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Purpose to explore the value of measuring maternal serum PLGF in the prediction of the outcome of microsomic fetuses. Methods Singleton pregnancies referred with suspicion of microsomia were included if they had: no indication for nor signs of imminent delivery, fetal abdominal circumference (AC) at or below the 10th centile and/or estimated fetal weight (EFW) at or below the 10th centile and/or umbilical artery pulsatility index (Umb-PI) at or above the 90th centile for gestation. Women with pre-eclampsia at presentation were excluded. Maternal blood was drawn at the first (index) visit and analyzed retrospectively. Results 51 fetuses were examined. Multiple regression analysis showed that history of microsomia, index EFW and PLGF were significant predictors of the birthweight centile; index femur length centile and PLGF were significant predictors of pre-eclampsia; PLGF and index systolic blood pressure were significant predictors of iatrogenic preterm delivery

The objective is to examine the incidence of agenesis of fetal ductus venosus (DV) at the routine ultrasound examination at 11-13 weeks.This is a retrospective study on women presenting for screening for chromosomal abnormalities. The fetal DV was routinely examined by color Doppler in the sagittal view.Out of 8,304 fetuses examined, there were 13 cases of DV agenesis (0.15%). The umbilical vein drainage was intra-hepatic in two-thirds of the cases, and all resulted in normal live births. In the remaining one-third of cases, the umbilical vein drained to the inferior vena cava and all had a poor outcome because of aneuploidies, cardiac defects, and Noonan syndrome.Fetal DV agenesis occurs in about one in 650 fetuses and the majority of cases have a benign course and a favorable outcome. Failure to identify the DV should prompt a detailed ultrasound examination, identification of the drainage site of the umbilical vein, and genetic testing.

The aim of this study is to investigate the predictive value of low levels of pregnancy associated plasma protein-A (PAPP-A) during the first trimester on adverse pregnancy outcomes, namely pregnancy induced hypertension (PIH), preeclampsia (PE), intrauterine growth restriction (IUGR), and fetal loss.This is a prospective cohort study including 2636 women with singleton pregnancies that attended the Prenatal Diagnosis Unit of the First Department of Obstetrics and Gynecology of National and Kapodistrian University of Athens in "Alexandra Hospital" between 2017 and 2019 for the first trimester combined screening routine scan. The study population was divided into two groups according to their PAPP-A levels. The cut-off value of the PAPP-A level was defined as the 0.4 multiple of median (MoM) which is in correspondence with the fifth centile. The women were followed-up prospectively until delivery and the primary outcome measures were the incidence of PIH, PE, IUGR (10th centile), and fetal loss. Results: PAPP-A levels of ≤0.4 MoM were associated with increased maternal body mass index (BMI), increased uterine arteries pulsatility index (PI), and lower birth weight. Women with PAPP-A levels ≤0.4 MoM were more likely to develop PE (2.3% vs. 0.2%, p0.001), PE or PIH (2.3% vs. 0.4%, p=0.003), IUGR (2.3% vs. 0.4%, p=0.003), and combined adverse outcome (25.5% vs. 1.9%, p0.001) compared to women with PAPP-A0.4 MoM.This study confirms that among women with PAPP-A levels ≤0.4 MoM in the first trimester, there are increased odds for PE or PIH, IUGR, and combined composite pregnancy outcome.

Spontaneous Preterm Delivery (sPTD) is one of the leading causes of perinatal mortality and morbidity worldwide. The present case–control study aims to detect miRNAs differentially expressed in the first trimester maternal plasma with the view to identify predictive biomarkers for sPTD, between 320/7 and 366/7 weeks, that will allow for timely interventions for this serious pregnancy complication. Small RNA sequencing (small RNA-seq) of five samples from women with a subsequent sPTD and their matched controls revealed significant down-regulation of miR-23b-5p and miR-125a-3p in sPTD cases compared to controls, whereas miR-4732-5p was significantly overexpressed. Results were confirmed by qRT-PCR in an independent cohort of 29 sPTD cases and 29 controls. Statistical analysis demonstrated that miR-125a is a promising early predictor for sPTL (AUC: 0.895; 95% CI: 0.814-0.972; p < 0.001), independent of the confounding factors tested, providing a useful basis for the development of a novel non-invasive predictive test to assist clinicians in estimating patient-specific risk.

