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Objectives: The present study aimed: 1) to simultaneously investigate the relationship between blood flow volumes of the two fetal liver afferent venous systems of normally appropriate for gestational age newborns. 2) to establish the normal reference range centiles values that will serve as a basis for future investigations., Methods: A cross-sectional, prospective study of singleton low obstetric risk pregnancies. Doppler examination included the measurement of the umbilical and the main portal vein vessels' diameters and time-averaged maximum velocity. The absolute and per kilogram of estimated fetal weight flow volumes and the ratio between the placental and portal blood volume flow were calculated from these data., Results: Three hundred and sixty-three pregnant women were included in the study. The umbilical and portal flow volumes' capacity to provide blood flow per kilogram of fetal weight, in the period of maximum fetal growth, was diverse. The placental flow decreased continuously from a mean of 121.2 mL/min/kg at the 20th week of gestation to 64.1 mL/min/kg at the 38th week of gestation. Meanwhile, the portal flow volume per kilogram of fetal weight increased from 9.6 mL/min/kg at 32 weeks of gestation to 10.3 at the 38th week of gestation. This resulted in a decrease in the umbilical to portal flow volume ratio from 13.3 to 9.6 during this period., Conclusion: Our results indicate that in the period of maximum fetal growth, the placental/portal ratio diminishes emphasizing the portal flow's predominance with low oxygen and nutrient supply to the liver., (© 2023 American Institute of Ultrasound in Medicine.)

Objectives: Abnormal fetal tongue size is a phenotypic feature of various syndromes including Beckwith-Wiedemann, Pierre-Robin, oromandibular limb hypoplasia, chromosomal aberrations, etc. Current data regarding normal fetal tongue size are limited. Hence, micro/macroglossia are subjectively determined. The aim of the study was to construct a contemporary fetal tongue nomogram and to assess its clinical contribution., Methods: A prospective cross-sectional study was performed in well dated, low risk, singleton pregnancies. Fetal tongues were measured by 5 trained sonographers. Highest quality images were selected. Intra- and interobserver variability was assessed. Tongue length, width, area, and circumference 1st to 99th centiles were calculated for each gestational week. Based on the normal tongue size charts, we created a Tongue Centile Calculator., Results: Over 18 months, 664 tongue measurements were performed. A cubic polynomial regression model best described the correlation between tongue size and gestational age. The correlation coefficient (r 2 ) was 0.934, 0.932, 0.925, and 0.953 for tongue length, width, area, and circumference, respectively (P < .001). Intra- and interobserver variability had high interclass correlation coefficients (>0.9). Using the new charts, we were able to identify 2 cases of macroglossia, subsequently diagnosed with Beckwith-Wiedemann, and 4 cases of microglossia, 3 associated with Pierre-Robin sequence, and 1 associated with persistent buccopharyngeal membrane., Conclusions: We present novel fetal tongue size charts from 13 to 40 weeks of gestation. Clinical application of these nomograms may be beneficial in the prenatal diagnosis of syndromes or malformations associated with abnormal fetal tongue size., (© 2022 The Authors. Journal of Ultrasound in Medicine published by Wiley Periodicals LLC on behalf of American Institute of Ultrasound in Medicine.)

Objectives: To assess the prenatal growth pattern of the normal kidney contralateral to a multicystic dysplastic kidney (MCDK)., Methods: A retrospective study was conducted in a single referral center over 4 years. Cases diagnosed prenatally as MCDK and confirmed postnatally constituted the study group. For creation of nomograms, only isolated cases of MCDK were included., Results: Sixty-one fetuses had a diagnosis of an MCDK during the study period. After exclusion of cases with associated malformations, 47 fetuses remained, providing 94 measurements for creation of nomograms. The growth pattern of the normal kidney contralateral to an MCDK was linear throughout gestation (percentile = 20.01 + 1.5 gestational age; linear R 2  = 0.753; r = 0.868) and was significantly higher during the third trimester (29-38 weeks' gestation) compared to the second trimester (22-28 weeks' gestation; P < .001). A comparison of the growth pattern of the normal kidney contralateral to the MCDK to the growth pattern of a solitary kidney revealed a significant higher compensatory trend during the third trimester (P < .0001). The mean kidney lengths at 22 and 38 weeks' gestation correlated with the 52nd and 88th and with the 84th and 90th percentiles for the normal kidney contralateral to the MCDK and a solitary kidney, respectively., Conclusions: According to our study, the normal kidney contralateral to an MCDK has a unique growth pattern during intrauterine life, with dominant growth during the third trimester. The exact mechanism for this pattern, in comparison to early renal hypertrophy shown in solitary kidneys, is currently not clear. These data provide relevant information for the multidisciplinary prenatal counseling of future parents regarding the future renal outcome., (© 2020 American Institute of Ultrasound in Medicine.)

Objectives: First arch syndromes are congenital defects caused by failure of neural crest cells to migrate into the first branchial arch. First arch syndrome is classified into 2 main clinical manifestations: Treacher Collins syndrome, characterized by bilateral underdevelopment of the zygomatic bones; and Pierre Robin sequence. The aim of this study was to describe the feasibility of visualization of the fetal zygomatic bone and assess its application in cases referred for features suggestive of first arch syndrome., Methods: A prospective cohort study was conducted. The feasibility of visualization of the zygomatic bone was performed in 50 sequential fetuses with a normal anatomic scan between 12 and 24 weeks' gestation using 3-dimensional sonography. Following this, cases referred for targeted scans for suspected first branchial arch syndrome were assessed for the presence or absence of the zygomatic bones., Results: Visualization of the fetal zygomatic bone was feasible in all low-risk cases. Cases referred for targeted scans included 11 isolated cases of micrognathia or retrognathia, 3 cases of microtia, and 3 cases of auricular or facial vestiges. Within this group, the zygomatic bones were visualized in all but 2 cases. No associated extrafacial malformations were detected; therefore, this phenotype was consistent with Treacher Collins syndrome., Conclusions: Prenatal imaging of the zygomatic bones offers a clinically based sonographic approach to cases referred for features suggestive of first arch syndrome and enables differentiation between the 2 main clinical manifestations: Treacher Collins syndrome and Pierre Robin sequence., (© 2020 by the American Institute of Ultrasound in Medicine.)

