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Objective To describe spontaneous preterm birth prevention practices self-reported before and after the dissemination of relevant guidelines, and to identify personal and organisational factors associated with adherence. Design A repeated cross-sectional vignette-based survey study. Setting French obstetricians. Population French obstetricians practicing in public or private maternity units. Methods Before and after the dissemination of the 2017 French guidelines on the prevention of spontaneous preterm birth, participants were asked to complete a web-based self-administered questionnaire based on two clinical vignettes. Vignette 1 focused on respondents' attitudes towards strict bed rest, cerclage, and progesterone treatment for women with a short cervix in mid-trimester; vignette 2 focused on attitudes towards strict bed rest and maintenance tocolysis after successful tocolysis for preterm labour. A mixed quantitative and qualitative analysis was conducted. Main outcome measures Non-adherence to guidelines for the prevention of spontaneous preterm birth in responses to each vignette. Results We obtained complete responses from 286 obstetricians before and 282 obstetricians after guideline dissemination, including 145 obstetricians participating in both. After dissemination, 51.4% of obstetricians self-reported non-adherent practices for vignette 1 and 22.3% of obstetricians self-reported non-adherent practices for vignette 2. No improvement was observed after dissemination. The quantitative analysis identified factors associated with non-adherence, including older age and practice in non-university or small hospitals, whereas the qualitative analysis highlighted barriers to implementation, including fear of change, habits, work overload, and lack of time. Conclusions Adherence to guidelines was generally low, with practices unmodified by their dissemination. Improvement is required, especially regarding applicability. Tweetable abstract Adherence to guidelines to prevent spontaneous preterm birth was generally low and remained unmodified after guideline dissemination.

OBJECTIVE: To evaluate the morbidity and mortality of neonates with left-sided isolated congenital diaphragmatic hernia (CDH) according to gestational age at delivery. METHODS: This was a retrospective study of fetuses diagnosed prenatally with isolated left-sided CDH that were delivered in the University Hospitals of Antoine Béclère-Bicêtre and Leuven between 1 January 2010 and 31 December 2018. The Kaplan-Meier method was used to calculate cumulative survival at 28 days after birth according to gestational age at delivery. The association between gestational age at delivery, as a continuous variable, and survival at 28 days was modeled using a fractional polynomial. Adjustment for position of the liver, management center and mode of delivery was performed. The association was also evaluated according to the severity of CDH, as defined by the observed-to-expected lung-to-head ratio (o/e-LHR), which was classified as severe (o/e-LHR 45%). RESULTS: We included 213 fetuses with isolated left-sided CDH, with a median gestational age at delivery of 38 + 2 weeks (interquartile range, 37 + 0 to 39 + 1 weeks). The survival rates at 28 days and at 6 months were 66.7% (142/213) and 64.3% (137/213), respectively. Kaplan-Meier analysis showed a higher survival rate at 28 days for babies delivered between 37 + 0 and 38 + 6 weeks than for those delivered at or after 39 + 0 weeks (log-rank test, P

Objective To investigate the value of fetal stomach position in predicting postnatal outcome in left-sided congenital diaphragmatic hernia (CDH) with and without fetoscopic endoluminal tracheal occlusion (FETO). Methods This was a retrospective review of CDH cases that were expectantly managed or treated with FETO, assessed from May 2008 to October 2013, in which we graded, on a scale of 1–4, stomach position on the four-chamber view of the heart with respect to thoracic structures. Logistic regression analysis was used to investigate the effect of management center (Paris, Brussels, Barcelona, Milan), stomach grading, observed-to-expected lung area-to-head circumference ratio (O/E-LHR), gestational age at delivery, birth weight in expectantly managed CDH, gestational ages at FETO and at removal and period of tracheal occlusion, on postnatal survival in CDH cases treated with FETO. Results We identified 67 expectantly managed CDH cases and 47 CDH cases that were treated with FETO. In expectantly managed CDH, stomach position and O/E-LHR predicted postnatal survival independently. In CDH treated with FETO, stomach position and gestational age at delivery predicted postnatal survival independently. Conclusion In left-sided CDH with or without FETO, stomach position is predictive of postnatal survival. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Objectives The aim of this research was to describe precisely prenatal ultrasound (US) features in congenital cytomegalovirus (CMV) infection. Methods We retrospectively evaluated the US descriptions of cases of congenital CMV infection between 2004 and 2013. Results In 69 congenital CMV infections, related US abnormalities were reported in 30 cases (43.5%). There were both extracerebral and cerebral abnormalities in 16 cases, purely abnormal brain features in ten, and purely extracerebral features in two. About 19/30 cases presented extracerebral features of 11 different sorts of abnormalities, mainly hyperechogenic bowel (ten cases) and intrauterine growth retardation (nine cases). About 24/30 cases presented cerebral features of 13 different sorts, mainly brain calcifications (12 cases) and occipital horn cavity (11 cases). The main US findings in our series are not specific to CMV infection. However, a frequent finding attracted our attention: the anechogenic cavity located on the extremity of the occipital horn, a region which contains numerous proliferating and differentiating germinal cells. Conclusions By improving knowledge of US findings linked to CMV infection, US sensitivity may be improved. Understanding why CMV leads to lesions of the occipital horn may help clarify the pathophysiology of congenital infection. © 2014 John Wiley & Sons, Ltd.

