ISUOG Practice Guidelines (updated): performance of the routine mid-trimester fetal ultrasound scan

Prenatal diagnosis and pregnancy outcomes in fetuses with vertebral abnormalities

OBJECTIVE

To investigate the genetic risk and pregnancy outcomes of fetuses who had the sonographic diagnosis of vertebral abnormalities (VA).

METHODS

Fifty-two fetuses with sonographically detected VA (excluding neural tube defects) were included in the study. Data on prenatal ultrasound scan, prenatal genetic testing by amniocentesis, and pregnancy outcomes were collected and reviewed.

RESULTS

Four types of VA were identified among 52 fetuses: butterfly vertebrae (26.9%, 14/52), hemivertebrae (59.6%, 31/52), hemivertebrae combined with butterfly vertebrae (9.6%, 5/52), and block vertebrae (3.9%, 2/52). Of the 52 fetuses, 33 presented VA as the sole sonographic anomaly, while the remaining 19 had associated anomalies. The positive rate of prenatal diagnosis for fetuses with VA was 19.2% (10/52). Chromosomal analysis, including karyotyping and chromosomal microarray analysis (CMA), detected one case of mosaic trisomy 9 and six cases of (likely) pathogenic copy number variants (CNVs). Whole exome sequencing (WES) identified four likely pathogenic variants in three cases with negative CMA results, specifically c.5110-1G > A in FLNB, c.8366G > A in KMT2D, and c.1275_1283dup as well as c.870 + 2T > C in DLL3. Among the 10 cases with diagnostic genetic testing results, seven fetuses exhibited isolated VA. There was no significant difference in the diagnostic rates between the isolated VA group (21.2%, 7/33) and the non-isolated VA group (15.8%, 3/19) (odds ratio [OR] 0.696, 95% confidence interval [CI] 0.157-3.087, p = 0.910). However, the live birth rate was significantly higher in the isolated VA group (71.9%, 23/32) compared to the non-isolated VA group (38.9%, 7/18) (OR 4.016, 95% CI 1.184-13.622, p = 0.022). Among the 30 live birth cases, two underwent spinal surgery and another two were identified with additional abnormalities. Following appropriate interventions, no apparent abnormalities were observed in the growth and development of 30 live birth cases.

CONCLUSION

Invasive prenatal diagnosis is recommended for all fetuses diagnosed with VA, regardless of whether associated anomalies are present. WES can enhance the diagnostic yield for fetuses with negative CMA results. Fetuses with isolated VA can have favorable pregnancy outcomes when genetic testing results are negative. However, long-term follow-up remains necessary for the assessment of the prognosis of these fetuses.

Combining lipidomics and machine learning to identify lipid biomarkers for nonsyndromic cleft lip with palate

Nonsyndromic cleft lip with palate (nsCLP) is a common birth defect disease. Current diagnostic methods comprise fetal ultrasound images, which are mainly limited by fetal position and technician skills. We aimed to identify reliable maternal serum lipid biomarkers to diagnose nsCLP. Eight-feature selection methods were used to assess the dysregulated lipids from untargeted lipidomics in a discovery cohort. The robust rank aggregation algorithm was applied on these selected lipids. The data were subsequently processed using 7 classification models to retrieve a panel of 35 candidate lipid biomarkers. Potential lipid biomarkers were evaluated using targeted lipidomics in a validation cohort. Seven classification models and multivariate analyses were constructed to identify the lipid biomarkers for nsCLP. The diagnostic model achieved high performance with 3 lipids in determining nsCLP. A panel of 3 lipid biomarkers showed great potential for nsCLP diagnosis. FA (20:4) and LPC (18:0) were also significantly downregulated in early serum samples from the nsCLP group in the additional validation cohort. We demonstrate the applicability and robustness of a machine-learning algorithm to analyze lipidomic data for efficient and reliable biomarker screening.

TIER-LOC: Visual Query-based Video Clip Localization in fetal ultrasound videos with a multi-tier transformer

In this paper, we introduce the Visual Query-based task of Video Clip Localization (VQ-VCL) for medical video understanding. Specifically, we aim to retrieve a video clip containing frames similar to a given exemplar frame from a given input video. To solve the task, we propose a novel visual query-based video clip localization model called TIER-LOC. TIER-LOC is designed to improve video clip retrieval, especially in fine-grained videos by extracting features from different levels, i.e., coarse to fine-grained, referred to as TIERS. The aim is to utilize multi-Tier features for detecting subtle differences, and adapting to scale or resolution variations, leading to improved video-clip retrieval. TIER-LOC has three main components: (1) a Multi-Tier Spatio-Temporal Transformer to fuse spatio-temporal features extracted from multiple Tiers of video frames with features from multiple Tiers of the visual query enabling better video understanding. (2) a Multi-Tier, Dual Anchor Contrastive Loss to deal with real-world annotation noise which can be notable at event boundaries and in videos featuring highly similar objects. (3) a Temporal Uncertainty-Aware Localization Loss designed to reduce the model sensitivity to imprecise event boundary. This is achieved by relaxing hard boundary constraints thus allowing the model to learn underlying class patterns and not be influenced by individual noisy samples. To demonstrate the efficacy of TIER-LOC, we evaluate it on two ultrasound video datasets and an open-source egocentric video dataset. First, we develop a sonographer workflow assistive task model to detect standard-frame clips in fetal ultrasound heart sweeps. Second, we assess our model's performance in retrieving standard-frame clips for detecting fetal anomalies in routine ultrasound scans, using the large-scale PULSE dataset. Lastly, we test our model's performance on an open-source computer vision video dataset by creating a VQ-VCL fine-grained video dataset based on the Ego4D dataset. Our model outperforms the best-performing state-of-the-art model by 7%, 4%, and 4% on the three video datasets, respectively.

Sonographic diagnosis of fetal eye anomalies and their association with syndromal diseases: A retrospective multicenter analysis of 264 cases

INTRODUCTION

This study aims to systematically describe eye malformations and correlate these with extraocular findings. Based on these findings, we propose a protocol for ultrasound evaluation of the fetal eye.

MATERIAL AND METHODS

In this multicentric retrospective cohort study, 264 fetuses with ocular malformations from two tertiary referral centers for prenatal medicine were analyzed. Anophthalmia, microphthalmia, exophthalmos, hyper- or hypotelorism, cataract, aphakia, cyclopia, and retinal detachment were assessed, and their association with extraocular findings and genetic changes was investigated.

RESULTS

The majority of the cases (99.2%) were non-isolated and presented further extraocular findings. Most commonly, the brain and central nervous system (65.9%), the limbs and the heart (46.6% each) and the cranial anatomy (41.2%) were affected. Significant associations were found between exophthalmos and anomalies of the fetal skeletal system (OR = 4.8, 95% CI 1.6-14) and cranial malformations (OR = 3.3, 95% CI 1.5-7.4). Hypotelorism showed an increased risk of cardiac anomalies (OR = 1.8, 95% CI 1.1-3.5) and brain malformations (OR = 2.16, 95% CI 1.2-4.1), with holoprosencephaly being the most common one. Fetuses with microphthalmia were more likely to have anomalies in the renal system (OR = 2.3, 95% CI 1.2-4.3). In 51.4% of the cases, a genetic aberration could be found, among them most frequently trisomy 13.

CONCLUSIONS

There is a significant association between specific fetal eye anomalies and certain extraocular anomalies, as well as genetic changes. Systematic evaluation of the eye using the proposed protocol is simple to learn and highly reproducible and could help to concentrate diagnosis on a certain group of malformations. Data from this study could help to develop targeted diagnostic molecular tools.

Prenatal manifestations of 3q29 deletion: A potential relationship with enlarged nuchal translucency

BACKGROUND

The 3q29 deletion syndrome is characterized by neurodevelopmental and/or psychiatric manifestations after birth. Few cohort studies have been focused on prenatal manifestations of this syndrome.

OBJECTIVES

This study is aimed to reveal the prenatal manifestations of 3q29 deletion syndrome.

METHODS

In this 5-year retrospective cohort study, gravidas with singleton pregnancies who underwent invasive prenatal diagnosis via single nucleotide polymorphism array for chromosomal abnormalities were included. First-trimester ultrasound screening was performed at 11+0--13+6 weeks' gestation for all included gravidas, and detailed mid-trimester fetal anomaly scans were performed at 20+0--24+0 weeks' gestation.

RESULTS

The prevalence of 3q29 deletion was 0.24 per thousand (9/36,978) in the prenatal period. Approximately 77.78 % (7/9) fetuses with 3q29 deletion were observed with unseptate enlarged nuchal translucency (NT) without major heart defects. Except for one was inherited from the gravidas with mild intellectual disability, all the other eight were proven to be de novo. The incidence of 3q29 deletion in fetuses with enlarged NT was significantly higher than those without enlarged NT (P < 0.001).

CONCLUSION

The 3q29 deletion was enriched in fetuses with enlarged NT. Enlarged NT was the most specific prenatal presentation for 3q29 deletions.

External validation of a risk-scoring model for predicting adverse perinatal outcomes in pregnancies with fetal growth restriction

AIM

This study aimed to validate the Prince of Songkla University (PSU) risk-scoring model for predicting adverse perinatal outcomes in pregnancies with an antenatal diagnosis of fetal growth restriction (FGR) in an independent cohort.

METHODS

A retrospective study was conducted on 121 non-anomalous singleton pregnancies affected by FGR between July 2022 and April 2024. The predictive performance of the PSU risk-scoring model, which combines maternal factors and simple ultrasound measurements to predict adverse perinatal outcomes in FGR, was evaluated by applying the original model to this independent cohort. Model variables included a history of hypertensive disorders of pregnancy (HDP) (1 point), chronic hypertension (3 points), HDP (2 points), maternal weight gain <8 kg (1 point), early-onset FGR (1 point), estimated fetal weight < 5th percentile (2 points), amniotic fluid index <5 cm (3 points), and abnormal umbilical artery Doppler (2 points). Predictive performance was evaluated using area under the receiver operating characteristic curve (AUC). Sensitivity and specificity were calculated at different cut-off values.

