS in future pregnancies, rather than the R-TAS (96% vs. 6%). Although patients reported greater satisfaction with EAS (93% vs. 74%), for reasons that could not be determined, they expressed a preference for R-TAS in a subsequent pregnancy (23% vs. 63%).

CONCLUSION

Performing EAS along with R-TAS improves completion rates for anatomic evaluation in the obese gravida and is associated with greater patient and sonographer satisfaction.

Can Ultrasound in Early Gestation Improve Visualization of Fetal Cardiac Structures in Obese Pregnant Women?

OBJECTIVES

To determine whether ultrasound (US) imaging of obese pregnant women in early gestation improves fetal cardiac visualization.

METHODS

We report a prospective longitudinal trial comparing late first- and early second-trimester US to traditional second-trimester US for fetal cardiac screening in maternal obesity. All study participants received US for fetal cardiac screening at a gestational age of 13 weeks to 15 weeks 6 days using a transvaginal or transabdominal approach (UST1). All patients also underwent a traditional transabdominal examination at 20 to 22 weeks (UST2). If UST2 failed to complete the cardiac visualization, a follow up examination (second UST2) was performed 2 to 4 weeks later. Imaging was considered complete if the visceral situs, 4 chambers, outflow tracts, and 3 vessels were visualized. The completion rates between UST1 and UST2 were the primary outcomes. A power analysis (85%) and sample size calculation (n = 145) were performed.

RESULTS

A total of 152 pregnancies met study criteria. Completion rates of cardiac screening were 77% for UST1 and 70% for UST2 (P = .143). This comparison reached statistical significance in patients with a body mass index of greater than 40 kg/m² (UST1 [69%] versus UST2 [38%]; P = .001). Sixty-two percent of patients with a body mass index of greater than 40 kg/m² required second UST2. The highest fetal cardiac screening completion rate was achieved when UST1 was combined with UST2 (96.1%). In 1 fetus, congenital heart disease was detected at UST1 and later confirmed.

CONCLUSIONS

This study represents the largest prospective trial assessing early-gestation US for fetal cardiac screening in the setting of maternal obesity. In obese pregnancies, the addition of early-gestation US to the 20- to 22-week US substantially improves the visualization of fetal cardiac anatomy.

Improving image quality of mid-trimester fetal sonography in obese women: role of ultrasound propagation velocity

OBJECTIVE

The quality of ultrasound images is impaired in obese patients. All ultrasound scanners are calibrated for an ultrasound propagation velocity of 1540 m/s, but the propagation in fatty tissue is slower (in the order of 1450 m/s). The main objective of this study was to evaluate the quality of images obtained with different ultrasound propagation velocity settings during the mid-trimester fetal ultrasound examination in obese patients.

METHODS

This was a cross-sectional study using image sets of four recommended scanning planes collected from 32 obese pregnant women during their mid-trimester fetal scan. Each image set comprised three images obtained successively at three different propagation velocity settings (1540 m/s, 1480 m/s and 1420 m/s). A panel of 114 experts assessed the quality of 100 image sets, grading them from A (most acceptable) to C (least acceptable). Scanning-plane-specific indicators of adiposity (fatty layer thickness, probe-to-organ distance) were analyzed for each scanning plane.

RESULTS

The experts had a mean of 18.1 ± 10.2 years of experience. The grade distribution (A, B, C) differed significantly (P < 0.0001) between the three propagation velocity settings tested; at the lower speed of 1480 m/s, images were most often graded A, while at the conventional speed of 1540 m/s, they were most often graded C. Regardless of the scanning plane, the thicker the fatty layer of the abdominal wall in a given plane, the lower the preferred speed (P < 0.0001).

CONCLUSION

The construction of images taking into account ultrasound propagation velocities lower than 1540 m/s can improve significantly the quality of images obtained during mid-trimester fetal ultrasonography in obese women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

A score-based method for quality control of fetal hard palate assessment during routine second-trimester ultrasound examination

INTRODUCTION

When an orofacial cleft lip is discovered, precise characterization of this malformation is necessary, especially the extension of this cleft to the secondary palate. We aimed to develop and evaluate the feasibility/reproducibility of a score-based quality control for the visualization of the fetal hard palate during the second-trimester scan.