Objective To analyze the outcome of maternal primary cytomegalovirus (CMV) infection. Methods Retrospective analysis of a cohort of 238 patients with maternal primary CMV infection detected at routine screening. The cases were managed with serial ultrasound (US) scans, and amniocentesis was performed in 36.1% of cases. All prenatal results were confirmed at birth. Results The average age was 31.9 (18–44) years. Patients were symptomatic in 21% of cases. The rate of intrauterine transmission was 24.9%, and it was 8.8%, 19%, 30.6%, 34.1% and 40% in the preconceptional period, the periconceptional period, and the first, second and third trimesters of pregnancy, respectively (p = 0.025). There was a significantly higher risk of US abnormalities when maternal infection occurred during the preconceptional or periconceptional period and the first trimester compared with later (p

To evaluate the feasibility of completing in one session a second-trimester ultrasound scan in obese pregnant women, to compare the quality of images obtained with those of non-obese women and to analyze factors that can improve the completion rate.This prospective study, from 2009 to 2011, included all obese pregnant women (prepregnancy body mass index (BMI) 30 kg/m2) who had an ultrasound examination at 20-24 weeks in our department, and a control group of pregnant women with normal BMI (20-24.9 kg/m2) who had the same examination. A single operator reviewed the standardized ultrasound images (three biometric and six to assess key anatomical features) required under French guidelines, to assess their presence, evaluate the quality of all images and score the quality of the six anatomical images. Each image was assessed according to between four and six criteria, each worth one point. We sought excellent quality, defined as the frequency of maximum points for a given image type. The factors associated with completing the scan in one session were evaluated with multivariate logistic regression.The obese group included 223 women and the control group 60; a complete scan in one session was achieved in 70.4% and 81.7% of these, respectively (P = 0.08). The completion rate for each image type was at least 95% in the control group and 90% in the obese group, except for diaphragm and right outflow tract images. Significant factors associated with completing the scan in the multivariate model were: having 10 additional minutes for the scan (P = 0.03), moving the fetus so that the back was in posterior or lateral position (P = 0.01), more experienced sonographer (P = 0.03) and thinner maternal abdominal wall thickness (P = 0.01). Overall, the excellence rate varied from 35% to 92% in the normal BMI group and from 18% to 58% in the obese group, and was significantly lower in the latter for all images except abdominal circumference (P = 0.26) and spine (P = 0.06). Anatomical quality scores were also significantly lower in the obese group (22.3 vs. 27.2; P = 0.001).Although ultrasound scans of obese pregnant women are feasible, image quality and global anatomical scores are significantly lower among obese than normal-weight women. However, certain simple improvements may increase fetal visualization.

Please cite this paper as: Azria E, Anselem O, Schmitz T, Tsatsaris V, Senat M, Goffinet F. Comparison of perinatal outcome after pre-viable preterm prelabour rupture of membranes in two centres with different rates of termination of pregnancy. BJOG 2012;119:449–457. Objective To assess perinatal outcomes after expectant management in the case of preterm prelabour rupture of membranes (PPROM) before 25 weeks of gestation, according to the rate of termination of pregnancy (TOP). Design Retrospective comparative cohort study. Population Singleton pregnancies complicated by PPROM between 150/7 and 246/7 weeks of gestation, from January 2003 to January 2007. Methods Comparison of perinatal outcomes in two French tertiary care referral centres presumed to have different rates of TOP. Main outcome measure Rates of TOP, survival and survival without major morbidity. Results A total of 113 women experienced PPROM (49 in centre A and 64 in centre B). A lower proportion of patients opted for TOP in centre A (40.8%) than in centre B (56.3%). The baseline characteristics of patients and pregnancies, and gestational age at PPROM, were not different between the two centres. Mean gestational age at delivery (28.1 versus 25.4 weeks of gestation; P

Objective To evaluate the clinical use of hourly fetal urine production rate (HFUPR) in polyhydramnios. Methods This was a retrospective review of 33 singleton pregnancies with polyhydramnios, 30 of them unexplained and three due to gastrointestinal atresia. HFUPR was estimated using three-dimensional ultrasound and was compared with recently established nomograms. Abnormal midterm outcome, defined as diagnosis or persistence of pathology after the neonatal period until the age of 2 years, was analyzed according to prenatal HFUPR measurements and other polyhydramnios characteristics. Results Seventeen of the 30 fetuses with unexplained polyhydramnios had an HFUPR above the 95th centile, and five (29.4%) of them developed midterm disorders. None of the 13 with normal HFUPR developed midterm disorders. The HFUPR was 1.9 (SD, 0.7) multiples of the median (MoM) in fetuses with an adverse childhood outcome and 1.4 (SD, 1.2) in fetuses with normal childhood outcome (P = 0.34). In the three fetuses with gastrointestinal atresia, the HFUPR was significantly lower than in those with unexplained polyhydramnios (P = 0.003). Conclusion HFUPR was associated with the mechanism of polyhydramnios but failed to help in the prognosis of unexplained polyhydramnios because of lack of power. Children with prenatal unexplained polyhydramnios and HFUPR above the 95th centile should nevertheless receive detailed pediatric follow-up. Copyright © 2009 ISUOG. Published by John Wiley & Sons, Ltd.

