Search

Objective: To determine the perinatal outcome of monochorionic diamniotic (MCDA) twin pregnancies complicated by selective intrauterine growth restriction (sIUGR), which were classified according to the umbilical artery (UA) Doppler flow pattern of the IUGR twin.Methods: This was a retrospective cohort study of all MCDA twin pregnancies diagnosed with sIUGR and managed at a single tertiary referral center between 2012 and 2018. Cases were classified according to the UA Doppler flow pattern of the IUGR twin as Type I (positive end-diastolic flow), Type II (persistently absent/reversed end-diastolic flow) or Type III (intermittently absent/reversed end-diastolic flow). Patients with Type-II or -III sIUGR were hospitalized at 26-28 weeks of gestation for increased fetal surveillance. Perinatal and immediate and long-term neurodevelopmental outcomes were stratified according to the UA Doppler flow pattern at the final examination. Intact survival rate was defined as the number of infants surviving without neurological impairment, divided by the total number of fetuses. Composite adverse outcome, defined as any mortality, presence of severe brain lesions on postnatal transcranial ultrasound or severe neurological morbidity, was also assessed.Results: Of 88 MCDA twin pregnancies with sIUGR included in the study, 28 underwent selective termination by cord occlusion using radiofrequency ablation, resulting in a perinatal survival rate of 89.3% and a median gestational age (GA) at delivery of 33.8 (interquartile range (IQR), 28.8-38.2) weeks for the large cotwin. Expectant management was employed in 60 cases. In 26 (43.3%) cases in the expectant-management group, the classification according to the UA Doppler flow pattern changed during gestation, resulting in 26 (43.3%) cases of Type-I, 22 (36.7%) cases of Type-II and 12 (20.0%) cases of Type-III sIUGR at the final examination. The perinatal survival rate of both twins with sIUGR Types I, II and III at the final examination was 100%, 81.8% and 75.0%, respectively (P = 0.04). Two cases of double fetal death and one case of single fetal death occurred 1-4 weeks after the Doppler pattern had changed from Type I or Type II to Type III. The median GA at delivery was 34.8 (IQR, 33.1-35.7) weeks in Type I, 30.3 (IQR, 28.6-32.1) weeks in Type II and 32.0 (IQR, 31.3-32.6) weeks in Type III (P < 0.01). The total intact survival rate was 100% for Type I, 77.3% for Type II and 75.0% for Type III (P < 0.001). Multivariate analysis demonstrated that early GA at diagnosis (odds ratio (OR), 0.83 (95% CI, 0.69-0.99); P = 0.04) and the presence of Type II or III vs Type I at the last examination (OR, 13.16 (95% CI, 1.53-113.32); P = 0.02) were associated with preterm birth < 32 weeks' gestation. Early GA at diagnosis was also associated with the composite adverse outcome (OR, 0.60 (95% CI, 0.36-0.99); P = 0.04).Conclusions: The classification system of MCDA pregnancy complicated by sIUGR, according to the UA Doppler flow pattern of the IUGR twin at final examination, is associated with perinatal outcome. Importantly, the UA Doppler flow pattern can change during gestation, which has an impact on the risk of fetal death. Nevertheless, under strict fetal surveillance, the perinatal outcome of these pregnancies is favorable. © 2020 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objectives: To determine the rate of pregnancy complications and adverse obstetric and neonatal outcomes of twin pregnancies that were reduced to singleton at an early compared with a later gestational age.Methods: This was a historical cohort study of dichorionic diamniotic twin pregnancies that underwent fetal reduction to singletons in a single tertiary referral center between January 2005 and February 2017. The study population was divided into two groups according to gestational age at fetal reduction: those performed at 11-14 weeks' gestation, mainly at the patient's request or as a result of a complicated medical or obstetric history; and selective reductions performed at 15-23 weeks for structural or genetic anomalies. The main outcome measures compared between pregnancies that underwent early reduction and those that underwent late reduction included rates of pregnancy complications, pregnancy loss, preterm delivery and adverse neonatal outcome.Results: In total, 248 dichorionic diamniotic twin pregnancies were included, of which 172 underwent early reduction and 76 underwent late reduction. Although gestational age at delivery was not significantly different between the late- and early-reduction groups (38 weeks, (interquartile range (IQR), 36-40 weeks) vs 39 weeks (IQR, 38-40 weeks); P = 0.2), the rates of preterm delivery < 37 weeks (28.0% vs 14.0%; P = 0.01), < 34 weeks (12.0% vs 1.8%; P = 0.002) and < 32 weeks (8.0% vs 1.8%; P = 0.026) were significantly higher in pregnancies that underwent late reduction. Regression analysis revealed that late reduction of twins was an independent risk factor for preterm delivery, after adjustment for maternal