Objectives: The aim of the study was to assess the sonographic feasibility of measuring the fetal pancreas and its normal development throughout pregnancy., Methods: We conducted a cross-sectional prospective study between 19 and 36 weeks' gestation. The study included singleton pregnancies with normal pregnancy follow-up. The pancreas circumference was measured. The first 90 cases were tested to assess feasibility., Results: Two hundred ninety-seven fetuses of nondiabetic mothers were recruited during a 3-year period. The overall satisfactory visualization rate was 61.6%. The intraobserver and interobserver variability had high interclass correlation coefficients of of 0.964 and 0.967, respectively. A cubic polynomial regression described best the correlation of pancreas circumference with gestational age (r = 0.744; P < .001) and significant correlations also with abdominal circumference and estimated fetal weight (Pearson r = 0.829 and 0.812, respectively; P < .001). Modeled pancreas circumference percentiles for each week of gestation were calculated. During the study period, we detected 2 cases with overgrowth syndrome and 1 case with an annular pancreas., Conclusions: In this study, we assessed the feasibility of sonography for measuring the fetal pancreas and established a normal reference range for the fetal pancreas circumference throughout pregnancy. This database can be helpful when investigating fetomaternal disorders that can involve its normal development., (© 2017 by the American Institute of Ultrasound in Medicine.)

Objectives: Bladder exstrophy is a rare severe congenital malformation. Early prenatal diagnosis is scarcely described in the literature. Low insertion of the umbilical cord is a constant anatomic feature of bladder exstrophy. The aim of our study was to assess whether early measurements of the umbilical cord insertion-to-genital tubercle length may serve as quantitative measurements for a low-inserted umbilical cord in cases of bladder exstrophy., Methods: The umbilical cord insertion-to-genital tubercle length was prospectively measured in all cases referred for a nonvisualized urinary bladder before 18 weeks' gestation. Final diagnoses were compared with prenatal measurements., Results: Fifteen fetuses were evaluated for a nonvisualized bladder at a mean gestational age of 15.7 weeks (range, 14-17 weeks). Of them, 6 cases were diagnosed with bladder exstrophy, and 9 cases had a normal urinary bladder. All cases with bladder exstrophy had an umbilical cord insertion-to-genital tubercle length below the fifth percentile for gestational age, whereas cases with a normal bladder had a normal measurement., Conclusions: Fetuses with bladder exstrophy have an umbilical cord insertion-to-genital tubercle length below the fifth percentile of the general population. This measurement may serve as a complementary objective sonographic parameter in the prenatal assessment and counseling of cases suspected of having bladder exstrophy during early pregnancy., (© 2017 by the American Institute of Ultrasound in Medicine.)

Objectives: The purpose of this study was to describe the characteristics and outcomes of fetuses with a diagnosis of nonobstructive diffuse dilated bowel loops., Methods: We conducted a retrospective study of all pregnancies with fetal diagnosis of nonobstructive diffuse dilated bowel loops over 14 years in a large tertiary referral center. Fetomaternal and neonatal characteristics and outcomes were assessed., Results: Seven fetuses had sonograms showing diffuse dilated bowel loops; none of them had intestinal obstruction after labor. The median gestational age at diagnosis was 33 weeks 1 day (range, 27 weeks-34 weeks 1 day). The median gestational age at delivery was 34 weeks 1 day (range, 32 weeks 4 days-39 weeks 1 day). Four cases had premature rupture of membranes beyond 32 weeks. Four among the 7 had gastrointestinal manifestations. Three cases presented with hematochezia, which resolved with conservative treatment. One fetus had intractable diarrhea, had a diagnosis of rare microvillus inclusion disease, and died of sepsis after 92 days. Not a single case of Hirschsprung disease was observed in our group., Conclusions: Nonobstructive diffuse dilated bowel loops diagnosed in the second half of pregnancy are associated with premature rupture of membranes and premature labor. As neonatal gastrointestinal complications may be anticipated, prenatal parental counseling with a neonatologist and pediatric gastroenterologist should be conducted., (© 2016 by the American Institute of Ultrasound in Medicine.)

Objectives: Recent research provides evidence that anogenital distance may serve as a novel metric to assess reproductive potential in men. In children, a shorter anogenital distance was linked with cryptorchidism, hypospadias, and micropenis. Scarce data exist in the literature regarding anogenital distance measurement in the fetus. The aim of our study was to assess whether intrauterine measurement of fetal anogenital distance could assist in the differential diagnosis of male genital anomalies., Methods: Anogenital distance was prospectively measured in all cases referred for suspected isolated abnormal male genitalia. Final diagnoses, confirmed by a pediatric urologist, were compared with anogenital distance prenatal measurements., Results: Fifty-two cases were referred for evaluation because of suspected male external genital malformation during a 12-month period. Cases with normal-appearing genitalia, associated major malformations, and early severe fetal growth restriction were excluded from the study. Postnatal examination revealed 14 cases of hypospadias in varying severity and 8 cases of a buried penis. All fetuses with hypospadias had an anogenital distance measurement below the fifth percentile. Statistical analysis revealed a significant difference between the normal mean anogenital distance for gestational age versus those with hypospadias (mean ± SD, 16.90 ± 4.08 and 11.68 ± 3.31 mm, respectively; P = .001). No significant difference was found between the normal mean anogenital distance for gestational age versus those with a buried penis (18.85 ± 2.76 and 19.46 ± 3.41 mm; P = .700)., Conclusions: Fetuses with hypospadias have a statistically significant shorter anogenital distance compared with the general population. Therefore, anogenital distance may serve as a complementary objective sonographic parameter in the prenatal assessment and counseling of male external genital anomalies., (© 2016 by the American Institute of Ultrasound in Medicine.)

Objectives: The thymus has a pyramidal shape, which is best shown in coronal planes. The aim of this study was to evaluate the potential of virtual organ computer-aided analysis to estimate fetal thymus volume in normal pregnancies., Methods: Three-dimensional volume data sets from the axial upper mediastinal section were acquired from 37 normal pregnancies between 12 and 35 weeks' gestation. Thymus volume was calculated by virtual organ computer-aided analysis by 2 separate examiners. In 12 cases, volumes were also acquired with 4-dimensional sonography and spatiotemporal image correlation software to assess the variability in thymus size between the systolic and diastolic periods of fetal heart motion. Linear regression analysis was used to assess the relationship between the fetal thymus volume and gestational age. Paired Student t tests were used to evaluate both the level of agreement for interobserver and intraobserver variability and the difference between diastolic and systolic thymus volumes., Results: Identification of the borders of the thymus and calculation of its volume were successful in 28 patients (77.7%). Statistically significant linear growth of the thymus during pregnancy, from 12 to 35 weeks, was found. The growth coefficient for each gestational age was 0.43 (95% confidence interval, 0.355 to 0.504; P < .001). The difference in thymus size between systole and diastole was minor (0.0798 cm(3); 95% confidence interval, -0.044 to 0.203 cm(3)). Interobserver and intraobserver variability was not statistically significant., Conclusions: Although the thymus has a complex shape, it was possible to determine its borders and to calculate its volume by virtual organ computer-aided analysis in 77.7% of cases. Linear growth during pregnancy was found, and the minor changes during systole and diastole could be explained by condensation of the soft tissue of the thymus secondary to cardiac activity., (© 2015 by the American Institute of Ultrasound in Medicine.)