We describe the findings on computed tomography (CT) in a prenatally diagnosed case of bladder exstrophy, and compare them with the findings on two- and three-dimensional sonography. The CT data of the affected fetus were compared with the CT findings of 14 fetuses with normal bony pelvises. The CT images showed differences in the structure of the bony pelvis in the case of bladder exstrophy, with a wide gap between the iliopubic and ischiopubic rami and a widening of the iliac bones. CT scanning was useful in confirming the sonographic diagnosis of bladder exstrophy, and it may also be helpful for planning early surgery following delivery. Copyright © 2009 ISUOG. Published by John Wiley & Sons, Ltd.

We present the case of a 31-year-old woman, gravida1, who was referred at 22 weeks’ of gestation toour center to explore abnormalities revealed by herroutine second-trimester ultrasound examination. Thepatient had an unremarkable medical and obstetricalhistory. The couple was not consanguineous. The firstscreening ultrasound scan, at 13 weeks, was normal.At 14 weeks, genetic serum screen for Down syndromeyielded normal results placing the fetus at low risk forchromosomal abnormalities. A routine second-trimesterultrasound revealed an abnormal intracranial mass.The ultrasound scan performed at our center at23 weeks revealed a 9-mm hyperechoic area withina hypoechoic area triangular in shape, about 4 cm

Objectives To evaluate the proportion of pregnant women agreeing to cytomegalovirus (CMV) serologic screening. To collect data on CMV infection during pregnancy. Design Prospective study. Setting During two years, all pregnant women were informed on CMV infection. If the patient agreed, serological testing was performed around 12 weeks of gestation (WG) and, if negative, redone around 36 WG. Population Four thousand two hundred and eighty-seven pregnant women followed from 12 weeks to delivery. Methods If the first CMV serologic test was negative, detailed hygiene information was given to the parents. Diagnosis of primary infection was based on the detection of CMV-G, CMV-M and low CMV-G avidity index. When maternal infection was confirmed, diagnosis of CMV congenital infection was done in the newborns by urine culture within the three days following birth. Crude infection-rate data consisted of the number of CMV infection cases and person-time units for both exposed to hygiene CMV information (12 to 36 WG) and unexposed pregnant women (first 12 WG). Main outcome measures Rate of CMV seropositive and seronegative women. Rate of women agreeing for screening. Rate of primary infection. Rate of seroconversion. Number of CMV-infected newborns. Results Among the 4287 women followed, 3792 were either seronegative or with an unknown immune status. 96.7% out of them agreed for screening. 53.2% were initially CMV-specific IgG negative. Primary infection was detected in nine women between 0 and 12 WG (0.46%) and seroconversion was diagnosed in five women between 12 and 36 WG (0.26%) (mid P = 0.02, 95% CI [1.07–13.6]). Conclusions If clear information on CMV infection during pregnancy is given, patients frequently agree to screening. The rate of seroconversion after information, observed in this study, is low after counselling.

Hydrocolpos should be considered systematically when an abdominopelvic cystic mass is diagnosed in a female fetus. Because the prognosis and neonatal management of isolated hydrocolpos with spontaneous resolution differs greatly from that of hydrocolpos associated with a cloacal malformation, it is important to ascertain prenatally whether there are associated anomalies. We report the prenatal characteristics of three fetuses with hydrocolpos; in two cases there was spontaneous resolution and one infant was born with digestive tract atresia. The principal ultrasound findings were an oblong anechoic pelvic mass with or without a sagittal septum, located behind a normal bladder. On magnetic resonance imaging (MRI), the cervical imprint on the vagina confirmed the diagnosis of hydrocolpos and helped to diagnose cloacal malformation by demonstrating the absence of meconium beside the bladder on T1 sequences. Our cases show that MRI is useful for differentiating isolated hydrocolpos from hydrocolpos associated with cloacal malformation.

Objectives Examination of the fetal nasal bones by ultrasound between 11 and 14 weeks of gestation has been proposed as an additional tool in the detection of trisomy 21 in a high-risk population. However the variability in the identification of fetal nasal bones by ultrasound has not yet been investigated. The aim of this study was to assess the intraobserver and interobserver reproducibility of fetal nasal bone identification by ultrasound between 11 and 14 weeks of gestation. Methods A total of 1040 consecutive ultrasound examinations were performed at 11–14 weeks of gestation for nuchal translucency (NT) measurement and nasal bone identification by ultrasound. A total of 657 consecutive video-loops were assessed by three experienced operators. Each operator assigned cases to one of three categories, namely present, uncertain or absent nasal bones, and the results were compared between operators. To assess the intraoperator variability each operator reviewed 100 randomly selected videos out of the 657 loops and again used the same classification. Results were compared by pairwise unweighted and weighted Kappa index to evaluate the inter- and intraoperator variability. Results Among the 1040 fetuses, there were 51 (4.9%) with an NT measurement above the 95th centile. Nasal bones were identified by ultrasound in 948, not seen in eight and impossible to assess in 84 fetuses. Four fetuses had trisomy 21 including three with absent nasal bones and increased NT and one with present nasal bones and normal NT. The Kappa and weighted Kappa values for interoperator variability between the three operators were between 0.26 and 0.37 and 0.33 and 0.44, respectively. The Kappa and weighted Kappa values for intraoperator variability were between 0.35 and 0.48 and 0.43 and 0.55, respectively. Conclusion The assessment of fetal nasal bones is only fairly reproducible. Although the performance of the test in fetuses at high risk for trisomy 21 has been reported to be good, its implementation as an additional screening technique in the general population must be accompanied by teaching and quality control programs. Copyright  2003 ISUOG. Published by John Wiley & Sons, Ltd.