MATERIAL AND METHODS

All ultrasound images of fetal hard palate assessed routinely during second-trimester scan were retrospectively retrieved for a 6-month period. One hundred of these images were randomly selected and analyzed by two blinded reviewers, according to a scoring system (0-6 points). Criteria retained in the score were complete palate bone horizontal plate, presence of two pterygoid processes, visible alveolar ridge, and horizontal axis of insonation. A score ≥4 defined images of good quality. Inter- and intra-reviewer reproducibility was assessed.

RESULTS

Inter-reviewer reproducibility was excellent with significant correlation (Pearson coefficient 0.953; P < .0001), global adjusted κ coefficient (0.86, 95% CI 0.79-0.94) and individual criteria adjusted κ coefficient always > 0.8. Rates of images of good quality (score ≥ 4) were 75%-77%, also with excellent agreement (κ coefficient 0.89, 95% CI 0.79-0.99). Intra-reviewer reproducibility retrieved the same results (excellent agreement) except for the axis of insonation (satisfactory agreement).

CONCLUSIONS

This simple image scoring system for the fetal palate is easy, has excellent inter- and intra-reviewer reproducibility and could also help sonographers to correctly identify the palate structure.

Association between amniotic fluid evaluation and fetal biometry: a prospective French "Flash" study

We aimed to study the association between three different methods of assessing the amount of amniotic fluid (subjective method (SM), deepest vertical pocket (DVP) and amniotic fluid index (AFI)) and estimated fetal weight (EFW) (in percentile or Z-score) after adjustment on maternal-fetal parameters. We performed a nationwide cross-sectional study through the French network of obstetric sonographers using the "flash" study method and including low-risk singleton pregnancies from 18-40 weeks. Crude and adjusted odds ratio were computed after stratification upon 2nd and 3rd trimester of pregnancy. 1667 ultrasound scans performed by 65 operators were included. Only Z-score of EFW was significantly associated with SM in both trimesters. For DVP and AFI, Z-score of EFW and male fetal gender was significantly associated with them in 2nd trimester. In the 3rd trimester, both Z-score of EFW and large (LGA) or small for gestational age (SGA) fetus were significantly associated with AFI. and DVP. Overweight woman and class I obesity women were also significantly associated with DVP modification. In conclusion, all three methods of amniotic fluid evaluation are significantly associated to estimated fetal weight. DVP and AFI appeared equivalent except that maternal-fetal factors seemed to have a higher impact in DVP than AFI.

Second trimester ultrasound detection of fetal anomalies in the obese obstetrical population: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to identify, appraise and synthesize the best available evidence on the impact of maternal obesity on mid second trimester ultrasound detection of fetal anomalies in pregnancy.

Third trimester ultrasound accuracy and delivery outcome in obese and morbid obese pregnant women

OBJECTIVE

Several studies have highlighted the negative impact of maternal obesity on ultrasound accuracy for fetal weight estimation (EFW). However, the evidence is conflicting. We aimed in our study to find if the ultrasound accuracy for EFW would differ or decrease in obese and morbid obesity classes. We also studied the mode of delivery within the same cohort.

METHODS

It is a retrospective study of obese patients with recorded BMI ≥30 kg/m², class I and II (BMI: 30-39.9 kg/m²) compared with extreme obese class III (BMI ≥40 kg/m²), who gave birth after 28-week gestation of viable singleton, who had an ultrasound within 7 d of delivery with reported normal amniotic fluid and no major fetal anomaly; the EFW was consistently measured through Hadlock regression formula in the period of 2014-2015 inclusive. Differences between the EFW and actual birth weight (ABW) were assessed by percentage error, accuracy in predictions within ±10% of error and the Pearson correlation coefficient were used to correlate EFW with the ABW. The study's secondary outcome was to study the mode of delivery and the rate of cesarean section in obese and morbid obese patients.