The novel COVID-19 global pandemic has raised, among many others, major concerns regarding the impact of infection during pregnancy. Current evidence suggests that vertical transmission from mother to baby, antenatally or intrapartum, does occur, but is uncommon. According to the published reports of infants born to COVID-19-affected mothers, as well as the anecdotal experience of current practices worldwide, it appears that investigations regarding the potential of SARS-COV-2 vertical transmission in pregnancy have so far been based, to a large extent, on PCR testing of neonatal pharyngeal swab samples. Given that the transplacental route of intrauterine transmission for SARS-COV-2 is less likely to immediately involve the upper respiratory tract of the newborn, contrary to what happens after birth, it would be advisable to include appropriate biological samples, such as cord blood, placenta, amniotic fluid and neonatal blood, along with the pharyngeal samples, in order to contribute significantly to such investigations. It is important to point out that negative PCR tests of neonatal pharyngeal samples do not exclude the possibility of intrauterine viral transmission, while positive pharyngeal swabs are more likely to reflect intrapartum or postpartum contaminants, rather than antenatal intrauterine transmission, in the absence of other criteria. Revision and enhancement of the so far prevailing practices appear important, in order to facilitate the development of good clinical practice for managing neonates and ensuring safety of families and healthcare providers.

Background. The coexistence of an intrauterine pregnancy and an ectopic pregnancy (heterotopic pregnancy) is an extremely rare, yet major, complication during pregnancy. The early diagnosis of a heterotopic pregnancy is of great importance for fetal viability, maternal safety, and the progression of an uncomplicated intrauterine pregnancy. Case Presentation. We report a case of a naturally conceived heterotopic tubal pregnancy in a 37-year-old primigravida. The patient presented with continuous, dull, lower abdominal pain and a positive urine pregnancy test which was conducted a week prior to the start of the pain. The patient was hospitalized, and based on the clinical image and after strict monitoring, she was diagnosed with a heterotopic pregnancy. She was treated with laparoscopic salpingectomy after the rupture of the ectopic pregnancy while the desired intrauterine gestation continued without any complications. The pregnancy resulted in the birth of a healthy infant through vaginal delivery. Discussion. Strict monitoring with multiple sonographic evaluations should always be conducted in women with abnormal serum beta-hCG, adnexal abnormalities, or clinical symptoms, while heterotopic pregnancy should be in differential diagnosis and treatment should not be delayed since emerge management is important for the progression of the intrauterine pregnancy.

Arachnoid cysts represent 1% of all intracranial lesions and appear on the arachnoid membrane (subarachnoid space). The etiology and pathogenesis of arachnoid cysts remain unclear and in their majority they are asymptomatic. Due to the developmental origin of arachnoid cysts, these formations can be identified on prenatal fetal imaging. In this report we presented a case of an enlarged suprasellar arachnoid cyst detected incidentally during a routine fetal sonographic examination at 33 weeks of gestation. The cyst remained stable in size prenatally and postnatally without compressive symptoms and signs and the patient has been set under expectant management with serial clinical evaluation and serial imaging of the cyst.