RESULTS

Median (interquartile range) gestational age at FGR diagnosis was 29 (22-39) weeks. Adverse perinatal outcomes occurred in 35 cases (28.9%). A cut-off score of 2 provided the highest sensitivity (85.7%) with a specificity of 51.2% for predicting adverse perinatal outcomes, with an AUC of 0.809 (95% confidence interval 0.714-0.905).

CONCLUSIONS

This study confirms the predictive performance of the PSU risk-scoring model for adverse perinatal outcomes in FGR pregnancies, highlighting its potential to identify at-risk patients for referral, particularly in low-resource settings.

We Should Perform a Systematic Evaluation of the Placenta

Despite its critical importance, the placenta receives substantially less attention during obstetric ultrasound examinations compared to the fetus. The evaluation of the placenta is typically limited to determining its location within the uterus, particularly its relationship to the cervix. Abnormal placenta findings are the result of gross anomalies identified by chance during obstetric examinations, rather than from a systematic evaluation. Here we describe a standardized protocol evaluating four placental regions: 1) the uterine wall/decidua/chorion interface; 2) the amnion/chorion interface; 3) the placental body; and 4) cord insertion and marginal area, which can improve the identification of placental anomalies in all pregnant subjects.

Ultrasonographic findings in mid-trimester adolescent pregnancy: prevalence and risk of abnormalities

Background

Adolescent pregnancy, defined as pregnancy in females aged 19 or younger, is associated with higher risks for adverse outcomes compared to older women. Ultrasound imaging during the mid-trimester is crucial for prenatal care, providing insights into fetal development and maternal health.

Objective

The primary aim of this study is to evaluate and compare mid-trimester ultrasound findings between adolescent and older pregnant women and to assess the prevalence and risk of any abnormalities detected during ultrasound examinations.

Methods

This retrospective study was conducted in the Silesian Voivodeship, Poland, from January 1, 2004, to February 29, 2024. Data were collected from reference prenatal centers. The study included 37,366 individuals, of which 1,152 were adolescents. Participants underwent second-trimester prenatal screening, and ultrasound findings were categorized into fetal abnormalities and maternal factors.

Results

The study found significant differences in ultrasonographic findings across different age groups. Adolescent pregnancies showed a higher prevalence of fetal abnormalities, 437.075 per 1,000 pregnancies (95% CI: 409-465). Brain, spine, facial, heart, and urinary tract abnormalities were notably higher in group adolescents.

Conclusion

Adolescent pregnancies are associated with increased detection of various fetal abnormalities during mid-trimester ultrasound scans. Contrary to common belief, the young age of adolescent pregnant individuals does not protect against fetal abnormalities. These findings underscore the necessity for comprehensive, population-based ultrasound screening for pregnant adolescents and the classification and management of adolescent pregnancies as high-risk.

Feasibility and limitations of the prenatal sonographic assessment of choanal flow and neonatal implications

ObjectiveTo evaluate the factors associated with the prenatal detection of choanal flow (CF) in a normal population.MethodsFifty pregnant women underwent CF evaluation using B-Mode and color Doppler. Screening for CF began at 22 weeks, standardized according to two section planes: sagittal and transverse. CF was considered positive when flow was seen, and negative if no flow was detected after 1 minute. The screening was repeated monthly until flow was observed. We assessed maternal BMI, fetal gender, gestational age at the first detection of flow, placental site, visibility noted by the sonographer, nasal asymmetry, and possible nostril dilatation.ResultsChoanal flow was established in all patients except two cases where the fetal face was consistently downwards (48/50). The gestational age at first detection of choanal flow was 28 weeks ± 3.5 weeks. Flow was unilateral in 56.3% of cases and bilateral in 43.8% of cases. Visibility assessed by the operator was rated as good in 72% of cases, average in 20%, and poor in 8%. The only factor significantly associated with the gestational age at first detection of choanal flow was visibility (p = 0.006).ConclusionThe average gestational age for the detection of choanal flow is 28 weeks. Relying solely on second-trimester morphological ultrasound may result in missed detections.

Performance of ChatGPT and Microsoft Copilot in Bing in answering obstetric ultrasound questions and analyzing obstetric ultrasound reports

To evaluate and compare the performance of publicly available ChatGPT-3.5, ChatGPT-4.0 and Microsoft Copilot in Bing (Copilot) in answering obstetric ultrasound questions and analyzing obstetric ultrasound reports. Twenty questions related to obstetric ultrasound were answered and 110 obstetric ultrasound reports were analyzed by ChatGPT-3.5, ChatGPT-4.0 and Copilot, with each question and report being posed three times to them at different times. The accuracy and consistency of each response to twenty questions and each analysis result in the report were evaluated and compared. In answering twenty questions, both ChatGPT-3.5 and ChatGPT-4.0 outperformed Copilot in accuracy (95.0% vs. 80.0%) and consistency (90.0% and 85.0% vs. 75.0%). However, no statistical difference was found among them. When analyzing obstetric ultrasound reports, ChatGPT-3.5 and ChatGPT-4.0 demonstrated superior accuracy compared to Copilot (P < 0.05), and all three showed high consistency and the ability to provide recommendations. The overall accuracy and consistency of ChatGPT-3.5, ChatGPT-4.0, and Copilot were 83.86%, 84.13% vs. 77.51% in accuracy, and 87.30%, 93.65% vs. 90.48% in consistency, respectively. These large language models (ChatGPT-3.5, ChatGPT-4.0 and Copilot) have the potential to assist clinical workflows by enhancing patient education and patient clinical communication around common obstetric ultrasound issues. With inconsistent and sometimes inaccurate responses, along with cybersecurity concerns, physician supervision is crucial in the use of these models.

Spectrum of congenital anomalies detected through anatomy ultrasound at a referral hospital in Ghana

BACKGROUND

Africa has a high burden of congenital anomalies due in part to limited preconception care, infections, and environmental exposures. However, the true prevalence of congenital anomalies is unclear because of insufficient access to prenatal diagnostic services. We aimed to determine the rate of congenital anomalies, and characterize the anomalies detected prenatally at a referral hospital in Ghana.

METHODS

We performed a four-year retrospective review of all fetal anomaly ultrasounds performed and congenital anomalies detected from January 1st, 2020, to December 31st, 2023, at Korle Bu Teaching Hospital, Accra, Ghana. Data were extracted from the electronic database on maternal age, gestational age at time of ultrasound, and occupation. Detected congenital anomalies were identified, and each anomaly was categorized by ICD-10 code and EUROCAT classification. Descriptive statistics were performed.

RESULTS

The mean maternal age and median gestational age at the time of ultrasound were 31.1 (SD 6.3) years and 26.9 (IQR 22.5-31.0) weeks, respectively. 3,981 anatomy ultrasounds were performed during the study period, and 7.0% (280/3,981) of fetuses had anomalies. Most (70.7%, 198/280) had anomalies detected in an isolated organ system. Anomalies were most identified in the central nervous system (CNS) (45.0%, 126/280), genitourinary (GU) (28.6%, 80/280), and gastrointestinal (GI) systems (21.8%, 61/280). The most common CNS anomaly identified was ventriculomegaly (70.6%, 89/126), out of which 26.2% (33/126) had severe ventriculomegaly, with an overall detection rate of 0.8% (33/3,981). The most common GU anomalies were congenital hydronephrosis (70.0%, 56/80), and congenital posterior urethral valves (28.8%, 23/80). The most common GI anomalies were exomphalos (49.2%, 30/61), and duodenal atresia (23.0%, 14/61). Unrelated to a specific organ system, 3.2% (9/280) of cases had hydrops and 6.1% (17/280) had an associated soft marker of aneuploidy.

CONCLUSIONS

Our study highlights the substantial burden of congenital anomalies detected through prenatal ultrasound at a tertiary referral center in Ghana, with a notably high detection rate of severe ventriculomegaly. This work underscores the feasibility and importance of performing detailed anatomy ultrasounds in Africa. Beyond the clinical benefit, these data lay the groundwork for studies to identify the underlying causes of high rates of anomalies to inform preventive policy and clinical interventions in low-resource settings.

Elective Terminations Because of Fetal Abnormalities: Findings in A Tertiary Maternity Center Over 41 Years (1972-2012)

Finding abnormalities in a fetus by prenatal testing during pregnancy is a common reason why parents choose to terminate a pregnancy. A malformations surveillance program of all births at a tertiary center in Boston was used to identify each elective termination because of a malformation detected prenatally. A severity scale of malformations was used: lethal (anencephaly), severe-handicapping (Down syndrome; myelomeningocele), moderate-fixable (omphalocele) and mild (postaxial polydactyly, type B). Demographic characteristics and the findings in prenatal testing were recorded. Six hundred and sixty-nine elective terminations because of fetal abnormalities were identified. A destructive procedure (dilation and evacuation; D&E) was the primary method used to end the pregnancy. The gestational age at the time of termination was 18 to 19 weeks. The two most common sequences of events were: (1) imaging by ultrasound established the diagnosis; (2) imaging by ultrasound led to amniocentesis which established the diagnosis. Ninety-four percent of the abnormalities were either lethal or severe-handicapping. The discovery of a fetal abnormality was a surprise to 98% of the parents. Single women differed from married women in being younger, less well-educated, less likely to have health insurance, and more likely to terminate a pregnancy with moderate-fixable malformations.

Partial agenesis of the corpus callosum: Prenatal ultrasound characteristics, associations, and outcome

INTRODUCTION

To investigate prenatal ultrasound characteristics, associated abnormalities, and outcomes of partial agenesis of the corpus callosum (pACC).

MATERIAL AND METHODS

A total of 118 fetuses with pACC diagnosed using prenatal ultrasound were studied, and their prenatal ultrasound characteristics, associated abnormalities, genetics, and outcomes were collected. The fetuses were categorized into three groups according to gestational age: <24 weeks, 24-28 weeks, and >28 weeks, and the brain transverse plane ultrasound signs were compared among the three groups.

