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Objective: The aim of this study is to evaluate the possible role of antenatal administration of corticosteroids for fetal lung maturation on short term perinatal outcomes in late FGR.Methods: This cohort study is a secondary analysis of a multicenter prospective observational study, the TRUFFLE-2 feasibility study, conducted between 2017 and 2018 in 33 European perinatal centers. We included women with singleton pregnancy from 32+0 to 36+6 weeks of gestation with a fetus considered at risk for FGR, defined as estimated fetal weight (EFW) or abdominal circumference (AC) <10th centile, or umbilico-cerebral ratio (UCR) >95th centile, or a fall of more than 40 centile points in AC measurement from the 20 weeks scan. The primary adverse outcome was a composite of abnormal condition at birth or major neonatal morbidity.Results: A total of 86 pregnancies who received antenatal corticosteroids (exposed) were matched with non-exposed pregnancies. Both groups were similar regarding gestational age at inclusion (33 weeks), EFW (1673 g) and UCR (0.68), gestational age at delivery (35.5 weeks) and birth weight (1925 g); the presented values are for both groups combined. No significant differences were observed between exposed and non-exposed for composite adverse outcome (28% vs. 24%; p=0.73) or for any of its elements.Conclusion: The present data do not show a beneficial effect of steroids on short term outcomes in fetuses with late FGR. This article is protected by copyright. All rights reserved. [ABSTRACT FROM AUTHOR]

Objectives: To identify antenatal ultrasound markers that can differentiate between simple and complex gastroschisis and assess their predictive value.Methods: This was a prospective nationwide study of pregnancies with isolated fetal gastroschisis that underwent serial longitudinal ultrasound examination at regular specified intervals between 20 and 37 weeks' gestation. The primary outcome was simple or complex (i.e. involving bowel atresia, volvulus, perforation or necrosis) gastroschisis at birth. Fetal biometry (abdominal circumference and estimated fetal weight), the occurrence of polyhydramnios, intra- and extra-abdominal bowel diameters and the pulsatility index (PI) of the superior mesenteric artery (SMA) were assessed. Linear mixed modeling was used to compare the individual trajectories of cases with simple and those with complex gastroschisis, and logistic regression analysis was used to estimate the strength of association between the ultrasound parameters and outcome.Results: Of 104 pregnancies with isolated fetal gastroschisis included, four ended in intrauterine death. Eighty-one (81%) liveborn infants with simple and 19 (19%) with complex gastroschisis were included in the analysis. We found no relationship between fetal biometric variables and complex gastroschisis. The SMA-PI was significantly lower in fetuses with gastroschisis than in healthy controls, but did not differentiate between simple and complex gastroschisis. Both intra- and extra-abdominal bowel diameters were larger in cases with complex, compared to those with simple, gastroschisis (P < 0.001 and P < 0.005, respectively). The presence of intra-abdominal bowel diameter ≥ 97.7th percentile on at least three occasions, not necessarily on successive examinations, was associated with an increased risk of the fetus having complex gastroschisis (relative risk, 1.56 (95% CI, 1.02-2.10); P = 0.006; positive predictive value, 50.0%; negative predictive value, 81.4%).Conclusions: This large prospective longitudinal study found that intra-abdominal bowel dilatation when present repeatedly during fetal development can differentiate between simple and complex gastroschisis; however, the positive predictive value is low, and therefore the clinical usefulness of this marker is limited. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objective: In the TRUFFLE (Trial of Randomized Umbilical and Fetal Flow in Europe) study on the outcome of early fetal growth restriction, women were allocated to one of three groups of indication for delivery according to the following monitoring strategies: (1) reduced fetal heart rate (FHR) short-term variation (STV) on cardiotocography (CTG); (2) early changes in fetal ductus venosus (DV) waveform (DV-p95); and (3) late changes in fetal DV waveform (DV-no-A). However, many infants per monitoring protocol were delivered because of safety-net criteria, for maternal or other fetal indications, or after 32 weeks of gestation when the protocol was no longer applied. The objective of the present posthoc subanalysis was to investigate the indications for delivery in relation to 2-year outcome in infants delivered before 32 weeks to further refine management proposals.Methods: We included all 310 cases of the TRUFFLE study with known outcome at 2 years' corrected age and seven fetal deaths, excluding seven cases with inevitable perinatal death. Data were analyzed according to the allocated fetal monitoring strategy in combination with the indication for delivery.Results: Overall, only 32% of liveborn infants were delivered according to the specified monitoring parameter for indication for delivery; 38% were delivered because of safety-net criteria, 15% for other fetal reasons and 15% for maternal reasons. In the CTG-STV group, 51% of infants were delivered because of reduced STV. In the DV-p95 group, 34% of infants were delivered because of abnormal DV and, in the DV-no-A group, only 10% of infants were delivered accordingly. The majority of infants in the DV groups were delivered for the safety-net criterion of spontaneous decelerations in FHR. Two-year intact survival was highest in the DV groups combined compared with the CTG-STV group (P = 0.05 for live births only, P = 0.21 including fetal death), with no difference between DV groups. A poorer outcome in the CTG-STV group was restricted to infants delivered because of FHR decelerations in the safety-net subgroup. Infants delivered because of maternal reasons had the highest birth weight and a non-significantly higher intact survival.Conclusions: In this subanalysis of infants delivered before 32 weeks, the majority were delivered for reasons other than the allocated monitoring strategy indication. Since, in the DV group, CTG-STV criteria were used as a safety net but in the CTG-STV group, no DV safety-net criteria were applied, we speculate that the slightly poorer outcome in the CTG-STV group might be explained by the absence of DV data. The optimal timing of delivery of fetuses with early intrauterine growth restriction may therefore be best determined by monitoring them longitudinally, with both DV and CTG monitoring. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