Gestational diabetes mellitus (GDM) is defined as impaired glucose tolerance with onset or first recognition during pregnancy, which is characterized by increased insulin resistance. GDM affects about 10% of pregnancies and its prevalence is rising worldwide mainly due to the advancing maternal age and the increased prevalence of obesity. GDM is associated with pregnancy-related maternal and fetal morbidity (both antenatal and perinatal). Traditional treatments for the GDM include diet and, if it is necessary, insulin. However, the percentage of macrosomic newborns does not appear to be significantly reduced. Safe and effective preventive interventions are therefore, needed in an attempt to lower the incidence of gestational diabetes. Myo-inositol has been suggested to improve insulin resistance in women with insulin resistant syndromes such as GDM, polycystic ovarian syndrome, type 2 diabetes and metabolic syndrome. Several studies report a significant decrease in GDM incidence in women at risk for GDM comparing to the placebo group. However, the option of myo-inositol supplementation needs to be further explored as the current evidence is relatively limited.

A number of energy sources are used in gynecologic laparoscopy. Monopolar electrosurgery, bipolar electrosurgery, advanced bipolar devices, ultrasonic energy and various types of lasers are some of the technologies used nowadays to facilitate surgeons tasks during laparoscopic operations. A lack of basic knowledge or ignorance of principles of electrosurgery and equipment among obstetricians and gynecologists is reported. As a result thermal injuries during laparoscopic electrosurgery occur, which frequently lead to significant morbidity and mortality and medicolegal actions. It is important though that surgeons have an understanding of the biophysics of these technologies in order to understand their limitations and potential dangers and to utilize the most appropriate energy source in the appropriate clinical setting to minimize the risk of a potential complication. This review provides an overview of the basic principles of these energy sources, the tissue effects and the complications that may arise. It aims to highlight any potential advantages or disadvantages of various energy sources and help surgeons to achieve better knowledge of their instrumentation.

Objectives The aim of our study is to present the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy and evaluate its impact on maternal and neonatal outcomes. Methods We retrospectively reviewed the medical records of all COVID-19 positive pregnant women who were admitted to “Alexandra” maternity hospital from March to December 2020 (n=40). The infection status was determined via real-time polymerase chain reaction (RT-PCR) of nasopharyngeal swab specimen. We documented the demographic features, clinical status, pregnancy characteristics and maternal and fetal outcomes. Results Forty COVID-19 positive pregnant women were admitted to our clinic during the study period. Mean maternal age was 27.6 years. Gestational age (GA) ranged from 10–42 weeks of pregnancy with mean GA calculated at 38+3 weeks. Associated comorbidities included hypertension, hypothyroidism, epilepsy, hepatitis B and asthma. Thirty-five out of 40 women delivered within the study period. Cesarean section was performed in 57.1% of the cases. Most of the cases (87.5%) were asymptomatic while ventilation was required for only one patient. All neonates tested negative for SARS-CoV-2. Neither maternal nor neonatal deaths occurred. Conclusions In alignment to other studies, our data show that the course of coronavirus disease 2019 (COVID-19) during pregnancy in the majority of cases is mild and neonatal outcomes also appear favorable.

IntroductionOver the last decades, a large body of literature has shown that intrapartum clinical digital pelvic estimations of fetal head position, station and progression in the pelvic canal are less accurate, compared with ultrasound (US) scan. Given the increasing evidence regarding the advantages of using US to evaluate the mechanism of labour, our study protocol aims to develop sonopartograms for fetal cephalic presentations. They will allow for a more objective evaluation of labour progression than the traditional labour monitoring, which could enable more rapid decisions regarding the mode of delivery.Methods/analysisThis is a prospective observational study performed in three university hospitals, with an unselected population of women admitted in labour at term. Both clinical and US evaluations will be performed assessing fetal head position, descent and rotation. Specific US parameters regarding fetal head position, progression and rotation will be recorded to develop nomograms in a similar way that partograms were developed. The primary outcome is to develop nomograms for the longitudinal US assessment of labour in unselected nulliparous and multiparous women with fetal cephalic presentation. The secondary aims are to assess the sonopartogram differences in occiput anterior and posterior deliveries, to compare the labour trend from our research with the classic and other recent partogram models and to investigate the capability of the US labour monitoring to predict the outcome of spontaneous vaginal delivery.Ethics and disseminationAll protocols and the informed consent form comply with the Ministry of Health and the professional society ethics guidelines. University ethics committees approved the study protocol. The trial results will be published in peer-reviewed journals and at the conference presentations. The study will be implemented and reported in line with the Strengthening the Reporting of Observational Studies in Epidemiology statement.Trial registration numberClinicalTrials.gov Registry (NCT02326077).