age, parity, body mass index and the location of the reduced sac. Rates of early complications linked to the reduction procedure itself, such as infection, vaginal bleeding and leakage of fluids, were comparable between the groups (7.0% for early reduction vs 9.2% for late reduction; P = 0.53). There was no significant difference in the rate of pregnancy loss before 24 weeks (0.6% for early reduction vs 1.3% for late reduction; P = 0.52), and no cases of intrauterine fetal death at or after 24 weeks were documented. There was no significant difference in the prevalence of gestational diabetes mellitus, hypertensive disorders of pregnancy, preterm prelabor rupture of membranes or small-for-gestational age. The rates of respiratory distress syndrome (6.7% vs 0%; P = 0.002), need for mechanical ventilation (6.7% vs 0.6%; P = 0.01) and composite neonatal morbidity (defined as one or more of respiratory distress syndrome, sepsis, necrotizing enterocolitis, intraventricular hemorrhage, need for respiratory support or neonatal death) (10.7% vs 2.9%; P = 0.025) were higher in the late- than in the early-reduction group. Other neonatal outcomes were comparable between the groups.Conclusions: Compared with late first-trimester reduction of twins, second-trimester reduction is associated with an increased rate of prematurity and adverse neonatal outcome, without increasing the rate of procedure-related complications. Technological advances in sonographic diagnosis and more frequent use of chorionic villus sampling have enabled earlier detection of fetal anatomic and chromosomal abnormalities. Therefore, efforts should be made to complete early fetal assessment to allow reduction during the first trimester. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Objective: To determine the short‐ and long‐term outcome of pregnancies with proven first‐trimester fetal cytomegalovirus (CMV) infection in a large prospective cohort. Methods: This was a prospective cohort study of pregnancies with documented primary maternal CMV infection in the first trimester and evidence of fetal infection, referred for further evaluation between January 2011 and January 2018. Maternal serological diagnosis of primary CMV infection was documented by seroconversion. Vertical CMV transmission was identified by amniocentesis with polymerase chain reaction (PCR) for the CMV genome. After birth, fetal infection was re‐tested by PCR in neonatal urine or saliva samples. All patients underwent serial prenatal ultrasound scans and fetal magnetic resonance imaging (MRI) at 32–33 weeks' gestation. All neonates underwent ocular fundus examination, an ultrasound brain scan and hearing evaluation, and were followed periodically for a median of 2 years (range, 6 months to 10 years). Follow‐up information was obtained from hospital charts and by telephone interviews with parents. The CMV‐associated outcomes assessed were sensorineural hearing loss (SNHL), neurodevelopmental abnormality, composite clinical outcome (including SNHL and neurodevelopmental abnormality) and composite outcome (additionally including termination of pregnancy (TOP)). The association between prenatal ultrasound or MRI findings and abnormal outcome was assessed. Results: Primary CMV infection in the first trimester occurred in 123 patients. The rate of an abnormal ultrasound finding was 30.9%, and the rate of an abnormal MRI finding was 30.1% overall and 14.1% in the subgroup of patients with normal ultrasound. Of the 85 patients with normal ultrasound, 12 had an abnormal MRI finding, of whom five (5.9%) had true anatomical findings. Fifteen patients decided to terminate the pregnancy owing to abnormal prenatal findings on either ultrasound or MRI. Overall, the rate of CMV‐associated postnatal and childhood sequelae was 27.8%, with a rate of 16.7% for SNHL and 11.1% for neurodevelopmental abnormalities, mostly slight motor or verbal delay. Approximately half of the cases with CMV‐associated sequelae did not have any abnormal prenatal imaging findings. Abnormal prenatal findings on ultrasound were not associated significantly with SNHL, neurodevelopmental delay or composite clinical outcome (P = 0.084, 0.109 and 0.176, respectively), but they were associated with the composite outcome including TOP (P < 0.001). We identified a non‐significant trend for a higher rate of SNHL in the group with abnormal ultrasound than in those with normal ultrasound. For abnormal MRI findings, we found a correlation only with neurodevelopmental abnormality and composite outcome (P = 0.014 and P < 0.001, respectively). Conclusions: The risk of childhood sequelae after first‐trimester fetal CMV infection is most often associated with abnormal prenatal imaging findings. However, normal imaging does not rule out the development of SNHL and minor neurodevelopmental abnormalities. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd. Linked article: There is a comment on this article by Picone and Mandelbrot. Click here to view the Correspondence. [ABSTRACT FROM AUTHOR]