RESULTS

Prenatal ultrasound revealed the presence of abnormal cavum septi pellucidi (CSP), distention of the interhemispheric fissure (IF), dilated and elevated third ventricle (TV), and ventriculomegaly in 102 (86.4%), 91 (77.1%), 56 (47.4%), and 42 (35.6%) cases, respectively, in the transverse plane of the brain. Among the cases with dilatation and elevation of the TV, 38 (67.8%) showed posterior displacement, manifested by a cystic mass in the midline that communicated with the TV. There were statistically significant differences in the incidence of ventriculomegaly and abnormal CSP among the three groups at <24 weeks, 24-28 weeks, and >28 weeks. However, there were no statistically significant differences in the distention of the IF and TV among the three groups. Moreover, our cohort studies demonstrated that 32.2% (38/118), 18.6% (22/118), and 17.8% (21/118) of the cases were associated with intracranial, extracranial, and intra-extracranial anomalies, respectively. The most common intracranial and extracranial anomalies were cerebral cortical dysplasia and cardiovascular anomalies. Genetic analysis demonstrated that 37.8% (17/41) of patients had genetic abnormalities. 25% (4/16) and 52% (13/25) of isolated and non-isolated pACC cases showed genetic abnormalities. Eight isolated cases were born, with an average age of 28 months, and their neurological development was normal.

CONCLUSIONS

Abnormal CSP was the most common indirect sign of pACC. A cystic mass in the midline communicating with the TV can be another indirect sign of a pACC. pACC is likely to be accompanied by intracranial and extracranial abnormalities. The detection rate of genetic abnormalities was higher in non-isolated pACC cases than in isolated cases. Isolated pACC has a good prognosis but requires long-term follow-up of neurological development.

Indications for fetal echocardiography: consensus and controversies among evidence-based national and international guidelines

OBJECTIVE

Fetal echocardiography (FE) is an indication-driven examination for pregnant women with a fetus at high risk for congenital heart disease (CHD). Several familial, maternal and fetal factors are reported to increase the risk of CHD. The aim of this study was to highlight the existing differences in recommended indications for FE among recently published guidelines and consensuses of experts.

METHODS

Guidelines and expert consensuses published from January 2008 to October 2023 were identified through a systematic literature search. FE guidelines and consensus statements were excluded if not written in the English language and if indications for FE were not reported. All familial, maternal and fetal risk factors for CHD reported in the consensuses and guidelines were listed and comparisons were made between documents. The agreement or disagreement for each risk factor between guidelines and consensuses was classified as: complete agreement (all analyzed documents reported the same indication); partial agreement (all documents considered a risk factor as an indication, but with inconsistency in its definition); or complete disagreement (inconsistency between documents for the considered risk factor as an indication).

RESULTS

Six guidelines and expert consensuses that met the inclusion criteria were identified. Overall, a total of 17 risk factors were identified as an indication for FE. Complete agreement was reached for 3/17 (17.6%) risk factors, all of which are fetal risk factors (suspected CHD at the anomaly scan, presence of major fetal extracardiac abnormality and non-immune hydrops fetalis). Partial agreement was recorded for 8/17 (47.1%) risk factors (family history of CHD, increased nuchal translucency, multiple gestation, maternal diabetes mellitus, maternal phenylketonuria, maternal infection, maternal autoimmune disease and autoantibody positivity, and teratogen exposure). Complete disagreement was recorded for 6/17 (35.3%) risk factors (inherited genetic disease associated with CHD, fetal genetic anomaly, suspected abnormality of heart rate or rhythm, first-trimester sonographic markers of CHD, abnormality of umbilical cord and venous system, and use of assisted reproductive technology).

CONCLUSIONS

Areas of controversy regarding which CHD risk factors warrant FE were greater in quantity than were the areas of consensus. An internationally standardized agreement would be valuable for physicians and guideline developers. For many risk factors, further evidence is needed to justify their use as an indication for FE. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Perinatal genetic diagnostic yield in a population of fetuses with the phenotype arthrogryposis multiplex congenita: a cohort study 2007-2021

Arthrogryposis multiplex congenita (AMC) presents challenges for prenatal detection due to its heterogeneous etiology, onset, and phenotypical manifestations. This study aims to describe the genetic diagnostic yield in a population of fetuses with detailed phenotypic description over a 15-year period (2007-2021) at the Fetal Medicine Unit of Amsterdam UMC, the Netherlands. The fetal and neonatal phenotypes were classified into three clinical AMC Groups, with the exception that Groups 1 and 2 were combined in the prenatal classification. Group 1 involves limb involvement primarily, Group 2 includes musculoskeletal involvement plus other system anomalies, and Group 3 involves musculoskeletal involvement with central nervous system disability, lethality, fetal akinesia deformation sequence, and/or intellectual disability. The cohort consisted of 64 consecutive cases, 13 in Groups 1 + 2 and 51 in Group 3. Perinatal genetic testing occurred in all cases: prenatally in 56 of the 64 (88%), postnatally in 36 of the 64 (56%), and combined testing in 28 of the 64 cases (44%). The overall genetic diagnostic yield was 28% (18/64), and it increased over the 5-year period from 14% to 50%. Whole exome sequencing had the highest yield (41.7%). The yield per phenotype was 30.8% (4/13) for AMC Group 1 + 2 and 27.4% (14/51) for AMC Group 3. Detailed fetal phenotyping and perinatal genetic testing in all cases showed improved diagnostic yield over time, likely due to the introduction of Next-generation sequencing-based tests. The availability of stored DNA will be beneficial for future investigations since further improvements in genetic testing possibilities are expected.

Incremental yield of prenatal exome sequencing in fetuses with skeletal system abnormalities: A systematic review and meta-analysis

INTRODUCTION

Fetal skeletal abnormalities can be caused by various factors and genetic cause plays an important role. Prenatal exome sequencing (ES) has been shown to be a powerful approach for accurate prenatal molecular diagnoses. Diagnostic yield of ES in fetal skeletal abnormalities varies significantly across studies. This study aimed to perform a systematic review of the literature and meta-analysis to assess the incremental yield of ES in fetuses with different kinds of skeletal abnormalities and a negative result on chromosome microarray or karyotyping.

MATERIAL AND METHODS

The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched up to November 26, 2022. Relevant data were collected from observational studies containing five or more cases of skeletal abnormalities who underwent ES. The incremental yield of ES was evaluated by single proportion analysis and 95% confidence interval (CI), both according to the article features and individual phenotypes. This study was registered on PROSPERO as CRD42022382800.

RESULTS

Twenty-six studies including 524 individuals met the inclusion criteria. The pooled incremental yield was 60.2% (95% CI, 53.4%-66.9%) for all fetuses with skeletal abnormalities. In subgroup analysis, the additional diagnostic yield was 83.9% (95% CI, 76.4%-90.4%) in isolated dysplasia cases (group I), 52.0% (95% CI, 32.9%-70.9%) in dysplasia with non-skeletal abnormalities cases (group II), 33.3% (95% CI, 19.3%-48.6%) in isolate dysostoses cases (group III), 47.8% (95 % CI, 35.8%-60.0%) in dysostoses with non-skeletal abnormalities cases (group IV), 83.0% (95% CI, 63.7%-97.1%) in combination of the two phenotypes without non-skeletal abnormalities cases (group V), 74.5% (95% CI, 54.9%-90.9%) in combination of the two phenotypes with non-skeletal abnormalities cases (group VI). The origin of the pathogenic variations differed among the groups. Most causative variants were de novo in groups I (97/133, 72.9%), V (14/23, 60.9%), and VI (15/26, 57.7%). Meanwhile, pathogenic variations in III (18/25, 72.0%) and IV (37/67, 55.2%) were more often inherited from a parent.

CONCLUSIONS

ES had a favorable incremental yield in fetuses with skeletal abnormalities. The common pathogenic variations and genetic patterns of skeletal abnormalities vary among different subtypes. Interpreting this difference is beneficial for personalized clinical consultation.

Maternal oxygen inhalation affects the fetal hemodynamic in low-risk with uncomplicated late pregnancy

BACKGROUND

Maternal oxygen inhalation during labor has not been shown to provide significant benefits to newborns. However, its impact on fetal hemodynamics in late pregnancy remains uncertain.

OBJECTIVE

This study aimed to investigate the association between maternal oxygen inhalation in the late trimester and changes in fetal hemodynamics. Specifically, we assessed the short-term effects of maternal oxygen administration on fetal Doppler parameters and evaluated whether this practice has potential benefits or risks for the fetus.

STUDY DESIGN

These retrospective data were obtained from singleton pregnancies who underwent a after 32+0 weeks prenatal ultrasound examination between January 2022 and December 2022. Participants were categorized into oxygen inhalation and non-oxygen inhalation groups. Oxygen inhalation was administered based on maternal request, primarily due to concerns about hypoxia from prolonged mask use during the COVID-19 pandemic, rather than clinical indication. Our study analysis was performed in August 2023. In oxygen inhalation group, pregnant women received oxygen inhalation with 3 L/min for 30 min by nasal cannula, and before went to department of ultrasound for sonographic assessment within 1 h. The CPR and PPI were predefined as primary outcomes prior to analysis. Each woman was recorded Doppler index and calculated placental pulsatility index (PPI) and cerebroplacental ratio (CPR). Moreover, fetal cardiac function was assessed within pulsed Doppler or M-mode.

MAIN OUTCOME

The primary outcome presented higher PPI, lower CPR, and lower birth weight for the exposure maternal oxygen inhalation group, compare to non-oxygen inhalation group.

