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Role of Sonographic Second Trimester Soft Markers in the Era of Cell-Free DNA Screening Options: A Review. REPRODUCTIVE MEDICINE 2022. [DOI: 10.3390/reprodmed3030017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Soft markers are sonographic structural, nonspecific signs with little pathological significance, often transient, usually considered as normal variants. However, they may also be associated with chromosomal abnormalities. The most widely examined soft markers include absent or hypoplastic nasal bone (NB), intracardiac echogenic focus (IEF), ventriculomegaly (VM), thickened nuchal fold (NF), choroid plexus cyst (CPC), echogenic bowel, short long bones, and urinary tract dilation (UTD). Although the use of noninvasive prenatal testing (NIPT) has been spreading quickly in maternal–fetal medicine, it is not a diagnostic test and it still remains unavailable or cost-prohibitive for most of the population in many countries. After normal screening test results in the first trimester, there is no uniform consensus regarding the clinical significance of isolated soft markers for aneuploidy. Nowadays, the search for soft markers in an ultrasound is still part of clinical evaluation, and the interpretation of these findings is often a matter of debate. In the present review, we summarize the recent literature about the role of soft markers in the era of NIPT and propose an overview of the different clinical guidelines.
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Bernardeco J, Cruz J, Rijo C, Cohen Á. Nasal bone in fetal aneuploidy risk assessment: are they independent markers in the first and second trimesters? J Perinat Med 2022; 50:462-466. [PMID: 35085431 DOI: 10.1515/jpm-2021-0562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/12/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES In the mid-trimester ultrasound, nasal bone (NB) length can be used to correct the a priori risk for trisomy 21. Our study aims to evaluate if there is a correlation between an absent NB in the first trimester and a hypoplastic NB in the second trimester. METHODS Our two year retrospective analysis of data derived from routine clinical practice. Single euploid fetuses were included. The NB was assessed in both trimesters according to international guidelines and transformed into categorical variables. Logistic regression was performed in order to accomplish our main objective. RESULTS From the 759 normal pregnancies included, 45 (5.93%) had abnormal NB in the first trimester and 23 (3%) in the second trimester. Eleven cases (47.8%) of the abnormal NB in the second trimester were abnormal in the 11-14 weeks scan. After the diagnosis of an absent NB in the first trimester the odds ratio (OR) for a hypoplastic NB in the second trimester is 18.926 (7.791-45.977; p-value <0.01). CONCLUSIONS Our data suggest a strong association between the NB in the first and in the second trimester in normal euploid fetuses. This is important information to consider when counseling patients on the basis of this ultrasound marker.
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Affiliation(s)
- Joana Bernardeco
- Obstetrics and Gynecology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Jader Cruz
- Fetal Medicine Unit, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Claudia Rijo
- Fetal Medicine Unit, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Álvaro Cohen
- Fetal Medicine Unit, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
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Hu T, Tian T, Zhang Z, Wang J, Hu R, Xiao L, Zhu H, Lai Y, Wang H, Liu S. Prenatal chromosomal microarray analysis in 2466 fetuses with ultrasonographic soft markers: a prospective cohort study. Am J Obstet Gynecol 2021; 224:516.e1-516.e16. [PMID: 33122027 DOI: 10.1016/j.ajog.2020.10.039] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/07/2020] [Accepted: 10/23/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Soft markers are nonspecific findings detected by ultrasonography during the second trimester that are often transient and nonpathologic but may imply an increased risk of underlying fetal aneuploidy. However, large-scale prospectively stratified studies focusing on the prevalence of chromosomal aberrations, including copy number variants, in fetuses with different types of isolated soft markers have rarely been published in the literature. OBJECTIVE This study aimed to investigate clinical outcomes in fetuses with isolated soft markers by single nucleotide polymorphism array with long-term follow-up and to propose a diagnostic algorithm based on specific types of soft markers. STUDY DESIGN The prevalence of fetal isolated soft markers was 13.2% (7869 of 59,503). A total of 2466 fetuses with ultrasonographic soft markers during the second trimester, which were subjected to single nucleotide polymorphism array with long-term follow-up, were selected in this prospective study over a 5-year period. Soft markers were categorized into 12 groups. The demographic profile and chromosomal microarray analysis detection results were analyzed and compared among different groups. RESULTS The overall prevalence of chromosomal aberrations in fetuses with soft markers was 4.3% (107 of 2466), which comprised 40.2% with numeric chromosomal abnormalities, 48.6% with pathogenic copy number variants, and 11.2% with likely pathogenic copy number variants. The incidence of numeric chromosomal abnormalities was significantly higher in multiple soft markers (5.5% vs 1.5%; P=.001) and the thickened nuchal fold group (8.3% vs 1.7%; P=.024). Meanwhile, the incidence of pathogenic copy number variants was significantly higher in multiple soft markers (5.5% vs 2.4%; P=.046) and the short femur length group (6.6% vs 2.2%; P<.0001). The incidences of pathogenic copy number variants in fetuses with isolated echogenic intracardiac focus, enlarged cisterna magna, choroid plexus cysts, echogenic bowel, or single umbilical artery were lower than 1.5%. The normal infant rate in fetuses without chromosomal aberrations was 91.7%; however, it was significantly lower in the mild ventriculomegaly (86.2% vs 93.0%; P<.0001) and short femur length groups (71.4% vs 93.6%; P<.0001). CONCLUSION The potential chromosomal aberrations and clinical prognoses varied widely among different types of isolated soft markers. Pathogenic copy number variants are more often present in specific soft markers, especially when multiple soft markers are found. Thus, a specific soft marker type-based prenatal genetic testing algorithm was proposed.