The article focuses on the Trial of Randomized Umbilical and Fetal Flow in Europe (TRUFFLE) study which analyzed singleton pregnancies at 26–32weeks of gestation with a diagnosis of fetal growth restriction. The study primarily concluded survival without cerebral palsy or neurosensory impairment. It discusses neurodevelopmental impairment change with gestational age and its relation to neonatal morbidity.

Abstract: Objectives: To explore whether, in early fetal growth restriction (FGR), the longitudinal pattern of fetal heart rate (FHR) short‐term variation (STV) can be used to identify imminent fetal distress and whether abnormalities of FHR recordings are associated with 2‐year infant outcome. Methods: The original TRUFFLE study assessed whether, in early FGR, delivery based on ductus venosus (DV) Doppler pulsatility index (PI), in combination with safety‐net criteria of very low STV on cardiotocography (CTG) and/or recurrent FHR decelerations, could improve 2‐year infant survival without neurological impairment in comparison with delivery based on CTG monitoring only. This was a secondary analysis of women who delivered before 32 weeks and had consecutive STV data recorded > 3 days before delivery and known infant outcome at 2 years of age. Women who received corticosteroids within 3 days of delivery were excluded. Individual regression line algorithms of all STV values, except the last one before delivery, were calculated. Life tables and Cox regression analysis were used to calculate the daily risk for low STV or very low STV and/or FHR decelerations (below DV group safety‐net criteria) and to assess which parameters were associated with this risk. Furthermore, it was assessed whether STV pattern, last STV value or recurrent FHR decelerations were associated with 2‐year infant outcome. Results: One hundred and forty‐nine women from the original TRUFFLE study met the inclusion criteria. Using the individual STV regression lines, prediction of a last STV below the cut‐off used by the CTG monitoring group had sensitivity of 42% and specificity of 91%. For each day after study inclusion, the median risk for low STV (CTG group cut‐off) was 4% (interquartile range (IQR), 2–7%) and for very low STV and/or recurrent FHR decelerations (below DV group safety‐net criteria) was 5% (IQR, 4–7%). Measures of STV pattern, fetal Doppler (arterial or venous), birth‐weight multiples of the median and gestational age did not usefully improve daily risk prediction. There was no association of STV regression coefficients, a low last STV and/or recurrent FHR decelerations with short‐ or long‐term infant outcomes. Conclusion: The TRUFFLE study showed that a strategy of DV monitoring with safety‐net criteria of very low STV and/or recurrent FHR decelerations for delivery indication could increase 2‐year infant survival without neurological impairment. This post‐hoc analysis demonstrates that, in early FGR, the daily risk of abnormal CTG, as defined by the DV group safety‐net criteria, is 5%, and that prediction is not possible. This supports the rationale for CTG monitoring more often than daily in these high‐risk fetuses. Low STV and/or recurrent FHR decelerations were not associated with adverse infant outcome and it appears safe to delay intervention until such abnormalities occur, as long as DV‐PI is within normal range. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