RESULTS

A total of 104 singleton pregnancies were included in the final analysis (oxygen inhalation group: n = 48). No significant differences were observed in the resistance indices of the uterine arteries, umbilical arteries, middle cerebral arteries, descending aorta, ductus venosus, or umbilical vein. However, variations were noted in the oxygen inhalation group. Notably, indices with higher sensitivity for predicting adverse outcomes demonstrated significant differences between groups: PPI was higher in the oxygen inhalation group compared to the non-oxygen inhalation group (0.81 ± 0.12 vs. 0.76 ± 0.11, p < .05), while CPR was also lower in the oxygen inhalation group (1.98 ± 0.56 vs. 2.28 ± 0.70, p < .05). Additionally, birth weight was significantly lower in the oxygen inhalation group compared to the non-oxygen inhalation group (2983.78 ± 468.18 g vs. 3178.41 ± 477.59 g, p < .05).

CONCLUSION

Our study found that brief maternal oxygen inhalation in the third trimester was associated with significant changes in fetal hemodynamics, specifically higher PPI and lower CPR. Both of these indices are sensitive markers of unfavorable prenatal outcomes, indicating that maternal oxygen inhalation may adversely affect fetal health. These findings underscore the importance of carefully evaluating the use of oxygen inhalation in pregnant women, especially those in high-risk pregnancies. Additionally, monitoring Doppler indices before and after oxygen administration may help assess fetal well-being and guide clinical decision-making in these situations.

Two Souls, One Birth: The Vaginal Delivery of Parapagus Conjoined Twins

Conjoined twins (CTs) are a rare occurrence. A timely prenatal diagnosis of this anomaly by ultrasonography is crucial for counseling regarding various management options like pregnancy termination, selective feticide, or postdelivery surgical separation. However, some cases can still remain undetected until birth. We report the case of a grand multipara in her 30s who came to our labor room at 28 weeks of gestation, as an unbooked case and had vaginal delivery of dithoracic parapagus CTs, weighing 2,000 g. Although cesarean section is considered the preferred mode of delivery for CTs, undiagnosed cases presenting directly at birth, as in our instance, pose significant challenges. In extreme cases, destructive procedures may become necessary. Such cases highlight the need for preparedness during delivery. Sharing the experiences of vaginal deliveries of CTs might help in exploring the optimal approaches for trial of vaginal birth in specific scenarios.

Introduction of a nationwide first-trimester anomaly scan in the Dutch national screening program

BACKGROUND

A significant proportion of major fetal structural anomalies can be detected in the first trimester by ultrasound examination. However, the test performance of the first-trimester anomaly scan performed in a low-risk population as part of a nationwide prenatal screening program is unknown. Potential benefits of the first-trimester anomaly scan include early detection of fetal anomalies, providing parents with more time for reproductive decision-making.

OBJECTIVE

To investigate the uptake, test performance, and time to a final prenatal diagnosis after referral.

STUDY DESIGN

A nationwide implementation study was conducted in the Netherlands (November 2021-November 2022). The FTAS was performed between 12+3 and 14+3 weeks of gestation by certified sonographers using a standard protocol. Women were referred to a tertiary care center if anomalies were suspected. Uptake, test performance, and time to a final prenatal diagnosis (days between referral and date of final diagnosis/prognosis for reproductive decision-making) were determined. Test performance was calculated for first-trimester major congenital anomalies, such as anencephaly and holoprosencephaly and all diagnosed anomalies <24 weeks of gestation.

RESULTS

The first-trimester anomaly scan uptake was 74.9% (129,704/173,129). In 1.0% (1313/129,704), an anomaly was suspected, of which 54.9% (n=721) had abnormal findings on the detailed first-trimester diagnostic scan and 44.6% (n=586) showed normal results. In 0.5% (n=6), intrauterine fetal death occurred. In the total group of 721 cases with abnormal findings, 332 structural anomalies, 117 genetic anomalies, 82 other findings (abnormal fetal biometry, sonomarkers, placental/umbilical cord anomaly, an-/oligohydramnios), and 189 cases with transient findings (defined as ultrasound findings which resolved <24 weeks of gestation) were found, with 1 case having an unknown outcome. 0.9% (n=1164) of all cases with a normal first-trimester anomaly scan were diagnosed with a fetal anomaly in the second trimester. Test performance included a sensitivity of 84.6% (126/149) for first-trimester major congenital anomalies and 31.6% (537/1701) for all types of anomalies. Specificity for all anomalies was 99.2% (98,055/98,830); positive predictive value 40.9% (537/1312); negative predictive value 98.8% (98,055/99,219); positive likelihood ratio 40.3; negative likelihood ratio 0.7; false positive rate 0.8% (775/98,830), and false negative rate 68.4% (1164/1701). The median time to diagnosis for structural anomalies was 20 days (6-43 days; median gestational age 16+3), for genetic anomalies 17 days (8.5-27.5 days; median gestational age 15+6 weeks), and for first-trimester major congenital anomalies 9 days (5-22 days; median gestational age 14+6 weeks).

CONCLUSION

The performance of a newly introduced nationwide first-trimester anomaly scan in a low-risk population showed a high sensitivity for first-trimester major congenital anomalies and a lower sensitivity for all anomalies combined. The program was accompanied by a referral rate of 1.0%, of which 59.1% involved cases where anomalies were either not confirmed or resolved before 24 weeks gestation. Timing of diagnosis was around 16 weeks of gestation for referred cases. To evaluate the balance between benefits and potential harm of the first-trimester anomaly scan within a nationwide prenatal screening program, it is essential to assess the effectiveness of the program over time and to consider the perspectives of both women and their partners, as well as healthcare professionals.

Effectiveness and clinical impact of using deep learning for first-trimester fetal ultrasound image quality auditing

BACKGROUND

Regular auditing of ultrasound images is required to maintain quality; however, manual auditing is time-consuming and can be inconsistent. We therefore aimed to develop and validate an artificial intelligence-based image quality audit (AI-IQA) system to audit images from the four key planes used in first-trimester scanning.

METHODS

The AI-IQA system was developed based on the YOLOv7 structure detection network and a multi-branch image quality regression network using a large multicenter internal dataset. Clinical validation was performed using 567 cases scanned by four radiologists with different experience levels, of which 349 were performed without AI-IQA feedback (clinical test set 1) and 218 were performed after 2-3 rounds of AI-IQA feedback (clinical test set 2). The proportion of standard images obtained and detailed expert audit results were compared to verify whether AI-IQA could objectively and accurately provide feedback on deficiencies in nonstandard images to assist radiologists at different experience levels in improving image quality.

RESULTS

In the internal test set, the AI-IQA system achieved high average accuracy precision, recall and F1-score in auditing the overall plane quality (0.881, 0.833, 0.842 and 0.837, respectively) and structure quality (0.906, 0.861, 0.857 and 0.859, respectively). In clinical test sets 1 and 2, AI-IQA results showed strong consistency with expert assessment results, with the average Cohen's Kappa coefficient exceeding 0.8 for all four planes. In addition, following AI-IQA feedback, the proportion of standard images obtained by junior and mid-level radiologists increased by 7.7% and 5.1%, respectively. AI-IQA takes only 0.05 s to assess each image, while experts require more than 20 s (p < 0.001).

CONCLUSIONS

The proposed AI-IQA system proved to be a highly accurate and efficient method of automatically auditing first-trimester scanning image quality, providing precise and rapid key plane quality control. This tool can also assist radiologists with different levels of experience to improve the image quality.

Evaluating the efficacy of low-molecular-weight heparin in managing umbilical artery thrombosis during pregnancy: does it offer therapeutic benefits?

Introduction

Umbilical artery thrombosis (UAT) is a rare but serious pregnancy complication, potentially causing fetal growth restriction, distress, and stillbirth. Diagnosis relies on Doppler ultrasound and pathological assessment. Close monitoring and potential low-molecular-weight heparin (LMWH) therapy aim to prolong gestation and improve outcomes, but debate persists on its efficacy compared to expectant management.

Methods

A retrospective study, conducted between January 2013 and December 2023, enrolled singleton pregnant women diagnosed with UAT during pregnancy. The experiment group included pregnant women who underwent LMWH with anti-coagulation therapy during pregnancy, while the expectant group comprised pregnancies that received standard prenatal care without any specific intervention for UAT.

Results

The expectant group showed a significant increase in birth weight (expectant vs. experiment: 2434.40 ± 770.20 g vs. 1874.46 ± 717.83 g, P < 0.05) and a significant decrease in the incidence of births before 34 weeks (expectant vs. experiment: 42.24% vs. 82.75%, P < 0.05). Gestational age at birth was notably higher in the expectant group as compared to the experiment group (35.32 ± 3.89 vs. 33.59 ± 4.17), although the difference did not reach statistical significance (p = 0.110). The multi-factor ANOVA revealed statistically significant effects of anti-coagulation therapy (F = 4.479, p = 0.039) and gestational age at birth (F = 179.110, p = 0.000) on birth weight. This study found that the relationship between these variables can be formulated as: birth weight = -3314.782-256.106 × anti-coagulation therapy (coded as 1 if yes and 0 if no) +161.858 × gestational age at birth.

Conclusion

Our study suggests that expectant therapy may offer substantial benefits compared to experimental therapy involving the administration of LMWH.

3rd trimester ultrasound assessment

The third-trimester scan allows not only the assessment of foetal growth but also its presentation and anatomy, and placental, amniotic fluid, and umbilical cord anomalies. Although there is a great disparity when considering its recommendation, most recent studies raise the question for its usefulness considering its impact in a potential reduction of perinatal morbidity and mortality. For this to be a reality in a population-wide setting, a systematic approach should be made considering performing it between 35 + 0 and 36 + 6 weeks', including the assessment of estimated foetal weight, foetal Doppler (umbilical and middle cerebral artery), placenta, amniotic fluid, foetal anatomy, and presentation. In high-risk cases, additional evaluation of the placenta, umbilical cord, or advanced foetal anatomy assessment can be warranted. Furthermore, pre-defined and evidence-based protocols should be followed after anomalies are detected in order to improve maternal and perinatal outcomes.