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Cao Q, Li DZ. The role of midtrimester soft markers for aneuploidy in the era of cell-free DNA screening. Am J Obstet Gynecol 2021; 224:546-547. [PMID: 33306968 DOI: 10.1016/j.ajog.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
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Sussman BL, Chopra P, Poder L, Bulas DI, Burger I, Feldstein VA, Laifer-Narin SL, Oliver ER, Strachowski LM, Wang EY, Winter T, Zelop CM, Glanc P. ACR Appropriateness Criteria® Second and Third Trimester Screening for Fetal Anomaly. J Am Coll Radiol 2021; 18:S189-S198. [PMID: 33958112 DOI: 10.1016/j.jacr.2021.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Betsy L Sussman
- The University of Vermont Medical Center, Burlington, Vermont.
| | - Prajna Chopra
- Research Author, The University of Vermont Medical Center, Burlington, Vermont
| | - Liina Poder
- Panel Chair, University of California San Francisco, San Francisco, California
| | - Dorothy I Bulas
- Children's National Hospital and George Washington University, Washington, District of Columbia, Chair, ACR International Outreach Committee, Director, Fetal Imaging Prenatal Pediatric Institute, Childrens National Hospital
| | | | | | | | - Edward R Oliver
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Eileen Y Wang
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, American College of Obstetricians and Gynecologists
| | - Tom Winter
- University of Utah, Salt Lake City, Utah
| | - Carolyn M Zelop
- Valley Hospital, Ridgewood, New Jersey and NYU School of Medicine, New York, New York, American College of Obstetricians and Gynecologists
| | - Phyllis Glanc
- Specialty Chair, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Li L, Fu F, Li R, Liu Z, Liao C. Prenatal diagnosis and pregnancy outcome analysis of thickened nuchal fold in the second trimester. Medicine (Baltimore) 2018; 97:e13334. [PMID: 30431620 PMCID: PMC6257687 DOI: 10.1097/md.0000000000013334] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To summarize the results of prenatal diagnoses and pregnancy outcomes of fetuses with thickened nuchal fold (TNF) in the second trimester.From 2009 to 2016, we studied 72 pregnant women with fetal nuchal fold (NF) measurements over 5 mm at 14 to 19 + 6 weeks or 6 mm at 20 to 28 weeks of gestation who received prenatal diagnosis. Karyotypes were first used to detect common chromosomal diseases, and then chromosome microarray analysis (CMA) was performed if karyotypes were normal. Prognoses were followed up by documentation in the hospital or over the telephone.In total, 12 fetuses with chromosomal defects, including 5 pathogenic copy number variants (CNVs) were detected. The risk of chromosomal defects when a TNF was associated with structural malformations (SMs) (35.5%) was much greater than that of an isolated TNF (3.7%) and a TNF associated with soft markers (0%). The rate of SMs when the NF measured ≥10 mm was greater than that NF measured 5 to 7.9 mm or 8 to 9.9 mm. Totally 27 fetuses had adverse pregnancy outcome.A TNF is not only associated with a high risk of trisomy 21 but also with other chromosomal abnormalities, including pathogenic CNVs. The rates of SMs and adverse outcomes increase when the NF thickness increases.
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Kazemi K, Adibi A, Hovsepian S. Reference values of nuchal fold thickness in an Iranian population sample. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2018; 23:94. [PMID: 30505332 PMCID: PMC6225456 DOI: 10.4103/jrms.jrms_357_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 06/13/2018] [Accepted: 07/25/2018] [Indexed: 12/30/2022]
Abstract
Background: Considering that ethnicity and gestational age (GA) could affect the value of nuchal fold thickness (NFT) in mid-trimester, we aimed to determine the reference intervals of NFT values for each gestational week from 16 to 24 weeks of pregnancy among a group of Iranian pregnant women. Materials and Methods: In this cross-sectional study, medical files of pregnant women who underwent fetal anomaly scanning at 16–24 weeks of gestation were reviewed and the following data were extracted: GA, value of NFT, value of nuchal translucency (NT) in their previous ultrasound study, if available, and head circumference (HC). The 5th, 25th, 50th, 75th, and 95th percentiles of NFT for each gestational week were determined. The association between NFT and HC, GA, and NT were also determined. Results: Medical files of 882 pregnant women were studied. The expected 95th percentile value of NFT between 16th and 24th weeks of gestation ranged from 4 mm to 5.9 mm. The mean (standard deviation) of NFT increased with GA from 2.67 (0.90) mm at 16th weeks to 4.69 (0.71) mm at 24th weeks. There was a significant positive association between NFT and GA (β = 1.11, p < 0.001), HC (β = 0.21, p < 0.001), and NT (β = 0.351, p < 0.001). Conclusion: The findings of this study revealed that before the 20th week of gestation, the appropriate cutoff value of NFT is 5 mm, and for 21st to 24th weeks, the proper cutoff is 6 mm. However, for providing more conclusive results, further studies with larger sample size and considering the impact of other influencing variables are recommended.