Objectives: The purpose of this study was to evaluate a novel sonographic scoring system for risk assessment of complications in patients suspected of having morbidly adherent placenta., Methods: This retrospective study evaluated the association between maternal complications and a grayscale sonographic scoring system for adherent placenta before surgery. Criteria for adherent placenta included uteroplacental and uterobladder demarcation lines and the presence of lacunae. Placentas were classified into 4 stages: stage 0, normal placentation; stage 1, low probability of adherence; stage 2, moderate possibility of adherence; and stage 3, high suspicion of adherence. Placental adherence as assessed by a surgical team, estimated blood loss, and postoperative hospitalization days were determined for each group, as well as the rates of the need for packed blood cells, cryoprecipitate units, and hysterectomy., Results: One hundred nine women were included in the study. Twenty-six (23.8%) women were given a score of stage 0, 22 (20.2%) stage 1, 28 (25.7%) stage 2, and 33 (30.3%) stage 3. Linear regression analysis demonstrated that the sonographic staging was the only variable significantly associated with the number of packed cells or cryoprecipitate units transfused (P< .001) and a clinical diagnosis of adherent placenta (P< .001). In addition, both sonographic staging and a history of cesarean delivery were significantly associated with hysterectomy (P = .01; P = .03, respectively), treatment with any blood products (P< .001; P= .01), and the duration of postoperative hospitalization (P< .001; P = .006)., Conclusions: A scoring system based on simple grayscale parameters may be effective for antenatal risk assessment of maternal complications in cases of suspected morbidly adherent placenta., (© 2015 by the American Institute of Ultrasound in Medicine.)

Objectives: The purpose of this study was to investigate the ability to depict the 4-chamber and 3-vessel and trachea views of the fetal heart using 3-dimensional sonography., Methods: Three-dimensional color Doppler volumes of the fetal heart were acquired prospectively in 31 fetuses between 19 and 25 gestational weeks. The initial plane consisted of the 4-chamber view. Postprocessing included navigation within the volume solely in plane A in the caudal direction to visualize the stomach and in the cephalic direction to the plane of the 3-vessel and trachea view to visualize the pulmonary artery, the aorta, the V shape and color of the arches, the superior vena cava, and the trachea. The feasibility of showing these organs was evaluated., Results: The estimated time for volume acquisition and manipulation was about 60 seconds. The detection rates for the 4-chamber view, stomach, 3-vessel view, trachea, and V sign were 100%, 93.5%, 92.0%, 77.4%, and 83.9%, respectively, with interobserver agreement of 0.76 to 1.0., Conclusions: We describe a simple technique in which a single sweep on 3-dimensional sonography starting at the level of the 4-chamber view can visualize the situs, stomach, 4-chamber view, and transverse view of the outflow tracts of the heart.

Objectives: The purpose of this study was to examine the uterine cavity within 48 hours of delivery using 2- and 3-dimensional sonography after normal vaginal deliveries, instrumental deliveries, exploration of the uterine cavity, and cesarean deliveries., Methods: A prospective study was performed in puerperal women with normal clinical examination findings. Measurements of the uterine length and width were taken in the midsagittal and coronal planes. Midsagittal measurements of the endometrium using 2- and 3-dimensional sonography and virtual organ computer-aided analysis were performed. Comparisons were made between normal and surgical vaginal deliveries, cesarean deliveries, and after exploration of the uterine cavity., Results: A total of 123 patients were examined. Seventy-seven patients had normal vaginal deliveries; 21 had assisted vaginal deliveries; and 25 had cesarean deliveries. Thirteen underwent exploration of the uterine cavity. The uterine volume increased significantly as the birth weight increased and after cesarean delivery (P < .05). No correlation was found between the endometrial volume and parity, birth weight, and mode of delivery, including no correlation with exploration. Five cases of placental residua were found in asymptomatic women. All delivered vaginally. None underwent exploration of the uterus. All had irregular echogenic masses in the uterine cavity with positive color Doppler findings. The endometrial thickness and volume were significantly higher in these patients., Conclusions: Sonography along with Doppler assessment has added value in the clinical evaluation of the puerperal women, being able to also show residua in asymptomatic women. Three-dimensional sonography did not show an advantage over 2-dimensional sonography in the estimation of the puerperal uterus or residua.

The objectives of this series were to describe the prenatal sonographic findings of a fetal isolated prominent left brachiocephalic vein with its in utero natural history and neonatal outcome and to discuss the differential diagnosis, especially with a total or partial anomalous pulmonary venous return malformation. We reviewed all cases referred to 2 tertiary medical centers with the presenting finding of a prominent, upper thorax transverse vein entering the superior vena cava. The primary suspicion of a subjective dilated left brachiocephalic vein, as a part of a supracardiac anomalous pulmonary venous return malformation, was investigated by a systematic anatomic evaluation. After exclusion of other cardiac and structural anomalies, we followed the pregnancies and their outcomes. Eight cases were recruited during a 7 year period. The mean maternal age was 31 years, and the mean gestational age at the time of diagnosis was 17 weeks. In 7 cases, the dilatation was not evident during 6 weeks of follow up. In 1 case, the dilatation was evident until delivery at 39 weeks and was not apparent on postnatal echocardiography or spiral computed tomography. All neonates developed without any heart or other complications. We conclude that after exclusion other malformations, a prominent left brachiocephalic vein is a benign transient phenomenon that does not persist post-partum in the neonate.

The pituitary gland is crucially important in the function of the endocrine axis. So far, antenatal depiction of the pituitary gland was possible only using magnetic resonance imaging. We describe antenatal visualization of the pituitary gland using 2- and 3-dimensional sonography. The appearance of the gland on sonography seems to be superior compares to prenatal magnetic resonance imaging. In cases with midline anomalies of the brain, face, or cranium, depiction of the pituitary gland is feasible and recommended.