Objective: The antenatal diagnosis of twin anemia-polycythemia sequence (TAPS) in monochorionic-diamniotic (MCDA) twin pregnancies is based on elevated peak systolic velocity in the middle cerebral artery (MCA-PSV) in the donor twin and decreased MCA-PSV in the recipient twin. However, the association between these parameters and polycythemia has not yet been established. The aim of this study was to determine whether MCA-PSV can predict polycythemia in MCDA pregnancies.Methods: This was a prospective cohort study of MCDA pregnancies recruited at 14-18 weeks' gestation from a single tertiary care center between January 2011 and June 2014. Fetal MCA Doppler waveforms were recorded every 2 weeks from 18 weeks' gestation until delivery. Only those with an MCA-PSV measurement within 1 week of delivery were included in the analysis. Neonatal hematocrit level was determined in all twins from venous blood obtained within 4 h of delivery. Polycythemia was defined as a hematocrit of > 65%, and anemia as a hematocrit of < 45%. TAPS was diagnosed when an intertwin hemoglobin difference of > 8 g/dL and reticulocyte count ratio of > 1.7 were observed.Results: Of 162 MCDA pregnancies followed during the study period, 69 had an MCA-PSV measurement within 1 week of delivery and were included in the study. Twenty-five neonates were diagnosed with polycythemia and nine twin pairs met the criteria for TAPS. In a pooled analysis, MCA-PSV was negatively correlated with neonatal hematocrit (P = 0.017, r = -0.215) and was significantly higher in anemic fetuses than in normal controls (1.15 multiples of the median (MoM) vs 1.02 MoM, respectively; P = 0.001). However, MCA-PSV was similar among polycythemic and normal fetuses (0.95 MoM vs 1.02 MoM, respectively; P = 0.47). Intertwin difference in MCA-PSV (delta MCA-PSV) was positively correlated with intertwin hematocrit difference (P = 0.002, r = 0.394). Moreover, twin pregnancies with an intertwin hematocrit difference of > 24% had a significantly greater delta MCA-PSV than did those with an intertwin hematocrit difference of ≤ 24% (delta MCA-PSV, 19 vs 5 cm/s; P < 0.001).Conclusions: MCA-PSV is not significantly decreased in polycythemic MCDA twins. However, delta MCA-PSV is associated with a large intertwin difference in hematocrit, and its use may be better than conventional methods for the risk assessment of TAPS. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of cytomegalovirus (CMV) infection on apparent diffusion coefficient (ADC) values of the fetal brain in utero.Methods: In this retrospective analysis we compared 58 fetal head magnetic resonance imaging (fhMRI) scans of PCR-verified CMV-infected fetuses, obtained in 2008-2012, with those of a normal control group of 36 gestational age (GA)-matched uninfected fetuses scanned between 2006 and 2012. Estimated GA at infection ranged from 1 to 32 weeks, and fhMRI was performed at 24 to 38 weeks. The frontal, parietal, temporal and occipital lobes (mainly white matter), basal ganglia, thalamus, pons and cerebellum were analyzed by assessing ADC values. Two pregnancies were terminated and postmortem confirmation was available in these cases.Results: ADC values of CMV-infected fetuses correlated significantly and negatively with GA in all brain regions except the basal ganglia. The cerebellum had the greatest reduction (r = -0.52, P < 0.0001). Maternal age correlated positively with ADC in the frontal lobe (P < 0.05). GA at infection and overt pathological changes did not affect ADC significantly. Compared with non-infected fetuses, ADC values of affected fetuses were significantly reduced in the frontal (P < 0.0001), parietal (P < 0.0001), occipital (P = 0.0005) and temporal (P = 0.001) lobes and thalamus (P = 0.006).Conclusion: CMV infection of the fetal brain results in a highly significant, region-dependent reduction of ADC values in the frontal, parietal, occipital and temporal lobes and thalamus, probably reflecting hypercellularity and inclusion bodies in damaged areas. Further studies are needed to determine if reduction in ADC values may serve as a prognostic factor in CMV-infected fetuses. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Objectives: To compare the outcomes of radiofrequency ablation (RFA) and bipolar cord coagulation (BPC) methods for selective feticide in complicated monochorionic (MC) twin gestations and to determine risk factors for adverse pregnancy outcome.Methods: This was a retrospective cohort study of all patients with complicated MC twin pregnancy who underwent selective reduction in a single tertiary care center between 2000 and 2014. We compared the two methods with respect to various demographic, obstetric and perinatal outcome variables.Results: Fifty-three selective terminations in complicated MC twin gestations were performed, 36 by RFA and 17 by BPC. Each technique resulted in a similar overall survival rate of the remaining twin (88.9% vs 76.5%, P = 0.25). Likewise, the mean procedure-to-delivery interval, the rate of spontaneous preterm delivery < 37, < 34, < 32 and < 28 weeks and the rate of preterm prelabor rupture of the membranes did not differ between the groups. However, among patients in the BPC group, there was a trend towards earlier gestational age at delivery (31.3 vs 35.0 weeks, P = 0.09) compared with in the RFA group. There was selective reduction by RFA due to selective intrauterine growth restriction (sIUGR) in 19 cases, 17 (89.5%) of which survived perinatally, with delivery at a median gestational age of 37 weeks. There were no significant differences in perinatal outcome, irrespective of whether the procedure was performed pre- or post-viability. All post-viability reductions, most of which were by RFA, resulted in perinatal survival.Conclusions: Perinatal outcome of complicated MC twin gestations undergoing selective feticide seems to be similar regardless of whether termination is by BPC or RFA. Nevertheless, RFA appears to be particularly useful in MC twins complicated by sIUGR and in cases requiring selective reduction beyond the age of viability. [ABSTRACT FROM AUTHOR]