Objective To assess the use of lidocaine (1%) to induce permanent fetal cardiac asystole for fetocide in late termination of pregnancy. Design Prospective observational study. Setting One tertiary referral fetal medicine unit in France. Sample Fifty patients undergoing termination of pregnancy between 20 and 36 weeks of gestation for severe abnormalities or severe maternal conditions. Methods Fetocide was performed by umbilical vein puncture under ultrasound guidance with injection of sufentanil (5 μg) followed by 7 to 30 mL of lidocaine (1%). Main outcome measures Percentage of successful procedures to obtain permanent fetal cardiac asystole and maternal side effects. Results The procedure was successful in 92% of cases (46/50) with complete cessation of heart activity. The mean amount of lidocaine was 15.3 (6.5) mL. In three cases, fetocide was performed by cardiocentesis and in one case lidocaine was unsuccessful and fetocide was performed with KCl. There were no maternal side effects. Conclusion Lidocaine is an effective drug to perform fetocide with doses below the toxic dose for the mother.

Objective Intrauterine death of one twin in monochorionic pregnancies is associated with an increased mortality and morbidity of the cotwin. This is likely to occur as a consequence of acute hemodynamic changes due to feto–fetal hemorrhage at the time of death of the cotwin. We assessed the role of fetal blood sampling and intrauterine transfusion to rescue the survivor. Materials and methods We managed 12 cases of single intrauterine death at between 17 and 26 weeks' gestation in monochorionic twins complicated by twin-to-twin transfusion syndrome (TTTS). All these cases had been treated either by laser therapy or by serial amniodrainage. When the demise of one twin occurred, ultrasound-guided fetal blood sampling was performed in the surviving twin using a 20-gauge needle within 24 h of death. Intrauterine transfusion was performed at the same time in cases where the survivor was anemic. All survivors were assessed in the neonatal period and at 1 year of age. Results Six of the 12 surviving fetuses were found to be anemic and underwent intrauterine transfusion. All fetuses survived the procedure. Four of these fetuses had normal neurological development at 1 year of age. Periventricular leukomalacia developed in one case and the patient underwent termination of pregnancy at 34 weeks. In one case delivery occurred at 34 weeks' gestation and the baby developed periventricular leukomalacia at 1 month of age. In all six non-anemic fetuses pediatric examination was normal at birth and at 1 year of age. Conclusion Intrauterine death of one monochorionic twin in TTTS puts the survivor at high risk of intrauterine death or of developing ischemic/hypoxic lesions. Our results suggest that fetal blood sampling is a useful diagnostic tool to identify those fetuses that are not anemic and hence unlikely to be at risk of developing a cerebral lesion. Copyright © 2002 International Society of Ultrasound in Obstetrics and Gynecology

Objective This study was conducted to evaluate pregnancy outcome and mid- and long-term prognosis of cases with nuchal translucency ≥4 mm and normal karyotype. Methods Retrospective analysis of 160 cases who presented with a nuchal translucency ≥4 mm when the CRL was between 45 and 84 mm was undertaken. Cystic hygromas were excluded. When the karyotype was normal a detailed anomaly scan was performed at 20 to 24 weeks followed by serial ultrasound examination. Clinical examination of the neonates was performed by a paediatrician. Long-term follow-up was completed through a questionnaire filled in by parents, GPs and paediatricians. Results 160 fetuses had an NT ≥4 mm. 44.3% had an abnormal karyotype. Of the 55.7% with normal karyotypes, 74 % did not show any abnormalities on follow-up ultrasound scan. Mid- and long-term outcome was known in 91% of the cases. 6.4% had a malformation diagnosed only at birth. Among the normal neonates, 11.1% are considered to have a significant neurological handicap or orthopaedic problems at 12 to 72 months of age. Conclusion In an unselected population, NT ≥4 mm is associated with a high incidence of chromosomal and non chromosomal abnormalities. Even when the fetal karyotype and serial ultrasound examinations are considered to be normal, the risk of fetal malformation and developmental delay should not be underestimated. Copyright © 2002 John Wiley & Sons, Ltd.

Hydrocephalus-stenosis of the acqueduct of Sylvius sequence (HSAS) is characterized by hydrocephalus, macrocephaly, adducted thumbs, spasticity, agenesis of the corpus callosum and mental retardation. X-linked hydrocephalus is known to be due to mutations in the gene coding for the neural cell adhesion molecule L1 (L1-CAM) and diagnosis is made by identification of a mutation in the L1-CAM gene. Prenatal diagnosis of HSAS is usually suggested on ultrasound examination showing hydrocephalus in a male fetus associated with bilateral adducted thumbs. Mutation screening of the L1-CAM gene is indicated when neuropathological examination shows hypoplasia of the corticospinal tract associated with aqueductal stenosis. We report here two cases of HSAS diagnosed within the same family by ultrasound examination in the first trimester of pregnancy when bilateral adducted thumbs were the only early ultrasound marker.