The aim of this Editorial is to review Level I evidence regarding the effectiveness of interventions in women identified as having short cervix on mid-trimester ultrasound, discuss some of the remaining challenges and outline areas for future research. [ABSTRACT FROM AUTHOR]

Linked article: This Correspondence comments on Burger et al. Click here to view the article. [ABSTRACT FROM AUTHOR]

The article presents a study which describes the individual intrauterine growth patterns of fetuses of Type 1 diabetic women. The study uses latent class analysis (LCA) to identify subgroups of homogeneous cases and Bayesian information criterion (BIC) to determine the optimal number of patients' clusters. The results show that growth trajectory of individual fetus is set in the early stage and the contemporaneous degree of maternal glycemia functions a role in birth weight determination.

Objectives: Ultrasound examination of the fetus is a powerful tool for assessing gestational age and detecting obstetric problems but is rarely available in developing countries. The aim of this study was to assess the intraobserver and interobserver agreement of fetal biometry by locally trained health workers in a refugee camp on the Thai-Burmese border.Methods: One expatriate doctor and four local health workers participated in the study, which included examinations performed on every fifth pregnant woman with a singleton pregnancy between 16 and 40 weeks' gestation, and who had undergone an early dating ultrasound scan, attending the antenatal clinic in Maela refugee camp. At each examination, two examiners independently measured biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL), with one of the examiners obtaining duplicate measurements of each parameter. Intraobserver measurement error was assessed using the intraclass correlation coefficient (ICC) and interobserver error was assessed by the Bland and Altman 95% limits of agreement method.Results: A total of 4188 ultrasound measurements (12 per woman) were obtained in 349 pregnancies at a median gestational age of 27 (range, 16-40) weeks in 2008. The ICC for BPD, HC, AC and FL was greater than 0.99 for all four trainees and the doctor (range, 0.996-0.998). For gestational ages between 18 and 24 weeks, interobserver 95% limits of agreement corresponding to differences in estimated gestational age of less than +/- 1 week were calculated for BPD, HC, AC and FL. Measurements by local health workers showed high levels of agreement with those of the expatriate doctor.Conclusions: Locally trained health workers working in a well organized unit with ongoing quality control can obtain accurate fetal biometry measurements for gestational age estimation. This experience suggests that training of local health workers in developing countries is possible and could allow effective use of obstetric ultrasound imaging. [ABSTRACT FROM AUTHOR]

The article presents a study which aims to determine which prenatal ultrasound findings can predict the survival and mental and motor functioning of children with spina bifida. The study uses sample of 41 live-born children who were prenatally diagnosed with spina bifida. Results of the study show that lesion levels and head circumference on prenatal ultrasound are predictive factors to survival of children with spina bifida.

The article presents a quantitative study on the quality of the nuchal translucency (NT) measurements in The Netherlands in 2005-2006 and its relevance to screening performance. Analysis of quality standards is done to study the record of NT measurements from the Dutch Institute for Public Health and the Environment (RIVM). Results show that only 22% met the requirements of quality standards. It concludes that monitoring prompted improvements in the accuracy of NT measurements.

The article discusses a study which aims to predict spontaneous onset of labor through serial transvaginal ultrasound measurement of cervical length (CL) in nulliparous women. Women with singleton pregnancies who were examined at weekly intervals from 36 weeks of pregnancy to delivery. CL was measured by transvaginal ultrasound and a decrease in CL before delivery was noticed. The study revealed that onset of labor before 41 weeks can be determined using CL measurement.

The article discusses a study which will determine gestational age (GA) estimation within the first-trimester Down syndrome prenatal screening is standardized in the Netherlands. The last menstrual period (LMP) and the crown-rump length (CRL) were evaluated. The study found that GA estimation is not standardized in Netherlands. Researchers suggest that in prenatal screening for Down syndrome, ultrasound test should be the basis for estimation of GA.

The article investigates the value of abnormal umbilical artery Doppler findings in predicting the outcome of uncomplicated monochorionic (MC) twin pregnancies. Research findings show that a subgroup of MC twins at risk for neonatal morbidity, low birth weight and preterm delivery is identified by the abnormal Doppler flow of the umbilical artery. Also cited are the issues' implications for ultrasound in obstetrics.