Objectives: The purpose of this study was to describe the characteristics and outcomes of umbilical cord hernias diagnosed prenatally., Methods: We conducted a retrospective study of all pregnancies with the diagnosis of a fetal umbilical cord hernia during a 5-year period. All women received care from a multidisciplinary team and underwent complete meticulous sonography for structural malformations as well as fetal echocardiography and amniocentesis., Results: Between 2004 and 2009, isolated fetal umbilical cord hernias were diagnosed in 8 pregnant women. The gestational ages at the time of referral ranged from 16 to 28 weeks (median, 20 weeks). In 1 case, intrauterine fetal death occurred at 35 weeks due to rupture of the umbilical cord. All remaining cases were delivered at 36 to 40 weeks, and the neonates underwent corrective surgery with good outcomes., Conclusions: Despite 1 case complicated by intrauterine fetal death in this study, the outcome of an isolated fetal umbilical hernia seems favorable.

Objectives: The purposes of this study were to identify the fetal hippocampus and fornix using 3-dimensional sonography, to measure their curved length during pregnancy, and to describe a systematic method for volume data set analysis of the fetal hippocampus and fornix., Methods: Three-dimensional volumes of the fetal brain were acquired prospectively in 34 patients between 14 and 37 weeks' gestation. Volumes were acquired with trans-abdominal and transvaginal transducers. All volumes were analyzed offline by 2 examiners separately. The feasibility of identifying the fetal hippocampus and fornix was analyzed. The curved length of the hippocampus-fornix structure was measured on the right and left hemispheres., Results: The fetal hippocampus and fornix were identified bilaterally in 32 of 34 fetuses (94%) at gestational ages of 14 weeks 5 days to 37 weeks 1 day (mean, 23 weeks 3 days). In 1 fetus (3%), only one side was shown, and in another fetus (3%), both sides were obscured by acoustic shadows. A systematic approach for identification of the fetal hippocampus is described. Linear growth of the fetal hippocampus and fornix was shown during pregnancy and was correlated with both the gestational week and the head circumference (R = 0.71 and 0.74, respectively; P = .01). The length of the hippocampus and fornix did not differ between the left and the right hemispheres (P = .598)., Conclusions: The fetal hippocampus and fornix can be identified by a systematic analysis of 3-dimensional data set volumes. The normal hippocampus and fornix show linear growth throughout pregnancy.

Objectives: The purpose of this study was to report the outcomes of fetuses with the finding of an umbilical cord cyst during nuchal translucency examination in a low-risk population., Methods: A retrospective study was conducted in a large tertiary referral academic center over a 3-year period. All fetuses with umbilical cord cysts during the nuchal translucency scan were recruited, and their medical data concerning the pregnancy and neonatal course were analyzed., Results: Eight fetuses (0.7%) had a diagnosis of an umbilical cord cyst among the 1080 nuchal translucency examinations. The mean cyst diameter was 19 mm (range, 10-38 mm). The male to female ratio was 6:2. Isolated umbilical cord cysts were found in 5 cases (62.5%), and in all, the nuchal translucency measured less than 2 mm; the cysts resolved; and the outcomes were normal. Three fetuses (37.5%) had additional associated malformations. In all of them, the cysts persisted during pregnancy. Two of them had increased nuchal translucency (3.2 and 4.2 mm). In these 2 cases, 1 fetus had a hypoplastic left heart with a normal karyotype, and the other had multiple malformations and trisomy18. Both pregnancies were terminated. The third case, with normal nuchal translucency, had an ectopic kidney and a patent urachus, which closed spontaneously at 23 weeks and resulted in a normal pregnancy outcome., Conclusions: A favorable outcome is expected when an umbilical cord cyst diagnosed during late first trimester presents as an isolated finding associated with normal nuchal translucency and resolves later on.

Objectives: The purpose of this study was to characterize bowel blood flow and its relationship with cerebral and placental circulations in normally grown and growth-restricted fetuses., Methods: In a cross-sectional prospective study of singleton normally grown fetuses, Doppler blood flow pulsatility indices were measured in the superior mesenteric artery, middle cerebral artery, and umbilical artery from 19 to 38 weeks' gestation. The same Doppler parameters were examined in intrauterine growth-restricted (IUGR) fetuses and analyzed as two groups: (1) without a brain-sparing effect, defined as an umbilical artery/middle cerebral artery ratio of less than 1; and (2) with a brain-sparing effect, defined as an umbilical artery/middle cerebral artery ratio of greater than 1., Results: A total of 262 appropriate-for-gestational-age fetuses were analyzed for superior mesenteric artery Doppler pulsatility index values; 196 were simultaneously examined for umbilical artery and middle cerebral artery pulsatility index values. Forty-three IUGR fetuses were similarly analyzed. In appropriate-for-gestational-age fetuses, both the bowel and brain circulations showed a globally higher pulsatility index as pregnancy advanced, resulting in an almost constant middle cerebral artery/superior mesenteric artery ratio (r(2) = 0.079). The IUGR fetuses had a lower superior mesenteric artery pulsatility index compared to the appropriate-for-gestational-age fetuses, which was more pronounced in those with brain sparing (group 2) than in group 1 (Z = -0.97 and -0.53, respectively; P < .0001). The middle cerebral artery/superior mesenteric artery ratio was higher with respect to the appropriate-for-gestational-age fetuses in group 1, whereas the ratio in group 2 was lower (Z = 0.16 and -0.60)., Conclusions: We have shown the existence of a superior mesenteric artery sparing effect in IUGR fetuses. This reaction seems to correlate positively with the severity of the growth restriction.