Second trimester echocardiography

Fetal echocardiography involves a comprehensive cardiac assessment aiming to make a complete structural examination of the heart as well as to detect signs of cardiovascular adaptation to different insults. For the former, this assessment entails expert's evaluation of the anatomy of the heart including additional views beyond the five axial views used in cardiac screening examinations and always complemented with colour and pulsed Doppler. Echocardiography may accurately diagnose most congenital heart defects in fetal life, which enables adjusting the perinatal management. For the latter, echocardiography encompasses cardiac morphometric assessment to identify signs of cardiac remodeling indicative of cardiac adaptation in structure, shape, and size in response to underlying diseases, and cardiac functional assessment to detect signs of systolic and/or diastolic dysfunction. The most used parameters to study the systolic function (stroke volume, cardiac output, ejection fraction, fractional shortening, and mitral and tricuspid annular plane systolic excursion), diastolic function (characteristics of flow in the precordial veins and through the atrioventricular valves) and global myocardial function (myocardial performance index) will be discussed in this review.

Concordance Between Estimated Fetal Weight by Ultrasound and Birth Weight and Its Association with Adverse Perinatal Outcomes

Objective: The aim of this study was to analyze the concordance between estimated fetal weight (EFW) and birth weight among ultrasound examinations with fetal biometry considered adequate and inadequate according to the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guidelines, and its association with adverse perinatal outcomes. Methods: This was a retrospective and cross-sectional study carried out in two centers, involving parturients who delivered between 37 and 41 weeks. The following parameters were evaluated: biparietal (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) measurement; EFW; the interval between the ultrasound and delivery; and the discrepancy between EFW and birth weight. A minimum of 140 participants were required to assess the association between EFW and birth weight. Results: A total of 305 ultrasound examinations were selected and divided into two groups: adequate (Group I n = 115) and inadequate (Group II n = 190) fetal biometry. The measurements of the cephalic pole (BPD + HC), AC, and FL were inadequate in 69.5% (132/190), 91.6% (175/190), and 72.1% (137/190) of participants, respectively. Group I had a lower gestational age at ultrasound examination (38.4 vs. 39.9 weeks, p < 0.001), a larger BPD measurement (93.9 vs. 91.6 mm, p = 0.001), a longer interval between ultrasound examination and delivery (3.8 vs. 2.0 days, p < 0.001), and a smaller discrepancy between EFW and birth weight (7.2 vs. 9.5%, p = 0.002) than Group II. In Group I, EFW was a strong significant predictor (AUC:0.94, 95%CI 0.85-0.99, p = 0.032) for identifying birth weight >4000 g. An EFW cut-off value of 4019.0 g was found to be a correct identifier for 85.7% of newborns with a birth weight >4000 g, with a false-positive rate of 13.7%. Group I had a lower risk of postpartum hemorrhage (7.0% vs. 15.8%, OR:0.39, 95%CI 0.17-0.90, p = 0.024) and composite adverse perinatal outcomes (13.0 vs. 23.3%, OR:0.49, 95%CI 0.26-0.94, p = 0.030) than Group II. In Group I patients, undergoing an ultrasound 7 days before delivery was an independent predictor of composite adverse perinatal outcomes [x2(1) = 4.9, OR:0.49, 95%CI: 0.26-0.94, R2 Nagelkerke:0.026, p = 0.030]. Conclusions: We observed a high rate of inadequate fetal biometry. There was poor concordance between EFW and birth weight. EFW was a strong significant predictor for identifying macrosomia. Ultrasound examination performed 7 days before delivery was an independent predictor of adverse perinatal outcomes.

Fetal Face: Enhancing 3D Ultrasound Imaging by Postprocessing With AI Applications: Myth, Reality, or Legal Concerns?

The use of artificial intelligence (AI) platforms is revolutionizing the performance in managing metadata and big data. Medicine is another field where AI is spreading. However, this technological advancement is not amenable to errors or fraudulent misconducts. International organization and recently the European Union have released principles and recommendations for an appropriate use of AI in healthcare. In prenatal ultrasound diagnosis, the use of AI in daily practice is having a revolutionary impact. Notwithstanding, the diagnostic enhancement should be regulated, and AI applications should be developed to guarantee correct imaging acquisition and further postprocessing.

Outcomes of pregnancies diagnosed with absent or abnormal fetal gallbladder in a tertiary center

OBJECTIVE

The objective of this study was to investigate the ultrasonographic characteristics and outcomes of fetuses with atypical and non-visualized fetal gallbladder in our tertiary care hospital.

METHODS

A retrospective analysis was conducted on cases in which the fetal gallbladder was not visualized or exhibited atypical characteristics at our institution over a four-year period. The patients were divided into two groups: absent gallbladder and atypical gallbladder. The groups with isolated and additional anomalies were analyzed according to their ante- and postnatal characteristics.

RESULTS

The study comprised 78 patients (37 absent, 41 atypical gallbladder). In the isolated fetal absence of gallbladder group, the gallbladder was visualized in three of 13 patients during antenatal ultrasonographic follow-up and in half of the remaining 10 patients during postnatal follow-up. In the postnatal period, five newborns with absent isolated gallbladder are being followed up with suspicion of biliary atresia and isolated gallbladder agenesis. In the absence of a gallbladder with an additional anomaly group, 58% of fetuses died during the intrauterine and neonatal period. Fetuses in the isolated atypical gallbladder group are being followed as healthy after birth. Pregnancies with atypical gallbladder appearance and additional anomalies resulted in 33% neonatal death, 12% intrauterine demise, and 25% termination of pregnancy.

CONCLUSION

In instances where the fetal gallbladder is not consistently discernible, it is imperative to exercise caution with regard to the possibility of biliary atresia. In the event that the fetal gallbladder exhibits unusual characteristics, a meticulous examination for the presence of additional anomalies is recommended.

Fetal bilateral hyperechogenic kidneys: Prenatal progression and long-term postnatal outcome

OBJECTIVE

To determine the prenatal progression and long-term outcome of fetal bilateral hyperechogenic kidneys (HK).

DESIGN

Retrospective study 2005-2016. Fetal/maternal demographics, scan findings, postnatal diagnoses and outcomes were collected from electronic patient records and post-mortem reports.

RESULTS

Data available for 65 out of 72 fetuses with bilateral HK. Forty-five (69 %) had normal amniotic fluid index (AFI); of these, 23 had isolated HK and all survived the neonatal period. The remaining patients with normal AFI had other renal and multi-system anomalies; diagnoses included 13 trisomies and genetic syndromes - only one patient with suspected bladder outlet obstruction survived. Of 20 pregnancies with reduced AFI, HK were isolated in 5 fetuses, and only one survived (diagnosed with 17q12 microdeletion). The remaining 15 fetuses had multisystem anomalies and none survived; diagnoses included Meckel-Gruber Syndrome and Dandy-Walker malformation. Survival with bilateral HK and oligohydramnios was 5 %. Overall survival was 25/65 (38 %); follow-up data was available for 23 patients. HK resolved in 17 (74 %) and persisted in 6 children, who were followed-up for median 15 years (4-19 years). Of these, 3 patients developed bilateral renal cysts and were diagnosed with HNF1b/17q12 deletion kidney disease (one patient is in CKD2a, whereas the rest have normal renal function). The remaining patients were found to have a PKD1 variant; bilateral renal cysts (lost to follow-up before a genetic diagnosis) and a unilateral hydronephrosis: all have normal renal function.

CONCLUSION

Isolated HK with normal AFI is associated with survival past the neonatal period and normal renal function in most cases (96 %). As normal kidney function may be due to glomerular hyperfiltration in early childhood to teenage years, long-term follow up is advisable, in particular for those with a genetic diagnosis that predisposes to chronic renal impairment in adulthood (HNF1b, 17q12 deletion in this study). HK in the presence of reduced AFI carries a poor prognosis, with only 5 % survival (this patient had 17q12 deletion related kidney disease). Overall survival in this study was 38 % in the first year and 34 % long-term.

Transfer learning method for prenatal ultrasound diagnosis of biliary atresia

Biliary atresia (BA) is a rare and severe congenital disorder with a significant challenge for prenatal diagnosis. This study, registered at the Chinese Clinical Trial Registry (ChiCTR2200059705), aimed to develop an intelligent model to aid in the prenatal diagnosis of BA. To develop and evaluate this model, fetuses from 20 hospitals across China and infants sourced from public database were collected. The transfer-learning model (TLM) demonstrated superior diagnostic performance compared to the basic deep-learning model, with higher area under the curves of 0.906 (95%CI: 0.872-0.940) vs 0.793 (0.743-0.843), 0.914 (0.875-0.953) vs 0.790 (0.727-0.853), and 0.907 (0.869-0.945) vs 0.880 (0.838-0.922) for the three independent test cohorts. Furthermore, when aided by the TLM, diagnostic accuracy surpassed that of individual sonologists alone. The TLM achieved satisfactory performance in predicting fetal BA, providing a low-cost, easily accessible, and accurate diagnostic tool for this condition, making it an effective aid in clinical practice.

Sonographic visualization and measurement of the fetal optic chiasm and optic tract and association with the cavum septum pellucidum

OBJECTIVES

To assess the sonographic visualization of the fetal optic chiasm (OC) and optic tracts (OTs), establish mid-trimester reference values, and assess the relationship between OC and OT dimensions and cavum septum pellucidum (CSP) measurements.

METHODS

This prospective cross-sectional study included 154 morphologically normal fetuses between 19 and 23 weeks of gestation. The diameters of the fetal OC and OTs were measured using two-dimensional transabdominal ultrasound in a transventricular axial section angled approximately 20-40° caudally. CSP length as well as anterior, middle, and posterior widths were measured by placing the cursor on the inner surfaces in the transventricular section. The average CSP width was included in the analysis.