RESULTS

Total 106 cases fulfilled our criteria. Class I and II as the first group (n = 53). Class III as the second group (n = 53). Maternal and birth characteristics were similar. The Pearson correlation coefficient equal 1 in both groups. The overall mean absolute difference (MAD) in grams of the whole obese cohort was 242 ± 213. The MAD was 242 ± 202 and 242 ± 226 g for the first and second group, respectively (p = 1.0). The overall mean absolute percentage error (MAPE) in this obese cohort was 8%. The MAPE for the first and second group, respectively were 8 and 7% (p = 0.4). The overall rate of cesarean delivery was 60% (64/106) with no differences between the obese and morbid obese BMI classes. Sixty-six percentage (42/64) of these cesarean cases was for repeat cesarean section.

CONCLUSION

Despite what has been previously reported about the negative impact of maternal obesity on EFW accuracy, we could not demonstrate this relationship in our obese cohort (MAPE <10%). In addition, we could not illustrate a significant difference in ultrasound accuracy across various obesity classes. However, we found a significantly increased rate of delivery by repeated cesarean section in this obese cohort.

Pilot Study of a Software-Supported Protocol for Second-Trimester Ultrasound Screening

OBJECTIVES

To evaluate the feasibility and impact of using a software-supported protocol for routine second-trimester ultrasound scanning.

METHODS

We conducted a comparative observational study of 2 sets of 25 randomly selected normal routine second-trimester examinations performed by the same expert sonographer before and 1 year after the introduction of a software-supported protocol. The scanning protocol was identical during both periods and conformed to International Society of Ultrasound in Obstetrics and Gynecology guidelines. Two independent expert sonographers reviewed the temporal sequences of fetal anatomic visualization. The examination duration, number of images, time per stored image, and number of recorded anatomic features according to the International Society of Ultrasound in Obstetrics and Gynecology guidelines were compared between the periods.

RESULTS

The mean examination duration and the number of images stored ± SD were both significantly higher during the period with the software-supported protocol than during the previous period (18.9 ± 5.3 versus 15.3 ± 2.8 minutes, respectively; P = .005; and 52.0 ± 2.4 versus 35.2 ± 3.4; P < .001). The mean time per image was also shorter with the software-supported protocol (19 ± 7 versus 26 ± 4 seconds; P < .001). Recording of the placental location, amniotic fluid quantification, cavum septi pellucidi, thoracic shape, both kidneys, both arms, and genitalia was significantly more consistent with the software-supported protocol (P < .001; P = .001; P = .022; P = .050; P = .022; P < .001; and P = .048).

CONCLUSIONS

This pilot study suggests that a software-supported protocol standardizing image acquisition may improve operator efficiency during second-trimester ultrasound scans.

The Role of Early Gestation Ultrasound in the Assessment of Fetal Anatomy in Maternal Obesity

OBJECTIVES

The 2012 Eunice Kennedy Shriver National Institute of Child Health fetal imaging consensus suggested that fetal anatomy ultrasound in obese pregnancies be performed at 20 to 22 weeks, with follow-up in 2 to 4 weeks if anatomy is incomplete. It was postulated that imaging in early gestation may improve visualization, although no prospective trials had been done to date.

METHODS

We performed a prospective longitudinal blinded trial comparing an early gestation ultrasound (13 + 0 to 15 + 6 weeks) with the traditional second-trimester ultrasound for completion of the fetal anatomy survey in obese patients. Inclusion criteria included singleton gestation, body mass index (BMI) more than 30, less than 16 + 0 weeks' gestation, and no karyotype abnormality; exclusion criteria included age younger than 18 years, more than 16 weeks' gestation at time of consent, and BMI less than 30. Participants received a transvaginal and/or transabdominal sonogram for fetal anatomic survey at 13 + 0 to 15 + 6 weeks' gestation (US1). Images from US1 were blinded to physicians and sonographers performing subsequent examinations. All participants underwent the traditional transabdominal sonogram at 18 to 24 weeks (US2). If US2 failed to complete the anatomic survey, a repeat transabdominal sonogram (2-US2) was performed 2 to 4 weeks later.