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Affiliation(s)
- Kimia Kazemi
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Atoosa Adibi
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Silva Hovsepian
- Emam Hossein Children's Hospital, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
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Werner H, Lopes Dos Santos JR, Ribeiro G, Araujo Júnior E. Prenatal Phenotype of Down Syndrome Using 3-D Virtual Reality. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:886-889. [PMID: 28483332 DOI: 10.1016/j.jogc.2017.03.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 03/13/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Down syndrome is a chromosomal abnormality characterized by an additional acrocentric chromosome, resulting in an aneuploid number of 47 chromosomes (trisomy 21). Fetal face phenotype of Down syndrome is typical in the second trimester and characterized by plane face and a big and protruding tongue. CASE We present a case of Down syndrome at 29 weeks of gestation in which the fetal face was created using 3-D virtual reality model from 3-D ultrasound scan data. CONCLUSION A 3-D virtual model from 3-D ultrasound or magnetic resonance imaging scan data allowed an immersive real environment, improving the understanding of fetal congenital anomalies by the parents and the medical team.
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Affiliation(s)
- Heron Werner
- Department of Radiology, Clínica de Diagnóstico por Imagem, Rio de Janeiro, Brazil
| | | | - Gerson Ribeiro
- Department of Arts and Design, Pontifícia Universidade Católica, Rio de Janeiro, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil.
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Vos FI, De Jong-Pleij EAP, Bakker M, Tromp E, Bilardo CM. Trends in Serial Measurements of Ultrasound Markers in Second and Third Trimester Down Syndrome Fetuses. Fetal Diagn Ther 2015; 38:48-54. [PMID: 25661756 DOI: 10.1159/000368047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 08/18/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate trends of nasal bone length (NBL), prenasal thickness (PT), nuchal fold (NF), prenasal thickness to nasal bone length (PT-NBL) ratio, and prefrontal space ratio (PFSR), measured serially in second- and third-trimester Down syndrome (DS) fetuses. METHODS Prenatal databases were searched for cases of continuing DS pregnancies with serial measurements, taken at least two weeks apart. Trends were plotted on previously reported normal ranges. RESULTS Serial measurements were available in 25 Down syndrome fetuses. Median gestational age (GA) was 25 weeks; average number of visits per case was 2.44, with a median interval of 39 days between investigations. In DS fetuses, NBL and PT showed fairly stable trends with gestation. PFSR, but especially NF, had a more unpredictable trend. The PT-NBL ratio was the most stable marker, remaining unchanged in 95% of cases. NBL, PT, and NF showed more deviance from the normal range with advancing gestation, but MoM values remained stable. All but two fetuses had ultrasound markers or structural anomalies, especially heart defects. CONCLUSIONS The PT-NBL ratio is the most constant DS marker throughout gestation, following a predictable trend.
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Affiliation(s)
- F I Vos
- Fetal Medicine Unit, University Medical Centre Groningen, Groningen, The Netherlands
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Araujo Júnior E, Martins WP, Pires CR, Santana EFM, Zanforlin Filho S. Fetal nuchal fold thickness measurement between 18 and 24 weeks of pregnancy: reference intervals for a Brazilian population. J Matern Fetal Neonatal Med 2014; 28:234-6. [DOI: 10.3109/14767058.2014.908845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Sonographic soft markers of fetal Down syndrome were first reported in the 1980s. With improvements in aneuploidy screening, detection rates of 90% and higher are possible, and such screening is offered to women of all ages. The utility of sonographic detection and reporting of soft markers, particularly to women at low risk of fetal aneuploidy, is controversial. Some soft markers have no additional significance beyond an association with aneuploidy, while some potentially indicate other pathology, and therefore require sonographic follow-up or other evaluation. The definitions of soft markers vary among reported series, and any practice using such markers to adjust the risk of aneuploidy should carefully determine the most appropriate definitions as well as likelihood ratios and how to apply these in practice.
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Affiliation(s)
- Mary E Norton
- Stanford University School of Medicine, 300 Pasteur Drive, HH333, Stanford, CA 94305.
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Kontopoulos E, Odibo A, Wilson RD. Current controversies in prenatal diagnosis 2: are we ready to screen for fetal anomalies with first trimester ultrasound? Prenat Diagn 2013; 33:9-12. [PMID: 23296714 DOI: 10.1002/pd.4030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Eftichia Kontopoulos
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Miami Miller Medical School, Miami, FL, USA
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The continuing enigma of the fetal echogenic intracardiac focus in prenatal ultrasound. Curr Opin Obstet Gynecol 2013; 25:145-51. [DOI: 10.1097/gco.0b013e32835e14eb] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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