RESULTS

The OC and OTs were successfully visualized in 109 fetuses and included in the analysis. Visualization success in transabdominal axial sections at 19-23 weeks was 70.8 %, with high intraobserver and interobserver reproducibility. Additionally, visualization rates were higher in advanced gestational weeks and in fetuses with breech presentation (p=0.007 and p=0.017, respectively). OC and OT dimensions were positively correlated with CSP length and width, biparietal diameter (BPD), head circumference (HC), and gestational age (p<0.05, for all).

CONCLUSIONS

The OC and OTs were successfully visualized transabdominally in axial sections with high intraobserver and interobserver reproducibility. Additionally, OC and OT dimensions were positively correlated with gestational age, as well as with BPD, HC, and CSP measurements.

Unravelling complexity: simultaneous detection of fetal omphalocele and myelomeningocele misdiagnosed as sacrococcygeal teratoma

Targeted imaging for fetal anomalies (TIFFA) is an important antenatal ultrasound scan to detect any congenital anomalies in the growing fetus, and the results assist the clinician to make the required decision for the remainder of pregnancy. The scan totally depends on the operator and his/her skills to pick up an abnormality correctly. If the ultrasound scan is not performed accurately with proper precision and focus, then many anomalies can be missed or even misdiagnosed potentially. Therefore, it is pertinent to pay specific attention to details and devote a dedicated time to each and every TIFFA scan for the thorough and correct evaluation to prevent any mistake. Our case highlights one such example of an incomplete and misdiagnosed congenital abnormality, detected outside, which was ultimately proven to be a completely different congenital anomaly along with the presence of another synchronous abnormality, all detected together at our institute.

Fetal imaging, phenotyping, and genomic testing in modern prenatal diagnosis

Genetic tests available in the prenatal setting have expanded rapidly with next generation sequencing, and fetal imaging can detect a breadth of many structural and functional abnormalities. To identify a fetal genetic disease, deep phenotyping is increasingly important to generate a differential diagnosis, choose the most appropriate genetic tests, and inform the results of those tests. The Human Phenotype Ontology (HPO) organizes and defines the features of human disease to support deep phenotyping, and ongoing efforts are being made to improve the scope of the HPO to comprehensively include fetal phenotypes. There are important limitations of fetal phenotyping to understand, including ongoing structural development and limited knowledge of how many genetic diseases present uniquely in utero. This article provides an overview of the use of HPO terms and artificial intelligence in the approach to fetal phenotyping and genetic testing.

The Prenatal Ultrasound Diagnosis and Perinatal Outcome of Polydactyly: A Retrospective Cohort Study, 2016-2023

OBJECTIVE

To determine the significance of polydactyly identified on prenatal ultrasonography and provide a detailed analysis of characteristics and perinatal outcomes of fetal polydactyly.

METHODS

This is a retrospective cohort study of pregnancies with a postnatal diagnosis of fetal polydactyly between January 2016 and December 2023. The population was divided into 2 groups at postnatal diagnosis: the isolated polydactyly group and the nonisolated polydactyly group. Clinical data, prenatal ultrasonography, related genetic results, and postnatal outcomes were obtained.

RESULTS

Our study cohort comprised 328 fetuses with polydactyly. The overall detection rate of polydactyly by prenatal ultrasound was 19.2%, and the first detection rate in the first-, second-, and third-trimester were 0.9%, 14.6%, and 3.7%, respectively. Preaxial polydactyly (PPD) of hand was the most common type and the most common type of foot polydactyly was postaxial polydactyly (PAP) both in the isolated group and in the nonisolated group; the central polydactyly is rare. Syndactyly was the most common abnormality complicated with polydactyly. Between the nonpolydactyly group, the isolatedpolydactyly group and the nonisolated polydactyly group, there was a significant difference in perinatal outcome (P < .001).

CONCLUSION

The second trimester is the best gestational age for prenatal ultrasound detection of polydactyly. Polydactyly of hand was more likely PPD, while polydactyly of foot was more likely PAP. When polydactyly is detected by routine prenatal ultrasound, detailed ultrasound examination and prenatal counseling should be performed to determine the possibility of an underlying genetic syndrome.

Sleep quality during pregnancy and fetal growth: A prospective cohort study

The aim of this study is to investigate the association between sleep quality during pregnancy and fetal growth. Pregnant women and their fetuses at 16-20 gestational weeks in Nantong Maternal and Child Health Hospital were recruited. Women were classified as having "good sleep quality" (Pittsburgh Sleep Quality Index score ≤ 5) and "poor sleep quality" (Pittsburgh Sleep Quality Index score > 5) according to the Pittsburgh Sleep Quality Index scores. The fetal growth was evaluated by three ultrasonographic examinations, birth weight and birth length. We used general linear model and multiple linear regression models to estimate the associations. A total of 386 pairs of mother and infant were included in the data analysis. After adjusting for gestational weight gain, anxiety and depression, fetuses in the good sleep quality group had greater abdominal circumference (p = 0.039 for 28-31+6 weeks gestation, p = 0.012 for 37-40+6 weeks gestation) and femur length (p = 0.014 for 28-31+6 weeks gestation, p = 0.041for 37-40+6 weeks gestation) at 28-31+6 weeks gestation and 37-40+6 weeks gestation, and increased femur length (p = 0.007) at 28-31+6 weeks gestation. Birth weights (p = 0.018) were positively associated with sleep quality. Poor sleep quality was associated with poor intrauterine physical development, decreased abdominal circumference and femur length, and lower birth weight after adjusting for confounding factors. Attention to the fetal growth of pregnant women with poor sleep quality has the potential to decrease the risk of adverse fetal outcomes.

Evaluation of Fetal Heart Using Fetal Heart Quantification (fetalHQ) Technique in an Indian Cohort

OBJECTIVE

To evaluate the intra- and interobserver reproducibility of parameters used to determine cardiac morphometry and deformation using FetalHQ in Indian population.

METHODOLOGY

Two operators blinded to each other performed FetalHQ analysis independently on 35 normal fetuses of gestational age between 18 + 0 and 37 + 0 weeks and days. Intra- and interobserver correlation coefficient and limits of agreement were ascertained for parameters obtained from HQ analysis.

RESULTS

Excellent reproducibility (ICC > 0.9) was observed for global morphometric parameters. Ejection fraction, stroke volume, stroke volume/kg demonstrated excellent reliability (ICC > 0.9), cardiac output, fractional area change showed a lower correlation (ICC < 0.8), and right and left ventricular global strain showed no correlation. Twenty-four segment sphericity index of left ventricle (LV) and right ventricle (RV) showed low to moderate correlation (LV-ICC 0.48-0.79; RV-ICC 0.43-0.82). Fractional shortening (FS) showed poor intraobserver reliability in RV.

CONCLUSION

FetalHQ provides reliable estimates of the global cardiac morphometry but not for global cardiac strain. Regional transverse contractility represented by FS has poor correlation in right ventricle, especially in the apical region, possibly due to moderator band. Nevertheless, it is a promising tool which requires technical advancements and validation to improve its accuracy and reliability.

Association of uterine fibroids with late miscarriage: multicenter cohort study

OBJECTIVE

To investigate the correlation between the number, location and size of uterine fibroids and the incidence of late miscarriage during pregnancy.

METHODS

This was a retrospective, multicenter cohort study of singleton pregnancies, with a live fetus at the first-trimester ultrasound examination, without known genetic anomalies or major fetal defects, from January 2012 to December 2022. We assessed the impact of fibroids and their characteristics, identified on ultrasound imaging at 11 + 0 to 13 + 6 weeks, on the risk of late miscarriage occurring at 11 + 0 to 21 + 6 weeks. Fibroid number, location and size were investigated, and adjusted odds ratios (aORs) with 95% CIs were calculated using multiple logistic regression and propensity score analysis via inverse probability of treatment weighting (IPTW) to minimize confounding. Singleton pregnancies without uterine fibroids comprised the control group. We further calculated the adjusted absolute risk (aAR) for the control group and the adjusted risk differences (aRD) for the study groups.

RESULTS

In total, 31 355 singleton pregnancies were analyzed, of which 942 (3.0%) had uterine fibroids. Multiple logistic regression analysis showed that pregnancies with a single fibroid did not have higher odds for late miscarriage compared to those without fibroids (aOR, 1.2 (95% CI, 0.6-2.4)), but women with multiple fibroids did have higher odds of late miscarriage (aOR, 2.5 (95% CI, 1.0-6.2)). Similarly, multiple logistic regression analysis after IPTW did not find higher odds of late miscarriage in pregnancies with a single fibroid (aOR, 1.7 (95% CI, 0.9-3.0) and aRD, 0.7% (95% CI, -0.2 to 2.1%)) but revealed increased odds of late miscarriage in women with multiple fibroids (aOR, 2.9 (95% CI, 1.1-7.3) and aRD, 2.0% (95% CI, -0.6 to 9.7%)). Analysis of the location of single fibroids revealed that submucosal fibroids significantly increased the odds of late miscarriage by 4.7 times, while the presence of fibroids in other locations did not have a statistically significant association with late miscarriage. When we limited our study population to cases with submucosal and intramural fibroids, logistic regression showed no significant increase in the odds of miscarriage for a single fibroid (aOR, 1.8 (95% CI, 0.9-3.5) and aRD, 1.2% (95% CI, -0.1 to 3.1%)), but revealed significantly higher odds for multiple fibroids (aOR, 3.8 (95% CI, 1.4-10.6) and aRD, 5.1% (95% CI, 0.6-22.0%)) compared with controls. IPTW analysis found a 2.3-fold increase in the odds of late miscarriage for a single fibroid (aOR, 2.3 (95% CI, 1.2-4.2)) and an even larger increase in the odds of late miscarriage for multiple fibroids (aOR, 5.7 (95% CI, 2.2-15.1)).