Neuroblastoma is the most common malignant extracranial solid tumor in infancy with an incidence rate of 58 per million infants younger than one year old. It originates from the neural crest during fetal development and may arise from the sympathetic ganglia or the adrenal medulla (Gurney JG, et al. J Pediatr Hematol Oncol. 1997; 19: 428). Prenatal detection of neuroblastoma was first described in 1983 (Fenart D, et al. Journalde Radiologie 1983; 64: 359). In the majority of antenatally diagnosed cases, neuroblastomas are adrenal in origin and right-sided. Differentiating neuroblastomas from other fetal suprarenal masses such as extralobar pulmonary sequestration, congenital adrenal hyperplasia, renal duplication, urinoma, gastric duplication cyst, and splenic cyst may be very difficult. However, improvements in ultrasound technology have made early detection possible and, combined with fetal MRI, facilitate differential diagnosis. Finally, prenatal diagnosis of a neuroblastoma is associated with a better prognosis, as it can resolve spontaneously either in utero or shortly after birth (Maki E, et al. J Ultrasound Med 2014; 33:895–904). This is a case of a mixed cystic and solid suprarenal tumor that was identified during a routine antenatal visit in the third trimester of pregnancy and was diagnosed as an adrenal neuroblastoma. Case description A 27-year-old pregnant woman presented to the outpatient clinic of Alexandra Maternity Hospital in Athens, Greece during the third trimester of her pregnancy. The woman was Gravida 2 Para 0 (G2P0). The gestational age of the pregnancy was 38 weeks and 2 days. The woman’s past medical history was uneventful. During her pregnancy, she underwent prenatal testing including first trimester scan, anomaly scan, 3 rd trimester Doppler scan without any abnormal findings. During the initial ultrasound scan we detected one fetus in occiput anterior position. All growth parameters (biparietal diameter, head circumference, abdominal circumference, femur length, estimated fetal weight) and the amniotic fluid index were within normal range for the gestational age. During the scan a well circumscribed mass was detected over the left kidney ( Fig. 1 ). The mass appeared to have both cystic and solid areas and appeared to originate from the left adrenal gland ( Fig. 1 ). The anatomy of the left kidney was not altered. The mass measured 4.40 × 4.12 cm ( Fig. 2 ). Doppler evaluation did not reveal increased blood flow towards the mass nor a single feeding vessel ( Fig. 3 ). The right kidney and right adrenal gland appeared normal ( Fig. 4a and b). Extensive ultrasound examination of the fetus revealed no other abnormalities. After careful evaluation of the ultrasound appearance of the tumor, the diagnosis of adrenal neuroblastoma was suggested. Open in a separate window Fig. 1 The mass is well circumscribed with both cystic and solid areas and appears to originate from the left adrenal gland.

The aim is to provide an overall view of the association of low pregnancy-associated plasma protein A (PAPP-A) levels with adverse perinatal outcomes. The available literature in PubMed/Medline regarding PAPP-A and adverse pregnancy outcomes was searched for related articles, including terms such as "PAPP-A," "intrauterine growth restriction (IUGR)," "small for gestational age (SGA)," "stillbirth," "adverse outcome," and others. The fifth percentile is supported by many recent studies to be PAPP-A's cutoff for adverse outcome detection and the increased risk seems to be extremely high below 0.2 PAPP-A MoM (multiple of the median). Apart from chromosomal abnormalities, preeclampsia, intrauterine fetal demise, and pregnancy loss have been associated with maternal serum PAPP-A. For results below the first centile, PAPP-A has a strong positive predictive value for SGA and IUGR. Except for its vital role on the cleavage of insulin-like growth factor binding proteins (IGFBP), PAPP-A has proven to be a reliable marker for prenatal screening. Even though PAPP-A as a single predictor proved to be valuable for the prediction of some adverse perinatal outcomes, in some cases, a combination of PAPP-A to other maternal serum markers led to an increase in detection rates. PAPP-A is a promising maternal serum marker for pregnancy outcome prediction with more studies needed in order for its potentials to be fully understood and exploited.