Objective To describe the time sequence of changes in fetal monitoring variables in intrauterine growth restriction and to correlate these findings with fetal outcome at delivery. Methods This was a prospective longitudinal observational multicenter study on 110 singleton pregnancies with growth-restricted fetuses after 24 weeks of gestation. Short-term variation of fetal heart rate, pulsatility indices of fetal arterial and venous Doppler waveforms and amniotic fluid index were assessed at each monitoring session. The study population was divided into two groups: Group 1 comprised pregnancies with severely premature fetuses, which were delivered ≤ 32 weeks and Group 2 included pregnancies delivered after 32 completed weeks. Logistic regression was used for modeling the probability for abnormality of a variable in relation to the time interval before delivery. Trends over time were analyzed for all variables by multilevel analysis. Results Ninety-three (60 in Group 1 and 33 in Group 2) fetuses had at least three data sets (median, 4; range, 3–27) and had the last measurements taken within 24 h of delivery or intrauterine death. The percentage of abnormal test results and the degree of abnormality were higher in Group 1 compared to Group 2. Amniotic fluid index and umbilical artery pulsatility index were the first variables to become abnormal, followed by the middle cerebral artery, aorta, short-term variation, ductus venosus and inferior vena cava. In Group 1, short-term variation and ductus venosus pulsatility index showed mirror images of each other in their trend over time. Perinatal mortality was significantly higher if both variables were abnormal compared to only one or neither being abnormal (13/33 (39%) vs. 4/60 (7%); P = 0.0002; Fisher's exact test). Conclusion Ductus venosus pulsatility index and short-term variation of fetal heart rate are important indicators for the optimal timing of delivery before 32 weeks of gestation. Delivery should be considered if one of these parameters becomes persistently abnormal.Copyright © 2001 International Society of Ultrasound in Obstetrics and Gynecology

Objective To evaluate the changes in flow velocity waveforms in the transverse cerebral sinus in growth-restricted fetuses and to correlate these changes with (1) flow velocity waveforms in the ductus venosus and (2) changes in computerized analysis of the fetal cardiotocogram. Design Fetuses between 22 and 37 weeks' gestation with an estimated fetal weight below the fifth centile were included in this prospective longitudinal study. Doppler measurements of the umbilical artery, descending aorta, middle cerebral artery, transverse cerebral sinus and ductus venosus were recorded. Fetal heart rate was analyzed by a computer system according to the Dawes–Redman criteria. Results We measured a significant correlation between pulsatility index in the cerebral transverse sinus and in the ductus venosus over the study period and at delivery. There was a negative correlation between these indices and short- and long-term variability of the fetal heart rate. There was a parallel increase in pulsatility in the ductus venosus and the transverse cerebral sinus. These changes were inversely correlated with fetal heart rate variability and preceded fetal distress. Conclusion Cerebral venous blood flow in IUGR fetuses may be a useful additional investigation to discriminate between fetal adaptation and fetal decompensation in chronic hypoxemia. Copyright © 2000 International Society of Ultrasound in Obstetrics and Gynecology

Objective To compare retrospectively the distribution of foetal biometry data as measured by midwives and physicians during second and third trimester screening of an unselected population of pregnant women. Methods Standard measurements of biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) were performed by four midwives and ten physicians at 20 to 24 weeks of gestation and at 30 to 34 weeks of gestation as part of routine ultrasound examinations over a 26-month period (Jan. 2005–Mar. 2007). All measurements were converted into Z-scores using different prediction equations. The reference chart best fitting our practice was determined for each fetal parameter (French College of Sonographers for BPD, Chitty et al. for HC and FL, Snidjers and Nicolaides for AC). The means and SDs of the Z-score distributions for data collected by midwives and physicians were compared using Student's t-test for means and the Fisher-Snedecor test for SDs. Results We retrieved 1566 and 1631 measurements made by midwives and physicians respectively between 20 and 24 weeks of gestation, and 1710 and 1578 measurements made by midwives and physicians respectively between 30 and 34 weeks of gestation. Mean values recorded by midwives were significantly closer to 0 (p < 0.05) for many foetal parameters. SD values were also significantly lower and were below 1. Conclusion In this study, midwives have a greater tendency than physicians to normalize biometry data. Such normalization may hamper the sensitivity of routine ultrasound screening for abnormal foetal growth. Copyright © 2009 John Wiley & Sons, Ltd.