CONCLUSION

Uterine fibroids are associated with increased odds of late miscarriage, particularly when they are multiple and submucosal. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

The Intrauterine Treatment of Open Spinal Dysraphism

BACKGROUND

Open spinal dysraphism is a congenital malformation that causes major morbidity. Its consequences include sensory and motor impairment as well as bladder- and bowel dysfunction. It is often also associated with prenatal ventriculomegaly, which, in turn, necessitates postnatal treatment with a ventriculoperitoneal shunt in approximately 80% of cases. Prenatal therapy with coverage of neural tube defect can reduce the shunt rate and preserve motor function. In this review, we describe the different surgical procedures and their outcomes.

METHODS

This review is based on publications that were retrieved by a selective literature search in the MEDLINE, Web of Science, EMBASE, Scopus, and Cochrane databases, employing pertinent keywords. Studies of all types (except case reports) that were published in English or German in the period 2010-2024 were included.

RESULTS

The randomized, controlled MOMS trial showed that intrauterine surgery for defect closure resulted in less progressive neural tissue damage than postnatal surgery and reduced the need for shunting by approximately half (40% vs. 82%). Since the publication of these results, various prenatal surgical procedures have been established, including hysterotomy-assisted, percutaneous fetoscopic, and laparotomy-assisted fetoscopic closure. The individual surgical methods yield comparable results in terms of motor function and shunt rate. A problem with these procedures is that they increase the likelihood of preterm birth, to an extent that varies from one type of procedure to another.

CONCLUSION

Prenatal surgery improves motor function and reduces the shunt rate but long-term outcomes beyond adolescence are still lacking. Transparent and interdisciplinary counseling is essential in prenatal communication to inform parents not only about the potential benefits of this treatment, but also about its limitations and risks.

Screening for Structural Heart Defects: A Single-Center Retrospective Cost Analysis for Fetal Echocardiography in Adults with Congenital Heart Disease

Fetal echocardiography (FE) is recommended for parents with congenital heart disease (pCHD) due to a 3-6% recurrence risk of congenital heart disease (CHD). This study aimed to evaluate the cost of FE for detecting neonatal CHD in pCHD. FE data were collected between 12/2015 and 12/2022. Parents were stratified by CHD complexity: "simple" (class I) and "complex" (class II/III). Cost analysis compared universal FE with selective FE following a positive level II screening anatomical ultrasound (SAU). Primary outcomes included the cost and number needed to screen (NNT) to detect one case of neonatal CHD. Of 419 pCHD cases, 48 were analyzed separately due to additional FE indications. Among the remaining 371 cases (73% maternal, 27% paternal; mean maternal age: 31 years), 14 postnatal CHD cases were detected (3.8%). Recurrence rates were 1.9% for simple pCHD (n = 156) and 5.1% for complex pCHD (n = 215). Universal FE increased the cost of detecting neonatal CHD. The cost per detected case was $267,157 for simple CHD (NNT = 560) and $135,125 for complex CHD (NNT = 288). The lower sensitivity of SAU reduced the cost of universal FE. In this single-center cohort, the recurrence risk of CHD in pCHD is higher than in the general population, particularly in complex cases. Universal screening in simple pCHD is costlier with high-sensitivity SAU. Targeted screening in complex pCHD may offer a better cost-to-risk ratio, highlighting the need for early detection to improve outcomes. The cost effectiveness is dependent on local SAU sensitivity rates.

Whole examination AI estimation of fetal biometrics from 20-week ultrasound scans

The current approach to fetal anomaly screening is based on biometric measurements derived from individually selected ultrasound images. In this paper, we introduce a paradigm shift that attains human-level performance in biometric measurement by aggregating automatically extracted biometrics from every frame across an entire scan, with no need for operator intervention. We use a neural network to classify each frame of an ultrasound video recording. We then measure fetal biometrics in every frame where appropriate anatomy is visible. We use a Bayesian method to estimate the true value of each biometric from a large number of measurements and probabilistically reject outliers. We performed a retrospective experiment on 1457 recordings (comprising 48 million frames) of 20-week ultrasound scans, estimated fetal biometrics in those scans and compared our estimates to real-time manual measurements. Our method achieves human-level performance in estimating fetal biometrics and estimates well-calibrated credible intervals for the true biometric value.

Effect of abnormal placental cord insertion on hemodynamic change of umbilical cord in a tertiary center: a prospective cohort study

BACKGROUND

Our study aims to evaluate the umbilical vein (UV) hemodynamic change in the prenatal cohort of pregnancies diagnosed with abnormal placental cord insertion (aPCI).

METHODS

From January 2022 to December 2022, the fetal umbilical cord insertion site was sonographically examined in singleton fetuses, and umbilical cord blood flow was calculated. The umbilical artery and UV Doppler flow indexes were assessed in cases of normal and abnormal cord insertion.

RESULTS

Among 570 singleton fetuses between 18 + 0 and 40 + 6 weeks of gestation in the final study, the umbilical vein blood flow (UVBF) in the 3 groups of normal umbilical cord insertions, marginal umbilical cord insertions, and velamentous umbilical cord insertions was 145.39 ml/min, 146.18 ml/min, and 93.96 ml/min, respectively. UVBF was significantly lower in the velamentous cord insertion (VCI) group than in the other groups (P < 0.05). Compared with the normal cord insertions group, lower birth weight (2820 ± 527 g vs. 3144 ± 577 g, P < 0.05), delivery at an earlier gestational age (38.0 ± 1.55 weeks vs. 38.8 ± 2.34 weeks, P < 0.05), higher bicarbonate (25.08 ± 1.72 mmol/L vs. 22.66 ± 4.05 mmol/L, P < 0.05), and higher standard base excess (-1.14 ± 1.50 mmol/L vs. -3.30 ± 3.22 mmol/L, P < 0.05) were found in the VCI group.

CONCLUSIONS

We observed lower UVBF volume with aPCI. Hence, we propose UVBF analysis to evaluate fetal aPCI according to UV hemodynamics as an advisory in prenatal care. This would be useful and improve obstetricians' clinical explanation about the potential prenatal consequences so that parents can opt for future prenatal care during pregnancy.

CLP-Net: an advanced artificial intelligence technique for localizing standard planes of cleft lip and palate by three-dimensional ultrasound in the first trimester

BACKGROUND

Early diagnosis of cleft lip and palate (CLP) requires a multiplane examination, demanding high technical proficiency from radiologists. Therefore, this study aims to develop and validate the first artificial intelligence (AI)-based model (CLP-Net) for fully automated multi-plane localization in three-dimensional(3D) ultrasound during the first trimester.

METHODS

This retrospective study included 418 (394 normal, 24 CLP) 3D ultrasound from 288 pregnant woman between July 2022 to October 2024 from Shenzhen Guangming District People's Hospital during the 11-13+ 6 weeks of pregnancy. 320 normal volumes were used for training and validation, while 74 normal and 24 CLP volumes were used for testing. Two experienced radiologists reviewed three standard lip and palate planes (mid sagittal, retronasal triangle, and maxillary axial planes) as ground truth (GT) and the CLP-Net was developed to locate these planes.

RESULTS

In normal test set, mean angle(± SD)° and distance(± SD)mm differences were 6.24 ± 4.83, 9.81 ± 5.48, 15.36 ± 18.14 and 0.86 ± 0.72, 1.36 ± 1.15, 1.96 ± 2.35 for MSP ± SD, RTP ± SD and MAP ± SD, NCC and SSIM were 0.931 ± 0.079, 0.819 ± 0.122, 0.781 ± 0.157 and 0.896 ± 0.058, 0.785 ± 0.076, 0.726 ± 0.088 respectively. In the CLP cases, there were 8.61 ± 5.52, 10.67 ± 5.08, 16.91 ± 17.42 and 1.03 ± 1.20, 1.17 ± 1.08, 1.34 ± 0.95 for mean angle and distance in MSP, RTP, and MAP, respectively. NCC and SSIM were 0.876 ± 0.104, 0.803 ± 0.084, 0.793 ± 0.089 and 0.841 ± 0.105, 0.812 ± 0.085, 0.764 ± 0.100, respectively. CLP-Net predictions had a highly visual acceptance rate among radiologists (MSP: 95%, RTP: 70%, MAP: 70%), with improved localization speed 15s(31.3%) for senior radiologists and 63s(38.9%) for junior radiologists.

CONCLUSIONS

CLP-Net accurately locates three planes for CLP screening, aiding radiologists and enhancing the efficiency of ultrasound examinations.

Can cavum septum pellucidum width and length measurements also be reliable indicators of corpus callosum measurements in normal fetuses?

OBJECTIVE

To examine the association between cavum septum pellucidum (CSP) and corpus callosum (CC) length and width measurements in mid-trimester sonographic screening in normal fetuses.

METHODS

This prospective cohort study examined 152 pregnant women who underwent mid-trimester sonographic fetal anomaly screening. CSP and CC lengths and their anterior, middle, and posterior width measurements were examined sonographically. The association between length and width measurements of both structures, gestational week and CSP ratio (length/width) were evaluated.

RESULTS

The mean CSP length was 7.96 ± 1.09 mm, and the mean middle width was 3.43 ± 0.82 mm. The mean CC length was 20 ± 3.76 mm, and the mean middle width was 3.43 ± 0.82 mm. There was a positive correlation between CSP and CC lengths (r = 0.691, p < 0.001). There was also a significant correlation between CSP and CC anterior, middle and posterior widths (anterior (r = 0.366, p < 0.001), middle (r = 0.305, p < 0.001), and posterior (r = 0.233, p = 0.004)). All CSP and CC measurements were correlated with gestational age, biparietal diameter (BPD), and head circumference (HC) (p < 0.001, for all). The CSP ratio was not related to CC dimensions (p > 0.05, for all) and also decreased with the increase in BPD and HC dimensions (r = -0.186, p = 0.022, and r = -0.174, p = 0.032; respectively).

CONCLUSION

In normal fetuses, the length and width of the CC and CSP structures developed in relation to each other, as well as to the gestational week, BPD, and HC dimensions. In addition, while the CSP ratio was not found to be associated with CC dimensions, it decreased due to the increase in BPD and HC sizes.