RESULTS

A total of 152 pregnancies met the criteria. Anatomy completion rate was 57.2% for US1 and 62.5% for US2, which was not statistically significant, even when stratified by BMI. Excluding the philtrum, the US1 performed better than US2 for class III obesity (65.5% versus 45.5% [P = .035]). Combination of US1 + US2 yielded a higher completion rate than US2 + 2-US2 (94.1% versus 83.6% [P = .0023]).

CONCLUSIONS

In the setting of maternal obesity, the addition of an ultrasound in early gestation may be of highest benefit for patients with class III obesity (BMI > 40 kg/m² ).

The Performance of First-Trimester Anatomy Scan: A Decision Analysis

Introduction First-trimester ultrasound (US) for anatomy assessment may improve anomaly detection, but it may also increase overall US utilization. We sought to assess the utility of first-trimester US for evaluation of fetal anatomy. Materials and Methods A decision analytic model was created to compare first- plus second-trimester anatomy scans to second-trimester scan alone in four populations: general, normal weight women, obese women, and diabetics. Probability estimates were obtained from the literature. Outcomes considered were number of: major structural anomalies detected, US performed, and false-positive US. Multivariable sensitivity analyses were performed to evaluate the consistency of the model with varying assumptions. Results A strategy of first- plus second-trimester US detected the highest number of anomalies but required more US examinations per anomaly detected. The addition of a first-trimester anatomy US was associated with a small increase in the false-positive US (< 10/10,000). In populations with higher anomaly prevalence and lower second-trimester US sensitivity (i.e., diabetes, obesity), the number of additional US performed per anomaly detected with the first-trimester US was < 60. Discussion In high-risk populations, a first-trimester US in addition to a second-trimester US may be a beneficial approach to detecting anomalies.

Helping expectant mothers understand inadequate ultrasound images

BACKGROUND

Obstetric ultrasound scans may fail to provide all the information that is needed because of poor visualisation. Two main causes of poor visualisation are addressed. These are poor foetal position and poor quality imaging due to beam distortion by overlying fatty tissue.

METHOD

To improve communication with patients attending obstetric scans, a poster and leaflet were designed to explain these causes of inadequate scans. A questionnaire was used to assess the value of the poster.

RESULTS

57/66 (86%) questionnaires were completed. 52 (91%) found the information on the poster was helpful and well explained. For 8 (14%) the information changed their thoughts about the scan.

CONCLUSION

Clear communication aids the expectant mothers understanding of why scans may be suboptimal. The way this is recorded in the scan results is discussed.

Maternal abdominal subcutaneous fat thickness as a predictor for adverse pregnancy outcome: a longitudinal cohort study

OBJECTIVE

To assess maternal abdominal subcutaneous fat thickness (SFT) measured by ultrasound as an independent predictor of adverse pregnancy outcomes.

DESIGN

A prospective longitudinal cohort study performed on pregnancies delivered between 2012 and 2014.

SETTING

Sydney, Australia.

POPULATION

About 1510 pregnant women attending routine obstetric ultrasounds.

METHODS

Maternal SFT was measured on routine ultrasounds at 11-14 weeks' gestation (SFT1) and 18-22 weeks' gestation (SFT2). SFT measurements were assessed for estimating risks for obesity-related pregnancy outcomes using logistic regression modelling adjusted for maternal age, parity, smoking status and body mass index (BMI).

MAIN OUTCOME MEASURES

Hypertensive disease, gestational diabetes, caesarean section, low birthweight, preterm delivery, neonatal respiratory distress, Apgar scores, and admission to a neonatal intensive care unit.