Objective To report prospectively the prenatal diagnosis, management and outcome of 14 cases of unilateral ventriculomegaly. Methods Fourteen fetuses were diagnosed as having one ventricle of ≥ 10 mm, as measured at the level of the atrium. Results In ten cases, the scan showed mild unilateral ventriculomegaly with an atrium width between 11 and 13 mm and this remained stable up to term. Eight of these fetuses had a magnetic resonance imaging scan in utero between 32 and 34 weeks of gestation which confirmed the diagnosis of mild ventriculomegaly without other brain abnormalities and showed a normal cortical mantle. No obvious cause was found and the outcome was normal in all cases. In four cases, the unilateral ventriculomegaly evolved rapidly with an atrium width up to 20–25 mm. Causes included atresia of the foramen of Monro, toxoplasmosis, brain atrophy and Weaver syndrome. Three underwent termination of pregnancy and the postmortem examination confirmed the diagnosis. The baby with brain atrophy and schizencephaly had a ventriculoperitoneal shunt placed at 1 month of age and has severe developmental delay at 9 months. Conclusion The prognosis of unilateral ventriculomegaly is uncertain. Examination of both ventricles during the anomaly scan should be performed, as should ultrasound follow-up of these cases up to the end of the third trimester. Fetuses with an isolated, mild, stable unilateral ventriculomegaly seem to have a favourable neurological outcome. However, fetuses with rapidly evolving unilateral ventriculomegaly or cases associated with other brain abnormalities may have a poor neurological outcome. Copyright © 1999 International Society of Ultrasound in Obstetrics and Gynecology

Objectives To evaluate first trimester pregnancy screening for fetal aneuploidy and congenital heart defects by maternal age and nuchal translucency measurement and screening for fetal aneuploidies and congenital heart defects by ultrasound in an unselected population. Design A prospective study. Setting Fetal medicine unit, St George's Hospital, London. Sample 4523 consecutive viable fetuses at 10–14 weeks with a crown–rump length between 38 and 80 mm were scanned transabdominally (93%) or transvaginally (7%). Methods Screening was performed by calculating the background risk from maternal age, gestational age and obstetric history, which was then adjusted with the nuchal translucency measurement in relation to crown–rump length (adjusted risk). Main outcome measures Measurements of crown–rump length and nuchal translucency thickness. An adjusted risk of > 1:270 was considered as a positive screening test. Pregnancy outcome was obtained through karyotyping, outcome questionnaires and examination of the newborn infants. Results Mean maternal age was 29.4 years and mean gestational age 12.2 weeks. Screening was positive in 230/4523 fetuses (5.1%), when the adjusted risk (mean 1:2649) was > 1:270. Fetal karyotype was abnormal in 23 (0.51%) cases, including twelve with trisomy 21, five trisomy 18, one trisomy 13, one trisomy 10, one monosomy X and two triploidies. For a false positive rate of 4.7%, the sensitivity of this test was 78% in detecting any fetal aneuploidy. Only one out of nine major congenital heart defects in this population was found within the 110 euploid fetuses with increased nuchal translucency thickness (> 2.5 mm). Conclusion Screening for fetal aneuploidy by maternal age and nuchal translucency measurement can be effective in an unselected population. However, our results do not support its effectiveness in the detection of cardiac abnormalities.

Objective To date, there have been no studies on the optimal timing of second-trimester ultrasound screening for fetal abnormalities. The purpose of this study was to investigate whether, of three gestational ages (18, 20 and 22 weeks), any one was associated with a significant advantage in terms of identification of abnormalities or need for further ultrasound assessment. Design Prospective, randomized study of second-trimester unselected pregnant women, who had had an ultrasound examination with normal results at 10–14 weeks. Subjects and methods A total of 1206 women were randomized into three mutually exclusive groups relating to their second-trimester appointment for a screening ultra-sound examination for fetal abnormalities in the second trimester of pregnancy: Group 1 at 18−18 + 6 weeks, Group 2 at 20−20 + 6 weeks and Group 3 at 22−22 + 6 weeks. The anomaly scans were carried out according to a standardized protocol. The fetuses were examined for structural and developmental abnormalities. Uterine artery Doppler measurements, including waveform recordings, were performed in all cases. The main end-points were the need for rescanning of all or part of the fetal anatomy, fetal outcome, placental localization, and incidence of notches in the uterine artery waveform. Results The baseline demographic characteristics and risk factors in the three groups were similar and gestational age-related fetal measurements were comparable. There were significantly higher percentages of completed scans in Group 2 (90%) and Group 3 (88%) than in Group 1 (76%; p < 0.001), but no significant difference between those scanned at 20 and at 22 weeks. This was associated with a higher incidence of non-cephalic presentation in Group 1 (46%) than in the other two groups (36%, p < 0.001). Significant differences in completing the assessment of the thorax, heart, spine and skeleton were also observed. There was no significant difference in maternal body habitus, fetal movements or the occurrence of uterine fibroids between the study groups. The incidences of low-lying placenta and of abnormal uterine artery Doppler screening were also higher at 18 weeks than at 20 and 22 weeks (p < 0.001 for both variables), with no difference seen between Groups 2 and 3. The numbers of fetal anomalies detected in the three groups were three, two and two, respectively; these did not differ significantly between the groups. Conclusions This study suggests that, in an unselected pregnant population, second-trimester ultrasound screening is easier to perform and less likely to require an additional scan at 20–22 weeks than at 18 weeks. Copyright © 1999 International Society of Ultrasound in Obstetrics and Gynecology

We present four cases of fetal adrenal masses detected by routine prenatal ultrasound, of which three were adrenal hemorrhages and one was a fetal neuroblastoma. The differential diagnoses of fetal adrenal mass include adrenal hemorrhage, neuroblastoma, adrenal and cortical renal cysts, pulmonary sequestrations, duplication of the renoureteral system and Beckwith-Wiedemann syndrome. These can pose a diagnostic and therapeutic dilemma. A systematic comparison of the pre- and postnatal sonographic features including color Doppler imaging may help to differentiate adrenal hemorrhage from neuroblastoma prenatally.