Factors affecting the accuracy of fetal cardiac ultrasound screening in the first trimester of pregnancy

PURPOSE

Most studies on the performance of first-trimester cardiac screening have concentrated on comparing the detection rate between different protocols and not on the actual reason for false-negative results. Herein, we report the performance of first-trimester congenital heart disease (CHD) screening and factors that may affect the detection rate of CHDs.

METHODS

This retrospective observational study included patients who underwent first-trimester screening and subsequently gave birth at our facility. We analyzed the performance of first-trimester screening for CHD and major CHD (CHD requiring cardiac surgery or interventional catheterization within 12 months of birth).

RESULTS

Of the 6614 fetuses included, 53 had CHD and 35 had major CHD. For the prenatal diagnosis of CHD, the detection rate, specificity, positive predictive value, negative predictive value, and first-trimester detection rate for CHD were 64.1%, 99.9%, 94.4%, 99.7%, and 82.9%, respectively; the respective values for major CHD were 85.7%, 99.96%, 93.75%, 99.92%, and 85.7%. The detection rate was not significantly different when classified by crown-rump length or number of fetuses. A weak correlation was observed between low detection rate of major CHD and lower maternal body mass index (BMI) (correlation ratio: 0.17). The detection rate was significantly higher when the fetus was scanned with its spine at the 5-7 o'clock position (posterior spine) than at other positions (odds ratio: 3.82, 95% confidence interval: 1.16-12.5, p = 0.02).

CONCLUSION

Posterior spine contributes to an improved diagnostic rate in first-trimester CHD screening. In addition, sonographers must recognize that low maternal BMI is a risk factor of false-negative results.

Expanded phenotypes and pathogenesis of geleophysic dysplasia 3 resulted from a de novo LTBP3 mutation: A case report

RATIONALE

The aim of this study is to investigate the de novo mutation and clinical features of latent transforming growth factor-beta-binding protein 3 (LTBP3) gene-associated geleophysic dysplasia 3, and possible mechanisms of action.

PATIENT CONCERNS

A nonconsanguineous couple was recruited for this study due to the presence of intrauterine growth restriction. The pregnant woman and her elder daughter presented with skeletal abnormalities with diabetes. The pregnant woman underwent amniocentesis for cytogenetic analysis and copy number variation sequencing. Furthermore, we employed a combination of pedigree whole exome sequencing and bioinformatics analysis to predict the effects of mutations.

DIAGNOSES

The results of karyotyping and copy number variation sequencing were normal. And the whole exome sequencing results indicated that the family carried a de novo mutation c.852_853insAGG (p.L284_P285insR) in the LTBP3 gene (NM_001130144.3) inherited from the mother. The results of bioinformatics prediction demonstrated the mutation influenced the stability of the LTBP3 gene, thereby enhanced the transforming growth factor β signaling pathways.

INTERVENTIONS

The couple terminated the pregnancy after comprehensive consideration.

OUTCOMES

A de novo non-frameshift mutation of the LTBP3 gene might enhance the transforming growth factor β signaling pathways, thereby leading to geleophysic dysplasia 3.

LESSONS

As a rare multi-system musculoskeletal disorder, geleophysic dysplasia 3 necessitates early prenatal diagnosis and multidisciplinary consultation in order to facilitate further diagnosis and evaluation of the patient and the fetus.

Cost-effectiveness analysis of AI-based image quality control for perinatal ultrasound screening

PURPOSE

This study aimed to compare the cost-effectiveness of AI-based approaches with manual approaches in ultrasound image quality control (QC).

METHODS

Eligible ultrasonographers and pregnant volunteers were prospectively recruited from the Hunan Maternal and Child Health Hospital in May 2023. The ultrasonographers were randomly and evenly assigned to either the AI or Manual QC groups with baseline scores determined in June-July. From August to October, these groups received real-time AI or post-scan manual QC with post-interventional scores recorded monthly. We applied the repeated measures analysis of variance to analyze the between-subject and within-subject effectiveness and time trends in effectiveness (QC score improvement) assessment. An extra 50 pregnant volunteers underwent real-time manual QC, with their screening images utilized for post-scan AI and manual QC. The time cost of real-time AI QC was zero since it only required trainees' involvement. We used Friedman's M and Quade tests to compare multiple independent medians in cost assessment.

RESULTS

This study recruited 14 ultrasonographers, equally divided into the AI and Manual QC groups. No significant difference existed between the groups concerning age, service year in perinatal diagnosis, male proportion, and QC frequency. The simple effect of the group revealed that the AI QC method outperformed the Manual QC method at least once (F = 13.113, P = 0.004, η2 = 0.522). The simple effect of the month in the AI QC groups indicated an improvement in the mean QC scores (F = 9.827, P = 0.003, η2 = 0.747) while that of manual QC groups suggested no improvement (F = 0.144, P = 0.931, η2 = 0.041). Baseline scores were equal in June-July (F = 0.031, P = 0.864, η2 = 0.003). However, the AI QC group surpassed the Manual QC group in August (F = 14.579, P = 0.002, η2 = 0.549), September (F = 28.590, P < 0.001, η2 = 0.704), and October (F = 35.411, P < 0.001, η2 = 0.747). Within the Manual QC group, no significant differences were found in scores between June-July and August, September, or October (all P values of 1.000, nominal significance level of 0.0083). In contrast, the AI QC group showed significantly higher scores in August, September, and October compared to June-July (all P values of 0.001, nominal significance level of 0.0083). The time costs of real-time AI QC, post-scan AI QC, post-scan manual QC, and real-time manual QC were 0 s, 13.76 s (interquartile range, IQR: 4.79-46.79 s), 1239.50 s (IQR: 1141.00-1311.25 s), and 1541.00 s (IQR: 1453.50-1635.25 s), with significant differences in both overall and multiple comparisons.

CONCLUSIONS

The AI QC method, more cost-effective than the manual method, shows great potential for application in image QC scenarios. The AI QC can enhance operators' skills in perinatal ultrasound screening, while the manual method can only maintain the existing level.

Fetal Isolated Single Umbilical Artery (ISUA) and Its Role as a Marker of Adverse Perinatal Outcomes

Single umbilical artery (SUA) is considered an ultrasound marker of anomalies. Although it may be present in about 0.5% to 6% of normal pregnancies, it has been linked with an increased risk of fetal growth restriction (FGR), as well as cardiac, genitourinary and gastrointestinal malformations and chromosomal anomalies such as trisomies 21 and 18. Objectives: This study aims to evaluate whether the presence of isolated SUA (ISUA) is associated with adverse perinatal outcomes. Methods: A descriptive, observational and retrospective study was conducted, analyzing 1234 pregnancies (1157 normal gestations with a three-vessel cord and 77 cases of ISUA). Results: ISUA was associated with a lower gestational age (38 vs. 39 weeks) and a lower birth weight (3013 vs. 3183 g) when performing a univariate analysis. However, after performing a multivariate analysis adjusted for maternal age and BMI, the association between single umbilical artery (SUA) and lower birth weight could not be proven. No significant differences were found in the rate of malformations, genetic disorders, Apgar score, pH at birth or admissions in the neonatal ICU. Conclusions: ISUA is associated with a lower birth weight but does not increase the risk of prematurity or low-birth-weight-related neonatal admissions. Additionally, ISUA is not significantly associated with a lower gestational age, genetic disorders, fetal malformations, worse Apgar scores or lower pH values at birth.

Automated craniofacial biometry with 3D T2w fetal MRI

OBJECTIVES

Evaluating craniofacial phenotype-genotype correlations prenatally is increasingly important; however, it is subjective and challenging with 3D ultrasound. We developed an automated label propagation pipeline using 3D motion- corrected, slice-to-volume reconstructed (SVR) fetal MRI for craniofacial measurements.

METHODS

A literature review and expert consensus identified 31 craniofacial biometrics for fetal MRI. An MRI atlas with defined anatomical landmarks served as a template for subject registration, auto-labelling, and biometric calculation. We assessed 108 healthy controls and 24 fetuses with Down syndrome (T21) in the third trimester (29-36 weeks gestational age, GA) to identify meaningful biometrics in T21. Reliability and reproducibility were evaluated in 10 random datasets by four observers.

RESULTS

Automated labels were produced for all 132 subjects with a 0.3% placement error rate. Seven measurements, including anterior base of skull length and maxillary length, showed significant differences with large effect sizes between T21 and control groups (ANOVA, p<0.001). Manual measurements took 25-35 minutes per case, while automated extraction took approximately 5 minutes. Bland-Altman plots showed agreement within manual observer ranges except for mandibular width, which had higher variability. Extended GA growth charts (19-39 weeks), based on 280 control fetuses, were produced for future research.

CONCLUSION

This is the first automated atlas-based protocol using 3D SVR MRI for fetal craniofacial biometrics, accurately revealing morphological craniofacial differences in a T21 cohort. Future work should focus on improving measurement reliability, larger clinical cohorts, and technical advancements, to enhance prenatal care and phenotypic characterisation.

Counselling in Fetal Medicine: Complications of Monochorionic Diamniotic Twin Pregnancies

Twin pregnancies are at increased risk of morbidity and mortality compared to singletons. Among all twins, monochorionic pregnancies are at higher risk of specific and non-specific complications compared to dichorionic pregnancies. Therefore, it is of great importance to properly counsel future parents with monochorionic pregnancies regarding the risks of adverse outcomes and the modalities of monitoring and intervention of the potential complications. Conditions related to the monochorionicity include twin-to-twin transfusion syndrome (TTTS), twin reversed arterial perfusion sequence (TRAP), and twin anemia polycythemia syndrome (TAPS); other complications include selective fetal growth restriction (sFGR) and congenital anomalies. This review aims to summarize the information available in the current literature regarding the complications in monochorionic diamniotic twin pregnancies, including outcomes and guideline recommendations about the clinical surveillance, management, and timing of interventions of these conditions that should be included in counselling in routine clinical practice.