Three-dimensional prenatal diagnosis of frontonasal malformation and unilateral cleft lip/palate

Prenatal diagnosis of a severe form of frontonasal dysplasia with severe limb anomalies, hydrocephaly, a hypoplastic corpus callosum, and a ventricular septal defect using 3D ultrasound: a case report and literature review

BACKGROUND

Frontonasal dysplasia (FND) is a rare congenital anomaly resulting from the underdevelopment of the frontonasal process, and it can be syndromic or nonsyndromic. The typical features of FND include a deformed nose and ocular hypertelorism, which are sometimes associated with cleft lip and/or palate. Only approximately 10 cases of prenatally diagnosed nonsyndromic FND have been reported in the past 30 years.

CASE PRESENTATION

A 33-year-old woman (G2P1) was referred to our center at 20 gestational weeks for bilateral hydrocephaly. We detected typical features of FND, including severe hypertelorism, median nasal bifidity, a minor cleft lip, and multiple limb anomalies using three-dimensional (3D) ultrasound. A hypoplastic corpus callosum, unilateral microtia, and a ventricular septal defect were also detected. Genetic testing, including karyotype analysis, copy number variation (CNV) analysis, trio-whole exome sequencing (trio-WES), and trio-whole-gene sequencing (trio-WGS), was performed; however, we did not find any de novo gene variants in the fetus as compared to the parents. Postmortem examination confirmed the prenatal diagnosis of FND.

CONCLUSION

The present case expands the wide phenotypic spectrum of prenatal FND patients. 3D ultrasound is a useful tool for detecting facial and limb deformities.

Integrating 3D Sonography With Targeted MRI in the Prenatal Diagnosis of Posterior Cleft Palate Plus Cleft Lip

Cleft lip and cleft palate are among the more common congenital abnormalities, present in 1.82 per 1000 live births. Although high-quality antenatal 2D sonography can diagnose clefts of the lips and the alveolar ridge, 3D may enhance detection by examining the fetal face in the frontal plane followed by a secondary rotation through 180 degrees on the vertical axis to examine the secondary palate, which has been called the “reverse face” view. Sonographically 3D targeted ultrafast magnetic resonance imaging (MRI) has been shown to improve the diagnostic accuracy of facial cleft by identifying whether a cleft in the primary palate extends to the secondary palate. Further investigation may confirm the ability of MRI to define the extent of the cleft to the secondary palate at a less advanced gestational age (18-23 weeks), where either fetal development or movements could reduce the accuracy of the technique.

Early Detection of Cleft Lip by Three-Dimensional Transvaginal Ultrasound in Niche Mode in a Fetus With Trisomy 18 Diagnosed by Celocentesis

Transabdominal ultrasound examination carried out at 11.3 weeks' gestation suggested the diagnosis of holoprosencephaly (HPE). Transvaginal three-dimensional (3D) scan performed using the niche-mode technique enabled diagnosis of HPE, hypotelorism, and cleft lip (CL). The fetus was diagnosed with trisomy 18 by means of transvaginal celocentesis at the time of pregnancy termination. Although prenatal diagnosis of orofacial cleft can be enhanced by 3D ultrasound, only a few cases have been detected early in pregnancy. Here, we report a first-trimester case in which 3D ultrasound in niche mode improved the antenatal diagnosis of CL. Early fetal karyotyping can be accomplished by celocentesis in these cases.

[A new prenatal diagnosis case of frontonasal dysplasia]

In a 30-year-old patient, the systematic second trimester fetal ultrasound discovered major facial abnormalities suggesting a frontonasal dysplasia (FND). The fetal karyotype was normal but no additional genetic testing was performed. Fetal MRI found an important hypertelorism and an asymmetric cerebral ventricle, with a partially visualized corpus callosum. After several consultations and interviews, the couple made a formal demand for pregnancy interruption, which was approved. Fetal pathologic examination confirmed the diagnosis of FND with no other major associated malformation. This rare pathology results from a midline facial dysgraphia comprising a hypertelorism, a large nasal base, a large clefted nose tip and, a V-shaped hair implantation on the forehead. It often occurs sporadically, of unknown cause, related to a defect in the embryonic nasal capsule development. Syndromic forms have been described with cerebral lesions and possible intellectual deficiency. Consequently, a long and difficult surgical management is necessary, at the expense of poor aesthetic outcome. Seven cases of prenatally diagnosed FND have been reported in the literature, three of which had 3D ultrasound.

Three-dimensional ultrasound in prenatal diagnosis

PURPOSE OF REVIEW

Several technological advances have greatly improved three-dimensional sonography, which have improved acquisition and display capabilities. This review describes these technical changes as well as current applications of 3D sonography in prenatal diagnosis.

RECENT FINDINGS

Recently published papers have emphasized the potential of getting a precise 'any plane of choice' from a three-dimensional volume, as a new way of scanning, based on the off-line analysis of a volume dataset. Surface mode has been used to demonstrate malformations and genetic diseases. The maximum rendering mode, which highlights bones, has great potential for imaging the nasal bones and the frontal bones with the metopic suture. Organ volume can be measured, but the utility of this in clinical practice remains to be determined. Three-dimensional ultrasound needs to be standardized.