We report a case of the prenatal diagnosis of trisomy 10 in a fetus presenting with an increased nuchal translucency thickness (5 mm) on a routine first-trimester anomaly scan at 12 weeks' gestation. Multiple abnormalities were diagnosed by ultrasound and fetoscopy. Karyotyping on chorionic villus sampling led to the diagnosis of homogeneous trisomy 10 which was confirmed by in situ hybridization on fetal tissue samples. Postmortem examination confirmed major anatomical malformations, including facial cleft, arthrogryposis of the upper and lower limbs and bilateral diaphragmatic hernia, and also revealed hypoplastic lungs, right renal agenesis and a complex cardiac malformation. Trisomy 10 is an uncommon chromosomal abnormality that is likely to be associated with increased fetal nuchal translucency. This case also emphasizes the value of a detailed anomaly scan in high-risk patients in the first trimester of pregnancy.

We present the case of a 28-year-old woman, gravida1 para 0, who was referred at 22 weeks of gestation(WG) to our center to explore abnormalities revealedby second-trimester routine ultrasound examination. Thepatient’s medical and obstetrical history was unremark-able. The couple was not consanguineous. The firstscreening ultrasound scan, at 13 weeks, showed a 70-mm crown-rump length and a 2.4-mm nuchal translu-cency thickness. The levels for serum markers for Downsyndrome at 15 weeks were normal, and she was atlow risk for chromosomal abnormalities. The second-trimester ultrasound revealed a polymalformative syn-drome. The fetus was characterized, in two-dimensional(2D) and 3D ultrasound scan, by rhizomelic limb short-ness, with a single leg bone, strain spine, macrocra-nium, flattened temporal bones, retrognatism, unusualface with hypoplastic nose and widely spaced eyes,broad hands and digits, and club feet. The study ofthorax and abdomen was considered normal. Three-dimensional helical computed tomography was per-formed at 24 weeks to improve accuracy of the prenataldiagnosis of this skeletal dysplasia. It revealed a dou-ble curve configuration of the cervical spine, shorts ribs,vertebral hypoplasia with platyspondyly, thoraco-lumbarcoronal clefting and hypoplastic iliac wings with verticalblock-like ischia (Figure 1). The face was flattened andnarrow, associated with hypoplastic maxillary and thinmedian cleft palate, hypoplastic mandible, and pointedchin. The femurs were short, curved, and proximallyflared, the tibiae were slightly dumbbell-shaped andbowed, and the fibulae were absent. The humeri weremarkedly short with rounding and flaring of the proximal

Objective To compare the effects of betamethasone and dexamethasone on fetal heart rate in appropriately grown fetuses. Methods Eighty-two pregnant women (97 fetuses) with preterm labour were randomly allocated to receive betamethasone (n= 42) or dexamethasone (n= 40) for fetal lung maturation in a nonblinded fashion. Computerised cardiotocogram (CTG) parameters were compared before, during and after treatment. Results A decrease in fetal heart rate variability was found with betamethasone but no significant changes were found with dexamethasone. Fetal heart rate variability returned to pre-treatment values within a week after cessation of treatment with betamethasone. Neonatal outcome was similar in the two groups. Conclusions These findings might prove useful in the management of compromised fetuses with decreased fetal heart rate variability in which the CTG should be used together with other parameters to assess fetal wellbeing during corticosteroid treatment. Dexamethasone may be preferable as the drug of choice since it was associated with significantly less alteration in fetal heart rate variability compared with betamethasone.

Retrospective examination of ultrasound images obtained at 12 weeks of gestation in two fetuses with spina bifida demonstrated retraction of the frontal bones, resulting in an acorn-shaped head, the cerebral peduncles appearing parallel to each other. These craniocerebral signs may improve the accuracy of first-trimester diagnosis of spina bifida by sonography.

We present the case of a 28-year-old woman with an unremarkable medical and obstetrical history. Both parents are Caucasian; the couple is not consanguineous and have already had a healthy child after a normal pregnancy. The first ultrasound scan at 13 weeks was considered normal. Second trimester serum markers suggested a chromosomal abnormality risk of 1/108, leading to another diagnostic ultrasound at 18 weeks, which identified an omphalocele. Karyotype analysis of the fluid sampled by amniocentesis was normal, 46, XX. The 22-week ultrasound confirmed the omphalocele. The latter contained only the small bowel, and its collar measured 20 mm. The liver was in a normal position. In addition, the fourth ventricle was open, communicating with the cisterna magna through a large canal, with hypoplasia of the posterior vermis (Figure 1). No facial anomaly was noticed. A multidisciplinary group of staff explained the poor prognosis of these morphological abnormalities to the couple, whose request that the pregnancy be terminated was approved in accordance with French law. At 25 weeks, a 1040-g female fetus (95th percentile for term) was delivered. The subsequent pathology examination confirmed the features we had observed and also showed craniofacial dysmorphy involving macroglossia, large ears with indentation of the left lobe, and a marked under-eye crease, together with organomegaly. The placenta was hypertrophic and dysmature, with heterogeneous villi. Microscopic analysis highlighted cytomegaly of the extravillous placental trophoblast cells and the fetal adrenal cortex. The association of these anomalies led to a diagnosis of Beckwith–Wiedemann syndrome (BWS). Subsequent