The Kurjak's antenatal neurodevelopmental test (KANET) is currently used by many centers in everyday clinical practice as the investigational tool for normal and high-risk fetuses. It has acceptable sensitivity and specificity, adequate positive and negative predictive vales, inter- and intra-observer realiability, and can be easily learned by US specialists with access to 4D US machines. The aim of the KANET is to be widely applied in clinical practice for the selective screening of fetuses with moderate and high neurological risk; hopefully, the early detection of these fetuses would allow at last the diagnosis of severe cases in utero and also an early intervention that could improved the outcome for these neonates. How to cite this article Kurjak A, Antsaklis P, Stanojevic M, Porovic S. Fetal Behavior assessed by Four-dimensional Sonography. Donald School J Ultrasound Obstet Gynecol 2017;11(2):146-168.

Background Delayed interval intertwin delivery rates are expected to rise during the next years as potent and targeted tocolytic agents are employed and antenatal surveillance methods become more sophisticated and specific in predicting the critical delivery timepoint of optimal perinatal outcome. Case presentation We present a case of delayed intertwin delivery after delivery of the first twin due to premature prelabor rupture of the membranes. Maternal serum White Blood Cells and C-Reactive Protein levels remained high until delivery of the second twin (34 days after the first was delivered), although maternal temperature remained constant. The mother underwent close antenatal surveillance and she was hospitalized. She had an uncomplicated delivery of the second twin at 29+ 2 weeks by cesarean section due to an abnormal Non-Stress Test. Conclusion We strongly suggest future evaluation of maternal serum inflammatory markers among these rare cases as these could predict intraamniotic infection.

Background. Uterocervical angle (UCA) has been recently proposed as a potential marker that could accurately predict preterm birth (PTB). The purpose of the present systematic review is to accumulate current evidence and provide directions for future research. Materials and Methods. We used the Medline (1966–2018), Scopus (2004–2018), Clinicaltrials.gov (2008–2018), EMBASE (1980-2018), Cochrane Central Register of Controlled Trials CENTRAL (1999-2018), and Google Scholar (2004-2018) databases in our search. Results. Eleven studies were finally included in the present systematic review that evaluated data from 3,018 women. The significant heterogeneity in terms of outcome reporting and outcome reporting measures (use of optimal cut-off values) precluded meta-analysis. However, existing data support that second trimester UCA measurement might be used as a predictive factor of PTB Conclusions. UCA measurement during the second trimester of pregnancy may be a useful method of determining women at risk of delivering preterm. However, more studies are needed to assess the reproducibility of these findings and reach conclusive evidence.

Evaluation of the patient at risk for fetal infection is challenging. Serologic studies may be inconclusive and often do not provide meaningful information about prognosis. Recent technologic advances have expanded the role of prenatal ultrasound in both anomaly detection and guidance for invasive diagnostic procedures. For the patient with a known or suspected fetal infection, sonographic identification of characteristic abnormalities can provide useful information for counseling and perinatal management. This article reviews the sonographic manifestations of fetal infection and the role of ultrasound in the evaluation of the fetus at risk for congenital toxoplasmosis, rubella, cytomegalovirus (CMV), and the herpes viruses (TORCH infections). How to cite this article Natsis S, Antsaklis P, Grigoriadis T, Antsaklis A. Sonographic Signs of Perinatal Infection. Donald School J Ultrasound Obstet Gynecol 2015;9(3):275-279.