In 6/23 (26%) pregnancies and 7/46 (15.2%) fetuses pre or postnatal brain lesions were detected, of whom five were the polycythemic twins and two were the anemic twins. Pregnancies were followed with fetal brain neurosonogram every 2 weeks and fetal brain MRI (magnetic resonance imaging) was performed when indicated at 28-32 weeks of gestation; postnatal brain imaging included neonatal brain ultrasound. To determine the rate of fetal and neonatal brain lesions and define risk factors for such lesions in pregnancies complicated by twin anemia polycythemia sequence (TAPS). [Extracted from the article]

ABSTRACT Objective Monochorionic twins treated by fetoscopic laser coagulation ( FLC) for twin-twin transfusion syndrome ( TTTS) are at increased risk of neurodevelopmental impairment. Our aim was to evaluate the additional value of diffusion-weighted imaging ( DWI) over fetal sonography and T2 magnetic resonance imaging ( MRI) in the detection of acute ischemic cerebral lesions shortly following FLC. Methods This was a prospective cohort study of fetuses with TTTS treated by FLC. All fetuses underwent brain DWI and T2-MRI within 24-96 h after the procedure and a follow-up MRI at 30-32 weeks' gestation. All fetuses also had frequent ultrasound evaluation until delivery. Results Thirty pregnancies with TTTS were included in the study. Eight resulted in survival of only one twin after the procedure (Group A), while the other 22 pregnancies resulted in the survival of both twins (Group B), as assessed at the time of initial MRI. Two fetuses in Group A and four in Group B had evidence of transient bleeding in the germinal matrix. Three fetuses in Group B and none in Group A had diffuse ischemic changes in the white matter. One fetus died in utero 24 h after MRI. The other two fetuses in Group B demonstrated an acute infarct 24-48 h after the procedure. Subsequent scans at 28-29 and 32 weeks showed brain atrophy compatible with an old infarct. Conclusions DWI can demonstrate cerebral damage immediately after FLC. Larger cohorts are needed to determine the role of fetal MRI in the prenatal assessment and follow-up of patients with TTTS. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective The aim of this study was to describe the nature of central nervous system (CNS) anomalies diagnosed during the third trimester following a normal anatomy scan at 21-24 weeks of gestation. Methods Retrospective cohort study of all pregnant women referred to the fetal medicine unit at Sheba Medical Center between 2005 and 2011 due to fetal CNS anomalies detected at the late second and third trimesters following a normal anatomy scan at 21-24 weeks of gestation. Results During the study period, 47 patients were diagnosed with fetal CNS anomalies at a median gestational age of 31.1 weeks (range 24-38). The four most common anomalies found included intracranial cysts (19%), mild ventriculomegaly (15%), absence or dysgenesis of the corpus callosum (10%), and intracerebral hemorrhage (10%). Other CNS anomalies detected in this group of patients included hydrocephalus, Dandy walker malformation, large cysterna magna, microcephalus with lissencephaly, craniosynestosis, periventricular pseudocysts, global brain ischemia, cerebellar hypoplasia, and sub-ependymal nodule. Conclusions Fetal brain continues to evolve throughout gestation, and therefore, some of the CNS anomalies can be diagnosed only during late second and third trimesters of pregnancy. Consequently, in patients who have a third trimester scan for any reason, assessment of the fetal CNS should be considered. © 2013 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective To determine the outcome of pregnancies with documented fetal cytomegalovirus (CMV) infection with and without abnormal findings on ultrasound examination and magnetic resonance imaging (MRI). Methods In this prospective cohort study of pregnant women with documented fetal CMV infection, vertical CMV transmission occurred during the first and second trimesters following primary maternal infection. Patients underwent serial prenatal ultrasound scans and fetal MRI. All neonates underwent ocular fundus examination, ultrasound brain scan and hearing evaluation, and were then followed periodically by a pediatrician. Results Primary CMV infection occurred during the first and second trimesters of pregnancy in 71 and 74 patients, respectively. Seven patients (4.8%) decided to terminate pregnancy because of prenatal findings and one neonate died because of CMV complications. Patients with first-trimester infection had infants with significantly more associated sequelae (either auditory damage or neurodevelopmental disabilities) than did patients with second-trimester infection (19.7% vs 5.6%, respectively; P = 0.01). Abnormal prenatal findings on ultrasound examination were associated with increased risk of sequelae. When both ultrasound and MRI findings were normal, the rate of sequelae was decreased to 15.6% for first-trimester infections and to 2.0% for second-trimester infections, partial hearing loss being the sequela in most cases. In the presence of abnormal ultrasound and/or MRI findings the risk was 25% and 16%, respectively, and in most cases the sequelae were deafness and neurodevelopmental delay. The rate of intrauterine growth restriction (IUGR) in the study group was 11.7% and was not affected by the time of onset of maternal infection. Isolated IUGR was not associated with increased risk of sequelae. Conclusion The risk of sequelae is higher following first-than second-trimester CMV infection. However, the risk of severe sequelae is significantly reduced in the presence of normal prenatal ultrasound and MRI findings. [ABSTRACT FROM AUTHOR]

The article presents a study on the value of magnetic resonance imaging (MRI) and prenatal ultrasound in the evaluation of outcome of pregnancies with congenital cytomegalovirus (CMV) infection. Procedural elements related to study involve ultrasound examinations during the third and four weeks of the delivery and MRI assessments around the gestation period and upon diagnosis. Moreover, results show favorable outcome of CMV infection with normal prognostic value of MRI and prenatal ultrasound.

The article examines three- (3D) and four-dimensional (4D) ultrasound applications for the examination of fetal thoracic anomalies. According to the authors, the anomalies identified were diaphragmatic hernia, lung dysplasia, skeletal dysplasia with small thorax/thanatophoric dysplasia, abnormal situs, hydrothorax and esophageal atresia. They stressed that 3D-4D technique enhances precise diagnosis and provides better spatial visualization of the anomalies involved.

Objective: To assess the value of antenatally determined observed to expected fetal lung area to head circumference ratio (LHR) in the prediction of postnatal survival in isolated, congenital diaphragmatic hernia (CDH). Methods: Two groups of fetuses were examined. The first group included 650 normal fetuses at 12-32 weeks' gestation, and the data collected were used to establish a normal range of observed to expected LHR with gestational age. The second group included the data of a retrospective multicenter study of 354 fetuses with isolated CDH in which the LHR was measured on one occasion at 18-38 weeks' gestation. The patients were divided into those with left-sided CDH with and without intrathoracic herniation of the liver and right-sided CDH. Regression analysis was used to determine the significant predictors of postnatal survival. Results: In both the normal fetuses and those with CDH the LHR increased but the observed to expected LHR did not change significantly with gestational age. In normal fetuses the mean observed to expected LHR in the left lung was 100% (95% CI, 61-139%) and in the right lung it was 100% (95% CI, 67-133%). In fetuses with CDH the mean observed to expected LHR was 39% (range 7-79%). Regression analysis demonstrated that significant predictors of survival were the observed to expected LHR (odds ratio (OR) 1.09, 95% CI, 1.06-1.12), side of CDH (left side OR 11.14, 95% CI, 3.41-36.39) and gestational age at delivery (OR 1.18, 95% CI, 1.02-1.36). Conclusion: In CDH, the LHR increases while observed to expected LHR is independent of gestational age. In fetuses with both left- and right-sided CDH, measurement of the observed to expected LHR provides a useful prediction of subsequent survival. [ABSTRACT FROM AUTHOR]