Objectives: The purposes of this study were to describe a 3-dimensional sonographic technique for evaluation of the fetal vermis and to compare vermian biometric parameters in fetuses with a normal and an abnormal posterior fossa., Methods: A prospective study was conducted from 2006 through 2008 on 12 fetuses with an abnormal posterior fossa and 73 healthy control fetuses from 18 to 35 weeks' gestation. Three-dimensional scans of the fetal head were performed in the axial plane, using static volume contrast imaging in the C-plane. The vermian perimeter, cross-sectional area, and superoinferior diameter were measured and compared between abnormal and normal fetuses using the Wilcoxon nonparametric test. Linear regression analysis was used to describe trends of the vermis during gestation. The z scores for perimeter, cross-sectional area, and superoinferior diameter measurements in the abnormal posterior fossa group in each 2-week interval were calculated., Results: Twelve fetuses with an abnormal posterior fossa were recruited: 3 with a Blake pouch cyst, 1 vermian cyst, 1 enlarged cisterna magna, 2 Dandy-Walker malformation, 4 partial vermian agenesis, and 1 hemicerebellar hypoplasia. The vermian cross-sectional area was reduced significantly in the fetuses with an abnormal posterior fossa compared with the control fetuses starting at 18 to 19 weeks' gestation (P = .01); the mean vermian superoinferior diameter was lower only from 22 to 23 weeks (P = .01); and the mean vermian perimeter was decreased from 28-29 weeks' gestation (P = .03). Linear regression analysis of the parameters showed that fetuses with an abnormal posterior fossa had a statistically significantly lower growth rate than control fetuses during gestation (P < .001)., Conclusions: Measurements of the cross-sectional area were more useful than those of the perimeter and superoinferior diameter in distinguishing between fetuses with a normal and an abnormal posterior fossa during the early stages of gestation.

Objectives: The purpose of this study was to establish in utero reference ranges for the fetal umbilical cord insertion-to-genital tubercle length in early gestation., Methods: A prospective cross-sectional study was performed on 140 normal low-risk singleton pregnancies between 12 and 18 weeks' gestation. The umbilical cord insertion-to-genital tubercle length was measured in a midsagittal section with high-resolution transvaginal or transabdominal sonography. The mean and 95% prediction limits were defined for each gestational week and analyzed by regression equations and correlation coefficients., Results: Adequate measurements were obtained in 134 patients. The umbilical cord insertion-to-genital tubercle length as a function of gestational age was expressed by the following regression equation: umbilical cord insertion-to-genital tubercle length = -3.079452 + 1.09 × week (R(2) = 0.7117). The correlation R(2) = 0.7117 was found to be highly statistically significant (P < .001). The normal mean and 95% prediction limits were defined for each gestational week. During the study period, 2 cases were referred to our unit because of nonvisualization of the urinary bladder. The umbilical cord insertion-to-genital tubercle lengths in these cases were below the 95th percentile, confirming the diagnosis of bladder exstrophy., Conclusions: The normative data established in this study may be helpful for early pre-natal diagnosis congenital bladder exstrophy.

Objective: Congenital anomalies are the leading cause of infant mortality in the United States, and congenital heart defects (CHDs) are the most common type of birth defects. Recently, 4-dimensional ultrasonography (4DUS) with spatiotemporal image correlation (STIC) has been introduced for fetal echocardiography. Accumulating evidence indicates that 4DUS with STIC may facilitate the examination of the fetal heart. Our objectives were to determine the accuracy of 4DUS for the diagnosis of CHDs and the agreement among centers., Methods: This study included 7 centers with expertise in 4D fetal echocardiography. Fetuses with and without confirmed heart defects were scanned between 18 and 26 weeks, and their volume data sets were uploaded onto a centralized file transfer protocol server. Intercenter agreement was determined using a κ statistic for multiple raters., Results: Ninety volume data sets were randomly selected for blinded analysis. Overall, the median (range) sensitivity, specificity, positive and negative predictive values, and false-positive and -negative rates for the identification of fetuses with CHDs were 93% (77%-100%), 96% (84%-100%), 96% (83%-100%), 93% (79%-100%), 4.8% (2.7%-25%), and 6.8% (5%-22%), respectively. The most frequent CHDs were conotruncal anomalies (36%). There was excellent intercenter agreement (κ = 0.97)., Conclusions: (1) Four-dimensional volume data sets can be remotely acquired and accurately interpreted by different centers. (2) Among centers with technical expertise, 4DUS is an accurate and reliable method for fetal echocardiography.

Objective: The purpose of this study was to identify fetal abdominal vasculature with 3-dimensional (3D) ultrasonography and to describe a systematic method for analysis of volume data sets., Methods: Three-dimensional volumes of the fetal abdomen were acquired prospectively in 30 patients between 15 and 34 weeks' gestation with color Doppler, high-definition (HD) flow, power Doppler, and B-flow imaging. All volumes were analyzed offline by 2 examiners separately. The feasibility of identifying the fetal abdominal blood vessels was analyzed. A standardized approach was applied to identify specific vessels by correlating the images with known anatomic landmarks., Results: The volumes were rotated into an anatomic orientation in the multiplanar mode, and then the vessels were identified in the following order: aorta (30 of 30), celiac trunk (29 of 30), superior mesenteric vein (28 of 30 and 26 of 30 for readers 1 and 2, respectively), superior mesenteric artery (29 of 30), left renal artery (25 of 30 and 26 of 30), right renal artery (27 of 30), common iliac arteries (30 of 30), umbilical arteries (26 of 27), external iliac arteries (20 of 22), umbilical vein (29 of 30), ductus venosus (30 of 30), hepatic vein (29 of 30), right portal vein (29 of 30), inferior vena cava (28 of 30), adrenal artery (2 of 30), hepatic artery (24 of 30 and 23 of 30), splenic artery (24 of 30 and 23 of 30), gastric artery (14 of 30 and 9 of 30), splenic vein (19 of 30 and 15 of 30), and renal vein (1 of 30). A step-by-step systematic approach to identify the abdominal vasculature from the ultrasonographic volume data set was developed., Conclusions: Fetal abdominal vessels can be easily visualized when a systematic analysis is performed on 3D data set volumes. Visualization of the vessels was optimal when volumes were acquired with HD flow imaging.

Objective: The purpose of this study was to establish the normality of the fetal vermis, ie, the time of appearance of the primary fissure, as well as its measurements between 18 and 26 weeks' gestation, using 3-dimensional (3D) ultrasonography., Methods: A prospective cross-sectional study of normal singleton pregnancies was conducted. Examinations were performed with high-resolution transabdominal ultrasonography using the axial plane in 173 fetuses between 18 and 26 weeks' gestation. Postprocessing measurements of the fetal vermis were done with 4-dimensional software using static volume contrast imaging and tomographic ultrasound imaging in the C-plane. Detection of the primary fissure was evaluated in all cases, and the time of appearance was documented., Results: Adequate vermis measurements were obtained in 173 fetuses. Vermian length as a function of gestational age was expressed by regression equations, and the correlation coefficients were found to be highly statistically significant (P < .001). The normal mean +/- 2 SD for each gestational week was defined. The primary fissure was observed at 24 weeks' gestation in all cases, at 22 weeks in 94% of cases, and as early as 18 weeks in 40%., Conclusions: This 3D study documents the appearance of the primary fissure and presents the normal range of vermian measurements, confirming normal development of the fetal vermis starting as early as 18 weeks' gestation. It also shows an easy method for visualizing the vermis with 3D ultrasonography at every gestational week regardless of fetal presentation.