RESULTS

SFT1 and SFT2 were measured on 1461 and 1363 women, respectively. Mean thickness (range) were 21.2 mm (6.9-73.9) for SFT1 and 20.3 mm (7.5-68.0) for SFT2. Complete outcome data were available for 1385 pregnancies. In all, 54% of the women were overweight/obese. The SFT measures decreased from early to mid-pregnancy in overweight/obese women. There was moderate correlation between BMI and SFT1 (R(2) = 0.56) and BMI and SFT2 (R(2) = 0.55). In a multivariate model, SFT1 and SFT2 were better predictors for adverse pregnancy outcomes than BMI.

CONCLUSION

Maternal SFT is a significant independent predictor of adverse pregnancy outcomes. Incorporation of SFT into future models for adverse pregnancy outcome may prove valuable.

Ultrasound (in)accuracy: it's in the formulae not in the technique - assessment of accuracy of abdominal circumference measurement in term pregnancies

Introduction: Fetal abdominal circumference (AC) is utilised in calculations for the estimation of fetal weight (EFW) and has been proposed as a method of monitoring diabetic pregnancies. We evaluated true ultrasound accuracy by comparing fetal AC biometry with neonatal anthropometry and compared this with standard ultrasound estimations of fetal weight.

Methods: A prospective observational study was performed at a tertiary referral centre. Women who were having their confinement of a term, singleton gestation either by induction of labour or elective caesarean section from 2009–2011 were approached to participate. An ultrasound was performed within 24 hours of delivery measuring the biometric parameters of AC, head circumference (HC), biparietal diameter and femur length. Following delivery the AC, HC and birthweight were measured on the neonate.

Results: Fifty‐two patients were enrolled in the study with data collected from 50. Mean AC measurement was 35.1 ± 2.1 cm and birth weight was 3596 ± 517 g. A Bland‐Altman plot was used to compare the two AC measurements with the 95% limits of agreement ranging from −2.33–4.69 cm around a mean difference of 1.2 cm. Mean percentage error was 5.0% and 6.2% for the AC and HC measurements respectively, in comparison with percentage errors of 7.0–13.8% for estimation of fetal weight (EFW) from 27 formulae.

Conclusions: Sonographic AC measurement is accurate in term pregnancies, with a percentage error less than HC or EFW. Perceptions of ultrasound inaccuracy may relate to the application of formulae rather than the ultrasound technique itself. Fetal surveillance using serial AC measurement has been proposed, in particular monitoring of diabetic pregnancies and in such a group AC may be easier and faster to obtain and more meaningful than EFW.

Optimal visualization of the fetal four-chamber and outflow tract views with transabdominal ultrasound in the morbidly obese: Are we there yet?

BACKGROUND

To compare optimal visualization of the four-chamber and outflow-tract views of the fetal heart on sonographic examination between morbidly obese (body mass index [BMI] ≥ 40 kg/m(2) ) and nonobese (BMI < 25 kg/m(2) ) pregnant women.

METHODS

In this retrospective cohort study, we included records and images from 509 pregnant women who had first undergone sonographic examination between 18 and 36 weeks' fetal gestational age.

RESULTS

Compared with the nonobese women, morbidly obese women had lower optimal visualization of the four-chamber and outflow-tract heart views: four-chamber view, morbidly obese, 83/186 (44.6%), versus nonobese, 283/323 (87.6%), and outflow-tract view, morbidly obese, 80/186 (43%) versus nonobese, 258/290 (89%); p < 0.0001 for each comparison. Similar outcomes were observed when the results from each subcategory of morbidly obese women (ie, BMI 40-49.9, 50-59.9, and ≥60 kg/m(2) ) were compared with that from nonobese women; p < 0.0001 for each comparison. These outcomes remained the same regardless of whether this comparison was made among those who had their examination before or at 19 weeks' or more gestational age. Among the morbidly obese women, there was no difference in optimal visualization of the four-chamber or outflow-tract views regardless of whether the examination was performed at <23 weeks' or at ≥23 weeks' gestational age: four-chamber view <23 weeks, 44.8% (78/174), versus four-chamber view ≥23 weeks, 41.7% (5/12); p = 0.8, and outflow-tract view <23 weeks, 43.1% (75/174), versus outflow-tract view ≥23 weeks, 41.7% (5/12); p = 0.9. After controlling for maternal age and race, the odds of visualizing the four-chamber and outflow-tract views in the morbidly obese were reduced compared with those in their nonobese counterparts: odds ratio (OR) for four-chamber, 0.13; 95% confidence interval (CI), 0.08-0.21, and OR for outflow-tract, 0.11; 95% CI, 0.07-0.17.