Objective To assess the role of peak systolic velocity in the middle cerebral artery (MCA-PSV) in the management of pregnancies complicated by Kell isoimmunization. Methods Sixteen fetuses were monitored by conventional protocol (Group 1) and eight fetuses by an MCA-PSV-guided protocol (Group 2). The conventional protocol included a weekly ultrasound evaluation and measurement of maternal anti-Kell titers every 4—6 weeks. In Group 2 Doppler assessment of the MCA-PSV was performed at intervals of 4 to 7 days and MCA-PSV >1.5 multiples of the median (MoM) was considered as an indication for fetal blood sampling (FBS). Results No parameter emerged as a reliable predictor of isoimmunization severity in Group 1. In Group 2, no FBS was necessary in one case since the MCA-PS V values obtained during the follow-up were < 1 .29 MoM. In two cases the first FBS was already indicated after 1 week of follow-up, but five other fetuses were followed for 3–9 weeks before FBS was indicated. All fetuses with MCA-PSV > 1.5 MoM prior to intrauterine transfusion (IUT) had severe fetal anemia on FBS. In fetuses with severe anemia on the first PBS, the MCA-PSV values 7 days before the first FBS were < 1.29 MoM (four cases), between 1.29 and 1.5 MoM (two cases) and > 1.55 MoM (one case). Conclusions In the management of Kell isoimmunization invasive procedures may be avoided by implementing MCA-PSV measurements. Delineation of appropriate intervals between reassessments, the reliability of MCA-PSV following repeated IUTs, and cut-off values for FBS await further study. [ABSTRACT FROM AUTHOR]

Objective To study the outcome of 20 twin pregnancies with evidence of primary or recurrent cytomegalovirus (CMV) infection during pregnancy. Design Observational study. Setting Two tertiary perinatal departments in Israel. Population Twenty women with twin pregnancies who were referred because of serologic investigation indicating CMV infection. Seventeen women had evidence of primary CMV infection, and three women appeared to have recurrent CMV infection. Methods Prenatal diagnosis was made by amniocentesis of both sacs after 21 weeks of gestation. CMV isolation was performed by culture on fibroblasts, shell vial technique and polymerase chain reaction (PCR) amplification of CMV DNA. After birth, the neonatal urine and saliva were cultured for CMV. Main outcome measures Intrauterine CMV infection defined as positive PCR at amniotic fluid analysis and congenital CMV infection defined as positive CMV cultures after birth. Results Except for one, all women underwent amniocentesis of both gestational sacs. In 14 (70%) women, no evidence of vertical transmission to any of the 28 fetuses was found and none of the newborns had evidence of congenital CMV infection. Intrauterine infection was detected by amniocentesis in five women and by ultrasound findings with positive maternal serology in one. In three women, CMV was detected in only one amniotic sac. In five of our six total cases, both twins were found to have congenital CMV infection at birth, all of whom had dichorionic–diamniotic placentation, three fused and two separate. Conclusions In twin gestations, as in singletons, intrauterine and congenital CMV infection occurs in about 30% of women with primary or recurrent infection. The placenta type did not predict if one or both twins would be infected. Our data do not exclude the possibility that intrauterine transmission of the virus from one fetus to the other can occur. [ABSTRACT FROM AUTHOR]

Objectives: To examine the ultrasonographic feasibility of imaging the fetal pons and to construct a reference chart for its normal development during gestation. Methods: A cross-sectional, prospective study on 293 healthy fetuses of low-risk pregnancies between 19 and 34 weeks was performed. The transfontanel approach, via the abdominal or vaginal routes, was used to evaluate the fetal metencephalon (pons and cerebellum). The anteroposterior diameter of the fetal pons was measured in a mid-sagittal plane. The longitudinal diameter of the cerebellar vermis was measured at the same plane and the vermis-pons ratio (VPR) was established. Results: One hundred and forty-four fetuses were in vertex position. In 140 (97.2%) satisfactory visualization and measurements of the pons and cerebellar vermis were obtained. One hundred and forty-nine fetuses were breech presentations and measurements were successfully performed in 147 (98.6%). The pons anteroposterior and vermis longitudinal diameters showed a linear correlation with gestational age (GA) (r = 0.95 for both measurements; P < 0.001). The mean VPR was 1.5 (+/-0.1 SD) and did not change in the gestational interval that was considered. Conclusion: By using the transfontanel approach, evaluation of the fetal pons is feasible via the mid-sagittal plane. The nomograms developed and the ratio to fetal vermis provides reference data that may be helpful when evaluating anomalies of the brainstem. [ABSTRACT FROM AUTHOR]