Objective: The purpose of this study was to describe the clinical importance of an abnormal number of fetal ribs., Methods: A retrospective study of all fetuses that were found to have an abnormal number of ribs during routine ultrasonographic examinations was performed. Volume data sets of the fetal ribs were acquired by either static 3- or 4-dimensional volume contrast imaging in plane C. In all cases, a meticulous survey of the fetal anatomy was performed, and prenatal and postnatal records were reviewed., Results: Seventy-five fetuses were found retrospectively to have an abnormal number of ribs. Ultrasonographic examinations were done between 14 and 31 weeks' gestation (mean, 21.8 weeks; median, 23 weeks). More than 24 ribs were found in 28 fetuses (37%), and fewer than 24 ribs were found in 47 (63%). Additional anomalies were found in 22 fetuses (29%). Cardiovascular anomalies were detected in 10 fetuses. Seven fetuses had renal anomalies. Two fetuses had mild ventriculomegaly, and 1 fetus had holoprosencephaly. Lung dysplasia was found in 2 cases. One fetus had enlarged nuchal translucency with wormian bones. Termination of pregnancy was performed in 3 cases because of major malformations. The other 19 fetuses with associated abnormalities and the 53 without associated anomalies were born alive with only minor anomalies., Conclusions: An abnormal number of fetal ribs is an isolated finding in most cases. It may also be seen with major anomalies; however, more frequently the anomalies are minor, and the overall prognosis is good.

Objective: Isolated levocardia is a rare type of situs inversus in which the heart is in the normal levo position, but the abdominal viscera are in the dextro position. We aim to describe our experience with prenatal diagnosis and management in fetuses with isolated levocardia., Methods: Of all the cases referred to our tertiary ultrasound unit, 3 cases of isolated levocardia were diagnosed. Patients and fetuses were evaluated every 4 weeks until delivery and postnatally., Results: Two of the 3 fetuses had interruption of the inferior vena cava with azygous continuation. However, postnatal evaluation revealed polysplenia in 1 neonate and asplenia in another. Polysplenia was also diagnosed in the third neonate, who had a normal inferior vena cava on antenatal examination. One neonate had a small ventricular septal defect., Conclusions: Fetal isolated levocardia is associated with a good outcome, in which other malformations are excluded. Therefore, we suggest conservative management in such cases.

Objective: The purpose of this series was to describe the prenatal diagnosis and pregnancy outcome of fetuses affected by a transient idiopathic fetal sternal cyst., Methods: Two fetuses had the diagnosis of an isolated presternal cyst at routine sonography at 15 weeks. A follow-up sonographic examination was done, and the neonates were examined after birth., Results: In both cases, the cyst disappeared at 20 weeks' gestation, and both fetuses had only a small dimple at the location of the cyst., Conclusions: An isolated presternal cyst is an extremely rare finding. It should be followed sonographically, and if it disappears within a few weeks, the diagnosis of a dermal inclusion cyst should be suspected. Parents can be informed to anticipate a small depression on the neonate's chest.

Objective: The purpose of this study was to perform high-resolution sonographic examinations to determine the normal anatomic relationship of the conus medullaris (CM) of the spinal cord with the vertebral column during different stages of gestation., Methods: In this prospective study, fetal sonographic evaluations were performed between 13 and 40 weeks' gestation. Transvaginal probes (7.5-8 MHz) or abdominal probes (5-8 MHz) were used, depending on gestational age and position of the fetus. The CM was located in coronal longitudinal sections. The positions of the kidneys and lumbosacral junction and the origin of the ribs determined the location of the vertebrae. The locations of the CM were divided into 5 groups according to their positions relative to the vertebrae., Results: A total of 110 fetuses between 13 and 40 weeks' gestation were studied. Between 13 and 18 weeks' gestation, the CM was situated at the level of the L4 vertebra, or more caudally, in 100% of the fetuses. At term, all fetuses showed the CM above L2. A distinct ascent of the CM was detected between 13 and 40 weeks' gestation. The results were statistically significant (P < .0001)., Conclusions: A distinguishable ascent of the CM in relation to the vertebral column during fetal life was detected.

Objective: To describe our experience in prenatal diagnosis of hemivertebra., Methods: This is a case series of patients referred to our tertiary medical center over a 3-year period. All fetuses were scanned by high-resolution real-time scanners. The apparent vertebral anomaly was assessed in a real-time manner by a joint team of obstetricians, sonographers, and pediatric orthopedic surgeons. A complete anomaly survey of other fetal organs was performed on each fetus. All patients were given proper counseling by the same joint team. All patients had detailed obstetric and neonatal follow-up. Prenatal sonograms, neonatal medical records, and clinical courses were evaluated retrospectively., Results: During the 3 years, 6 cases of hemivertebra were identified in our department. Gestational age at diagnosis was 14 to 23 weeks. Two patients had conception by assisted reproductive technology. Associated anomalies included VATER syndrome (vertebral defects, imperforate anus, tracheoesophageal fistula, and radial and renal dysplasia), gastroschisis, and pyelectasis. Outcomes in fetuses without major associated anomalies were fair., Conclusions: Diagnosis of isolated hemivertebra might be associated with a favorable outcome. The 3 key factors in achieving an optimal spine at maturity, early diagnosis, anticipation, and prevention of deterioration, might be enhanced by our joint multidisciplinary approach to the diagnosis of skeletal anomalies.