Monochorionic twin pregnancies (MC) are less frequent but they are considered higher risk pregnancies compared to dichorionic pregnancies. As a result, determining the chorionicity of a twin pregnancy is of vital importance for the surveillance and management of the pregnancy. The problem originates from the fact that monochorionic twins have one placenta, and as a result the circulation of the two fetuses is closely related to each other mainly through anastomosis of the placenta. The number and type of anastomosis is of great importance for the course of the pregnancy. Diagnosis of chromosomal abnormalities in such pregnancies requires excellent knowledge of invasive procedures and good clinical skills. Monochorionic twins are at increased risk for unique complications including twin-to-twin transfusion syndrome (TTTS), selective intrauterine growth restriction (sIUGR), and twin-reversed arterial perfusion (TRAP) sequence. Twin-to-twin transfusion syndrome is a very well known and described complication of monochorionic twin pregnancies and must be considered and checked in each monochorionic pregnancy. Selective feticide is not a method used very commonly in MC pregnancies, but may be applied in selected cases. For TTTS laser treatment of the anastomosis is a method of choice, but should be performed in centers with experience. How to cite this article Antsaklis A, Antsaklis P. Invasive Procedures in Monochorionic Twins. Donald School J Ultrasound Obstet Gynecol 2015;9(3):280-292.

Neurological failure is the most apprehension complication of pregnancy, labor and the neonatal period. The origin and outcome correlation is frequently doubtful. The arrival of four-dimensional ultrasonography (4D US) and its function to study fetal behavior patterns have initiated to offer insight into the structural and functional fetal brain development. Although many fetal behavioral studies have been conducted, it is still questionable whether the assessment of continuity from fetal to neonatal behavior could improve our ability of early detection of brain pathology. Neurological assessment of fetus in utero is extremely difficult even having such sophisticated equipment like 4D ultrasound. As it is well known that quantity of GMs is not so informative and predictive for neurological impairment, their quality should be assessed. Gestalt perception of premature GMs we are dealing with in utero and several weeks postnatally are not as predictive for the detection of neurologically abnormal fetuses or newborns as fidgety GMs. Therefore, some additional parameters should be added to the prenatal neurological examination in order to improve our ability to make the distinction between normal and abnormal fetuses. How to cite this article Kurjak A, Antsaklis P, Stanojevic M. Fetal Neurology: Past, Present and Future. Donald School J Ultrasound Obstet Gynecol 2015;9(1):6-29.

Purpose of investigation To describe a novel approach for longitudinal vaginal septum (LVS) resection. Materials and Methods: Two cases of young girls with a uterus didelphys and a longitudinal vaginal septum. The technique consisted in grasping the vaginal septum with a laparoscopic 33-cm long bipolar cutting forceps, five-mm in diameter, and divided it to its midportion towards the two cervices. Results In both cases, the procedure was straightforward, uncomplicated, completed within three minutes and the patients were discharged four hours later. It was associated with minimal blood loss, short recovery time, absence of local ischemia, and optimum healing process. Conclusion The authors believe that surgical safety, efficacy and operative result make bipolar cutting forceps a tailored option for LVS resection.

Defining normal and abnormal fetal neurological function in utero in order to better predict antenatally which fetuses are at risk for adverse neurological outcome has remained a great challenge in perinatal medicine. Fetal behavioral patterns have been considered as indicators of fetal brain development. It has been suggested that the assessment of fetal behavior in different periods of gestation may make possible the distinction between normal and abnormal brain development. Advances in ultrasound technology and particularly the introduction of real time four-dimensional (4D) ultrasonography, allowed direct observation of in utero life and offered a new insight for the assessment of fetal behavior. Fetal behavioral movements, the full range of facial expressions and mobility of fetal upper and lower extremities and fingers can be clearly visualized with 4D ultrasound. A new scoring system for the assessment of fetal neurobehavior based on prenatal assessment of the fetus with 4D sonography has been developed based on the same technique that neonatologists assess newborns during the first days of their postnatal life. This overview focuses on the study of fetal behavior and neurological assessment with 4D ultrasound. How to cite this article Antsaklis P, Kurjak A, Izetbegovic S. Functional Test for Fetal Brain: The Role of KANET Test. Donald School J Ultrasound Obstet Gynecol 2013;7(4):385-399.