Objectives: To evaluate whether the antenatal umbilical coiling index (aUCI) as measured by ultrasonography predicts the postnatal umbilical coiling index (pUCI) and adverse pregnancy outcome. Methods: In a prospective study in 117 pregnancies, the aUCI was measured between 28 weeks and term by ultrasonography. The aUCI was calculated as the reciprocal value of the mean pitch of one complete coil. The pUCI was calculated as the number of coils divided by the cord length in cm. The correlation between aUCI and pUCI was assessed and likelihood ratios for adverse pregnancy outcome were calculated. Results: We had complete data on 81 subjects. Mean aUCI +/- SD was 0.30 +/- 0.09 and mean pUCI +/- SD was 0.17 +/- 0.08. The correlation coefficient between aUCI and pUCI was 0.66, P < 0.001. Limits of agreement were 0-0.28 coils/cm. The positive likelihood ratio for small-for-gestational-age infants was 2.6 (95% confidence interval (CI) 0.6-11.6) for ultrasound hypocoiling, and 5.7 (95% CI 1.3-24.8) for ultrasound hypercoiling. The positive likelihood ratio for interventional delivery for non-reassuring fetal status was 1.2 (95% CI 0.2-9.0) for ultrasound hypocoiling, and 10.3 (95% CI 2.1-50.2) for ultrasound hypercoiling. Conclusions: Strong correlation coefficients comparing the aUCI and pUCI do not reflect agreement. Since the limits of agreement were almost as wide as the full range for the pUCI, the aUCI does not predict the pUCI with sufficient precision. Larger prospective studies are required to confirm the predictive potential of the aUCI for adverse pregnancy outcome. [ABSTRACT FROM AUTHOR]

The presence of maternal autoantibodies to SS-A/Ro and/or SS-B/La is associated with the development of fetal heart block. There are data suggesting that maternal treatment with steroids might reverse heart block. We report on a pregnancy in a mother with secondary Sjögren syndrome and systemic lupus erythematosus with presence of autoantibodies to SS-A/Ro and SS-B/La, which was complicated by the development of incomplete fetal heart block. Oral dexamethasone treatment could not prevent progression to complete heart block and was associated with a number of complications. A review of the literature revealed 19 studies (including ours) in which 93 cases of fetal heart block were treated with maternal steroid therapy. Complete heart block proved irreversible in all cases; and of 13 fetuses with incomplete heart block which received maternal steroid therapy, three had a reduction in their degree of block and one reverted to sinus rhythm. Maternal steroid therapy, initiated early in pregnancy and potentially preventing the onset of heart block, did not decrease the incidence of heart block in nine studies with 43 cases. Furthermore, the literature review revealed numerous serious side effects of maternal steroid administration during pregnancy. Data on these potential side effects are lacking in the 28 studies discussed in this review. Maternal dexamethasone therapy to prevent or treat fetal heart block remains, in our opinion, a questionable intervention and can as yet not be recommended in the clinical situation. [ABSTRACT FROM AUTHOR]

Objective Fetal tachycardia is a condition associated with congestive heart failure and development of fetal hydrops, which may result in neurological morbidity and mortality. The aim of this study was to investigate the long-term outcome of hydropic fetuses. Methods This was a retrospective study on cognitive and neurological functioning of 11 infants, aged 6 months to 12 years, who experienced fetal tachycardia complicated by hydrops. Results Seven fetuses had supraventricular tachycardia (SVT), three had atrial flutter (AF) and one had ventricular tachycardia (VT). Nine fetuses converted to sinus rhythm within a mean time of 8.2 days of presentation; resolution of hydrops was achieved in six of these patients in a mean time of 8.8 days. Mean gestational age (GA) at birth was 35 + 4 weeks. Neonatal cranial ultrasound was normal in seven infants and all but one of these were normal at follow-up: one infant who initially had no abnormalities developed multiple cerebral lesions as a result of a malignant long QT syndrome (LQTS) and died at the age of 2 years. Three infants had periventricular echogenicity (PVE) on neonatal cranial ultrasound, associated with a pseudocyst in one infant. The remaining infant showed a parenchymal hemorrhage of antenatal onset, seen as a porencephalic cyst at birth. One of these infants was normal at follow-up, one died 2 days after birth and two infants had neurological abnormalities at follow- up, consisting of mild hemiplegia with normal cognitive function in one, and a cognitive developmental delay in the other. Conclusions In this study, neurological outcome was good in eight out of 11 infants. Initiation of therapy should not be withheld or delayed on the assumption of poor neurological outcome. [ABSTRACT FROM AUTHOR]