Objective: To evaluate pulmonary blood flow in fetuses of diabetic mothers by measuring changes in fetal segmentary pulmonary artery blood flow velocimetry throughout pregnancy., Methods: Thirty-eight women with pregestational diabetes between weeks 18 and 38 were compared with 99 women with singleton low-risk gestations as controls. Flow velocity waveforms at the proximal middle and distal segments of the right pulmonary artery were obtained with power and color Doppler sonography in all fetuses. The pulsatility index of each segment was compared between the 2 groups. The mean value and 95% confidence interval for each segment were determined in correlation with gestational age for both groups., Results: The highest mean pulsatility indices were obtained in the proximal segment of the pulmonary artery and were 2.25 in the diabetes group and 2.36 in controls. The mean pulsatility indices were significantly decreased in the middle and distal segments to 1.59 and 1.10 in the diabetes group and to 1.57 and 1.02 in controls (P < .05). There were no significant differences in pulsatility indices measured at the proximal and middle segments between the study and control groups. However, the mean pulsatility index +/- SD measured at the distal segment in the diabetic group was 9% higher than in controls (1.10 +/- 0.13 versus 1.02 +/- 0.12; P = .01). The mean pulsatility index (in the study and control groups) in each arterial segment did not change significantly throughout gestation (P > .1)., Conclusions: . In human fetuses throughout gestation, the pulmonary circulation maintains stable vascular resistance in both diabetic and normal pregnancies. However, in all gestations, the pulsatility index in each segment of the pulmonary artery is unique and reflects the proximity to the heart and the impedance at each location. The significantly higher pulsatility index in the diabetes group might be related to alterations in the microcirculation of diabetic patients.

Objective: The upper limit of the fetal atrial width in normal fetuses is debated. This was a prospective cohort evaluation of the lateral ventricular width with special regard to the upper limit of its size., Methods: Measurements of fetal atrial ventricular size were obtained by abdominal ultrasonography in 427 male and female fetuses between 20 and 40 weeks' gestation of normal singleton pregnancies. In addition, reanalysis of previous data (8 studies) and the current data was performed to produce a pooled mean and SD., Results: The mean ventricular width +/- SD was 6.2 +/- 1.2 mm. The ventricular width did not show significant modification throughout gestation. Reanalysis of the current and previous studies (8216 cases) yielded a pooled mean of 6.4 +/- 1.2., Conclusions: According to the current and previous studies, the upper cutoff of fetal ventricular atrium width should be 10 mm. This cutoff represents a range of approximately 3 SDs above the pooled mean, corresponding to a 99.74% confidence interval.

Objective: The introduction of high-resolution ultrasonography combined with color-coded Doppler imaging offered a breakthrough in the evaluation of the human fetal venous system, considerably enhancing our understanding of fetal venous circulation in normal physiologic conditions, as well as providing us the ability to study circulatory changes in abnormal circumstances. The purpose of this study was to describe the normal anatomic development and complex of anomalies of the human fetal venous system and to review recently published series of these anomalies., Methods: Normal embryologic and anatomic development is described. An English language literature search of recent MEDLINE listings was performed to glean data from recently published series reporting prenatal diagnosis of the various anomalies and their associated malformations., Results: Anomalies of the human fetal venous system occur sporadically, often associated with cardiac or other malformations. The pathophysiologic mechanisms leading to abnormal in utero development of the human venous system remain largely undetermined. On the basis of the type of vein involved, embryologic precursor, and etiologic correlation (primary or secondary), classification into 4 major groups is described., Conclusions: Prenatal evaluation of fetuses found to have anomalies of the venous system should include a careful search for cardiac anomalies, including pulmonary venous drainage, and a detailed anatomic survey of the umbilical, portal, hepatic, and ductal systems to determine aberrant communication and, if possible, to discover clues to systemic diseases or thromboembolic phenomena.

Objective: To evaluate our experience with sonography and color Doppler blood flow in the diagnosis and management of chorioangiomas of the placenta., Methods: All cases with placental chorioangiomas diagnosed in our sonography unit between 1992 and 2001 were included in the study. Sonographic and color Doppler flow characteristics were evaluated in all cases. Our cases were compared with all cases of placental chorioangiomas diagnosed antenatally by sonography published in the English literature between 1978 and 2001., Results: Six cases of placental chorioangioma were identified antenatally, with a mean size of 6.5 cm (range, 4-13 cm). With the use of color Doppler flow, all cases of chorioangioma were shown to have either abundant blood flow or a large feeding vessel within the tumor. During follow-up, 2 cases had reduction of the intratumoral blood flow, and the outcomes were favorable. Three of our cases had delivery before 33 weeks' gestation (1 with intrauterine fetal death and 1 with termination of pregnancy). Review of the literature revealed 72 cases of antenatally diagnosed placental chorioangioma. Two thirds of the cases had dismal outcomes., Conclusions: The sonographic diagnosis of chorioangiomas of the placenta is feasible and necessitates close surveillance of these pregnancies because of the dismal prognosis in more than half. The addition of color Doppler flow is important in the diagnosis and antenatal follow-up of these pregnancies.

Objective: To assess the efficacy, safety, and associated complications of sonohysterography for the diagnosis of residual trophoblastic tissue., Methods: We conducted a prospective study of 23 consecutive patients admitted to our ultrasonography unit with clinical and ultrasonographic signs of retained intrauterine tissue., Results: Twelve patients had hydrosonographic features suggestive of residual trophoblastic tissue (i.e., an intrauterine lesion not detachable from the uterine wall after instillation of saline), whereas in 11 cases the hydrosonographic findings were negative for retained tissue. Blood flow was detected within abnormal intrauterine masses in 4 of 12 patients with trophoblastic tissue, whereas it was not detected in any patient without retained tissue (P = .093). No complications were encountered during the procedure or the postprocedure period. None of the patients had anesthetic complications, perforation of the uterus, fluid overload, or any other surgical complication. All 12 patients underwent hysteroscopic removal of the suspected residual trophoblastic tissue, and histologic confirmation of residual trophoblastic tissue was obtained in all cases., Conclusions: Sonohysterography for detection and diagnosis of residual trophoblastic tissue is an accurate and safe procedure. Further studies comparing the efficacy of sonohysterography with that of diagnostic hysteroscopy are warranted.

Our objective was to evaluate the preoperative clinical, laboratory, and sonographic characteristics of struma ovarii in comparison to ovarian dermoid cysts. A retrospective review of gynecologic patients operated on for mature cystic teratoma over a 10 year period identified 12 cases of struma ovarii. These cases, combined with 4 additional cases from an earlier report, were the subject of this study. Results were compared to 32 cases of ovarian dermoid cysts. Ovarian struma ovarii occurred in 12 (4.8%) of 251 cases of ovarian dermoid cysts. Most patients were premenopausal, and the mean lesion diameter was 57.3 mm (range, 30-95 mm). Struma ovarii occurred more frequently (68.8%) in the right adnexa and was seen with a normal CA-125 level. Blood flow, assessed by Doppler ultrasonography, was located in the center of the lesion in all cases of struma ovarii. Rare cases were seen with elevated tumor markers and low resistance blood flow. With regard to dermoid cysts, blood flow had a higher resistive index. In addition, no blood flow could be detected from the center of the echoic lesion in dermoid cysts (P < 0.0001). In summary, it is difficult to distinguish between struma ovarii and dermoid cysts on the basis of their sonographic appearance. Nevertheless, Doppler flow may aid in the preoperative diagnosis of struma ovarii. Blood flow signals, detected from the center of the echoic lesion, and low resistance to flow may be more common in struma ovarii.