Objective To evaluate the clinical application of a new classification system of fetal lung anomalies. Methods Forty fetal diagnoses of lung lesions were analyzed according to our proposed classification system in which each lung component is considered using two-dimensional ultrasound and color and power Doppler technology. Medical files, natural history and neonatal follow-up were recorded. Results Type I dysplasia: Four cases of agenesis of the lung were diagnosed, three with right lung agenesis and one with left lung agenesis. Three of the four patients elected to undergo termination of pregnancy (TOP). The surviving fetus was diagnosed with scimitar syndrome and postnatal embolization of the aberrant vessel was performed. Type II dysplasia: One case of normal lung with abnormal systemic feeding artery was diagnosed with normal neonatal outcome. Type III dysplasia: Abnormal lung with abnormal vascularity was found in 14 cases, presenting in most cases as echogenic lung masses. Seven were supradiaphragmatic, six subdiaphragmatic and one case was of undetermined position. All 14 fetuses showed an aberrant systemic artery emerging from the aorta. Abnormal venous drainage could be identified in only five (36%) of the fetuses: three had prominent azygos vein, one showed drainage to the inferior vena cava and one had multiple intra pulmonary veins forming a huge arteriovenous (A-V) shunt. Two cases in this group underwent TOP, the case with A-V shunt following development of hydrops, and one on maternal request. The remaining 12 fetuses (86%) survived and were alive and well at the time of writing; only one of them needed immediate postnatal embolization of the bilateral aberrant feeding arteries. Type IV dysplasia: Abnormal lung with no vascular abnormality was diagnosed in 20 fetuses. In this group there was one case of intrauterine fetal death, two patients underwent TOP, one complicated with hydrops and one on maternal request. The survival rate in this group was 85%. Only two cases needed immediate surgical repair. Type V miscellaneous dysplasia: One fetus demonstrated echogenic lung with split notochord syndrome and survived. Conclusions Congenital bronchopulmonary and related vascular anomalies can be categorized using the new classification system. This new approach enabled prenatal evaluation of each lung component and facilitated cogent management of the fetus with congenital lung dysplasia. [ABSTRACT FROM AUTHOR]

Objective To describe our management of pregnancies complicated by twin reversed arterial perfusion (TRAP) sequence. Methods This was a retrospective study involving all cases of TRAP sequence referred to our fetal medicine unit in a 3-year period (2000–2002). Patients were routinely managed by repeat sonographic surveillance with sonographic anatomical evaluation and detailed echocardiography. Cases with signs of impending cardiac failure were treated by in-utero YAG-laser coagulation of the umbilical vessels of the acardiac twin. Results Six cases were studied. Three patients in whom there were no signs of deterioration in the status of the pump twin, and in whom the acardiac twin was smaller than the pump twin, were managed conservatively. However, one of these with monoamniotic twins ended in intrauterine fetal death of the pump twin. The other two cases presented with spontaneous cessation of blood flow in the umbilical artery of the acardiac twin. Both delivered at term normal neonates whose follow-up revealed no signs of neurological sequelae. One case of quadruplet pregnancy (with TRAP sequence and two dichorionic twins) was treated by selective termination of the monochorionic twins. Two cases with signs of impending cardiac failure were treated by in-utero YAG-laser occlusion of the vessels in the acardiac mass. Both interventions had a favorable outcome. Conclusions Conservative treatment is suitable for milder cases of TRAP sequence in which the pump twin is the larger one. Cases in which the acardiac twin is larger have a poorer prognosis and should be treated by invasive intervention and cord occlusion. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective To describe a novel, sonographic approach for in-utero evaluation of normal and abnormal aortic arch. Methods Aortic arch was evaluated by imaging of the axial view of the upper fetal mediastinum. The normal left aortic arch was defined by the V-shaped appearance of the junction between the ductus arteriosus and aortic arch, with the trachea situated posteriorly. Right and double aortic arches were diagnosed when the great vessels appeared U-shaped, with intermediate location of the trachea. Results Between 1997 and 1999, 18 347 women were scanned in three prenatal centers, and pathological findings were prospectively recorded. In a retrospective analysis of the records, we identified 19 fetuses (0.1%) with atypical, U-shaped appearance, and no other structural abnormalities present. With the exception of one fetus with a ventricular septal defect, no congenital cardiac defects were present. Right aortic arch was found in 18 cases, while color Doppler made it possible to diagnose one case with double aortic arch, and one fetus was demonstrated as having Kommerell's diverticulum. In all 18 cases, a left descending aorta and left ductus arteriosus were present, the latter coursing to the left of the trachea, forming a loose partial vascular ring. All were asymptomatic at birth and early infancy. The fetus with double aortic arch that had a true vascular ring underwent early infantile correction. Conclusions It is possible to diagnose right and double fetal aortic arch using prenatal ultrasound. The use of color Doppler facilitated in-utero evaluation of possible complications, such as true vascular ring. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective To establish a nomogram for fetal vermis measurements during gestation. Methods A prospective cross-sectional study of normal singleton pregnancies. Measurements of the fetal vermis width (in the axial plane) and height (in the sagittal plane) were performed by high-resolution transabdominal ultrasonography between 18 and 38 weeks of gestation in 256 fetuses. Results Adequate vermis measurements were obtained in 256 fetuses. Vermian width and height as a function of gestational age and biparietal diameter were expressed by regression equations and the correlation coefficients were found to be highly statistically significant (P < 0.0001). The normal mean (± SD) for each gestational week was defined. Conclusions The present data offer the normal range of the vermian measurements throughout gestation. These values may allow intrauterine assessment of the development of the cerebellar vermis, as well as the posterior fossa. [ABSTRACT FROM AUTHOR]