Objective To assess the potential of first-trimester sonography in the detection of fetal abnormalities using an extended protocol that is achievable with reasonable resources of time, personnel and ultrasound equipment. Methods This was a prospective two-center 2-year study of 5472 consecutive unselected pregnant women examined at 12 to 13 + 6 gestational weeks. Women were examined using an extended morphogenetic ultrasound protocol that, in addition to the basic evaluation, involved a color Doppler cardiac sweep and identification of early contingent markers for major abnormalities. Results The prevalence of lethal and severe malformations was 1.39%. The first-trimester scan identified 40.6% of the cases detected overall and 76.3% of major structural defects. The first-trimester detection rate (DR) for major congenital heart disease (either isolated or associated with extracardiac abnormalities) was 90% and that for major central nervous system anomalies was 69.5%. In fetuses with increased nuchal translucency (NT), the first-trimester DR for major anomalies was 96%, and in fetuses with normal NT it was 66.7%. Most (67.1%) cases with major abnormalities presented with normal NT. Conclusions A detailed first-trimester anomaly scan using an extended protocol is an efficient screening method to detect major fetal structural abnormalities in low-risk pregnancies. It is feasible at 12 to 13 + 6 weeks with ultrasound equipment and personnel already used for routine first-trimester screening. Rate of detection of severe malformations is greater in early- than in mid-pregnancy and on postnatal evaluation. Early heart investigation could be improved by an extended protocol involving use of color Doppler. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

Background The incidence of multifetal gestation and particularly of twin pregnancy has raised as a result of the introduction of assisted reproduction techniques (ART). Twinto- twin transfusion syndrome (TTTS) is a serious complication observed in monochorionic pregnancies producing severe morbidity and ultimately resulting in loss of one or all fetuses. We assessed the potential of early prediction of TTTS among three markers screened early in pregnancy [nuchal translucency (NT)] and its discrepancy and discordance, crown-rump length (CRL) and its discrepancy and discordance among twins and ductus venosus (DV) Doppler abnormalities. Materials and methods We conducted a systematic review searching Medline (1966-2011) and Scopus (2004-2011) engines, as well as reference lists from all included studies. Twelve studies were finally enrolled in the present review, including seven prospective studies, three prospective studies and one that could not be defined either as prospective or retrospective. Conclusion It seems that DV Doppler may denote this syndrome's possible future development and should be assessed early in monochorionic pregnancies. Further studies are definitely needed in order to evaluate the place of CRL and NT discrepancy and discordance in predicting TTTS. How to cite this article Antsaklis A, Pergialiotis V, Theodora M, Papazefkos V, Antsaklis P. Early Prediction of Twin-to-Twin Transfusion Syndrome with the use of First Trimester Ultrasound Markers: Is it Possible? Donald School J Ultrasound Obstet Gynecol 2013;7(1):66-72.

Fetal neurology is an evolving field in prenatal diagnosis and fetal medicine with great interest. The identification and diagnosis of brain damage prenatally has been a great challenge in obstetrics for many years and early identification of this damage would have implications on the perinatal management and is of great importance in cases of medical litigation. Defining normal and abnormal fetal neurological function in utero in order to better predict antenatally which fetuses are at risk for adverse neurological outcome still is under investigation. Several attempts have been made in the past to form a system that could detect fetuses with compromised central nervous system (CNS) function or brain impairement. Assessment of fetal behavior gave a promising opportunity to understand the hidden function of the developmental pathway of the fetal CNS. The assessment of normal neurobehavioral development by fourdimensional (4D) ultrasound gave the opportunity to investigate functional characteristics of the fetus that could predict neurological developmental dysfunction. These series of studies lead to the formation of Kurjak's antenatal neurodevelopmental test (KANET). KANET combines the assessment of fetal behavior, general movements and three out of four signs that have been postnatally considered as symptoms of possible neurodevelopmental impairment (neurological thumb, overlapping sutures and small head circumference). Assessment of fetal behavior by 4D ultrasound and application of KANET scoring test has been recently published in several journals and summarized results are presented in this review How to cite this article Antsaklis P, Antsaklis A. The Assessment of Fetal Neurobehavior with Four-dimensional Ultrasound: The Kurjak Antenatal Neurodevelopmental Test. Donald School J Ultrasound Obstet Gynecol 2012;6(4):362-375.