Objective To study the effects of antenatal glucocorticoid (betamethasone) therapy on blood flow velocity wave form patterns in the umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV) in severely intrauterine growth-restricted (IUG R) fetuses. Methods Fifty-five severely IUG R fetuses at 24-34 weeks of gestation were included in the study. The effect of antenatal glucocorticoid administration on Doppler findings in the UA, MCA and D V was studied using two statistical approaches, namely paired sample analysis and multilevel analysis. Results There were no effects of betamethasone on the pulsatility index (PI) of the vessels studied. The only changes noticed during the 14 days of observation were a gradual decrease of PI in the MCA, an increase in the UA-PI/MCA-PI ratio and an increase in the DV-PI. These changes with time may be explained by a progressive and gradual deterioration of the fetal condition. Conclusion Antenatal glucocorticoids (betamethasone) do not affect fetal Doppler waveform patterns of the UA, MCA and DV in severely IUGR fetuses. [ABSTRACT FROM AUTHOR]

Objective To investigate whether pathological changes in the umbilical artery (UA), ductus venosus (DV) and short-term fetal heart variation are related to perinatal outcome in severe, early intrauterine growth restriction (IUGR). Methods This multicenter, prospective, longitudinal, observational study was carried out in the Departments of Fetal Medicine and Obstetrics in Hamburg, Amsterdam, Utrecht and London. In 70 singleton pregnancies with IUGR fetuses, delivered at 2 6-33 weeks of gestation because of antepartum fetal distress, short-term variation (STV) of fetal heart rate, pulsatility index of the fetal UA (UA P1) and DV pulsatility index for veins (DV PIV) were assessed at least weekly. The final measurement was performed within 24 h of delivery. Standard cut-off levels (2 SD or 3 SD, absent flow or reversed flow) were used and new cut-off levels were calculated by means of receiver-operating characteristics analysis. Adverse outcome was defined as perinatal death, cerebral hemorrhage (> Grade II) or broncho pulmonary dysplasia before discharge. The predictive value for adverse outcome was calculated for different cut-off levels of the monitoring parameters, adjusted for gestational age (GA), by multivariate logistic regression analysis. Data were analyzed separately for three different time blocks, namely 8-14, 2-7 and 0-1 days before delivery. Results Adverse perinatal outcome occurred in 18/70 (26%) infants. During the last 24 h before delivery DV PIV and UA P1 were significantly higher and STV lower in the adverse outcome group, while 2-7 days before delivery only DV PIV was significantly higher. Adverse perinatal outcome could be predicted at 0-1 days before delivery by DV PIV at a cut-off of three multiples of the SD (odds ratio (OR) 11.3; 95% CI 2.3-57) and GA (OR 0.4; 95% CI 0.3-0.8), at 2-7 days by DV PIV at 2 SD (OR 3.0; 95% CI 0.8-12) and GA (OR 0.5; 95% CI 0.3-0.8) and at 8-14 days by DV PIV at 2 SD (OR 3.9; 95% CI 0.8-20) and GA (OR 0.5; 95% CI 0.3-0.8). Other parameters did not contribute to the multivariate model. Conclusions DV Ply measurement is the best predictor of perinatal outcome. This measurement may be useful in timing the delivery of early IUGR fetuses and in improving perinatal outcome, even when delivery may be indicated at an earlier GA. However, as GA was also an important factor influencing outcome, with poorer outcome at earlier gestation at delivery, this hypothesis needs to be tested in a multicenter, prospective, randomized trial. [ABSTRACT FROM AUTHOR]

AbstractObjectiveTo monitor behavioral development in a fetus affected by the Pena–Shokeir phenotype due to fetal akinesia deformation sequence of myogenic origin. MethodsFetal behavioral development was studied sonographically in a fetus suspected of having fetal akinesia deformation sequence, between 15 and 35 weeks of gestation at 1–4-week intervals. ResultsFetal body movements were quantitatively and qualitatively abnormal from 28 weeks onwards. Behavioral deterioration coincided with the observation of structural anomalies such as club feet. Fetal heart rate and its variation remained within normal limits and showed normal ultradian cyclicity, but the temporal linkage between body movements and heart rate pattern worsened with advancing gestation. Breathing movements, although present until the end of pregnancy, became increasingly shallow. ConclusionOur results provide sound evidence that the trajectory of behavioral development with fetal akinesia deformation sequence, which has been hypothesized to occur in man exclusively on the basis of retrospective analyses and animal experiments, does indeed take place. [ABSTRACT FROM AUTHOR]