Our objective was to characterize tubal abnormalities with color Doppler ultrasonography. We evaluated 25 women with adnexal masses suggestive of tubal masses using gray scale sonography. Color Doppler flow was added to further characterize the adnexal lesion. Of 18 women diagnosed as having hydrosalpinx, in 6 cases the diagnosis was tuboovarian abscess and in 1 case the diagnosis was tubal torsion. In the periphery of the hydrosalpinx, color Doppler flow revealed a mean resistive index of 0.752 +/- 0.04. In the periphery of the tuboovarian abscess, an abundant flow with reduced resistance to flow (mean resistive index = 0.448 +/- 0.04) was seen. The difference was statistically significant (P < 0.0001). In the case of adnexal torsion, no blood flow was detected in the lesion. All cases but one were confirmed in either laparoscopy or laparotomy or during colpotomy and drainage of the abscess. For adnexal masses suggestive of tubal lesions, color Doppler flow can further characterize the masses by detecting a significantly richer and low resistant blood flow in cases of tuboovarian abscess in comparison to hydrosalpinx.

Our objectives were to describe the flow velocity waveform of the fetal superior mesenteric artery and to establish a nomogram for its pulsatility index. In a cross-sectional study using color Doppler ultrasonography, superior mesenteric artery flow velocimetry was investigated prospectively in 96 healthy fetuses of between 14 and 37 weeks of gestation. In normal fetuses the pulsatility index measurements showed a slight but insignificant increase over the course of gestation (r = 0.26; P > 0.5). The lowest mean +/- standard deviation for pulsatility index in the superior mesenteric artery was 1.86 +/- 0.45 (95% confidence interval 1.67-2.06), recorded between 18 and 21 weeks' gestation. Thereafter the pulsatility index increased to 1.94 +/- 6.4 (95% confidence interval 1.74-2.8) at 22 to 25 weeks, and from weeks 26 to 29 it increased to 2.18 +/- 0.52 (95% confidence interval 1.91-2.46). During the third trimester and at term, the mean pulsatility index of 2.23 +/- 0.32 (95% confidence interval 1.43-3.03) did not change significantly with gestational age. In normal fetuses, except for the early stages, a relatively stable vascular resistance of the intestinal circulation was found. The application of this nomogram in clinical practice may facilitate evaluation of intestinal perfusion in compromised fetuses with blood flow centralization.

The knowledge of fetal lung circulation in normal and abnormal human fetuses is limited. Our objectives were to assess normal values for flow velocity waveforms in the fetal pulmonic circulation and to test the hypothesis that Doppler velocimetry can predict lung hypoplasia. In a cross-sectional study, peripheral right pulmonary artery flow velocimetry was investigated prospectively in 96 healthy fetuses between 14 and 37 weeks' gestation and four fetuses with abnormalities known to induce lung hypoplasia. The pulsatility index was used to quantify the velocity waveforms. In normal fetuses the mean pulsatility index in the peripheral right pulmonary artery was low, being equivalent to that corresponding to 14 to 17 weeks' gestation (2.89; confidence interval = 2.35 to 3.42), increasing at midgestation to 3.44, with a confidence interval of 3.04 to 3.83; P < 0.01. Thereafter, during the late second and third trimesters the mean pulsatility index did not change significantly with GA, being 3.66 (confidence interval = 3.04 to 4.04) at term. In fetuses with proven lung hypoplasia, the pulsatility index measurements were within the 95% confidence limits of those for normal fetuses. In a normal pregnancy, except for the early stages, a relatively stable high vascular resistance of the fetal pulmonary circulation was found. Our preliminary data suggest that the pulsatility index of the lung circulation cannot be used as an indicator of lung hypoplasia.

Most menopausal patients with breast cancer receive tamoxifen therapy. In these patients, TVS may show thickened, irregular cystic endometria. For better visualization of these patients' uterine cavities, we performed transvaginal sonohysterography. During vaginal ultrasonography, sterile saline was introduced by transcervical 8 French Foley catheter into the uterine cavity of 20 women who were referred with tamoxifen-associated cystic thickened endometria. In eight women, transvaginal sonohysterography provided the means to diagnose occult, free-floating endometrial polyps, whereas in 12 women, the fluid contrast augmented the diagnosis of an irregular cystic endometrial-myometrial junction. All 20 patients underwent diagnostic hysteroscopy: eight polyps, none of which were malignant, were confirmed and removed by hysteroscopic resection. Of the remaining 12 patients with an irregular endometrial-myometrial junction, endometrial curettage showed no significant pathologic findings. Transvaginal sonohysterography seems to enhance the differentiation between endometrial polyps that should be resected by operative hysteroscopy and an abnormal endometrial-myometrial junction that may benefit from biopsy sampling only.

The object of our investigation was to evaluate the potential of transvaginal echocardiography for a complete anatomic study of the fetal heart, and for detection of congenital heart diseases in low-risk pregnant patients between 13 and 15 weeks' gestation. High-frequency (6.5 MHz and 7.5 MHz) transvaginal probes were employed for fetal echocardiographic assessment. Six hundred and sixty patients considered at low risk for congenital heart disease underwent in utero ultrasonographic studies, neonatal records, postnatal imaging studies, and pathologic examination. The four-chamber view was obtained in 100% of the fetuses, while the extended fetal heart examination was completed in 98%. Six fetuses with cardiac defects were diagnosed during the study: three had major heart defects (aortic atresia, tetralogy of Fallot, and persistent truncus arteriosus), all detected at the early transvaginal scan; three cardiac anomalies escaped our early diagnosis; two fetuses had a minor ventricular septal defect diagnosed only postnatally; and one had multiple cardiac rhabdomyoma diagnosed in the third trimester. Our results demonstrate that between 13 and 15 weeks' gestation transvaginal echocardiographic assessment of the fetal heart in the low-risk population is feasible. Moreover, some severe anomalies may be detected at such an early gestational age.