Autoimmune disease has affected up to 50 million Americans, according to the American Autoimmune Related Diseases Association (AARDA) and 75 percent of those affected are women. These inflammatory diseases have variable activity and a lot of women will have to undergo major therapies during and after pregnancy. Many of the women suffering from these disease will improve during gestation. However a lot of women will require continuation of disease-modifying therapies (i.e., biological therapies) throughout pregnancy and post-partum involving many risks. In the past decade all gaze turned to biological therapies, as an attempt, to obtain even more effective medications in order to suppress the exacerbation of autoimmune disease, even at the most unfit circumstances such as pregnancy. The results are both satisfying and promising since increasingly proven thoughts prevail on making anti-TNF agents first-line medications, clearing up the limited knowledge over human influence. The purpose of this review is to summarize the results of the reports with the highest and representative range of patients of the last decade involving the use of anti-TNF agents during pregnancy.

Ultrasound is a crucial part of everyday obstetrical practice and becomes more and more important in the management of traditionally clinical aspects of obstetrics, such as management of labor and delivery, offering a possibly more objective method of examination. The rate of labor induction has doubled in the last two decades and more objective methods are needed to assess the possible outcome of an induction and help clinicians in order to counsel women appropriately. Regarding the management of labor there is extensive evidence that clinical assessment during labor is not accurate, with potential consecutive major implications in the decision-making and the prognosis of the delivery mode. Several studies have shown that ultrasound is an objective method of assessing labor and its progress and is very helpful in decision-making for instrumental deliveries. The purpose of this article is to review the evidence available in literature regarding the benefits and the role in general of ultrasonography in prelabor and labor. How to cite this article Iliescu D, Antsaklis P, Paulescu D, Comanescu A, Tudorache S, Antsaklis A, Ceausu I, Novac L, Cernea N, Kurjak A. Applications of Ultrasound in Prelabor and Labor. Donald School J Ultrasound Obstet Gynecol 2012;6(3):257-269.

This study aimed to determine whether the number of nucleated red blood cells (NRBCs) in maternal circulation during the first trimester of pregnancy could identify pregnancies that will have an anomalous Doppler in the second trimester. A total of 85 blood samples were obtained at 11–14 weeks of gestation with mean uterine arterial perfusion index >1.6, as noted by Doppler ultrasonography. NRBCs were enriched by magnetic automated cell sorting using anti-CD71 and were stained with May/Grunwald/Giemsa. A total of 4.8 NRBCs (range 1–75) were identified in 68 cases. Follow-up scans at 22–24 weeks were available in 46 cases. In 39 women, blood flow in the uterine arteries normalized, whereas in seven, high resistance was noted. One woman in the high-resistance group developed preeclampsia (PET; four NRBCs) and another delivered an intrauterine growth restriction (IUGR) baby (75 NRBCs). The number of NRBCs in women whose Doppler indices later normalized and in those who continued to have increased impedance was similar. The study indicates that NRBC number in maternal circulation during the first trimester cannot be used to screen pregnancies at high risk for developing preeclampsia (PET)/IUGR. High-impedance blood flow in the uterine arteries in the first trimester may be due to an unfinished process of trophoblastic invasion, most likely to be completed successfully by 22–24 weeks.