CONCLUSIONS

Optimal visualization of the fetal four-chamber and outflow-tract views was achieved in less than 50% of morbidly obese women, compared with almost 90% in nonobese women.

Elevated hsa-miR-99a levels in maternal plasma may indicate congenital heart defects

The current standard for prenatal screening is mostly based on biochemical marker tests and the use of ultrasonography. There is no secure stand-alone screening marker for congenital heart defects (CHDs). MicroRNAs (miRNAs) that are associated with cardiogenesis enter the maternal peripheral bloodstream during pregnancy and allow non-invasive prenatal testing (NIPT). The present study investigated the plasma expression profile of fetal hsa-miR-99a in maternal blood. Peripheral blood samples were collected from 39 pregnant patients, comprising 22 with CHD-positive fetuses and 17 with CHD-free controls. miRNAs were isolated from the maternal serum and reverse transcription-quantitative polymerase chain reaction was carried out to determine the expression of hsa-miR-99a. While the miRNA concentrations were almost identical among the affected and control groups (5.54 vs. 6.40 ng/µl), significantly upregulated hsa-miR-99a levels were identified in the affected group (1.78×10^-2±3.53×10^-2 vs. 1.09×10^-3±3.55×10^-3 ng/µl, P=0.038). In conclusion, according to the present study, hsa-miR-99a is involved in cardiac malformation and may serve as a biomarker during fetal development, and therefore presents as a candidate for monitoring cardiomyogenesis and potential use as a NIPT-biomarker for fetal CHD.

Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging workshop

Given that practice variation exists in the frequency and performance of ultrasound and magnetic resonance imaging (MRI) in pregnancy, the Eunice Kennedy Shriver National Institute of Child Health and Human Development hosted a workshop to address indications for ultrasound and MRI in pregnancy, to discuss when and how often these studies should be performed, to consider recommendations for optimizing yield and cost effectiveness, and to identify research opportunities. This article is the executive summary of the workshop.

Obesity and the challenges of ultrasound fetal abnormality diagnosis

Prenatal ultrasound has become an essential clinical tool for aneuploidy screening, detection of fetal congenital anomalies, and assessment of fetal growth and well-being. Maternal obesity, an increasing global problem, has been shown to decrease the accuracy of ultrasound examination in high-risk pregnancy. The purpose of this review is to provide an evidenced-based perspective on the challenges of performing fetal ultrasound in obese women and to provide a practical guide on how to care for these patients in the ultrasound suite.

Limitations of Aneuploidy and Anomaly Detection in the Obese Patient

Obesity is a worldwide epidemic and can have a profound effect on pregnancy risks. Obese patients tend to be older and are at increased risk for structural fetal anomalies and aneuploidy, making screening options critically important for these women. Failure rates for first-trimester nuchal translucency (NT) screening increase with obesity, while the ability to detect soft-markers declines, limiting ultrasound-based screening options. Obesity also decreases the chances of completing the anatomy survey and increases the residual risk of undetected anomalies. Additionally, non-invasive prenatal testing (NIPT) is less likely to provide an informative result in obese patients. Understanding the limitations and diagnostic accuracy of aneuploidy and anomaly screening in obese patients can help guide clinicians in counseling patients on the screening options.