We report on a case of maternal varicella during preg-nancy one year after vaccination against VZV (Varivax,Sanofi Pasteur MSD, two-doses protocol: time intervalbetween the two injections: 4 weeks). A 40-year-old,gravida 5, para 1 woman was referred to our prenataldiagnosis center because typical varicella (numerous dis-seminated vesicles, without pulmonary symptoms) wasclinically diagnosed at 17 weeks of gestation (WG),15 days after her child had a varicella maculopapular-vesicular rash. On the basis of the knowledge of vac-cination one year before, she did not take any particu-lar measures of prevention. Varicella-zoster-virus (VZV)serology was performed in this pregnant woman 3 daysafter varicella exposure (February 13, 2007) and 1 dayafter the onset of rash (February 23, 2007). As VZVassays may vary in terms of sensitivity and specificity,VZV-specific antibodies were determined with differentassays (VZV-specific IgG: EIA DiaSorin, Italy; Trin-ity Biotech, Bray, Ireland; Vidas bioM´erieux, Marcy-l’Etoile, France. VZV-specific IgM: EIA DiaSorin; Trin-ity Biotech). The results obtained (Table 1) show that,3 days after exposure, neither VZV-specific IgM, norVZV-specific IgG were detected. One day after rash,VZV-specific IgM remained negative whereas VZV-specific IgG was detected whatever the technique used.VZV infection was without complication for her andher fetus. Prenatal diagnosis of fetal VZV infection wasnot performed. Monthly ultrasound examination did notreveal any fetal abnormalities. At 39 WG she delivereda healthy 3520 g male infant.The varicella observed in this pregnant woman canbe considered as a primary failure of vaccination (i.e.primary infection) or as a secondary failure (i.e. rein-fection). The probability that she did not respond to atwo-dose vaccine is highly unlikely. It seems more prob-able to us that her levels of IgG waned so as to no longer

The primary aim of this study was to calculate, based on a mathematically modelled decision tree the cost effectiveness of the RM as an intervention for improving fetal medicine specialist’s decisions. Methods: 106 cases of fCNS were prospectively followed up until either termination of pregnancy (TOP) or postnatal follow up (PF). All of them underwent dedicated ultrasonographic (US) assessment and MR, at least once during prenatal evaluation. Neurological postnatal outcome and anatomo-pathology records were registered as gold standards. Positive and negative likelihood ratios (LR) were calculated for four specific regions: posterior fosa (PF), ventricular zone (VZ), cortex and subcortical region (CSC) and middle line (ML). After refinement of univariate analysis, a discriminative likelihood ratio (LR) was calculated for every region and technique, based on direct and indirect cost and calculated post-test probability a Markov’s chain was designed to modelate the real effectiveness of each test. Results: Table 1 summarizes LR results for region and technique, based on post test probabilities and costs, the probability of improving diagnosis with MR before 22 weeks is 15% for PF, 18,5% for VZ, 11% for CSC, 23% for ML, once modified the model for gestational age, the probability at 33 weeks increases to 53%, 78%, 65% and 42% respectively.

genitourinary malformations (7%); 15 gastrointestinal anomalies (6%) and 71 miscellaneous (26%). In 244 (89%) both ultrasound and MRI findings were in agreement with postnatal diagnoses. MRI changed the US diagnosis in 16 (5,8%) cases. Relevant additional information were provided in 7 (2,5%) cases: 3 central nervous system anomalies; 3 thoracic defects; 1 abdominal malformations. Ultrasound was more accurate than MRI in 4 (1,4%) cases: 1 case of placenta previa; 1 exomphalos; 1 CCAM in a twin pregnancy; 1 hypoplasia of corpus callosum. In 9 (3,2%) cases, the diagnoses at both US and MR imaging were not correlated with postnatal outcome. Conclusions: Prenatal US remains the primary fetal imaging modality. Prenatal diagnosis of even complex malformations was accurate in over 90% of cases. In a few selected patients in our experience, particularly in late pregnancy, MRI may however add relevant information.

ensuing weeks the mass increased in size, causing compression of venous return with increase in pericardial effusion, development of cariomegaly with A-V valves regurgitation, polyhydramnios, and ascites. Pericardiocentesis was performed. By 34 wks the mass had grown to 43 × 44 mm with worsening cardiac failure; the baby was delivered by C/S followed by neonatal cardiac surgery (Fig 1b), but the baby died on the 5th day of life. Pathology analysis of tumor tissue showed invasive immature teratoma (Fig 1b-c). Discussion: Pericardial teratoma is generally a benign tumor, with good outcome after neonatal cardiac surgery. In this case the fastgrowing tumor proved to be a lethal invasive immature teratoma.