Abstract Objectives To compare the outcome of multifetal pregnancy reduction from triplets to twins performed either early (at 11–12 weeks’ gestation) or late (at 13–14 weeks). Methods Ninety-five high-order pregnancies following assisted conception were studied. Transabdominal sonographically guided multifetal pregnancy reduction was performed early in 46 women, while 49 women first underwent a sonographic fetal anomaly scan before undergoing selective reduction. Results Sonographic screening led to selective termination of a specific fetus in nine cases due to increased nuchal translucency and relative intrauterine growth restriction in three cases each, and meningomyelocele, abdominal cyst and cystic hygroma in one case each. In the early reduction group a diagnosis of hypoplastic left heart in the two remaining twins was subsequently made, and one pair of twins suffers from cerebral palsy. The rate of pregnancy loss was not statistically different between the early (4.3%; 2/46) and late (4.0%; 2/49) termination groups. The birth weight and gestational age at birth were not statistically different between the early ( n = 85) and late ( n = 94) groups (2110 ± 580 vs. 2140 ± 490 g, and 35.8 ± 3.0 vs. 35.7 ± 3.5 weeks). Similarly there was no statistically significant difference between early and late groups in the incidence of very premature (24–32 weeks; 9.3 vs. 8.3%) and premature (33–36 weeks; 46.5 vs. 47.9%) births. Conclusions Early second-trimester multifetal pregnancy reduction from triplets to twins may allow more selective termination of abnormal fetuses without an adverse effect on the outcome of pregnancy. However, further studies are needed in order to confirm our observations in a larger series. [ABSTRACT FROM AUTHOR]

Urorectal septum malformation sequence (URSMS) is a rare congenital malformation, which includes ambiguous genitalia, a phallus-like structure, imperforate anus, bladder, vaginal and rectal fistulas and Müllerian duct defects. We report two cases of prenatally diagnosed URSMS, both occurring in two sets of discordant twins. To the best of our knowledge, this is the first antenatal description of such an anomaly. The first fetus, one of a set of monochorionic, monoamniotic twins was detected sonographically at 21 weeks of gestation due to an enlarged phallus-like formation. The second fetus, one of dichorionic, diamniotic twins, was suspected of having an abnormally enlarged rectum at 13 weeks of gestation. The diagnosis of URSMS was established at 29 weeks of gestation by showing abnormal female external genitalia, with a dilated bowel that contained echogenic foci due to enterolithiasis. The diagnosis of both cases was confirmed postnatally. Sonographic findings and differential diagnosis are presented. [ABSTRACT FROM AUTHOR]

Objectives Anomalies of the fetal venous system are poorly documented and their pathogenesis is not well understood. The present study was undertaken to review the spectrum of fetal central veins and umbilico-portal system anomalies, and to propose a classification system. Methods A 7-year restrospective survey was conducted. Results Nineteen fetuses showed abnormal connection between central veins and the fetal heart. Three fetuses showed abnormal connections of the cardinal veins, two of which had interruption of the inferior vena cava, and one had isolated persistent left superior vena cava. Anomalies of pulmonary veins were seen in four fetuses: in two with asplenia syndrome, a vertical confluent pulmonary artery was observed. In a further two cases total anomalous pulmonary venous connections were found. Abnormalities of the umbilical vein (UV) were seen in 10 cases; seven had persistent right UV, and three had a spectrum of anomalies: One had abnormal connections of the UV to the left iliac vein associated with agenesis of the ductus venosus (DV) and hydrops fetalis. One case showed in utero occlusion of the DV by echogenic foci that resulted in a persistent left proximal UV and porto-systemic shunt. One case had obliteration of the D V secondary to in utero fetal hepatic fibrosis. Abnormalities of the vitelline veins or portal system were demonstrated in two cases. One had a left portosystemic shunt which resolved spontaneously at 3 months of age, and one had secondary partial occlusion of the left portal system with liver echogenicities and direct communication of the UV with the right atrium. None of the 19 cases had an abnormal karyotype or evidence of in utero infection. Conclusions Detection of various fetal vein anomalies in utero is feasible. The anomalies vary according to embryologic precursors or etiology. Two major mechanisms seem to be involved in the genesis of fetal vein anomalies: in most cases primary maldevelopment of the venous sys... [ABSTRACT FROM AUTHOR]

To evaluate changes in human, fetal segmentary, pulmonary artery blood flow velocimetry throughout pregnancy. Ninety-nine women with a singleton, low-risk gestation between 14 and 37 weeks of pregnancy were selected to participate in a prospective, cross-sectional study. All fetuses were evaluated using power and color Doppler ultrasound. Flow velocity waveforms at three sites of the right pulmonary artery were obtained. The pulsatility index (PI) was calculated in the proximal, mid and distal segment of the pulmonary artery. Mean values and 95% confidence interval (CI) for each segment were determined in correlation with gestational age. A full study that included Doppler measurements of all three segments of the pulmonary artery was completed on 99 fetuses. The highest mean PI of 2.36 was obtained in the proximal segment of the right pulmonary artery (CI = 2.29–2.42), whereas in the mid and distal segments the mean PI decreased significantly to 1.57 (CI = 1.53–1.61) and 1.02 (CI = 1.0–1.0) (P < 0.001), respectively. Throughout gestation, the mean PI measurements in the proximal, middle and distal segments of the branch pulmonary artery increased slightly, but without statistical significance (r = 0.274, 0.248, 0.047), respectively; (P > 0.5). The data obtained suggests that pulmonary circulation maintains stable vascular resistance during gestation in the human fetus. However, the PI obtained from the separate segments of the branch pulmonary artery is unique and each differs from the other, reflecting the proximity to the heart and the peripheral impedance at each location. [ABSTRACT FROM AUTHOR]