Fetal imaging: Executive summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop

Given that practice variation exists in the frequency and performance of ultrasound and magnetic resonance imaging in pregnancy, the Eunice Kennedy Shriver National Institute of Child Health and Human Development hosted a workshop to address indications for ultrasound and magnetic resonance imaging in pregnancy, to discuss when and how often these studies should be performed, to consider recommendations for optimizing yield and cost-effectiveness and to identify research opportunities. This article is the executive summary of the workshop.

Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop

Given that practice variation exists in the frequency and performance of ultrasound and magnetic resonance imaging (MRI) in pregnancy, the Eunice Kennedy Shriver National Institute of Child Health and Human Development hosted a workshop to address indications for ultrasound and MRI in pregnancy, to discuss when and how often these studies should be performed, to consider recommendations for optimizing yield and cost effectiveness, and to identify research opportunities. This article is the executive summary of the workshop.

Standardized fetal anatomical examination using magnetic resonance imaging: a feasibility study

OBJECTIVE

To determine whether a standard complete fetal anatomical survey, as recommended for ultrasound examination guidelines, is feasible using a standardized magnetic resonance imaging (MRI) protocol.

METHODS

Based on guidelines for ultrasound examination, we created a specific MRI protocol for fetal anatomical survey. This protocol was then tested prospectively in 100 women undergoing fetal MRI examination for various specific indications at a median gestational age of 30 weeks. The feasibility of using MRI to perform the fetal anatomical survey was analyzed by two reviewers (A and B) based on 26 predefined anatomical criteria, yielding a score ranging from 0 to 26 (26 meaning successful complete anatomical study). Reproducibility was analyzed using percentage agreement and modified kappa statistics.

RESULTS

The mean score for the standardized MRI anatomical survey was 24.6 (SD, 1.4; range, 15-26) for Reviewer A and 24.2 (SD, 1.7; range, 15-26) for Reviewer B (P = 0.1). Twenty-two, two and two criteria could be assessed in > 95%, 80-95% and < 80% of cases by Reviewer A and 19, four and three criteria could be assessed in > 95%, 80-95% and < 80% of cases by Reviewer B. For both reviewers, the two most difficult criteria to evaluate were aorta and pulmonary artery. Inter-reviewer agreement was above 90% for 22 of the 26 anatomical criteria and adjusted kappa coefficients for each criterion demonstrated good, moderate and poor agreement for 22, two and two criteria, respectively.

CONCLUSION

Our data support the hypothesis that standardized fetal anatomical examination might be achieved and reproducible using MRI, although improvement is required for the cardiac part of the examination.

A comparison of transumbilical single-port laparoscopic appendectomy and conventional three-port laparoscopic appendectomy: from the diagnosis to the hospital cost

Purpose

Recently many cases of appendectomy have been conducted by single-incision laparoscopic technique. The aim of this study is to figure out the benefits of transumbilical single-port laparoscopic appendectomy (TULA) compared with conventional three-port laparoscopic appendectomy (CTLA).

Methods

From 2010 to 2012, 89 patients who were diagnosed as acute appendicitis and then underwent laparoscopic appendectomy a single surgeon were enrolled in this study and with their medical records were reviewed retrospectively. Cases of complicated appendicitis confirmed on imaging tools and patients over 3 points on the American Society of Anesthesia score were excluded.

Results

Among the total of 89 patients, there were 51 patients in the TULA group and 38 patients in the CTLA group. The visual analogue scale (VAS) of postoperative day (POD) #1 was higher in the TULA group than in the CTLA group (P = 0.048). The operative time and other variables had no statistical significances (P > 0.05).

Conclusion

Despite the insufficiency of instruments and the difficulty of handling, TULA was not worse in operative time, VAS after POD #2, and the total operative cost than CTLA. And, if there are no disadvantages of TULA, TULA may be suitable in substituting three-port laparoscopic surgery and could be considered as one field of natural orifice transluminal endoscopic surgery with the improvement and development of the instruments and revised studies.