SUMMARY

Three-dimensional ultrasonography is the most rapidly developing technique in fetal imaging. New features will permit the transition from the era of 'sonography in two-dimensional planes' to 'volume ultrasound'.

Prenatal diagnostics of cleft deformities and its significance for parent and infant care

INTRODUCTION

This study aimed to demonstrate clefts of the secondary palate in embryos found to have cleft lip in order to evaluate the validity of prenatal ultrasound examination and, thus, to assess the significance of this diagnostic method for coordination and care of parents and infant.

PATIENTS AND METHODS

Over a period of 2.5 years, 7 fetuses with cleft deformities were examined sonographically during the 20th and 25th gestational week. The results were compared to postnatal clinical diagnosis. This study was made by two experienced examiners using 2D ultrasound devices (Acuson 128 XP-10/ C7; Toshiba Aplio XV). Postnatal clinical diagnosis was made by an orthodontist.

RESULTS

Three of the ultrasound-based diagnoses coincided with the postnatal result. In three of the examined cases the extent of the cleft was underestimated, whereas a greater extent suspected in one patient could not be confirmed clinically.

CONCLUSION

The results of the present study support the propositions of current literature: Diagnosis of a cleft of the lip and the alveolar process could correctly be made by an experienced ultrasound diagnostician. However, problems arise with clefts of the secondary palate.

Ultrasound antenatal diagnosis of cleft palate by a new technique: the 3D "reverse face" view

OBJECTIVE

To assess the clinical value of a novel three-dimensional (3D) ultrasound technique, the reverse face view (3D RF view), in the antenatal categorization of facial clefting and in particular clefting of the hard palate.

METHODS

Eight cases of suspected orofacial clefting were examined by 3D surface rendering. The fetal lips and alveolar ridge were examined in the frontal plane and the face was then rotated through 180 degrees on the vertical axis to examine the secondary palate by the 3D RF view.

RESULTS

In each case described, we were able to visualize the fetal face, lips and palate and make an antenatal diagnosis as to whether the palate was affected. In all cases, the antenatal diagnosis was subsequently confirmed. In one case with a left-sided cleft in the lips and alveolar ridge and an intact hard palate, the correct diagnosis was made but a cleft in the soft palate was missed.

CONCLUSION

Although clefts of the lips and alveolar ridge are readily diagnosed on high-quality antenatal ultrasound, visualization of the fetal palate using existing techniques is unreliable. In the patients described here, the 3D RF technique allowed relatively straightforward assessment of the fetal palate with a high degree of accuracy.

Nomograms of sonographic measurements throughout gestation of the fetal hard palate width, length and area

OBJECTIVE

To assess the feasibility of sonographic depiction of the fetal hard palate and secondarily to create nomograms throughout gestation of its sonographic width, length and area.

METHODS

This was a cross-sectional study of pregnant patients between 15 and 41 weeks' gestation. Inclusion criteria consisted of well-established dates (confirmed by early ultrasound), and singleton, non-anomalous fetuses. Sonographic measurements obtained included biparietal diameter, head circumference, abdominal circumference and femur length. Fetal hard palate measurements included maximum width, maximum length and the calculated area. Tables were prepared depicting the estimated mean +/- SD and 5(th), 50(th) and 95(th) centiles at each gestational week between 15 and 41 weeks. Pearson's correlation coefficient and associated P-values for the relationships between fetal hard palate measurements and other sonographic measurements and coefficients of variation for each of the fetal hard palate measurements were calculated.

RESULTS

The study included 602 consecutive patients. The mean maternal age was 28.7 +/- 6.3 years, with median gravidity of 2 (range, 1-12) and parity 1 (range, 0-8). All attempts at obtaining fetal hard palate ultrasound measurements were successful. Mean fetal hard palate width (cm) = -0.73579345 + 0.11370432 x GA - 0.00083919 x GA(2) and SD = -0.017842055 + 0.005142475 x GA, where GA is gestational age in weeks. Mean fetal hard palate length (cm) = -0.82020463 + 0.11767777 x GA - 0.00092801 x GA(2) and SD = -0.043064317 + 0.006378869 x GA. Mean fetal hard palate area (cm(2)) = -2.40090641 + 0.17136556 x GA + 0.00097308 x GA(2) and SD = -0.603647741 + 0.040740282 x GA. Sonographic measurements of the fetal hard palate width, length and area correlated significantly and strongly with gestational age (all P < 0.001) and significantly but less strongly with femur length (P = 0.004).

CONCLUSION

The fetal hard palate may be depicted sonographically with relative ease between 15 and 41 weeks' gestation and measurements of the fetal hard palate width, length and area correlate well with gestational age, biparietal diameter, abdominal circumference, sonographic estimated fetal weight, and femur length.