Objective To establish in-utero reference ranges for fetal transverse aortic arch diameter (TAD) and distal aortic isthmus diameter (DAID) using high-resolution ultrasound techniques. Design A prospective, cross-sectional study was performed on 125 normal singleton pregnancies between 14 and 38 weeks' gestation. Transverse and diameter and DAID were measured by transvaginal ultrasonography until 17 weeks' gestation, and by abdominal ultrasound between 18 and 38 weeks' gestation. Results Transverse arch diameter as a function of gestational age was expressed by the regression equation TAD = - 1.17 + 0.169 X GA, and DAID = - 1.39 + 0.189 X GA; TAD and DAID are transverse aortic and distal aortic isthmus diameters expressed in millimeters and GA is gestational age in weeks. The correlation r = 0.924 and 0.938 was found to be highly statistically significant (P < 0.001) for TAD and DAID. The normal mean of TAD and DAID per week and the 95% prediction limits were also defined. Conclusions The normative data established by us may be helpful in the prenatal diagnosis of congenital heart defects, including abnormal growth of the aortic arch. [ABSTRACT FROM AUTHOR]

Objective To assess the relationship between gestational age and sonographic appearance of the various sternal components and establish growth during human gestation. Design A prospective cross-sectional study. Methods The study was performed on 252 consecutive normal singleton pregnancies from 19 weeks of gestation until term, using transabdominal high-resolution ultra-sound techniques. The sternal length, as well as the number of ossification centers at each gestational age, were recorded. Results The first occasion at which a fetal human sternum could be visualized with two to three ossification centers was at 19 weeks' gestational age. The fifth ossification center was first visualized at 29 weeks' gestation. The mean ± SE of sternal length varied from 15 ± 0.98 mm (95% confidence interval (CI) 12.79–17.21) at 19–20 weeks, to 36.50 ± 0.29 mm (95% CI 35.58–37.42) at 37–38 weeks' gestation. Sternal length as a function of gestational age was expressed by the regression equation: sternal length (mm) = -11.06 + 1.39 × gestational age (weeks). The correlation coefficient, r = 0.924 for sternal length, was found to be highly statistically significant (p < 0.0001). Conclusions The presented data offer normative measurements of the fetal sternum which may be helpful in the prenatal diagnosis of congenital syndromes that include, among other manifestations, abnormalities of sternal development. [ABSTRACT FROM AUTHOR]

Objective To evaluate the outcome of fetuses with isolated borderline, unilateral ventriculomegaly. Design A retrospective survey was conducted at four perinatal centers in Israel. Subjects and methods Only fetuses with one ventricular width of ≥ 11 mm and the other < 10 mm were included in the study. In all cases, the difference of the ventricular width between the two ventricles was > 2.4 mm (two standard deviations). Fetuses with other malformations, chromosomal abnormalities, or those with evidence of in utero infection, were not included in the study. Results Unilateral ventriculomegaly was found in 27 subjects (after excluding one case with unilateral ventriculomegaly and Down's syndrome). The mean width of the enlarged ventricle was 11.7 ± 0.9 mm, while the other normal ventricle was 7.2 ± 0.9 mm. The mean gestational age at diagnosis of the unilateral ventriculomegaly was 23.6 ± 2.7 weeks. In one case, pregnancy was terminated, and pathological examination of the fetal brain failed to detect any structural abnormality. Twenty-five patients delivered at term and only one at 34 weeks' gestation. The neurological development in all 25 fetuses was normal, and one fetus had petit mal seizures. Conclusion Fetuses with isolated, borderline unilateral ventriculomegaly, but without other abnormalities, have a good neurological outcome. [ABSTRACT FROM AUTHOR]

Focuses on a study which examined the construction of centile chart for fetal scrotal size to determine gestational age. Utilization of transvaginal ultrasonography to measure scrotal circumference; Discussion on male genital abnormalities; Importance of prenatal diagnosis in congenital syndrome detection.

The study was conducted to construct a normal range for the diameters of the aortic root and pulmonary artery during the first half of gestation. With the use of transvaginal and transabdominal high-resolution ultrasound techniques, a prospective, cross-sectional study was performed on 139 normal singleton pregnancies at between 14 and 26 weeks. Great vessel diameters were measured by transvaginal ultrasonography until 17 weeks, and by transabdominal ultrasound between 18 and 26 weeks' gestation. The results showed that the aortic diameter (AD) as a function of gestational age (GA) was expressed by the regression equation AD = -16.0331 + 2.2563 × GA, and the pulmonary artery diameter (PD) by PD = -14.7637 + 2.4026 × GA; AD and PD are expressed in millimeters and GA in weeks. The correlation r2 = 0.94 was found to be highly statistically significant (p < 0.0001) for both great vessels. The normal mean of aortic and pulmonary artery diameter per week and the 95% prediction limits were also defined. During the study period we evaluated two cases with arterial diameters outside the 95% confidence limits; one had aortic coarctation and the other tetralogy of Fallot. The normative data established by us may be helpful in the prenatal diagnosis of congenital heart defects that include, among their manifestations, discordant diameters of the great vessels. [ABSTRACT FROM AUTHOR]

Outcome variables included termination of pregnancy (TOP), hearing abnormalities (SNHL), neurological disabilities (NDI) or composite outcome (all three). When sonographic abnormalities were excluded, MRI findings were not associated with NDI (9.1% vs. 5.1%, p = 0.48), SNHL (8.4% vs. 7.3%, p = 0.91) or composite outcome (13.6% vs. 11.1%, p = 0.86). [Extracted from the article]

In this study, we aimed to compare brain volumes of fetuses with CMV infection and non-infected controls. A retrospective cohort study examined MRI brain scans of 42 fetuses (at 30-34 weeks gestational age) that were diagnosed with intrauterine CMV infection. [Extracted from the article]